Chapter 11: The Electronic Health Record and Clinical Informatics.
Introduction:
EHRs implications are broad, ranging from the ways in which care is delivered, to the types of interactions providers have with patients in conjunction with the use of technology, to the research surrounding EHRs that will inform disciplinary practice for tomorrow.
Setting the Stage:
The U.S. healthcare system faces the enormous challenge of improving the quality of care while simultaneously controlling costs. EHRs were proposed as one ietsolution to achieve this goal.
American Recovery and Reinvestment Act of 2009 (ARRA) - This legislation included the HITECH Act, which specifically sought to incentivize health organizations and providers to become meaningful users of EHRs.
The HITECH Act resulted in payment of a penalty by any healthcare organization that had not adopted an EHR by January 2015.
The final rule was published by the Department of Health and Human Services (HHS) in July 2010 for the first phase of implementation.:
Stage 1: Meaningful use criteria focused on data capture and sharing.
Stage 2: Criteria that were implemented by 2014 advanced several clinical processes and promoted health-information exchange and more patient control over personal data.
Stage 3: Implemented on or before 2016, focused on improved outcomes for individuals and populations and introduced patient self-management tools.
EHRs are scored on a metric consisting of seven levels.
Higher stages of the electronic medical record adoption model include more sophisticated use of CDSS and medication administration tools, with HIMSS stage 7—the highest level consisting of EHRs that have health-information exchange capabilities, data analytics, robust privacy and security, disaster recovery, and governance
Components of Electronic Health Records:
Under ARRA, there is now an explicit requirement for providers and hospitals to use a certified EHR that meets a set of standard functional definitions to be eligible for the increased reimbursement incentive.
HHS granted two organizations the authority to accredit EHRs:
The Drummond Group.
The Certification Commission for Healthcare Information Technology.
The initial National Institute of Standards and Technology (NIST) test procedure included 45 certification criteria, ranging from the basic ability to record patient demographics, document vital signs, and maintain an up-to-date problem list to more complex functions, such as electronic exchange of clinical information and patient summary records .
Despite the points articulated in the ARRA, the IOM definition of an EHR also remains a valid reference point. This definition is useful because it has distilled all the possible features of an EHR into eight essential components with an emphasis on functions that promote patient safety—a universal denominator that everyone in health care can accept:
The eight components:
Health information and data - Make up the patient data required to make sound clinical decisions, including demographics, medical and nursing diagnoses, medication lists, allergies, and test results. Includes care management data indicating details of patient visits and interactions with patients; medication reconciliation; consents and directives.
Results Management - The ability to manage results of all types electronically, including laboratory and radiology procedure reports, both current and historical.
Order entry management - The ability of a clinician to enter medication and other care orders, including laboratory, microbiology, pathology, radiology, nursing, supply orders, ancillary services, and consultations, directly into a computer
Decision support - Entails the use of computer reminders and alerts to improve the diagnosis and care of a patient, including screening for correct drug selection and dosing; screening for medication interactions with other medications; preventive health reminders in such areas as vaccinations, health risk screening, and detection; and clinical guidelines for patient disease treatment
Electronic communication and connectivity - Include the online communication among healthcare team members, their care partners, and patients, including email, Web messaging, and an integrated health record within and across settings, institutions, and telemedicine.
Patient support - Encompasses patient education and self-monitoring tools, including interactive computer-based patient education, home telemonitoring, and telehealth systems.
Administrative processes - Activities carried out by the electronic scheduling, billing, and claims-management systems, including electronic scheduling for inpatient and outpatient visits and procedures, electronic insurance eligibility validation, claim authorization and prior approval, identification of possible research study participants, and drug-recall support
Reporting and population health management - The data-collection tools to support public and private reporting requirements, including data represented in a standardized terminology and machine-readable format
EHR standards and functionality is Health Level Seven International. Health Level Seven International is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services.
Advantages of Electronic Health Records:
Possible methods to estimate EHR benefits include using vendor supplied data that have been retrieved from their customers’ systems, synthesizing and applying studies of overall EHR value, creating logical engineering models of EHR value, summarizing focused studies of elements of EHR value, and conducting and applying information from site visits.
The four most common benefits cited for EHRs:
Increased delivery of guidelines-based care.
Enhanced capacity to perform surveillance and monitoring for disease conditions.
Reduction in medication errors.
Decreased use of care.
EHR advantages include simple benefits, such as no longer having to interpret poor handwriting and handwritten orders, reduced turnaround time for laboratory results in an emergency department, and decreased time to administration of the first dose of antibiotics in an inpatient nursing unit.
The ONC listed the advantages of EHRs as follows:
Providing accurate, up-to-date, and complete information about patients at the point of care.
Enabling quick access to patient records for more coordinated, efficient care
Securely sharing electronic information with patients and other clinicians.
Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care.
Improving patient and provider interaction and communication, as well as healthcare convenience.
Enabling safer, more reliable prescribing.
Helping promote legible, complete documentation and accurate, streamlined coding and billing.
Enhancing privacy and security of patient data.
Helping providers improve productivity and work–life balance.
Enabling providers to improve efficiency and meet their business goals.
Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health.
Davies Award - Recognizes healthcare organizations that have achieved both excellence in implementation and value from health information technology.
9 benefits of an EHR from the patient perspective:
Personal access to records.
The ability to correct incorrect information.
Patient portals.
Access to physicians.
Providing secure information exchange.
Maintenance reminders for chronic illness care.
Identifying medication interactions.
Big data for population health management.
Greater efficiency and quality of care resulting in cost savings.
EHRs also hold the promise of transforming health care by supporting:
Better health care by improving all aspects of patient care, including safety, effectiveness, patient centeredness, communication, education, timeliness, efficiency, and equity.
Better health by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.
Improved efficiencies and lower healthcare costs by promoting preventative medicine and improved coordination of healthcare services as well as by reducing waste and redundant tests.
Better clinical decision making by integrating patient information from multiple sources
EHRs also support epidemiologic research by providing access to large sample sizes and accessible data on culturally diverse populations.
EHR data must be formatted in a machine-readable manner to support interoperable exchange of information and data mining.
Ownership of Electronic Health Records:
Historically, many systems were developed locally by the information technology department of a healthcare organization.
As commercial offerings were introduced and matured, it became less and less common to see homegrown or locally developed systems.
The first step of ownership is typically a vendor selection process for a commercially available EHR. During this step, it is important to survey the organization’s level of interest, identify possible barriers to participation, document desired functions of an EHR, and assess the willingness to fund the implementation .
The second step of the selection process is to select a system based on the organization’s current and predicted needs. The organization should establish key evaluation criteria to compare the different vendors and products. These criteria should include both subjective and objective items .
Training may be delivered in a variety of media. Often a combination of approaches works best, including classroom time, electronic learning, independent exercises, and peer-to-peer, at-the-elbow support. Training must be workflow based and reflect real clinical processes. It must also be planned and budgeted for through the postlive period.
The implementation plan should account for the long-term optimization of the EHR. This step is commonly overlooked and often results in benefits falling short of expectations because the resources are not available to realize them permanently.
Flexibility and Expandability of Electronic Health Records:
An EHR must be flexible and expandable to meet the needs of patients and caregivers in all these settings despite the challenges.
At a very basic level, no EHR system yet available can provide all functions for all specialties to such a degree that all clinicians would successfully adopt it.
Interoperability exists through what is called a continuity-of-care document. This data set includes patient demographics, medication, allergy, and problem lists, among other things, and the formatting and exchange of the continuity-of-care document is required to be supported by EHR vendors and healthcare organizations seeking ARRA meaningful use incentives.
Accountable Care Organizations and the EHR:
EHRs with data-sharing capabilities are central to the support of accountable care organizations (ACOs), a payment incentive program established by the Centers for Medicare and Medicaid Services.
Many EHRs also can serve as a program’s care management system, eliminating the need for a separate system to document care management efforts and help care teams engage with patients.