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HIM 500 Healthcare Informatics

Module 9 – Final Project

By: Stephanie Shea

8/19/2017

Preparation for Consult

Key Historical Events

Electronic health records (EHRs) have evolved over the years which has allowed for

several advantages in the way health information is managed. The first EHR systems were

developed in the 1960s. At this point, many academic medical centers and universities were

developing their own systems. Lockheed Corporation developed a system (now part of

Allscripts), which influenced many other systems due to processing speed and multi-user

capabilities. The University of Utah also developed a system which was the first of its kind to

allow for clinical decision support systems. (Atherton, 2011).

In the 1970s and 80s, computerized medical records emphasized alerting systems,

physician orders, medical record administration, and progress notes. In the early 90s, the

Institute of Medicine released a report called “The Computer-based Patient Record: An Essential

Technology for Healthcare”. This report envisioned a computer based patient record (CPR) that

housed information from multiple episodes of care, different providers, and multiple facilities.

This was a key event because it allowed for a more comprehensive view of the patient’s medical

care as well as computerized decision support systems and other safety mechanisms (Green,

2015).

In the late 90s, the term electronic medical record (EMR) was introduced. The EMR was

initially used in the outpatient arena; however, some inpatient facilities used them as well. Early

EMR systems had limited capability for networking between inpatient and outpatient.

Two Presidents have endorsed the use of electronic medical records and advocated for

policy changes. In 2004, President George W. Bush signed an executive order to create a

National Coordinator of Health Information Technology within the Office of the Secretary of

HHS and in 2009, Congress, under President Obama, enacted the American Recovery and

Reinvestment Act. These actions promoted the use of EMRs to improve care and $19 billion

was invested to advance the health information technology field. One section of this legislation

is the Health Information Technology for Economic and Clinical Health Act which offers

financial incentives to institutions who meet the “meaningful use” objectives set by CMS

(Green, 2015).

Guidelines for Technology Use

EHRs are legal documents containing sensitive information. Therefore, there are

guidelines that Featherfall must follow to ensure governmental regulations are met. The CMS

EHR Incentive Program Stage 3 Objectives and Measures for 2017 offers some guidelines. For

example, the EHR must protect patient information through technical, administrative, and

physical safeguards. There must be computerized physician order entry (CPOE) and

transmission of electronic prescriptions. They must implement clinical decision support

interventions and optimize health information exchange through a summary of care record. The

patient also needs to be engaged in their care. The EHR should provide the patient (or caregiver)

with timely access to health records and education. Lastly, there should be public health

reporting using EHR technology (Medicaid, 2016).

Furthermore, the Health Insurance Portability and Accountability Act (HIPAA) passed in

1996 impacts how EHRs are used and sets the standard that only authorized healthcare

professionals specifically caring for the patient should have access to the individual’s medical

record. Routine monitoring of employees accessing records as well as HIPAA compliance

training should be completed.

Other standards and guidelines that should be used by Featherfall include ensuring the

use of International Classification of Diseases (ICD-10) codes provided by the World Health

Organization. Policies and procedures regarding healthcare information management should be

established by the institution and in line with state and national regulations. Lastly, standards set

by the Joint Commission (an accrediting agency) should be followed; for example, completing a

history and physical within 24 hours (AHIMA, 2013).

Standard Technologies

Some standard technologies currently used in the field of health information management

include accessing full medical histories for their patients, including laboratory tests and

radiology results which can be downloaded to the EHR, even if the patient is being followed by

several different providers. Computerized Physician Order Entry (CPOE) is another common

technology in use. Most EHRs also allow for alerts of potential drug interactions and allergies

and e-prescriptions which allows electronic transfer of prescriptions directly to a pharmacy

(Blumenthal, 2010).

The three most common electronic medical record keeping systems that I’ve come across

in my career are Cerner, Allscripts, and EPIC. These systems are all different from each other in

several ways. They can also be customized by the institution. For example, EPIC at one facility

may have different capabilities than EPIC at another facility.

Pertinent Roles

There are three main pertinent roles at Featherfall that would interact with the EHR: the

Health Information Management (HIM) team; the clinical staff; and administrative staff. The

health information management team is responsible for collecting and analyzing patient health

information and disseminating to appropriate parties such as doctors’ offices, insurance agencies,

hospitals, and research companies. They review documentation and ensure proper coding and

billing based on diagnosis and procedures performed during the encounter. They are also

responsible for making sure the information kept in a medical record is kept private and secure.

The clinical staff may consist of a variety of different disciplines. Each of these clinical

roles can interact with the EHR in different ways depending on their individual workflows. For

example, physicians will be responsible for using the CPOE, e-prescribing, and clinical

decision-making features. Bedside nurses will be responsible for entering vital signs, reviewing

and acknowledging physician orders, as well as documenting in the medication administration

record. Ancillary staff such as physical therapy, clinical nutrition, and respiratory therapy would

be responsible for assessing the patient, documenting in a progress note, and communicating

recommended care plans to physicians. Training on where various information is kept, how to

use the EHR, and documentation standards is necessary to meet regulatory guidelines.

The administrative staff is responsible for registering patient information such as name,

date of birth, contact information, and insurance provider. It may also require scheduling clinic

visits or transcribing physician dictated notes. Other administrative tasks, depending on the role,

may be monitoring outcomes, revenue, and quality data.

Evaluation of New Systems

HealthIT.gov offers great suggestions for evaluating new EHRs or any upgrading needs.

The first step I would use is a full analysis of the current state of practice. Interviewing front line

staff is a great way to further evaluate if current workflows and processes are efficient, well

organized, and what barriers exist. I would evaluate if staff is computer literate and able to speak

to current technology processes. I would evaluate the financial impact of upgrading or

implementing a new EHR. I would carefully plan my approach and select an appropriate EHR

upgrade. I would make sure to achieve meaningful use criteria set forth by CMS as well as

standards from Joint Commission and make sure all staff is knowledgeable on the changes.

Lastly, I would continue quality improvement and monitoring practices. (How to Implement,

2013).

I would have a strong focus on safety and privacy of patient information. HIPAA

requires that organizations must designate both a privacy and security officers (Privacy and

Security, 2013). There would be documentation of our security measures and how information is

monitored. I would conduct a risk analysis and action plan for current security measures using

the HHS Office for Civil Rights’ Guidance on Risk Analysis. Lastly, I would make sure to

provide ongoing training to staff.

Health Regulations and Laws Ramifications

Financial impact

The primary financial impact of not addressing these violations would be that it puts the

institution at risk for civil law suits due to security breaches and HIPAA violations. The hospital

could be found responsible for recovering damages in these cases. Not only would they require

to pay the impacted patient or patients, but regulating agencies may have additional fines that the

hospital may have to pay depending on the violation.

One example is Pinnacle Health, a 3-hospital system in Pennsylvania. This facility is

being held accountable for two incidences where a patient became hypotensive after being

discharged on the wrong medications and another where an MD was unable to place an order for

Vitamin K to prevent bleeding in a newborn. Pinnacle Health is among the first to make a

countersuit against the EMR system it was using at the time of these events. Such litigations can

be very costly and poor publicity (which can also lead to a financial impact) for the hospital

(Schencker, 2016).

Additionally, New York Presbyterian Hospital (NYP)/CUMC settled a lawsuit in 2014

for $4.8M dollars for HIPAA violations after a physician attempted to deactivate a personally

owned server on the NYP network containing electronic protected health information (PHI).

This resulted in PHI of 6,800 patients being leaked to Google in 2010. NYP is not unique and

the Office of Civil Rights has collected over $25 million in fines due to data security breaches.

In addition to the financial responsibilities associated with the courts, as well as the state/federal

fines, there are other associated financial costs. When data is breached, often the institution will

also offer free credit monitoring to the impacted patients (to look for fraud/identity theft),

outsourcing of hotline support, and forensic investigations. These fees can average around $2M

for each healthcare facility over the course of 2 years (McCann, 2014).

Continuing to ignore regulatory and governmental laws would eventually fall under the

category of “willful neglect”. Fines for intentionally ignoring these laws can start at $1,000 per

violation and go as high as $10,000. However, there is a cap on how much the institution would

have to pay. (Search Compliance, 2009).

Impact on Daily Operations

Daily operations can be significantly impacted if violations are not addressed in a timely

manner. As healthcare becomes more electronic and available on different devices such as

mobile applications and lap tops, there is a significant risk of data being stolen. Additionally, a

data breach can occur when information is not properly encrypted.

An article from Online Tech describes the negative operational impact of these security

breaches. These breaches can lead to diminished productivity, damaged reputation, and loss of

patient trust. (Pham, 2011). Additionally, health IT violations will likely lead to investigations

and more surveys by regulatory agencies which can be a very stressful time for everyone in the

hospital.

Furthermore, the Final Rule published by the Federal Register establishes what must be

done at a hospital after a security breach, which ultimately diverts resources from an operations

standpoint. For example, victims must be notified of the security breach within 60 days via first

class mail. The media must also be notified if the breach involves more than 500 patients.

Regulations and laws are put in place for a reason, namely to provide the best and safest

care for patients. If violations of health regulations and laws regarding technology are not

addressed, patient safety is at risk. Complications associated with errors in medication

administration is one example that could ultimately lead to patient death. Coding and billing

violations could put the provider’s license in jeopardy.

Impact of Security

The Health Information Technology for Economic and Clinical Health (HITECH) Act

under President Obama, expanded the reach of HIPAA and provided funding for better use of

health information technology. Just as laws and regulations for technology are put in place for

the safety of patients, they are also meant to establish the highest level of security for protected

health information. Security safeguards must be implemented to ensure that facilities,

equipment, and patient information are safe from damage, loss, tampering, theft, or unauthorized

access (Green, 2015). Additionally, patients must be notified of their security rights.

Technology System Recommendations

Needs of the Organization

Featherfall has several organizational needs when it comes to their health informatics

systems. First, there have been recent regulatory violations and the system is severely out of

date. Additionally, staff is not always aware of the technologies available to them and therefore,

the system is not being used to its full capacity. This has caused a significant financial drain on

the organization. Lastly, the needs of different clinical staff members were not taken in to

account and the system does not work for many users’ workflows.

Featherfall needs a major systems replacement to improve operations. The hospital needs

a system that securely transfers information, is password protected, and meets HIPAA standards.

Additionally, it requires the capability to adjust clinical documents and easily create new

templates based on the needs of different departments. There also needs to be a large amount of

training invested to all users of the system to ensure all practice standards and functionalities are

utilized. Employees organization wide need to be able to receive messaging about new

technology features. The ability to maintain patient records using agile and secure reporting

systems is also much needed. Lastly, given the financial losses from the previous system, the

new system will need to be cost effective for the organization.

Recommendations:

RFPs were completed by two vendors, Intel and Alert. After reviewing the needs of

Featherfall and completing an evaluation matrix for the two systems, my recommendation is to

implement the Intel (SOA Expressway for Healthcare). While this system does not meet all

needs of the organization in its current state, the system has substantial benefits. Additionally,

the next version coming out in 8 months will soon have many other features needed at

Featherfall.

The master patient index (MPI) module is preferred using Intel. An MPI links a patient’s

medical record number (MRN) with other common data elements (Green, 2015). According to

the AHIMA, the MPI serves as the most important element of an electronic medical record. It

allows for accurate identification and use of patient data. It also traces the individual’s activity

within the organization. (Demster, 2013). Intel can allow for aliases, look for former names,

maintain old MRNs, and merge duplicate MRNs. Additionally, the next version will meet

HIPAA standards which is vital from a regulatory and ethical perspective in maintaining patient

privacy. Lastly, there are high security standards associated with intel.

Intel will also help improve workflows, allow for custom builds of document templates,

and improve safety features such as monitoring for drug interactions and allergies. It offers

barcode scanning to improve medication administration documentation and quick access to

patient clinical information such as lab results.

Furthermore, Intel can message employees hospital wide as well as provide training to

staff. There is a cost associated with training and the cost is higher than other systems.

However, Intel is a widely used system by many larger organizations. The company has been in

place for 30 years and has a long history. There is significant benefit to using a larger, more

widely used company that outweighs cost.

Investing Financial Resources

A capital request would be needed to invest in a new technology system. To offset the

cost of changing the clinical system, Featherfall will need to effectively manage their financial

resources in other ways. Investing in technologies that will result in a cash flow would be

beneficial. Intel can help improve clinical decision making and documentation that will result in

improved coding and billing practices. Additionally, ensuring compliance to meaningful use

standards can improve government funding. If the decision to go with Intel moves forward,

Featherfall should also do further negotiating with the vendor with the help of legal. This may

result in decreased cost or other value added services that are free of charge.

Intel has strong ability to admit, discharge and transfer patients from various areas within

the organization (ED, outpatient, etc). It also helps calculate census statistics. Furthermore, the

next release will have better ability to notify housekeeping when a patient is discharged. These

features help improve patient flow, which ultimately will have a financial benefit to the

organization and offset some of the financial costs for implementing a new system.

Monitoring

There are several ways Featherfall can monitor the effectiveness of a new EMR. Prior to

the monitoring phase, Featherfall should develop SMART goals to determine what measures of

success they wish to monitor. For example, if a goal is to improve productivity by a certain

percentage, reports can be generated using user IDs and time spent to evaluate improvements.

Security controls can be implemented by monitoring log ins and determine whether staff are

sharing log ins or not logging in enough. Monitoring this can also help improve HIPAA

compliance and ethical management of protected health information. Evaluating log in patterns

is imperative.

After implementation, it would be important to monitor frequency of calls to the HELP

desk in the initial phase. If there are no calls, it could indicate the employees are finding work

arounds which is not ideal. If there are too many calls, it could indicate a training problem.

Over time, the number of calls to the HELP desk should decrease (HealthIT.gov, 2013).

Featherfall can also monitor how often alerts are being ignored or overridden. It is

important that alert fatigue does not set in with the clinical decision support features of Intel.

One study in BMC Medical Informatics & Decision Making, indicated that primary care

clinicians are less likely to receive alerts when they receive more of them. Ignoring these alerts

poses a patient safety risk, so monitoring these alerts is important. (Ancker, 2017).

Implementation

The University of Texas Health Science Center published about their experience

implementing an EHR. The article offers lessons learned which could be translated to

Featherfall’s implementation of a new heath information technology system. First, there should

be extensive efforts made to evaluate workflow and understand the needs of a new, redesigned

practice. Additionally, there should be willingness and trust to design protocols that allows

non-clinicians to safely deliver prescription related work. There certainly needs to be physician

champions, and ideally champions in all clinical areas, to participate in the implementation

phases. Featherfall should ensure ongoing training and IT support. There should be targeted

communication to all stakeholders early in the implementation phase. Lastly, there should be

ongoing efforts to monitor the system and offer continued improvements. (Jaen, 2011).

References

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Ethics. Volume 13, Number 3: 186-189. Retrieved on July 9​th​, 2017 from:

http://journalofethics.ama-assn.org/2011/03/mhst1-1103.html

Green, M. A., & Bowie, M. J. (2015). Essentials of health information management: principles

and practices. Boston, MA: Cengage Learning.

Medicaid Eligible Professionals. EHR Incentive Program Stage 3 Objectives and Measures for

2017 (2016). Retrieved on July 9​th​, 2017 from:

https://www.cms.gov/Regulations-and

Guidance/Legislation/EHRIncentivePrograms/Downloads/TableofContents_EP_Medica

d_Stage3.pdf

AHIMA (2013). Standards: Required for Health Information Management. Retrieved on July

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Blumenthal, D. MD (2010). The Future of Health Care and Electronic Records. Retrieved on

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https://www.healthit.gov/buzz-blog/electronic-health-and-medical

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How to Implement EHRs (2013). Retrieved on July 10​th​, 2017 from:

https://www.healthit.gov/providers-professionals/ehr-implementation-steps

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Schencker, L. (2016). EHR Goes to Court. Retrieved on July 11​th​, 2017 from:

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Search Compliance (2009). HITECH FAQ: What is the Impact of HITECH ACT on IT

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http://searchcompliance.techtarget.com/feature/HITECH-FAQ-What-is-the-impact-of-the

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df

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