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Electronic Medical Record Vincent N. Carrasco, MD LAIR MSIS ‘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. EHR Electronic Medical Records Electronic Health 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 • • • • • 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 Analytics TM How are they used? INTRODUCTION TO USE CASE vs. USE CASE SCENARIO Path to Understanding USE CASE SINGLE PATH USE CASE = SINGLE PATH Path to Understanding MULTIPLE PATHS USE CASE SCENARIO USE CASE SCENARIOS = MULTIPLE PATHS Path to Understanding USE CASE USE CASE SCENARIO OpenEMR Functions and Features OpenEMR Features • • • • • • • • • • Patient scheduling Patient Demographics Electronic Medical Records Prescriptions Medical Billing Clinical Decision Rules Support Patient Portal Reports Security Q&A Next up OPENVISTA