EHR history and what it is

Chp-4 Hoyt

What is an Electronic Health Record (EHR)?

Computerized record of patient's history and care across all facilities and admissions

What is the main purpose of an EHR?

To store, manage, and share patient health information electronically

What does "real-time" mean in EHR?

Information is updated and available immediately

What is a major problem with paper records?

They are hard to share between providers

Why is handwriting an issue in paper records?

It can be illegible and cause medical errors

How do EHRs improve access to patient data?

They allow instant retrieval of records

How do EHRs improve patient safety?

By reducing errors and providing alerts

How do EHRs improve efficiency?

Faster workflows and less duplicate testing

How do EHRs help communication?

They allow multiple providers to access the same patient record

How do EHRs reduce costs?

By preventing duplicate tests and improving billing accuracy

What basic information is included in an EHR?

Demographics, medical history, medications, allergies, lab results, and notes

What type of results are stored in an EHR?

Lab tests and imaging results

What are clinical notes?

Documentation written by healthcare providers about patient care

What is CDSS?

Clinical Decision Support System that provides alerts and recommendations

Give an example of CDSS.

Warning about drug interactions

what is CPOE

Computerized Provider Order Entry

What does CPOE do?

Allows doctors to enter orders (medications, tests) electronically

Why is CPOE important?

It reduces errors from handwriting

What does "S" stand for in SOAP?

Subjective, what the pt says

What does "O" stand for in SOAP?

Objective (what is observed/measured)

What does "A" stand for in SOAP?

Assessment (diagnosis)

What does "P" stand for in SOAP?

Plan (treatment)

What is the HITECH Act?

A law that promotes the adoption of EHRs

What did the HITECH Act provide?

Incentives and penalties related to EHR use

What is ARRA?

A 2009 law that included the HITECH Act, reduce papers

What is Meaningful Use?

-an incentive program to encourage the adoption of EHR

What is the goal of Meaningful Use?

Improve quality, safety, and efficiency of healthcare

What is a major disadvantage of EHRs?

High cost

Why do staff resist EHRs?

require training and change workflows

What is a security concern with EHRs?

pt data privacy and potential breaches

When did EHR development begin?

40 yrs ago

Why were early EHR systems unsuccessful?

Infelxable and hard to use