The Electronic Health Record

Presented by:
Amanda Foster,
Erin Frankenberger,
Amy Larrabee,
& Michelle Wisniewski

Electronic Health Record

An Electronic Health Record (EHR) is an

electronic record of health-related information
on an individual that conforms to nationally
recognized standards and that can be
created, managed, and consulted by
authorized clinicians and staff across more
than one health care organization (LaTour)

Benefits of the EHR

There are countless benefits to the
implementation of EHRs to an organization.
They include:
more available space due to the lack of physical paper
charts
patient records are more easily accessible
patient records can be accessed more quickly than an
actual paper chart
more accurate diagnoses
reduction in costs
the organization becomes more efficient
Reduction in the number of duplicate records

Benefits of the EHR

involving patients in their own health care
helping patients become more conscious about taking
preventative measures when it comes to their health
easier data retrieval for medical research

And the most important benefit of all:

the improvement of patient care

The Electronic Health Record

An electronic health record is not just a single
application but rather a complex collection of
hardware and software
EHRs are capable of communicating data
with many different sources, which include
administrative applications, financial systems,
practice management systems and ancillary
systems.
Ancillary systems include pharmacy systems,
laboratory systems and radiology systems.

Pharmacy Information Systems

Pharmacy Information Systems (PIS) are

ancillary systems that generate clinical
information
Functions of the PIS include drug ordering,
drug dispensing, drug dispensing,
maintaining the drug formulary, and billing
services.

Pharmacy Information Systems

PIS that are integrated with an

electronic health record are linked with
the healthcare organizations other
systems, such as CPOE
An integrated PIS offers improved data
management

Pharmacy Information Systems

A hospitals clinical pharmacy system
functions to receive medication orders, track
and maintain drug inventories, manage
pharmacy staff and monitor performance
quality
Unlike the hospital PIS, physicians offices do
not have clinical pharmacies, but rather write
prescriptions to be filled by retail pharmacies

Pharmacy Information Systems

Pharmacy Information System Applications:

Computerized provider order entry (CPOE)

e-Rx
Bar code medication administration records
Medication reconciliation systems
Automated drug dispensing

Pharmacy Information Systems

CPOE systems reduce medication errors

Eliminate illegible handwriting & transcription
errors
Allow for the transcription of medication orders
Identify drug allergies and drug contraindications

Physicians offices use e-Rx

write and transmit prescriptions to retail

pharmacies

Pharmacy Information Systems

Bar code medication administration records
(BC-MAR)
Patient is identified with a bar code wrist band
Patient receives matching packaged drugs
Ensures that 5 medication rights are followed

Medication reconciliation systems

Automatic review of patients medications upon
transfers and admissions across levels of care

Automated drug dispensing

Machines filled by the pharmacy that ensure the
availability of ordered drugs

Pharmacy Information Systems

An integrated pharmacy information system
allows for:
Physicians reviewing medication orders on mobile
devices at the patients bedside
Orders are transmitted to the pharmacy where
patient profiles are made and dispensing labels
are made
Automated updating of drug inventories
Automatic production of patient charges from their
medication orders
Tracking of medication errors

Laboratory Information Systems

Laboratory Information Systems (LIS)-one of
the most common computer applications
Two primary functions:
1) Automate test processes
2) Process laboratory data
LISs can be used independently or in conjunction
with lab automation systems

Laboratory Information Systems

Linking lab
instruments
directly to
computers

Results are
stored in patient
files and may be
printed or
viewed from
computer station

Calculations of
formulas are
performed

Signals from test

equipment are
captured

Converted to a
digitized format

Laboratory Information Systems

Common Functions of LIS include:

Recording test
Generating alerts for
requisitions
follow ups
Scheduling and tracking Providing summary
specimen collections
reports of tests
Recording results of
Monitor technician
completed tests
productivity
Producing reports to be
included in patient
records

Radiology Information Systems

The functions of Radiology Information
Systems (RIS) include:

record test requests

schedule procedures
record and report test results
generate charges
prepare management reports for the radiology
department

Radiology Information Systems

RISs allow clinicians to view x-rays, MRIs,

Pet Scans, sonograms and other imaging
techniques through the use of picture
archiving and communication systems
Picture archiving and communications
systems (PACS) are servers used to transmit,
store, retrieve and display digital images

Radiology Information Systems

PACS use the standard communication
protocols of imaging devices, which is called
digital imaging and communication in
medicine, or DICOM
PACS allows for the speedy transmission and
storage of digital images ensuring that
images are available when needed

EHR Systems Impact Reporting and

Improved Data Analysis and Audits
The EHR brings data together in one place,
ensuring easy access to the most current
information by all providers from various
locations at any given time.
Data is available, legible, and can be
extracted into various reports, audits, and
administrative alerts.

Reporting

Healthcare facilities can easily analyze and

evaluate clinical trends (such as antibiotic
usage or ordering of labs without documented
symptoms) to support the organization's
quality assurance and improvement
initiatives.

Reporting

Many EHRs can be programmed to run

specific audit checks on time frames specified
by the facility. These audits can include
documentation checks, integrity checks, and
user access audits for HIPAA compliance.

Security within the EHR

Enforced by using encryption- specifically
public key infrastructure (PKI)
Firewalls protect from outside unauthorized
users
Biometrics- ex: fingerprints to access the
Pyxis for medications
User names and passwords to sign into EHR
for all authorized users

Auditing
Audit trails: chronological set of records that
provide evidence of computer system
utilization
Can determine security violations
Identify areas of improvement
Included trigger flags for automatic review

Auditing
Suggested data elements to track activity in
HIS audit trails include:
1)
2)
3)
4)
5)
6)
7)
8)

Data and time of event

Patient identification
User identification
Access to device used
Type of action (view, read, print, update)
Identification of patient data access by category of content
Source of access and software application used
Reason for access by category (patient care, research, billing)

EHR Systems Impact Reimbursement

Having more precise and timely

documentation can lead to more accurate
billing and in turn more reimbursement for an
organization
Average billable gain of $26/patient
(HealthIT.gov)

Reimbursement

A clinical system that is fully integrated with

the financial system will further streamline
operations. Codes assigned by qualified HIM
professionals can be pulled directly to the
patient's bill for proper reimbursement.

Reimbursement
Clinical documentation can also link directly
to the billing operation (e.g., administration
and charting of vaccines or use of certain
wound supplies).

Linking this process with an effective data

analysis and audit process helps ensure
compliant billing.

References
Burke, L. & Weill, B. (2013). Information technology
for the health professions (4th Edition). PrenticeHall.
Glandon, G.L., Smaltz, D.H., & Slovensky, D.J.
(2008). Austin and boxermans information systems
for healthcare management. Chicago, IL: Health
Administration Press.
Latour, K.M. & Eichenwald-Maki, S. (2012). Health
information management: concepts, principles, and
practice. AHIMA

References
The Benefits of Electronic Health Records (EHRs).
HealthIT.gov. Retrieved from http://www.healthit.gov/
providers-professionals/benefits-electronic-healthrecords-ehrs