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Chapter 6

Electronic Health Records and Applications for Managing Patient Care

Electronic Medical Record versus Electronic Health Record

Electronic medical record (EMR)

Is an all-inclusive record that is institution specific.

Does not interact with outside systems.

Is provider controlled.

Electronic health record (EHR)

Is the favored term for a lifetime patient record.

Includes data from all specialties.

Patient can interact with the system.

Components of an Electronic Health Record

Administrative processes

Electronic communication and connectivity

Decision support

Health information and data

Order entry management

Patient support

Results management

Population health management

Electronic Health Record Adoption

Interoperable EHR is mandated (2004).

EHR collaborative is formed to support rapid adoption.

Key capabilities of an EHR system are developed.

The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted (American Recovery and Reinvestment Act [ARRA], 2009).

Uses health information technology to improve healthcare quality, safety, and efficiency.

Stimulates EHR adoption and health information exchange networks.

Meaningful Use

Provides incentives for providers who:

Implement and use certified EHR technology

Meet objectives of meaningful use

Stage 1 began in 2011 and will end in 2014.

Stage 2 starts in the fiscal year 2014.

Health Practitioner Role in Electronic Medical Record Adoption

Provide care coordination and patient education.

Assist in designing clinical decision support systems.

Assist with developing data set standards.

Engage in local, regional, and national initiatives to improve care.

Collaborate with the patient and other providers to manage care.

Providing care coordination and patient education are key objectives of the Meaningful Use requirements.

Health practitioners assist in designing clinical decision support systems that can be used to enhance patient adherence to disease management.

Other activities include developing data set standards to improve outcomes, increase patient safety, and evaluate quality of care.

Engage in local, regional, and national strategic initiatives to improve care coordination using EHRs and HIE.

Computerized Provider Order Entry

Allows providers and clinicians to enter orders via the computer.

Medications, laboratory and diagnostic tests, consultations

Interfaces with other EHR components to process orders.

Order management system allows orders to be:

Entered

Tracked

Processed

Updated

Completed

Discuss the benefits and medical errors related to CPOE.

Benefits:

Reduce medication errors

Improved drug dosing

Decrease number of allergic reactions

Decrease transcription errors

Decrease medication turn-around time

Decrease length of stay

Lowered costs

Improved quality of care

Faster results reporting

Medical Errors:

Process of entering and retrieving information

Communication and coordination

Fragmented data and processes

Lack of integration among systems

Human-computer interaction issues

Electronic Medication Administration Record

Electronic medication administration record (eMAR) is the medium to view and document medication use.

Orders are entered via computerized provider order entry (CPOE) and verified by the pharmacy.

eMAR includes the drug name, administration time, dose, and route.

Can be displayed in a variety of ways (e.g., scheduled, as needed, pending, past due, completed).

Bar Code Medication Administration

Bar code medication administration (BCMA) is best combined with a CPOE, the pharmacy dispensing system, and an eMAR.

Is designed to prevent errors during medication administration.

Scanner verifies the five “rights.”

Right patient

Right drug

Right dose

Right time

Right route

Discuss the benefits of BCMA:

Easy to use

Reduce medication errors

Save time

Improve medication documentation

Clinical Documentation

Records, manages, and reports patient care activities through software application.

Format may differ by application and organization.

Using standardized vocabularies and taxonomies has advantages.

Should support clinician workflow.

Offers functionality for plans of care, decision support, viewing, and trending data.

Discuss the benefits of clinical documentation.

Better communication between providers

Promote profession accountability

Streamline workflow

Access to literature sources, guidelines, policies, procedures

Support EBP

Specialty Applications

Are also referred to as “niche” systems

System is designed for specific departments or groups of users.

May stand alone or be integrated or interfaced with EHRs.

Examples include:

Perioperative or surgical services

Maternity care

Neonatal intensive care

Emergency department

Clinical Decision Support

Provides tools and applications that assist with decision making.

CPOE may include alerts for duplicate orders, allergies, and dosing errors.

Reminders are related to the patient’s condition, follow-up, preventive care, and immunizations.

Internal and external links to resources are provided.

Ancillary Systems

Software programs are used by support departments.

Common systems include:

Laboratory Information System (LIS)

Radiology Information System (RIS)

Pharmacy System

Are designed to address the specific needs of a department.

Collect, process, and report results, as well as manage resources and costs.

Consumer Perspectives

Saves time.

Streamlines registration.

Tracks his or her own health record.

Improves quality of care.

Reduces duplicated services.

Increases engagement in healthcare decisions.

Provides safer emergency care.

Accesses online medical information.

Provides appointment reminders.

Offers educational resources.

Offers greater control over personal health outcomes.

Supports patient privacy and confidentiality.

Nursing Perspectives

Increases productivity.

Improves performance.

Enhances effectiveness.

Supports clinical care.

Provides centralized access to patient information.

Improves clinical documentation.

Monitors patient status.

Provides resources for patient education.

Improves discharge follow-up with patients.

Supports compliance with regulatory requirements.

Healthcare Provider Perspectives

Increases efficiencies related to billing and care coordination.

Accesses current and past medical records.

Stores patient information.

Facilitates a partnership between the physician and the patient.

Improves overall office operation.

Increases patient teaching by sharing online medical information.

Improves prescribing and medication safety.

Improves decision making, which can reduce liability.

Supports compliance with quality and regulatory requirements.

Healthcare Organization Perspectives

Improves efficiency.

Strengthens communications.

Increases patient safety.

Supports compliance.

Improves record security and storage.

Improves care coordination.

Enhances the quality of care.

Offers faster turnaround.

Offers better disease management and reporting of services.

Supports pay for performance.

Can integrate with billing and coding structures.

Provides data to control costs and manage expensive procedures.

State and National Government Perspectives

Improves the coordination of care.

Improves the quality of care.

Reduces medical errors.

Shares data across organizations.

Provides a dataset for public health and research.

Improves overall healthcare for all citizens.

What improvements are needed?

Nationwide interoperable EHR

Health Information Exchange Networks

Communication Standards

Nomenclatures, Taxonomies, Vocabularies

Coding Structures

Key Issues

Cost

Ownership

Data integrity

Privacy and confidentiality

Standards

Organization culture

Human factors

Cost

Providers may spend 54,000 – 100,000 for EHR

Hospitals may spend 100 million or more

Additional costs for maintenance, support, upgrades, training, etc.

Unclear who will pay for links to health information exchange

Ownership

Traditional records owned by service facility

Cross-institutional records will make ownership more complex

Consumer consent and critical elements of nationwide HER

How will this impact documentation and access?

Data Integrity

Refers to the accuracy and consistency of stored and transmitted data

Data can be compromised if:

information is entered incorrectly

deliberately altered

system protections are not working correctly

system suddenly fails mutual understanding of terms and improved communication among healthcare professionals along with a common way to collect and aggregate data. A universal language would allow us to consistently capture, represent, access, and communicate clinical data, information, and knowledge across all settings.

Privacy and Confidentiality

Major concern for healthcare

Patients must feel free to reveal personal information

Healthcare provider must treat patient information confidentially

Security of information is required

Increased risk for unauthorized use and disclosure of confidential patient information

Standards

EHR implementation hindered by

disagreement on which terminologies to use

lack of standards to harmonize multiple coding structures

cultural and language barriers

interpretation of meaning

threats to autonomy

user resistance

Organizational Culture

User Resistance major issue:

lack of computer skills

complexity of application

lack of available hardware

difficulty adjusting to change

interferes with routine workflow

takes time away from bedside

impact on clinician role

Human Factors

Problems with usability

Complex human-computer interfaces

Poorly designed systems

Lack of training

Increased cognitive workload

Unnecessary clerical tasks

Overly structured data entry requirements

Fragmented data retrieval designs

Address Issues

Early user involvement

Attention to system design and testing

Adequate technical support

Training

Future Directions

Personalized medicine

Genetic testing

Customized medications

Expansion of a national EHR

Global sharing of health information