An Introduction to Electronic Health Records Chapter 1 An Introduction to Electronic Health Records McGraw-Hill © 2012 The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 1 Content 1.1 Brief history of electronic health records (EHRs) 1.2 History of standards development for the EHR and nursing’s role in their development 1.3 Certification bodies for the EHR 1.4 Benefits of the EHR 1.5 Government involvement in the EHR 1.6 Role of nursing informatics in healthcare
L.O. 1.1 The EHR History
L.O. 1.1 The EHR History Impetus for development 1960s Quality patient care 1960s First EMR programs First electronic databases
L.O. 1.1 The EHR History Terms and Definitions CPR: Computer-Based Patient Record EMR: Electronic Medical Record EHR: Electronic Health Record CCD: Continuity of Care Document PHR: Personal Health Record
L.O. 1.1 The EHR History Point of care documentation Modes of Data Entry Keyboard Voice recognition Handwriting recognition Templates and data selection Touch screens COWs/WOWs
L.O. 1.1 The EHR History Security and reliability Local area network (LAN) Internet Intranet Data encryption Application server provider (ASP)
L.O. 1.2 Development of EHR Standards
L.O.1.2 Development of EHR Standards Barriers to EHR adoption Cost Organization Lack of unified standards, functionality, and interoperability
L.O.1.2 Development of EHR Standards IOM’s Committee on Data Standards for Patient Safety – 2003 Identified key competencies Became foundational benchmark for EHR development and programming Consolidated Health Informatics (CHI) standards - 2004 Enabled agencies to share information Common clinical vocabularies Standard methods of transmission
L.O.1.2 Development of EHR Standards Role of nursing in standards development Promotes standardization to identify nursing’s contribution to patient care Promotes research Promotes identification of relationships among nursing interventions and outcomes
L.O.1.2 Development of EHR Standards Technology Informatics Guiding Educational Reform (TIGER) Initiative Goal to ensure nursing input into the standardization process for EHRs Calls for agreement on the standardized nursing terminology to promote interoperability Standardized nursing language examples NANDA-I, NOC, NIC ICNP
L.O. 1.3 EHR Certification Agencies
L.O. 1.3 EHR Certification Agencies The Certification Commission for Health Information Technology (July 2004) Mission: To accelerate the adoption of health information technology by creating an efficient, credible, and sustainable product certification program
L.O. 1.3 EHR Certification Agencies CCHIT Creates inspection process for: Ambulatory care EHRs for the office-based healthcare provider Inpatient EHRs for hospitals and health systems Network components through which EHRs interoperate and share information
L.O. 1.3 EHR Certification Agencies Office of the National Coordinator for Health Information Technology (ONC) - 2004 Purposes Serve as a resource to the entire health system Support the adoption of health information technology Promote a nationwide health information exchange in order to improve healthcare in the United States
L.O. 1.4 Benefits of The EHR
L.O. 1.4 Benefits of The EHR Enhanced accessibility to clinical information Patient safety Quality patient care Efficiency and savings
L.O. 1.5 Government Involvement in the EHR
L.O. 1.5 Government Involvement in the EHR President George W. Bush (2004) Called for universal EHRs by 2014 “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
L.O. 1.5 Government Involvement in the EHR Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Positive incentives for practitioners who use e-prescribing Penalties for practitioners who do not e-prescribe after 2014 Surescripts National clearinghouse for e-prescribing
L.O. 1.5 Government Involvement in the EHR American Recovery and Reinvestment Act (ARRA) - 2009 The Health Information Technology for Economic and Clinical Health (HITECH) Act $20 billion to aid in the development of a healthcare infrastructure and to promote adoption and use of health information technology, including EHRs Requires “meaningful use” of a “certified” EHR Provides bonus/incentive payments
L.O. 1.6 Nursing Informatics
L.O. 1.6 Nursing Informatics Florence Nightingale Recognized the need for standardization of nursing language to facilitate communication and enhance quality care Harriet Werley first provided nursing input for computer use in the healthcare arena in the 1950s 1970s: Nursing applications for computers began to be developed
L.O. 1.6 Nursing Informatics 1973 North American Nursing Diagnosis Association (NANDA) Developed initial set of nursing diagnoses 1980s Development of personal computers Nursing informatics courses 1994 Nursing informatics recognized as nursing specialty Scope and standards of nursing informatics practice developed
L.O. 1.6 Nursing Informatics Supports quality of nursing decisions by enhancing access to nursing knowledge and patient information Promotes development and use of tools compiled from a variety of sciences Assists with managing and communicating information and knowledge between healthcare team members Promotes access to current evidence-based nursing practice