Are You Ready?

As you begin your studies in health

information technology, you probably do
not know where your career will take you.
One thing is for certain, though: no matter
what aspect of health care you plan to
pursue, you will come into contact with
an electronic health record (EHR). With
that in mind, the simulated EHR software
accompanying this textbook will teach
you the basic skills necessary to master
the real-world EHR system that is a future
certainty for all healthcare facilities.

Beyond the Record

• In 2015, there were more than • Today more than 80% of
1,100 different EHR software healthcare providers use
vendors. This number doubled smartphones or tablets to
in four years. help aid medical decisions.

• A six-character password
takes a hacker about 10
minutes to crack, and the
most common password is
123456. To ensure security,
passwords in an EHR system
need to be strong.

s s w o r d
Pa
• • • • •
66
••••
Introduction to
Electronic Health
Chapter

3
Record Software
This textbook uses a comprehensive, realistic electronic health
records (EHR) system called EHR Navigator. EHR Navigator
is designed to introduce and practice the key functions
found in EHR systems (e.g., patient admission, registration,
scheduling, communication, privacy, security, coding, billing,
reimbursement, clinical decision support, and patient portals).
Using the EHR Navigator throughout this textbook will help you
experience how an EHR system works in the field.

Field Notes
Electronic health records (EHRs) have impr
oved quality
of care with regard to documentation, help
ing to
standardize processes throughout our hosp
itals at a
regional level. We can now quickly and effectivel
y analyze
patient information to prevent any issues
that may
arise. Physicians complete charts timely and
accurately
with fewer medical errors (e.g., poor legibility,
unapproved
abbreviations). Maintaining an EHR saves mon
ey and
time by eliminating the cost of storing, retr
ieving,
transporting, and printing records. An EHR
also allows
practitioners to quickly view records from
other hospitals
and hospital affiliates, thus improving pati
ent care.

– Misty A. Glasgow, MBA

HIM/Privacy Officer
67
 Learning Objectives
3.1 Understand the terms input, output, processing, storage, and
local area network.
3.2 Demonstrate how to navigate an EHR system.
3.3 Describe the password and security measures of an EHR system.
3.4 Identify menu options in EHR Navigator.
3.5 Examine charting features in EHR Navigator.
3.6 Review the various scheduling features of EHR Navigator.
3.7 Examine secure messaging, document management, laboratory
integration, and e-prescribing features of EHR Navigator.
3.8 Explain the importance of backing up the EHR system.
3.9 Examine mobile features in an EHR system.

An electronic health record (EHR) system manages all aspects of a patient visit,
from the time a patient contacts the healthcare facility to the time the insurance and
billing are both processed. This system can be accessed by healthcare personnel who
work in an acute care setting as well as those individuals who work in an ambulatory
care facility. As defined in Chapter 2, an acute care facility treats patients who have
acute health issues that require inpatient care. An ambulatory care setting services
outpatients or patients who do not require admission to acute care facilities. There
are many types of ambulatory care facilities such as a physician’s office, a hospital
emergency department, a dental office, a surgery center, or a health clinic. An EHR
system provides interoperability among various healthcare facilities, which allows
the facilities to communicate with each other and view the patient’s health record.
To help you understand how an EHR system operates, you must become familiar
with the system’s features and have plenty of opportunities for practice. The EHR
Navigator will help you do just that.
The EHR Navigator is a comprehensive EHR and practice management system
that provides you with hands-on experience within a realistic EHR system. This prac-
tice software, accessed through the Navigator+ learning management system, provides
you with the necessary skills to work in any EHR system you might encounter in
either an acute care or ambulatory care setting. You will become familiar with patient
management, scheduling, medical charting, laboratory integrations, medical docu-
ments, e-prescribing, clinical collaboration, reporting, coding, and billing. You will
also practice patient portal activities.
In addition to the explanation of the features of an EHR system, the text exam-
ines the security settings and requirements of a typical EHR system, discusses the

68 Chapter 3 Introduction to Electronic Health Record Software

 importance of having a backup system, and
explains how to evaluate and implement
an EHR system. Lastly, this chapter dis-
cusses the current and future role of digital
devices as healthcare providers embrace
the adoption of EHR systems. Together,
the text and the EHR Navigator activities
will guide you through the concepts and
applications of EHR systems.

Information Processing Cycle

The information processing cycle provides the building blocks for the EHR system
and includes four components: input, processing, output, and storage (see Figure 3.1).
The information processing cycle converts data entered into the computer into valuable
information for healthcare personnel.
The input component is the data entered by the user of an EHR system (e.g., the
patient’s first name, last name, identification number).
The processing compo-
Figure 3.1 Information Processing Cycle
nent permits data to be usable
by analyzing that data to deter-
mine test value results that
are within a critical or normal
range. In an EHR, the process- Storage Input
ing component determines
whether entered test results
are values within a critical or
normal range.
The output component
is the data produced that pro-
vides meaningful information
for the user. A report on a
patient’s laboratory test results Output Processing
is an example of an output in
an EHR system. A healthcare
provider may use the report
to guide treatment decisions.
Storage is the fourth component of the information processing cycle. Patient
information is stored so that it can be retrieved, added to, or modified for later use.
Data are processed once they are entered into an EHR. There are various types of
storage devices that an EHR system uses. EHR systems may be stored on a dedicated
server at the healthcare facility or on a server provided by a vendor. If an EHR system
is networked, then the storage may exist on the healthcare system’s server. Cloud stor-
age is data stored on virtual servers.

Chapter 3 Introduction to Electronic Health Record Software 69

 As technology continues to develop, EHR systems become easier to use. Internet
and intranet technologies will allow you to access and share an EHR system in one
building as well as in remote locations. This accessibility can be a liability, which is why
an EHR system must be secure and accessed based on necessary functions to perform a
specific job. As an additional security measure, the data entered and extracted from the
EHR system is encrypted to maintain security and protect patient privacy.

Hardware Support
An EHR system is most commonly accessed through a computer workstation. A
typical workstation includes a computer and input and output devices. Healthcare
providers may also be supplied with digital mobile devices not wired to a workstation.
Both computer workstations and digital devices can be found in healthcare facilities
today. An input device—such as a
keyboard, mouse, scanner, micro-
phone, camera, stylus, or touch
screen—is used to enter data into an
EHR system. An output device—such
as a computer monitor, digital device
screen, or printer—displays the results
from EHRs. Because the printing
functionality of an EHR is a security
issue, healthcare staff members must
EHR systems are commonly accessed through a
adhere to their facilities’ policy and
computer workstation. procedure manuals for the permissible
circumstances for printing a patient’s
health record.

Network Systems
The workstation also includes access to the Internet and intranet system. Computer
workstations are networked through a local area network (LAN). A LAN is a group of
computers connected through a network confined to a single area or small geographic
area such as a building or hospital campus. The network is secure and reliable, enabling
safe transfer of the data among the workstations. The networked computer system
allows computer workstations to work and communicate together. The network should
provide a great deal of flexibility and should be adaptable to new technologies, such
as fiber-optic cables, new software, and wireless communication. The LAN utilizes a
dedicated server for the workstations. The network is connected through either wired
or wireless connections. The advantage of a wireless connection is that the healthcare
provider may be anywhere and have access to an EHR system. Figure 3.2 shows a
visual representation of a network system.
A wide area network (WAN) is a network that covers a broader area than a LAN.
It is a computer network that spans regions, countries, or the world. As health care
becomes more global and interoperable, more WANs will be used to connect the
LANs of separate healthcare facilities.

70 Chapter 3 Introduction to Electronic Health Record Software

Figure 3.2 Network System

Workstation in Computer at Admission Desk

Patient’s Room Nurses’ Station Computer

Physician’s
Laptop

Physician’s
Mobile Device

Hospital Server

E X PA N D EHR Accessibility
YOUR LEARNING
The expense of having a computer workstation in every service room may prevent
The use of EHR providers from expanding an EHR system as widely as necessary for maximum
software can be efficiency. However, not having access to a workstation may cause a delay in updating
instrumental in the
and adding information to an EHR for other healthcare providers to view. One
training of healthcare
providers. Because solution for this accessibility issue is the use of mobile and digital devices, which
healthcare providers some healthcare providers are beginning to utilize. Mobile and digital devices will be
may be exposed explored later in this chapter.
to different types of Data may be entered into EHRs via a keyboard. Some EHR systems have voice
EHR systems, the
providers are able
recognition software that will adapt to your voice and speech patterns and input data
to recognize the into the system. Electronic handwriting or touch screen input may also be available,
benefits. Watch a depending on the EHR system design. Some EHR systems have templates that allow
video testimonial you to select text options from a drop-down menu, allowing standard data to be quickly
about the benefits of
added to the patient’s record.
EHRs at http://EHR2
.ParadigmEducation
.com/Testimonial.

Chapter 3 Introduction to Electronic Health Record Software 71

CHECKP INT 3.1
1. Name the four components of the information 2. Explain how a LAN affects the use of an
processing cycle. EHR system.
a._____________________________________
_______________________________________
b._____________________________________
_______________________________________
c._____________________________________
_______________________________________
d._____________________________________
_______________________________________

Privacy and Security in the EHR System

The privacy and security settings of an EHR system must conform to Health Insurance
Portability and Accountability Act of 1996 (HIPAA) regulations. (For more infor-
mation on HIPAA regulations, refer to Chapter 6.) These settings include the use of
passwords and user permissions.

Password Protection
An EHR system must allow acute and ambulatory care facilities to create, change,
and safeguard passwords. Facilities must have policies and procedures in place for
managing passwords. Typically, passwords are six to eight characters long, with a
combination of alphanumeric characters, and typically contain at least one uppercase
letter. When you enter your password, characters appear as dots, asterisks, or other
symbols, thus preventing other users from seeing the password. Generally, you must
change your password every 90 to 120 days. In addition to using a password to
enter the system, specific areas of an EHR system may also be password protected to
maintain the privacy and security of patient health records. The password is encrypted
in the transmittal process between your workstation and an EHR system. An audit
manager or administrator records the user log-ins and log-outs to monitor use of the
EHR system. EHR systems allow for backend auditing so there is an objective record
available that indicates all users who have accessed a patient’s chart. Audit records can
be reproduced to address access issues or HIPAA noncompliance.
When you first log in to an EHR system, you key in a default password, then fol-
low the prompts to change your password. Typically, you can attempt to log in three
times before being locked out and requiring the password to be reset by the adminis-
trator or information technology (IT) manager at the facility.

User Permissions
An EHR contains a patient’s protected health information (PHI). If you are an
employee of an acute care or ambulatory care facility, you must have a unique user
name that registers your identity and tracks your activity in an EHR system. Each
user’s access to information is based on the type of information he or she will need to
view or modify. Therefore, users are assigned access according to their job functions
(e.g., healthcare provider, nurse, health information professional, registrar). For

72 Chapter 3 Introduction to Electronic Health Record Software

 example, a registration or admission clerk may not have access to a patient’s X-rays
but would have access to the patient’s insurance information. This assigned access
ensures the security and confidentiality of patient records. Figure 3.3 illustrates how
an administrator can assign you permission to access various areas of an EHR system
based on your job position. These permissions define the areas of the software in which
a user may view, add, edit, or delete information. For example, a front desk clerk at
an outpatient facility may see a screen similar to the one shown in Figure 3.4 when
accessing the EHR Navigator. When admitting a patient, an admission clerk would
view a screen similar to the one shown in Figure 3.5.
Figure 3.3 Assign User Permissions

Figure 3.4 Home Screen—Outpatient

Chapter 3 Introduction to Electronic Health Record Software 73

 Figure 3.5 Patient Admission—Inpatient

Hibernation Mode
When you must step away from your workstation, an EHR system should be set to
hibernation mode, a privacy feature that prevents disclosure of PHI. Patients and
healthcare providers alike may be able to see a workstation as they pass by, so the
information on the screen must be protected. When you are not actively using the
EHR system, or if you must step away for a few minutes, it must be in the hiberna-
tion mode. If you do not set the hibernation mode manually, it will automatically go
into hibernation mode after a period of inactivity. To escape the hibernation mode
and reaccess a patient’s health record, you must reenter your username and password.
Figure 3.6 shows these precautions.
Figure 3.6 Log-in Due to Hibernation

74 Chapter 3 Introduction to Electronic Health Record Software

 Accessing the EHR Navigator
In this chapter as well as throughout Exploring Electronic Health Records, Second Edi-
tion, hands-on tutorials, practice assessments, and assessments using the web-based
EHR Navigator will provide you with practical experience. Each interactive tutorial is
designed to demonstrate an EHR concept. After completing the interactive tutorial,
you have the opportunity to practice the skills you just learned by taking a variety
of practice assessments. Once you feel you have mastered the skill, you can take the
automatically graded assessment that corresponds to each of the tutorials offered
throughout the chapters. These tutorials, practice assessments, and assessments are
based on a review of many inpatient and outpatient EHR systems and therefore are
transferable to a variety of healthcare settings. When you log in to the Navigator+
learning management system to launch the tutorials, you will be guided by an audio
recording through each step of the tutorial. The tutorials will begin by reviewing vari-
ous features and capabilities of the software. Once you have mastered the software,
you will begin to apply the EHR concepts presented in the text via the practice assess-
ments. As a final check, there are assessments at the end of each chapter that test your
understanding of the chapter concepts and their applications.

Capabilities of EHR Systems

The Office of the National Coordinator for Health Information Technology (ONC)
has defined the capabilities that are necessary for the meaningful use of EHR tech-
nology. These capabilities were originally defined by the Certification Commission
for Health Information Technology (CCHIT), the organization that was previously
responsible for certifying EHR systems. These capabilities include functionality,
interoperability, and security. Functionality is the ability to create and manage
EHRs for all patients in a healthcare facility. In addition, functionality includes the
ability to automate workflow in a healthcare facility. Interoperability is the abil-
ity of an EHR system to exchange data with other sources of health information,
including pharmacies, laboratories, and other healthcare providers. Interoperabil-
ity is achieved through standards such as Health Level Seven International (HL7),
which aims to facilitate sharing and transferring clinical information from one
system to another. Security is the standard that prevents data loss and ensures that
patient health information is private.

EHR Software Features

This section addresses the software features that improve efficiency in the
administrative and clinical components of a healthcare facility. Some of the
administrative features examined include messaging, to-do list, scheduling, patient
management, billing, and coding. Several features that are used in a clinical setting
are also discussed, including medical charting, clinical collaboration, results reporting,
clinical decision support, and patient portals.

Chapter 3 Introduction to Electronic Health Record Software 75

 Using the EHR Navigator
The EHR Navigator encompasses inpatient and outpatient EHR systems. Within
each menu are submenu options. Figure 3.7 illustrates the inpatient system,
Northstar Medical Center. The outpatient system, Northstar Physicians, is shown in
Figure 3.8.
Figure 3.7 EHR Overview—Inpatient

Figure 3.8 EHR Overview—Outpatient

76 Chapter 3 Introduction to Electronic Health Record Software

 Menus
The menu bar is at the top of the screen. The options on the Northstar Medical
Center menu bar are Home, To Do, Charts, Schedule, Billing, eRx, Admission/Dis-
charge, Labs, Messages, Documents, Reports, Coding, ROI (release of information), and
Settings (see Figure 3.9).
Figure 3.9 Menus—Inpatient

The options on the Northstar Physicians menu bar are Home, To Do, Charts, Sched-
ule, Billing, eRx, Admission/Discharge, Labs, Messages, Documents, Reports, Coding,
ROI, and Settings (see Figure 3.10).

Figure 3.10 Menus—Outpatient

When you click each of the menu options, a list of functions appears below the menu
option.

Settings
The EHR Navigator has a Settings feature that allows the healthcare facility to add
users, edit facility information, grant user permissions, and customize features to
meet the needs of the healthcare facility. Figure 3.11 illustrates the Settings feature
for both inpatient and outpatient facilities.

Chapter 3 Introduction to Electronic Health Record Software 77

 Figure 3.11 Settings

Users
In the Users submenu option, all users are listed along with their respective roles
(e.g., physician, HIM professional, unit clerk, pharmacist). This site is also where the
EHR administrator or office manager can add or edit users (see Figure 3.12).

Figure 3.12 Users Submenu

78 Chapter 3 Introduction to Electronic Health Record Software

 Profiles
By selecting Profiles, you may update your basic information (see Figure 3.13).
Figure 3.13 Profiles Submenu

Facility
The Facility submenu of the EHR Navigator (see Figures 3.14 and 3.15) allows you to
view basic information about the facility, including the following:
• Identifiers such as a National Provider Identifier (NPI); Employer Identification
Number (EIN); and Medicare, Medicaid, and the TRICARE provider numbers
• Healthcare organizations list (details a list of related healthcare organizations)
• Payer list (details a list of payers)
Figure 3.14 Facility Submenu

Chapter 3 Introduction to Electronic Health Record Software 79

 Figure 3.15 Facility Submenu (continued)

Permissions
The Permissions submenu in the EHR Navigator is where employee access to EHR
functions is managed. Options to view, add, edit, and delete permissions are selected
for each user. For example, all users are granted access to the To Do option on the
Users menu, but only certain healthcare personnel that can order medications (such
as physicians, physician assistants, nurse practitioners, and pharmacists) can override
drug allergies. Figure 3.16 provides an example of how adjustments for permissions
may be made to drug-drug and drug-allergy alerts.

Figure 3.16 Permissions for Drug Alerts

Templates
The Settings menu allows you to manage charting templates. When you select
Templates, facility templates appear on the left panel, and a list of templates you may
like to use in a patient’s chart appears on the right panel. You may create custom
templates by selecting Add Templates. Figure 3.17 provides a list of templates.

80 Chapter 3 Introduction to Electronic Health Record Software

 Figure 3.17 Facility and User Templates

Tutorial 3.1
Viewing Features in the EHR
Go to Navigator+ to launch Tutorial 3.1. As a physician, practice logging in, view-
ing permissions, examining the hibernation feature, and unlocking the system
using the EHR Navigator.

Tutorial 3.2
Adding a New Employee and Assigning Rights to the EHR
Go to Navigator+ to launch Tutorial 3.2. As an IT administrator, practice adding a
new employee and assigning rights using the EHR Navigator.

Administrative Features
The administrative features in the EHR Navigator include reports, messages, schedul-
ing, billing, some charting information, and documents.

Home
On the Home menu there are six submenus: Calendar, To Do, Appointments, Patient
Tracker, and Messages (see Figure 3.18). The Calendar provides quick access to spe-
cific dates, and the To Do section allows you to create reminders, prioritize activities,
and organize lists to be more efficient and effective on the job. Appointments displays
appointments for the current week, and Patient Tracker identifies a patient’s physical
location while he or she is in the facility. Messages is an internal communication tool
for all users of the EHR Navigator.

Chapter 3 Introduction to Electronic Health Record Software 81

 Figure 3.18 Home Menu

Patient Tracker
In the Home menu, a Status feature allows
Figure 3.19 Patient Tracker Status
you to change the status of the patient. For
instance, the patient status may change
from Scheduled to Arrived, No Show, or
Canceled. This allows the administrative
staff to easily track patients. Once a patient’s
status is changed to Arrived, the patient is
displayed in the Patient Tracker. Then the
administrative staff or healthcare provider
may change the status to Arrived, Checked
Out, Doctor Ready, Exam in Progress, Lab in
Progress, Nurse Ready, or Ready for Checkout
in the system. Figure 3.19 shows the Patient
Tracker status.

Reports
As you learned in Chapter 1, the Health Information Technology for Economic and
Clinical Health Act (HITECH Act) provides incentives for implementing an EHR
system based on meaningful use criteria, and many of these systems have a dashboard
to track this use. Typically, an administrator of an EHR system monitors the progress
the healthcare facility has made toward completing each criterion. In the EHR Naviga-
tor, the meaningful use information can be accessed under the Reports tab. Figure 3.20
illustrates an example of a typical Meaningful Use report. Criteria may be calculated
based on provider, year, attestation duration, and start and end dates.

82 Chapter 3 Introduction to Electronic Health Record Software

 Figure 3.20 Meaningful Use Report

You can also access the Activity Feed feature on the Reports tab. The User Activity
Feed feature in the EHR Navigator tracks your access to various components in the
system. Each time you log in or out, or each time you make updates or add data to a
patient’s chart, the activity is tracked. If you create an appointment or submit a
prescription to the pharmacy, that activity will also appear in the User Activity Feed.
This feed, seen in Figure 3.21, enables the administrator to get a longitudinal view of
actions occurring in the healthcare facility.

Figure 3.21 User Activity Feed

Chapter 3 Introduction to Electronic Health Record Software 83

 The Reports feature in the EHR Navigator allows users of Northstar Medical
Center and Northstar Physicians to convert the facility’s data into information that can
be analyzed. Reports may be run on clinical data or administrative information, or by
provider and date range. Figure 3.22 lists the various reports and descriptions available
in the EHR Navigator.

Figure 3.22 List of Reports

The EHR Navigator Reports feature queries special reports based on particular
criteria. An example of a query report might include generating a list of women age
50 and older who have not yet scheduled mammography in the past year. Many of the
reports will be covered more in depth in Chapter 9.

Messages
The EHR Navigator messaging system allows you to communicate with other system
users in your organization. Some EHR systems contain a HIPAA-compliant messaging
feature that permits physicians, nurses, and other healthcare providers to communicate
with medical colleagues outside their healthcare facilities. This feature is similar to a
social media type of messaging system used to improve the collaboration and continu-
ity of patient care.
The Message function allows you to send messages to patients, providers, and
employees of the healthcare facilities using the EHR Navigator. The menu provides
three options: Inbox, Sent Messages, and Archived Messages.
The Inbox lists messages received by the user or healthcare facility. Figure 3.23
illustrates the EHR Navigator Inbox. You may reply, forward, save, or delete messages.
You may also send a new message, as illustrated in Figure 3.24. As shown in Figure
3.25, messages may be archived to allow you to document communication among
healthcare providers, facilities, pharmacies, and the patient.

84 Chapter 3 Introduction to Electronic Health Record Software

 Figure 3.23 Messages—Inbox

Figure 3.24 Messages—New Message

Figure 3.25 Messages—Archived Messages

Chapter 3 Introduction to Electronic Health Record Software 85

 Schedules
The Schedules feature in the EHR Navigator gives you access to the calendar in daily and
monthly views. The Schedules overview allows you to quickly view the available practice
areas at the facility and see what patients have appointments there on any given day. For
example, a front desk clerk at Northstar Physicians can view all of the the appointments in
Exam Room 1 and potentially move a patient to Exam Room 2 by dragging and dropping
the appointment (see Figure 3.26).
The view-only calendar overview allows you to quickly see all of the appointments
for the entire month. The appointment types are color coded for easy viewing (see
Figure 3.27).
In addition to the schedule and calendar overviews, Northstar Medical Center and
Northstar Physicians can use the Hours feature to customize the availability of appoint-
ments by setting parameters for the days and times that Northstar is able to schedule
patients. Figures 3.28 and 3.29 illustrate how Northstar may select days and hours,
respectively, when appointments are available.

Figure 3.26 Schedules Overview—Northstar Physicians

86 Chapter 3 Introduction to Electronic Health Record Software

 Figure 3.27 View Only Calendar—Northstar Physicians

Figure 3.28 Facility Days and Hours

Figure 3.29 Customize Hours

Chapter 3 Introduction to Electronic Health Record Software 87

 Schedules
The administrative and clinical staff are likely to use the Schedules feature in a variety of
ways. Schedules allows you to see the appointments scheduled for the healthcare facility
on a given day in each of the facility areas (Exam Room 1, Exam Room 2, Lab Area,
and Nurse Area for Northstar Physicians; Clinic, Operating Room, Radiology, and
Labor and Delivery for Northstar Medical Center). An appointment can be made by
clicking an open time slot in the desired room. A Schedule Appointment dialog box
opens, allowing the user to fill out the details of the patient appointment (see Figure
3.30). Appointments can also be dragged from one room to another, or they can be
edited when you click the appointments (see Figure 3.31).
Figure 3.30 Schedule Appointment Dialog Box

Figure 3.31 Edit Appointment Dialog Box

88 Chapter 3 Introduction to Electronic Health Record Software

 Billing
Billing for treatment and services rendered is a main function of any healthcare
organization. Figure 3.32 shows the main billing screen found in the EHR Navigator.

Figure 3.32 Billing

The main subsections of the Billing tab are Electronic Superbill, Claims Manage-
ment, Billed, Transmit Claims, Patient Bills, Patient Ledger, and Deposit Reports.
On the Electronic Superbill subsection, a biller can view a superbill (a list of all
charges relating to a patient visit) and can also add charges, add payments, and add
adjustments using the buttons in the Actions section. Figure 3.33 shows the Add
Superbill dialog box.
Figure 3.33 Add Superbill

Chapter 3 Introduction to Electronic Health Record Software 89

 Under Claims Management, a biller can view, edit, and bill for patient visits.
You can also access the CMS-1500 form on this screen in Northstar Physicians and
CMS-1450/UB-04 form in Northstar Medical Center. These are specialized billing
forms that will be covered in more detail in Chapter 9. See Figures 3.34 and 3.35.

Figure 3.34 CMS-1500 Form

Figure 3.35 CMS-1450/UB-04 Form

90 Chapter 3 Introduction to Electronic Health Record Software

 The Billed subsection shows the patient bills that have already been processed.
Transmit Claims allows you to see the visits that are ready for review and transmit the
claims (see Figure 3.36).

Figure 3.36 Transmit Claims

Patient Bills shows an archive of patient bills. The Patient Ledger allows you to see a
history of services, payments, and adjustments for a patient (see Figure 3.37).
You will experience the billing functions of the EHR Navigator in Chapter 9.

Figure 3.37 Patient Ledger

Chapter 3 Introduction to Electronic Health Record Software 91

 Charts
The Charts feature in the EHR Navigator contains both administrative and clinical
information. This section addresses only the administrative information, and the
clinical information will be discussed in the Clinical Features section on page 92. In
the Charts feature, a list of patients treated at the healthcare facility appears. The user is
able to find, filter, and add patients. The administrative features in the EHR Navigator
contain patient demographics, insurance information, setting, clinical information,
and a list of appointments. Within the patient chart, the healthcare facility can enroll a
patient in a PHR, print a patient chart, send a referral or response letter, export a
patient record, export an immunization registry, and provide public health surveillance
information. Figures 3.38 and 3.39 provide examples of the patient list and patient
chart found in the Charts feature.

Figure 3.38 Charts—List of Patients

92 Chapter 3 Introduction to Electronic Health Record Software

 Figure 3.39 Charts—Patient Chart

Documents
The EHR Navigator allows you to add documents from a predetermined list—
Summary Report, Insurance Form, or a dictation—to a patient’s chart. This action can
be taken at the Documents tab or on the patient’s chart. The system also allows you to
make notations on a document before assigning the file to a patient’s chart and to
digitally sign documents. Figure 3.40 shows how to add a document.

Figure 3.40 Adding Documents

Chapter 3 Introduction to Electronic Health Record Software 93

 Documents can be viewed either as pending or signed, and they may be filtered by
provider and document type. Figure 3.41 illustrates pending documents. For example,
a pending document may be a physician order waiting for a doctor to authenticate.

Figure 3.41 Pending Documents

CHECKP INT 3.2

1. Explain why Messages is an important feature 2. Name two different ways to view
in an EHR system. appointments in the Schedules tab.

_______________________________________ a._____________________________________

_______________________________________ b._____________________________________

_______________________________________

Tutorial 3.3
Scheduling an Appointment
Go to Navigator+ to launch Tutorial 3.3. As a physician, practice the
administrative features using the EHR Navigator

Clinical Features
In addition to the administrative features, there are a number of clinical features available
to an EHR user. The clinical features of the EHR Navigator include patient chart
information, e-prescriptions (eRx), managing physician orders, and viewing laboratory
and diagnostic test results.

94 Chapter 3 Introduction to Electronic Health Record Software

 Charts
The EHR Navigator Charts feature is the source for the patient’s clinical data, includ-
ing medical diagnoses, treatments, procedures, allergies, medical history, medications,
test results, and reports. Charts provides you with a unique view of the entire record at
a glance, without having to navigate to other areas of the EHR system to view patient
information. The EHR Navigator allows multiple users to have access to a patient’s
chart. Figure 3.42 illustrates the past medical history component of the patient chart.
The EHR Navigator Charts feature also allows you to add a chart note, as shown
in Figure 3.43.

Figure 3.42 Charts—Patient History

Figure 3.43 Add Chart Note

eRx
A typical EHR system has an eRx (electronic prescription) feature that enables the
system to electronically submit prescriptions to pharmacies all across the United
States. The use of e-prescribing helps to reduce medication errors, thus improving
patient safety and increasing practice efficiency. An EHR system that integrates an
e-prescribing function increases facility productivity and efficiency by allowing a
healthcare provider to view the patient’s medication history in the EHR rather than
pulling a chart and writing a prescription by hand. Figure 3.44 shows the eRx screen in
the EHR Navigator.

Chapter 3 Introduction to Electronic Health Record Software 95

 Figure 3.44 eRx

Labs
EHR systems include an integrated laboratory feature, which enables healthcare
facilities and providers to connect with national and regional laboratories or maintain
an existing laboratory partner. The EHR Navigator Labs feature allows you to
view Pending Labs and Signed Labs. Pending labs are those awaiting test processing
and results reporting. Signed labs are those that have been viewed and signed by a
physician, physician assistant, or nurse practitioner. Integrating laboratories into an
EHR system gives you the ability to create laboratory orders and view results from any
computer at any time, with abnormal results flagged and organized for easy review.
Figure 3.45 illustrates the Labs feature in the EHR Navigator.
Figure 3.45 Labs—Views

96 Chapter 3 Introduction to Electronic Health Record Software

 Manage Orders
Every EHR system contains a computerized physician order entry (CPOE)
component. In the EHR Navigator, the CPOE component is located by clicking
Charts, selecting the patient, and clicking Manage Orders. Manage Orders is a button
located on the patient’s chart. Depending on their level of access, users add, view,
and cancel physician orders for treatment and care—for example, laboratory orders,
dietary orders, and therapy orders—by using Manage Orders. Figure 3.46 illustrates the
Manage Orders dialog box in EHR Navigator. You will learn about CPOE, in detail, in
Chapter 8 of this text.

Figure 3.46 Manage Orders

CHECKP INT 3.3

1. Name four types of clinical information found in 2. Explain the importance of an integrated
a patient’s chart. laboratory feature.
a._____________________________________
_______________________________________
b._____________________________________
_______________________________________
c._____________________________________
_______________________________________
d._____________________________________

Tutorial 3.4
Reviewing a Patient’s Chart and Locking and Unlocking the EHR
Go to Navigator+ to launch Tutorial 3.4. As a physician, practice reviewing patient
clinical information using the EHR Navigator.

Chapter 3 Introduction to Electronic Health Record Software 97

 Backing Up and Accessing EHR Systems
EHR systems can be web-based or locally installed. Regardless, the EHR system data
belongs to the healthcare facility. If the healthcare facility decides to switch from a
web-based to a locally installed EHR system, the data may be exported from a cloud-
based server into the local EHR system.

Backup System
No matter what type of server is used, the EHR system must have a secure backup plan.
This contingency plan is critical in the event of a disaster that destroys the health records.
Web-based or locally installed EHR systems should have a secure backup system.
A healthcare facility that has a locally installed EHR system should have its backup
plan recorded in the facility’s policy and procedure manual. The backup system must
provide an exact copy of patient health records. Depending on the backup system—be
it on-site, magnetic storage, cloud-based, or off-site—the same security measures must
be followed to prevent the unauthorized access or release of patient PHI. Policies and
procedures must include controlled access, password protection, and a secure location.
A web-based EHR system is stored on a secure server utilizing the highest levels of
encryption software.

E X PA N D
YOUR LEARNING
Mobile Devices
According to a study An EHR system may be accessible through a mobile device such as a smartphone or
published in the US tablet with computer capabilities. Mobile devices allow you to remotely access the
National Library of EHR system, which will help improve your productivity and quality of patient care.
Medicine’s online Healthcare providers may choose to use a mobile device because they can bring the
research journal,
approximately 50% of
device with them when caring for patients. These easy-to-use devices help inform
healthcare providers and show patients images such as the location of an injury. However, digital devices
use some type of in a healthcare facility are not without their challenges; you must ensure that they
mobile device for comply with the security requirements of HIPAA. Integration with the EHR system
clinical decision-
can be difficult with some devices. Figure 3.47 illustrates the use of an EHR system,
making. Review the
study at http://EHR2 drchrono, on an iPad.
.ParadigmEducation
.com/Smartphones
Figure 3.47 Drchrono for the iPad
to learn more about
the advantages and
challenges healthcare
providers face while
using mobile devices
when caring for
patients.

Source: drchrono. Used with permission.

98 Chapter 3 Introduction to Electronic Health Record Software

 Chapter Summary
There are two primary healthcare settings—inpatient and outpatient—and each
setting requires its own features within an electronic health record (EHR) system.
Rather than learning one specific EHR system, mastering the knowledge behind
an EHR system allows you the flexibility of working with a variety of EHR
systems that you may encounter in the workplace. ONC-certified EHRs pos-
sess similar capabilities and functions as a result of standardized requirements for
compliant EHRs.
With that in mind, the EHR Navigator provides you with the hands-on
activities to help you master this basic knowledge. Assigning rights and permis-
sions, managing and scheduling patients, reviewing medical documents, charting,
reviewing laboratory results, filling e-prescriptions, and sending secure messages
are all important features to understand, no matter what EHR system you use.
The structure of an EHR system, such as the information processing cycle, is also
crucial background knowledge to learn.
Data security and accessibility are important features of an EHR system.
EHRs should always have a backup system and a secure server location. Accessing
this server via mobile devices is becoming more commonplace as mobile technol-
ogy becomes more affordable, secure, and adaptable to various EHR systems.

EHR Review
The following EHR Review, EHR Application, and EHR Evaluation activities are also available
online in the Navigator+ learning management system. Your instructor may ask you to complete
these activities online. Navigator+ also provides access to flash cards, study games, and prac-
tice quizzes to help strengthen your understanding of the chapter content.

Acronyms/Initialisms
Study the following acronyms discussed in this chapter. Go to Navigator+ for flash cards of
the acronyms and other chapter key terms.

CCHIT: Certification Commission for HL7: Health Level Seven International

Health Information Technology IT: information technology
CPOE: computerized physician order LAN: local area network
entry
NPI: National Provider Identifier
EIN: Employer Identification Number
PHI: protected health information
HIPAA: Health Insurance Portability
PHR: personal health record
and Accountability Act
WAN: wide area network
HITECH Act: Health Information
Technology for Economic and Clinical
Health Act

Chapter 3 Introduction to Electronic Health Record Software 99

 Check Your Understanding
To check your understanding of this chapter’s key concepts, answer the following questions.

1. Data storage in an electronic health record (EHR) may be handled by all of

the following methods except a
a. cloud server.
b. vendor server.
c. facility server.
d. flash drive.
2. The four components of the information processing cycle are
a. input, print, output, and save.
b. input, output, print, and storage.
c. input, processing, output, and storage.
d. enter, print, save, and storage.
3. Which of the following is the organization that is responsible for certifying
EHR vendors?
a. Certified Commission for Health Information Technology
b. American Medical Association
c. Office of the National Coordinator for Health Information Technology
d. Health Information Technology
4. Meaningful use provides
a. incentives for a healthcare facility that meets established criteria for an
EHR system.
b. a report to the patient on his or her healthcare information.
c. a measurement of the functionality of the EHR system.
d. incentives for patients who use a personal health record.
5. Mobile devices include
a. iPads.
b. iPhones.
c. Androids.
d. all of the above.

100 Chapter 3 Introduction to Electronic Health Record Software

 6. True/False: Interoperability allows various healthcare facilities to
communicate with each other.
7. True/False: A microphone is a type of input device.
8. True/False: A local area network is a computer connected to the Internet.
9. True/False: All users of an EHR system have the right to access all
components of the EHR.
10. True/False: EHR systems may be customized to meet the needs of the
facility.

EHR Application
Go on the Record
To build on your understanding of the topics in this chapter, complete the following short-
answer activities

1. Discuss the importance of assigning passwords and rights to users of an

electronic health record (EHR) system.
2. Explain why it is important to lock an EHR system when not actively
working with it.
3. Compare and contrast the advantages and challenges of using mobile devices
with an EHR system.
4. Explain the advantage of using the e-prescribing feature of an EHR system.

Navigate the Field

To gain practice in handling challenging situations in the workplace, consider the following
real-world scenarios and identify how you would respond to each.

1. You are the health information technology (HIT) training specialist at

Northstar Medical Center, and you have been tasked with training new
employees on the EHR Navigator. Prepare an outline you will follow for
training employees.
2. After completing an overview of the EHR Navigator in this chapter,
prepare a list of features that are most important to your job as the HIT
training specialist at Northstar Medical Center. Explain why each feature is
important and how each will help you complete your job more effectively
and efficiently.

Chapter 3 Introduction to Electronic Health Record Software 101

 EHR Evaluation
Think Critically
Continue to think critically about challenging concepts and complete the following activities.

1. Tabitha Iris Wang calls to schedule an appointment with Dr. Alana Feltner.
List the steps of an EHR system that you must take to schedule this
patient.
2. You are the information technology (IT) manager for your healthcare
facility. A new employee will begin in the Health Information
Management (HIM) department. Prepare a list of the steps you would take
to add a new user and assign permissions to this new HIM employee.

Make Your Case

Consider the scenario and then complete the following project.
You are chairing a committee on selecting the EHR system for Cincinnati Grace Medi-
cal Center. The committee has decided to select a web-based EHR system because the
facility does not have a large IT staff. You are in charge of researching Practice Fusion,
a free, web-based EHR system. Create a presentation based on the instructions pro-
vided to you by your instructor.

102 Chapter 3 Introduction to Electronic Health Record Software

 Explore the Technology
Complete the EHR Navigator practice assessments that align to each tutorial and the assess-
ments that accompany Chapter 3 located on Navigator+.

Chapter 3 Introduction to Electronic Health Record Software 103