Documenting In The Age of EMR SPAP 2019 EMR/EHR Beginnings Mid - - PowerPoint PPT Presentation

▶
documenting in the age of emr
SMART_READER_LITE
LIVE PREVIEW

Documenting In The Age of EMR SPAP 2019 EMR/EHR Beginnings Mid - - PowerPoint PPT Presentation

Jan 24, 2023 10 likes •661 views

Documenting In The Age of EMR SPAP 2019 EMR/EHR Beginnings Mid 1960sClinical Information Systems Lockheed -> Tenhnicon -> TDS Healthcare -> Eclipsys -> Allscripts University of Utah with 3M developed Health Evaluation

slide-1
SLIDE 1

Documenting In The Age

  • f EMR

SPAP 2019

slide-2
SLIDE 2
slide-3
SLIDE 3

EMR/EHR Beginnings

  • Mid 1960’sClinical Information Systems
  • Lockheed -> Tenhnicon -> TDS Healthcare -> Eclipsys -> Allscripts
  • University of Utah with 3M developed Health Evaluation through Local

Processing (HELP)

  • Mass General with Harvard made Computer Stored Ambulatory Record

(COSTAR) in 1968

  • 1970’s Department of Veteran Affairs made VistA
  • 1980-90’s Institute of Medicine published a study to argue the case

for using EHR

slide-4
SLIDE 4

Recent Developments

  • President Bush mentioned in 2004 State of the Union
  • President Obama incorporated EHR into the American Recovery and

Reinvestment Act of 2009 as part of the Health Information Technology for Economic and Clinical Health Act (HITECH)

  • Where “Meaningful Use” started which mandates transition to HER treating

patients covered by government programs

slide-5
SLIDE 5
slide-6
SLIDE 6

Most Common EMRs

slide-7
SLIDE 7
slide-8
SLIDE 8
slide-9
SLIDE 9
slide-10
SLIDE 10
slide-11
SLIDE 11
slide-12
SLIDE 12

Pediatric patient safety event report data from inpatient and outpatient settings that were entered in the period 2012–17 were retrieved from three large academic health care institutions (two stand-alone pediatric institutions and one adult and pediatric institution) that used Epic and Cerner EHRs (two institutions used Epic, and one used Cerner).

slide-13
SLIDE 13

More than 3,000 medical errors at pediatric hospitals from 2012 to 2017 were due in part to EMR/EHR problems, a study in Health Affairs found. About 1 in 5 of these could have caused patient harm.

slide-14
SLIDE 14

In the first evaluation of its kind, we found that nearly two-thirds of safety reports related to the EHR and medication at three pediatric hospitals were associated with usability issues.

slide-15
SLIDE 15
slide-16
SLIDE 16
slide-17
SLIDE 17

Where We Make Mistakes

  • Demographics
  • Templates
  • Importing (copy and paste)
  • Actual/factual documentation
  • Privacy
slide-18
SLIDE 18

Demographics

  • Name issues
  • Gender issues
  • Wrong chart
slide-19
SLIDE 19

Name Issues

  • Sound alike names
  • Spacing or punctation
  • Computer problems
slide-20
SLIDE 20

Gender Issues

  • EMR limitations
  • Insurance companies
  • Need factual information
slide-21
SLIDE 21
slide-22
SLIDE 22
slide-23
SLIDE 23

Wrong Patient

  • Same issues from paper charts,

but can be easier to miss

  • More mistakes in a busier

practice

  • Name issues (demographics)
slide-24
SLIDE 24

Templates

  • Insurance companies
  • Personalization
  • Right template
  • Time saver?
slide-25
SLIDE 25

Insurance Companies

  • MagMutual one of the first to oppose templates
  • Templates the most common place for errors to

happen

  • Improved over time
slide-26
SLIDE 26

Personalization

  • Make it your own
  • Metadata mark
slide-27
SLIDE 27

Make It Your Own

  • Design your own

templates with your wording

  • Document
  • r change something
slide-28
SLIDE 28

Metadata

slide-29
SLIDE 29

Importing

  • Cloning
  • Every chart looks the

same

slide-30
SLIDE 30

Cloning

slide-31
SLIDE 31
slide-32
SLIDE 32

Documenting

  • Did you actually do it?
  • Did you do it and not

document?

  • Personalization
slide-33
SLIDE 33

In the past: You did not do it if you did not document it!

slide-34
SLIDE 34
slide-35
SLIDE 35

Did you do it?

  • If exam and other

elements are left unaltered its harder to prove they were done

  • Finished note looks

incomplete at times

slide-36
SLIDE 36
slide-37
SLIDE 37
slide-38
SLIDE 38
slide-39
SLIDE 39
slide-40
SLIDE 40
slide-41
SLIDE 41
slide-42
SLIDE 42
slide-43
SLIDE 43
slide-44
SLIDE 44
slide-45
SLIDE 45
slide-46
SLIDE 46
slide-47
SLIDE 47
slide-48
SLIDE 48
slide-49
SLIDE 49
slide-50
SLIDE 50
slide-51
SLIDE 51
slide-52
SLIDE 52
slide-53
SLIDE 53
slide-54
SLIDE 54
slide-55
SLIDE 55
slide-56
SLIDE 56
slide-57
SLIDE 57

Privacy

  • Portals
  • Printed notes
  • Insurance EOB
  • Can lead to missed information
slide-58
SLIDE 58
slide-59
SLIDE 59
slide-60
SLIDE 60

Restrictions not always good

slide-61
SLIDE 61
slide-62
SLIDE 62
slide-63
SLIDE 63
slide-64
SLIDE 64
slide-65
SLIDE 65