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slide 1 welcome to health management information systems electronic health records this is lecture a the component health management information systems is a theory component that provides an introduction to healthcare applications and the systems that use them health information technology standards health-related data structures and enterprise architecture in healthcare organizations lecture a will define an electronic medical record EMR and electronic health record EHR and explain their similarities and differences identify attributes and functions of an EHR discuss the issues surrounding EHR adoption and implementation and describe the impact of EHRs on patient care slide 2 the objectives for this unit electronic health records are to state the similarities and differences between an electronic medical record EMR and electronic health record EHR identify attributes and functions of an EHR describe the perspectives of health care providers and the public regarding acceptance of or issues with an EHR which can serve as facilitators of or major barriers to its adoption and explain how the use of an EHR can affect patient care safety efficiency of care practices and patient outcomes slide 3 additional objectives for this unit electronic health records are to discuss how health information exchange hie and nationwide health information network and H I n impact healthcare delivery and the practice of health care providers outline issues regarding governmental regulation of EHR systems such as meaningful use of interoperable health information technology and a qualified EHR summarize how the institute of medicine's vision for 21st century healthcare and wellness may impact health management information systems and identify how ongoing developments in biomedical informatics can affect future uses and challenges related to health information systems slide 4 as a way of introduction to electronic health records let's identify why a patient or medical record exists in the first place according to doctor Reiser the purpose of a patient record is to recall observations to inform others to instruct students to gain knowledge to monitor performance and to justify interventions Rizer 1991 page 902 the medical record is a way of communicating between staff managing patient care it also allows for an integrated view of patient data the patient medical record is also the legal business record for a healthcare provider as the American Health Information Management Association AHIMA a heme workgroup on maintaining the legal EHR pointed out in the article maintaining a legally sound health record paper and electronic in this same article the workgroup states as such it must be maintained in a manner that follows applicable regulations accreditation standards professional practice standards and legal standards AHIMA 2005 paragraph 1 slide five historically patient records have been paper-based however more and more health care providers are moving away from paper-based to adoption of an electronic form there are two terms associated with the electronic form they are electronic medical record or EMR and electronic health record or EHR the report defining key health information technology terms defines an EMR as an electronic record of health-related information on an individual that can be created gathered managed and consulted by authorized clinicians and staff within one healthcare organization and a H IT 2008 page six this same report stated health-related information encompasses health wellness administrative data and information derived from public health and scientific research it includes past and present observations and facts documented in the provision of health care that may be related to preventing illness and promoting wellness or that may be used in the process of informing consent and a H IT 2008 page 10 an electronic medical record is a record of medical care created managed and maintained by one healthcare organization this does not mean a single physical location there may be instances when information is shared among multiple facilities and still be within one EMR for example an electronic record used in a physician practice with several offices is still an EMR when all sites are using the same proprietary data structure and architecture and the information is not moving outside the confines of the organization EMRs are the electronic equivalent of an individual's legal medical record for use by providers and staff within one healthcare organization slide 6 the purpose of an EMR is to provide an electronic equivalent of an individual's legal medical record for use by providers and staff within one healthcare organization the EMR is understood to meet specific business needs for care reimbursement and disclosure follow regulation and rules promulgated by federal state or accrediting entities and contain information as defined by the provider organization the electronic medical record encapsulate a record of medical care provided in a single healthcare organization that is an intra organizational medical record slide seven the other term associated with electronic records is electronic health record or EHR the report defining key health information technology terms also provided a definition for electronic health record an EHR is an 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 an a.h IT 2008 page six being a repository of individual health records that reside in numerous information systems and locations EHRs are intended to support efficient high quality integrated health care independent of the place and time of health care delivery consequently EHRs are part of a health information technology infrastructure slide 8 the purpose of an EHR is to provide an electronic equivalent of an individual's health record for use by providers and staff across more than one healthcare organization an EHR is inter-organizational that is two or more unrelated healthcare organizations contribute to the record which becomes an aggregation of one record focused around a person's comprehensive health history rather than being one providers record however to arrive at this level of information aggregation all contributors must be able to send and receive information using standards that facilitate the interoperable exchange of health-related information an EHR is intended to support efficient high-quality integrated healthcare independent of the place and time of health care delivery it encapsulate san electronic equivalent of an individual's health record for use by provider and staff in multiple unrelated facilities as the National Alliance for health information technologies report defining key health information technology terms explained the principle difference between an EMR and an EHR is the ability to exchange information interoperable an EMR aligns with the prevailing state of electronic records today whether the record is branded an EMR or an EHR however the movement of the industry is toward electronic records that are capable of using nationally recognized interoperability standards which is a key defining component of an EHR and aah IT 2008 page 5 slide 9 adding to nehi t's principle difference other comparisons illustrating similarities and differences between an EMR and EHR are shown in table 3.1 the first row in table 3.1 states and EMR is a record of medical care created managed and maintained by one healthcare organization intra-organizational while an EHR is a repository of individual health records that reside in numerous information systems and locations inter-organizational the second row explains an EMR is an integration of health care data from a participating collection of systems from one health care organization in contrast to an EHR which is an aggregation of health-related information into one record focused around a person's health history that is a comprehensive longitudinal record the third row points out an EMR is consulted by authorized clinicians and staff within one healthcare organization while an EHR is consulted by authorized clinicians and staff across more than one healthcare organization the fourth and final row reiterates nhi T's principle difference that is in an EMR data continuity exists throughout one healthcare organization but in the case of an EHR data interoperability across different organizations occurs while these distinctions can be made between an EMR and EHR many regard the two terms as synonymous slide 10 according to a Centers for Medicare and Medicaid Services fact sheet electronic health records at a glance electronic health records improve care by enabling functions that paper records cannot deliver these include EHRs can make a patient's health information available when and where it is needed it is not locked away in one office or another EHRs can bring a patient's total health information together in one place and always be current clinicians need not worry about knowing the drugs or treatments prescribed by another provider so care is better coordinated EHRs can support better follow-up information for patients for example after a clinical visit or hospital stay instructions and information for the patient can be effortlessly provided and reminders for other follow-up care can be sent easily or even automatically to the patient EHRs can improve patient and provider convenience patients can have their prescriptions ordered and ready even before they leave the providers office and insurance claims can be filed immediately from the providers office CMS 2010 paragraph 5 slide 11 additionally EHRs can link information with patient computers to point to additional resources patients can be more informed and involved as EHRs are used to help identify additional web resources EHRs don't just contain or transmit information they also compute with it for example a qualified EHR will not merely contain a record of a patient's medications or allergies it will also automatically check for problems whenever a new medication is prescribed and alert the clinician to potential conflicts EHRs can improve safety through their capacity to bring all of a patient's information together and automatically identify potential safety issues providing decision support capability to assist clinicians CMS 2010 paragraph 5 slide 12 the final group of ways in which EHRs can improve care according to CMS are EHRs can deliver more information in more directions while reducing paperwork time for providers for example EHRs can be programmed for easy or automatic delivery of information that needs to be shared with public health agencies or quality measurement saving clinician time EHRs can improve privacy and security with proper training and effective policies electronic records can be more secure than paper EHRs can reduce costs through reduced paperwork improved safety reduced duplication of testing and most of all improved health through the delivery of more effective health care CMS 2010 paragraph 5 with regards to improving privacy and security EHRs can be encrypted and stored on password-protected systems thereby restricting their access to only those authorized in addition systems can track who accessed a record when it occurred and for what purpose firewalls and other physical security measures can be put in place to prevent unauthorized users from gaining access to patient records overall EHRs have the potential for improvements in patient safety and quality however improvements are not an automatic result of in mounting an EHR slide 13 thus an electronic health record is not an electronic version of the paper record an electronic health record has additional attributes or properties that a paper record does not the healthcare information and management systems society or hims described eight attributes of an electronic health record in their report hims electronic health record definitional model the first two attributes are that the EHR provides secure reliable real-time access to patient health record information where and when it is needed to support care captures and manages episodic and longitudinal electronic health record information handler at all 2003 page 3 slide 14 the next three attributes as described in the hims report are the EHR functions as clinicians primary information resource during the provision of patient care assists with the work of planning and delivering evidence-based care to individual and groups of patients and supports continuous quality improvement utilization review risk management and performance monitoring handler at all 2003 pages 4 & 5 slide 15 the final three attributes listed in the hims report are the EHR captures the patient health related information needed for reimbursement provides longitudinal appropriately masked information to support clinical research public health reporting and population health initiatives and supports clinical trials handler at all 2003 pages 6 and 7 in addition to those identified in the hims report two additional attributes are the EHR supports timely access to patient information and by more than one person at a time and provides the ability to generate reports that can help measure activity and determine levels of compliance with policies and evidence-based medicine protocols slide 16 in addition to the hims report health level 7 international or hl7 published an EHR system functional model according to hl7 s website hl7 is an 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 hl7 2011 paragraph 1 the hl7 EHR system functional model establishes EHR systems EHRs standards that will enable the development of EHRs based on one set of functional requirements the model contains three sections they are direct care functions supportive functions and information infrastructure functions slide 17 according to the hl7 EHRs model 2007 direct care functions are functions employed in the provision of care to individual patients direct care functions are the set of functions that enable delivery of health care or offer clinical decision support subsets of direct care functions include care management clinical decision support and operations management and communication some examples of the care management subset are the capability to identify and maintain a patient record manage patient demographics and manage problem lists for the clinical decision support subset examples of direct care functionality include support for standard care plans guidelines protocols support for medication and immunization administration and orders referrals results and care management examples for the operations management and communication subset are clinical workflow tasking support clinical communication and support for provider pharmacy communication slide 18 the hl7 EHRs model 2007 describes supportive functions as functions that support the delivery and optimization of care but generally do not impact the direct care of an individual patient these functions assist with the administrative and financial requirements associated with the delivery of healthcare provide support for medical research and public health and improve the global quality of healthcare slide 19 the final section information infrastructure functions define the heuristics of a system necessary for reliable secure and interoperable computing hl7 EHRs model 2007 these functions are not involved in the provision of health care but are necessary to ensure that the infirm patience system provides safeguards for patient safety privacy and information security as well as operational efficiencies and minimum standards for interoperability the functions for this section include security health record information and management registry and directory services standard terminologies and terminology services standards-based interoperability business rules management and workflow management slide 20 in addition to hl7 s EHR systems EHRs standards the office of the National Coordinator for health information technology published the health information technology initial set of standards implementation specifications and certification criteria for electronic health record technology final rule 2010 which includes the following standards for the certification of EHR technology content exchange standards for exchanging electronic health information for example the National Council for the prescription drug programs NCPDP prescriber pharmacist interface script standard or the hl7 clinical document architecture CDA release - continuity of care document CCD vocabulary standards for representing electronic health information - examples of vocabulary standards are the systematized nomenclature of medicine clinical terms and logical observation identifier names and codes standards for health information technology to protect electronic health information created maintained and exchanged for example one standard is any encryption algorithm identified by the National Institute of Standards and Technology and ist as an approved security function in annex of the federal information processing standards Phipps publication 140 - - another example is a hashing algorithm with a security strength equal to or greater than sha-1 secure hash algorithm sha-1 as specified by the NIS t in fib 180 - three-page 44,000 650 slide 21 with more and more health care providers moving away from paper-based to adoption of an electronic medical record with the ultimate goal of implementing an electronic health record it stands to reason a question one might ask is why aren't we there yet to answer that question the perspectives of health care providers and the public regarding acceptance of or issues with an EHR will be explored first from the standpoint of the provider EHR acceptance is on the rise throughout the health care community as more and more research supports the benefits far outweigh the costs regarding costs to implement monetary incentives have been put in place by the federal government to stimulate EHR adoption momentum for widespread adoption and implementation has picked up since the American Recovery and Reinvestment Act or ARRA was signed into law February 2009 ARRA provides many different stimulus opportunities one of which is nineteen point two billion dollars for health IT the health information technology for economic and clinical Health often referred to as hi-tech is a provision of the American Recovery and Reinvestment Act the funding is expected to assist providers and states in adopting and utilizing health IT in order to achieve widespread adoption of health IT and enable electronic exchange of health information providers have also begun to accept EHRs since the establishment of the certification Commission for health information technology or CCH IT with certification a certain comfort level exists with regards that the EHR purchased and implemented will have longevity and meet specific requirements in addition to CCH IT ONC authorized testing and certification bodies our Drummond group info Guard laboratories sli Global Solutions ICS a labs and sure scripts the American National Standards Institute ANSI has been approved as the ONC approved accreditor a a for the permanent certification program slide 22 as cited in the ihe moves EHR goals forward the public has mixed feelings about EHRs a national Harris Interactive survey found that 45% of adults believe that tools to track and maintain their own personal medical information with an EHR system are very important but they worry that computerization could increase rather than decrease medical errors and that federal health privacy rules will be reduced in the name of efficiency RS and a 2005 paragraph 9 slide 23 a more recent poll conducted by Harris Interactive 2010 online from June 8th through the 10th 2010 among 2035 US adults showed little change from 2009 to 2010 with regards to adults attitudes of electronic medical records 78% in both 2009 and 2010 answered strongly / somewhat agree that all physicians treating me should have access to information contained in my EMR seventy two and seventy one percent in 2009 and 2010 respectively answered strongly / somewhat agree that an EMR would be a valuable tool to track the progress of my health slide 24 even with the acceptance on the rise barriers still exist an editorial stimulating the adoption of health information technology describes barriers to adoption as their substantial cost the perceived lack of financial return from investing in them the technical and logistical challenges involved in installing maintaining and updating them and consumers and physicians concerns about the privacy and security of electronic health information Blumenthal 2009 each one of these has its own complexities for example logistical challenges would include resources issues training and Retraining resistance by potential users and development of new workflow processes the possibility of poor clinical system performance would impact provider productivity and also become a significant barrier to adoption privacy and security concerns include identity theft and widespread exposure of personal health information with the risk of it being seen by unauthorized personnel if it is sent electronically breaches through stolen laptops or hacking is also a concern another barrier to adoption is the perceived lack of return on investment to the practitioner slide 25 even though perceived or bonafide barriers do exist potential benefits to adopting and implementing EHRs are surfacing with respect to having an effect on patient care safety they include reducing the need to repeat tests reducing the number of lost reports and supporting provider decision making slide 26 eh ours also have an effect on efficiency by improving accessibility of patient information for example being able to access reports anytime anywhere integrating data from multiple internal and external sources for example improving charge capture and facilitating coordination of healthcare delivery for example no need to retrieve and copy paper charts slide 27 the final effect of EHR adoption and implementation is on patient outcomes an EHR has the potential to improve the quality of patient care and help providers practice better medicine being a repository of individual health records that reside in numerous information systems and locations EHRs are intended to support efficient high quality integrated health care independent of the place and time of health care delivery an EHR also has the potential to provide seamless exchange of information among providers slide 28 this concludes lecture a of electronic health records this lecture defined an electronic medical record EMR and an electronic health record EHR and explained their similarities and differences identified EHR attributes and functions discuss the issues surrounding EHR adoption and implementation and describe the impact of EHRs on patient care