EHR Ch 1-6
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IOM Eight Core Functions
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Health information and data Result management Order management Decision suport Electronic communication and connectivity Patient support Administrative processes and reporting Reporting and population health
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CPRI three key criteria
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Capture data at point of care Integrate data from multiple sources Provide decision support
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HITECH Act
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Provides CMS incentives for provider to use a certified EHR
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ONC
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Office of the National Coordinator Established Authorized Testing and Certification Bodies to certify EHR systems
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Soap documentation
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Subjective: SX & HX Includes patient symptoms and history Objective: PX & TX Physical Examination and Test Results Assessment: DX The physicians diagnosis Plan: RX Includes physicians orders for treatments, meds, and further testing, lab orders, etc.
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EHR Data Formats
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Images -Scanned documents -Diagnostic images (x-ray, CT, etc) Text Files -Imported word processing files (read by hand) Discrete Data -Fielded and Coded data -This type of data can be quickly searched by computer to create graphs, alerts, trending, etc
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ehr Nomenclatures
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Coding systems designed to codify the details and nuances of the patient-clinician encounter. MEDCIN is a point of care nomenclature. Snomed-CT classifies and indexes medical information for research. LOINC is a nomenclature for use in a laboratory
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Nursing code sets
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CCC is based on home care nursing NANDA-I nursing diagnosis and interventions NIC and NOC Nursing interventions & outcomes ICNP International nursing system Omaha System is community based nursing NMDS comparison of patient outcomes PNDS perioperative nursing PCDS has a stronger acute care origin
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Cataloging images
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Images are scanned into the patient's chart. In order to connect the image to the patient's chart, the name, patient number, medical number, date and time, provider, etc. must be entered into the system with the image. This process can be automated by scanning barcodes containing the information.
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Pac
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Picture Archival and Communication System This system is a separate system that stores the digital radiology pictures. When the patient's EHR is accessed by computer, it will access the link to PAC and the x-ray image will be seen on the patient's chart, even though it is not actually in the record. These images can also be remotely accessed by the patient's physician for viewing
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HL7
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A nonprofit organization standard used by healthcare computer systems to exchange information. Many different code sets are used and HL7 can be used to translate and interface data into a main EHR system HL7 is very flexible and supports multiple coding standards, allowing data to be transferred to other healthcare facilities.
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CDISC
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A subgroup of HL7 that with a specific focus on clinical drug trials.
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v
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Digital Imaging and Communications in Medicine. Most widely used format for storing and sending diagnostic images, such as: Digital x-rays, CT scans, MRI's, ultrasound, angiography, endoscopy, laparoscopy, medical photography, and microscopy.
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BIOMEDICAL DEVICES
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Many newer medical devices such as patient monitors, vital sign instruments, cardiac and arterial blood gas instruments can be wired or wirelessly transmit data to the patient's EHR.
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sig
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Refers to the instructions for labeling a prescription. When the physician enters the sig into the record, the DUR software checks prescription against a of most known drugs; prescription, over the counter (OTC), and nutritional herb and vitamin supplements. The DUR software can create an alert when the drug can be affected by food or alcohol.
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DUR or Drug Utilization Review
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Drug is checked against the patient's current medication list to determine if there is a conflict Ingredients are checked against the current meds duplicate therapy. Drug is checked against patient's allergies. The DUR checks previous diagnostic medical history for contraindications. Checks to ensure recommended guidelines for the drug are used.
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Alerts
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Refers to a message or reminder that is automatically generated by the system. Alerts are based on programmed rules that alert when two or more conditions are met. Alerts can be programmed for just about anything
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Formulary Alerts
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Alert the physician when your insurance will not cover the prescription, so that he may make a different choice if it is medically advisable. Formularies are lists of medications provided by your insurance company that indicates: Preffered Drugs Nonpreffered,Drugs, and Noncovered Drugs
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Other types of alerts
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Lab orders not covered by Medicare Changes in values of certain blood tests, or when the result is outside of normal range. An alert may notify when preventative screening is due, An alert may send a reminder for immunizations
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Decision Support
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The ability of the EHR to store or quickly locate materials relevant to the findings of the current case. Defined protocols Results of case studies Standard care guidelines from specialists, medical societies, or government organizations. Protocols are standard plans of therapy established for different conditions. Decision support also assists with medication dosing
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ROS Review of Symptoms
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A way of organizing an exam by body systems starting from the head down. Located in the toolbar at the top of medcin. Changes symptoms from HPI into an ROS Symptoms from the chief complaint are entered from the HPI. The remainder of systems are reviewed in the ROS. Using auto negatives, the entire body can be documented quickly
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FORMS
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Templates that display a desired group of findings in a consistent position every time. Electronic forms are one of the easiest ways to use an EHR and to increase speed of data entry. Allow you to organize questions in the order you would ask them. Forms also can allow entry of free-text notes right on the form
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Auto-Negs
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This is really an Auto Normal feature
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List
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Invokes a list manager window from which you can select and load a List. List Size: Increases or Decreases the number of findings in the displayed list. Sizes are 1-3.
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CPOE
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-Computerized Provider Order Entry: One of the key features of an EHR that can improve quality of care, patient safety, and clinician efficiency. -Process Improvement Preventing lost orders Illegible handwriting Reduced drug errors Monitors for duplicate orders Reduces time to fill orders
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CPOE improvements
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Automatically generates related orders Improves clinician productivity Easy access Reduces lag time Automated display of previous test results Better interpretation and detection of abnormalities for follow-up Access to consults and patient consents improves coordination among multiple providers
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Lab Orders and Reports
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When an order for lab or other diagnostic tests is ordered, a unique ID called a requisition number is assigned. It may also be called an accession number. Many lab instruments are automated and enter results directly by electronic interface into the LIS, or Laboratory Information System.
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LIS
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LIS assigns codes and records values for each component of the test and stored until being transferred electronically to the EHR, or printed on a paper lab result report. Results are complied into a report that includes the information from the original requisition, test codes, codes for each component of the test, as well as standard reference ranges for each associated with the actual value measured with the component, and any notes
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Three areas of pathology
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Clinical Pathology: Uses chemistry, microbiology, hematology, and molecular pathology to analyze blood, urine, and other body fluids. Anatomic Pathology: Performs gross, microscopic and molecular examination of organs and tissues and autopsies of whole bodies. Surgical Pathology: Performs gross and microscopic exam of tissue removed from a patient by surgery or biopsy
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Point of care testing
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Tests that are done outside the laboratory, at the patient's location. Example: Glucose monitoring. This point of care testing can be electronically transmitted to the EHR. In a hospital, it will usually be transmitted to the LIS, and then to the patient's EHR from there.
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Reference Laboratories
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These are outside testing facilities that process tests for places that don't have their own laboratory, or for tests that are beyond the capabilities of the hospital laboratory
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ABN
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Certain tests may not be covered by the patient's insurance and the patient must sign an acknowledgement that he or she has been advised that the test will not be paid by insurance. This form is an Advance Beneficiary Notice.
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EHR Lab Result ADVANTAGES
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Reduction of turn-around time for results. Tracks results not yet reviewed by the physician Result reports of patient's current result, can also show his previous results. Trending is comparing the change of certain test components or vital signs over a period of time. Graphs can be easily created to show changes
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search
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Performs automatic word completion Provides an extensive list of synonyms Identifies related findings and makes them automatically available in other tabs. Searches first in current tab; if no results, it will continue on to the next tab with results
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prompt
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Short for \"prompt with current finding.\" Generates a list of findings that are clinically related to the finding currently highlighted. Shorter than the full nomenclature Contains only relevant findings Easier to read and navigate Functions in all tabs
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RIS
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While many radiology departments are capable of receiving electronic orders, virtually all departments enter received orders into the Radiology Information System, and are handled electronically for the remainder of the process
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Radiology Tests
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X-rays are now recorded on a special plate that captures the image digitally and store in PAC. CAT, or Computerized Axial Tomography uses x-rays to see into the patient's body and capture thousands of digital images. Also called CT. MRI, or Magnetic Resonance Imaging, uses magnetic fields and pulses of energy to create images of organs and structures inside the body that cannot be seen by x-ray or CAT scan
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Radiology Tests and terms
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PET, or Positron Emission Tomography, combines CT and nuclear scanning using a radioactive substance called a tracer, which is injected into a patient's vein. A study is a set of related images interpreted by a radiologist. A hanging protocol refers to the number of images that simultaneously display on the radiologist's monitor.
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Radiology Reports
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Usually dictated by the radiologist and typed by a medical transcriptionist, although some use speech recognition software that converts it into a typed report. Radiology reports are seldom available as a codified EHR record. Radiology observations that are codified are those related to the size and stage of tumors
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Medication Orders
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Efforts to increase safety by hospitals include: CPOE Computerizing the pharmacy Positive identification systems to correctly match the medication with the patient. A pharmacy benefit manager An intermediary company that electronically checks the patient's formulary for the pharmacy system
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Electronic prescriptions
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Prescription is issued and recorded in one step. Any problems with the prescription can be corrected immediately before being sent. Prescriptions are transmitted electronically to the pharmacy. Medication errors due to handwriting are reduced
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Closed loop process for med safety
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Clinician writes prescription using CPOE. Prescription is checked and approved b y the pharmacist. Nurse receives order electronically and removes vial from medication-dispensing system. A handheld scanner device is used to read a barcode on the patient's armband to be sure the medication is being given to the right patient. Nurse scans the barcodes on each medication or intravenous solution and the computer program checks the electronic order and warns the nurse of any discrepancies. Nurse administers the medication to the patient Nurse documents the patient's chart. (Some systems repeat scan the armband, or scan the nurses badge to complete documentation electronically
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The 5 rights of medication administration
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1 Right patient 2 Right time and frequency 3 Right medication 4 Right dose 5 Right route of administration
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WHO
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WORLD HEALTH ORGANIZATION
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ICD-9-cm 1900-1979
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International Classification of Diseases, 9th Revision, Clinical Modification Three volumes: Volumes 1 and 2 provide a listing and an index of diagnosis codes. Volume 3 lists codes for hospital inpatient procedures. Code consists of three characters, a decimal point, and up to two numerals. First three letters represent primary diagnosis. The ending numerals further refine the diagnosis specificity
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Insurance Billing
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In 1989, the ICD-9-CM codes became required for insurance carriers to process claims. Allows for the use of multiple ICD-9-CM codes for a single procedure, indicating one code as the primary diagnosis, and the rest as secondary conditions for which the treatment was done
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Specialized codes
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V codes represent circumstances other than disease or injury. E codes are for classification of external causes of injury or poisoning. ICD-10-CM has about twice as many codes. The US Dept of Health and Human Services has proposed it be adopted for billing in the US effective October 1, 2013
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ICD-9-CM and the EHR
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Most EHR's contain an internal reference table that can add the ICD-9-CM codes automatically. The primary diagnosis is the reason the patient sought care. (chief complaint) Secondary diagnoses (or comorbidities) are classified as: POA Present On Admission, or HCA Hospital Acquired Condition
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Multiple diagnoses
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Occur mainly in patients with ongoing or chronic conditions requiring regular visits. It is correct and appropriate to continue to use diagnosis codes from past visits as long as the patient continues to ave the illness or condition and that condition is clearly documented in the record
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Rule-Out Diagnosis
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ICD-9-CM does not have specific codes or modifiers for \"possible, probable, suspected, or rule-out\" conditions. Services performed for in-patients, support the concept of \"rule-out\". Guidelines for out-patients, are not supported, therefore, the insurance claim for an outpatient visit should not be coded with a diagnosis for the suspected disease
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