NCM 110: EHR, EMR, CPOE

EHR

Offers a more inclusive health information source for patients

EHR goals

• Reduces errors and harm

• Cutting costs

• Improving the decision-making process

• Making access to patient information by HC providers and personnel more easier

EHR content

• Px's demographic, billing, and insurance information

• Physical history and physicians’ orders

• Medication allergy lists

• Nursing assessments, notes, and graphics of vital signs

• Laboratory and radiology results

• Trending labs, vital signs, results, and activities pages for easy reference

• Links to important clinical information and support

• Reports for quality and safety personnel

Electronic Medical Records

• records used by the physicians in their own offices

• medical information about the patient related to that specific office and may include most of the following:

  • Medical history, physicals, notes by providers, and consults from other physicians

  • Medications and allergies, including immunization history

  • Alerts to the office and the patients for preventative tests and/or procedures, e.g., lab tests to follow-up colonoscopies

Similarities of both EMR and EHR

• advance healthcare information to a higher level

• Making real-time medical information available for clinicians to make quality decisions with patients.

• Sharing information between those caring for the patient, reducing duplication of costly tests or procedures and errors in prescribing medications.

• Eliminating illegible handwriting can cause errors.

• Instantly sharing lab and radiology images after reading, with results

• Sending order entry by providers to the required department.

• Providing evidence-based or best practice information to help with decision-making. Links are embedded into the software and placed in order sets, diagnosis areas, and medication

  pages to assist staff.

• Including built-in medical billing and coding tools for accurate capturing of codes needed for reimbursement.

Information technology and clinical information

have combined forces to create electronic health records (EHRs) and electronic medical records (EMRs)

Electronic Medical Records (EMR)

are the electronic medical records used inside a physician's office for the:

• patient's history

• physical

• medication

• allergies

• office notes

• consulting physician notes

• They may also include lab and x-ray reports and billing information

Electronic health records (EHR)

• have more information and allow access by multiple providers caring for the patient

• they can include many different types of records, from labs to x-rays and much more

• makes test results available more quickly, decreasing time and cost of care, and increasing communication between providers

• records also contain demographic information to help support billing, as well as contacts with family, research, and insurance companies

Electronic health records

• Are central data repositories for healthcare information

Electronic health records for HC providers

• allows doctors, nurses, and other members of the care team to

  • quickly share amounts of data

  • interpret results

  • help caregivers make decisions with the use of algorithms, specially designed process flows and paths

EHR functions and benefits helpful to HC team

• Easily retrieve past medical history

• Access any previously entered data, including allergies or other pertinent information

• Compare current test results with normal values

• Improve the coordination of care through electronic communication and documentation

EMR abilities that boost patient engagement

• Communication with providers

• Convenient access to care coordination

  • For example, making appointments and ordering medical supplies

• Awareness of health status

Computerized physician order entry

The process in which a physician or other prescribing provider inputs an order for a medication or treatment directly into a computerized system

Types physician orders for CPOE

• medication

• Lab work

• Nursing instructions

• Imaging or other testing

• Consults to other specialty services

2014

The year when the federal government enacted a law requiring Medicare and Medicaid providers to establish meaningful use of electronic records

meaningful use

• refers to not only implementing electronic records and technology but utilizing it in a way that improves care and convenience for patients

Center for Medicare and Medicaid Services

Organization where healthcare services are required to submit evidence exemplifying Meaningful Use in practice to gain reimbursement incentives and avoid penalties

main benefits of CPOE

• Reduce errors caused by poor handwriting

• transcribing errors

• other miscommunications (e.g. incorrectly used abbreviations)

• helps provide efficient communication among the HC team

safety stops

built within computerized order entry systems that give warnings to help prevent providers from making mistakes when entering orders

Brigham and Women’s Hospital and El Camino Hospital

early adopters of the CPOE during the 1980s and 1990s

benefits of CPOE

• handles simple tasks to range of more complex decision support

• lowers patient mortality

• reduces drug adverse effects by avoiding errors

• reduces overall cost of admission

HITECH

health information technology for economic and clinical health act (2009)

HITECH

• Acts as the standard on using health records

• the aim of this is to promote the adoption and meaningful use of HIT

• If meaningful use isn’t implemented then a penalty occurs

nurse

the center; patient care coordinator

CDS

clinical decision support

P in CPOE

• Commonly stands for ‘provider”

• Also appears as physician or prescriber

• In CPOE, the transcription step is removed, and the provider places an order directly into the system

• It is implied that the Provider is authorized to give or sign that order

HC professionals that are CPOE trained

advanced practice nurses and physician assistants

Clinical Decision Support System

• enables the checking and presentation of px safety rules during ordering such as:

  • drug-drug interaction

  • duplicate checking

  • corollary orders

  • dose calculations

• uses px informations to make decisions

M in CPOE

• sometimes replaces E in CPOE

• stands for computerized physician/ provider order management

M in CPOE

• implies that these orders are no longer once and done

• will require ongoing review and updates

• management of an order means that it is more than simply entered

• also communicated to other members of the team, reviewed and acted upon

three types of CPOE

• Basic

• Intermediate

• Advanced

Dr. Michael McCoy

proposed the three types of CPOE in 2005

basic CPOE

• Incorporates order entry with simple decision support features such as allergy or drug-drug interaction

intermediate CPOE

Includes additional relevant results displayed at the time of ordering and the ability to save their order preferences

advanced

represents Advanced Clinical Order Management, more sophisticated decision support in the of guided ordering

implementation of CPOE

• Requires a project plan, with appropriate time to complete workflow analysis, build, testing, and training

• It often impacts the healthcare organization on a much broader and deeper scale

• CPOE is at the heart of patient care and cannot be done in isolation to one department or discipline

common barriers to successful adoption

• digital divide that persists and low adoption rate

• population that are at greatest risks

• four main drivers

• too much time on CPOE affects time in comparison to traditional time such as rounds and consultations

populations at greatest risks (CPOE common barrier)

• primary care practices

• minority or uninsured-like patients that are Medicaid

• small hospitals

• organizations that are not able to recruit and retain skilled IT personnel

medicaid

a public health insurance program that helps low-income people pay for medical care

medicare

a federal health insurance for anyone age 65 and older; 65 and below with disabilities regardless of income

four main drivers

• influences a provider’s decision on EHR

  • affordability

  • product availability

  • practice integration

  • provider attitudes

main drivers addressed by HITECH

• Affordability

• product availability

• product integration

key strategies for a successful CPOE implementation

• executive leadership

• physician involvement

• multidisciplinary approach

• good EHR system response time

• flexible training strategies

Electronic software used for practice to prepare CPOE use

• Powerpoint

• MS word

• e-mail

requirement of comprehensive change management plan

needs to meet organizational factors that must be considered before, during, and after the implementation in order to promote successful adoption

change in practical terms

‘requires willingness and capacity to change’

three dimensions of organizational readiness

• psychological factors

• structural factors

• level of analysis

AHRQ

Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality (AHRQ)

• Organization funded in 2009 and 2010

• to establish a common set of recommendations, use cases, policy, research agenda items to the usability of EHR systems

Functions of an EHR into 4 roles as categorized by AHRQ

• Memory aid

• computational aid

• decision support aid

• collaboration aid

memory aid

reduces the need for memory to complete

computational aid

need to mentally group, compare, and analyze

decision support aid

integrates information from multiple sources

collaboration aid

enhances ability to communicate to other providers

usability

a quality attribute that assesses how easy user interfaces are to use

quality attributes that represent usability

• learnability

• efficiency

• errors

• satisfaction

• utility

Jakob Nielsen

stresses that it is better to run several small tests in iterative approach, where five end users are typically enough to identify the most important usability problems

three types of testing activities that promotes system usability

• gap analysis

• shadowing

• care team simulation

Studer (2005)

concluded that organizational factors must be considered before, during, and after the implementation in order to promote successful adoption

8 Specific Implementation Tactics

• building relationships to gain trust

• hiring staff that understands the domain of the physician practice

• setting realistic expectations and obtainable goals

• ensuring there is enough physical space for hardware so that providers may work effectively

• aligning the organization’s vision with the goals of the implementation

• developing a business case to identify the expected benefits of CPOE

• creating sustainable support model for ongoing improvement efforts

gap analysis

evaluation and study between the current and future state content and workflows

shadowing

a provider that is real-time working in current state with the new CPOE system

care team simulation

• BLS training

• AED demonstration

Usability problems

issues that arise from testing that makes way for:

• possible work redesign

• CPOE system enhancements

• training and change management plans

process improvement methods

• process may be iterative and starting small and then expanding scope ensures both judicious use of resources and acceptance of the change

• PDSA model

plan-do-study-act model

this approach facilitates assembling a team to;

• define the problem

• set an improvement goal

• brainstorm solutions in order to identify which solutions are most effective

goals of improving CPOE

• primary goal: ensure a safe and reliable CPOE system

• secondary goal: anticipate and plan for the work redesign required of providers

how to successfully accomplish CPOE secondary goal

• by identifying and meeting the provider and care team needs that surface during the testing and improvement work

Risk mitigation plan

created when the needs identified in the secondary goal of CPOE is not met

coordinated care

the goal standard for healthcare workers working to their full scope to facilitate key CPOE processes

Key CPOE processes

• medication reconciliation

• orders management

increasing patient engagement

• another core component to healthcare reform

• includes a new role for patients in the future of CPOE

• pilot study conducted by VA Boston Health Care system enabled patients to electronically verify their medication list post discharge

advantages of the pilot study conducted by VA Boston Health Care system

• reinforces patient’s decisions

• Virtual Medication Reconciliation avoids potential adverse drug events

• Used to review using telehealth technology

• reduces the cost in going for face-to-face consultations

alert fatigue

• occurs when a HC provider receives many alerts in the system

• can lead to medication errors

nurse informaticist

every hospital and care setting needs this one HC professional in order to meet the government’s visions for EHRs

Charles Safran, M.D.

• chair of American Medical Informatics Association

• stated that every hospital and care setting needs nurse informaticist in order to meet the government’s visions for EHRs

20th Annual HIMSS Leadership Survey

• IT professionals indicated that a focus on clinical systems will be their organizations’ top IT priority

  • it is a responsibility for them to stay updated

• a significant barrier identified was a lack of IT staffing, particularly in applicant level support and process/ workflow design

application level knowledge

• represents the ability to assemble the building blocks of a clinical information system

  • relies on the nurse informatics’ ability to assess, plan, and implement

• includes the ability to assess the integration points and impact a particular application like CPOE with other applications

nurse informaticist as a consultant

• possesses the domain knowledge of CPOE workflows and clinical processes

• essential for successfully translating and aligning the needs of the end user

workflow analysis skills of a nurse informaticist

• draw on the nurse’s underlying ability to interview clients for their history

primary for NI implementing CPOE

Ensuring a usable system

core competencies in CPOE

• systems knowledge

• workflow analysis

• change management

• possibilities

• process improvement

• human factors

• healthcare policies

electronic medical record

• a digital replacement for a px’s paper chart

• is accessible by a single practice and is primarily used for diagnosis and treatment

• includes px medical history, previous and current medications, diagnosis, allergies

• are NOT designed to be shared

electronic health record

• includes all the information contained in an electronic medical record and more

• designed to be shared with other healthcare providers

• to aid the level of care provided across the care continuum

• allows you to track additional patient information

• plays a significant role in Meaningful Use

ANA, 2008

As a consultant, the nurse informaticist may add the greatest value to solving the complex issues of CPOE through:

• expert domain knowledge

• change management theory and planning

• process improvement methods

• patient safety review

errors due to illegibility

• wrong medication

• wrong dose

• wrong route

• wrong frequency

• wrong prescriber

benefits of CPOE

• faster med administration

• order to patient receiving

• more accurate as five rights are met

• less handling

  • doctor > pharmacist > nurse > patient

• CDS (clinical decision support)

red color in CPOE

Allergies

green color in CPOE

meds that have been accepted and saved previously

blue color in CPOE

orders that we have put in that are unsaved

• an exception is the Primary Diagnosis which always remains in this color

black color in CPOE

orders that are current and saved

grey color in CPOE

orders that are one-time/ overue