Transcript Whatcom-MA120-EMRs

ELECTRONIC
MEDICAL RECORD
SYSTEMS
Session 3 – Who has access
to what?
And how do you enter vital
signs into an EMR system?
Session 3
Sessions 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.openemr.org:2100/openemr/interface/
login/login_frame.php
(If you’re looking at slides, rightclick 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: receptionist
Password: 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 Schedule
b. New Encounters
c. Patient Reports
d. Procedures
e. Demographics
f. Medical Problems
g. 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
As Receptionist you
can access only
a. Office Schedule
and
e. Demographics
Why are you limited to
seeing only a few
pieces of information
about patients?
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 EMRs
The 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: clinician
Password: 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 Schedule
b. Demographics
c. Vitals
d. Patient Results of Procedures
e. Clinical Reminders
f. Medical Problems
g. Billing and Payment
• If you guessed a, b, c, d, e and f,
you are correct.
How well did
you do?
• As Clinician, the only set of data
you cannot access is category
g. Billing and Payment.
• Add this patient:
Now, add the
patient for whom
you will enter
vital signs.
•
•
•
•
•
•
•
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 vitals
and 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
What if you
entered the
wrong
information?
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?
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.