Introduction to Electronic Health Records                                      

Course Description:    

The introduction to Electronic Health Records discusses the rapidly changing technology in the health care environment.  The course will introduce the basic functions of the Electronic Health Record, its’ benefit to us as healthcare workers and the benefit to physicians and patients.  The course will explore the technological requirement for an Electronic Health Record system and discuss some of the available options.  The course will also introduce the best practices for transition from a paper based record to an Electronic Health Record.  It also discusses the current Health Information technology standards as well as the rules and regulations that govern the Electronic Health Record Software.

Course Objectives:

Upon completion of this course, students will be able to:

• Describe the functions of electronic health records and explain the advantages they offer physicians and patients over paper-based records.
• Recognize and discuss best practices for transition from a paper based record to an Electronic Health Record.
• Create a workflow to demonstrate how electronic health records are used in physician practices and other outpatient settings.
• Create a workflow to demonstrate how electronic health records are used in hospitals.
• Identify and describe the functions of a Regional Health Information Organization RHIO and explain how the RHIO is dependant on the Electronic Health Record.
• Identify and describe the functions of a Personal Health Record (PHR) and explain how the PHR is dependent on the Electronic Health Record.
• Explain the importance of and define the clinical standards as well as the HIPAA standards in the development of interoperable electronic health records.
• List the challenges that electronic health information poses to the privacy and security of patient’s health information.

Course Content:

Lesson 1 – Introduction to Electronic Health Records

This lesson introduces the topic of electronic health records.  It explains what they are, why they are needed, and what they can do, as well as the impact of information technology on allied health careers.  This lesson covers the following topics:

• What is a Medical Record?
• The purpose and use of Health Records
• Core functions of an Electronic Health Record
• Advantages of an Electronic Health Record
• Implementation Issues
• Trends in Technology, the economy, and government policies
• The impact of information technology on allied health careers

Lesson 2 – Electronic Health Records in the Hospital

In this lesson, the student will learn about the use of the electronic health record in a hospital setting.   The student will be able to create an Electronic Health Record workflow for a hospital.  The workflow will demonstrate an understanding of how information from other electronic systems may interact with a hospital based Electronic Health System.  This lesson covers the following topics:

• The need for clinical information systems
• The complexity of hospital information systems
• Components of an inpatient Electronic Health Record system
• Clinical documentation
• Computerized physician order entry
• Medication management in hospitals
• Results reporting
• Patient flow using the Electronic Health Record in a hospital

Lesson 3 – Electronic Health Records in the Physician Office

In this lesson, the student will learn about the use of electronic health records in outpatient settings, such as a physician’s office.   The student will be able to create an Electronic Health Record workflow for a physician practice.   The workflow will demonstrate how hospital electronic health records as well as stand alone laboratory information systems interact with a physician office based electronic health record. This lesson covers the following topics:

• Clinical tools in the electronic health record
• E-prescribing and electronic health records
• Coding and reimbursement in electronic health records
• Patient flow using the Electronic Health Record in a Physician practice.

Lesson 4 – Transitioning to an Electronic Health Record and the Need for Clinical Information Standards

This lesson prepares the student for choosing an Electronic Health Record product as well as understanding the technological requirements and possible system limitations.  The student will understand the best practices for transitioning from a paper based record to an Electronic Health Record.  This lesson covers the following topics:

• Choosing an Electronic Health Record product
• Choosing an Electronic Health Record  hosting option
• Computer requirements for the Electronic Health Record
• Best Practices for converting paper based records to Electronic Health Records.
• Entering data into an Electronic Health Record.

Lesson 5 – Personal Health Records and Regional Health Information Organizations

This lesson defines and explains what personal health records are as well as how they interact with the Electronic Health Record.  This Lesson also defines and explains Regional Health Information Organizations and how they differ from the Personal Health Record.  This lesson covers the following topics:

• Defining personal health records
• The role of personal health records in managing health
• How Personal Health Records rely on the Electronic Health Record
• Defining Regional Health Information Organizations
• The role of Regional Health Information Organizations in managing health
• How Regional Health Information Organizations rely on the Electronic Health Record

Lesson 6 – The Privacy and Security of Electronic Health Information

This lesson covers the challenges to privacy and security that are created by the widespread use of electronic health record systems, including the impact of the HIPAA legislation.  This lesson covers the following topics:

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
• The HIPAA privacy rule and its impact on the Electronic Health Record
• The HIPAA security rule and its impact on the Electronic Health Record
• Threats to the security of electronic information
• Privacy and security risks and electronic health information exchange
• The importance of public trust

Evaluation:

A student’s final grade will be based on and calculated using test scores, case studies, and additional work assignments, as given. The final exam will count as 20% of the total grade, chapter tests 60%, and case studies, workflows and all other scores 20%.

Instructional Materials:

Books

Electronic Health Records for Allied Health Careers, Susan Sanderson, McGraw-Hill, 2009

Introduction to Electronic Health Records Student Manual, Career Tech Services, 2009

Working with Electronic Health Records

Course Description:         

This course will provide students with the knowledge and skills required to work with electronic health records in today’s rapidly changing health care environment.  This course provides the student with an in-depth and practical training on a widely used Electronic Health Record software program.  Students will be able to apply theoretical knowledge to equip them to successfully enter the medical community with a comprehensive working experience and understanding of an EHR as well as their components.

Course Objectives:

Upon completion of this course, students will be able to:

·      Identify and enter/manipulate Basic Demographic and Clinical Health Information

·      Recognize and list Clinical Decision Support Tools

·      Describe and enter/manipulate Physician Order Entry Screens and Electronic Prescribing

·      Define, formulate and interpret Health Quality Information from an Electronic Health Record

·      Exchange and accept Electronic Health Information from downstream systems

·      Analyze and manage security on an Electronic Health Record system

·      Arrange and create detailed workflows using an Electronic Health Record

Lesson 1 - Demographics and Clinical Health Information

This lesson defines demographics and explains the uses and necessity of Clinical Health Information.  The student will be able to enter, modify and display patient demographics as well as identifying critical Clinical Health Information needed for a patient visit.  The student will be able to:

·      Describe the uses as well as the necessity of Demographics and Clinical Health Information       

·      Enter, Modify and Display essential patient information

·      Manage a patient’s problem/diagnoses list

·      Enter, Modify and  Display patient’s medications

·      Enter, display and search for test results

·      Enter, display and search for clinical data

·      Display and Review clinical notes

Lesson 2 - Clinical Decision Support Tools

This lesson explains and defines what Clinical Decision Support tools are.  It discusses the purpose of clinical decision support tools and why they are needed for patient care. The lesson also defines Disease Management Tools and explains the difference between Clinical Decision Support Tools and Disease Management Tools.

The student will be able to:

·      Define and list the uses and purpose of Decision Support Tools

·      Identify abnormal test results

·      Explain Alerts

·      Create Alert examples for an Electronic Health Record system

·      Define and list the uses and purpose of Disease Management Tools

·      Recognize the differences between Decision Support Tools and Disease Management Tools

Lesson 3 - Physician Order Entry and Electronic Prescription Tools

This lesson discusses Computerized Physician Order Entry (CPOE).  The lesson explains the benefits of Computerized Physician Order Entry and how they are used in hospital and outpatient settings. The student will be able to:

·      Define and discuss the uses of Computerized Physician Order Entry (CPOE) systems.

·      Obtain and read an order

·      Review and print a patient’s prescription

·      Review, obtain and print a patient referral

Lesson 4 - Quality Assurance of Health Information

This lesson explains what Quality Assurance is and how it affects Health Information as well as patient care.  The lesson will describe how to design Quality Assurance reports and how to analyze and apply the findings.  The student will be able to:

·      Describe and list how the EHR can support quality improvement activities

·      Design, generate and analyze reports from clinical information

·      Design, generate and analyze to identify and trend patient populations

Lesson 5 - Exchanging and Sharing Health Information

This lesson describes how health information is exchanged and shared among providers and health systems.  This lesson explains the uses and benefits of a patient care summary as well as the uses and benefits of patient medication lists.  The lesson reviews the uses of downstream information and how the information can be used.  The student will be able to:

·      Generate and print a Patient Care Summary

·      Generate and print a patient medication list

·      Obtain and import lab information from downstream systems

Lesson 6 - Managing Security in an EHR environment

This lesson describes the importance of security in an EHR environment and various tools within an EHR to assist with security management.  The lesson will define audit trails and roles based access and how they are used in the EHR environment.  The lesson will list and explain authentication regulations and how to ensure compliance.  The student will be able to:

·      Define and identify the uses of audit trails

·      Produce and maintain an audit trail

·      Define and explain the reasons for Role Based Access

·      Produce a role based access grid and assign access rights based on the grid.

·      Identify and list the rules and regulations regarding authentication.

Lesson 7 - Workflow Management Tools

This lesson will explain what workflow management tools are and how to use them in a health care setting.  The lesson will illustrate how to obtain insurance eligibility benefits as well as appropriate billing codes.  The student will be able to:

·      Define task queues and discuss how they are used in health care settings.

·      Create, assign and reassign a task to populate a task queue

·      Upload and review a physician’s schedule

·      Describe the steps needed to obtain insurance eligibility and benefits

·      Describe the steps needed to apply appropriate physician billing codes

·      Apply billing codes as needed

Evaluation:

A student’s final grade will be based on and calculated using test scores, case studies, and additional work assignments, as given. The final exam will count as 20% of the total grade, chapter tests 60%, and all other scores 20%.

Instructional Materials:

Books

Working with Electronic Health Records Student Manual, Career Tech Services, 2009