E lectronic M edical R ecord ( EMR )

1. Electronic Medical Record (EMR)

2. Presentation Q&A Agenda

3. An electronic medical record (EMR) is a digital version of the patient-specific medical information that is traditionally kept in a paper "chart" or medical record What is EMR?

4. Provide the electronic equivalent of the patient chart Bring together all of the data about a patient into a single source Support patient care and improve its quality Support and enhance physician decision making Purpose of EMR

5. HL7 Health Insurance Portability and Accountability Act (HIPAA) Digital Image Communications in Medicine (DICOM) Systematized Nomenclature Of Medicine (SNOMED) Logical Observation Identifier Names & Codes (LOINC) ICD 9CM and CPT Healthcare Standards - EMR

6. OPEMR Scanning Drawing EMR interface Drug Formulary IPEMR EMR Application scope

7. Appointment List Case Summary History Examination Specialty workups Advice Referrals OP Procedure requests and results Lab requests and results Out Patient (OP) EMR

8. Drawing Application • Windows Based Tablet PC application • Integrated with EMR Web application • Uploads the drawing to the file server • Features • Template based Drawing • Different Pen colors • Varying Pen Width • Different Fill Pattern (Hash pattern, Solid pattern…) • Transparency • Eraser facility • Viewable in web browser

9. IP EMR Anesthesia details Physician’s fitness Surgery notes Progress notes Nursing notes Drug Formulary Allergy Drug to drug interactions MIS Inpatient (IP) EMR

10. Windows Based Application Uploads scanned files to the file server Files uploaded Patient manual records (existing patient record) Referral letters Report of tests performed in another hospital ( CT Scan, MRI Scan...) Scanned images of test performed in the hospital (ERG, EOG…) Scan Application

11. Interface with Lab equipments Serial port RS-232 interface Bi-directional communications Eliminates data entry error Equipment Interface

12. Picture Archiving and Communication System (PACS) is a comprehensive computer system that is responsible for the electronic storage and distribution of medical images in the medical enterprise. The system is highly integrated with digital acquisition and display devices and is often related closely to other medical information systems, such as the radiology information system or hospital information system PACS

13. Imaging Interface

14. HMS RFID Medical Transcription Equipment Interface EMR Interfaces EMR Document Scanning system Telemedicine

15. Protected Health Information Information that relates to patient past, present, or future, physical or mental health or condition of an individual Information regarding payment for the healthcare to an individual Information regarding the delivery of health services Information is or can be reasonably identifiable Information is transmitted or held in electronic form or any other form or medium, including paper Data Privacy

16. What Is C,I,A Confidentiality (only the right people see it) Integrity (the information is what it is supposed to be – it hasn’t been changed) Availability (the right people can see it when needed) Data Security

17. Administrative Safeguards Security management process Assigned security responsibility Workforce security Information access management Security awareness training Security incident procedures Contingency plan Evaluation Business associate contracts & others Physical Safeguards Facility access controls Workstation use Workstation security Device and media controls Technical Safeguards Access controls Audit controls Integrity Person or entity authentication Transmission security Data Security

18. Thank You!