Chapter 1

1. Electronic Health Records for Allied Health Careers Cover goes here when ready Chapter 1 Introduction to Electronic Health Records

2. Learning Outcomes After studying this chapter, you should be able to: List three reasons why paper-based medical records are no longer adequate. Discuss the economic pressures forcing changes in the health care system. Describe the role of the government in bringing about changes in the health care system. Explain the differences between electronic medical records, electronic health records, and personal health records. Compare the content of a medical record in ambulatory and acute care settings.

3. After studying this chapter, you should be able to: List the eight core functions of an electronic health record. Describe the advantages of electronic health records. Explain the issues surrounding the implementation of electronic health records. Explain how electronic health records will affect existing jobs in allied health as well as create new jobs. Learning Outcomes

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. Some Definitions Electronic medical record Electronic health record Personal health record

17. Contents of a Health Record acute care ambulatory care

18. The Purpose and Use of Health Records Primary Purpose To assist health care professionals in providing the most effective patient care.

19. The Purpose and Use of Health Records Secondary Uses Billing and Reimbursement Legal Issues Quality Review Research Education Public Health and Homeland Security Credentialing

20. Core Functions of an Electronic Health Record System Health Information and Data Results Management Order Management Decision Support Electronic Communication and Connectivity Patient Support Administrative Processes Reporting and Population Management

21. Advantages of Electronic Health Records Safety Quality Efficiency Future Cost Reduction

22. Implementation Issues Cost Lack of Standards Learning Curve Workflow Changes Changes in the Software Market Privacy and Security Risks

23. 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).

24. 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)

25. 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.