preface EHR HIM EHR Matters!

Transcription

1 preface EHR Matters! Welcome to Integrated Electronic Health Records: An Online Course and Worktext for Greenway Medical Technologies PrimeSUITE! Electronic Health Records implementation in the United States is creating great opportunities for people who want to work in the health professions. From front office staff to nurses, doctors, and every worker in between, understanding how health information is transferred and how that information can improve the quality of healthcare is a valuable skill. Everyone working in a healthcare setting will be impacted by electronic health records as they complete their daily tasks. Developed as a comprehensive learning resource, this hands-on course for Integrated Electronic Health Records is offered through McGraw-Hill s Connect Plus. Connect Plus uses the latest technology and learning techniques to better connect professors to their students, and students to the information and customized resources they need to master a subject. It includes a variety of digital learning tools that enable instructors to easily customize courses and allow students to master content and succeed in the course. Integrated Electronic Health Records: A Worktext for Greenway Medical Technologies s PrimeSUITE complements the online Connect Plus course, and is written by an author with an extensive Health Information Management/Health Information Technology background Beth Shanholtzer, MAEd, RHIA. Both the worktext and online course include coverage of Greenway Medical Technologies PrimeSUITE, an ONC-ATCB-Certified, fully integrated, online Electronic Health Records, Practice Management, and interoperable physician-based solution. The book is not meant to be an extensive user manual for PrimeSUITE, but rather it covers the key topics for Electronic Health Records, with PrimeSUITE as the vehicle to demonstrate those topics. Attention is paid to providing the why behind each task so that the reader can accumulate transferable skills. Electronic Health Records impact a variety of programs in the health professions; as such, this content will be relevant to Health Information Management, Health Information Technology, Medical Insurance, Billing, & Coding, Medical Assisting, and even Nursing programs! To help you determine with exercises would most benefit your students, all exercises are designated with PM (Practice Management), EHR (Electronic Health Records), HIM (Health Information Management) tags, or some combination of those three. PM EHR HIM Instructors can access a correlation of the worktext s Learning Outcomes to key accrediting bodies such as CAHIIM, ABHES and CAAHEP via the book s website, vii

2 Here are the advantages you will gain using this Online Course and Worktext: The opportunity to work hands-on with simulated content of real software PrimeSUITE is used in physician practices across the country by more than 8,000 providers, impacting more than 29 million patient charts. The course contains 45 simulated PrimeSUITE exercises in the areas of Practice Management, Electronic Health Records, and Health Information Management. Having the same content for each mode of an exercise (Demo, Practice, Test, and Assessment) gives the student an opportunity to master the tasks. Simulating the software means the students work can be assessed. Connect Plus is completely online no software to install! Here s How Instructors Have Described Integrated EHR: This course is an excellent introduction for a student looking to become a part of the health information administration team! Multiple levels of knowledge and application are utilized in hands-on exercises to help you feel more comfortable in the challenging health dynamics of today. Jill Ferrari, MA, MT, MLT (ASCP), Sullivan University I would list the following strengths for this product: it provides hands-on exposure to software that is compatible with those in current use in medical offices across the country; it provides exposure to day-to-day and administrator functions; and it introduces the use of the term meaningful use as well as demonstrating examples of meaningful use. Kathleen G. Bailey, CPA, MBA, CPC, CPC-I, Ultimate Medical Academy This product has the following strengths: it develops key concepts in understanding the function of an Electronic Health Record; it has a very methodical approach; and it uses a very hands-on skill development method allowing for as much review and practice as needed. Kathy Jo Ellison, RN, DSN, Auburn University I like the approach of the book. It helps set the stage and prepare the student for a more in-depth approach later, after they have mastered the basics. Many of my textbooks jump right into the middle of a concept without laying the groundwork. This means the instructor has to set the stage. This book already has done that, and that allows the instructor to present more in-depth material, if desired, in the lectures. Marsha Dolan, MBA, RHIA, FAHIMA, Missouri Western State University I would describe the book as... [one] that allows students to complete an entire EHR from registration to discharge of the patient. It allows the students to understand how reports are utilized and the importance of understanding the material to successfully run a medical office. In terms of the approach, hands-on experience can never be replaced with lecture. Most students become bored with lecture so using a hands-on approach brings the lecture to life and provides a more thorough understanding of the topic. Laura Michelsen, MS, RHIA, Joliet Junior College viii

3 Content Highlights of Integrated EHR by Chapter Chapter Coverage 1 Introduces students to the applications used for administrative purposes (practice management) and electronic health records (EHR) EHR s pros and cons, as well as EHR s purpose and how EHR can improve patient care. Also included is an overview of the flow of patient information from registration to a complete health record and complete billing process. 2 Covers the transformation of data into information and the professionals who play key roles in the collection, maintenance, storage, and use of electronic information. The various tools used to collect data and the individual computerized applications used in healthcare are explored. Finally, the laws and standards that govern health information are introduced. 3 Administrative data that which is collected to conduct the business side of healthcare is addressed. The individual data elements that make up administrative data and the uses of that data are covered. The steps necessary to make an appointment and register a patient, collect administrative, including demographic data, and capture insurance information are all practiced through the exercises. 4 Data collection and maintenance from a clinical perspective is the focus. The past medical, surgical, family and social histories are collected through simulations. The importance of data accuracy, and proper handling of inconsistent, unclear, or incorrect data is covered in detail and practiced in PrimeSUITE. 5 Emphasizes the care provider s collection and use of healthcare data including the documentation of a patient s History of Present Illness, Review of Systems, and Physical Exam. Documentation methods, past and present, are discussed. Meaningful use of electronic health information is introduced in this chapter in relation to maintaining a Problem List, eprescribing, and computerized order entry. 6 Returning to the administrative functions, this chapter addresses the claims management process including the use of a computer-generated Superbill, ICD-9-CM, CPT, and HCPCS coding using the practice management functionality of Prime- SUITE. The student will come away with a basic knowledge of billing and coding procedures through theory and practice. An introductory comparison of ICD-9-CM to ICD-10-CM/PCS coding is also addressed. Finally, the importance of billing and coding policies and standards to ensure compliance with regulations and agency requirements rounds out this chapter. 7 Regulations such as HIPAA and HITECH as well as legal concerns related to privacy and security are the emphasis. The HIPAA privacy and security standards are covered in depth. Through completion of PrimeSUITE simulated exercises, students learn methods to maintain security, safeguard data integrity, and audit compliance with access and release of information. Exercises also include Meaningful Use of electronic data for continuity of care and accounting for data disclosures. 8 Communication and managing information stored in an electronic environment is the focus. Storing all of this information and doing nothing with it is not the intent of an electronic health record. Improving the efficiency and effectiveness of communication is a goal of most offices; the electronic environment facilitates that. Documents do not always originate in an electronic format; thus, scanning of paper to a digital format is necessary and easily achieved through an electronic record. The use of templates allows for standardized data collection (and therefore more accurate and thorough information about a patient). An alert system prevents necessary screenings and testing from slipping through the cracks, thus improving patient outcomes. Customization of screens permits flexibility and personal preferences of care providers and healthcare professionals to be taken into consideration, thus improving satisfaction with the electronic tools. 9 Explores the database its use in decision support not only for clinical reasons but also for administrative reasons. In this chapter students will have the chance to write custom reports as well as system-generated reports. The differences between an index and a registry are covered as well. The credentialing process is covered in this chapter not because the process utilizes the database, but because data is collected on care providers and healthcare professionals, which results in information that is supplied for a myriad of reasons. 10 Takes a look at where an electronic environment is taking healthcare barriers that still exist though are diminishing; mobile access that makes caring for patients more efficient for care providers, for instance, the emergence of telemedicine, telehealth, and patient medical homes. And it includes an introduction to security methods currently used to ensure the sharing of electronic health information does not get into the wrong hands. (Information about the worktext s pedagogical elements appears in the Walkthrough starting on page xiii.) ix

4 What You Can Expect from the Online Course in Connect Plus HIM PM EHR Questions from the Worktext: Check Your Understanding (CYU) Questions only appear in Chapters 1, 2, and 10. There are two to four questions at the end of each section. These are conceptual chapters. End-of-Chapter (EOC) Questions include: Matching Questions for Key Terms Multiple Choice Questions Short Answer Questions Applying Your Knowledge Questions [Critical Thinking] The CYU and EOC Questions are all tagged with the following in Connect Plus: Learning Outcome Level of Difficulty Level of Bloom s Taxonomy Correct Response Feedback All of the Learning Outcomes are correlated to the key accrediting bodies: CAHIIM, ABHES, and CAAHEP for instructors at Forty-Five Hands-On Simulated PrimeSUITE Exercises: PrimeSUITE Exercises appear in Chapters 3 through 9. All are correlated to Learning Outcomes. PrimeSUITE Exercises include the following modes: Demo Mode watch a demonstration of the exercise. Practice Mode try the exercise yourself with guidance. Test Mode complete the exercise on your own. Assessment Mode answer three to four conceptual questions about the exercise you just completed. For each PrimeSUITE Exercise, the same data is used for all of the modes in order to reinforce the skill being taught in that exercise. This is a proven learning methodology. Each PrimeSUITE Exercise is labeled with: HIM (Health Information Management) PM (Practice Management) EHR (Electronic Health Records) Or some combination of the above three. The tagging for the PrimeSUITE Assessments is provided in the Instructor s Manual at the book s website. The tags are the same as the ones for the CYU and EOC questions. Much more information on how to complete the exercises in Connect Plus, including detailed screenshots, can be found in the McGraw- Hill Guide to Success for The Greenway/Shanholtzer Integrated EHR Online Course at The guide is divided into the following sections: Welcome, Connect Plus Functionality, Demo Mode, Practice Mode, Test Mode, Assessment Mode, Tips for Working with the Content, Instructor Resources, and Technical Support. x

5 To the Instructor McGraw-Hill knows how much effort it takes to prepare for a new course. Through focus groups, symposia, reviews, and conversations with instructors like you, we have gathered information about what materials you need in order to facilitate successful courses. We are committed to providing you with high-quality, accurate instructor support. You can rely on the following materials to help you and your students work through the material in the book, all of which are available on the book s website, (instructors can request a password through their sales representative): Supplement Features Instructor s Manual (organized by Learning Outcomes) PowerPoint Presentations (organized by Learning Outcomes) - Sample Syllabi and Lesson Plans - Answer Keys for Check Your Understanding Exercises, End-of-Chapter Exercises, and Prime- SUITE Exercises including tagging for Learning Outcomes, Level of Difficulty, and Level of Bloom s Taxonomy - Documentation of Steps and Screenshots for PrimeSUITE Exercises - Key Terms - Key Concepts - Teaching Notes Electronic Testbank - EZ Test Online (computerized) - Word Version - Questions are tagged with: Learning Outcome Level of Difficulty Level of Bloom s Taxonomy Feedback Tools to Plan Course - Correlations of the Learning Outcomes to Accrediting Bodies such as CAHIIM, ABHES, and CAAHEP - Sample Syllabi and Lesson Plans - Certificate of Completion - Asset Map clickable PDF with links to all key supplements, broken down by Learning Outcomes, as well as information on the content available through Connect Plus McGraw-Hill Guide to Success for the Greenway/Shanholtzer Integrated EHR Online Course - Welcome - Connect Plus Functionality - Demo Mode - Practice Mode - Test Mode - Assessment Mode - Tips for Working with the Content - Instructor Resources - Technical Support Need help with the book or online course? Contact McGraw- Hill Higher Education s Customer Experience Team. Visit our Customer Experience Team Support website at www. mhhe.com/support. Browse our FAQs (Frequently Asked Questions) and product documentation, and/or contact a Customer Experience Team representative. The Customer Experience Team is available Sunday through Friday. xi