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Lecture Nursing documentation using electronic health records: Chapter 1 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 1 - An introduction to electronic health records. Chapter 1 content: Brief history of electronic health records (EHRs), history of standards development for the EHR and nursing’s role in their development, certification bodies for the EHR, benefits of the EHR, government involvement in the EHR, role of nursing informatics in healthcare. | Chapter 1 An Introduction to Electronic Health Records © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 1 Content 1.1 Brief history of electronic health records (EHRs) 1.2 History of standards development for the EHR and nursing’s role in their development 1.3 Certification bodies for the EHR 1.4 Benefits of the EHR 1.5 Government involvement in the EHR 1.6 Role of nursing informatics in healthcare L.O. 1.1 The EHR History L.O. 1.1 The EHR History Impetus for development Quality patient care 1960s First EMR programs First electronic databases L.O. 1.1 The EHR History Terms and Definitions CPR: Computer-Based Patient Record EMR: Electronic Medical Record EHR: Electronic Health Record CCD: Continuity of Care Document PHR: Personal Health Record L.O. 1.1 The EHR History Point of care documentation Modes of Data Entry Keyboard Voice recognition Handwriting recognition Templates and data selection Touch screens COWs/WOWs L.O. 1.1 The EHR History Security and | Chapter 1 An Introduction to Electronic Health Records © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 1 Content 1.1 Brief history of electronic health records (EHRs) 1.2 History of standards development for the EHR and nursing’s role in their development 1.3 Certification bodies for the EHR 1.4 Benefits of the EHR 1.5 Government involvement in the EHR 1.6 Role of nursing informatics in healthcare L.O. 1.1 The EHR History L.O. 1.1 The EHR History Impetus for development Quality patient care 1960s First EMR programs First electronic databases L.O. 1.1 The EHR History Terms and Definitions CPR: Computer-Based Patient Record EMR: Electronic Medical Record EHR: Electronic Health Record CCD: Continuity of Care Document PHR: Personal Health Record L.O. 1.1 The EHR History Point of care documentation Modes of Data Entry Keyboard Voice recognition Handwriting recognition Templates and data selection Touch screens COWs/WOWs L.O. 1.1 The EHR History Security and reliability Local area network (LAN) Internet Intranet Data encryption Application server provider (ASP) L.O. 1.2 Development of EHR Standards L.O.1.2 Development of EHR Standards Barriers to EHR adoption Cost Organization Lack of unified standards, functionality, and interoperability L.O.1.2 Development of EHR Standards IOM’s Committee on Data Standards for Patient Safety – 2003 Identified key competencies Became foundational benchmark for EHR development and programming Consolidated Health Informatics (CHI) standards - 2004 Enabled agencies to share information Common clinical vocabularies Standard methods of transmission L.O.1.2 Development of EHR Standards Role of nursing in standards development Promotes standardization to identify nursing’s contribution to patient care Promotes research Promotes identification of relationships among nursing interventions and outcomes L.O.1.2 Development of EHR Standards Technology Informatics Guiding Educational Reform (TIGER) Initiative Goal to