ELECTRONIC HEALTHCARE RECORD SYSTEMS Czarina Joyce B. Sarno Hyacinth Mae Abueva

EHR-S The term EHR-S is often used interchangeably with computerized patient record, clinical information system, electronic medical record, and many others. By including the word system, the term forces a distinction between an EHR, which is a physical or logical (virtual) repository of data, and an EHR-S, which can be made up of one or more applications. EHR-S provides the components that support clinical and healthcare functions including business rules, procedures, and so forth by accessing the EHR to write and/or read patient data.

The IOM’s 1991 definition of computer- based patient record system is currently the basis for domestic and international definition of an EHR-S: –The set of components that form the mechanism by which the patient records are created, used, stored, and retrieved. A patient record system is usually located within a healthcare provider setting. It includes people, data, rules and procedures, processing and storage devices (e.g. paper and pen, hardware and software), and communication and support facilities.

Recently, the IOM modified this definition in its report, Key Capabilities of an Electronic Health Record System, reiterating the new definition in a report on patient safety. An EHR-S includes the following: Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or healthcare provided to an individual, Immediate electronic access to person- and population-level information by authorized, and only authorized users; Provision of knowledge and decisions to support that enhances the quality, safety, and efficiency of patient care; and Support of efficient process for healthcare delivery.

Federal Initiatives Within federal government, different departments exert different influences toward the common goal of an EHR for most Americans. Agencies providing direct healthcare offer enterprise is a realistic goal with measurable, repeatable positive outcomes. Other agencies provide leadership by offering monetary incentives; funding research, development, and demonstration projects; and shaping regulations and policy.

Government as Provider and Early Adopter Federal agencies that provide direct care have been early adopters of EHR-S. The Veterans Health Administration in the Department of Veterans Affairs (VA) and the National Institute of Health (NIH) in the Department of Health and Human Services(HHS) are two examples of the initiation of systems in the 1970s that were actively used by clinicians. The Department of Defense (DoD) and the Indian Health Service (HIS) in the Department of HHS both acquired the VA’s original clinical information system years ago, customizing it to meet their clinical and business needs.

Department of Veterans Affairs The Veterans Health Information Systems and technology Architecture (VistA) supports day-to-day clinical and administrative operations at local VA healthcare facilities. VA dates its computerization efforts back to the early 1980s. In the 1990s- a GUI was added to bundle all existing functions from VistA and present them in an interface that was easier for the clinical user. The new interface named the computerized patient record system (CPRS) provided a single place for healthcare providers to review and update a:  patient’s health record and order medications  special procedures  x-ray  nursing orders  diets, and  laboratory tests

All electronic records are password protected to guarantee patient privacy. Other feature include the following: a checking system that alerts clinicians if an order they are entering could cause a problem a notification system that immediately alerts clinicians to clinically significant events a visual posting system that alerts healthcare providers to issues specifically related to the patient on the opening of the patient’s electronic charts, including crisis notes, adverse reactions, and advance directives a template system that allows the healthcare provider to automatically create reports a clinical reminder system that electronically alerts clinicians when certain actions, such as examinations, immunizations, patient education, and laboratory tests, need to be performed. Remote data viewing to allow clinicians to see the patient’s medical history to all the VA facilities where the patient was seen.

Department of Defense Within DoD, providers have had computerized physician order entry capability that enables them to order lab tests and radiology examinations and issue prescriptions electronically for over 10 years DoD began a wordwide rollout of the next generation system, the composite health care system(CHCS II), a secure, scalable, patient- centric EHR-S. Tricare Online – as secure Web portal through which its 8.9 million beneficiaries and physicians can access 19 million pages of verified health information and schedule appointments.

Indian Health Service (IHS) Has long been a pioneer in using computer technology to capture clinical and public health data. Resource and Patient Management Systems (RPMS) – 1970s ; many facilities have access to decades of personal health information and epidemiologic data on local populations. Patient Care Component – RPMS’ primary component and has been in place since 1980s. IHS-EHR - the next phase of clinical software development for IHS Many of its components are imported from the VA’s CPRS and adapted to fit the business needs of the IHS clinical environments of care.

Government as a Leader Federal agencies that do not provide direct care are taking multiple approaches to promote use of EHR-S by : Decreasing the cost and risk of acquisition Providing incentives for their use. Federal activities are focused on the development and adoption to terminologies and standeards, grants for community demonstrations of data exchange, and other pilot projects.

Office of the National Coordinator for Health Information Technology (ONCHIT ) Created to coordinate HIT efforts in the federal sector and to collaborate with private sector in driving HIT adoption across the healthcare system. David Brailer – was named to fill the subcabinet-level post. In July 2004, HSS Secretay Tommy Thompson and David Brailer released a framework for strategic action.

National Committee on Vital and Health Statistics (NCVHS) In 2000 and 2001, NCVHS held a series of national hearings to develop a consensus vision of the National Health Information Infrastructure NCVHS presented the concept of an infrastructure that emphasizes health- oriented interactions and information-sharing among individuals and institutions, rather than simply the physical, technical, and data systems that make those interaction possible.

Agency for Healthcare Research and Quality (AHRQ) With grants, contracts, and other activities to demonstrate the role of HIT in improving patient safety and the quality of care. Funded demonstration grants to establish and implement interoperable health information systems and data sharing to improve the quality, safety, efficiency, and effectiveness of healthcare for patients and populations on a specific state or regional level they also funded five contracts of about $1 million per year for 5 years for each state and regional demonstration of health IT.

Centers for Medicare and Medicaid Services (CMS) Initiated several pilot projects to promote health IT. May CMS awarded a $100,000 grant to the American Academy of Family Physicians (AAFP) for a pilot project to provide a comprehensive, standardized EHR software to small and medium sized ambulatory care practices. Chronic Care Improvement Program (CCIP) – pilots that offer self –care guidance and support to chronically ill beneficiaries

PUBLIC-PRIVATE PARTNERSHIP A number of collaborative efforts are focused on the EHR-Ss and HIT to improve care. Among these private sector organizations are those formed specifically to address issues of connectivity, HIT, and standard development. Others are established standard development organizations ; some are based in professional association, where they arose in efforts to serve their membership.

Connecting for Health A large private collaborative with federal participants supported by the Markle and Robert Wood Johnson Foundations Is addressing the barriers to development of an interconnected health information infrastructure. Organized several working groups focusing on understanding the business and organizational issues of community based information exchange.

eHealth Initiative is an independent, nonprofit affiliated organization established to foster improvement in the quality, safety, and efficiency of healthcare through information and IT. Connecting Communities for Better Health - major program of the foundation for eHealth Inititative. -A nearly $4 million program that provides seed funding and technical support to multistakeholder collaborative within communities that are using electronic health information exchange and other HIT tools to drive improvements in healthcare quality, safety, and efficiency.

Institute of Medicine (IOM) Championed that advantages of use of IT to improve healthcare since its 1991 foundational work IOM showcased federal programs and encouraged the development of an information infrastructure for the comparison of data to evaluate performance at the request of HHS, the IOM issued a report, Key Capabilities of an Electronic Health Record System, which identified key functions of EHR in four settings : hospitals, ambulatory care, nursing homes, and care in the community. The report created a framework for identifying core functions of an EHR-S, along with the primary and secondary uses of these systems.

Certification Commission for Health Information Technology (CCHIT) The Health Information and Management Systems, American Health Information Management Association, and National Alliance for Health Information Technology have joined together to establish the CCHIT. Goal is to support the Goal: “Reduce the risk of EHR investment”

Health Level System (HL7) Known for its large body of work in the production of technical specifications for the transfer of healthcare data. This transport mechanism, known as messaging, is widely used domestically and internationally. The HL7 EHR-S functional model contains a list of functions in 3 categories: direct care, supportive, and information infrastructure. Direct Care- functions are familiar to clinicians. Supportive- functions involve secondary use of the data captured via the direct care function Information Infrastructure- is the “backend” of the system; unfamiliar by many clinicians, this is considered essential by informaticist and technical staff.