HI- Ch 5

What are the key considerations to keep in mind in the development of the personal health record (PHR) and what goals should a PHR accomplish?

-Considerations- a. Eases the transition from paper to electronic record keeping b. Allows the patient to refill prescriptions electronically c. Addresses health literacy skills (reading and writing) in the context of language and culture d. Is designed so that interfaces are patient-friendly e. Can custom tailor views f. Enables information sharing among patient and providers g. Is portable and remains with the patient h. Helps organize personal health information i. Assists patients with decision making, wellness, self-care plans, and patient safety alerts -GOALS- a. To increase public awareness and understanding of the issues surrounding personal health information and health records. b. To provide individuals with the information they need to better manage their personal health information and to encourage them to maintain a PHR to improve the quality of care they receive. c. To create greater public awareness of the HIM professional and the important role HIM professionals play in effective management of personal health information needed to deliver quality health care to the public.

Explain the difference between the legal health record and a designated record set.

Legal health record is used to substantiate the care given for reimbursement and quality proposes. It is also a legal document that confirms whether treatment was delivered in a manner appropriate for the given health problem, is used to show proof in a court of law. A designated record set includes the records that contain protected health information maintained by or for a covered entity. This is basically just the health record and all of its contents for proper record and billing purposes.

Provide definitions for the following abbreviations:

a. HL7 - Health Level 7 b. ONCHIT - Office of the National Coordinator of Health Information Technology c. PHR - Personal Health Record d. SNOMED - Systematized Nomenclature of Human and Veterinary Medicine e. UHDDS - Uniform Hospital Discharge Data Set f. HITECH - Health Information Technology for Economic and Clinical Health g. HRSA - Health Resources and Services Administration h. CCHIT - Commission of Certification of Health Information Technology i. HIE - Health Information Exchange j. ASTM - American Society for Testing and Materials k. HIMSS - Health Information Management Systems Society

In 2003, the IOM issued a report "Key Capabilities of an EHR System" calling for basic functions or applications to be included in EHR systems. Please list these applications and briefly provide a description of each.

a. Health information and data- central repository for patients' data from a variety of sources b. Results management- from diagnostic tests c. Order entry/management- order tests and prescribe medications and treatments d. Decision support- help clinicians manage care through evidence-based guidelines e. Electronic communication and connectivity- communicate among providers and resources to coordinate care f. Patient support- offer education for the patients g. Administrative processes- better scheduling and billing h. Reporting and population health management- report infections disease, support epidemiology research

What is bedside documentation? How does it contribute to increased efficiency for nursing personnel and better documentation for patient records?

a. It is software and hardware located at the patient's bedside that encourages recording of information about patient care at or near the time of its delivery.

Discuss how the basic limitations of the paper patient medical record can be addressed through an electronic health record system.

a. Paper records cannot meet the needs of complex care environments and their use is becoming unrealistic in the presence of pressures to control operational costs and deliver information effectively. An EHR system can address a multitude of issues that come with paper records. Rapid access to various test results, style and completeness of the record, access to an aggregate form of the health record versus just a chronological style, and new resources to both internal and external studies of patient care. These all will help patient care to be more thorough, consistent, and efficient. The above listed pros of the EHR are where the paper record falls short or inhibits the access and ease of patient care through this method of recording.

The EHR enhances the capacity to use and work with data. Describe some of the administrative uses and benefits of an EHR system.

a. Patient registration b. Master patient index maintenance c. Scheduling d. Referral management e. Record and document completion f. Disease and procedure coding g. Revenue cycle management h. Data analysis i. Abstracting j. Billing k. Financial processing l. Auditing access to the record m. Handling requests for data from patient records n. Quality improvement studies o. Providing internal and external reports

Documentation standards remain the same for both manual and electronic health records. List these important documentation principles.

a. Unique patient identification b. Legibility c. Accuracy d. Completeness e. Timeliness f. Integrity g. Authentication h. Privacy, confidentiality, and security