Electronic Health Record (EHR)

Amy Konow

Monmouth University

Health Information Technology for Economic and Clinical Health

(HITECH) ACT• Title XIII of the American Recovery and

Reinvestment Act• Healthcare organization can qualify for

healthcare incentives based on level of meaningful use achieved

Electronic Health Record (HER)

• Computer based data regarding the health status of a client• Replacing paper based medical record• Can be processed, stored, transmitted, and accessed by authorized

professionals • Purpose is to provide efficient high-quality health care access across

the continuum

8 Components of the EHR

• Health information and data• Results management• Order entry management• Decision support• Electronic communication and connectivity• Patient support• Administrative processes• Reporting and population health management

H e a l t h I n f o r m a t i o n a n d Da t a• Patient data required to make sound

clinical decisions • Demographics• Medical and nursing diagnosis• Medication lists• Test results

Results Management• Ability to manage results of all types

electronically• Laboratory and radiology procedure

reports

Order Data Management• Ability of a clinician to enter orders

such as medications, laboratory, radiology, nursing, supplies, and consultations into the computer

Decision Support

• Computer reminders and alerts to improve the diagnosis and care of a patient• Screening for correct drug selection and dosing• Screening for medication interactions with other medications• Preventative health reminders such as vaccinations• Health risk screening and detection• Clinical guidelines for patient disease treatment

Electronic Communication and Connectivity

• Online communication between healthcare team members, their care partners, and patients

• Email• Web messaging• Integrated health record across the continuum of

care

Patient Support

• Patient education • Self-monitoring tools• Interactive computer-based patient education• Home telemonitoring• Telehealth systems

Administrative Processes

• Electronic scheduling, billing and claims management system

• Inpatient and outpatient visits and procedures• Electronic insurance eligibility validation• Claim authorization and prior approval• Identification of research study participation• Drug recall and support

Reporting and Population Health Management

• Data collection tools to support reporting requirements

• Standardized terminology• Machine-reliable format

Advantages of EHR

• Increased delivery of guidelines-based care• Enhanced capacity to perform surveillance

and monitoring for disease conditions• Reduction in medication errors• Decreased use of care

Reference

McGonigle, D., & Mastrian, K. (2015). Nursing informatics and the foundation of knowledge(3rd ed.). Sudbury, Mass.: Jones and Bartlett.