B Y: C A S S I D Y W H I T E , S A N D Y P A R K , N I C H O L E R O D R O C K , & M E A G H A N B O L A N D

THE ELECTRONIC HEALTH RECORD

OVERVIEW-WHAT IS A CLINICAL INFORMATION

SYSTEM (CIS)?• McGonigle and Mastrain (2009) state that a clinical

information system (CIS) is a assemblage of applications, medical equipment and technologies working together to collect patient data to enhance patient care.

• Clinical information systems are utilized at the point of care with data recorded in real time and allow for interventions to be made immediately.

• Patient care data is stored in a centralized location and includes history of present illness, treatment options and wellness activities.

WHAT IS A CLINICAL DECISION MAKING SYSTEM?

• A clinical decision making system is a support system that “offers the possibility to improve the quality and reduce the cost of care by influencing medical decisions at the time and place that these decisions are made” (Farukhi).• A clinical decision making system can alert

healthcare workers to possible drug interactions and patient complications (Farukhi).

HOW SHOULD A CLINICAL DECISION MAKING SYSTEM BE STRUCTURED?

• There is an easy way for nurses to see how a clinical decision making system should be structured, because it is similar to a process a nurse uses before giving a med. • The “Five Rights” of clinical decision making systems for

effective delivery• The clinical delivery system should “provide the Right information

to the Right person in the Right format through the Right channel at the Right time” (Berner, 2009)

• So a clinical decision making system should make sure that the right person receives the alert about the patient before an action is taken. • this can prevent duplicate tests and med errors• It also can alert a health care worker to critical lab results

HOW OFTEN SHOULD THE EVIDENCE BASED PRACTICE (EBP) GUIDELINES BE UPDATED?

• Clinical decision making systems should provide “new relevant studies, identify those that are of high quality, and then incorporate the best evidence into patient-specific assessments or practice recommendations” (Sim, et al., 2001).• EBP guidelines should be updated frequently to

ensure that patients are receiving the best standard of care.

WHAT COMPANIES CREATE CLINICAL DECISION MAKING SYSTEMS?

• There are many companies that create clinical decision making systems. • RADARmed http://www.radarmed.com/• Zynx Health http://www.zynxhealth.com/• Webmedx http://corpweb.webmedx.com/• Anvita Inc. http://www.anvitahealth.com/

• You can visit Health Tech JAZD markets healthcare directory for more companies.

DEFINING THE ELECTRONIC HEALTH

RECORD (EHR)

• Clinical information systems come in many applications and contribute to the formation of the electronic health record (EHR) or electronic medical record (EMR).

• The EHR is an indispensable tool in patient care and functions to replace the paper medical record.

• The EHR serves as a systematic documentation of a patient’s care including current and past health status.

• EHRs allow for patient data to be recorded in a digital format, stored securely, and accessible by all disciplines providing patient care (McGonigle & Mastrain, 2009).

1. Health Information and Data

2. Results Management

3. Order Entry Management

4. Decision Support5. Electronic

Communication and Connectivity

6. Patient Support

7. Administrative Processes

8. Reporting and Population Health Management

8 COMPONENTS OF EHR

• Patient data required to make sound clinical decisions• Demographics• Medical and nursing diagnosis• Medication lists• Allergies• Test results

• Patient, and clinicians need access to this information as well as registration and case manager/social worker for any outpatient set ups

HEALTH INFORMATION AND DATA

• Ability to manage results of all types electronically• Lab reports• Radiology procedure reports• Current & historical

• Physicians and clinicians caring for a patient need access to these information for vital information for care

RESULTS MANAGEMENT

• Ability of a clinician to enter orders into a computer• Medications• Microbiology• Pathology• Radiology• Nursing• Supply orders• Ancillary services• Consultations

• Clinicians and related staff need access to place an order for tests or supplies for a patient

ORDER ENTRY MANAGEMENT

• Computer reminders and alerts to improve the diagnosis and care of a patient • Screening for correct drug selection and dosing• Medication interaction with other medications• Preventive health reminders i.e. vaccinations• Health risk screening and detection• Clinical guidelines

• Alerts clinicians, physicians, pharmacists and nurses to important information such as an allergy, indication and interaction of meds for patient safety 

DECISION SUPPORT

• Online communication along with healthcare team members, their care partners, and patient• Email• Web messaging• Integrated health record within and across

settings, institutions, and telemedicine

• Access required for healthcare members for referrals and consultation and availability of records to prevent delay in recommendations and orders

ELECTRONIC COMMUNICATION AND CONNECTIVITY

• Interactive computer based patient education• Home telemonitoring• Telehealth systems

• Patient and clinical staff should have access so education can be provided and supported for successful outcome of learning.

PATIENT SUPPORT

• Electronic scheduling, billing, and claims management systems• Electronic scheduling for inpatient and

outpatient visits & procedures• Electronic insurance eligibility validation• Claim authorization and prior approval• Identification of possible research study

participants• Drug recall support

ADMINISTRATIVE PROCESSES

• Receptionist, case managers, social workers, billings, and pharmacist should have access. Data are populated throughout the record and generally remain constant. For clinical researchers, alerts can be established to assist with recruitment efforts by identifying eligible research participants ("Electronic health records," 2006)

ADMINISTRATIVE PROCESSES CONT.

• Data collection tools to support public and private reporting requirements including data represented in a standardized terminology and machine readable format

• Assigned Information Technology sector would need access to these info to built the most appropriate EHR for different setting, i.e. child health, cardiology, and ER.

REPORTING AND POPULATION HEALTH MANAGEMENT

IMPLEMENTING AN EHR

• Choosing to implement an EHR has many benefits for both patients and clinicians including:

-improvements in quality, safety and efficiency

-reduction in health disparities-engagement of patients and families in their healthcare-improvements in care coordination and public health-ensure adequate privacy and security

of protected health information (Woodrock, 2010)

IMPLEMENTING AN EHR, CONT.

• Effective implementation of an EHR depends solely on who is involved.

• “End-users” are the key players involved and consist of the staff nurses, nurse managers and physicians that will be utilizing the system.

• Ancillary staff such as respiratory therapy and physical therapy also play a key role in the design and execution of a CIS.

• By involving all areas of the health care staff, consistency is created which leads to better patient outcomes.

• Input from clinicians is critical to the success of the system construction and application (McGonigle & Mastrain, 2009).

EDUCATION AND TRAINING

• Jeffery Grant(2010) states that any organization that has made the transition to the HER has met challenges along the way. “Not enough training and not enough time for training” are two pitfalls that can be avoided with proper planning.

• Conducting an in house assessment to gauge each staff member’s strengths and weaknesses is beneficial to a successful EHR software launch.

• Consider the amount of training that will be required prior to

implementation of the EHR and the costs associated with the training (Jain, 2010).

EDUCATION AND TRAINING, CONT.

• Grant (2010) also emphasizes the benefit of bringing in the EHR vendor to train staff with considerations being made for employee numbers and facility size.

• “Power Users” are individuals who display exceptional knowledge in the EHR and have received additional training with the vendor.

• These advanced users can be available to train and assist other basic users.

• Practice sessions simulating patient visits are conducive to the learning process and allow for the recognition of problem areas.

EDUCATION AND TRAINING, CONT.

• After initial training is complete, a mock program could be utilized before the “go live” period takes place to assess needs for improvement.

• Practice computers should be made available to physicians and staff utilizing vendor supplied online and tutorial training.

• Having a power user and project manager present during the “go live” process will help the transition go smoothly.

• Implementing an EHR is “a process, not an event” (Grant, 2010)and education and training will be a continuous process.

• President Bush’s executive order given to develop nationwide interoperable EHR within 10 yrs in 2004• “Annual spending on Health Care IT will reach

$10.8 billion by 2012” (INPUT, 2008a)• It could cost at least $75 billion to $100 billion

over the ten years for hospitals to implement program (CNN, 2009)• The biggest cost will be paying and training the

labor force needed to create the network

COST OF IMPLEMENTING EHR

CONCERNS OF PATIENTS AND THE EHR

• Privacy and confidentiality remain the biggest concern for people and the EHR• Consumers believe

“they should have a say in how their data is shared and used” (Conn 2010)

CONFIDENCE IN PRIVACY DATA

• A 2009 survey done by National Public Radio/Kaiser Family Foundation/Harvard School of Public Health shows how confident people feel that their data is protected in an EHR

SECURITY OF EHR

• Security is improved with the EHR• By computerizing the EHR, protected health information (PHI) is more protected • “The EHR, when maintained according to the HIPAA Privacy and Security Rules, actually offers more safeguards than the paper record” (The EHR: Benefits for Privacy and Security, 2008)

CONTROLLING WHO VIEWS THE INFORMATION

• Hospitals should implement policies on who is allowed to access patients’ records (Conn 2010)

• Administration should offer classes and educate on policies and procedures

• Ultimately the patient should control who can view and access their health information (Wainer 2008)

SECURING THE INFORMATION

• Systems need to be physically inaccessible to any unauthorized users

• “Contingencies in place to recover or restore lost data in case of a disaster or emergency” (The EHR: Benefits for Privacy and Security, 2008)

• Everyone accessing the EHR should have a unique user name and password that only they will know• “Strong” passwords should be implemented

• Access control lists give specific users certain or specific privileges to particular information• For example: a physical therapist would not be able to

access the same information that a physician would have

PROTECTING INFORMATION IN THE HOSPITAL

• Workstations should be closely monitored

• No records should be left unattended on the screen

• Staff should stay alert for over the shoulder readers

• Each hospital should have a team who audits the information, making sure of no unnecessary viewing of patient information (The EHR: Benefits for Privacy and Security, 2008)• Especially important in high

profile patients

BREACHING SECURITY

• Identifying weaknesses in a system before a major breach is always good prevention.

• Intrusion detection not only identifies attempts at unauthorized access, but also looks at traffic patterns of users (The EHR: Benefits for Privacy and Security, 2008)

• Auditing users and transaction logs on a regular basis is also fundamental to privacy and security

• It is important for each health care system to educate users on the consequences of looking at unauthorized information

IN CONCLUSION..

• Implementation of an EHR not only allows for better care of the patient but also allows information to be shared among different physicians• The EHR allows for easy access to patient’s past

and present medical history• With proper security the EHR, is safer than paper

charts

THE FUTURE OF EHR

REFERENCES

Berner, E. S. (2009, June). Clinical decision support systems: State of the art. Retrieved October 14, 2010, from Agency for healthcare research and quality:http://healthit.ahrq.gov/images/jun09cdsreview/09_0069_ef.html

Conn, J. (2010). Yet another study: HHS plans survey on IT privacy, security issues. Modern Healthcare, 40(15), 34. Retrieved from CINAHL Plus with Full Text database.

Electronic health records overview. pdf (2006, April). Retrieved from http://www.ncrr.nih.gov/publications/informatics/ehr.pdf

Farukhi, F. (n.d.). Clinical Decision Support Systems. Retrieved October 14, 2010, from http://www.case.edu/med/epidbio/mphp439/Clinical_Decision.htm

Goldman, D. (n.d.). Obama's health care challenge - Jan. 12, 2009 . Business, financial, personal finance news - CNNMoney.com. Retrieved October 17, 2010, from http://money.cnn.com/2009/01/

REFERENCES

Grant, J.T. (2010, March). EHR: from paper to electronic. Opthamology Times, 35(6), 44-46.

Grant, J.T. (2010, April). Allow time to implement ehr. Ophthalmology Times, 35(7), 54-56.

INPUT, (2008a). State & local health care technology spending to reach $10.8 billion by 2012. Retrieved Oct 20, 2010, from http://www.input.com/corp/press/detail.cfm?news=1361

Jain, V. (2010). Evaluating ehr systems. Health Management Technology, 31(8), 22-24.

McGonigle, D., & Mastrain, K. (2009). Nursing Informatics and the Foundation of Knowledge. Sudlbury, MA: Jones and Bartlett Publishers, LLC.

Sim, I., Gorman, P., Greenes, R., Haynes, R. B., Kaplan, B., Lehmann, H., et al. (2001, July 11). Clinical decision support systems for the practice of evidence-based medicine. Retrieved October 19, 2010, from Journal of the American Medical Informatics Association:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC130063/

The EHR: Benefits for Privacy and Security. (2008, September). Retrieved October 25, 2010, from AHIMA: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_039956.hcsp?dDocName=bok1_039956

Woodrock, E. (2010). Ehr criteria. Dermatology Times, 31(2), 68- 70.

Wainer, J. (2008, December 24). Security Requirements for a Lifelong Electronic Health Record System: An Opinion. Retrieved October 25, 2010, from PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669643/

REFERENCES