ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee ii 11//44//0088 44::4444::5544 PPMM uusseerr //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 0 VV ELECTRONIC HEALTH RECORDS for Allied Health Careers 0 Susan M. Sanderson ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee iiii 11//99//0088 55::2200::5522 AAMM eellhhii //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 ELECTRONIC HEALTH RECORDS FOR ALLIED HEALTH CAREERS Published by McGraw-Hill, a business unit of The McGraw-Hill Companies, Inc., 1221 Avenue of the Americas, New York, NY, 10020. Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of The McGraw-Hill Companies, Inc., including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning. Some ancillaries, including electronic and print components, may not be available to customers outside the United States. This book is printed on acid-free paper. 1 2 3 4 5 6 7 8 9 0 VNH/VNH 0 9 8 ISBN 978-0-07-340197-3 MHID 0-07-340197-8 Vice President/Editor in Chief: Elizabeth Haefele Senior production supervisor: Janean A. Utley Vice President/Director of Marketing: John E. Biernat Designer: Marianna Kinigakis Senior sponsoring editor: Debbie Fitzgerald Senior photo research coordinator: Lori Hancock Managing developmental editor: Patricia Hesse Media project manager: Mark A. S. 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CLUE and CliniClue® are available as freeware from The Clinical Information Consultancy Ltd, http://www.cliniclue.com; p. 62: Dept. of Defense Photo by Airman 1st Class Kurt Gibbons III, US Air Force; p. 99: © The McGraw-Hill Companies, Inc./Andrew Resek, photographer; pp. 118–119: © The Leapfrog Group; p. 130: InteleViewer Workstation, © Intelerad Medical Systems Incorporated; 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 5.10, 5.11: Reprinted with permission. Copyright 2006 Medem, Inc.; pp. 152–153: Reprinted with permission. Copy- right 2006 Medem, Inc.; 5.15: © Dossia; 5.16: © IndivoHealth; 5.17: Reprinted with permission. Copyright 2006 Medem, Inc. Library of Congress Cataloging-in-Publication Data Sanderson, Susan M. Electronic health records for allied health careers / Susan M. Sanderson. p. ; cm. Includes index. ISBN-13: 978-0-07-340197-3 (alk. paper) ISBN-10: 0-07-340197-8 (alk. paper) 1 . Medical records—Data processing. 2. Allied health personnel. I. Title. [DNLM: 1. Medical Record Administrators. 2. C onfi dentiality. 3. Forms and Records Control—methods. 4. Medical Records Systems, Computerized. 5. Practice Management, Medical. WX 173 S216e 2009] R864.S263 2009 610.28’5—dc22 2007051786 The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a Web site does not indicate an endorsement by the authors or McGraw-Hill, and McGraw-Hill does not guarantee the accuracy of the information presented at these sites. All brand or product names are trademarks or registered trademarks of their respective companies. All names, situations, and anecdotes are fi ctitious. They do not represent any person, event, or medical record. www.mhhe.com 0 ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee iiiiii 11//99//0088 1100::1166::3388 PPMM tteeaammaa //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 0 Brief Contents Chapter 1 Introduction to Electronic Health Records 1 Chapter 2 Transitioning to an Electronic Health Record and the Need for Clinical Information Standards 40 Chapter 3 Electronic Health Records in the Physician Offi ce 70 Chapter 4 Electronic Health Records in the Hospital 108 Chapter 5 Personal Health Records 137 Chapter 6 The Privacy and Security of Electronic Health Information 172 Chapter 7 Introduction to Practice Partner 204 Glossary 237 Index 240 iii 0 ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee iivv 11//99//0088 33::4488::2211 AAMM eellhhii //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 0 Contents Preface vi EHR Hosting Choices: Local Versus Application Your Career in Allied Health vi Service Provider 51 The Importance of Clinical Standards 53 Overview of This Textbook vi Types of Clinical Information Standards 55 To the Student vi Voluntary Versus Mandatory Standards 63 What Every Instructor Needs to Know viii Chapter 3 Teaching Supplements viii Electronic Health Records in the Acknowledgments x Physician Offi ce 70 Chapter 1 Patient Flow in the Physician Practice 72 Introduction to Electronic Coding and Reimbursement in Electronic Health Records 1 Health Records 84 Clinical Tools in the Electronic Health Record 91 A Mandate for Change 3 E-Prescribing and Electronic Health Records 95 Trends in Technology, the Economy, and Government Policy 7 Chapter 4 What Is a Medical Record? 11 The Purpose and Use of Health Records 17 Electronic Health Records in the Core Functions of an Electronic Health Hospital 108 Record System 19 Advantages of Electronic Health Records 28 The Need for Clinical Information Systems 109 Implementation Issues 31 The Complexity of Hospital Information The Impact of Information Technology on Systems 110 Allied Health Careers 33 Components of an Inpatient EHR System 111 Clinical Documentation 114 Chapter 2 Computerized Physician Order Entry 115 Transitioning to an Electronic Health Medication Management in Hospitals 121 Results Reporting 126 Record and the Need for Clinical Information Standards 40 Chapter 5 Converting Existing Charts to an Electronic Personal Health Records 137 Health Record 42 Entering Live Data in an Electronic The Need for Personal Health Records 139 Health Record 44 The Role of Personal Health Records in Computer Requirements for Electronic Managing Health 141 Health Records 46 Defi ning Personal Health Records 144 iv ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee vv 11//99//0088 1100::1166::4444 PPMM tteeaammaa //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 Types of Personal Health Record Applications 148 Privacy and Security Risks of Electronic Health Benefi ts of Networked Personal Health Information Exchange 191 Records 163 The Importance of Public Trust 197 Barriers to the Implementation of Personal Health Records 166 Chapter 7 Introduction to Practice Partner 204 Chapter 6 Practice Partner: An Ambulatory EHR 205 The Privacy and Security of Electronic Passwords, Access Levels, and the Park Health Information 172 Feature 206 Exploring the Main Practice Partner Screen 209 The Health Insurance Portability and The Dashboard 210 Accountability Act of 1996 (HIPAA) 175 Patient Registration Information 213 The HIPAA Privacy Rule 176 The Patient Chart 214 Protected Health Information (PHI) 179 Threats to the Security of Electronic Glossary 237 Information 187 The HIPAA Security Rule 188 Index 240 Contents v PRACTICE PARTNER® is a registered trademark of McKesson Corporation and/or one of its subsidiaries. All rights reserved. Screen shots used by permission of McKesson Corporation. © McKesson Corporation 2007. All rights reserved. 0 ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee vvii 11//44//0088 44::4455::1100 PPMM uusseerr //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 0 Preface V Welcome to Electronic Health Records for Allied Billing professionals use information in the Health Careers. This text introduces you to the use EHR to prepare insurance claims and patient of electronic health records in today’s rapidly chang- statements ing health care environment. Whether you plan to V Respiratory therapists, occupational therapists, work as a medical assistant, a coding professional, physical therapists, and others review patient a lab technician, or in any other area of allied records, respond to orders sent from an EHR health, this book is addressed to you. and enter treatment plans in an EHR V Pharmacy technicans receive and process medi- cation orders sent from an EHR YOUR CAREER IN ALLIED HEALTH As you can see, many allied health careers require This is an exciting time to be entering the allied the use of computers, and because of this, there health fi eld. In all work settings, from hospitals is great demand for graduates who have a back- and physician group practices to laboratories, ground in health care as well as experience with long-term care facilities, and pharmacies, allied computers. In addition, employers are seeking health professionals are in demand. At the same individuals who are capable of operating within a time, major changes are taking place in health work environment that is always changing. To be care. As costs continue to rise, there are greater successful, workers must be willing and able to demands for improved quality and safety in patient learn new things throughout their career. In addi- care. To tackle these problems, the U.S. health tion to education, certifi cation from a nationally- care system is turning to technology. This text recognized organization brings more employment focuses on one part of the technology initiative— options and advancement opportunities. the shift from paper-recordkeeping systems to electronic health records. OVERVIEW OF THIS TEXTBOOK Why do allied health students need to know about electronic health records? The answer is simple— Whatever your particular course of study in health because you will use electronic health records to care, this text provides you with a broad introduc- accomplish tasks once on-the-job. The transition tion to electronic health records. The intention of from paper records to electronic records affects this book is not to make you an expert in one everyone working in health care today. Consider particular EHR program, although you will work just a few examples of the changes electronic with an EHR program in Chapter 7. The goal of health records (EHRs) bring to these jobs: the text is to explain the ways in which EHRs are V used in different health care settings, and how Medical assistants enter patient information, they are changing the nature of the work performed such as vital signs, into an EHR by individuals throughout the health care fi eld. V Coding professionals review electronic documen- tation in the EHR to determine the appropriate TO THE STUDENT codes for an encounter V Technicians working in blood and chemistry The chapters in this text follow a logical sequence. labs, radiology, nuclear medicine, cardiovascular The fi rst six chapters provide you with an under- medicine and other areas respond to electronic standing of electronic health records—what they orders and send test results electronically using are, who uses them, how they differ from paper an EHR records, and why have become so popular. The vi ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee vviiii 11//44//0088 44::4455::1111 PPMM uusseerr //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 V fi nal chapter provides you with the opportunity to Chapter 4 explains how electronic health records gain hands-on experience with an EHR program. are used in hospitals and how they interact with other hospital information systems. The chapter coverage is as follows: V V Chapter 5 explores personal health records Chapter 1 introduces the topic of electronic (PHRs), including how they differ from elec- health records. It explains what they are, why tronic health records, and the different types of they are needed, and what they can do, as well PHRs available. as the impact of information technology on V Chapter 6 covers the challenges to privacy and allied health careers. V security that are created by the widespread use Chapter 2 explains how paper records are con- of electronic health record systems, including verted to an electronic format, and the com- the HIPAA legislation. puter hardware required to use an electronic V Chapter 7 introduces you to the features and heath record system. It also provides an over- functions of an outpatient electronic health view of the common standards for clinical record program, McKesson’s Practice Partner. health information. V You will complete hands-on exercises working Chapter 3 covers the use of electronic health with the software. records in outpatient settings, such as a physi- cian’s offi ce. Preface vii PRACTICE PARTNER® is a registered trademark of McKesson Corporation and/or one of its subsidiaries. All rights reserved. Screen shots used by permission of McKesson Corporation. © McKesson Corporation 2007. All rights reserved. 0 ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee vviiiiii 11//44//0088 44::4455::1111 PPMM uusseerr //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 0 What Every Instructor Needs to Know WELCOME TO ELECTRONIC HEALTH RECORDS FOR ALLIED HEALTH CAREERS! As you know, the fi eld of health care is in the midst of an enormous transition from paper-based recordkeeping systems to electronic health records. Your students are entering the allied health fi eld at an excit- ing time, and you are teaching at an exciting time. While the demand for graduates with a background in allied health exceeds the supply, students entering the fi eld today also need a basic understanding of health information technology, specifi cally, electronic health records. That is the purpose of this text, which was developed specifi cally for students in allied health programs. TEACHING SUPPLEMENTS For the Instructor Instructor’s Manual (0-07-3284297) includes: V Course overview V Chapter-by-chapter lesson plans V Case Studies, Your Turn Exercises, and end-of-chapter solutions V Correlation tables: SCANS, AAMA Role Delineation Study Areas of Competence (2003), and AMT Registered Medical Assistant Certifi ca- tion Exam Topics. Instructor Productivity Center CD-ROM (packaged with the Instructor’s Manual) includes: V Instructor’s PowerPoint® presentation of Chapters 1 through 7. V Electronic testing program featuring McGraw-Hill’s EZ Test. This fl exible and easy-to-use program allows instructors to create tests from book specifi c items. It accommodates a wide range of question types and instructors may add their own questions. Multiple ver- sions of the test can be created and any test can be exported for use with course management systems such as WebCT, Blackboard, or PageOut. V Instructor’s Manual. viii ssaann0011997788__ffmm__ii--xx..iinndddd PPaaggee iixx 11//99//0088 33::4488::4444 AAMM eellhhii //VVoolluummeess//220022//MMHHBBRR001166//mmhhssaann11//ssaann11ffmm%%00 Online Learning Center (OLC), www.mhhe.com/SandersonEHR, includes: V Instructor’s Manual in Word and PDF format V PowerPoint® fi les for each chapter V Links to professional associations V PageOut link. For the Student Online Learning Center (OLC), www.mhhe.com/SandersonEHR, includes additional chapter quizzes and other review activities. What Every Instructor Needs to Know iixx PRACTICE PARTNER® is a registered trademark of McKesson Corporation and/or one of its subsidiaries. All rights reserved. Screen shots used by permission of McKesson Corporation. © McKesson Corporation 2007. All rights reserved.