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ELECTRONIC MEDICAL
RECORD
INTRODUCTION TO EMR
• EMR encompasses the information and capabilities required to
support healthcare service delivery, where the information is captured
in a computer-readable form that supports interoperability and clinical
decision support.
• In addition, it is likely that increasing numbers of consumers will have
direct access to EMR systems.
• An electronic health record is a representation of all a patients’ data
that would originally be found in the paper based record.
• It contains all information ranging from pathology, radiology and
clinical information that has been combined and structured in a digital
form.
WORKING OF EMR
The working of EMR is simple and can be made clear by the following
information.
1.Create your own medical record:
•As a doctor, you can create a own data base of your patient records.
•You can request to other clinics and contact to other doctors.
•Information is typed into a format such as an EMR records that
contain health care and medical information just as paper medical
records
•Each user is given a unique Medical Record number (MR no.) at the
time of registration.
•The user can access their profile anywhere at anytime to know their
health details.
2. Data storage
•Data is stored in computerized networks and data banks.
•Such data is typed into the computer by health information or
medical records personnel and stored in any number of medical
software systems accessed by health care providers around the
globe.
•Notes and prescriptions on patient care and treatments inserted
into a patient's electronic medical record enable physicians in
other locations, states or countries to access such information for
enhanced patient care and safety.
3.Accessing Information
•You can then access medical data via information exchanges accessible
to outpatient facilities, physicians and hospitals through a dedicated and
secure network of providers in order to share information. Your patients
are identified by codes or numbers assigned to patient profiles.
4.Web Browser Security
•Health care providers can access a patient's database or electronic
medical record by accessing health network exchanges on certain Web
browsers after entering encrypted passwords and user ID codes into the
system.
•Electronic medical records enable a constant secure and confidential
flow of information between medical and health care providers that can
cover and blend a variety of specialties and disciplines.
OBJECTIVES
• 1.Enable a user to electronically record, modify, and retrieve
patient demographic data including preferred language,
gender, race, ethnicity, and date of birth.
• 2.Maintain the patient’s active medication list
• 3.Maintain an up-to-date problem list of current and active
diagnoses
• 4.Computerized physician order entry (CPOE) of
medications
• 5.Capability to exchange key clinical information among
providers of care and patient-authorized entities
electronically
Our Features of EMR
1) Exchangeability
Multiple care providers, in different locations, can simultaneously view a
patient's medical record on their computers and get up-to-the-minute
information on test results and other doctors' recommendations. This
collaboration enables care providers to work more efficiently in determining
if further consultation or testing is required.
2) Easy adoption
Complete patient records can be accessed from any location equipped with
an Internet connection, allowing therapists to work from the clinic, home,
spas and corporate venues. Treatment can be initiated quicker and
duplication of tests is eliminated.
3)Free of cost
Our goal is to reach more people and make them aware of the importance
using Electronic medical record with which they make can access their
health issues very effectively. So, we are providing our service for free for
this social cause.
4) Up-to-date
Your health information is up-to-date. There is no delay as hand-
written notes wait to be transcribed.Test results and all of your
medical history are recorded directly into your EMR.
5) Reduced risk
1)EHR can provide information to improve risk management and
assessment outcomes.
2)Patient portals assist clinic owners in identifying clients that aren’t
likely to follow prescribed treatment and those inclined to self-
terminate their care.
6)Improved quality
Improved legibility, accuracy and completeness. With an EMR there
is less potential for medical errors as well as improved quality and
safety in patient care.
Reminders
1)Automatic reminders can improve disease prevention and early
diagnosis.
2) Reminders are activated when certain health maintenance tests
and/or procedures are due
Active decision
Standardization of data elements and information models to ensure
semantic interoperability enabling the implementation of active
decision support
Efficiency tool
Provides a tool for managers, executives, and auditors to measure
hospital performance based on primary source data by giving access
to atomic structured information in real time (as opposed to, for
example, scanned documents). This dramatically reduces the time
between the collection of data and the analysis of key performance
indicators and offers unparalleled richness and visibility of
operational activities from the point of care
Your BENEFITS
• Once an EMR system is installed and staff are trained in its proper
use, retrieving and updating patient clinical records is performed
substantially faster and with fewer errors.
• In most cases, this allows health care providers to finish patient
charting more quickly, and to do so while with the patient, increasing
accuracy and completeness of the record.
• This efficiency can result in an increase in scheduled visits per hour
with no degradation in patient care quality.
• Alternatively, by reducing the burden of administrative work, it allows
a health care provider to concentrate more on the patient and less on
paperwork.
• Besides improving the delivery of health care to patients, another
one of the benefits of electronic medical records integration is that it
can reduce administrative and other related costs for physicians.
• Storage space dedicated to paper charts can essentially be
eliminated once the transition to an EMR system is complete.
• Here we summarize our findings on how physician
practices used and generated clinical benefits from each
type of EMR capability and on the major barriers these
practices encountered.
• Our key insight with policy implications is that the path to
quality improvement and financial benefits lies in getting
the greatest number of physicians to use the EMR (and
not paper) for as many of their daily tasks as possible.
• The key obstacle in this path to quality is the extra time it
takes physicians to learn to use the EMR effectively for
their daily tasks.
1.Viewing
•All practices used EMR viewing capabilities, which improve chart
availability, data organization, and legibility.
•Quality benefits depended on the amount of viewable clinical data.
•The amount of initially viewable data depended on efforts to type in
existing paper-based medical record data and to electronically import
data from lab, billing, and other systems.
•As patient data accumulated over time, financial savings accrued from
less staff time spent finding, pulling, and filing charts and less physician
time spent locating information.
2.Documentation and care management
•We identified a consistent relationship between greater electronic
documentation by physicians and greater quality improvement and
financial benefits.
•Although most clinicians maintained electronic problem and allergy
lists, physicians varied greatly in how they documented progress notes.
•Basic use of the EMR improved the legibility and accessibility of
progress notes and increased the availability of electronic problem and
allergy lists. More advanced use of documentation templates led to
greater opportunities for improving quality of care.
•In most practices the bulk of EMR-related financial benefits came from
reductions in medical records and transcription staff as physicians
moved from dictation to typing their own notes. Some practices
increased billing revenue through more complete capture of services
and decreased under coding of services provided.
3.Ordering
•Basic use of electronic ordering typically consisted of physicians’
typing in prescription orders, responding to drug interactions and drug
allergy alerts, and printing out prescriptions.
•All but three practices we studied used electronic prescribing. In large
practices, basic ordering often also included electronic ordering of
referrals and laboratory and radiology tests.
• More advanced ordering capabilities included additional decision
support, electronic transmission of orders to pharmacies and
laboratories, and better tracking of test-order status and test results, all
of which can improve quality and decrease errors.
4.Messaging
•Basic use of electronic messaging among providers improved the
availability, timeliness, and accuracy of messages and increased
completeness of documentation, thus potentially reducing “dropped
balls” and safety problems.
• Much less common was advanced messaging, which included
messaging with outside providers (to improve care coordination) and
with patients (to improve patient satisfaction and, potentially, patient
self-care and compliance).
5.Analysis and reporting
•Few practices initially used physician performance monitoring
and feedback capabilities to improve quality and efficiency.
•Over time, some practices—especially larger ones—used
reporting capabilities more widely.
6.Patient-directed functionality
•Most practices had limited or nonexistent practice Web sites for
patients.
•A few large-practice Web sites enabled patients to schedule
visits, send secure e-mail messages to providers, receive e-mail
reminders, order medications, access their charts, and obtain
more individualized educational patient care information—all of
which have the potential to improve quality.
7.Billing
•Increased integration between billing and EMR software,
combined with electronic documentation, can yield financial
benefits through more complete capture of services provided,
more defensible Medicare coding at higher coding levels, and
reductions in data-entry staff
Your Benefits At a GLANCE..!!
•Increased Access and Efficiency
•Affordable and easy to adopt
•Feature rich EMR platform
•Enhance quality of care
•Improved Documentation
•Increased Resources
•Quality Assurance
•Eliminates Costs
•Reduced risk
GET STARTED…
YOU ARE A JUST A CLICK
AWAY TO GO….!!!

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Electronic medical record for Doctors

  • 2. INTRODUCTION TO EMR • EMR encompasses the information and capabilities required to support healthcare service delivery, where the information is captured in a computer-readable form that supports interoperability and clinical decision support. • In addition, it is likely that increasing numbers of consumers will have direct access to EMR systems. • An electronic health record is a representation of all a patients’ data that would originally be found in the paper based record. • It contains all information ranging from pathology, radiology and clinical information that has been combined and structured in a digital form.
  • 3. WORKING OF EMR The working of EMR is simple and can be made clear by the following information. 1.Create your own medical record: •As a doctor, you can create a own data base of your patient records. •You can request to other clinics and contact to other doctors. •Information is typed into a format such as an EMR records that contain health care and medical information just as paper medical records •Each user is given a unique Medical Record number (MR no.) at the time of registration. •The user can access their profile anywhere at anytime to know their health details.
  • 4. 2. Data storage •Data is stored in computerized networks and data banks. •Such data is typed into the computer by health information or medical records personnel and stored in any number of medical software systems accessed by health care providers around the globe. •Notes and prescriptions on patient care and treatments inserted into a patient's electronic medical record enable physicians in other locations, states or countries to access such information for enhanced patient care and safety.
  • 5. 3.Accessing Information •You can then access medical data via information exchanges accessible to outpatient facilities, physicians and hospitals through a dedicated and secure network of providers in order to share information. Your patients are identified by codes or numbers assigned to patient profiles. 4.Web Browser Security •Health care providers can access a patient's database or electronic medical record by accessing health network exchanges on certain Web browsers after entering encrypted passwords and user ID codes into the system. •Electronic medical records enable a constant secure and confidential flow of information between medical and health care providers that can cover and blend a variety of specialties and disciplines.
  • 6. OBJECTIVES • 1.Enable a user to electronically record, modify, and retrieve patient demographic data including preferred language, gender, race, ethnicity, and date of birth. • 2.Maintain the patient’s active medication list • 3.Maintain an up-to-date problem list of current and active diagnoses • 4.Computerized physician order entry (CPOE) of medications • 5.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
  • 7. Our Features of EMR 1) Exchangeability Multiple care providers, in different locations, can simultaneously view a patient's medical record on their computers and get up-to-the-minute information on test results and other doctors' recommendations. This collaboration enables care providers to work more efficiently in determining if further consultation or testing is required. 2) Easy adoption Complete patient records can be accessed from any location equipped with an Internet connection, allowing therapists to work from the clinic, home, spas and corporate venues. Treatment can be initiated quicker and duplication of tests is eliminated. 3)Free of cost Our goal is to reach more people and make them aware of the importance using Electronic medical record with which they make can access their health issues very effectively. So, we are providing our service for free for this social cause.
  • 8. 4) Up-to-date Your health information is up-to-date. There is no delay as hand- written notes wait to be transcribed.Test results and all of your medical history are recorded directly into your EMR. 5) Reduced risk 1)EHR can provide information to improve risk management and assessment outcomes. 2)Patient portals assist clinic owners in identifying clients that aren’t likely to follow prescribed treatment and those inclined to self- terminate their care. 6)Improved quality Improved legibility, accuracy and completeness. With an EMR there is less potential for medical errors as well as improved quality and safety in patient care.
  • 9. Reminders 1)Automatic reminders can improve disease prevention and early diagnosis. 2) Reminders are activated when certain health maintenance tests and/or procedures are due Active decision Standardization of data elements and information models to ensure semantic interoperability enabling the implementation of active decision support Efficiency tool Provides a tool for managers, executives, and auditors to measure hospital performance based on primary source data by giving access to atomic structured information in real time (as opposed to, for example, scanned documents). This dramatically reduces the time between the collection of data and the analysis of key performance indicators and offers unparalleled richness and visibility of operational activities from the point of care
  • 10. Your BENEFITS • Once an EMR system is installed and staff are trained in its proper use, retrieving and updating patient clinical records is performed substantially faster and with fewer errors. • In most cases, this allows health care providers to finish patient charting more quickly, and to do so while with the patient, increasing accuracy and completeness of the record. • This efficiency can result in an increase in scheduled visits per hour with no degradation in patient care quality. • Alternatively, by reducing the burden of administrative work, it allows a health care provider to concentrate more on the patient and less on paperwork. • Besides improving the delivery of health care to patients, another one of the benefits of electronic medical records integration is that it can reduce administrative and other related costs for physicians. • Storage space dedicated to paper charts can essentially be eliminated once the transition to an EMR system is complete.
  • 11. • Here we summarize our findings on how physician practices used and generated clinical benefits from each type of EMR capability and on the major barriers these practices encountered. • Our key insight with policy implications is that the path to quality improvement and financial benefits lies in getting the greatest number of physicians to use the EMR (and not paper) for as many of their daily tasks as possible. • The key obstacle in this path to quality is the extra time it takes physicians to learn to use the EMR effectively for their daily tasks.
  • 12. 1.Viewing •All practices used EMR viewing capabilities, which improve chart availability, data organization, and legibility. •Quality benefits depended on the amount of viewable clinical data. •The amount of initially viewable data depended on efforts to type in existing paper-based medical record data and to electronically import data from lab, billing, and other systems. •As patient data accumulated over time, financial savings accrued from less staff time spent finding, pulling, and filing charts and less physician time spent locating information.
  • 13. 2.Documentation and care management •We identified a consistent relationship between greater electronic documentation by physicians and greater quality improvement and financial benefits. •Although most clinicians maintained electronic problem and allergy lists, physicians varied greatly in how they documented progress notes. •Basic use of the EMR improved the legibility and accessibility of progress notes and increased the availability of electronic problem and allergy lists. More advanced use of documentation templates led to greater opportunities for improving quality of care. •In most practices the bulk of EMR-related financial benefits came from reductions in medical records and transcription staff as physicians moved from dictation to typing their own notes. Some practices increased billing revenue through more complete capture of services and decreased under coding of services provided.
  • 14. 3.Ordering •Basic use of electronic ordering typically consisted of physicians’ typing in prescription orders, responding to drug interactions and drug allergy alerts, and printing out prescriptions. •All but three practices we studied used electronic prescribing. In large practices, basic ordering often also included electronic ordering of referrals and laboratory and radiology tests. • More advanced ordering capabilities included additional decision support, electronic transmission of orders to pharmacies and laboratories, and better tracking of test-order status and test results, all of which can improve quality and decrease errors. 4.Messaging •Basic use of electronic messaging among providers improved the availability, timeliness, and accuracy of messages and increased completeness of documentation, thus potentially reducing “dropped balls” and safety problems. • Much less common was advanced messaging, which included messaging with outside providers (to improve care coordination) and with patients (to improve patient satisfaction and, potentially, patient self-care and compliance).
  • 15. 5.Analysis and reporting •Few practices initially used physician performance monitoring and feedback capabilities to improve quality and efficiency. •Over time, some practices—especially larger ones—used reporting capabilities more widely. 6.Patient-directed functionality •Most practices had limited or nonexistent practice Web sites for patients. •A few large-practice Web sites enabled patients to schedule visits, send secure e-mail messages to providers, receive e-mail reminders, order medications, access their charts, and obtain more individualized educational patient care information—all of which have the potential to improve quality. 7.Billing •Increased integration between billing and EMR software, combined with electronic documentation, can yield financial benefits through more complete capture of services provided, more defensible Medicare coding at higher coding levels, and reductions in data-entry staff
  • 16. Your Benefits At a GLANCE..!! •Increased Access and Efficiency •Affordable and easy to adopt •Feature rich EMR platform •Enhance quality of care •Improved Documentation •Increased Resources •Quality Assurance •Eliminates Costs •Reduced risk
  • 17. GET STARTED… YOU ARE A JUST A CLICK AWAY TO GO….!!!