Electronic

Health

Records Presented by

Jerome Scott

Describe the common components of Electronic Health Records (EHR).

Assess the benefits of an EHR.

Evaluate outcomes of EHR use in meeting needs of healthcare staff and patients.

Objectives

The Electronic Health Record (EHR) is a

longitudinal electronic record of patient

health information generated by one or

more encounters in any care delivery

setting. (Electronic Health Record, 2010)

Electronic Health Record (EHR)

Click for Reference

Avoid duplication of tests

Reduce medical errors

Make surgery safer

Encourage better self-care

Improve care of chronic illness

Identify proper medication dosages

The benefits of EHR

Hardware

Software

EHR Components

The physical or tangible parts of the EHR computer system

Computer terminals in patient care areas

Tablet PC’s

Handheld devices

Hardware

Tablet PC High mobility PC

Lightweight and high durability

Slim, flat battery is hot-swappable

Thin dimensions can be easily gripped

Three input modes (pen, voice & keyboard)

Hardware example

Computer Physician Order Entry

Security software

Lab Test Results

Patient-specific Educational Resources

Electronic Syndrome Surveillance

Immunization registries

EHR software offers integrated clinical and administrative capabilities and provides quick access to patient information

Software protection of sensitive patientInformation

Security software

Individual-based access

 

Role-based access

 

Context-based access

Security access control

Each user’s information needs is

individually evaluated and access

is provided accordingly.

Individual-based access control

Users with common jobs and/or access needs

Nurses

Administrators

Secretaries

Role-based access control

Users who serve in a common context

Specific discipline

Legal entity

Context-based access control

Healthcare information systems:

Clinical

Pharmacy

Laboratory

Radiology

Software

Early and central focus on users in the design,

development and purchase of systems

Iterative design

Empirical usability measures of observations of

users and information systems (Staggers, 2003)

Software must address the three axioms of usability

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PATIENT CARE TEAM

Laboratory Physicians officeEmergency Services

Pharmacy

Hospital

Home HealthRadiology

Specialist

EHR= Continuity of care

Enhancing care by providing data at the bedside

Containing observations

Interventions

Clinical notes

Hemodynamic data

Lab results

Clinical Information systems

Electronic chronic care management is

aimed at improving the health of patients

with chronic illness

Chronic care management software

Heart disease

Hypertension

Chronic Obstructive Pulmonary Disease (COPD)

Asthma

Diabetes

Chronic care management software areas

MedicsDocAssistant Electronic Health Records software

Physicians Quality Reporting Initiative (PQRI)

Computer Based Provider Order Entry (CPOE)

Evidence-Based Medicine

MedicsRX e-prescribing Solution

Medics On-Call™ for iPhone™

Virtual "sticky notes“ (MedicsDocAssistant Electronic Health

Records, 2010)

EHR package examples

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Systems analysis, design, and

implementation

Database management

Specialization in health care informatics

Current issues and trends in health care

informatics

Health care informatics internship

Nurse informatics competencies

Clinician computer education coordination

Project management for clinical systems

Supervises clinical informatics analysts

Leads nursing informatics vision and

strategic plan

Nurse informatics responsibilities

Start up costs

Transition period from paper to electronic

Feelings of depersonalization

Distraction from the patient

Computer problem delays

Security

Disadvantages of EHR

Third party access

Confidentiality

Beneficence and nonmaleficence

Value conflicts

Ethical and legal issues with HER

  Electronic Health Record. (2010). Retrieved February 25, 2010,

from Healthcare Information and Management Systems Society (HIMSS) Web site: http://www.himss.org

  Staggers, N. (2003). Human factors: Imperative concepts for

critical care. AACN Clinical Issues , 310-319. MedicsDocAssistant Electronic Health Records. (2010).

Retrieved March 2, 2010, from Advanced Data Systems Corporation: http://www.adsc.com

References

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