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Diagnosis, and Therapies

This document discusses tracking clinical outcomes through electronic health records (EHRs). It outlines approaches like using narratives or standardized terminologies to document patient status. It also lists several standardized coding systems used in EHRs like LOINC for lab tests and diagnoses, SNOMED CT for answers to tests, and ICD-10 for diseases. The ownership and components of EHRs are also covered, including things like clinical workflow, decision support, and reporting capabilities. Overall benefits of EHRs include increased guideline-based care, surveillance and monitoring of conditions, and reduced medical errors.

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59 views

Diagnosis, and Therapies

This document discusses tracking clinical outcomes through electronic health records (EHRs). It outlines approaches like using narratives or standardized terminologies to document patient status. It also lists several standardized coding systems used in EHRs like LOINC for lab tests and diagnoses, SNOMED CT for answers to tests, and ICD-10 for diseases. The ownership and components of EHRs are also covered, including things like clinical workflow, decision support, and reporting capabilities. Overall benefits of EHRs include increased guideline-based care, surveillance and monitoring of conditions, and reduced medical errors.

Uploaded by

Honey Macabuhay
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Tracking Clinical Outcomes

Ability to measure outcomes can be enhanced by the way an info system


is designed and used.

Approaches:
1. Narrative- provides a very good picture of the patient status by
narrative
2. Integration of standardized nursing terminologies
- not all clinicians are equally skilled in free-text form of communication
- integration of standardized terminologies enhances the ability of
reporting and further research
- provides a foundation for interoperability by improving the
effectiveness of information exchange.

Standardized EHR Codes


1. LOINC (logical observation identifiers names and codes)
- Is a universal code system for identifying health measurements,
observations, and documents
2. UCUM (the unified codes for units of measurements)
- is a code system intended to include all units of measures used in
international science, engineering and business to facilitate
unambiguous electronic communication of quantities together with their
units.
3. SNOMED CT (systematized nomenclature of medicine -Clinical terms)
- these codes often represent the “answer” for a test or measurement to
the LOINC “question” code
4. RxNorm
-provides normalized names for clinical drugs and links its names to
many of the drug vocabularies commonly used in pharmacy
management and drug interaction software
5. RadLex
- is a unified language by the American Medical standardized indexing
and retrieval of radiology information resources
6. MEDCIN
- is a medical terminology maintained by Medicomp Systems, that
encompasses symptoms, history, physical examinations, tests,
diagnosis, and therapies.
7. ICS-10
Is the 10th revision of the international statistical classification of
diseases and related health problems (ICD), a medical classification list
by the WHO. It contains codes for disease, signs and symptoms,
abnormal findings, complains, social circumstances and external causes
of injury or diseases.
8. CPT (Current Procedural Terminology_
- is a code set, maintained by the american meidcal assocation (AMA)
used to bill outpatient and office procedures
9. CDC CVX and MVX
- the centers
10. NDC (national Drug Code)
- is maintained by the FDA and provides a list of all drugs manufactures,
prepared, propagated, compounded or processed for commercial
distribution.
-database can be searched at www.himss.org

The Electronic Health Records


- a simple automation of clinical documentation

Implications:
*care delivery
*nurse-client interaction
*research

Governing Law:
Health information technology for economic and clinical health act of
2009 (HITECH)

ACCrediting organizations:
1. Drummond group
- provides high level testing services for software developers in the
healthcare practice, as well as in other industries.

Test offerings:
Auditing, quality assurance, conformance testing, cutomer software,
software certification, web service tests, intraoperability testing.

Roles of EHR accreditors:


*test EHR software operability ------> national institute of standards
and technology (NIST) test
*certify EHR vendors
COMPONENTS OF AND EHR
1. Health information and data
-comprises the px dara required to make a sound decision including
demograohics, medical and nursing dx, med list, allergies, and test
results
2. Results manamgemet
3. Order entry managemtn
-Ability of the clinicin to enter medication and othe rcare orders
-Direct into a computer
4. Decision support
-entails the use of computer reminder and alerts ti imporve the dx and
care of a px
-includes screening for correct drug selecxn and dosing, med intercxn
5. Electronic Communication and Connectivity
-online communicxn of pxs and providers bet the hc team members and
care partners
Modality:
*email
*web messaging
*Integrated health record w/in and across settings
*telemedicine
6. Patient Support
- encompasses px education and self monitoring tools, including
interactive computer based px education, home telemonitonring, and
telehealth system
7. Administrative Processes
-administrative processes including
*scheduling (px and staff)
* claims management, shceduling of inpatient and outpatient
procedures
Electronic insurance validity
Claims authorization and approval
Research
Drug recall support
8. Reposting and Population Health Management
9. Data collection tools to support public and private reporting
requirements (field health information system FHIS)

Advantages of Electronic Health Records


- increased delivery of guidelines-based care
-enhances capacity to perform surveillance and monitoring for dsx
conditions
- Reduction in med error
- Decreased use of care

Simple Benefits:
- no longer having to interpret poor handwriting and written orders
- maximize time especially in the administration of first dose medications
(antibiotics)
- reduced turn overtime for lab results in and ER department

OWNERSHIP OF ELECTRONIC HEALTH RECORDS


Key: from the executive evel to the clinican at the point of care

Sense of ownership to make the implementation successful for


themselves

Indicator:
Clinician adoption of the tool for selection, complementation, evaluation
and optimization of the EHR.

STEPS OF EHR OWNERS


1. Vendor selection process of commercially available EHR
*survey the organization’s level of interest
*identify possible barriers to p

2. Select a system based on the organization’s current predicted needs


* based on the completed needs assessment, the organization should
established key evaluation criteria to compare the diff vendors and
products
CRITERIA: (subj and obj topics concern)
*clinical workflowdecision support
Reporting
Usability
Technical buils
Maintenance of the system

Providing vendor with these guideline will ensure that the process meets
the organization needs
3. end user adoption
Clinicians must engage to use the ehr successfully in their prac and daily
workflows
Output: captured data drive the decision support that underlies behind
the patient care.

FHIS
Provides management on the diff public health programs. It is the official
system of DOH and designated national health statistics per executive
order no. 352

Objectives
*to update indicators based on the current needs
Components:
A. Recording tools
- facility based documents with more detailed data and contains day to
day activities of the health workers
*individual treatment record (ITR)
*target client list (TCL)
*summary Table
*monthly consolidation table

Recording tools: Target Client List


*the tool that enables the midiwfe or nurse to plan and carrues out px
care and service del
*considerablevalue to midwives/nurses in monitoring service del to
groups

THE TARget client lists to be maintained in the FHSISverion 2012


*for prenatal
For post partum
For nutrition and expanded program for immunization
For fam planning
For sick children

A. SUmmary tables
12 month
B. Morbidity dsxs
On a monthly basis
Source of ten leading causes of morbidity
Get the monthly trend of dsx

Reporting tools

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