Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to...
Transcript of Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to...
![Page 1: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/1.jpg)
Electronic Medical Records:
Benefits & Dangers Of The Paperless System
Presented By: Kirsten K. Ullman – Partner, Tampa
Co-Presenter: Bryan Reid – Partner, San Bernardino
![Page 2: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/2.jpg)
![Page 3: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/3.jpg)
Electronic Medical Records (EMRs): The Goal
• Improve Quality of Care
• Improve Efficiency of Care
• Share Medical Information with Other HCPs
Involved in The Patient’s Care
• Improve Legibility of Documentation
![Page 4: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/4.jpg)
Electronic Medical Records (EMRs): Legibility
![Page 5: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/5.jpg)
Electronic Medical Records (EMRs):
Benefits For Quality of Care
• Knowledge of and Coordination of Medications
Among Providers
• EMR Systems Are Backed Up In Case of
Disaster
• Access In Event of Accident/Emergency
• Able To Track Labs and Radiographic Studies
Without Duplication of Testing
![Page 6: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/6.jpg)
Safeguards From Breach
• Passwords and PIN Numbers
• Encryption-Only the users of the System That
Can Decrypt Can Access
• Audit Trails- Tracking of Users Who Access
The Health Information
• If a Breach, Notification Is Required
• Increased Protections Enacted In 2013
![Page 7: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/7.jpg)
Documentation Integrity
• Accurate and Complete Health Record
• Reflect Accurate Patient Condition
• Remove Default Template Data
– Automatic Population of Old Information
– Automatic Population of Old Findings In Review of
Systems
– Cut And Paste
![Page 8: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/8.jpg)
– Templates
• Different Patients
• Different Doctors
• Identical Descriptions Including Incision Size
![Page 9: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/9.jpg)
Legal Issues Of EMRs
![Page 10: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/10.jpg)
![Page 11: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/11.jpg)
![Page 12: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/12.jpg)
Increased Malpractice Risks Associated w/ EMRs
• Change Over From Paper To EHRs • Repetitive Data • Time Consuming
– From a Jotted Note To – 10 Mouse Clicks
• Prone To Shortcuts – Cut And Paste – Authorship Validation – Templates
• Re-population of Old Information • Confusion Re Timing of Entries • Drop Down Screens Can Prompt Error • Amendments/Changes In Entries • Verification of Author
![Page 13: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/13.jpg)
![Page 14: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/14.jpg)
Reduce Complexity & Duplication
![Page 15: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/15.jpg)
Reduce Complexity & Duplication
![Page 16: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/16.jpg)
Increase Safeguards
• Require Verification of Cut And Paste Entries
• Caution With Drop Down Menus
• Caution Re: Texts That Do Not Get Into EMR
![Page 17: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/17.jpg)
Legal Issues Of EMRs
![Page 18: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/18.jpg)
Legal Issues With EMRs
![Page 19: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/19.jpg)
Cut And Paste Shortcut
![Page 20: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/20.jpg)
Legal Issues With EMRs
![Page 21: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/21.jpg)
Legal Issues With EMRs
![Page 22: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/22.jpg)
![Page 23: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/23.jpg)
Informed Consent Issues With EMR
![Page 24: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/24.jpg)
Informed Consent Issues With EMR
![Page 25: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/25.jpg)
Informed Consent Issues With EMR
![Page 26: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/26.jpg)
Informed Consent Issues With EMR
![Page 27: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/27.jpg)
Informed Consent Issues With EMR
![Page 28: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/28.jpg)
Confusion Re Timing of Care
![Page 29: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/29.jpg)
Confusion Re Timing of Care
![Page 30: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/30.jpg)
Liability Exposure Due To EMR
• 9:33 Patient Arrived From Home
• 9:37/9:38 Call from L&D To Midwife’s Cell
• Midwife Enroute To Hospital
• 9:45 Emergent C Section Called By Midwife per
EMR notes
![Page 31: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/31.jpg)
Liability Exposure Due To EMR
![Page 32: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/32.jpg)
Liability Exposure Due To EMR
![Page 33: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/33.jpg)
Liability Exposure Due To EMR
![Page 34: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/34.jpg)
Liability Exposure Due To EMR
![Page 35: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/35.jpg)
Liability Exposure Due To EMR
![Page 36: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/36.jpg)
Liability Exposure Due To EMR
![Page 37: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/37.jpg)
Liability Exposure Due To EMR
• 9:45 Note Re Calling of STAT C Section
Inconsistent with Other EMR Charting
• 10 am Consent Signed
• 10:02 Call To Dr. P From Midwife
• 10:07 Moved to OR
• Other Op Records
• 10:23 Delivered
![Page 38: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/38.jpg)
![Page 39: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/39.jpg)
Liability Exposure Due To EMR
![Page 40: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/40.jpg)
Liability Exposure Due To EMR
![Page 41: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/41.jpg)
Liability Exposure Due To EMR
![Page 42: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/42.jpg)
Liability Exposure Due To EMR
![Page 43: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/43.jpg)
Liability Exposure Due To EMR
![Page 44: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/44.jpg)
Liability Exposure Due To EMR
![Page 45: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/45.jpg)
Physician EMR Experiences
• About the EMRs, I have Nextgen for my office and Mckesson/ Navicare Watchchild
for L&D.
• Nextgen pros: 1. allows me to see the patient’s prior encounters with all the other providers in our clinic. 2. facilitates e-prescribing. 3. improves medical record documentation and legibility. 4. facilitates medication reconciliation. 5. facilitates delivery of educational materials to patients as required by meaningful use 2.
• Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts can be very frequent and time consuming causing providers to override them. 3. Nurses or medical assistants can enter a wrong drug or dose. The doctor should always verify that info with the patient prior to submitting the prescription to the pharmacy.4. Providers often copy and paste info from prior notes into new notes without editing, as appropriate. 5. An item can be selected above or below the one desired, so “qd” can become “qid”.
• Navicare Watchchild pros: I can remotely log in and see at all times the fetal heart rate tracing from home or my office. This allows me to anticipate problems and not rely solely on the nurse’s knowledge or expertise.
• Navicare Watchchild cons: A limited number of available diagnoses that I can select from the drop-down list.
• On June 1st, 2015 our entire hospital will transition to a new EMR, called CERNER. I will keep you posted!
![Page 46: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/46.jpg)
Virtual Medicine And EMR
![Page 47: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/47.jpg)
Virtual Medicine And EMR
![Page 48: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/48.jpg)
Text Messages And EMR
![Page 49: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/49.jpg)
Recommendation
• In Developing EMR Systems, Consult Jury
Consultants Or Your Trial Counsel
![Page 50: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/50.jpg)
Recommendation
Example:
In Shoulder Dystocia Cases- Common Issues:
1) No Estimated Fetal Weight Before Admin of Pitocin
Drop Down Requiring Submission of Weight Estimate
1) Description of Delivery
Templates Re Gentle Downward Guidance; Assisted Natural Downward Guidance Versus Downward Traction Force
![Page 51: Electronic Medical Records · • Nextgen cons: 1. drop down menus and templates make it easy to overlook significant clinical info. 2. drug-drug interaction or drug allergies alerts](https://reader033.fdocuments.in/reader033/viewer/2022042203/5ea3fb0a8c6fd268f76120bc/html5/thumbnails/51.jpg)