preface EHR HIM EHR Matters!

(1)

PREFACE

vii

C o p y ri g h t © 2 0 12 T h e M c G raw -H il l C o m p a n ie s C o p y ri g h t © 2 0 12 T h e M c G raw -H il l C o m p a n ie s

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

valu-able 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

stu-dents, 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

Technolo-gies’ 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

demon-strate 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

Man-agement), EHR (Electronic Health Records), HIM (Health

Informa-tion Management) tags, or some combinaInforma-tion of those three.

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, www.mhhe.com/greenway.

EHR HIM

PM

sha08726_fm_i-xviii.indd vii

(2)

C o p y ri g h t © 2 0 12 T h e M c G raw -H il l C o m p a n ie s

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!

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

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

Here’s How Instructors Have Described Integrated EHR:

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.

(3)

PREFACE

ix

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 applica-tions 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 His-tory of Present Illness, Review of Systems, and Physical Exam. Documentation methods, past and present, are dis-cussed. 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, stu-dents learn methods to maintain security, safeguard data integrity, and audit compliance with access and release of infor-mation. 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 informa-tion 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 differ-ences 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 profession-als, 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 tele-medicine, 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.)

sha08726_fm_i-xviii.indd ix

(4)

What You Can Expect from the Online

Course in Connect Plus

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

accredit-ing bodies: CAHIIM, ABHES, and CAAHEP for instructors at

www.mhhe.com/greenway.

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 www.mhhe.com/greenway! 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.

EHR

(5)

PREFACE

xi

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, www.mhhe.com/greenway

(instruc-tors can request a password through their sales representative):

Supplement Features

Instructor’s Manual (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 PowerPoint Presenta-tions (organized by Learning Outcomes) - 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.

sha08726_fm_i-xviii.indd xi