Electronic Health Record

Agenda
 Introduction
 Role of HER
 Data Components documented in EHRs
 Tools of HER
 Technologies Involved in HER
 Benefits of HER
 Drawbacks

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 Electronic Health Record
(EHR)
 Electronic health record is the electronic
version of the client data found in the
traditional paper record

 EHRs are defined as “ a longitudinal

electronic record of patients health
information generated by one or more
encounters in any case delivery setting.

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 Role Of EHR
 Represnts patients health history
 Medium of communication among
health care practitioners
 Legal document for health care
 Source for clinical outcomes and
health services research
 Resource for practitioner education
 Alerts, Reminders, Quality
improvement

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Data components documented in EHR
An electronic health record should contain important data such as:

• Patient profile and demographics

• Medical History
• Medicine taken and its compatibility with drug interaction
• Records of appointment
• Admission nursing note,
• Daily charting
• Physical assessment
• Present complaints (e.g symptoms)
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Cont.…
• Diagnoses, test procedures, treatment
• Nursing care plan
• Medication administration, progress notes
• Laboratory data, and radiology reports
• Referral
• Discharge history
• Billing records

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 Tools of EHR
• Clinical decision support system( CDSS)

• Computerized physician order entry (CPOE) systems

• Health information exchange (HIE)

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1. Clinical decision support system( CDSS)

› A CDS system is software that assists the provider in making

decisions with regard to patient care

› CDSS provides physicians and nurses with real-time

diagnostic and treatment recommendations

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Functions of CDSS
› Managing clinical complexities
› Monitoring medication errors
› Avoiding duplicate and unnecessary tests
› Supporting clinical diagnosis & treatment plan processes
› Promoting the use of best practices & condition specific
guidelines
› Population-based management
› Providing the latest information about a drug
› Cross-referencing a patient allergy to a medication
› Alerts for drug interactions and other potential patient issues

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2. Computerized physician order entry (CPOE)
COPE is a computer application that accepts physician orders
such as :
• Medication
• Lab test
• Nursing orders
• Involves electronic communication of orders
• consultation

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3. Health information exchange

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 Benefit
• Sharing of patient information
• Reduce Cost Of tests
• HIE Facilitates the exchange of
this information via EHRs, which
can result in much more cost-
effective and higher-Quality care

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 Technologies Involved in EHR
› Picture Archiving and communications system
› Bar Coding
› Radio Frequency Identification
› Automated Dispensing medicines
› Electronic medication administration records

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Picture Archiving and Communications system

This system electronically stores images and

reports, instead of using the old method of
manually filing, retrieving, and transporting
film jackets, which are used for storing X-ray
film

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Bar Coding

• It consists of a bar code reader, a

portable computer with a wireless
connection.
• The nurse can verify patients as well
as drugs

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Radio Frequency Identification

• The technology tracks patients

throughout the hospital, and links
lab and medication tracking
through a wireless
communications system

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Automated Dispensing medicines

Automated dispensing medicines are

computerized drug storage devices
that allow medications to be stored
and dispensed near the point of care
while controlling and tracking the
drug distribution

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Electronic medication administration records

The EMAR alters the nurse about the next dose or

cautions about the medications

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 Benefits of EHRs
• Improved access to the medical record
• Decreased time spent in documentation
• Increased time for client care
• Improved quality care.
• Facilitation of data collection for research
• Improved communication and decreased potential for error

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 Drawbacks
• Financial issues
• Changes in workflow
• Temporary loss of productivity associated with HER
adoption
• Privacy and Security concerns

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THANKS!

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