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Defining Key Health Information Technology Terms

Health Information Technology (HIT) is at the forefront of patient safety initiatives in hospitals across the United States and abroad. As a part of an integrated HIT system, each facet of the technology is designed to eliminate human errors on the part of doctors and nurses that can lead to adverse events, such as a patient receiving the wrong medication or the wrong dose -- and thus leading to patient injury or death. When used consistently and correctly, the key HIT systems and devices have been proven to help health care professionals significantly reduce errors and save patient lives.

  1. CPOE

    • Computerized physician order entry (CPOE) systems are designed to prevent medical and medication errors brought about by illegible handwriting on paper orders and prescriptions. Using a secure password-protected CPOE system, physician orders can be entered and patient information can be retrieved through any computer with Internet access, including handheld mobile devices. Advanced CPOE systems give physicians real-time, 24/7 access to a patient's medical record and the ability to place orders and prescribe medication remotely, thus enabling treatment to be delivered more quickly to a patient. CPOE systems are usually integrated with a patient's electronic health record (EHR).

    BPOC

    • Barcode point-of-care (BPOC) technology is designed primarily to eliminate medication administration errors at a patient's bedside. The technology is delivered through handheld barcode scanners, which are integrated with the HIT system to deliver the scanned information directly to a patient's EHR and the electronic medication administration record (eMAR). Using a BPOC device, a nurse scans the medication package and a patient's wristband prior to administering the medication to confirm that the patient's identity and medication order match. BPOC devices also provide nurses with real-time pharmacy instructions, alerts, reminders and new medication orders, if any.

    eMAR

    • The electronic medication administration record (eMAR) is a computerized version of the traditional paper-based medication administration record. The eMAR is tightly integrated with BPOC technology within the HIT system to ensure that a patient's record is accurate and always up to date since all medications given to a patient are automatically documented via a bar-code scan at the bedside. Using an eMAR helps support patient safety by eliminating human error (e.g., forgetting to write down a medication or writing the wrong name or dosage) that can lead to an adverse event.

    EHR

    • An electronic health record (EHR) is the computerized version of a traditional paper-based patient medical record or chart, which contains the patient's personal information, symptoms, diagnosis, medications prescribed, lab reports, medical history and other health-related information. Because CPOE supports an EHR within an HIT system, hospitals can ensure the accuracy of patient records and documentation of services provided. Also, EHRs can be easily and quickly shared among multiple health care providers to facilitate and accelerate the delivery of patient care. In addition, by having more accurate patient records, hospitals can achieve more accurate and efficient insurance claims processing, leading to faster, more complete reimbursement of claims.

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