the electronic medical record

Copyright © 2011, 2007, 2004 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1

The Electronic Medical RecordThe Electronic Medical Record

Chapter 15


IntroductionIntroduction

Electronic Medical Records are the future of Electronic Medical Records are the future of medical documentation.medical documentation.

President Bush put forth an executive order that President Bush put forth an executive order that included the goal that every American’s medical included the goal that every American’s medical records be in electronic form by 2014.records be in electronic form by 2014.


This chapter will examine:This chapter will examine:

Difference between an electronic health record Difference between an electronic health record and an electronic medical recordand an electronic medical record

Advantages and disadvantages of using Advantages and disadvantages of using electronic medical records systemselectronic medical records systems

Capabilities of electronic medical records Capabilities of electronic medical records systemssystems

Core capabilities of a national health information Core capabilities of a national health information networknetwork

Role of the medical assistant in the midst of Role of the medical assistant in the midst of changing technologychanging technology


Physicians Using Electronic Physicians Using Electronic Medical RecordsMedical Records

Although only a small percentage of physicians Although only a small percentage of physicians use an electronic medical record system, this use an electronic medical record system, this percentage is likely to grow each year.percentage is likely to grow each year.

Some physicians will never change to an Some physicians will never change to an electronic system due to personal preference electronic system due to personal preference and the cost involved.and the cost involved.

Medical students are learning electronic Medical students are learning electronic systems and as they open their practices, they systems and as they open their practices, they will likely incorporate electronic systems.will likely incorporate electronic systems.


Executive OrderExecutive Order

Issued by President George W. Bush in August Issued by President George W. Bush in August 20062006

Promotes interoperability of health recordsPromotes interoperability of health records Promotes overall quality and efficiency of Promotes overall quality and efficiency of

recordsrecords Implementation date was January 1, 2007Implementation date was January 1, 2007 Contains five requirementsContains five requirements


1.1. Agencies are to implement interoperable systems as Agencies are to implement interoperable systems as current systems are upgraded.current systems are upgraded.

2.2. Providers and payors with whom agencies do business Providers and payors with whom agencies do business will also implement interoperable systems.will also implement interoperable systems.

3.3. Prices paid to beneficiaries will be available both to Prices paid to beneficiaries will be available both to beneficiaries and the public (if the agency chooses).beneficiaries and the public (if the agency chooses).

4.4. Agencies and providers will participate in development Agencies and providers will participate in development of information regarding the overall cost of healthcare of information regarding the overall cost of healthcare services and treatments.services and treatments.

5.5. Agencies and providers will develop approaches that Agencies and providers will develop approaches that encourage high-quality and efficient health care.encourage high-quality and efficient health care.

Requirements of an Executive OrderRequirements of an Executive Order


Electronic Health RecordElectronic Health Record

An electronic record of health-related An electronic record of health-related information on a patient that is created, information on a patient that is created, gathered, managed, and consulted by licensed gathered, managed, and consulted by licensed clinicians and staff from a clinicians and staff from a single organizationsingle organization involved with the patient’s care.involved with the patient’s care.


Electronic Medical RecordElectronic Medical Record

The aggregate electronic record of The aggregate electronic record of health-related information on a patient that is health-related information on a patient that is created and gathered cumulatively across created and gathered cumulatively across more more than one health care organizationthan one health care organization and is and is managed and consulted by licensed clinicians managed and consulted by licensed clinicians and staff involved in the patient’s health care.and staff involved in the patient’s health care.

aggregate: looking at all units as a wholeaggregate: looking at all units as a whole


Protected Health InformationProtected Health Information

Any information about health status, provision of Any information about health status, provision of health care, or payment for health care that can health care, or payment for health care that can be linked to an individual patient.be linked to an individual patient.


Advantages of the EMRAdvantages of the EMR Reduces medical errorsReduces medical errors Keeps records organizedKeeps records organized Helps to avoid duplicate testingHelps to avoid duplicate testing Less concern for illegible recordsLess concern for illegible records Requires individual names and passwords for Requires individual names and passwords for

securitysecurity Less storage spaceLess storage space Access information from various devicesAccess information from various devices Saves moneySaves money Promotes efficient patient carePromotes efficient patient care


Disadvantages of the EMRDisadvantages of the EMR

Reluctance of employees to embrace changeReluctance of employees to embrace change Patients’ concerns for confidentialityPatients’ concerns for confidentiality High start-up costsHigh start-up costs Extensive training necessaryExtensive training necessary Space for equipment neededSpace for equipment needed Interaction of office system with outside Interaction of office system with outside

systemssystems Security issuesSecurity issues


CapabilitiesCapabilities

Specialty softwareSpecialty software Appointment schedulerAppointment scheduler Appointment reminder and confirmationAppointment reminder and confirmation Prescription writerPrescription writer Medical billing systemMedical billing system Charge captureCharge capture Eligibility verificationEligibility verification


Capabilities (cont’d)Capabilities (cont’d)

Referral managementReferral management Lab order integrationLab order integration Patient portalPatient portal


The Patient and the EMRThe Patient and the EMR

Patients worry about the security of their health Patients worry about the security of their health information.information.

Patients may file lawsuits for unauthorized Patients may file lawsuits for unauthorized access to their medical records.access to their medical records.

Expect hesitation and reluctance from patients.Expect hesitation and reluctance from patients. Be prepared to answer patient questions.Be prepared to answer patient questions. Know how the EMR is protected and the Know how the EMR is protected and the

security measures that are in place so that security measures that are in place so that patients can be reassured.patients can be reassured.


Additions and Corrections to the EMRAdditions and Corrections to the EMR

Never delete a previous entry.Never delete a previous entry. Never change an entry after initials are Never change an entry after initials are

attached.attached. Make a new entry to correct the error. Make a new entry to correct the error. Note initials and date of change.Note initials and date of change.


Nonverbal CommunicationsNonverbal Communications and the EMR and the EMR

Make certain that nonverbal communications send the Make certain that nonverbal communications send the right message to the patients.right message to the patients.

Eye contact is essential.Eye contact is essential. Do not stare at the computer screen constantly.Do not stare at the computer screen constantly. Make the patient feel a part of the process.Make the patient feel a part of the process. Remember that the patient has the right to choose Remember that the patient has the right to choose

and make his or her own decisions regarding health and make his or her own decisions regarding health care.care.

Maintain timely communication with the patient.Maintain timely communication with the patient. Make sure the patient understands instructions by Make sure the patient understands instructions by

watching body language signals.watching body language signals.


Nationwide Health Information Nationwide Health Information Network Network (NHIN)(NHIN)

Developed to provide a secure, national, Developed to provide a secure, national, interoperable health information infrastructure interoperable health information infrastructure that will connect providers, consumers, and that will connect providers, consumers, and others in supporting health care.others in supporting health care.


Goals of NHINGoals of NHIN

Development of capabilities for Development of capabilities for standards-based, secure data exchange standards-based, secure data exchange nationwidenationwide

Improvement of the coordination of care Improvement of the coordination of care information among hospitals, laboratories, information among hospitals, laboratories, physician offices, pharmacies, and other physician offices, pharmacies, and other providersproviders

Ensure appropriate information is available at Ensure appropriate information is available at time and place of caretime and place of care

Ensure that consumers’ health information is Ensure that consumers’ health information is secure and confidentialsecure and confidential


Goals of NHINGoals of NHIN

Giving consumers new capabilities for Giving consumers new capabilities for managing and controlling personal health managing and controlling personal health records and providing access to health records and providing access to health recordsrecords

Reducing risks from medical errors and Reducing risks from medical errors and supporting the delivery of appropriate, supporting the delivery of appropriate, evidence-based medical careevidence-based medical care

Lowering healthcare costs resulting from Lowering healthcare costs resulting from inefficiencies, medical errors, and incomplete inefficiencies, medical errors, and incomplete patient informationpatient information


Core Capabilities of NHINCore Capabilities of NHIN

Ability to find and retrieve healthcare Ability to find and retrieve healthcare information with and between organizationsinformation with and between organizations

Ability to deliver a summarized patient record Ability to deliver a summarized patient record to support patient care and to support the to support patient care and to support the patient’s healthpatient’s health

Ability to support consumer preferences Ability to support consumer preferences regarding the exchange of his or her regarding the exchange of his or her information, including the ability to choose not information, including the ability to choose not to participate in the NHINto participate in the NHIN


Core Capabilities of NHINCore Capabilities of NHIN

Support secure information exchangeSupport secure information exchange Support of a common trust agreement that Support of a common trust agreement that

establishes the obligations and assurances to establishes the obligations and assurances to which all NHIN participants agreewhich all NHIN participants agree

Ability to match patients to their data without Ability to match patients to their data without a national patient identifiera national patient identifier

Support of harmonized standards among all Support of harmonized standards among all entities and networksentities and networks


Backup Systems for the EMRBackup Systems for the EMR

External hard driveExternal hard drive Full server backupFull server backup Online backup systemsOnline backup systems


The Medical Assistant and the EMRThe Medical Assistant and the EMR

Daily use of the EMR should become second Daily use of the EMR should become second naturenature

Remain open to change and be willing to learnRemain open to change and be willing to learn Set a good example for other employeesSet a good example for other employees Encourage other staff members during trainingEncourage other staff members during training Be patientBe patient Keep technical support phone numbers handyKeep technical support phone numbers handy Work as a teamWork as a team Project a great attitudeProject a great attitude


Summary of ScenarioSummary of Scenario

Sometimes a medical assistant is not a good Sometimes a medical assistant is not a good match for an office.match for an office.

Perform to the utmost ability even if the job is Perform to the utmost ability even if the job is unsatisfactory to get a good reference.unsatisfactory to get a good reference.

Do the job that you were hired to do.Do the job that you were hired to do. Develop a strong work ethic.Develop a strong work ethic.


Closing CommentsClosing Comments

Set the goal of quality, efficient health care.Set the goal of quality, efficient health care. Stay abreast of news and articles that relate Stay abreast of news and articles that relate

to EMR systems.to EMR systems. Remember that the healthcare industry is one Remember that the healthcare industry is one

of constant growth and change.of constant growth and change.

the electronic medical record

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