1. Managing Clinical Information: EHR Terms and Architecture
Nancy Staggers, PhD, RN, FAAN
Professor, School of Nursing
and Scott Narus, PhD, University of Utah and Intermountain Healthcare, Salt Lake City, UT

2. Definition EHR, EMR EMR = EHR; EMR is not EHR
EMR typically more limited in scope
EHR (
E-record of health information
Conforms to standards (although some may not)
Created, managed, consulted by authorized staff
More than one facility (or not)
EHR is the most commonly accepted term currently

3. TERMS Laboratory Information System (LIS)
Specimen processing and management, results
Radiology Information System (RIS)
Scheduling, results reporting
Usually integrated with PACS
Picture Archiving and Communication System (PACS)
Digital Imaging
Computerized Provider Order Entry
Program to manage and process patients’ orders that includes direct order entry by providers

4. TERMS Clinical Decision Support System (CDS)
is a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. Information recipients can include patients, clinicians and others involved in patient care delivery; information delivered can include general clinical knowledge and guidance, intelligently processed patient data, or a mixture of both; and information delivery formats can be drawn from a rich palette of options that includes data and order entry facilitators, filtered data displays, reference information, alerts, and others. (

5. EHR Functions Functions Complete longitudinal patient record
Clinical documentation, full CDS
Closed loop medication administration (the whole process from order to administration)
Orders management (CPOE with CDS)
Imaging, especially PACS
CDR (Clinical Data Repository), HIE (Health Information Exchange) capable
Ancillaries – lab, rad, pharm
EMR = Electronic Medical Record
CDSS = Clinical Data Support System
CPOE = Computerized Provider Order Entry
CDS = Clinical Decision Support
PACS = Picture Archiving and Communication System
CDR = Clinical Data Repository
HIE = Health Information Exchange

6. EMR Adoption Model EMR Adoption ModelSM Stage Cumulative Capabilities
Medical record fully electronic; HCO able to contribute CCD as by product of EMR; Data warehousing in use
Stage 6
Physician documentation (structured templates), full CDSS (variance & compliance, full R-PACS
Stage 5
Closed loop medication administration
Stage 4
CPOE, CDSS (clinical protocols)
Stage 3
Clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology
Stage 2
Clinical Data Repository, Controlled Medical Vocabulary, Clinical Data Support System, may have Document Imaging
Stage 1
Ancillaries – Lab, Rad, Pharmacy - All Installed
Stage 0
All Three Ancillaries Not Installed
©2008 HIMSS Analytics, LLC

7. Infrastructure Master Patient/Person Index (MPI)
Identifiers linked to one patient, e.g., age, name. The MPI is the key to integrating data across systems to the correct patient
Central Data Repository (CDR)
A computer server storing data integrated across applications /systems. Allows retrieval without regard for origin (Hebda & Czar, 2013)
Allows real-time data retrieval

8. Infrastructure Data Dictionary (DD) / Terminology Server
Stores standard definitions and terms to allow communication and integration across systems, such as a common definition for myocardial infarction
Knowledge Repository (KR)
Stores evidence-based knowledge such as guidelines, protocols, etc.
Not always a component of current EHRs
Continuity Care Document (CCD)
Summary of care from many providers to improve care continuity

9. Infrastructure Interface Engine (IE)
Software that allows systems to exchange, integrate and/or share data with each other (Hebda & Czar, 2013)
Requires specific communication protocols and shared understanding of terms
Allows many to many sharing

10. TERMS (Enterprise/Clinical) Data Warehouse (EDW or CDW)
Extremely large database storing all, or the majority, of an organization’s data. Data may be across clinical, financial and administrative systems
Allows off-line searching
Used for research, data mining, knowledge discovery, knowledge management

11. EHR Architecture Complex arrangement of EHR and networking components
Networks
Hardware and software allowing communication and electronic transfer of information between computers (Hedba & Czar, 2013)
Connected by a LAN (local area network) or WAN (wide area network)

12. Networks, Communication
Community Health Information Network (CHIN) or Community Health Information Exchange (CHIE)
Network and software to allow members to share information in a specific geographical area
Regional Health Information Network (RHIO)
aka Regional Health Information Exchange (RHIE)
aka Health Information Exchange
Same concept as above

13. EHR Architecture EHR 3 Ancillary Systems CDR EMR 2
EHR= Electronic Health Record
EMR = Electronic Medical Record
CDR = Clinical Data Repository
HIE = Health Information Exchange
MPI = Master Patient Index
DSS = Decision Support System
DW = Data Warehouse

14. EHR Architecture EHR 3 KR MPI CDR CDS DD DW Ancillary Systems CCR /
EMR 2
EMR 1
CCR /
CCD
EHR 3
Ancillary Systems DW
EHR= Electronic Health Record
EMR = Electronic Medical Record
CDR = Clinical Data Repository
HIE = Health Information Exchange
MPI = Master Patient Index
DSS = Decision Support System
DW = Data Warehouse

15. EHR Architecture IE EHR 3 KR MPI CDR DSS DD DW Security / Firewalls
EMR 2
EMR 1
CCR /
CCD
EHR 3
Ancillary Systems
Provider X
HIE IE DW
Security / Firewalls
EHR= Electronic Health Record
EMR = Electronic Medical Record
CDR = Clinical Data Repository
HIE = Health Information Exchange
MPI = Master Patient Index
DSS = Decision Support System
DW = Data Warehouse