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Electronic Medical Records

  1. Electronic Medical Records Dr. S. A. Tabish
  2. What is EHR? • An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care.
  3. EHR • ISO TC 215 defines an EHR as “a healthcare record in computer processable format.” EHRs are a vital part of health IT and can: • Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results • Allow access to evidence-based tools that providers can use to make decisions about a patient’s care • Automate and streamline provider workflow
  4. Electronic Health Record (EHR): • An electronic version of a patients medical history, that is maintained by the provider over time,and may include all of the key administrative clinical data relevant to that persons care under a particular provider, includingdemographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiologyreports.
  5. Electronic medical record • Should document history, examination, diagnoses intuitively, rapidly, efficiently • Should automate tests, medication, submission of diagnostic / procedure codes • Should include error checking rules to avert allergies / cross reactions
  6. Electronic Medical Record • An EMR contains the results of clinical and administrative encounters between a provider (physician, nurse, telephone triage nurse, and others) and a patient that occur during episodes of patient care. Consequently, the EMR reflects the practice style, job function, knowledge and skill of the providers who create it. It necessarily includes data structures and data elements that reflect those providers' systems. • The Institute of Medicine defined the basic functions of an EMR, then known as the computer-based patient record (CPR). The Institute of Medicine's definition remains the gold standard
  7. Electronic medical record • Evaluation and Management (E & M) electronic guidelines should be built into the code system • Should be compliant with HIPAA policies
  8. EHR • One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one health care organization. • EHRs are built to share information with other health care providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care.
  9. EHR Scope • EHR contain patient-level data collected during and for clinical care. Data within the electronic health record include diagnostic billing codes, procedure codes, vital signs, laboratory test results, clinical imaging, and physician notes. With repeated clinic visits, these data are longitudinal, providing valuable information on disease development, progression, and response to treatment or intervention strategies. The nearly universal adoption of EHRs nationally has the potential to provide population-scale real-world clinical data accessible for biomedical research, including genetic association studies
  10. EHR System Functions • Identify and maintain a patient record • manage patient demographics • manage problem lists • manage medication lists • manage patient history • manage clinical documents and notes • capture external clinical documents • present care plans, guidelines, and protocols • manage guidelines, protocols and patient-specific care plans • generate and record patient-specific instructions
  11. Requirements of EHR • EHRs must include the following assumptions: • The relevant information of general interest should always be present, easy to access and extract from the general information. This is the case for both family and personal histories that are kept and increase/are added to over time so they can be used to inform clinical decisions, regardless of where they take place. • The limited temporal information generated in isolated events may be well supported in closed electronic documents. These documents may contain the particularities of each specialty or service provided, in terms of design and functionality, as part of each care episode.
  12. EMR Inter-relationships
  13. Framework of EMR solutions
  14. Stages of EMR complexity 1 2 3 0 eMAR CDR is the central pivot
  15. EMR – Nuesoft Xpress
  16. ChiroChart EMR – MediPro
  17. EMR frontscreen – MediNotes
  18. EMR – FileMed
  19. EMR – NextGen
  20. EMR face sheet – AMBAS
  21. EMR progress notes – AMBAS
  22. EMR configuration – AMBAS
  23. MedicsDocAsst EMR – ADS
  24. MedicsDocAsst EMR – ADS
  25. EMR – Medinformatix
  26. RTS EMR – Customized page
  27. RTS EMR – Electronic sign
  28. Automated patient q’aire – ADS
  29. MDA Int Medicine EMR – ADS
  30. Cardiology EMR – MDS
  31. Pediatric EMR – MDS Medical
  32. Pediatric EMR – MDS Medical
  33. Pediatric EMR – MDS Medical
  34. Oncology EMR – Synergy
  35. Oncology EMR (Patient chart)
  36. Oncology EMR (Complaints)
  37. Oncology EMR (Diagnosis)
  38. Oncology EMR (Staging)
  39. 3-D EMR Mapping Engine
  40. ‘Bugle’ patient database – ARG
  41. PMS – Nuesoft Xpress
  42. PMS patient info – AMBAS
  43. PMS scheduler – AMBAS
  44. PMS online charge slip – AMBAS
  45. PMS + EMR – MedInformatix
  46. EPM appointment scheduling
  47. Automated docu distribution
  48. Accounts – Medinformatix
  49. Collections – Medinformatix
  50. Automated remittance module
  51. ADS MedicsElite – PDA access
  52. EMR data entry in PDA
  53. Conclusion • EMR is not about just installing a few computers and storing patient data • EMR has to be integrated with PMS / EPM • EMR is all about automating WORKFLOW process
  54. Automated clinical workflow
  55. Automated clinical workflow
  56. Automated clinical workflow
  57. Nature of big data in healthcare • Electronic health record (EHR) can empower progressed appraisal and offer assistance to clinical fundamental organization by giving colossal information
  58. Conclusion •EMR is ultimately geared towards reducing errors, improving safety and care and cutting costs of healthcare