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 EHRCertified 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 ChartsPatient 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 MaintenancePreventive 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 VisitGuided 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 NormalCritical 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-RayProtocols Based on Diagnosis Primary and Secondary Diagnoses Multiple Diagnoses The Rule-Out Diagnosis Using Symptoms and History to Prompt for FindingsGuided 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 RetrievalPart 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 PatientGuided 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 TrendsVisual 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 COPDCritical 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-VisitsPatient 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 PolicyAuthorization 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 ArrangementsPhysical 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 RequirementsIndividual Notice Media Notice Notice to the Secretary Notification by a Business Associate Electronic Signatures for Health RecordsHIPAA 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 ComponentsKey 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 CodeGuided 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