Presentation on theme: "History and Current use of Clinical Information Systems"— Presentation transcript:
1History and Current use of Clinical Information Systems Lecture 2History and Current use of Clinical Information Systems
2CH 4 History and Evolution of Health Care Information Systems DefinitionsAn Information System is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the organizationInformation Technology describes the combination of computer technology (hardware and software) with data and telecommunications technology (data, image, and voice networks).
3Types of Health Care Information Systems Administrative Information SystemPrimarily administrative or financial informationUsed to support management functions and general operationsHuman Resource Management, Materials Management, Patient Accounting or Billing, Staff SchedulingClinical Information SystemContains clinical or health-related information used by providers in diagnosing, treating, and monitoringDepartment: radiology, pharmacy, laboratory systemsClinical decision support: medication admin, CPOE, EMR
5History and EvolutionPolicy and market innovations and correlations with ITDemand for IT driven largely by the market (follow the money). The dollar seems to be a better motivator than “doing the right thing”1991 IOM report – The Computer-Based Patient Record: an Essential Technology for Health CareCalled on the adoption of computer-based records by the year 2001HIPAA in 1996IOM: To Err is Human (2000)IOM Patient Safety: Achieving a New Standard for Care (2004)
6Ch 5: Current and Emerging Use of Clinical Information Systems The systemsThe electronic medical recordCPR(computer-based patient record)EMRAn electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one health care organization.
7EMRCore FunctionsHealth information and data (diagnoses, medications, allergies, demographics, narratives)Results management (test and procedure results)Order entry and supportDecision support (computerized decision support capabilities such as reminders, alerts and diagnosing)
9HIMSS EMR Adoption Model StageCumulative CapabilitiesStage 0Some clinical automation may existStage 1All three major ancillaries installed – laboratory, pharmacy, and radiologyStage 2Major ancillary clinical systems feed data to a clinical data repository (CDR) that provides physician access for retrieving and reviewing results.CDR contains a controlled medical vocabulary (CMV) and the clinical decision support system and rules engine for rudimentary conflict checkingThe hospital may be health information exchange (HIE) capable at this stage and can share whatever information it has in the CDR with other patient care stakeholders.
10HIMMS EMR Adoption Model StageCumulative CapabilitiesStage 3Clinical documentation installed (eg. Vital signs, flow sheets, nursing notes, care plan charting, eMAR)First level of clinician decision support is implemented to conduct error checking with order entry (i.e., drug/drug, drug/food, drug/lab)Some level of medical image access from picture archive and communication systems (PACS) is available for access by physicians via the intranet or other secure networks.Stage 4CPOE for use by any clinician added to nursing and CDR environmentSecond level of decision support related to evidence-based medicine protocols implemented.
11HIMMS EMR Adoption Model StageCumulative CapabilitiesStage 5The closed loop medication administration environment is fully implemented in at least one patient care service area. The eMAR and bar coding or RFID are implemented and integrated with CPOE and pharmacy to maximize point-of-care patient safety processes for medication administrationThe “five rights” of medication administration are verified at the bedside with scanning of the bar code on the unit does medication and the patient IDStage 6Full physician documentation/charting (structured templates) are implemented for at least one patient care service area for progress notes, consult notes, discharge summaries or problem list and diagnosis list maintenance.A full complement of radiology PACS is implemented and provides medical images to physicians via an intranet and displaces all film-based images
12HIMMS EMR Adoption Model StageCumulative CapabilitiesStage 7The hospital no longer uses paper charts to deliver and manage patient care and has a mix of discrete data, document images, and medical images within its EMR environmentData warehousing is being used to analyze patterns of clinical data to improve quality of care and patient safety and care delivery efficiencyClinical information can be readily shared via standardized electronic transactions with all entities that are authorized to treat the patient or a HIE.The hospital demonstrates summary data continuity for all hospital services (e.g. inpatient, outpatient, ED, and with any owned or managed ambulatory clinics)
13Stage 7 Hospitals in Texas Baylor Scott&White (3 Hospitals)Children’s Medical Center (2 Hospitals)Texas Health Resources (11 Hospitals)https://www.himssanalytics.org/emram/stage7 caseStudies.aspx
14EHRs and DocsAMA: “The EHR has been reduced to a tool for billing, compliance and litigation that has sustained negative impacts on doctors’ productivity”Documenting a full clinical encounter is pure tormentThe government mandates that doctors use an EHR, the EHR vendors’ templates can create confusion and the appearance of fraud, which opens the door for payers to decline reimbursement.
15EHRs and Docs Recent evidence that EHRs perpetuate fraud Easier to “upcode”EHRs produce more complete and accurate documentation, and this could be leading medical providers to seek reimbursement for services they have always been providing but weren’t properly documenting before.CMS has history of billing and so can look for trends in billing.
16AHIMA American Health Information Management Association Recommendations:Code of ethics for both EHR vendors and Users to design and use the systems correctly and shared accountability for ensuring compliant documentation and coding practices
17AHIMA American Health Information Management Association Recommendations:Organization guidelines to assure the features of an EHR are used correctly, addressing issues such as acceptable ways to capture information, limitations on certain features, and correct copy/paste procedures
18AHIMA American Health Information Management Association Recommendations:National set of coding guidelines by CMSEducation and training on EHR use for all who access it.
19Adoption of EHRMeaningful Use of Electronic Health Records, April 2011 through May 2012.
20Physician AdoptionAs of the end of 2012, 62,226 had attested to meaningful use under the Medicare program.Or about 12.5% of the 509,328 eligible physicians.9.8% of specialists17.8% of primary care providers1.9% in Alaska to 24.2% in North DakotaEpic, Allscripts, eClinicalWorks, GE Healthcare, and NextGen accounted for almost 60%
22Physician Adoption Barriers to Adoption Cost Lack of knowledge Workflow challengesLack of interoperability
23Hospital Adoption44.4% of acute care hospitals had a basic EHR system in 2012.It was 12.2% in 2009.
24Basic vs. Comprehensive EHR RequirementComprehensiveBasicClinical DocumentationDemographic Characteristics of patientsXPhysicians’ notesNursing AssessmentsProblem ListsMedication listsDischarge SummariesAdvanced Directives
25Basic vs. Comprehensive EHR RequirementComprehensiveBasicTests and imaging ResultsLaboratory reportsXRadiologic reportsRadiologic imagesDiagnostic-test resultsDiagnostic-test imagesConsultant reports
26Basic vs. Comprehensive EHR RequirementComprehensiveBasicCPOELaboratory TestsXRadiologic TestsMedicationsConsultant RequestsNursing Orders
27Basic vs. Comprehensive EHR RequirementComprehensiveBasicDecision SupportClinical GuidelinesXClinical RemindersDrug-Allergy AlertsDrug-Drug Interaction AlertsDrug-Lab interaction AlertsDrug-Dose Supportx
35Reasons for increases Demographics As older physicians retire and a new cohort enters, resistance lessens.Fear factor is dissipating – even among older physicians.
36Reasons for increases Government incentives 2006 HHS granted Stark law exceptions and anti-kickback safe harbors to hospitals so they could help affiliated practices finance EMRs and other technology.About 1/3 of hospitals have offered financial assistance for EMRs and more than 60% offer physicians access to the hospital’s EMRHITECH
37Value of EMR Improved Quality, Outcomes, and Safety Improved Efficiency, Productivity?Time Savings?Cost Reduction?Improved Service and Satisfaction?
38Computerized Provider Order Entry (CPOE) Identified by the Leapfrog Group as one of the Four Leaps in Hospital Quality, Safety and Affordability (CPOE, Evidence-Based Referral, ICU “intensivist” staffing, Safe Practice Score).A CPOE accepts physician orders electronically, replacing handwritten or verbal orders
39Computerized Provider Order Entry (CPOE) Also provides decision support at the point of ordering (duplicate test, drug-drug interactions, allergies, etc). Might also show the physician the cost of the drugAlso called CPOM (management) to highlight that it is not just “entering orders” but more about managing orders.
41CPOE AdoptionCPOE seen as a major obstacle to getting to Meaningful Use.For Stage 1:More than 30% of unique patients with at least one medication in their medication list have at least one medication entered using CPOEFor Stage 2:More than 60% of medication, 30% of laboratory, and 30% of radiology orders created by the EP during the EHR reporting period are recorded using CPOE
42CPOE Adoption Involves major change in workflow Most hospitals have named a Chief Medical Information Officer – physician champion.Cerner, Eclipsys and Epic are the biggest vendors in CPOE, with Cerner having the most live hospitals. (McKesson and MEDITECH also in game)
45Electronic Medication Administration System eMAR About half of medication errors occur during the ordering process (CPOE), but errors also occur in dispensing, administering, and monitoring medications.Bar-code-enabled point of care (BPOC)The five rights:The right drugto the right patientthrough the right routeat the right doseat the right time.
46eMAR http://www.chartmeds.com/Demos.aspx Patient wristband with barcodeProvider identification band with barcodeBar-codes on the medicationLinked to orders
47TelemedicineThe use of medical information exchanged from one site to another via electronic communications to improve patients’ health.Specialist referral servicesRemote patient monitoringTwo delivery methodsStore and forward – digital images from one location to another. Teleradiology and teledermatologyhttps://www.youtube.com/watch?v=UyoooVg0CJQhttps://www.youtube.com/watch?v=mXgmX0k1se8
48TelemedicineInteractive videoconferencing – face to face consultation. Urban to rural.Peripheral devices such as stethoscopeeICU-Intensive-Care-Unit-eICUTelesurgery
49TelehealthTelehealth includes the use of technology to access remote health information, diagnostic images, and educationcommunicationRefilling prescriptionsRegistering patientScheduling appointments
50Personal Health Record An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources while being managed, shared, and controlled by the individualConsumer-empowermentComprehensiveLongitudinalIndividual controls
52Top 10 Barriers to Implementation 10. Usability - products are hard to use and not well engineered for clinician workflow.9. Politics/naysayers - every organization has a powerful clinician or administrator who is convinced that EHRs will cause harm, disruption, and budget disasters.8. Fear of lost productivity - clinicians are concerned they will lose 25% of their productivity for 3 months after implementation. Administrators are worried that the clinicians are right.7. Computer Illiteracy/training - many clinicians are not comfortable with technology. They are often reluctant to attend training sessions.6. Interoperability - applications do not seamlessly exchange data for coordination of care, performance reporting, and public health.