Special Topics in Vendor-Specific Systems Unit 2: EHR Functionality Welcome to Special Topics in Vendor-Specific Systems. Unit 2 is on Electronic Health Record Functionality. This material (Comp14_Unit2) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003. This material was updated by Columbia University under Award Number 90WT0004. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/

EHR Functionality Learning Objectives Objective 1: Describe EHR functionality of results review Objective 2: Describe the EHR functionality of Computerized Provider Order Entry (CPOE) Objective 3: Describe the EHR functionality of documentation Objective 4: Describe the EHR functionality of messaging among different vendor systems Objective 5: Describe the procedures for billing supported by EHR vendor systems The learning objectives for the electronic health record functionality unit are: number one, to describe five EHR functionalities. These are: results review, computerized provider order entry (CPOE), documentation, messaging among different vendor systems, and billing supported by EHR vendor systems.

Results review Laboratory results Imaging results Linked to laboratory information system E.g., bacterial cultures, complete blood count, therapeutic drug levels Imaging results Linked to radiology (imaging) information system Used with Picture Archiving Communications Systems (PACS) which manage digital radiography E.g., radiology reports, X-rays, CAT scans, MRI images Results review functionality within an electronic health record refers to the reviewing of results for laboratory tests as well as imaging tests. In the clinical setting, laboratory tests are drawn and collected by a clinician and sent to the laboratory to be processed. The results of that laboratory test are entered into the laboratory information system which links to the electronic health record to display the result to the clinician. Examples of laboratories include bacterial cultures, complete blood cell counts, and the monitoring of therapeutic drug levels. Imaging results are processed in the EHR in a similar way. The results of imaging tests and studies, such as radiology reports and x-ray, CAT scan, and MRI images, are linked from the radiology imaging information system into the electronic health record to be viewed by a clinician. The imaging information system uses picture archiving communication system, or PACS, which processes and manages digital radiography. Health IT Workforce Curriculum Version 4.0

Results review (Cont’d – 1) Vendor system of differences Critical results notification Viewing formats Table / flowsheet format Graph for display of trends Workflow configurations Interfaces with other systems, such as labs and imaging There may be differences in how different EHRs present results for review by clinicians. Some systems have different processes to notify a clinician of a critical lab result. If the lab result is abnormally high or abnormally low, then there may be functionality within the EHR to alert the clinician. Additionally, the format for presented results may differ. Results may be presented in a table or a flow sheet format, which may show all of the laboratory test and imaging results at one point in time. An alternative view is a graph that displays the trend for one type of laboratory value. This view allows the clinicians to assess how one particular laboratory value has changed overtime. Some vendor systems may have the functionality to display results in multiple formats and allow the clinician to choose their preference. Health IT Workforce Curriculum Version 4.0

Computerized provider order entry (CPOE) System used for direct entry of one or more types of orders by a provider into a system that transmits those orders electronically to the appropriate department (Armstrong, 2000) Computerized Provider Order Entry, which is also referred to as CPOE is another functionality within the electronic health record. The American Hospital Association definition of CPOE is: a system used for direct entry of one or more types of orders by a provider into a system that transmits those orders electronically to the appropriate department. Health IT Workforce Curriculum Version 4.0

CPOE types of orders Medications Nursing Laboratory Radiology / Imaging Provider referrals Blood bank Physical therapy Occupational therapy Respiratory therapy Rehabilitation therapy Dialysis Provider consults Discharge Transfer An example of the use of CPOE is ordering medications. A physician orders a medication for a hospitalized patient using the CPOE system. Next, the information is transmitted to the pharmacy for processing and is then delivered to the hospital floor in which the patient is located. When the nurse administers the medication to the patient he or she will document it as administered in the EHR. Other types of orders that may be entered into a CPOE system are nursing orders, laboratory orders, radiology or imaging orders, provider referrals, blood bank orders, physical therapy or occupational therapy orders, respiratory therapy orders, rehabilitation therapy, dialysis orders, provider consults and discharge and transfer orders. Health IT Workforce Curriculum Version 4.0

CPOE (Cont’d – 1) 2.1 Figure (Sideli, R., 2012) CPOE is an important functionality of electronic health record. It has been shown to have the potential to alleviate many different patient safety problems by limiting illegible handwriting of medication and medication doses, the use of dangerous abbreviations and verbal orders which may be misinterpreted, and transcription errors from handwriting an order from one clinical document to another. The Joint Commission has issued a “do not use list” of dangerous abbreviations and these should not be part of any CPOE system. Verbal orders typically occur during a telephone call between a nurse and a physician when a physician is not present on the patient care floor. CPOE prevents verbal orders because it allows a provider to electronically enter an order from any location in which they can access the electronic health record. However, these workflow changes may have some unintended consequences on patient care. CPOE systems often present lists of patients or medication for a clinician to select from. In a busy clinical environment, which is often rich with distractions, a clinician may inadvertently select the wrong patient, the wrong medication, or the wrong medication dose from a list. Additionally, the implementation of CPOE drastically changes the clinical workflow. The ability of a physician to enter an order from any location within or outside of the hospital or clinic setting may decrease communication between clinical disciplines by limiting the opportunity for face-to-face discussions to occur. Different EHRs will also have different workflow configurations for interfaces with other systems, such as separate labs and imaging systems. The interfaces attempt to provide the user with a seamless workflow for viewing and entering data. 2.1 Figure (Sideli, R., 2012) Health IT Workforce Curriculum Version 4.0

CPOE: vendor system differences Online formularies e-prescribing Medication prescriptions in ambulatory setting Health plan formulary Transmission of the prescription directly to pharmacy Vendor systems may have different CPOE online formularies. A formulary is a list of medications that reflects the medications that are available from a hospital or clinic pharmacy. ePrescribing is closely related to CPOE. It is a functionality for ambulatory or clinic settings that allows a provider to electronically prescribe a medication. The prescription is electronically transmitted to the patient’s pharmacy. An ePrescribing system may have a formulary of the medications that are covered by the patient's health insurance. Health IT Workforce Curriculum Version 4.0

CPOE: vendor system differences (Cont’d – 1) Decision support functionalities Dosing recommendations and calculations Customized order sets Bar coding scanning technology Medication administration process (pharmacy to administration) Right patient gets the right drug at the right time Alerts Allergy alert Drug interaction checking Laboratory alerts CPOE systems may also differ by the types of decision support functionalities. Some systems may provide medication dosing recommendations and calculations. Often these calculations are based on a patient’s weight or laboratory values. A CPOE system may have customized order sets based on a patient’s diagnosis. For example, an order set for a patient diagnosed with pneumonia may indicate specific laboratory tests and x-rays that should be performed and medications that should be prescribed. Some systems may have bar coding scanning technology to decrease medication errors during the medication administration process. A medication order entered into the CPOE system is electronically transmitted to the pharmacy. When the pharmacy processes that order, a bar code will be printed out and placed on the medication’s packaging. When the nurse administers the medication to the patient he or she will scan the bar code on the medication and scan the patient's ID band. The system will verify that it is the correct medication for the correct patient. Another form of decision support is alerts. For a patient with an allergy to penicillin, an alert will be displayed if the clinician attempts to prescribe Penicillin. A similar type of alert is drug interaction checking. There are instances in which two drugs should not be prescribed together because the combination may cause side effects or an adverse reaction. The system will check all of a patient’s medication prescriptions to ensure that none of them interact with each other. A final type of alert is one that we discussed earlier, laboratory alerts. If a laboratory value is critically abnormal the system will notify the clinician of the value so that he or she can take action. Health IT Workforce Curriculum Version 4.0

CPOE: vendor system differences (Cont’d – 2) Medication reconciliation process Outpatient Emergency department Hospital admission Inpatient course Hospital discharge Vendor systems may have different functionalities to support the medication reconciliation process. Reconciling a patient’s medications at each transition of care is a Joint Commission requirement. This means that when a patient is admitted to the hospital the provider checks to make sure that the medications that the patient had been taken at home are also ordered, as clinically appropriate, for the patient while they are in the hospital. This process should be performed throughout the patient’s hospital stay, at discharge from the hospital and during other health care encounters. Health IT Workforce Curriculum Version 4.0

Documentation: multiple disciplines Physician Nurse Social worker Physical therapist Respiratory therapist Other clinicians Now we are going to talk about documentation functionalities within the electronic health record. Documentation is used by multiple disciplines including physicians, nurses, social workers, physical therapists, respiratory therapists, as well as other types of clinicians. Health IT Workforce Curriculum Version 4.0

Documentation: electronic capture of clinical information Documentation within the electronic health record is the electronic capture of clinical information. One type of this is a clinical note, such as a visit note written by a primary care provider about a patient’s visit in an outpatient setting. Another example of a clinical note is a discharge summary written by a provider when a patient is being discharged from the hospital. A third example of a clinical note is the pre-operative note written for a surgical patient before they have surgery. Another type of documentation is a patient assessment such as a vital sign flowsheet where the patient’s vitals signs such as blood pressure and heart rate are entered. Clinical reports are a third type of documentation. An example of a report is the medication administration record, and this is a record of all of the medications that have been administered to a patient. Finally, documentation includes a patient's advanced directive and any informed consent forms that they may have signed for various procedures or inpatient admissions. This information may be paper based and scanned into the electronic health record. 2.2 Figure (Sideli, R., 2012) Health IT Workforce Curriculum Version 4.0

Documentation: methods of information capture We just discussed the different types of documentation, and now we will discuss the three different methods for representing clinical documentation within the electronic health record. The first is unstructured information. Unstructured information refers to narrative free text notes written by a clinician. The second method of representing clinical documentation is semi-structured. This refers to notes that have structured headings followed by free text entry. For example, a clinician may write a progress note on a patient during their stay within the hospital and it may have a heading for the patient assessment, below which the clinician may type a narrative description of the patient's assessment information. Finally, information may be represented in a completely structured format, such as checkboxes. For example, on the medication administration record the nurse checks off if a patient received a medication. Flow sheets are another example of structured documentation. A vital sign flowsheet is a grid of vital sign measurements such as blood pressure and heart rate. The rows indicate the type of vital sign and the columns indicate the time a vital sign measurement was taken. 2.3 Figure (Sideli, R., 2012) Health IT Workforce Curriculum Version 4.0

Documentation: potential barriers to implementation Workflow implications Increased documentation time Overuse of checkboxes may impact cognitive processes Less opportunity to thinking and synthesizing patient problems than when writing a narrative note Potential for inaccurate data selections that may persist Documentation within the electronic health record may have some potential implementation barriers related to workflow implications. Documenting in an electronic health record, as opposed to on paper, may increase the amount of time required for documentation. Additionally, the overuse of structured data or poorly structured data may lead to inaccurate data selections for a patient that may persist within a patient’s electronic record. Health IT Workforce Curriculum Version 4.0

Documentation: note creation options Templates Clinical discipline Specialty Type of note Macros Combination of keys generate a user predefined text set Voice recognition software / embedded dictation Copy and paste Structured documentation Tailored assessments Vendor systems offer a variety of options for creating clinical notes. Some systems provide semi-structured templates for note generation. A template may be designed for use by a specific clinical discipline such as physicians or nurses, or it may be for a specific specialty. For instance, a template for a note for a dialysis clinic visit will include different information than a patient visit at an orthopedic clinic. Additionally, notes templates may be specific to the type of procedure or care given. For example, when administering blood products to a patient a nurse will complete a blood administration note and upon admission of a patient to the hospital a nurse will complete a hospital admission note. Some vendor systems include macros. Macros are a functionality that allows clinician to use a combination of keystrokes to generate user-predefined text. For example, a physician may not want to type out all of the required information to state that a patient's neurological exam was normal because this is a lot of extra typing for a large volume of patients. Therefore, the physician can use a macro to generate text that states: "The neurological exam is within normal limits. The patient is alert and oriented to person, place, and time". Some vendor systems may have voice recognition software and embedded dictation functionalities which allow the clinician’s recorded voice to be automatically transcribed into text that generates a semi-structured note. Additionally, some electronic health records have a copy and paste function. For example, this functionality will allow a clinician to copy and paste a patient's past medical history from a previous note into his or her current note instead of typing the same unchanged information again. Finally, structured documentation within the electronic health record may have tailored assessments. A structured assessment tool may be presented to the clinician for a clinical issue such as assessing neurological status or a patient’s risk for falling, and using this information the EHR may generate a clinical note. Health IT Workforce Curriculum Version 4.0

Legal issues Discovery of electronic records for legal purposes Centers for Medicare and Medicaid and Joint Commission Accepted standards for Legal Health Record HIPAA privacy and security rules and Office of Civil Rights Organizations identify “designated record set” How the information is used (e.g., was it used to provide patient care?), not where it resides, determines if it is part of the legal record There are legal issues related to the information entered into the electronic health records and if it is considered a part of the ‘legal health record’. The discovery of information within the electronic health record for legal purposes has been defined by the Centers for Medicare and Medicaid and The Joint Commission. The HIPAA Privacy and Security Rules which are enforced by the Office for Civil Rights, states that organizations are responsible for identifying the designated legal record set. This definition is applied to all patients who receive care at that organization. The criteria for designating information within the electronic health record as being a part of the legal health record is how that information was used in providing care for the patient, not where it actually resides within the electronic health record. Health IT Workforce Curriculum Version 4.0

Vendor billing codes supported ICD-10 ICD-10-CM for diagnosis coding and ICD-10-PCS for inpatient hospital procedure coding There are over 70,000 ICD-10 codes (up from around 14,000 ICD-9 codes) Current Procedural Terminology (CPT) codes Identifies the services rendered rather than the diagnosis on the claim Billing is also an important functionality with electronic health records. All vendor systems support the codes that are used for billing purposes. ICD-10 coding consists of ICD-10-CM Diagnosis codes, and ICD-10-PCS, the procedure coding system. Another type of codes are CPT codes, or Current Procedural Terminology codes. We will discuss these codes in more detail in the following slide. Health IT Workforce Curriculum Version 4.0

Professional and hospital billing Professional billing (physicians’ and nurse practitioners’ services) ICD-10-CM codes Hospital discharge summary or outpatient visit note CPT codes Procedure (e.g., surgery) CPT codes E / M (Evaluation and Management) Level of evaluation and management service performed at patient visit Hospital billing Inpatients billing by hospitals Professional billing is done by providers such as physicians and nurse practitioners. These providers use of ICD-10 codes and CPT codes. For example, within a hospital discharge summary or an outpatient visit note, a provider will enter an ICD-10 code that is specific to the patient’s diagnosis. CPT codes are used to bill for procedures, such as surgery, or the level of evaluation and management performed by the provider in the outpatient setting. Hospital billing, such as for supplies used during surgery, is done using ICD-10-CM. Health IT Workforce Curriculum Version 4.0

Messaging Internal e-mail Secure email for patients EHR-linked automatic text page Intra-office group communications The last functionality that we are going to talk about today is messaging internally within the EHR. An EHR may provide internal e-mail for clinicians and staff and secure e-mail between providers and patients. Additionally, an electronic health records may allow a clinician to send a text page to another clinician through the EHR. Furthermore, an EHR may support interoffice group communication messages.

Messaging (Cont’d – 1) Copy chart or lab results to another provider with a note Telephone message documentation Patient scheduling Referral letter or consultation report Patient follow-up deficiency alerts Additionally, an EHR may allow a provider to copy a patient’s chart or laboratory results or an x-ray image and send those results to another provider with a note. Telephone messages may be documented within the EHR. Scheduling of patient appointments may be supported by the EHR. Additionally, a provider may attach a referral letter or a consultation report to a message to be sent to the appropriate provider. Finally, an EHR may generate messages for patient follow-up deficiency alerts for patients that have not made an appointment for a follow-up appointment or routine checkup.

Unit 2: EHR Functionality, Summary Five important functions of EHRs: Results review Computerized Provider Order Entry (CPOE) Documentation Messaging Billing These functionalities impact clinical workflow, patient safety, information retrieval, legal issues, billing, and communication This concludes the lecture on EHR Functionality. The summary of this lecture is that number one, we discussed five important functions that EHRs perform. These were: results review, CPOE, documentation, messaging, and billing. We discussed the implications of many of the functionalities on clinical care. As you learn more about these functionalities it is important to consider their impact on clinical workflow, patient safety, information retrieval, legal issues, billing, and communication.

EHR Functionality References Armstrong, C. W. (2000). American Hospital Association guide to computerized physician order-entry systems. Chicago, IL: American Hospital Association. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10- CM). Retrieved on March 28th, 2016 from http://www.cdc.gov/nchs/icd/icd10cm.htm Chart, Tables, and Figures 2.1 Figure: Sideli, R. (2012). CPOE Benefits. Department of Biomedical Informatics, Columbia University Medical Center. 2.2 Figure: Sideli, R. (2012). Electronic Capture of Clinical Information. Department of Biomedical Informatics, Columbia University Medical Center. 2.3 Figure: Sideli, R. (2012). Methods of Information Capture. Department of Biomedical Informatics, Columbia University Medical Center. No audio.

Unit 2: EHR Functionality This material (Comp 14 Unit 2) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Columbia University under Award Number 90WT0005. No audio.