PHS - Ch. 7 Slides #2 (Information Technology/Med Math)

In 2009 the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law

• This Law made significant changes to HIPAA privacy and security regulations

• There are specific penalties for violations of HIPAA rules

• Requires consistent level of security when working with health information

• Offers financial incentives for providers who demonstrate meaningful use of electronic health records

• Therapeutic workers will recognize many advantages to working with EHR's, including the speed of accessing Pt information and the clarity of typewritten vs handwritten entries.

• However, these electronic entries still need to be done in a timely manner, be complete, accurate.

• When using EHR's you will commonly see:

  • A Face page, or summary screen that shows Pt's contact info and medical hx (history)

  • Each patient visit has a separate file

  • Always label info that was forgotten as late entry

• IMPORTANT:

  • Never delete errors made in a medical record, always use an addendum to correct errors

  • Authenticate all addendums and late entries with digital signature

• E-Prescribing:

  • Electronic generation, transmission, and filling of a medical prescription.

  • Replaces handwritten, faxed notes, or prescriptions called in by phone.

  • Sent automatically to Pt's preferred pharmacy over the internet. This process improves patient safety by automatically checking for drug/allergy interactions and eliminating medication errors due to poor handwriting.

Electronic Charting:

• Electronic records contain all the information found in a paper chart, but EHR software combines many additional medical office functions.

  • Provide links to sites that show drug information

  • Provide printable patient instructions

  • Recommend codes for medical services

  • Search function to find patients’ charts (by name, DOB, etc. 

  • Alert providers to drug and allergy interactions

  • Allow access to patient records in multiple facilities

  • Streamline office communication (e-mail, messaging, and letter templates)

• Computerized therapeutic equipment

  • Robotic “hands” used in surgery 

  • Video games used for physical therapy

  • Software used by dentists to design crowns

• Social media (Twitter, Facebook)

  • May be used for doctor/patient communication, but privacy is an issue

• Mobile apps

  • Electronic health records

  • Point of care (translators, visuals)

  • Medical reference and education

  • Consumer health (pedometers, blood pressure measuring tools)

• Healthcare facilities use the 24-hour clock, or military time

• Assigns a number for each hour of the day

• Avoids confusion between a.m. and p.m. and prevents errors in documentation

Healthcare workers use both the metric system and US system

• Metric system units

  • meter (m) for length

  • gram (g) for weight

  • liter (L) for volume

  • Celsius (°C) for temperature

• US customary units

  • inch (in), foot (ft)

  • ounce (oz), pound (lb)

  • cup (c), quart (qt) 

  • Fahrenheit (°F)

• Apothecary system

  • May still be used for herbal medicines

  • Uses terms such as drams, grains, and minims

  • Uses Roman numerals

• International Units (IU)

  • Used for measuring the biological effect of manufactured medicinal drugs and vitamins

  • Used to measure insulin and heparin

• Healthcare workers often have to convert between household and metric systems

• Measurements may be converted from one system to another by cross-multiplying

Healthcare workers frequently take measurements using the metric system, but then communicate the measurements to patients using household units.

What could happen if a healthcare worker made an error in converting the units? Imagine at least one scenario.

Examples:

• Someone could take the wrong dose of medication

• Someone could think he/she had lost or gained weight or got taller/shorter

• Forms of medication

  • Liquid (aqueous suspension, suspension, syrup, or tincture)

  • Solid (capsule, tablet, lozenge)

  • Semisolid (ointment, suppository)

• Methods of administration

  • Oral (by mouth)

  • Rectal (in the rectum)

  • Topical (applied to the skin)

  • Sublingual (under the tongue)

  • Injection (with needle and syringe)

  • Inhalation (breathed in)

• Dose

  • portion of the medicine to be administered at one time

• Dosage

  • total quantity of medicine to be administered

• Concentration

  • how much of the drug is in a specific volume of liquid

Healthcare workers use angles for several purposes

• To measure and describe joint movement

  • Goniometer used in rehab to measure range of motion

• To inject medications properly

  • Different medications require different angles of injection

• To position patients in bed

  • Fowler’s positions