HCA 417 Electronic Health Record Health Care

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ELECTRONIC HEALTH RECORDS Understanding and Using Computerized Medical Records

CHAPTER LESSON

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Functional EHR Systems

CHAPTER TWO TWO

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Cataloging Images

• Process of scanning documents or importing scanned images into image system.

• Not only capturing image but tying it to correct patient and entering data in computer about document.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Cataloging Images

• Document images scanned and cataloged into EHR by many different people.

• Quality control is most important. • Catalog data is entered by hand; in some

instances image cataloging can be automated. – Barcode to identify catalog data. – Optical Character Recognition (OCR)

software.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• In this exercise you will catalog a scanned report and 2 diagnostic images for a patient.

• You will need access to the Internet.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 1 – Start web browser program; follow steps listed

inside cover of textbook to select discipline; click on book cover that matches this Electronic Health Records textbook; log in.

– When welcome page displayed, click on link “Activities and Exercises” or select “Activities” from drop-down list; click button labeled “Go.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 2 – Locate and click on link Exercise 6. – Information about exercise will be displayed. – Locate and click link “Click here to start the

Document/Image System program.” – Document image system screen will be

displayed (see Figure 2-3).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 2 (cont.) – Position mouse pointer over word “Select” in

Menu bar at top of screen; click mouse button once.

– Move mouse pointer vertically down list over word “Patient.”

– Click mouse to invoke Patient Selection window (Figure 2-10).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-10: Selecting Sally Sutherland from Patient Selection window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 3 – Find patient named Sally Sutherland in

Patient Selection window. – Position mouse pointer over patient name and

double-click mouse. – Once patient is selected, patient's name, age,

and sex are displayed in title at top of window. – Catalog pane displays message “No

Documents or Images” because Sally has no documents or images in catalog.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 4 – You are going to import a file that has already

been scanned but not yet cataloged. – Locate and click on Toolbar button labeled

“Import”. – The “Open Media File” window, displaying

available files, will open. – Compare your screen to Figure 2-11.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-11: Open Media window displays after clicking Import icon.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 5 – Locate and click on thumbnail image of

radiologist report document (suth70943rpt.tif). – Locate and click on button labeled “Open.” – Compare your screen to Figure 2-12.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-12: Data entry fields in Catalog pane; Image Viewer displays imported Radiology report.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 6 – Imported file displays in Image Viewer pane

and data entry fields replace catalog list. – Fields shown in Figure 2-12 are minimum for

most Document/Image systems. – Actual fields in catalog record will differ by

software vendor or medical facility. – Image imported should be radiologist's report.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 6 (cont.) – Catalog pane reminds you that it has not been

saved into patient's EHR. – First two fields in catalog pane are determined

automatically; Document/Image System recognizes you have imported file and that you are performing a manual entry of catalog data.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 6 (cont.) – Category field uses short mnemonic codes to

represent longer category names. – Category field is already set to “RAD.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 7 – First field you will enter is date of original

document for reference. – Note that system will automatically record

other dates for audit purposes. – Look at image displayed; locate date of

report, May 23, 2012. – Enter 5/23/2012.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 8 – Final field to complete is description; only first

portion displayed in catalog list. – Put most important information at beginning of

description. – In this case, type: Mammogram Rpt - Dr.

Gold.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 8 (cont.) – Compare your fields to left pane of Figure 2-

12. – If everything is correct, click on button labeled

“Save.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-12: Data entry fields in Catalog pane; Image Viewer displays imported Radiology report.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 9 – Catalog pane will now display cataloged

listing (Figure 2-13).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-13: Cataloged mammogram report.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 9 (cont.) – Catalog corresponding diagnostic images. – Locate and click on Toolbar button labeled

“Import.” – Open Media window (Figure 2-11) will be

displayed.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-11: Open Media window displays after clicking Import icon.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 9 (cont.) – Click on center Thumbnail (mammogram

image “suth70943mam2.tif). – Locate and click on button labeled “Open.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 10 – Enter catalog data in Catalog entry fields:  Date: 5/23/2012  Description: Mammogram right breast

w/abnormality – Compare your screen to Figure 2-14.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

Figure 2-14: Cataloged mammogram image.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 10 (cont.) – Click button labeled “Save.” – Catalog pane will now display two listings.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 11 – Catalog the other mammogram image by

clicking Toolbar button labeled “Import.” – When Open Media window appears, click on

left Thumbnail (mammogram image “suth70943mam1.tif).

– Locate and click on button labeled “Open.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 6: Importing and Cataloging Images

• Step 11 (cont.) – Enter catalog data in Catalog entry fields:  Date: 5/23/2012  Description: Mammogram left breast

– Click button labeled “Save.” – Catalog pane will display three listings. – Exercise is concluded. – Exit and close your browser.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Picture Archival and Communication System (PAC)

• At many facilities, digital images (x-rays, CAT scans) reside on separate Picture Archival and Communication System (PAC). – These images can be associated with

radiology report in the EHR. – They appear to be part of the EHR record,

even though they are on a separate system. – Diagnostic image is not actually imported into

the EHR, but linked to patient EHR record.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Text to the EHR

• Text data consists of words, sentences, and paragraphs, but is not fielded data. – Text records are searchable by computer. – Text data can be dynamically reformatted for

display on smaller devices.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Importing coded data produces a better EHR and eliminates need to re-key data or scan reports into chart.

• Most medical devices have ability to transfer data they have collected to a computer.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Health Level 7 (HL7) – Nonprofit organization and leading messaging

standard used by healthcare computer systems to exchange information.

– Comprised of healthcare providers, institutions, government representatives, software developers.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Health Level 7 (HL7) (cont.): – Uses a consensus process to arrive at

specifications acceptable to everyone involved.

– Specifications are independent of any application or vendor.

– Successful because it is very flexible.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• DICOM: Digital Imaging and Communications in Medicine. – Standard used for medical images. – Most widely used format for storing and

sending diagnostic images. – Standard for communication between

diagnostic imaging equipment and image processing software.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• CDISC: Clinical Data Interchange Standards Consortium. – Focus of HL7 is to facilitate message

standards for a broad range of healthcare. – CDISC specific focus on clinical drug trials. – Standards enable sponsors, vendors, and

clinicians to acquire and exchange data used in clinical trials.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Biomedical devices can output important and useful medical information that can be received and stored as data in patient's EHR. – HL7 often used to exchange demographic

information. – Many biomedical devices in hospitals have

capability of exporting data to the EHR.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Telemonitors – Patients with chronic conditions monitored at

home using these devices. – Store readings and transfer data to doctor's

system either by using modem and phone line or by downloading from device during a patient encounter.

– Advantage: allows provider to study values measured many times over course of patient's normal daily activity.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

Figure 2-17: An IQholter™ worn by the patient gathers cardio data.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• Regional Health Information Organizations (RHIO) and the Office of National Coordinator for Health Information Technology's development of a national health information network (NHIN) are examples of projects to enable electronic transfer of health records between providers.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Importing Coded EHR Data

• RHIOs encourage exchange of patient's health information across medical practices.

• Obstacles include: – Technical – Economic – Political issues

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Patient-Entered Data

• Only patient has information about what symptoms were present at outset of illness.

• Only patient knows outcome of medical treatment of those symptoms.

• Patient is source of past medical, family, and social history.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Patient-Entered Data

• Patient-entered data is a more accurate reflection of a patient's complaints.

• Patients who can review their histories are better prepared for visit.

• Patient-entered data saves time and allows triage nurse to focus on review of information with patient rather than on keying of data.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Patient-Entered Data

• Allows clinician more time to discuss treatment plan with patient.

• Patient-entered data is reviewed by doctor or nurse during exam and before being merged into the EHR.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Provider-Entered Data

• Surest source of reliable coded EHR data is that entered by providers (doctor, nurse, medical assistant) during patient encounter using a standardized nomenclature.

Slide Number 1
Cataloging Images
Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Guided Exercise 6: �Importing and Cataloging Images
Picture Archival and Communication System (PAC)
Importing Text to the EHR
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Importing Coded EHR Data
Patient-Entered Data
Patient-Entered Data
Patient-Entered Data
Provider-Entered Data