1. Health Information Management: Concepts, Principles, and Practice
Chapter 9: Electronic Health Records
Unit 3 Seminar
Michele Smith

2. Unit 3 at a Glance Chapter 9 EHR
Discussion board of physician resistance to EHR- 25 points
Quiz -10 points
Project The Challenges of Interoperability points
Seminar

3. Unit 4 at a Glance
Chapter 19 in text: Expert Systems & Decision Support
Discussion board on DSS- 25 points
Quiz -10 points
Assignment DSS development is evaluation - 35 points
Seminar

4. Introduction to EHR Concept since late 1960s
In 2004, President Bush referenced the importance of every American having an EHR by 2014
But there are challenges!
Textual and contextual data
Mobile professionals
Heuristic thought
Workflows and process changes

5. Information Management
Information Technology
Health Information management
HIE
HIS POC
Source
Systems
Registry
PHR
EHR
NHIN

6. Clinical Transformation
Comprehensive, ongoing approach to care delivery excellence that offers value while measurably improving quality, enhancing service, and reducing costs through the effective alignment of people, process, and technology. (The Joint Commission)
In other words, the EHR is not just about automating the paper chart but about using information to improve health care

7. Theory into Practice Remote connectivity Clinical messaging
Integration of voice, data, and video
Knowledge sources
Work flow tasking
Clinical decision support
Integration with external sources and uses of health information

8. Benefits of EHR Improve quality Enhance patient safety
Support health maintenance
Increase productivity
Reduce hassle factors
Support revenue enhancement
Support predictive modeling
Maintain patient confidentiality and exchange data securely

9. Field Trip! Electronic Health Record - CBS Sunday Morning
Questions to consider:
What are some of the stated benefits to an EHR?
How will an EHR help avoid errors?
What are some of the stated barriers or considerations to implementation?

10. EHR Terms and Concepts EHR (NAHIT definition) EMR (NAHIT definition)
Electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization
EMR (NAHIT definition)
Electronic record of health-related information on an individual that can be created, managed, and consulted by authorized clinicians and staff within one healthcare organization
Could also refer to a hospital achieving a paperless environment with a document imaging system, or
Physician office EHR system

11. Neither NAHIT Definition . . .
Provides a statement of purpose
EHR is not an end goal; EHR is a part of an ongoing program of healthcare improvement
Institute of Medicine (IOM):
EHR is a “comprehensive system of applications that afford access to longitudinal (from birth to death) health information about an individual across the continuum of care, assist in documentation, support clinical decision making, and provide for knowledge building”

12. Key Concepts Structured data Unstructured data Values of variables
Patient name
Value:
Suzie Jones
Computer processable:
Example: Can alphabetize all names
Unstructured data
Narrative notes
Image of a document
Accessible within a computer, but each element within the note or image is not processable

13. Reporting and Population Health
EHR is a System
Many applications exchange and process data
Hospital EHR
Ambulatory EHR
PHR
Reporting and Population Health

14. EHR Migration Path Strategic plan to describe:
Applications
Technology
Operations
Necessary to achieve the organization’s goals for clinical transformation
Over time, potentially use bridge technology along the way

15. S.M.A.R.T. Goals Goal statements that support the migration path are
Specific
Measurable
Attainable
Realistic
Timely
Example: Within six months of using BC-MAR (medication five rights), reduce medication timing errors by 15%

16. Migration Path Example Figure 9.2 of text page 235
Designed to accomplish clinical transformation
Broken down into 5 phases
Labels for operations, technology, applications and goals
Copyright © 2008, Margret\A Consulting, LLC

17. Supporting Systems
Today, CCHIT only certifies EHRs, focusing on the clinical components needed to assist in documentation, support clinical decision making, enable continuity of care, and provide for knowledge building
There is a large “supporting cast” of applications, technology, and operations that must be present to achieve these purposes

18. Source Systems for Inpatient EHR
Clinical
Data
Repository
Other CDO Apps
Fin/Adm Apps
Long Term Care
Rehab
Home Health
Public Health
Dental
Ambulance
R-ADT/MPI
Ancillary Apps
Pt. Accts.
LIS
Clinical Apps
Order Comm.
Spec Clinical Apps
PIS
CPOE
Perioperative & Surgery
Cardiology
Oncology
Emergency Department
Intensive Care Units
Labor & Delivery
Behavioral/Mental Health
Results Retrieval
RIS
EMAR
Dietary
Clinical
Documentation
PACS
Smart Peripherals
Results Mgt.
Medicine Dispensing Devices
Robotics
Smart infusion pumps
Monitoring Equipment
Reporting
PHRs
Copyright © 2008, Margret\A Consulting, LLC

19. Financial/Administrative Systems
Fin/Adm Apps
These are foundational to EHR
Register and find a patient
Support billing
Direct orders from the nursing unit to respective departmental systems
Display diagnostic study results (lab and radiology)
Might include picture archiving and communication systems (PACS) – to display x-rays
HIM functions of chart tracking, encoding, release of information, digital dictation, transcription, electronic signature – will eventually be incorporated into EHR functionality
R-ADT/MPI
Pt. Accts.
Order Comm.
Results Retrieval

20. Ancillary Systems
Ancillary Apps
These have primarily served to manage the operations of the respective departments: Lab, Pharmacy, Radiology, etc.
These supply data to an EHR
LIS
PIS
RIS
Dietary
PACS

21. What Does an LIS do? Supports operation of lab to generate results
For a given lab test:
Receives order
Paper requisition
(Internal) order communication system
(External) source
Computerized provider order entry
Order is accessioned
Order identifies tests, based on standard list of tests able to be performed
Generates
Checks for Medicare medical necessity
Specimen collection lists
Bar code labels for specimen collection containers
Tracks chain of custody for specimen from receipt through analysis to discard
Interfaces to auto analyzers
Matches specimen to requisition
Reports results of analysis
Results verified
Delta checking, reflex testing
Interfaces to EHR for medication checking, etc.
Results released
Preliminary
Final
Billing
For laboratory management:
Generates
Technician worksheets
Workload balancing
Inventory management
Specimen collection vials
Reagents
Other
Enables
Patient setup
Test setup
Panel setup
Report setup
Quality control
Analyzer calibration
Daily controls
CLIA requirements
Supports operation of lab to generate results

22. Systems to Support Access
ECRM (archiving and LHR)
Clinical messaging (secure – provider portal)
Access to knowledge (articles, drug information)
Registries
E-forms
Abstraction of data from chart documents
Management
Document
View
Only

23. Systems to Provide Connectivity
Web portals
Secure (patient portal) for e-visits
Health information exchange
Connects disparate care delivery organizations within a locale, region, or state
Access to health plans: case management, disease management
E-Prescribing
Structured Data
Send
Receive

24. POC and CDS
Clinical Apps
CPOE and EMAR (or BC-MAR) are fundamental functions for EHR inpatient product certification
Point of care charting
Guides user in necessary data collection
Context-sensitive templates
Clinical decision support – embedded in CPOE and EMAR/BC-MAR
Integrates structured data and processes with other data to provide
Alerts, reminders, graphic views of data, trend lines, etc.
CPOE
EMAR
Clinical
Documentation
Results Mgt.
Reporting

25. Technologies to Support EHR
Legacy Systems
Older systems focused on financial/ administrative and operations
Often do not integrate data with newer systems
IT Acquisition Strategies
So what do you do with old and new systems?

26. IT Acquisition Strategies
Best of fit
(Mostly one vendor with weak clinicals)
Dual Core
(Two main vendors;
often financial vs. clinical)
Best of Breed
(Many vendors)
Rip & Replace
(Mostly one vendor
with strong clinicals)
Copyright © 2008, Margret\A Consulting, LLC

27. Functional Interface Diagram
ABC
Pt Acct
Chart
Chart Scribe
Chart Image OR
CDR
EMAR
Pharmacy
RIS
PACS
LIS
Dispensing
CPOE
Auto
Analyzer
EIS
ORYX
Chart ROI
R-ADT CH
Copyright © 2008, Margret\A Consulting, LLC

28. Databases
Place to compile related data into one place for subsequent retrieval and/or processing
Clinical Data Repository
Collects and supplies
data for EHR transactions
to support patient care:
Look at lab results
Post vital signs
Order medication
LIS
CPOE
Smart
peripheral
Receives data (from claims, abstraction, CDR)
Performs sophisticated analysis, data mining to generate knowledge
Clinical Data Warehouse
OLAP
OLTP

29. Standards to Exchange Data
Message format standards – protocols for structure and format of data (syntax) to which applications are written to enable writing interfaces to exchange data between two systems
HL7
DICOM
NCPDP
ASC X12 B A
Interface

30. Standard Vocabularies
Structured data need consistent definition (semantics) to ensure meaningful results
Example: How many patients have “hypertension?”
Blood pressure reading of __/__, X number of times, under Y circumstances, with ______.
SNOMED
LOINC
RxNorm
UMDNS

31. Continuity of Care CCR + CDA = CCD
Massachusetts Medical Society members frustrated with incomplete, inconsistent information coming from providers for referrals
Created, under ASTM standards organization, the Continuity of Care Record to define content of information that should be supplied when referring a patient from one physician to another
HL7 created a Clinical Document Architecture as a Web Services Architecture (WSA) to support the exchange of documents
ASTM and HL7 have harmonized these content and message standards to become the Continuity of Care Document standard

32. ECRM Document imaging (scanning) Record indexing, forms indexing
Content management (indexing parts of forms, such as allergy information)
Electronic feed (COLD) of digital documents (e.g., voice files, transcribed documents, print files from lab, , efax)
Workflow support (queues work for coders, patient financial services, ED)

33. Data Retrieval Technology
Results review
Ability to access results, often in print file (document) format
Results management
Ability to process results in structured data format, e.g., graph, trend, drug-lab result alerting
Dashboard
Screen density is important. Clinicians prefer screens with all of the screen “real estate” used, so they can view many pieces of data at one time
Color, animation, icons, and sound are appropriate, but use judiciously

34. VA EHR (VistA CPRS)

35. Data Capture Technology
Structured data entry through point-and-click, drop-down, structured templates, macros (“smart text”)
Speech and handwriting recognition – largely collect unstructured data, but may be used to issue voice commands or fill fields
Devices–the great debate:
Desktops vs. tablets vs handhelds
Wired vs. wireless
“Smart peripherals”
Patient data entry
Natural language processing

36. Data Quality Management
American Health Information Management Association

37. Clinical Decision Support
Copyright © 2008, Margret\A Consulting, LLC

38. System Architecture
Mainframe
Client/server
Web services architecture

39. Network Technology   MD Clinic Frame Relay T1 Rehab T1 O2 Dx Imaging
EHR
Frame
Relay T1
Internet
VPNs 
Dx Imaging
Rehab O2 T1
DMZ
RAID CD
SAN
UPS
UPS
Copyright © 2008, Margret\A Consulting, LLC

40. Storage Technology Storage devices Redundancy Back Up
Storage media
Encryption
Redundancy
Back Up
Business Continuity
Disaster Recovery
Storage Area Networks
Storage Management
E-Discovery
Metadata
CDS Rules
Knowledge sources
Audit Trails
Source Code

41. Privacy and Security HIPAA HIPAA Privacy HIPAA Security
Protected health information
Held by covered entities, and business associates of covered entities
HIPAA Privacy
Uses and Disclosures
Rights
Administrative
HIPAA Security
Administrative
Physical
Technical
Data breach notification laws
Any personal information
FTC “red flag” rules (identity theft)

42. Security is Risk-Based
Threats Vulnerabilities Risk
Wrongful
Disclosure
Privacy
Violation
Confidentiality
Unauthorized
Access
Erroneous
Information
Medical Errors
Integrity
Modification/
Destruction of
Data
Lack of Critical
Productivity
Recovery Cost
Availability
Denial of Service
False Claims
Lack of Evidence
Accountability
Repudiation
Event
Target
Agent
Impact
Probability of Occurrence H M L
L M H 1 9 + =
Gaps
Copyright © 2008, Margret\A Consulting, LLC

43. Access and Audit Controls
Emergency Access Procedures (BTG)
Access
Denied
Minimum Necessary
Classes of
Users
Categories of
PHI
Conditions of
Access
Access Control
Assigns Privileges
User-based
To each user
Role-based
To classes of users to categories of PHI
Context-based
Based on conditions =
Copyright © 2008, Margret\A Consulting, LLC

44. Wet signature Authentication Digitized signature Electronic signature
Image of a wet signature
Electronic signature
Password, biometric, and/or token
Digital signature
Process of encryption and non-repudiation to represent a signature
Public key infrastructure (PKI) is a set of policies, procedures, standards, and practices that enable a digital signature – but is not the only form of digital signature

45. EHR Challenges Cost Executive support Clinician adoption
System building
Training
Maintenance
Legal and regulatory concerns
Privacy and security

46. Cost-Benefit, ROI, Financing
Total cost of ownership
Return on investment
Payback period
Internal rate of return
Net present value
Financing
Operations, reserves
Bank loans, lines of credit
Application service provider

47. Physician Concerns Changing old habits Value proposition
Workflows
Processes
Value proposition
Replacement for clerical staff
Loss of revenue during learning curve
Privacy and security
Computers coming between them and their patients

48. Nursing Staff Concerns
Workflow and process changes
Definition of errors
Charting issues
Left out of planning
Work arounds
Patient acceptance (e.g., wanding bar codes)
Privacy and security

49. Legal and Regulatory Hybrid records Designated record set (HIPAA)
Legal health record (AHIMA)
State statutes

50. e-HIM™ (AHIMA) Business process engineer
Clinical research protocol designer and manager
Clinical trials manager
Consumer advocate
Data facilitator
Data/information broker
Data/information presenter
Data sets, nomenclature, and classification standards developer
Data miner
Data navigator
Data quality and integrity monitor
Data resource manager
Data security, privacy, and confidentiality manager
Data translator
Information system designer
Work and data flow analyst

51. EHR System Planning Readiness assessment Organizational goals
Change management
Implementation vs. adoption
Organizational goals
Migration path
Planning and project manager

52. Project Manager
Projects have a defined beginning and end, whereas programs continue indefinitely
A project manager works in a matrix structure,
Reporting to several individuals
Not have any direct reports
Work is largely accomplished by “volunteers” in teams
Do you want to be a project manager?
Are you entrepreneurial? Do you care what’s next?
Do you generally get tasks done on time?
Do people respond well to your requests?
Do you like to share the spotlight?
Are you comfortable communicating with all?
Do you see “all sides”? Value opposing viewpoints?
Are you a diplomatic “straight-shooter”?
Do you see big picture, while attending to detail?
Are you comfortable with change?
Do you delegate appropriately?

53. Project Plan Tasks Timelines Milestones Dependencies Resources Budget
Progress
Milestones
Dependencies
Resources
Budget
Meetings
Agendas
Follow up
Communications
Team building

54. Process Redesign
Map current processes and workflows to understand information flow today
Understand functionality of EHR
Redesign workflows and processes to support improvements using EHR
Address:
Bottlenecks
Sources of delay
Rework due to errors
Role ambiguity
Unnecessary duplications
Unnecessary steps
Long cycle time
Lack of adherence to standards
Lack of information
Lack of quality controls

55. EHR System Selection Define functional requirements
Understand the marketplace
Develop key selection criteria
Issue a request for proposal (RFP)
Conduct due diligence
Analyze responses to RFP
Receive demonstrations
Conduct site visits
Check references
Corporate due diligence
Negotiate contract
Narrow field
of vendors
from many to
one

56. EHR Implementation Initial planning Hardware and software installation
Steering committee
Domain teams
War room
Hardware and software installation
Process redesign
System build
Testing
Training
Data conversion, chart conversion, roll out planning
Go-live
Celebration

57. Beyond the Project Benefits realization Ongoing maintenance Upgrades
Monitoring for adoption
Goal achievement
Course correction
Ongoing maintenance
Upgrades
Enhancements
Next steps in migration path