General Components of an EHR System

Keywords: electronic health record parts

Electronic health records and presents the advantages and benefits that will provide for hospitals and health institutions. Doctors, physicians, and nursing become an important factor of the EHR; Barbara A. Gabriel did a research to see whether electronic medical records made the doctors and the patient outcome better. Also Jeffrey Linder, an internist and assistant professor of medicine at Harvard Medical School asked these questions:” Does having an EMR really help you? Are patients more likely to get the tests they need, timely diagnoses, and proper treatments? Do you code more accurately now that your EMR is a part of your daily work flow? Does this result in higher reimbursements?” And for Doctors he asked in brief “Are you a better doctor – both clinically and operationally – with an EMR than you were without one?”These questions were asked by Jeffrey to improve his study that was about the relationship between electronic medical record usage and quality care.

A recognized supporter for electronic medical record implementation, he got the impression that made him strongly sure the answer to all these questions would be a resounding yes.

1.1 Definition of EHR:

EHR stand for Electronic Health Record according to the policy journal of health sphere. It accumulates patient health files in a computer database more willingly than with physical paper. The data that is accumulated in the computer is producing by several users in any care delivery institutions.

The data contains patient demographics, past health history, diseases, progress notes, very important signs, vaccinations, laboratory data and radiology repots. One of the elements of the Electronic Health Record is that it can generate a complete record of a clinical patient user consisting of quality management, outcomes reporting, and evidence-based decision. It is essential to state that an EHR is developed and maintained within organizations, like hospitals, integrated delivery network, clinics, or medical doctor offices.

• History of EHRs:

In the fifth century B.C the earliest health record was produced by Hippocrates. He put two main objectives:

1. “A medical record should accurately reflect the course of disease. “
2. “A medical record should indicate the probable cause of diseases”

These objectives are still proper, but the latest technology that identified as electronic medical record adds functionality, such as interactive flow sheets, interactive alerts to clinicians, and every feature that can not be made with manual system.

In 1960s: a problem-oriented medical record was planned by Dr. Lawrence weed which is a kind of EHRs. His aim was to provide better health care by integrated the medical data of patient from special doctors.

According to his idea, in 1970s the first Electronic Medical Record system established at the Vermont University. Its structure was uncomplicated, as it worked with touch-screen technology offered at the period to record procedures and various kind of pharmaceuticals used throughout those procedures.

In 1967: a premature Electronic Medical Record system was implemented and applied at the Latter Day Saints Hospital in Utah, this project was developed by (HELP) the Health Evaluation through Logical Processing.

In 1968: the Multiphasic Health Testing System (MHTS) and Computer-Stored Ambulatory Record (COSTAR) were produced

Until 1973: the MHTS was applied at Kaiser Permanente in San Francisco

Until 1980s: the COSTAR was applied at Massachusetts General Hospital in Boston

In 1973: the Regenstrief Electronic Medical Record program was applying in Indiana, and is yet in progress today.

2.2 Development:

In 1969: the initial main shift of manage patient information was completed with the Problem-Oriented Medical Record, making use of the so-called SOAP structure that included knowledge about the topic, the health goals, evaluation and a plan for the patient.

2.3 Technology:

In that time while a large amount of medical offices continue to accumulate patient data on paper using manual system in huge “Chart Libraries” where the system was used the alphabetical order, and some technological developments have made by medical imaging. The LanVision system catalogs logical images that have the ability to move without difficulty from one office to another on the system. The most important components of Electronic Medical Record applied in hospitals contain patient billing, pathology, radiology, admission, laboratory, scheduling, discharge and transfer, intensive care and Emergency Room units, pharmacology records, and the master Patient Index (MPI).

2.4 Government’s Role:

The federal government decides to set a time limit for computerized patient record system for 1999, but that time limit was neglected when groups disagreed with computerization on patient-privacy grounds. The group also mentioned the inability of programs to integrate images, texts and numbers, but all of these factors had definitely incorporated by latest computer programs.

Benefits of EMR:

Electronic Medical Record systems are much more fitting, important, and efficient than manual medical records, says the Mayo Clinic. Several Doctors have the ability to update patient record at the same time. Furthermore, Electronic Medical Record does not need huge capacity of space and manual work to record and accumulate data.

• Organization

The most important benefit of EMR is the way that a patient’s records can be managed and arranged. Paper records or files can simply be misplaced in a file room at the clinic, but an electronic medical record is accumulated on a network that is available throughout the service. Also IT professional are searching for the best way that connects the specialists with a network that give them the ability to treat the patient that are sent from another city.

• 2- Access

Physicians can access quickly to patient file using electronic medical record system. In each of the patients’ room and practice rooms there are computers that are provided with the facilities that are prepared with this technology. The patient’s record can be log on from any computers to update conditions, medications and procedures that have been performed on the patient.

• 3- Decision Support

Improved health decisions can be prepared for the patient, when his EMR is accessible by more than one physician. Repeatedly a patient is sent from physician to another when health problem appear to be dangerous or need to be diagnosed. These physicians may not have the ability to communicate or transmit the patient’s medical records to every facility. In this case, the patient can be subjected to repetitive or unwarranted actions because of the lack of transmission.

• 4- Standardization

Electronic medical record system will also provide better standardization once it takes place to keeping patient records throughout the health care system. Several medical services apply various terminologies for the similar procedures. Other services apply structures that are totally dissimilar from another facility’s. Electronic medical record system will make it easier for physicians and nurses to get the information they want for every patient by providing a standard way of filling out data on patient’s file.

• 5- Patients

A few Electronic medical record systems give the Patients the ability to log on their test results and other vital information from their health record through a protected site on the internet. This help patients better understand their health-care choice. Also the patients with restricted access to their personal Electronic medical record systems will be better notified and can be feasible with the decision that they require to generate.

Key Components of Electronic Health Records

Nearly all the commercial Electronic Health record system are made to merge data from the huge ancillary services, such as radiology, laboratory, and pharmacy with diverse health care components (for example medication administration records [MAR], nursing plans, and physician orders). The Electronic Health record possibly will bring in information from the ancillary system throughout a tradition interface or may provide interface for clinicians in order to log on the silo system through a portal.

• Administrative System Components

The main components of electronic health record are registration, admissions, discharge, and transfer (RADT) data. These data contain essential information for correct patient classification and evaluation, also it include name, demographics, next to skin, employer information, patient disposition, chief complaint, etc. the section of registration in electronic health record system has a unique patient identifier which generally consisting of numeric or alphanumeric order that is unidentifiable external the company or institution in which it serve. The medical data of the patient will be collected for use in medical analysis and research while use the RADT.

All medical observations, tests, procedures, criticisms, assessments, and diagnosis to patient will be linked by the patient ID because it is the core of the electronic health record.

The ID is sometimes known as medical record number or master patient index (MPI). Nowadays in computerized information systems the master patient index enterprise has applied extensively in the organizations or institutions, called enterprise-wide master patient indices.

• Laboratory System Components

Laboratory systems are interfaced to electronic health record systems which commonly are independent systems. Also there are (LIS) that stands for laboratory information system that are applied as centers or hubs to combined orders, schedules, billing, results from laboratory tools and other administrative data. Rarely laboratory information is integrated completely with the electronic health record. Lots of technologies and analyzers are applied in the diagnostic laboratory procedure when laboratory information system is prepared by the similar vendor as the electronic health record which is not simply integrated with electronic health record, such as the Cerner laboratory information system interface with more than 400 various laboratory tools. Cerner, a very important vendor of both systems the (laboratory information system) & (electronic health record system), stated that 60 percent of laboratory information system installations were not included with electronic health record system, and electronic health record system are implemented in federal form, which lets the user to log on the laboratory information system from a link within the electronic health record system interface.

6.3 Record keeping and mobility

Electronic health record systems gain a unique trait which is the benefit of being capable to connect to various EHR systems. Patients are shopping for their procedures, in the recent global medical environment. Also patients can easily check in their files whether they have been admitted to such a health center or if they contain any kind of allergies since they have been admitted before.

• Other Advantages of Electronic Medical Records Software

Chart Room. By converting a paper chart digital, a procedure can change the physical place of a chart room into workplaces, or extra rooms for exams, procedures, imaging equipment, labs, or other income generating spaces.

Managing Paper. A lot of procedures waste numerous hours of workers time searching for, moving, and organizing paper charts. By computerizing the health record, this procedure is rationalized and costs are eliminated. Other cost savings are achieved by the elimination of the paper, printers, toner, and other physical costs of the paper world.

Archived Records. Health practices are needed to remain patients’ health record for 7 years in nearly all countries. Accumulated an inactive patient’s chart offsite is a shared procedures. This cost is eliminated by accumulating the reports electronically.

There are more advantages of an entire EHR, which both Chart Logic EMR and Chart Logic iAchieve electronic medical record consist of:

Best Practices. By integrated a model based health office software; a medical procedures may ensure that all providers are achieving the needed goals of documentation and process.

Increased Reimbursement. The E&M coding tool can also indicate methods to properly up-code your document to a higher level, rising reimbursement.

Efficient Charting. Using templates lets the physician to finish documentation rapidly. By tinplating shared words or phrases, the documentation is quick, reliable, correct, and complete.

Cost and return on investment

It is not easy to measure the return of investment (ROI) of information technology systems for any commerce. Nearly all research has been alert on how to calculate the return of investment for medical information technology systems such as electronic health record systems.

The cost of implementing the EHRs will differ considerably; depending on what systems are now in place and what is being implemented. Fundamentally, in order to smooth integration and make customer commitment the vendors add the electronic health record capabilities at a favorable rate. However, there are installations that can be very expensive, e.g. Across the whole Kaiser Permanente network the roll out of an Electronic Medical Record was reported to cost over $1 billion.

A new American Hospital Association analysis and survey noticed that the median yearly funds investment on information technology was greater that $700,000 and stand for 15 percent of all fund expenses. And above $1.7 million were the Operating expenses, or 2 percent of all operating expenses.

Barriers to using EMR

• Technical Barriers

It is expensive to implement an Electronic Medical Record system in a physician’s office, mainly for minor practices. Moreover, install such a system in minor hospital institutions require external industrial support.

• Cultural Barriers

According to “For the Record Magazine” the patients and doctors could feel unsafe risking patient MRs to possible electronic theft. Furthermore, an Electronic Medical Record will extensively change a physicians flow and potentially decrease the quality of service the doctor provides by giving him more patients, however, before physicians expected a specific amount of work flow, because they were spending time filling out paperwork.

• Significance

According to Robert H Miller and Ida Sim of the Policy Journal of health Sphere In 2004 just 13 percent of physicians stated that using an Electronic Medical Record and 32 percent said they would consider as using an electronic filing system.

EHRs keep your health information safe and private:

You can choose and decide who gets to see your information:

EHRs are “locked”. Nobody can access your account except you because there is a special password that will keep your health information private.

EHRs have many security settings. The only ones that can access to your information and can see them your health provider, and the office staff can only see your name, address and birth date.

Whether or not your health care provider uses EHRs, you sign a consent form if you want to share your information. Ask your doctor for a copy of your consent and explanation of what it means

Private notes can be made in EHRs that only your health care provider can view. The patient can ask his doctor to see his information and tell him don’t let anyone else see them and keep them in secure that only you can read.

• Electronic Software

People go to hospitals to better their state; they rely on hospitals and physicians to practice the most advanced standards. The staff that works at the hospital faces many challenges at the day. They need highly efficient software and instrument to work properly and to finish their jobs requirements. Electronic software helps them meet the demands of the hospitals setting. In order to make sure that the health practice takes care of its operations in a prepared and well-coordinated manner Electronic Medical Record (EMR) Software is essential. The cost is around $850 dollars for setup and about $2500 for annual maintenance but is worth it for the reason that they save time and run the operations using the best defense mechanisms against liabilities electronic medical record software is used to manage and maintain EMR systems, patient or insurance billing, patient information management, multi-provider scheduling, electronic faxing, instructions and lab management, document management, and custom report templates.

And an example of that software is a Visionary Dream EHRs

• Dream EHR Workflow

When converting from a paper-based organization to a nearly paperless organization planning, preparation, training and a person within the office to make easy the change is an essential.

A process that relies on an electronic health record, the visual signs are on the desktop computer or tablet PC screen rather than placed on the wall or taking up space in the records room. Shifting from a paper-based practice to an electronic health record provides the process with the opportunity to assess its workflow for an electronic environment. Several administrative and operational steps may be considerably simplified. The workflow steps in an electronic health record can be decreased significantly.

The workflow in the health office has two main categories: administrative and clinical. Let’s have a look at some administrative and clinical workflow procedures so you can evaluate how the work flows in a paper-based environment and what that similar workflow procedure looks like in an electronic environment.

• Paper-based Environment
• Electronic-based Environment

Patient comes, signs in

Patient comes and enters new data into electronic health record desktop

Patients name be seen

Administrative employee is gave notice that patient has came and patient’s MR are got over from the procedure management scheduler and prepared for the day’s appointments.

Receptionist confirm for scheduled appointment

Receptionist greets patient, checks updates and sends record electronically to nurse’s in-box.

Receptionist asks for updated personal and insurance information

Patient’s record is into nurse’s in-box.

Patient returns data form with updates

Nurse calls patient into examination room, release patient records, takes and check in family history, medications, vitals, presenting symptoms, and makes a face sheet on the Tablet PC.

Medical records clerk drags chart and insert updated data.

Once done, nurse sends MR electronically into physician’s in-box.

Clerk gives chart to nurse

Patient’s file is in physician’s in-box. The doctor can look at this file before to entering the examination room.

Chart is located in nurse’s review stack

Physician enters the examination room and visits with patient.

Nurse checks chart and calls patient

Nurse captures crucial signs and files show symptoms on face sheet.

Nurse places medical chart out of examination room door.

Doctor looks into medical chart on door, knows that patient is waiting and checks information on face sheet.

physician enters and visits with patient

Features and Software Screens

Point-and-Click Chart Entry

Rapidly capture and produce chart notes with pre-defined medical templates. It presents hundreds of specialty templates to lessen the operation time.

Check chart notes, allergies, medications, procedures, diagnoses and further in one simple to navigate screen.

Customizable, user-definable chart areas.

Easy to Use

Files with electronic handwriting stylus pen, pre-defined or user defined templates, macros and / or voice dictation.

View or edit patient information from a desktop or tablet PC.

Simple direction-finding menu is planned to raise usage speed while streamlining the information recording process.

Point-of-Care Decision Making

Manage your reports with quick chart access and file patient documentation at the point-of-care.

One-click retrieval of patient notes, medications and very important documentation to assure the greatest medical decision.

Managing Orders / Lab Tracking

Check and get back test results, makes orders, doctor consultations or surgical procedures immediately from the patient’s chart.

Track past due lab tests and procedures as well as inform users through e-mail.

Lab results review reports feature side-by-side history of results and permits inter office lab result communications.

Differential Diagnosis

Simply file one or more differentials associated with a diagnosis.

This module can in addition be used to rapidly replace with a specific diagnosis for a non-billable or non-specific code.

Furthermore diagnosis connected practical codes, prescriptions and lab orders can be selected while seeing that diagnosis.

Coding Assistance