Integrated Electronic Health Records w/ PrimeSuite EHR Connect Plus

Integrated Electronic Health Records w/ PrimeSuite EHR Connect Plus

1st Edition

By M. Beth Shanholtzer

  • Copyright: 2012

  • Publication Date: Oct 25 2011

  • ISBN 10: 0077598547

  • ISBN 13: 9780077598549

Description

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Integrated Electronic Health Records: An Online Course and Worktext for Greenway Medical Technologies' PrimeSUITE?.

Developed as a comprehensive learning resource, this hands-on cou

Integrated Electronic Health Records: An Online Course and Worktext for Greenway Medical Technologies' PrimeSUITE?.

Developed as a comprehensive learning resource, this hands-on course is offered through McGraw-Hill?s Connect Plus. Connect Plus uses the latest technology and adaptive 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 professors to easily customize courses and allow students to learn and master content and succeed in the course.

Here?s what you can expect from the Worktext:

-A book meant to complement the online Connect Plus course, written by an author with an extensive HIM/HIT background?Beth Shanholtzer, MAEd, RHIA.

-Coverage of Greenway Medical Technologies? PrimeSUITE, an ONC-ATCB-Certified, fully-integrated, online EHR, PM and interoperability solution. The book is not meant to be an extensive user manual for PrimeSUITE, but rather it covers the key topics for EHR, 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.

-Content that will be appealing to HIM programs, HIT programs, MIBC programs and more. All exercises are designated with PM, EHR, HIM tags, or some combination of those three. Instructors can access a correlation of the Worktext?s Learning Outcomes to the key accrediting bodies such as CAHIIM, ABHES and CAAHEP via the book?s website, www.mhhe.com/greenway.

  • Language: English – lower case

  • Imprint: WCB/McGraw-Hill

  • Dimension: 8.8 x 10.8

  • Page Count: 0

New Features

  • Chapter Openers that include: Learning Outcomes?written to reflect Bloom?s Taxonomy and to establish the key points the student should focus on in the chapter. The major chapter heads are structured to reflect the LOs and are numbered accordingly. Key Terms that are defined in the chapter and the end-of-book glossary.
  • The Big Picture starts off the content for each chapter and sets the stage for what the student needs to know and why they need to know it.
  • Marginal Tips include: FYI Tips highlight information that may of interest to the reader, not related to the software. PrimeSUITE Tips highlight key things related to PrimeSUITE to which the reader should pay special attention.
  • Check Your Understanding Exercises appear in Chapters 1, 2 and 10 at the end of each section to reinforce the reader?s understanding of the material.
  • PrimeSUITE Exercises appear in Chapters 3-9: All background information and data needed to complete the exercises in Connect Plus is provided, along with a complete listing of the steps for each exercise. Each exercise is tagged with HIM (Health Information Management), PM (Practice Management, EHR (Electronic Health Records), or some combination of those tags so that the instructor can easily determine which exercises to assign based on their course needs.
  • End-of-Chapter Material includes: Chapter Summary?laid out in a tabular, step-by-step format organized by learning outcomes, with page references to help the reader review the material; Chapter Review?all questions are tagged with Learning Outcomes: Matching Questions, Multiple Choice Questions, Short Answer Questions, and Applying Your Knowledge.
  • PrimeSUITE Exercises in Connect Plus include the following parts: Demo?watch a demonstration of the exercise; Practice?try the exercise yourself with guidance; Test?complete the exercise on your own; and Assessment?answer 3-4 conceptual questions about the exercise you just completed.

Format

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Integrated Electronic Health Records w/ PrimeSuite EHR Connect Plus

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Chapter 1: AN OVERVIEW OF PrimeSUITE?s PRACTICE MANAGEMENT AND ELECTRONIC HEALTH RECORD SOFTWARE

1.1 Practice Management Applications

1.2 Why Adopt Electronic Health Record Applications? <

Table of Contents

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Chapter 1: AN OVERVIEW OF PrimeSUITE?s PRACTICE MANAGEMENT AND ELECTRONIC HEALTH RECORD SOFTWARE

1.1 Practice Management Applications

1.2 Why Adopt Electronic Health Record Applications?

1.3 Electronic Health Record Applications

1.4 The Flow of Information from Registration Through Processing of the Claim

1.5 The Use of the Help Feature

CHAPTER 2: HEALTH DATA STRUCTURE, COLLECTION AND STANDARDS

2.1 The Professionals Who Maintain and Use Health Information

2.2 Data Versus Information

2.3 Computer-Based Health Information Media

2.4 Screen-Based Data Collection Tools

2.5 Collecting Data Elements

2.6 Electronic Health (Medical) Records (EHR) (EMR)

2.7 Laws, Regulations, and Standards

2.8 The Similarities and Differences Between a Physician?s Office and Hospital Information Systems

CHAPTER 3: CONTENT OF THE HEALTH RECORD ? ADMINISTRATIVE DATA

3.1 Administrative Data Elements

3.2 Administrative Uses of Data

3.3 The Master Patient (person) Index (MPI)

3.4 Registering a New Patient in PrimeSUITE

Exercise 3.1: Register a new patient [PM]

3.5 Scheduling an Appointment

Exercise 3.2: Schedule an appointment [PM]

3.6 Editing Demographic Data

Exercise 3.3: Edit demographic information [PM, EHR]

3.7 Checking in a Patient

Exercise 3.4: Check in a patient who has arrived [PM]

3.8 Capture Insurance Information

Exercise 3.5: Capture insurance information of a patient [PM, EHR]

3.9 Utilize the Help Feature

Exercise 3.6: Use the help feature [PM, EHR]

CHAPTER 4: CONTENT OF THE HEALTH RECORD ? THE PAST MEDICAL, SURGICAL, FAMILY, AND SOCIAL HISTORY

4.1 Forms as Data Collection Tools

4.2 The Past Medical, Surgical, Family, and Social Histories

Exercise 4.1: Enter a patient?s past medical history [EHR]
Exercise 4.2: Enter a patient's list of current medications [EHR]
Exercise 4.3: Enter a patient's known drug allergies [EHR]

4.3 Handling Inconsistent or Unclear Information

4.4 Documenting Vital Signs

Exercise 4.4: Enter a patient's vital signs [EHR]

CHAPTER 5: CONTENT OF THE HEALTH RECORD ? THE CARE PROVIDER?S RESPONSIBILITY

5.1 The SOAP Note

Exercise 5.1: Look up the patient?s plan of care [EHR]

5.2 The History of Present Illness (HPI)

Exercise 5.2: Locate Juan Ortega's blood pressure [EHR]

5.3 The Review of Systems (ROS)

5.4 The Physical Exam

5.5 Medical Dictation and Transcription

5.6 Voice (Speech) Recognition Technology

5.7 Electronic Prescribing (ePrescribing)

Exercise 5.3: Using ePrescribe [EHR]

5.8 Computerized Physician Order Entry (CPOE)

5.9 Tracking Physicians? Orders

Exercise 5.4: Locate the status of an order [EHR]

5.10 The Problem List

Exercise 5.5: Utilizing the Problem List [EHR]

CHAPTER 6: FINANCIAL MANAGEMENT: INSURANCE AND BILLING FUNCTIONS

6.1 Claims Management ? Why and How

6.2 Use of a Superbill

6.3 The Claims Process Using PrimeSUITE

Exercise 6.1: Post a copayment to an account [PM]
Exercise 6.2: Given a scenario, look up the status of an insurance claim [PM]

6.4 Diagnosis and Procedure Coding Using PrimeSUITE

6.5 The Relationship Between Documentation and Coding

Exercise 6.3: Enter diagnoses and procedures to locate ICD-9 and CPT codes [PM, EHR, HIM]

6.6 The Conversion to ICD-10-CM/PCS

6.7 Accounts Receivable?Getting Paid

6.8 Managing Accounts Receivable in PrimeSUITE

Exercise 6.4: Post an insurance payment to an account [PM]

6.9 Compliance

CHAPTER 7: PRIVACY, SECURITY, CONFIDENTIALITY AND LEGAL ISSUES

7.1 The HIPAA Privacy and Security Standards

7.2 Evaluating an EHR System for HIPAA Compliance

7.3 The Role of Certification EHR Implementation

7.4 Applying Security Measures

Exercise 7.1: Add new clinical users and assign password [PM, HIM]
Exercise 7.2: Set up a care provider [PM, HIM]
Exercise 7.3: Assign user rights to an MA [PM, HIM]
Exercise 7.4: Assign user rights to an office manager [PM, HIM]
Exercise 7.5: Create a group [PM, HIM]
Exercise 7.6: Set general security [PM, HIM]
Exercise 7.7: Run an audit trail report [PM, HIM]

7.5 Data Integrity

Exercise 7.8: Amend a chart entry [PM, EHR, HIM]
Exercise 7.9: Hide a chart entry[PM, EHR, HIM]
Exercise 7.10: Recover a hidden chart entry [PM, EHR, HIM]

7.6 Apply Policies and Procedures to Release Health Information using PrimeSUITE

Exercise 7.11: Compose a correspondence letter to accompany the release of a patient's immunization record [EHR, HIM]

7.7 Accounting of Information Disclosures

Exercise 7.12: Run a report of information disclosures for a particular patient [EHR, HIM]

7.8 Information Exchange

Exercise 7.13: Exchange of information for continuity of care [EHR, HIM]

7.9 Compliance Plans

7.10 Safeguarding Your System and Contingency Planning

CHAPTER 8: MANAGEMENT OF INFORMATION AND COMMUNICATION

8.1 Internal Communications

Exercise 8.1: Send an electronic message using PrimeSUITE messaging [PM, EHR, HIM]

8.2 Importing Documents to the EHR

Exercise 8.2: Scan an insurance card into a patient's record [PM, EHR, HIM]

8.3 Master Files and Templates

Exercise 8.3: Build a master file in PrimeSUITE [PM, EHR, HIM]

8.4 Customization

Exercise 8.4: Customize a facesheet screen [PM, EHR, HIM]
Exercise 8.5: Customize a clinical desktop [PM, EHR, HIM]

8.5 Using Software to Organize Your Work --Task Lists

Exercise 8.6: Create a task for the receptionist [PM, EHR, HIM]

8.6 Using Software as a Reminder

Exercise 8.7: Assign a flag to a patient's chart [PM, EHR, HIM]

CHAPTER 9: DECISION AND COMPLIANCE SUPPORT: UTILIZING THE DATABASE

9.1 Using the Dashboard in PrimeSUITE to meet Meaningful Use standards

Exercise 9.1: View a practice's dashboard [PM, EHR, HIM]

9.2 Data and Information Used in Decision Support

Exercise 9.2: Build a clinical alert, Part A [PM, EHR, HIM]
Exercise 9.3: Build a clinical alert, Part B [PM, EHR, HIM]

9.3 Use of Report-Writer for System Reports

Exercise 9.4: Run a report of all patients between the ages of 60 and 80 [PM, EHR, HIM]

9.4 Custom Report Writing

Exercise 9.5: Build a custom report of all patients with a diagnosis of 428.0 who are female and over the age of 60, Part A [PM, EHR, HIM]
Exercise 9.6: Build a custom report of all patients with a diagnosis of 428.0 who are female and over the age of 60, Part B [PM, EHR, HIM]

9.5 Uses of Indexes

9.6 Uses of Registries

9.7 The Credentialing Process

Chapter 10: LOOKING AHEAD ? THE FUTURE OF HEALTH INFORMATION AND INFORMATICS

10.1 Health Information versus Health Informatics

10.2 Barriers to Adopting an Electronic Health Record

10.3 Emerging Technologies and Models

10.4 Making the World of Health Informatics User Friendly and Convenient

10.5 Virtual Private Networks ? Advancing the Use of EHRs Remotely Yet Securely

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About the Authors

M. Beth Shanholtzer

M. Beth Shanholtzer, MAEd, RHIA: Beth Shanholtzer has been in the HIM field for over 30 years. Her experience has included HIM department management positions within hospitals in New Jersey, Pennsylvania, West Virginia and Maryland. Seventeen years ago she moved to the academics, holding positions as program director/chair and instructor of associate degree programs in the for-profit arena. Most recently, she has been teaching at the community college level, currently with Blue Ridge Community and Technical College in West Virginia, Lord Fairfax Community College in Virginia, and Carroll County Community College in Maryland. She is active in the West Virginia Health Information Management Association as Education Chair, and as President for the 2011-2012 year. Beth lives in Martinsburg, WV with her husband and has three children.