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Abdulrhman.   electronic health record (EHR)

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Abdulrhman.   electronic health record (EHR)

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An electronic health record (EHR) is a digital version of a patient's medical record. It contains all the standard medical and clinical data gathered in a traditional paper-based record, but in a digital format that is stored and shared electronically.

points about EHRs

Purpose: EHRs are designed to provide a complete record of a patient's medical history, treatments, and health status. This allows for better coordination and continuity of care.

Accessibility: Unlike paper-based records, EHRs are accessible electronically to authorized users across different healthcare settings. This improves availability and reduces issues with missing records.

Data Management: EHRs use computer-based tools to help organize, interpret, and react to patient data. This allows for better data analysis and decision support compared to manual paper records.

Flexibility: EHRs are more flexible and adaptable than static paper records. Data can be updated, shared, and analyzed more easily in digital form.

Efficiency: EHRs can improve clinical workflow and efficiency through features like automated reminders, order entry, and billing integration.

In summary, the key differences from traditional paper records are the electronic storage, improved accessibility, advanced data management capabilities, and enhanced flexibility that EHRs provide. This allows for better coordination, continuity, and quality of patient care.

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the benefits and challenges of Electronic Health Record (EHR) systems(Abdulmalek).

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the benefits and challenges of Electronic Health Record (EHR) systems(Abdulmalek).

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- EHRs allow authorized clinicians to access patient data securely from anywhere, enabling timely informed decisions. EHRs also provide tools to control and track access to enforce privacy policies.

- EHRs can improve the legibility, organization, completeness, and quality of medical documentation compared to handwritten records. Features like spell checkers, reference range checks, and prompts can enhance data quality.

- Data entered into an EHR can be reused, improving provider efficiency (e.g. copying parts of notes into other documents).

- The benefits of an EHR depend on factors like the comprehensiveness of information, duration of use, degree of data structure, and ubiquity of access.

- EHRs require a larger initial investment than paper records, and physicians/staff need time to learn the systems and redesign workflows.

- There are also risks of computer system failures that can make data temporarily unavailable, unlike paper records.

- Capturing detailed clinical notes directly from physicians remains a challenge due to the time required. Some institutions scan paper charts into the EHR instead.

- Despite the challenges, there is growing recognition that EHRs are necessary to support care delivery, regulatory compliance, and business needs in healthcare.

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Here is the key points from the early history of hospital focus on medical records and electronic health record systems:

1. The Flexner report in 1910 was the first formal statement about the function and contents of the medical record, advocating for a more scientific approach.

2. The Mayo Clinic began recording diagnoses for every admitted patient in 1907, three years before the Flexner report.

3. In the 1940s, hospital accrediting bodies started requiring accurate, well-organized medical records as a condition for accreditation, and hospitals had to submit certain information as discharge abstracts.

4. In the late 1960s, early computer-based hospital information systems (HIS) emerged, focused mainly on communication, orders, and capturing charges rather than clinical care.

5. The introduction of the problem-oriented medical record (POMR) by Lawrence Weed in 1969 influenced thinking about the internal structure of medical records, emphasizing organization by medical problem.

6. Early pioneers like Morris Collen used hospital systems for preventive care screening and providing feedback to physicians to affect clinical decisions.

7. Influential early university hospital-based systems like HELP, CCC, and Regenstrief continued adding more clinical data and decision-support functionality.

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1. Radiology report flowsheet:

Display study summaries in a grid.

Icons allow access to full reports and images.

2. Chest X-ray Viewing:

Default quarter-sized view of PA and lateral images.

Zoom to full resolution and adjust brightness/contrast.

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1. Electronic Health Record (EHR) systems can integrate information from various sources, such as physician instructions, recent lab test results, etc. This is shown in this image

2. Patient encounters go beyond just face-to-face visits - they also include events like phone calls about new symptoms or prescription renewal requests. The EHR should have tools to handle these events, such as notification of the clinician, access to the patient's chart, and templates for communications.

3. EHRs are often limited to a single institution, but the National Health Information Infrastructure (NHII) aims to enable authorized providers to access relevant medical data about a patient from other organizations in their community.

4. Communication tools in the EHR can allow patients to securely access their records and perform tasks like asking questions or renewing prescriptions online.

5. Community-based EHRs can facilitate the creation and transmission of reports to support patient safety, quality improvement, public health, research, and other healthcare operations.

6. There are two main methods for capturing data in an EHR: electronic interfaces with existing systems (e.g. labs, instruments), and manual data entry when no electronic source exists. Scanning paper reports is also an option but the data is not searchable.

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-         The data-entry is complex process , involving the translation of data into ( free-text, coded form) or a combination of both.

-         Advantages: data are classified and standardized ,Coding lets the computer “understand” the data

-         Disadvantage: the human time it takes to translate the source text into valid codes, risk of error

-         Data can flow automatically to the EHR through message standards such as HL7

-         Transcription: Physicians write notes (present illness, past history, physical examinations, and treatment plan).

-         Direct Data Entry: Physicians enter data directly into the EHR using electronic templates.

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Data Integration Challenges & Integrated Patient Data Access (Fahad)

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Data Integration Challenges & Integrated Patient Data Access (Fahad)

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Data Integration Challenges:

Inconsistent terminologies and coding systems: Different source systems use varying standards.

EHR system adaptations: Message formats and coding systems must be revised to accommodate data from diverse sources.

Interface engines: These tools facilitate data integration but require human intervention for mapping.

Standardized code systems: LOINC and SNOMED can streamline integration.

Integrated Patient Data Access:

Multiple views: Clinicians need various views of patient data, including chronological, flowsheet, and specialty-specific.

Summary view: A snapshot of a patient's current status, updated with each encounter.

Web-based access: Remote access requires advanced security measures.

Radiology integration: Examples include flowsheet and image view.

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Summary of Electronic Health Record ( Mohaanad ) 

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Summary of Electronic Health Record ( Mohaanad ) 

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### Summary of Electronic Health Record (EHR):

#### 1. Definition of Electronic Health Record (EHR):

- An electronic health record is a digital repository that contains information about an individual's health status and health care throughout their life, and is stored to be available for use by various legitimate users.

#### 2. Difference between an electronic health record and a paper record:

- Flexibility: The electronic record is dynamic and allows data to be entered, stored, and displayed in different ways, unlike a static paper record.

- Accessibility: Electronic records can be accessed remotely and at any time by authorized individuals, which solves the common problem of inaccessibility in paper records.

- Integration: The electronic record can include multimedia information such as radiographs and videos, which cannot be achieved in paper records.

- Information Management: The electronic record provides tools to support clinical decision-making, such as alerts and reminders, and the collected data can be used for research and care management purposes.

#### 3. Functional Components of the Electronic Health Record:

- The electronic record includes tools for data entry, management, and interpretation, as well as interfaces with other systems and multimedia integration.

#### 4. Benefits of the Electronic Health Record:

- Improved immediate access to patient data.

- Enhanced data management and analysis capabilities.

- Provides better integration of health information across different care providers and care settings.

#### 5. Barriers to the Development and Use of the Electronic Health Record:

- Challenges include cost, user training, system integration, and potential resistance to change within healthcare organizations.

This summary reflects the key points about electronic health records as outlined in the chapter presented.

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Clinical decisions support

Decision support is thought to be most effective when provided at the point of care, while the physician is formulating his or her assessment of the patient’s condition and is making ordering decisions.

Feedback is used to improve the clinical protocol and the software program.

Clinician Order Entry

If the primary goal of an EHR system is to assist clinicians in making informed decisions, the system should provide relevant information at the moment of order entry.

The WIZ Order screen integrates information about a patient’s active orders, clin- ical alerts based on current data from the electronic patient record, and abstracts of rel- evant articles from the literature.

Physician order-entry systems can warn the physician about allergies and drug interactions before they complete a medication order

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1.Access to knowledge 2.Intergrated communication and Reporting support 

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1.Access to knowledge 2.Intergrated communication and Reporting support 

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1. Access to knowledge resources for clinicians:

1.PubMed: A free literature search site provided by the National Library of Medicine.

2.UpToDate: An online reference

3.OVID: A platform offering full-text resources

These resources can be integrated into clinical workflows, such as through an "Infobutton," to provide relevant literature and improve decision-making.

A Computer-based patient record (CPR) linked to knowledge resources so that con-text-specific information can be displayed at the time of clinical decision making.

2. Integrated communication and Reporting Support:

1 .EHR Integration: Attach messages and test results directly to a record for easy access.

2.Networked Communication: Connect team members across various locations (offices, hospitals, homes) to share patient information.

3 . Home Connectivity: Enable remote health monitoring and communication with patients at home.

4 .Push and Pull Communication: Send information via email or pager (“push”) or access it during routine system interactions (“pull”).

5.Community-Based EHRs: Share patient data across institutions for comprehensive care

6.Routine Handoffs: Use EHR systems to transfer care responsibilities smoothly between clinicians.

These measures improve coordination, timeliness, and quality of care by ensuring all relevant information is readily available to healthcare providers.