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Health IT and EHRs: Principles and Practice, Sixth Edition

Chapter 1: Introduction to Health IT

Health IT and EHR

Health IT includes all components of an EHR, as well as additional information technology to support all aspects of the healthcare delivery system.

EHR is a set of components that collects and integrates data at the point of care. It provides clinical decision support, helps exchange information among healthcare stakeholders, and assists in measuring, reporting, and improving healthcare.

EHR Terminology

EMR (electronic medical record) is often used to describe systems based on document imaging in a hospital or systems implemented in physician offices. NAHIT defines EMR as local to one healthcare organization.

EHR (electronic health record) is a system to achieve the goals of structured and standardized data collection that benefit patients wherever they may be treated. NAHIT adds the dimension of interoperability across more than one healthcare organization.

Fundamental Functions of EHR

Collects and

Integrates

Source Data

Captures and Enables Use of Data at POC

Supports Clinical Decision Making

Health Information Exchange

Quality Measurement Reporting and Improvement

EHR

Meaningful Use (MU) of EHR Incentive Program

Stage 1

2011-2012

Data Capture

& Sharing

Stage 2

2014

Advanced

Clinical

Processes

Stage 3

2016

Improved

Outcomes

The federal MU incentive program has driven widespread adoption of EHR technology in the US.

Meaningful Use Incentive Program

Three primary components:

Certification program, administered by ONC, certifies EHR technology as meeting the standards and criteria

Standards and criteria, administered by ONC, describes requirements of EHR technology

Objectives and measures, administered by CMS, provides funds for incentives

History of EHR Implementation

1970s 1980s 1990s 2000s 2010s

Pioneers Early Landmark Wake Up Incentives &

Limitations Effort Calls Controversy

Academic Feeder Hype & Clinical EHR & HIE

Experiments Systems EDMS Components

IOM/HMD Vision for EHRs

Improve quality, safety, and reduce health disparities

Engage patients and their families in their health care

Improve care coordination

Improve population and public health

Ensure adequate privacy and security protection for confidential information

IOM/HMD’s Wake Up Calls

The Computer-based Patient Record: An Essential Technology for Health Care (IOM 1991)

“Merely automating the form, content, and procedures of current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs.”

To Err is Human: Building a Safer Health System (IOM 1999)

Identified that at least 44,000 and as many as 98,000 hospitalized Americans die every year from medical errors

Preventing Medication Errors (IOM 2007)

Medication errors injure 1.5M people and cost $3.5B per year (exclusive of lost wages and productivity) in the US

EHR is a System

EHR is a system of components that meet the following criteria:

Integrates data from multiple sources

Captures data at the point of care

Supports clinical decision making

System is a set of interrelated elements that work together to achieve a goal.

EHR System Components

Conceptual Model of EHR

Source Systems

Collect data that relate in any way to the health record

Ancillary or departmental systems

Specialized source systems

Smart peripherals

Core Clinical Systems

Enable use of data at the point of care

They support specific clinical functionality and are the applications that define whether a care delivery organization has an EHR

Results management

Point of care (POC) charting

Medication management

Computerized provider order entry

Electronic (or barcode) medication administration record

Clinical decision support

Reporting

Supporting Infrastructure

Integrates data from applications internal to a given care delivery organization

Human-computer interfaces (HCI)

Clinical data repository (CDR)

Storage area network (SAN)

Rules engine (aka inference engine)

Knowledge sources

Registry

Clinical data warehouse (CDW)

Connectivity Systems

Support the integration of data across different organizations and with patients or their caregivers

Local area networks

Portals

Personal health records

mHealth

Cloud computing

Telehealth

Health information exchange

Continuity of care record or continuity of care document

Personal health records

Conceptual Model of Health IT

Health IT

Health IT is an evolving set of information technology that covers all aspects of healthcare delivery – not just clinical care, but services in both provider and health insurance plan settings that support administration, payment, and, increasingly, social determinants of health in a population

The federal government encourages widespread use of health IT to improve the quality, cost, and experience of care in the US

Sequence of Implementation

Should be based on a well-planned migration path and varies by individual organizational needs and preferences

Applications are most often implemented in the sequence as described on the next set of slides

R-ADT/PMS

Hospital

Registration-Admission, Discharge, Transfer system captures patient demographics and tracks admissions

Typically includes or links directly to master person index (MPI)

Ambulatory care

Practice management system captures patient demographics and used to schedule appointments

May or may not include a master person index (MPI)

Enterprise master person index (EMPI) serves as an index across multiple entities in an integrated delivery network

Patient Financial Services/Billing

Receives charges

Generates claims

Supports eligibility checking to validate insurance coverage, determine co-pay requirements, and potentially deductible amounts

Manages prior authorization

Checks claims status

Receives remittance advice

Administrative Systems

Health information management department systems

Chart tracking

Incomplete record control

Dictation and transcription

Encoders

Chargemasters

Registries

Others

Other administrative systems

Physician credentialing

Compliance

Contract management

Clinical documentation improvement

Clinical quality assurance

Others

EDMS

Electronic document management systems (EDMS)

Represent a wide range of functionality

Capture scanned images of documents

Compile documents electronically fed from transcription systems, voice files from digital dictation, email and efax, etc.

Formerly called COLD (computer output to laser disk) feed, when laser disks were used almost exclusively, where today both laser and magnetic disks are used)

Integrated with workflow technology (automatic work queue processing)

Allows viewing from multiple locations and by multiple users

OC/RR

Order Communications

Provides capability of transmitting orders to various ancillary departments

Results Retrieval

Provides capability of viewing results of laboratory tests, other diagnostics studies, and status of orders

Replaces telephone, faxing, and courier processes

Ancillary/Clinical Departments

Laboratory information system (LIS)

Pharmacy information system

Radiology information system (RIS)

Two primary purposes:

Manage the department in which they are used

Generate clinical results processed by the department, including charges

Other departmental systems (such as nutrition and food services, HIM, PFS) and specialty clinical applications serve patients with specific disease states or level of nursing care required (such as surgery, ICU, emergency department, labor and delivery, respiratory therapy, cardiology).

Example of Department Management

Laboratory Information System

Receives an order for a lab test

Generates specimen collection lists

Prints labels for specimen vials

Connects to auto-analyzers that perform diagnostic studies of specimens to generate laboratory test results

Tracks quality controls

Schedules staff

Inventories supplies

Specialty Clinical Applications and Smart Peripherals

Applications for special functions in hospitals or physician offices

Long term care

Behavioral health

Other health professionals

Medical devices that can be directly connected to an information system.

Fetal monitoring

Blood sugar

Robotics

Clinical Messaging Systems/Portals

Adds real-time access to applications through web-based technology

Functions via facility Intranet or through a secured web portal from the Internet

Provider portals provide connectivity between the hospital and its medical staff and provide access to applications such as electronic signature authentication, results review, and ordering.

Patient portals enable secure email between patients and providers and provide access to applications such as scheduling appointments and reviewing lab results.

Registries

Systems to which specific information is supplied for subsequent analysis and comparison. They support patient follow-up and aggregation of data for trending and statistical analysis.

Often disease- or procedure-specific:

Cancer registry

Diabetes registry

Immunization registry

Quality measurement data are often contributed to a registry for submission to intended recipients and comparisons

Core measures

Physician Quality Reporting System

Core Clinical Applications

Components essential for EHR

Used by physicians, nurses, and other clinicians to perform the core business of health care, which is taking care of patients

Includes:

Results management

Point of care charting

CPOE/e-Rx and EMAR/BC-MAR

Clinical decision support

Reporting

Structured Data

Refers to data that have been predefined in a table or checklist

Examples:

Drop-down menu options

Check boxes or radio buttons

Allows for accurate and distinct elements of documentation to be captured precisely and used in subsequent processing by computer.

Unstructured Data

Refers to narrative data entered via:

Keyboarding in a comment field

Dictation or transcription

Speech recognition (except that combined with natural language processing to produce structured data)

Scanning of handwritten documents

Individual data elements not as easily processed by computer

Example: If allergy information is recorded in a comment field and an order for a medication is placed in CPOE, the CDS in the CPOE will not pick up the allergy information present in the comment field because it is not placed in a specially designated field for allergy information

Results Management

Enables results in structured data form not only to be viewed, but also

Processed into tables and graphs, such as to illustrate a trend line

Compared with other structured data, such as medications administered in comparison to lab results and vital signs

Point of Care Charting

Also called clinical documentation systems

Emphasize the importance of using the application at the same time the patient is being cared for in order to take advantage of real-time alerts and reminders

Most often begins with nurse assessments, vital signs (not captured directly from monitoring devices), etc.

Physician progress notes, history and physical exam, etc. are often implemented much later

CPOE and e-Rx

Computerized provider order entry (CPOE) provides assistance for direct entry of orders to ensure legibility and consistency with clinical guidelines

Prompts, alerts, reminders, and warnings about the order are provided in real time

Enhances legibility to avoid medication errors and enhances patient safety

Identifies duplicate orders and prevents duplicative testing where applicable

Alerts providers to needed preventive care services

E-prescribing (e-Rx) is a special form of CPOE in which providers write prescriptions and transmit them to retail pharmacies

Medication Administration Record (MAR)

Automation of many processes associated with medication administration in a hospital

E-MAR systems may generate a printout of a paper MAR, or may supply a MAR template on the computer

Bar codes or radio frequency identification (RFID) may be added to positively identify patient, drug, and person administering the drug (BC-MAR)

Reminders, alerts, and safety measures are added to prevent medication administration errors

Reporting

Report writing software enables healthcare organization to develop reports from structured EHR data

For example, a clinic may want to create a report to monitor their improvement in reducing blood sugar levels in its diabetic patients by graphing the number of diabetic patients with Hgb A1c <7.

Clinical Decision Support (CDS)

Describes the help provided in association with data entry performed directly by the caregiver at the point of care

Generated by programmed logic, often in the form of “if-then” rules

Example: For a patient presenting to the emergency department with chest pain, CDS may remind the physician to check all applicable body systems for cause.

CDS may be active, in which the user is expected to respond in some way. These are typically alerts and reminders.

CDS may be passive, where information is provided but does not require a specific action. This may be in the form of advice that additional information is available, if desired.

CDS should be context sensitive, meaning that it relates to the specific data entered for the patient. For example, a template for structuring a history and physical exam will be different for male and female patients.

Executive decision support is a system that analyzes a large volume of aggregated data to provide retrospective, trending information. For example, it may help nursing managers staff according to number and acuity of patients expected to be admitted.

Clinical Data Repository (CDR)

Relational database that is optimized for processing many transactions with data from multiple source systems

Examples of transactions include:

Entry of vital signs for a patient

Review of an x-ray for a patient

Receiving a reminder that a certain drug is contraindicated for the patient due to poor liver function

A CDR forms the basis for ambulatory EHRs, but in a hospital, a CDR may not be acquired until many source systems and core clinical applications are implemented.

Personal Health Records (PHR)

Systems designed to support patient-entered data

May be associated with a provider via a web portal

Some only provide educational information

Some provide access to patient-friendly summary

Some provide access to entire health record

May be stand-alone not associated with a provider

May be fax-back system

May enable direct entry by patient

Telehealth and Home Monitoring

Use of medical information exchanged from one site to another via electronic communications to improve, maintain, or assist patients’ health status

Home monitoring may be a part of telehealth or independent

Health Information Exchange (HIE)

Seamless exchange of health information across disparate organizations

Big Data, Data Warehousing, Analytics, and Population Health

Big data refers to massive quantities of data, often from multiple organizations

Big data are often stored in a clinical data warehouse (CDW) that is a database optimized for performing sophisticated analysis, referred to as analytics

Population health refers to managing the health of a group of people in a given locale, and considers not only health data but social determinants of health which are often analyzed and fed back as part of managing the population’s healthcare

Clinical Data Warehouse (CDW)

Relational database optimized for performing sophisticated analysis on data:

Data mining

Predictive modeling