1. Chapter 16: Electronic Health Records
Health Information Management Technology: An Applied Approach Fourth Edition
Chapter 16: Electronic Health Records

2. Introduction
American Recovery and Reinvestment Act of 2009’s definition of “qualified EHR”:
A qualified EHR “includes patient demographic and clinical health information, such as medical history and problem lists, and has capacity to provide clinical decision support, support physician order entry, capture and query information relevant to health care quality, and exchange health information with and integrate such information from other sources.”

3. Computer-based Patient Record
Institute of Medicine’s definition:
“a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support, links to bodies of medical knowledge, and other aids”

4. Electronic Medical Record
System that integrates dictation, transcription, scanned documents, and print files

5. National Alliance for Health Information Technology
Electronic medical record: “An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.”
Electronic health record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than on health care organization.”

6. Health Information Technology
Term used to describe the use of information technology in healthcare

7. Goal of EHR Provide seamless exchange of information
Access to evidence-based medicine
Embedded clinical terminology

8. The Electronic Health Record System
EHR applications
Point of care charting
Computerized provider order entry
Electronic medication administration record
Clinical decision support
Ancillary systems
Picture archiving and communication systems
Health information exchange
Practice management system
E-prescribing

9. Health Level Seven EHR Systems Functional Model
Lists functions for EHR

10. Clinical Decision Support
Assists physicians, nurses, and other clinicians make decisions about patient care such as:
Provides documentation of clinical findings and procedures
Active reminders for medication administration
Suggestions for prescribing
Protocols for certain health maintenance procedures
Alerts that duplicate lab test is being ordered

11. Clinical Decision Support
Data must be captured in discrete data
Structured data
Examples: lab values, medication dosage

12. Continuity of Care Continuity of Care standards
Standard for format for data needed for patient referrals
Developed to eliminate data inconsistencies
ASTM: Continuity of Care Record (CCR) standard
HL7: Clinical Document Architecture (CDA)
Together the CCR and CDA is the Continuity of Care Document (CCD)
Continuity of Care record is subset of EHR

13. Quality Measurement and Reporting
Federal government promotes EHR to improve healthcare quality, efficiency, and patient safety.
CMS provides hospitals who report designated quality measures higher update to their payment rate.
Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program

14. Quality Measurement and Reporting
Collecting data has been burden for this type of reporting.
Physician Quality Reporting Initiative (PQRI)
Incentive pay program
Now includes e-prescribing
Basis of HITECH incentives

15. Evolution of the Electronic Health Record
Earliest efforts began in mid-1960s.
Clinical data are textual and contextual.

16. Evolution
In 1980s, the Institute of Medicine recommended new technologies were needed to improve state of medical records.
Quality of care and patient safety can be improved.

17. Document Management Systems
Document imaging
Now called electronic document management systems (EDMS)
Computer output to laser disk (COLD)
Now called electronic report management (ERM) systems
Electronic document/content management
Workflow

18. Document Management Systems
Electronic signature authentication
Digital dictation system
Speech recognition

19. Stages of EHR Clinical data repository (CDR) Database
Manages data from different sources
Allows for easier processing

20. Point of Care Charting Beginning point of many hospitals
Templates used to college appropriate data
Use data collection tools like check boxes and drop down menus
Logic built in
Follows practice guidelines
Knowledge databases
Practice guidelines vs. evidence-based guidance

21. Nursing, Medication Administration, and Provider Order Entry Applications
Many facilities implement nursing documentation first
Electronic medication administration record
Computerized provider order entry systems
Standard order sets
Clinical decision support
Bar-code mediation administration record
Medication reconciliation
Closed loop medication management

22. Computerized Provider Order Entry in Ambulatory Environment
CPOE is part of EHR, but fewer destination systems
Medication orders usually posted through e-prescribing

23. Transition State EHR is still being implemented. Hybrid record
Issues with the hybrid record
Identification of health information location and accessibility
Printing issues
Release of information coordination
Signatures on both paper and electronic records
Identification of users
Identification of legal health record
Identification of designated record set

24. Transition State Many organizations still print everything
Some organizations scan all paper documents

25. Initiatives and Framework for the EHR
Federal government initiatives
Health Insurance Portability and Accountability Act (HIPAA)
Office of the National Coordinator (ONC)
Health Information Technology for Economic and Clinical Health Act (HITECH)

26. ONC Health information exchange (HIE) Models of HIE HIE requires:
Federated
Consolidated
HIE requires:
Policies and procedures for exchanging health information
Security utilities
Matching algorithm
Record locator service

27. ONC Supports nationwide health information network
Would support national health information infrastructure

28. Health Information Technology for Economic and Clinical Health (HITECH)
Made ONC permanent
Focus on EHR with PHR and HIE being key elements
Meaningful use
Ability to demonstrate quality improvement through use of EHR

29. Local Efforts and Challenges
EHR vendors
May not be able to keep up with demand
Meeting HL7 EHR system functional requirements
Interoperability
Meaningful use
ICD-10-CM

30. Health Plans
Medicare provided consultation assistance to small physician practices through Doctors Office Quality—Information Technology program (ended 2008)
Blue Cross Blue Shield and commercial plans use incentives such as pay for performance or pay for quality

31. Healthcare Professionals
Many physicians may not be interested in EHR
Mobile devices may be first step toward implementing technology
Another early step is e-prescribing
Nursing and allied health professionals seek organizations with EHR

32. Patients Until now, patients have had little interaction with EHR
Patient may be concerned about privacy and security
Many organizations are educating patients on the EHR

33. Patients May allow patient generated information in EHR
Schedule appointments
Pay bills
Educational material
Informed consents
Enter health history
E-visit

34. Personal Health Record
AHIMA defines the PHR as:
An electronic, universally available, lifelong resource of health information needed by individuals to make health decisions
Patients manage information
Types of PHR
Integrated: integrated to existing EHR at healthcare facility
Stand-alone: obtained from vendor

35. PHR-System Functional Model
Defines functional that should be in PHR

36. MyPHR
AHIMA website to educate public on PHR

37. Technology that Support Electronic Health Records
Databases
Relational database
Data stored in tables
Database management system
Manage database
Clinical data warehouses
Data exchange standards
Vocabulary standards

38. Data Exchange Standards
Allow different databases to be used together
Methods database relate to each other
Send copy of data to other system
Generally requires interface
Requires data exchange standard
Protocols
Repository
Brings data together through standard interoperability protocols

39. Data Exchange Standards
Health Level Seven (HL7)
Family of standards that aid exchange of data
Digital Imaging and Communications in Medicine (DICOM)
National Council for Prescription Drug Programs (NCPDP)
Exchanges clinical images

40. Data Exchange Standards
American National Standards Institute (ANSI) Accredited Standards Committee X12 (ASC X12)
Provides standards for hospital, professional, and dental claims, eligibility inquiries, electronic remittance advice, and other standards
ASTM International E31 Committee on Health Informatics
Guidelines for EHR management processes

41. Data Compatibility Standards
Ensuring meaning of term is consistent across users
Semantics
Semantic interoperability
Standard vocabulary
Controlled vocabulary

42. SNOMED Developed by the College of American Pathologists
Now maintained by the International Health Terminology Standards Development Organization
Available in the United States through National Library of Medicine license

43. SNOMED
NLM has mapped SNOMED to ICD-9-CM and ICD-10-CM

44. Vocabulary vs. Classification
Vocabulary is set of all terms that may be used in a language
Classification is a grouping of the terms into various categories

45. Other Vocabularies
Logical Observation Identifiers, Name and Codes (LOINC)
RxNorm
Universal Medical Device Nomenclature System

46. Electronic Document/Content Management
Tags content within a document
Enables data to be processed separately from document

47. Enterprise Report Management
Captures data from print files and other digital documents such as
Stores them for viewing
Workflow tools
Clinical images

48. Results Retrieval and Management Technology
Accesses test results
May access one type of test results (e.g., lab) or multiple (e.g., lab, radiology, others)
Results management manipulates data
Example: graphing test results
Screen layout can be customized to user’s preference
Uses color, animation, icons and sound

49. Data Capture Technology
Technologies that make data capture easier
Discrete data entry through point-and-click fields, drop down menus, structured templates, or macros
Speech and handwriting recognition
Handheld and wireless devices
Direct data capture from a medical device attached to a patient
Patient data entry
Natural language processing

50. Clinical Decision Support
Address patient safety, healthcare quality improvement issues, and preventive care
Special analytical tools:
Reminders and alerts
Clinical guideline advice
Benchmarking
Expert system resources
Diagnostic or procedural investigative tools

51. System Communication and Networks
Architecture
Configuration, structure, and relationships of all components of a computer system
Two main types of architecture:
Client/server architecture
Web services architecture

52. System Communication and Networks
Network devices
Local area network
Wireless local area networks
Radio frequency identification
Wide area networks
Network protocols:
Ethernet
TCP/IP

53. System Communication and Networks
Intranet
Extranet

54. Storage Technology Storage device
Machine that contains nothing but storage media
Redundant arrays of independents disk
Storage area networks
Storage management software
Server redundancy
Mirrored processing

55. Storage Technology Retention schedule Determine impact of EHR
Retention of metadata
Audit logs
Data dictionary

56. Acquisition of EHR Systems
Requires extensive planning and organization
Readiness assessment
Determine barriers
Lack of appreciation for EHR
Costs

57. Benefits of EHR Implementation
Many benefits are difficult to quantify
Primary benefits
Quality of patient safety
Benefits that give financial payback
Impact of staff
Storage of paper charts
Improvements in charge capture
Reduce repetitive tests

58. EHR Implementation Issues
May need staff trained in health informatics
Very time consuming
Adoption
Training
Executive support
Patient’s concern for privacy and security
Legal and regulatory matters
E-prescribing

59. Planning Planning includes: EHR steering committee
Organizing the project
Developing a migration path
Communicating to stakeholders
Developing a strategy and plan to manage change
EHR steering committee

60. Planning Staff required Migration path IT staff Support staff
Project manager
Migration path

61. EHR Selection
Best of fit
Dual core
Best of breed
Rip-and-replace

62. EHR Selection
Request for proposal

63. Implementation Activities
Implementation strategies vary by vendor and system being implemented
Issues management
Implementation plan
Effecting chart conversion
Data from paper chart is converted to data
Data conversion
Data converted from existing source system

64. Implementation Activities
Establishing the technical infrastructure
Hardware, software, network and storage
Testing
Unit
System
Integration
Stress
Acceptance

65. Implementation Activities
Train users to use system
Super user

66. Maintenance and Improvement
Maintains system after go-live
Financial benefits realization
Determine if goals were met

67. Information Management in an Electronic Environment
New roles for HIM professionals
Data analysts
Information brokers
Data set developers
Data miners
Workflow analysts
Data security managers
Database administrators

68. Data Quality AHIMA Data Quality Model
EHR increases potential for poor data quality
Copy and paste
Macros
Standard orders
Others techniques that “reuse” data
Potential for discrepancies between comment fields and structured data

69. Data Quality Determining if entries are made by authorized individuals
Sharing passwords
Handling amendments, corrections, and deletions

70. Confidentiality and Privacy
CIA of security
Confidentiality
Integrity
Availability
EHR provides
Authentication
Access controls
Audit logs

71. HIPAA/HITECH Privacy and Security Requirements
Policies and procedures on uses and disclosures
Individual privacy rights
HITECH makes business associates more accountable for privacy and security regulations
EHR can place controls to manage access to special categories of information

72. HIPAA/HITECH Privacy and Security Requirements
Providers must accept request for restricting information sent to insurance company if services are paid in full
Security requirements more technical than privacy
Security does require policies and procedures
Breach notification requirement
Encryption

73. Legal Health Record, Retention, and Admissibility
AHIMA definition of legal health record: “generated at or for a healthcare organization as its business record and is the record that would be released upon request”
Each healthcare organization would have to define legal health record
Metadata

74. Retention
States generally allow destruction after 7 to 10 years from time records was created and last used
Exception is records of minors
Electronic records consume little space
Electronic media is durable but concerns regarding readability of old media

75. Admissibility
Printed electronic record may not look like traditional record
Electronic records will have to be printed or EHR retrieved in court

76. Future Directions in Information Technology
Every 18 months some form of technology is replaced with new technology.
Will create challenges for HIM professionals
Examples of changes
Internet and web-based technologies
Natural language processing