Electronic Medical Record

Vincent N. Carrasco, MDLAIRMSIS ‘14

JARGON• EMR• EHR• CCR• CCD• CDO• RHIO• NHIN• CDS• CPOE• ASTM• HL7• DEA• NPI• CQM• ICD-9, CPT, SNOMED• EOB

• Electronic Medical Record• Electronic Health Record• Clinical Care Record• Continuity Of Care Document• Clinical Delivery Organization• Regional Health Information Organization• National Health Information Network • Clinical Decision Support• Clinical Physician Order Entry• American Society for Testing & Materials• HL7• Drug Enforcement Agency• National Provider Identifier• Continuous Quality Management• Medical Coding systems for services• Estimate of Benefits

EMR VS. EHR

EMR vs. EHRElectronic Medical Records

• The legal record of the CDO.

• A record of clinical services for patient encounters in a CDO

• Owned by the CDO• These systems are being sold by

enterprise vendors and installed by hospitals, health systems, clinics, etc.

• May have patient access to some results info through a portal but is not interactive

• Does not contain other CDO encounter information

Electronic Health Records

• Subset (i.e. CCR or CCD) of information from various CDOS

• Where patient has had encounters

• Owned by patient or stakeholder• Community, state, or regional• Emergence today (RHIOS) – or --

Nationwide in the future.

• Provides interactive patient access as well as the ability for the patient to append Information.

• Connected by NHIN

© 2006 HIMSS AnalyticsTM

USE CASE vs. USE CASE SCENARIO

How are they used?

INTRODUCTION TO

Path to Understanding

USE CASESINGLE

PATH

SINGLE PATH

USE CASE =

Path to Understanding

MULTIPLE PATHS

USE CASE SCENARIO

MULTIPLE PATHS

USE CASE SCENARIOS =

Path to Understanding

USE CASEUSE CASE SCENARIO

OpenEMRFunctions and Features

OpenEMR Features

• Patient scheduling• Patient Demographics• Electronic Medical Records• Prescriptions• Medical Billing• Clinical Decision Rules• Support• Patient Portal• Reports• Security

Q & A

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