Electronic Health Record and Clinical Informatics Kayle Jhan L. Yap, RN

Clinical Informatics The scientific discipline that seeks to enhance human health by implementing novel information technology, computer science and knowledge management methodologies to prevent disease, deliver more efficient and safer patient care, increase the effectiveness of translational research, and improve biomedical knowledge access.

"Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship.“ (Gardner RM et al, 2009)

Electronic Health Record  A data warehouse or repository of information regarding the health status of a client, replacing the paper-based medical record  Systematic documentation of a client’s health status and healthcare in a secured digital format

Electronic Health Record  also known as an Electronic Medical Record  can be used to collect and look up patient data by physicians or health professionals at various locations such as doctor’s offices or hospitals

Information Included in the EHR: demographics patient problems medication allergies laboratory results, etc. (Certification Commission for Healthcare Information Technology [CCHIT], 2007)

Should individual consent be required before information is included in EHR or disclosed through EHR?

Who will have access to EHR? For what purposes? What security mechanisms are in place? What are the risks of unauthorized access?

Health Information the patient data required to make sound clinical decisions

Order Entry Management the ability for a clinician to enter medication and other care orders directly into a computer including laboratory, microbiology, pathology, radiology, nursing, supply orders, ancillary services and consults.

Decision Support the computer reminders and alerts to improve the diagnosis and care of a patient

Electronic Communication and Connectivity online communication among healthcare team members, their care partners and patients including , web messaging, and an integrated health record within and across settings, institutions and telemedicine

Patient Support patient education and self-monitoring tools including interactive computer based patient education, home telemonitoring and telehealth systems

Reporting and Population Health Management Data collection tools to support public and private reporting requirements including data represented in a standardized terminology and machine-readable format

Office of the National Coordinator for Health Information Technology was established after President Bush’s state of the union address in 2004 to address the nuances and gaps in defining an EHR. Primary Mission of ONCHIT: to assure users of health information technology systems that those systems “provide needed capabilities, securely manage information and protect confidentiality and work with other systems without reprogramming” (Department of Health and Human Services, 2007)

Privacy one’s right to control who has access to information about oneself

Confidentiality duty owed by one to preserve the secrets of another

Security mechanisms put in place to safeguard privacy and ensure confidentiality is maintained

Health Information Privacy Code right of privacy fundamental in a free and democratic society includes patient's right to determine with whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her right of privacy and consent are essential to trust and integrity of the patient-physician relationship.

Advantages  Convenient access to data When all care providers have access to the same data, they can avoid ordering duplicate tests and prescribing contraindicated medications. Care providers no longer have to interpret poor penmanship and handwritten orders.

Advantages  Improved patient care outcomes The data captured by EHR technology can also be used to calculate patient care trends and outcomes across a wider population, which is another key component of the health informatics discipline. EHR facilitates faster identification of possible research study participants and effective patient notification of medication recall.

Advantages  Greater efficiency and cost savings The technology enables more efficient patient visits, eliminates duplicate testing, and facilitates easier documentation. All of these aspects add up to cost savings for physicians and hospitals, as well as for patients and their insurance companies.

reduce turn- around-time for lab results in an emergency department for prompt administration of the first dose of antibiotics in an inpatient nursing unit More efficient billing and claims management systems through electronic transactions

Advantages  More empowered patients When patients have access to their personal health records while also extending a convenient way to schedule appointments, refill prescriptions and communicate electronically, then they can take an active role in managing their outcomes and overall well-being.

Concerns  At a very basic level, there is as yet no electronic health record system available that can provide all functions for all specialties to a degree that all clinicians would successfully adopt. Most healthcare organizations do not yet have the capacity to implement and maintain systems in all care areas.

Concerns  Patient privacy is a pivotal issue to determining how far and how easy it will be to share data across healthcare organizations. For health exchanges such as these to reach their full potential the public must be able to trust that their privacy will be protected, or else risk that patients may not share a full medical history or worse yet may not seek care, effectively making the exchange useless.

Concerns “Currently, there is significant variation in privacy laws and data access policies across the country that poses a challenge for EHR systems that are dependent on inter-sectoral and inter-jurisdictional flows of personal health information…” (Senator Kirby, Senate Report on the Health of Canadians (2002)

Points for Discussion 1.What are the implications for nursing education as the electronic health record (EHR) becomes the standard for caring for patients? 2. What are the ethical considerations related to interoperability and a shared electronic health record?

Conclusion Healthcare is an intensely data-driven discipline. However, even today, most of the information used as part of the patient care process is paper-based. Important health information about individuals is scattered across many systems that do not, and cannot, communicate with each other. New national and international initiatives aim to define and implement a secure, patient-centric, longitudinal electronic health record that will store an individual's past and present health status, care received and plan of care, and that can be appropriately shared to improve health outcomes and enhance patient safety.

Conclusion Equally important as a focus is how the EHR can support the development of evidence-based medicine through translational, clinical and outcomes-based research, while ensuring the security and privacy of individual patient information.

References: Buttell, Phillip. “The Privacy and Security of Health Information in the Electronic Environment Created by HIPAA” (2001) 10:3 Kansas Journal of Law & Public Policy 399. Gardner RM et al. Core Content for the Subspecialty of Clinical Informatics. J Am Med Inform Assoc Mar- Apr;16(2):153-7 Miller, R.; Sim, I. "Physicians‟ Use of Electronic Medical Records: Barriers and Solutions" (2004) 23 Health Affairs