Chapter 1. History and Evolution of Electronic Health Records
History of Electronic Health Records
Institute of Medicine (IOM)
Computer-based Patient Record Institute (CPRI)
Health Insurance Portability and Accountability Act (HIPAA)
EHR Defined
Social Forces Driving EHR Adoption
Health Safety
Health Costs
Changing Society
Group Discussion Topic: EHR News
Forces Driving EHR Evolution
Office of National Coordinator for Health Information Technology
Strategic Framework
Federal Health IT Strategic Plan
The HITECH Act
Strategic Plan Updates
Meaningful Use of a Certified EHR
Certified EHR
Meaningful Use and Clinical Quality Measures
EHR Adoption After HITECH
Why Interoperability Is Important
Group Discussion Topic: When the Chart Is Lacking
Documenting at the Point of Care
Real-Life Story: Where's My Chart?
Flow of Clinical Information into the Chart
Workflow of an Office Using Paper Charts
Workflow of an Office Fully Using an EHR
Group Discussion About Workflow
Inpatient Charts versus Outpatient Charts
Patient Registration and Appointment Scheduling
Patient Administration
Tutorial Exercise 1A: Overview of a Patient Administration Module
Patient and Provider Scheduling
Tutorial Exercise 1B: Overview of a Scheduling Module
Chapter One Summary
Chapter 2. Functional EHR Systems
Format of Data Determines Potential Benefits
EHR Data Formats
Limitations of Certain Types of Data
Standard EHR Coding Systems
Prominent EHR Code Sets
SNOMED-CT
SNOMED-CT Structure
Medcin
Medcin Structure
LOINC
Clinical Care Classification System (CCC)
RxNorm
UMLS
How EHR Code Sets Differ From Code Sets Used for Billing
ICD-10CM
CPT-4 (R)
Code Usage
Exchanging Data with Other Standard Code Sets
Capturing and Recording EHR Data
Importing Digital Images
Guided Exercise 2A: Exploring a Document Imaging System
Cataloging Digital Images
Guided Exercise 2B: Importing and Cataloging Images
Picture Archival and Communication System (PAC)
Importing Text to the EHR
Importing Coded EHR Data
Patient-Entered Data
Provider-Entered Data
Health Information Exchange
HL7
DICOM
CDISC
Biomedical Devices
Telemonitors
Real-Life Story: Enhancing Process Efficiency through Remote Access
Functional Benefits from Codified Records
Trend Analysis
Critical Thinking Exercise 2C: Retrieving a Scanned Lab Report
Lab Report as Digital Image
Lab Report as Text Data
Coded Lab Data
Alerts
Drug Utilization Review
Formulary Alerts
Other Types of Alerts
Health Maintenance
Preventive Care
Immunizations
Decision Support
Meeting the IOM Definition of an EHR
Chapter Two Summary
Chapter 3. Learning Medical Record Software
Introducing the Quippe (R) Student Edition Software
About the Exercises in This Book
Creating Your First Patient Encounter Note
Guided Exercise 3A: Understanding the Software
Understanding the Toolbar
Navigating Medcin Content
Guided Exercise 3B: Adding Clinical Concepts to the Workspace
Using a More Specific Finding
Guided Exercise 3C: Patient with Caffeine Withdrawal Headache
Adding Details to the Findings
Guided Exercise 3D: Using the Details Pop-up Window
Chief Complaint and Vital Signs
Guided Exercise 3E: Recording Chief Complaint and Vital Signs
Critical Thinking Exercise 3F: A Patient Suffering Withdrawal Headaches
Real-Life Story: Paperless in Less Than a Day
Chapter Three Summary
Testing Your Skill Exercise 3G: Another Cause of Headache
Chapter 4. Increased Familiarity with EHR Software
Applying Your Knowledge
Documenting a Brief Patient Visit
Guided Exercise 4A: Documenting a Visit for Common Cold
Visually Different EHR Styles
Real-Life Story: A Nurse's Notes
Guided Exercise 4B: Recording Findings Using Alternate Methods
Encounter Notes Without Yes/No Check Boxes
Additional Exercises
Critical Thinking Exercise 4C: A Patient with Sinusitis
Critical Thinking Exercise 4D: Patient with Urinary Problem
Chapter Four Summary
Testing Your Skill Exercise 4E: An Asthma Patient Who Sleeps with a Dog
Chapter 5. Data Entry at the Point of Care
Why Speed of Entry Is Important in the EHR
Templates, Lists, and Forms Speed Data Entry
Shortcuts That Speed Documentation of Typical Cases
The Concept of Templates
The Concept of Lists
Guided Exercise 5A: Using an Adult URI List
Review of Systems and Pertinent Negatives
Guided Exercise 5B: Using Lists and Otherwise Normal
Critical Thinking Exercise 5C: Using Syncope List for a TIA Case
The Concept of Forms
Comparison of Lists and Forms
Initial Intake Form for an Adult
Guided Exercise 5D: Using Forms
Customized Forms
Real-Life Story: How I Learned to Stop Worrying and Love Forms
Critical Thinking Exercise 5E: Using a Form and a List
Chapter Five Summary
Testing Your Skill Exercise 5F: A Patient with Dyspnea
Chapter 6. Understanding Electronic Orders
The Importance of Electronic Orders and Results
Recording Orders in the Student Edition
Learning to Use the Search and Prompt Features
How Search Works
Guided Exercise 6A: Using Search and Prompt, and Ordering Tests
Moving Concepts and Findings to a Different Section
Merge Prompt-Intelligent Prompting
Lab Orders and Reports
Workflow of Electronic Lab Orders and Results
Guided Exercise 6B: Ordering an X-Ray
Radiology Orders and Reports
Workflow of Radiology Orders
Critical Thinking Exercise 6C: Ordering Tests and an X-Ray
Protocols Based on Diagnosis
Primary and Secondary Diagnoses
Multiple Diagnoses
The Rule-Out Diagnosis
Using Symptoms and History to Prompt for Findings
Guided Exercise 6D: Patient With Multiple Diagnoses
Medication Orders
Electronic Prescriptions
Closing the Loop on Safe Medication Administration
Guided Exercise 6E: Writing Prescriptions in an EHR
Quick Access to Frequent Orders
Guided Exercise 6F: Ordering Medications Using Discharge Orders
Real-Life Story: When Orders and Results Are Critical
Chapter Six Summary
Testing Your Skill Exercise 6G: Discharging a Patient with Deep Vein Thrombosis
Comprehensive Evaluation of Chapters 1-6
Part I-Testing Your Knowledge of Chapters 1-6
Part II-Guided Exercise CE1: Document Image Retrieval
Part III-Critical Thinking Exercise CE2: ER Visit for Shortness of Breath
Chapter 7. Problem Lists, Lab Results, and Body Mass Index
Longitudinal Patient Records to Manage Patients' Health
Understanding Problem Lists
The Problem-oriented Chart
Guided Exercise 7A: Working With a Problem-oriented Chart
Citing Previous Encounter Data
Guided Exercise 7B: Adding Problems, Retrieving and Citing Lab Results
Orders and Results Management
Guided Exercise 7C: Retrieving Pending Lab Results
Critical Thinking Exercise 7D: Using Lab Results to Rule Out Lead Poisoning
Body Mass Index
Real-Life Story: Experiencing the Functional Benefits of an EHR
Waist Circumference and BMI
Critical Thinking Exercise 7E: Determining BMI Category for a Patient
Guided Exercise 7F: Calculating BMI and Trending Weight for a Diabetic Patient
Critical Thinking Exercise 7G: Discovering Your BMI and Category
Chapter Seven Summary
Testing Your Skill Exercise 7H: Patient with Upper Abdominal Chest Pain
Chapter 8. Flow Sheets, Annotated Drawings, and Graphs
Learning to Use Flow Sheets
Guided Exercise 8A: Working with a Flow Sheet
About the Flow Sheet View
Guided Exercise 8B: Obstetric Patient's Flow Sheet
Critical Thinking Exercise 8C: Flow Sheet with Multiple Diagnoses
Use of Anatomical Drawings in the EHR
Navigation by Body System
Annotated Drawings as EHR Data
Guided Exercise 8D: Annotated Dermatology Exam
Critical Thinking Exercise 8E: Examination of a Patient with Pressure Sores
Real-Life Story: First Patient Whose Life Was Saved by Expert System Software He Operated Himself
Using Graphs to View Trends
Visual Aids to Engage Patients in Their Own Healthcare
Guided Exercise 8F: Trending with a Graph and Flow Sheet
Critical Thinking Exercise 8G: Graphing Weight and BMI
Chapter Eight Summary
Testing Your Skill Exercise 8H: Diabetic with High Blood Pressure
Chapter 9. Using the EHR to Improve Patient Health
Prevention and Early Detection
Pediatric Wellness Visits
Guided Exercise 9A: Well-Baby Checkup
Understanding Growth Charts
What Is a Percentile?
CDC Growth Charts
Guided Exercise 9B: Pediatric Vitals and Growth Charts
The Importance of Childhood Immunizations
Guided Exercise 9C: Reviewing and Ordering Vaccines
Critical Thinking Exercise 9D: Determine Your Adult Immunizations
Preventative Care Screening
Clinical Quality Measures
Real-Life Story: Quality Care for Pediatric and Adult Patients
Guided Exercise 9E: Applying Quality Measures to Patient Care
About the Quality Measures Review
Critical Thinking Exercise 9F: Clinical Quality Measures for a Female Patient
The Patient-Centered Medical Home
Chapter Nine Summary
Testing Your Skill Exercise 9G: Baby's First Checkup
Chapter 10. Decision Support and Patient Involvement
Enriching the EHR Through Connectivity
Decision Support
Integrated Decision Support
Guided Exercise 10A: Patient with Dengue Fever
Critical Thinking Exercise 10B: Accidental Exposure to Paraquat
Patient Involvement in Their Own Healthcare
Patient Education Material
Guided Exercise 10C: Patient Education About Risk of COPD
Critical Thinking Exercise 10D: Patient Education About Diabetes
Using the Internet
Critical Thinking Exercise 10E: Internet Medical Research
Secure Internet Data
Remote EHR Access for the Provider
Practicing Medicine Online
Asynchronous Telemedicine at Mayo Clinic
Teleradiology
Telemedicine in Nursing
Telemedicine via E-Visits
Patient Entry of Symptoms and History
Workflow Using Patient-Entered Data
Internet Workflow
Improved Patient Information
Guided Exercise 10F: Experiencing Patient-Entered HPI
Guided Exercise 10G: Reviewing Patient-Entered Data
E-Visits
Real-Life Story: Using the Internet to Build a Patient-Centered Practice
Mayo Clinic Study of E-visits
E-Visits in Practice
Workflow of an E-Visit
Guided Exercise 10H: Patient Requests an E-Visit
Critical Thinking Exercise 10J: Clinician Completes the E-Visit
Patient Access to Electronic Health Records
Chapter Ten Summary
Testing Your Skills Exercise 10K: A Patient with Hepatitis A
Chapter 11. Privacy and Security of Health Records
Understanding HIPAA
Administrative Simplification Subsection
HIPAA Transactions and Code Sets
HIPAA Transactions
Standard Code Sets
HIPAA Uniform Identifiers
HIPAA Privacy Rule
Privacy Policy
Consent
Modifying HIPAA Consent
Critical Thinking Exercise 11A: Creating a Privacy Policy
Authorization
Research
Research Exceptions
Marketing
Guided Exercise 11B: Authorization for Release of PHI
Government Agencies
Minimum Necessary
Incidental Disclosures
A Patient's Right to Know About Disclosures
Patient Access to Medical Records
Personal Representatives
Minor Children
Critical Thinking Exercise 11C: What Is Required?
Business Associates
Electronic Health Information Exchange
Real-Life Story: The First Hipaa Privacy Case
Civil and Criminal Penalties
HIPAA Security Rule
Why a Security Rule?
The Privacy Rule and Security Rule Compared
Critical Thinking Exercise 11D: Comparing Privacy and Security Rules
Security Standards
Implementation Specifications
Administrative Safeguards
Security Management Process
Critical Thinking Exercise 11E: How to Assess Security Risk
Assigned Security Responsibility
Workforce Security
Information Access Management
Security Awareness and Training
Security Incident Procedures
Contingency Plan
Evaluation
Critical Thinking Exercise 11F: Developing a Contingency Plan
Real-Life Story: Contingency Plans Ensure Continued Ability to Deliver Care
Business Associate Contracts and Other Arrangements
Physical Safeguards
Facility Access Controls
Workstation Use
Workstation Security
Device and Media Controls
Technical Safeguards
Access Control
Audit Controls
Integrity
Person or Entity Authentication
Transmission Security
Organizational, Policies and Procedures, and Documentation Requirements
Organizational Requirements
Policies and Procedures
Documentation
Minimizing the Risk of Mobile Devices
Critical Thinking Exercise 11G: Securing EHR Access
Breach Notification Requirements
Individual Notice
Media Notice
Notice to the Secretary
Notification by a Business Associate
Electronic Signatures for Health Records
HIPAA Privacy, Security, and You
Chapter Eleven Summary
Chapter 12. EHR Coding and Reimbursement
The EHR and Reimbursement
HIPAA-Required Code Sets
Diagnoses Codes Justify Billing
Primary and Secondary Diagnoses
Multiple Diagnoses
Guided Exercise 12A: Using Code Review
CPT-4 and HCPCS Codes
Evaluation and Management (E&M) Codes
Four Levels of E&M Codes
How the Level of an E&M Code Is Determined
Undercoding
Accurate Coding
Using EHR Software to Understand E&M Codes
Guided Exercise 12B: Calculating the E&M Code from an Encounter
Key Components
Levels of Key Components
Key Component: History
Key Component: Examination
Guided Exercise 12C: Understanding the Examination Component
Levels of Key Component: Examination
Key Component: Medical Decision Making
Guided Exercise 12D: Understanding the MDM Component
Determining the Level of Medical Decision Making
Other Components: Counseling, Coordination of Care, and Time
Putting It All Together
Evaluating Key Components
How Changes in Key Components Affect the E&M Code
Guided Exercise 12E: Calculating E&M for a More Complex Visit
Guided Exercise 12F: Counseling Over 50 Percent of Face-to-Face Time
Critical Thinking Exercise 12G: Understanding How Procedures Are Posted to the Billing System
Real-Life Story: A New Level of Efficiency in Addition to Improved E&M Coding
Factors That Affect the E&M Code Set
Guided Exercise 12H: Exploring Other Factors of E&M Codes
Clinical Setting
Detailed Service Type
Exam Type
Chapter Twelve Summary
Testing Your Skill Exercise 12J: Counseling an Established Patient
Comprehensive Evaluation of Chapters 7-12
Part I-Testing Your Knowledge of Chapters 7-12
Part II-Critical Thinking Exercise CE3: Examination of a Patient with Arterial Disease
Part III-Critical Thinking Exercise CE4: Counseling and Education for a Patient with Arterial Disease
Part IV-Testing Your Skill Exercise CE5: Patient Signs HIPAA Authorization
Glossary
Index
Acronyms
