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Chapter 8 Applications: Electronic Health Records

Health Administration Press

Learning Objectives

Define the term electronic health record (EHR).

Understand the key capabilities of a robust EHR.

Discuss the benefits of a robust EHR.

Name some of the key cost categories associated with the purchase and implementation of an EHR.

Describe the Electronic Medical Record Adoption Model.

Describe some of the criteria that both individual providers and hospitals need to meet to earn incentives for meaningfully using an EHR.

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A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory results, and radiology reports

The EHR automates and (with appropriate operations management) can streamline the clinician’s workflow.

The EHR has the ability to generate a complete record of a clinical patient encounter—as well as support other care-related activities directly or indirectly via an interface—including evidence-based decision support, quality management, and outcomes reporting.

Electronic Health Record (Defined)

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Some Key Benefits of an EHR

Access to information: Unlike paper records, EHRs provide a means for clinicians to have access to information 24 hours a day, 7 days a week, from any authorized location.

Better organization of data: Rather than being housed in multiple silo applications, the EHR organizes all the data relevant to a particular patient.

Bills/claims processing efficiency: Data that are accessible in electronic form can ease the process of gathering and providing documentation for billing/claims purposes.

Improved monitoring and performance: Allows for individual provider profiles of performance as well as aggregate profiles of all providers. These data can be used within the organization to target quality improvement initiatives as well as inform cost-cutting initiatives.

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Some Key Benefits of an EHR (cont.)

Source: Smaltz and Berner, 2007

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Source: Smaltz & Berner, 2007

Some Key Benefits of an EHR (cont.)

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The EMR Adoption Model (EMRAM): Stages of Adoption

Sophistication

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When HIMSS and its subsidiary, HIMSS Analytics, were first envisioning the adoption model, the term EHR had not yet fully become an accepted distinguisher between an electronic health record that was able to interchange data with other EHRs even if they weren’t part of the hospital or health systems organizational control. The term EHR came to differentiate between EMRs (that could not exchange information outside of the organizational construct) and EHRs that could. Presumably for marketing purposes (since the EMR adoption model by then was fairly well known), HIMSS Analytics didn’t change the name to match, but clearly the definition being used under the EMR adoption model has the data interchange (via CCD for instance) capability of an EHR.

Overview. Stage 0 is no stage at all and is self-explanatory – the level of EHR adoption is so low that the hospital or health system doesn’t even have all three of its ancillary departments automated (lab, pharmacy, and radiology).

We now take each stage in turn and review it in more detail.

The ancillary components of an EHR include automated information systems to support workflow in the laboratory, radiology, and pharmacy departments. Examples of workflows include, but are not limited to:

Laboratory: capturing test results from various laboratory test devices and automatically pulling the results into an automated stand-alone laboratory information system or an integrated laboratory EHR module that physicians and other caregivers can access to obtain their patients’ test results.

Radiology: providing results of radiological exams to the physicians who ordered them.

Pharmacy: provides an automated means of managing the process of dispensing and delivering drugs to patients.

Picture archiving and communications systems (PACS) are information systems that capture radiological images from many different modalities (x-ray, CT scan, MRI, etc.). EHRs should have the ability to retrieve and display PACS images to caregivers throughout the organization.

Document imaging is the ability to take paper copies of medical records that patients typically bring in with them from other care settings, scanning an image of them, and storing it in the EHR for easy access by physicians and other caregivers.

EHR Adoption Stage 1: All Ancillary Systems in Place

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The clinical data repository (CDR) collects data from a variety of information systems and makes the data available to physicians and other caregivers in a unified view of each of their respective patients across all organizational care settings.

Ideally, the data presented to physicians and caregivers is presented in standardized medical vocabulary form such as that found in a controlled medical vocabulary (CMV).

A CMV is an EHR tool used to standardize information for purposes of capturing, storing, exchanging, searching, and analyzing data.

EHR Adoption Stage 2: Clinical Data Repository (CDR) with a Controlled Medical Vocabulary (CMV) for Internal Interoperability

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Reducing ambiguity that is inherent in normal human languages (e.g., how heart attack, myocardial infarction, and MI may mean the same thing when describing a patient condition but represent different conditions to a computer coding that information)

Making the exchange of information consistent between different providers, care settings, and researchers over time

Overcoming differences in medical information capture from one place to another

Summarizing medical information (in a consistent manner)

Allowing symbolic manipulation of data (searches for specific analysis)

Providing automated reasoning (clinical decision support)

EHR Adoption Stage 2: Examples of Uses of a CMV

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Published and regularly updated policies that address security and privacy requirements (e.g., an acceptable data use policy; a physical access policy)

A training program to include annual refresher training focused on current security threats and employees’ expected behavior to protect information assets

Information protection technologies in place (e.g., antivirus software that is routinely updated to address new known threats)

EHR Adoption Stage 2: Basic Security

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EHR Adoption Stage 3: Nursing and Allied Health Documentation; eMAR; Role-Based Security

50 percent of nursing/allied health professional documentation (e.g., vital signs, flowsheets, nursing notes, nursing tasks, care plans) is implemented and integrated with the CDR (hospital defines formula).

Ability for other allied health professionals to enter pertinent information into the patient’s record:

Respiratory therapy

Occupational and physical therapy

Dieticians

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EHR Adoption Stage 3: Nursing and Allied Health Documentation; eMAR; Role-Based Security (cont.)

An electronic medication administration record (eMAR) documents when medications are given to a patient during a hospital stay.

Used in conjunction with technologies such as bar codes, quick response (QR) codes, radio frequency identification (RFID) tags, or other near field communication (NFC) technologies.

Key benefit of eMAR is that it helps to promote a safer medication administration process by automating the “five rights” checks:

Right patient

Right medication

Right dose

Right route

Right time

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EHR Adoption Stage 3: Nursing and Allied Health Documentation; eMAR; Role-Based Security (cont.)

Role-Based Security – Role-based access control (RBAC): A method of regulating access to computer or network resources based on the roles of individual users within an enterprise.

Roles are defined according to job competency, authority, and responsibility within the enterprise (e.g., the functions of a nurse role in an EHR will differ from the functions of a physician role such as in the ability to order narcotic medications).

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EHR Adoption Stage 4: Computerized Provider Order Entry (CPOE) with Clinical Decision Support; Expanded Nursing and Allied Health Documentation; Basic Business Continuity

Computerized provider order entry (CPOE) is the component of an EHR that enables a patient’s care provider to enter an order for a medication, clinical laboratory or radiology test, or procedure directly into the computer. The system then transmits the order to the appropriate department or to individuals so it can be carried out.

The most advanced implementations of CPOE also provide real-time clinical decision support, such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug–drug and drug–allergy interaction checking.

At EHR Adoption Stage 4, it is expected that at least 50 percent of all medical orders are placed using CPOE by any clinician licensed to create orders.

At EHR Adoption Stage 4, nursing/allied health professional documentation has reached 90% (excluding the ED)

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EHR Adoption Stage 4: Computerized Provider Order Entry (CPOE) with Clinical Decision Support; Expanded Nursing and Allied Health Documentation; Basic Business Continuity (cont.)

Business continuity refers to the ability of the healthcare enterprise to continue to operate during computer outages (whether planned or unplanned).

For instance, during EHR downtimes, hospitals and clinics should use tools that enable a local computer or protected workstation to provide access to patient summary reports that include at least patient allergies, medications, a list of problems and diagnoses, and most recent lab results, so they can continue providing safe care to the patients.

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EHR Adoption Stage 5: Physician Documentation; Instrument/Device Protection

At EHR Adoption Stage 5, full physician documentation (e.g., progress notes, consult notes, discharge summaries, problem/diagnosis list, etc.) with structured templates and discrete data is implemented for at least 50 percent of the hospital. Capability must be in use in the ED, but the ED is excluded from the 50 percent rule.

Intrusion prevention system is in use not only to detect possible intrusions but also to prevent intrusions.

Hospital-owned portable devices are recognized and properly authorized to operate on the network, and can be wiped remotely if lost or stolen.

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EHR Adoption Stage 6: Technology-Enabled Medication; Blood Products; Human Milk Administration; Risk Reporting; Full CDS

Technology is used to achieve a closed-loop process for administering medications, blood products, and human milk, and for blood specimen collection and tracking. These closed-loop processes are fully implemented in 50 percent of the hospital. Capability must be in use in the ED, but the ED is excluded from the 50 percent rule.

A more advanced level of CDS provides for the “five rights” of medication administration and other “rights” for blood product, and human milk administration and blood specimen processing.

At least one example of a more advanced level of CDS provides guidance triggered by physician documentation related to protocols and outcomes in the form of variance and compliance alerts (e.g., venous thromboembolism [VTE] risk assessment triggers the appropriate VTE protocol recommendation).

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EHR Adoption Stage 7: The Complete EHR; External HIE; Data Analytics; Governance; Disaster Recovery; Privacy and Security

The characteristics of a complete EHR or a Stage 7 EHR, as it is sometimes called, include:

The hospital no longer uses paper charts to deliver and manage patient care and has a mixture of discrete data, document images, and medical images within its EMR environment.

Health information exchange (HIE) is the ability to securely and electronically send and receive data about relevant patients to aid patient assessment and care decisions not only intra-organizationally (i.e., across all inpatient, outpatient, ancillary, and complementary care settings within the organization) but also interorganizationally (i.e., across distinct, legal, organizational entity boundaries).

Data warehousing is being used to analyze patterns of clinical data to improve quality of care, patient safety, and care delivery efficiency.

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EHR Adoption Stage 7: The Complete EHR; External HIE; Data Analytics; Governance; Disaster Recovery; Privacy and Security (cont.)

The characteristics of a complete EHR or a Stage 7 EHR, as it is sometimes called, includes:

Mature governance processes are in place to oversee, vet, and make efficient decisions related to the continual improvement of EHR activities (e.g., order set maintenance, data definitional disambiguation, etc.).

Disaster recovery plans are in place and tested for viability.

Industry-leading data privacy and security practices and technologies are effectively implemented.

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Costs of an EHR: The Total Cost of Ownership (TCO)

The TCO of an EHR includes:

One-time, upfront costs of purchasing the hardware and software

The annually recurring costs of owning and operating the EHR

Best practice is to estimate all foreseeable costs over a 5- to 10-year period as well as estimating a small but meaningful contingency fund for unforeseen costs.

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Data in this chart not intended to be viewable on the slide. Refer to exhibit 8.6 on page 317 of textbook.

Component Costs of the TCO of an EHR

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Not intended to be viewable on this chart. Suggest providing a blow-up of this chart or print-out.

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