Traditional Health Record Management (HRM) concepts and processes. Definition and scope of an Electronic Health Record Management (EHRM). Definition, uses, benefits and impacts of an Electronic Health Record (EHR). Workflow scenarios: comparison of the flow of information in paper versus electronic systems. Data flow, data sources, data uses, structured versus unstructured data. Type of information collected and stored; magnitude, complexity and persistence of information; information storage; data sets, registries and data repositories; archetypes and micro-vocabularies. Lifecycle of an EHR; structure and content of an EHR. EHR system types; features and functions of EHR systems; components of an HER system; variations in content between care environments. Standards system must meet to be considered a legal business record. EHR systems (regionally, provincially, territorially or nationally); case summaries of existing systems (global perspective). How an EHRM supports particular functionality such as amendments, corrections, authentication, back-ups, down time, confidentiality, security, privacy, printouts and reports for disclosure purposes. How an EHRM can support other care-related activities including evidence-based based decision support, quality management and outcome reporting. Integrated-EHR systems; technical, semantic and process interoperability. Personally Controlled Health Records (PCHRs). Differentiate between terminology, nomenclature and classification; uses and benefits of coding; forms of EHR; the codified EHR. Comparison of Standard Coding Systems such as ICD-10, SNOMED-CT, READ, Unified medical language systems (UMLS); classification schemes and clinical terminologies used by health care professionals; coding compliance tools; reliability and interoperability of coding schemes; ISO/CEN.HL7; synergies between classification and clinical terminologies. EHR regulatory and standards environment, data quality and completeness; confidentiality, privacy and security of an EHR. Health Insurance Portability and Accountability Act (HIPAA): transactions and code sets; uniform identifiers. EHR data transport protocols; EHR data model standards. Quality improvement and the EHR. Legal considerations of an EHR: retention and durability; storage; signature issues; accuracy of entries, transmission integrity, admissibility, evidence, discoverability. EHRM technology: enabling solutions, emerging trends.

Differentiate between traditional health record management systems and electronic health record management systems. Explain how an electronic health record supports the direct and indirect delivery of health care. Review case summaries of electronic health record management systems. Identify the type and properties of information to be collected and stored in an electronic health record. Discuss the legal and ethical considerations surrounding electronic health records. Explain the standards that support the codified electronic health record and the exchange of data between systems and devices. Outline current and emerging technologies.

Defend the role of an electronic health record management system in supporting effective and efficient health care delivery. Describe the various technical and non-technical obstacles to electronic health record adoption in health care environments.

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