Chapter 1

Copyright © 2009 by The McGraw-Hill Companies, Inc. All Rights Reserved.

McGraw-Hill

Chapter 1

Introduction to Electronic Health

Records

Electronic Health Records for Allied

Health Careers

Cover goes here when ready

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Learning Outcomes

After studying this chapter, you should be able to:

1. List three reasons why paper-based medical records are no longer adequate.

2. Discuss the economic pressures forcing changes in the health care system.

3. Describe the role of the government in bringing about changes in the health care system.

4. Explain the differences between electronic medical records, electronic health records, and personal health records.

5. Compare the content of a medical record in ambulatory and acute care settings.

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Learning Outcomes

After studying this chapter, you should be able to:

6. List the eight core functions of an electronic health record.

7. Describe the advantages of electronic health records.

8. Explain the issues surrounding the implementation of electronic health records.

9. Explain how electronic health records will affect existing jobs in allied health as well as create new jobs.

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• acute care• adverse event• ambulatory care• continuity of care• electronic health record (EHR)• electronic medical record (EMR)• electronic prescribing• evidence-based medicine• health information exchange

(HIE)• health information technology

(HIT)• Health Insurance Portability and

Accountability Act of 1996 (HIPAA)

• medical error• medical record• Medicare Part D• Medicare Prescription Drug,

Improvement, and Modernization Act of 2003 (MMA)

• National Health Information Network (NHIN)

• pay for performance• personal health record (PHR)• regional health information

organization (RHIO)• standards

Key Terms

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A Mandate for Change

Enormous change in health care field shifting from paper-based records to electronic record systems.

Why?• increase in medical errors• rising health care costs• need for coordination of care

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Medical Errors

Adverse event: patient harm resulting from treatment by health care system, not health condition of patient.

Not all adverse events are errors (e.g., side effects of medications).

Medical error: preventable adverse event (e.g., dispensing incorrect dosage of medication, surgery performed on wrong site).

Medical errors = 8th leading cause of death in U.S.

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Causes of Medical Errors

• misfiled or lost medical records• mishandled patient requests and messages• inaccurate medical record data• illegible handwriting• mislabeled laboratory specimens• medication mistakes

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Rising Health Care Costs

• U.S. spends approximately $2 trillion a year on health care.

• About 31% for administration, not direct patient care.

• Tremendous amount spent on treatments that are ineffective, duplicate another procedure, or are inappropriate.

• U.S. adults benefit from treatment only about half the time.

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Coordination of Care

• Patients receive treatment from multiple medical professionals at various facilities.

• Providers maintain own paper-based medical records and do not have access to records of other providers treating same patients. As a result, they often do not have complete information

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Trends in Technology, the Economy, and Government Policy

• Widespread use of health information technology (HIT) could:– improve quality of health care– prevent medical errors– reduce health care costs

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Advances in Technology

• Today’s technology makes it feasible and practical for physician practices to use computer technology for patient records:– speed of data transmission– wireless communication– lower costs

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Economic Pressures

• Continuous rising costs for patients, government, physicians, and employers.– Administrative costs: paper-based systems have

heavy administrative costs– Medical Liability Premiums: medical liability insurance

premiums at all-time high– Employer-Sponsored Insurance Premiums: rose

87% since 2000; costs threatening businesses

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Government HIT Initiatives

• Federal government leading push for health information technology.– Health Insurance Portability and Accountability Act of

1996 (HIPAA)– Medicare Prescription Drug, Improvement, and

Modernization Act of 2003 (MMA)– In 2004, President Bush set goal of electronic health

records within 10 years

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What is a Medical Record

• Medical record: legal and business documentation of all encounters with a health care provider including:– medical history– assessment, diagnosis, and treatment plan– laboratory test results, x-rays, other test results– list of medications prescribed– surgical reports (and reports of other procedures)

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What is a Medical Record

• Medical records are used for:– supporting clinical decisions– documenting services provided for billing purposes– documenting patient conditions and responses to

treatment

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Some Definitions

• Electronic medical record• Electronic health record• Personal health record

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Contents of a Health Record

– acute care

– ambulatory care

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The Purpose and Use of Health Records

• Primary Purpose– To assist health care professionals in providing the

most effective patient care.

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The Purpose and Use of Health Records

• Secondary Uses– Billing and Reimbursement– Legal Issues– Quality Review– Research– Education– Public Health and Homeland Security– Credentialing

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Core Functions of an Electronic Health Record System

1. Health Information and Data

2. Results Management

3. Order Management

4. Decision Support

5. Electronic Communication and Connectivity

6. Patient Support

7. Administrative Processes

8. Reporting and Population Management

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Advantages of Electronic Health Records

• Safety• Quality• Efficiency• Future Cost Reduction

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Implementation Issues

• Cost• Lack of Standards• Learning Curve• Workflow Changes• Changes in the Software Market• Privacy and Security Risks

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The Impact of IT on Allied Health Careers

• Opportunities for employment in many environments (e.g., physician offices, hospitals, insurance carriers, pharmaceutical companies)

• Allied health graduates will need skills in HIT; demand for these skills will exceed the supply.

• HIT will create new careers (e.g., clinical analyst, health information technician, information privacy coordinator).

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Certification and Lifelong Learning

• Health care requires lifelong learning• Certification demonstrates proficiency; easier to find

jobs and typically paid more• Some health information technology certifications:

– Registered Health Information Technician (RHIT) and Registered Health Information Administrator (RHIA) offered by American Health Information Management Association (AHIMA)

– Medical Coding certifications: offered by AHIMA and American Academy of Professional Coders (AAPC)

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Outlook and Salaries

• Health care field remains one of fastest growing segments of economy.

• As population ages, health care needs increase and new jobs created.

• Salaries dependent on factors such as location, size of organization, education and experience of individual, etc.