1. Special Topics in Vendor-Specific Systems EHR Functionality This material (Comp14_Unit4) 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.

2. EHR Functionality Learning Objectives 2 Results Review Computerized Provider Order Entry (CPOE) Documentation Messaging among different vendor systems Billing supported by EHR vendor systems Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality

3. Outline EHR functionality –Results Review –Computerized Provider Order Entry (CPOE) –Documentation –Billing –Messaging 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality

4. Results Review 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Linked to laboratory information system e.g., bacterial cultures, complete blood count, therapeutic drug levels Laboratory 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 Imaging results Critical results notification Viewing formats Table/flowsheet format Graph for display of trends Workflow configurations Interfaces with other systems such as labs and imaging Vendor system differences

5. Computerized Provider Order Entry (CPOE) 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Medications, Nursing, Laboratory, Radiology/imaging, Provider referrals, Blood bank, Physical therapy, Occupational therapy, Respiratory therapy, Rehabilitation therapy, Dialysis, Provider consults, Discharge and transfer System used for direct entry of 1 or more types of orders by a provider into a system that transmits those orders electronically to the appropriate department (Armstrong, 2000)

6. CPOE (cont.) 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Unintended Consequences Wrong patient selected from list Wrong drug selected from list Changes workflow, may decrease interdisciplinary communication Potential to alleviate patient safety problems by limiting Illegible handwriting Use of dangerous abbreviations Verbal orders Transcription errors

7. CPOE: Vendor System Differences 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Online formularies e-prescribing Medication prescriptions in ambulatory setting Health plan formulary Transmission of the prescription directly to pharmacy

8. CPOE: Vendor System Differences (cont.) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Decision Support Functionalities Dosing recommendations and calculations Customized order sets Bar coding scanning technology Medication administration process (pharmacy – administration) Right patient gets the right drug at the right time Alerts Allergy alert Drug-interaction checking Laboratory alerts Medication reconciliation process Outpatient – Emergency Department – Hospital Admission – Inpatient Course – Hospital Discharge

9. CPOE: Meaningful Use Criteria 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Non-hospital setting: CPOE used for at least 80% of all orders e-prescribing used for at least 75% of all prescriptions Hospital setting: CPOE used for at least 10% of all orders Medication reconciliation performed for at least 80% of relevant encounters & transitions of care http://healthit.hhs.gov/portal/server.pt

10. Documentation: Multiple Disciplines 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality PhysicianNurse Social worker Physical Therapist Respiratory Therapist Other clinicians

11. Documentation: Electronic Capture of Clinical Information 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Visit Note, Discharge Summary, Peri- operative Note Clinical notes Vital Sign Flowsheet Patient assessments Medication Administration Record (MAR) Clinical reports For procedures Hospital admissions Advance Directives and Informed Consents

12. Documentation: Methods of Information Capture 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Narrative free-text notes Unstructured: Structured headings with some free-text entry Semi- structured: Check boxes in MAR Flow sheet vital signs and patient assessment Structured:

13. Documentation: Potential Barriers to Implementation 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality 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 Workflow implications

14. Documentation: Vendor System Differences 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality Note creation options: Templates Clinical discipline Specialty Or 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 Templates Clinical discipline Specialty Or 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

15. Legal Issues 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality 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 is resides, determines if it is part of the legal record

16. Billing 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality ICD-9-CM codes (The International Classification of Diseases, 9th Revision, Clinical Modifications) Transition to ICD-10-CM (The International Classification of Diseases, 10th Revision, Clinical Modifications) is delayed beyond previously established deadline of October 1, 2013 (as of February 2012 new deadline has not yet been announced). ICD-10 includes ICD- 10-PCS codes (Procedure Coding System). CPT codes (Current Procedural Terminology) All vendor systems support these

17. Billing 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality ICD-9-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 & management service performed at patient visit Professional billing (Physicians’ and Nurse Practitioners’ services) ICD-9-CM codes Inpatients billing by hospitals Transition to ICD-10-PCS delayed until after 2013 Hospital billing

18. Messaging Internal e-mail Secure email for patients EHR linked automatic text page Intraoffice group communications 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality

19. Messaging (cont.) 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 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality

20. 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 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality

21. EHR Functionality References References: 1.Armstrong, C. W. (2000). American Hospital Association guide to computerized physician order-entry systems. Chicago, IL: American Hospital Association. Retrieved June 15, 2010 from http://healthit.hhs.gov/portal/server.pthttp://healthit.hhs.gov/portal/server.pt 2.Center for Diseases Control and Prevention, International classification of diseases, Ninth revisions, clinical modification (ICD-9-CM). Retrieved on October 8 th, 2011 from http://www.cdc.gov/nchs/icd/icd9cm.htmhttp://www.cdc.gov/nchs/icd/icd9cm.htm 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Special Topics in Vendor-Specific Systems EHR Functionality