NURS 675 Electronic Health Record (EHR) System DQ

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NURS 675 Electronic Health Record (EHR) System DQ

NURS 675 Electronic Health Record (EHR) System DQ

What electronic health record (EHR) system does your
facility use? How long has it been in place? How was it chosen as the preferred
system? What type of struggles occurred during implementation? Now that it is
functional, what does the staff view as both pluses and minuses to this
particular system?

What is an Electronic Health Record

An Electronic Health Record is computer software used to capture, store, and share patient data in a structured way. An EHR is able to share medical information among all the authorized parties involved in the patient’s care: clinicians, labs, pharmacies, emergency facilities, nursing homes, state registries, and patients themselves.

The first EHR prototype called a Problem-Oriented Medical Record appeared 50 years ago. It consisted of a database of a patient’s complete clinical history, a problem list with the patient’s medical complaints, initial plan of care in which a doctor decides what to do about the problem, daily progress notes, and a discharge summary that tells about the fullest resolution of a problem emphasizing the remaining concerns.

Today EHR software is beyond basic record management. With helpful practice and revenue management tools, EHR is turning into a comprehensive clinic management system. Nabil Manzoor, an expert with over 15 years in healthcare consulting and a founding member of the Healthcare Blockchain Working Group INATBA, considers it a fundamental principle: “EHR should manage all the operations from the frontline care to the back office. It shouldn’t be just sorting out the bedside processes in isolation but rather linking them with the back office so that everyone is on the same page being equally informed.”

EHR Workflow

EHR exists to support the workflow already present in the clinic. It also implies the connectivity between all members of the patient care environment. What are these members and how does EHR help them?

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Patient. A patient wants to see a doctor. First, he or she needs to register at the clinic. It can be done either via a self-service check-in kiosk or at the front desk. There, a patient fills in their details including their history of present illness, allergies, treatment taken, as well as billing details. On registering, a patient gets an account at the patient portal where he or she will be able to view the summary of the visits, request appointments, etc.

Front office. A receptionist makes an appointment for a patient with a doctor in the centralized scheduling module. The system automatically accommodates each doctor’s workflow and distributes patient queues considering multiple sources: online scheduling, check-in counters, and reception desks.

Physician. Then, a physician is notified of the upcoming appointment. He or she can access the patient’s demographics, medical history, and symptoms in the patient chart. After the consultation, real or virtual, a doctor enters a clinical note from the visit into the practice’s EHR system including the diagnoses, prescription, and further instructions. Later, a nurse, therapist, or another physician can look up the note to carry out the necessary procedures.

Pharmacy. A prescription is transmitted to the pharmacy to order drugs. Then, a patient can pick them up at the pharmacy directly reducing the wait time.

Finance department. Based on the visit, the finance department uses the billing module to generate an invoice for the patient.

Insurance company. The EHR’s billing module then prepares an insurance claim. First, it checks it for errors at the clearinghouse, reformats the claim to match the insurer’s standards, and then sends the claim to the insurer to cover the expenses.

Labs. As an EHR is integrated with labs using HL7 standards, a physician can make direct lab requests to receive a patient’s results for review.

Post encounter, a patient can proceed to see a number of other doctors or specialists for further analysis and treatment. Each visit will generate its own record in that doctor’s separate EHR system. If these systems don’t talk to each other, the patient’s data remains fragmented across many data capture systems. This raises another question: how to link a patient’s disparate records from different facilities?

Interoperability among different EHR systems

Directed Exchange. Under the HIPAA Security Rule, an electronic health information exchange must ensure the confidentiality, integrity, and technical safety of patient information. So, healthcare providers use the Directed Exchange method that allows them to be compliant with HIPAA. DE is a secure email-based solution available within a certified EHR and it always has a specific sender and a designated receiver. Connected via Directed Exchange, EHRs enable physicians to share messages, attach information in interoperable formats, electronically manage referrals, etc.

Health information exchange organization. HIE is a secure central repository of patient data aggregated across multiple facilities and EHR systems. So, a participating provider can send out a query asking other connected EHRs whether they have information on a specific patient.

Health information exchange among the providers through an HIE, on the example of the West Virginia Health Information Network (WVHIN)

Health information exchange among the providers through an HIE, on the example of the West Virginia Health Information Network (WVHIN)

Patient matching algorithms. EHR’s automated algorithms match the records from different authorities comparing demographic data and making sure they refer to the same patient. Variations in the patient demographics formatting among systems can hinder accurate matches. That’s why ONC recommends standardizing demographic data and requires using the following elements for matching: address, name, birthdate, phone number, and sex. Using an email address or mother’s maiden name also contributes to the accuracy of matching.

EHR vs EMR

Talking about EHR, we can’t help mentioning Electronic Medical Records. EMR is a digitalized patient’s chart from a single provider or clinic. Its primary focus is on making the right diagnosis, prescribing necessary treatment, and monitoring patient’s medical state. An EMR system is designed to keep health information locally and isn’t intended for distribution outside the individual practice.

Though frequently EMR and EHR terms are used interchangeably, the Office of the National Coordinator of Health Information Technology (ONC) highlights the significant difference they have: EMR lacks interoperability which is the priority for EHR systems.

Next, we’ll tell you about the EHR features, key vendors, and how to navigate among this pool of offerings toward the implementation of the EHR system that will serve your unique operational needs.

EHR features and modules – how are they important?

EHR isn’t just a repository for digitized health records. It puts a patient’s information to work. “The simplest value chain of an EHR is capturing patient’s data, analyzing it, and providing insight for a clinician,” sums up Nabil Manzoor.

At the same time, EHR must ensure patient data protection. It should authenticate users and/or entities and determine their levels of access. EHR safeguards a patient’s details against potential threats and data loss with automatic data backups, automatic log-offs, data encryption, audit trails, access control, secure messaging system, etc.

Now we’ll describe the building blocks of an EHR system that manage operations from the front office to the finance department.

Front office management

Schedule management. The EHR provides the necessary data to a scheduling system to make an optimal agenda and keep up with it.

Patient scheduling dashboard

Patient scheduling dashboard, Source: AdvancedMD

Patient tracking. EHR can manage patient status, providing the front desk with their rooming updates, sending wait notifications, analyzing peak times, etc.

Task assignment and prioritization. EHR directs the flow of work assignments, delegation and transmission of tasks to the appropriate parties. Further, the system tracks tasks to guarantee they’ve been carried out and completed appropriately.

Generation of clinical documentation. EHR provides tools to build patient-specific care plans, organizational guidelines, and protocols to manage patient care and support order entry.

Reputation management. This feature performs ongoing satisfaction tracking and analysis, notifying of any disappointments a patient has experienced.

Physician support

Patient chart. EHR groups patient’s health information in an electronic chart. Accessing a patient’s chart, a doctor gets summarized data including patient demographics, immunization dates, allergies, medical history, lab and test results, radiology images, vital signs, prescribed medications, and current health problems along with the health insurance plan and billing details.

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