EHR Clinical Overview
The RPMS Electronic Health Record (EHR) is intended to help providers manage all aspects of patient care electronically, by providing a full range of functions for data retrieval and capture to support patient review, encounter and follow-up. By moving most (and eventually all) data retrieval and documentation activities to the electronic environment, patient care activities and access to the record are able to occur simultaneously at multiple locations without dependence on availability of a paper chart. Moreover, point-of-service data entry ensures that the record is always up to date for all users.
The RPMS EHR combines the powerful database capabilities of the Resource and Patient Management System (RPMS) with a familiar and comfortable presentation layer, or graphical user interface (GUI). Integration of various RPMS components into the user interface allows providers to obtain a more comprehensive view of the clinical process. Access to patient information is available via "point and click", rather than the user having to log in and out of separate RPMS applications to retrieve different types of data.
Installation of the most current RPMS applications and/or patches is required for optimal functionality of the EHR (see Technical Overview). With the appropriate server-side RPMS components, EHR supports such functions as:
- Patient lookup and management of personalized patient lists
- Problem list management
- Provider order entry for laboratory, radiology, medications
- Results notification and retrieval
- Report retrieval
- Health maintenance and disease state management reminders
- Clinical encounter documentation
- Clinical decision support (order checks and clinical reminders)
- Documentation of immunizations, patient education, health and personal health history, etc.
- Coding support (ICD and CPT)
- Consult/referral generation and tracking
Although implementation of EHR requires installation of the full suite of RPMS applications (plus a number of VA applications), facilities may use these components according to local preferences. The availability of a variety of solutions will allow the system to be flexible in meeting the needs of different facilities, which offer various levels of clinical services. The aim is to develop technology solutions that are easily extensible to tribes and other rural communities.