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Electronic Health Records for Quality Nursing and Health Care PDF

498 Pages·2016·10.457 MB·English
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ELECTRONIC HEALTH RECORDS for QUALITY NURSING & HEALTH CARE HOW TO ORDER THIS BOOK BY PHONE: 877-500-4337 or 717-290-1660, 9AM–5PM Eastern Time BY FAX: 717-509-6100 BY MAIL: Order Department DEStech Publications, Inc. 439 North Duke Street Lancaster, PA 17602, U.S.A. BY CREDIT CARD: American Express, VISA, MasterCard, Discover BY WWW SITE: http://www.destechpub.com E LECTRONIC H R EALTH ECORDS for Q N UALITY URSING H C & EALTH ARE Tiffany Kelley, Ph.D., MBA, RN Founder & CEO, Nightingale Apps LLC Affiliate, Duke University Adjunct Associate Professor, Northeastern University Electronic Health Records for Quality Nursing & Health Care DEStech Pub li ca tions, Inc. 439 North Duke Street Lanc as ter, Penns ylv an ia 17602 U.S.A. Copy right © 2016 by DEStech Pub li ca tions, Inc. All rights res erved No part of this pub lic at ion may be re prod uced, stored in a ret rieval sys tem, or transm itt ed, in any form or by any means, elec tronic, me chani c al, phot oc opyi ng, rec ordi ng, or oth erw ise, witho ut the prior writt en perm iss ion of the publ isher. Printed in the United States of Ameri ca 10 9 8 7 6 5 4 3 2 1 Main ent ry un der tit le: Electronic Health Records for Quality Nursing & Health Care A DEStech Pub lic at ions book Bib lio gr ap hy: p. Inc ludes in dex p. 471 ISBN: 978-1-60595-071-6 Table of Contents Foreword xi Preface xv 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.1. The Nursing Profession and Electronic Health Records 1 1.2. Format of Electronic Health Records for Quality Nursing Care 3 1.3. Overview of Chapter 2–Chapter 12 4 1.4. References 9 2. How it All Began: Electronic Health Records in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 2.1. Overview of the First Electronic Health Records and Initial Stages of EHR Development (1960s–1990s) 12 2.2. Emergence of National Involvement and Advocacy for EHRs (1990s–2000s) 20 2.3. Continued National Advocacy (2000s–Present) 28 2.4. Chapter Summary 31 2.5. Discussion Questions 32 2.6. References 33 3. Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . 37 3.1. Defining CPR, EMR, EHR, and PHR 38 v vi Table of Contents 3.2. Components of Electronic Health Records 43 3.3. Electronic Medical Record Adoption Models 58 3.4. Electronic Health Record Adoption Models 65 3.5. Benefits of Adoption and Use of Electronic Health Records 68 3.6. Challenges of Adoption and Use of Electronic Health Records 71 3.7. Certification of Electronic Health Records 74 3.8. Chapter Summary 75 3.9. Discussion Questions 75 3.10. References 76 4. Functions of Electronic Health Records . . . . . . . . . . 81 4.1. What is an Electronic Health Record Function? 82 4.2. Patient Searches 83 4.3. Patient Lists 83 4.4. Computerized Provider Order Entry Functions 85 4.5. Problem Lists 92 4.6. Structured Data Fields 93 4.7. Unstructured Data Fields and Notes 96 4.8. Copy and Paste 97 4.9. Device Integration 99 4.10. Electronic Medication Administration Record 103 4.11. Smart Infusion Pumps 104 4.12. Trending of Data 104 4.13. Scanning of Images and Documents 105 4.14. Calculations 106 4.15. Voice Recognition 108 4.16. Electronic Transmission of Data and Information 108 4.17. Security Settings in an Electronic Health Record 110 4.18. Chapter Summary 112 4.19. Discussion Questions 112 4.20. References 113 5. HITECH Federal Regulations and Requirements from ARRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 5.1. Overview of HITECH Provisions within ARRA 118 5.2. Expansion of the Office of the National Coordinator for Health Information Technology 119 Table of Contents vii 5.3. Funding Provisions to Expand the Health Information Technology Workforce 120 5.4. Privacy and Security Regulation Expansion 121 5.5. Regional Extension Centers to Support Providers with Electronic Health Records 123 5.6. Electronic Health Record Incentive Program 123 5.7. Chapter Summary 165 5.8. Discussion Questions 166 5.9. References 167 6. Privacy and Security Concerns with Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171 6.1. Relationship between Privacy and Security 172 6.2. Privacy 172 6.3. Security 177 6.4. Privacy and Security Federal Regulations and Requirements 184 6.5. Privacy and Security Steps for Health Care Organizations 188 6.6. Chapter Summary 192 6.7. Discussion Questions 192 6.8. References 193 7. Standards, Interfaces, and Interoperability in Electronic Health Records . . . . . . . . . . . . . . . . . . . 197 7.1. Relationship between Standards, Interfaces, and Interoperability 198 7.2. Standards 198 7.3. Interfaces 213 7.4. Interoperability 216 7.5. Chapter Summary 218 7.6. Discussion Questions 219 7.7. References 220 8. Selecting and Planning for an Electronic Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 8.1. System Development Life Cycle for an Electronic Health Record 226 8.2. Selecting an Electronic Health Record 228 8.3. Planning for an Electronic Health Record 260 viii Table of Contents 8.4. Chapter Summary 274 8.5. Discussion Questions 275 8.6. References 275 9. Designing, Building, and Testing an Electronic Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 9.1. Designing an Electronic Health Record 280 9.2. Building an Electronic Health Record 299 9.3. Testing an Electronic Health Record 302 9.4. Chapter Summary 314 9.5. Discussion Questions 315 9.6. References 315 10. Implementing and Maintaining an EHR . . . . . . . . . . 317 10.1. Implementing the Electronic Health Record 318 10.2. Maintaining an Electronic Health Record 332 10.3. Chapter Summary 340 10.4. Discussion Questions 340 10.5. References 341 11. Outcomes Evaluation with Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 11.1. Importance of Evaluating Outcomes from the Use of Electronic Health Records in Health Care Organizations 344 11.2. Evaluating Outcomes from a Quality Perspective 346 11.3. Chapter Summary 353 11.4. Discussion Questions 353 11.5. References 354 12. Future Directions of Electronic Health Records . . . 357 12.1. Mobile Health Technologies 358 12.2. Big Data and Advanced Analytics 372 12.3. Enhanced Electronic Communication 380 12.4. Increased Patient Engagement 384 12.5. Expansive Efforts Toward Nationwide Electronic Health Record Interoperability 385 12.6. Increased Use of Cloud-based Electronic Health Records and Other Clinical Information System Solutions 387 Table of Contents ix 12.7. Opportunities for Nurses in Informatics 388 12.8. Chapter Summary 390 12.9. Discussion Questions 391 12.10. References 392 Appendix A—Acronyms used in Electronic Health Records for Quality Nursing Care 399 Appendix B—List of Regional Extension Centers 403 Appendix C—Alternate Clinical Quality Measures for Eligible Providers in Stage I of the Electronic Health Record Incentive Program (2011–2013) 407 Appendix D—Clinical Quality Measures for Eligible Providers in 2014 for Stage I and Stage II of the Electronic Health Record Incentive Program 411 Appendix E—HIPAA Privacy Rule Protected Health Information Identifiers 415 Appendix F—Steering Committee Membership List 417 Appendix G—Electronic Health Record Project Sample Timeline 419 Appendix H—Workflow Process Map Example 421 Appendix I—Functional Test Script Examples 423 Appendix J—Integrated System Test Script Examples 427 Appendix K—Workflow Test Script Examples 431 Glossary 435 Index 471

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