electronic medical record systems

Session 3 – Who has access to what? And how do you enter vital signs into an EMR system?

ELECTRONIC MEDICAL RECORD SYSTEMS

Session 3Sessions 1 & 2 defined EMR and showed how EMR records differ from paper records. In OpenEMR you logged in, added a new patient, and located information about a patient.

Now let’s look at how HIPAA affects EMR access.

Then you’ll practice recording vital signs in an EMR.

Let’s see how HIPAA affects the way an EMR works

Go to the open-EMR website.

Click on this link:http://demo.open-emr.org:2100/openemr/interface/login/login_frame.php

(If you’re looking at slides, right-click on the link and choose “open hyperlink,” or else copy the link.)

This is the screen that should appear

Log in to the EMR.

Enter this information

Username: receptionistPassword: receptionist

Is this what you see? If so, then you’ve logged in correctly.

Which of the following can you access as Receptionist?a. Office Scheduleb. New Encountersc. Patient Reportsd. Procedurese. Demographicsf. Medical Problemsg. Vital Signs

1. Click on the list of items at the left of the screen.

If you are allowed to see an item, it will open.If you aren’t allowed, the item will be grayed out, and you will get this message if you click on the item.

Answer Why are you limited to seeing only a few pieces of information about patients?

As Receptionist you can access only

a. Office Scheduleand

e. Demographics

Access is determined by role• One way an EMR system differs from paper is in access. With paper, anyone who touches the file has access to the records.• In an EMR, you have to have certain “access rights” in order to see different information. These rights are determined by your work role. • For instance, the physician may have access to everything in a patient’s record.• A receptionist, on the other hand, may be able to see only certain parts of that record – the parts that are necessary to perform his or her work.

How HIPAA affects EMRsThe Health Insurance Portability and Accountability Act (HIPAA) of 1996 has a privacy provision that limits who can see a patient’s records.

• If you need to see patient information to do your job, then you can have access to it. • If you don’t need that information to perform your work, then you should not have access. That’s to protect the patient’s privacy.

For more information, you can check out the HIPAA Website

Now let’s add vital signs for a patient

1. Log out as receptionist.2. Log in again, this time as

Clinician.

Username: clinicianPassword: clinician

This screen appears.

How much can you see as “clinician”?

Which of the following can you access in your role of Clinician?

a. Office Scheduleb. Demographicsc. Vitalsd. Patient Results of Procedurese. Clinical Remindersf. Medical Problemsg. Billing and Payment

How well did you do?

• If you guessed a, b, c, d, e and f, you are correct.

• As Clinician, the only set of data you cannot access is category g. Billing and Payment.

Now, add the patient for whom you will enter vital signs.

• Add this patient:

• Name: Henry P. Patient• External ID: Driver’s license• Date of Birth: January 3, 1964• Sex: M• Social Security No: 555-55-5551• License/ID: HPP 1234• Marital Status: Married

Next, create the visit

1. Click on Create Visit at the left of the screen.

2. Go to the New Encounter Form at the bottom of the screen.

3. In the Consultation Brief Description box enter Checkup

4. Click Save to save the encounter.

Your screen should look like this:

After you’ve saved the encounter, this screen appears.

Where do you go to enter his vital signs? That’s right. Click on Vitals.

The Vitals section appears. You can scroll down in this section to enter all the information you want.

Enter Henry P. Patient’s vitalsand then click Save Form.

• VITAL SIGNS:

• Height 5’ 10”• Weight 180• Temperature 98.4 • Pulse 72 • Respirations 18 • Blood pressure 146/78• O2 saturation 96% on room air

The saved Vital Signs appear

Suppose after you entered 146/78 you realized that you should have entered 140/72?

Where do you click on the form to re-enter the data?

What if you entered the wrong information?

That’s right. Click on Edit. The Vitals entries reopen, and you can correct your error.

The corrected information now appears.

You’ve successfully entered the vital signs for your patient.

That’s it for this lesson.Remember to log out of OpenEmr.