HIS and EHR HIMA 4160 Fall 2009 Acronyms

HIS and EHR HIMA 4160 Fall 2009

Acronyms HIS: Health Information Systems EHR: Electronic Health Records EMR: Electronic Medical Records HIMA 4160 Fall 2009 11/2/2020 2

Data, Information, and Knowledge Level of conception. Data – factual Information – meaning of data Knowledge – model for information HIMA 4160 Fall 2009 11/2/2020 3

Example Data – Body temperature 103 Information – The patient is having a fever Knowledge -- The knowledge used to generate the information: if a patient temperature is > 100 F, he might a fever (or hyperthermia). HIMA 4160 Fall 2009 11/2/2020 4

Data Information Knowledge Concrete Abstract Factual Conceptual Volatile Stable HIMA 4160 Fall 2009 11/2/2020 5

Information System General term cover all three levels Database – data level Information storage and retrieval system – information level Knowledge system – knowledge level HIMA 4160 Fall 2009 11/2/2020 6

Components Information System HIMA 4160 Fall 2009 11/2/2020 7

Where is the information system located? In-house – developed and managed in the health care organization Shared – developed and managed at the vendor site Turnkey system – developed by vendor, installed and managed by health care organization Stand-alone – lack of information sharing. Legacy system. HIMA 4160 Fall 2009 11/2/2020 9

Trends of Health care Information Systems Integration Continuality Standards Consumer oriented HIMA 4160 Fall 2009 11/2/2020 10

HIMA 4160 Fall 2009 11/2/2020 11

Current applications of information systems in health care Clinical information systems – serving clinical activities ◦ ◦ ◦ ◦ Hospital information system Patient monitoring system Nursing information system Laboratory information system Pharmacy information system Computer based patient record Others HIMA 4160 Fall 2009 11/2/2020 12

Hospital Information Systems Provide communication among health facility workers and support organizational information needs for operations, planning, patient care, and documentation. Communication, coordination Various across different hosptials HIMA 4160 Fall 2009 11/2/2020 13

Freidman and Martin Model HIS should have following functions Central application Business and financial function Communications and Networking Department management Medical documentation Medical decision support HIMA 4160 Fall 2009 11/2/2020 14

Core hospital function Patient management ◦ Scheduling ◦ RADT (registration, admission, discharge, and transfer) ◦ RADT provides basic patient information to other clinical systems. HIMA 4160 Fall 2009 11/2/2020 15

Business and financial functions Payroll General ledger Accounts receivable Insurance HIMA 4160 Fall 2009 11/2/2020 16

Communications and Network Connect different systems. Need data standards to communicate. This is a disadvantage of paper based system. HIMA 4160 Fall 2009 11/2/2020 17

Departmental management system Needs of individual department Pharm, lab, radiology, dietary, pathology, etc The trend is to integrate these systems while maintaining their functional independence. HIMA 4160 Fall 2009 11/2/2020 18

Medical documentations system Medical record Will be paperless Provide support to managerial and administrative decision making In order to do so, the medical record has to be digitalized and codified. HIMA 4160 Fall 2009 11/2/2020 19

Decision support system Help clinicians make decision Not replace clinicians data from various sources – hard to managed by human Often integrated into physician order entry system focal role in decreasing medical errors HIMA 4160 Fall 2009 11/2/2020 20

Patient monitoring system Physiological data Emergency room, operating room, intensive are, critical care Can give real time alert HIMA 4160 Fall 2009 11/2/2020 21

Nursing information system Support nurse care process Clinical and managerial HIMA 4160 Fall 2009 11/2/2020 22

Laboratory Information System Associated with lab test Usually already available in the instrument Various types of lab tests have different demands HIMA 4160 Fall 2009 11/2/2020 23

Pharmacy Information System Data related to drug usage for patient Also can help decreasing medication errors HIMA 4160 Fall 2009 11/2/2020 24

Computer based patient record IOM 1991 report first proposed the concept Other names include electronic health record (EHR), electronic medical record (EMR). It is not a single computer product or program Based an changed model of managing patient data Computer and information technology is necessary but not sufficient factor. HIMA 4160 Fall 2009 11/2/2020 25

Current status Focus on integration Government support ◦ http: //www. cnn. com/2004/ALLPOLITICS/04/27/b ush. healthcare. ap/ ◦ National Health Information Infrastructure ◦ ARRA Standardization ◦ HL 7 HIMA 4160 Fall 2009 11/2/2020 26

Administrative and Management Applications in Health care Financial information system Accounting information systems Human recourse management information systems Material management information system Facilities management information system Management planning and decisin support system HIMA 4160 Fall 2009 11/2/2020 27

Trends in Health Information System Computer based patient record ◦ National health information infrastructure ◦ Medical errors E-Health and e-HIM ◦ Web based technology Standards Privacy and Security Technology ◦ Wireless ◦ Voice recognition ◦ Data warehouse and data mining Enterprise information management Virtual information system – results of integration, standardization, and personalization. HIMA 4160 Fall 2009 11/2/2020 28

Electronic Health Records (EHR) HIMA 4160 Fall 2009 11/2/2020 29

What is an Electronic Health Record? Before we answer that, what is a patient record? • commonly referred to as the patient's chart or medical record • amalgam of all the data acquired and created during a patient's course through the heath care system HIMA 4160 Fall 2009 11/2/2020 30

Purpose of a Patient Record "to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions" Reiser, S. (1991). The Clinical Record in Medicine. Part 1: Learning from Cases. Annals of Internal Medicine, 114(10): 902 -907 HIMA 4160 Fall 2009 11/2/2020 32

Purpose of Patient Records • create the basis for the historical data • support communication among providers • anticipate future health problems • record standard preventive measures • identify deviation from expected trends • provide a legal record • support clinical research and public health HIMA 4160 Fall 2009 11/2/2020 33

Weakness of the Paper Record System • Pragmatic and Logistical issues. • • • Can I find the data I need when I need them? Can I find the medical record in which they are recorded? Can I find the data within the record Can I find what I need quickly? Can I read and interpret the data once I find them? Can I update the data reliably with new observations in a form consistent with the requirements for future access by me or other people? • Redundancy and Inefficiency • Influence on Clinical Research HIMA 4160 Fall 2009 11/2/2020 35

Difference between Paper and Electronic Health Records Accessibility Legibility Adaptive Structure Reusability Flexibility HIMA 4160 Fall 2009 11/2/2020 36

Value of an EHR is determined by Comprehensiveness of information Duration of use and retention of data Degree of structure of data Ubiquity of access HIMA 4160 Fall 2009 11/2/2020 37

Influences on EHR Disease Pattern Change Health Care Delivery System Change Specialization of Medicine Advances of Computer and Information Technology HIMA 4160 Fall 2009 11/2/2020 38

Primary and Secondary Uses of an EHR Primary Uses Second Uses ◦ ◦ ◦ ◦ ◦ Patient Care Delivery Patient Care Management Patient Care Support Processes Financial and Other Administrative Processes Patient Self-Management Education Regulation Research Public Health and Homeland Security Policy Support HIMA 4160 Fall 2009 11/2/2020 39

Core Functionalities Health Information and Data Results management Order entry/management Decision support Electronic communication and connectivity Patient support Administrative processes Reporting and population health management HIMA 4160 Fall 2009 11/2/2020 40

Health Information and Data Key Data ◦ ◦ ◦ Problem list Procedures Diagnoses Medication list Allergies Demographics Diagnostic test results Radiology results Health maintenance Advance directives Dispositions Level of service HIMA 4160 Fall 2009 11/2/2020 41

Health Information and data Minimum Data Set (MDS) for nursing homes ◦ From CMS ◦ Support Long Term Care ◦ Current Version 3. 0 HIMA 4160 Fall 2009 11/2/2020 42

Health Information and Data Narrative (clinical and patient narrative) ◦ Free text ◦ Template based ◦ Deriving structures from unstructured text NLP ◦ Structured and coded Signs and symptoms Diagnoses Procedures Level of service ◦ Treatment plan Single discipline interdiscipline HIMA 4160 Fall 2009 11/2/2020 43

Health Information and Data Patient Acuity/Severity of Illness/ Risk Adjustment ◦ Nursing workload ◦ Severity adjustment Capture of identifiers ◦ People and roles ◦ Products/devices ◦ Places (including directions) HIMA 4160 Fall 2009 11/2/2020 44

Results Management Results Reporting Results notification Multiple views of data/presentations Multimedia support ◦ ◦ ◦ Laboratory Microbiology Pathology Radiology Consult HIMA 4160 Fall 2009 11/2/2020 45

Order Entry/Management Computerized provider order entry ◦ ◦ ◦ ◦ ◦ Electronic prescribing Laboratory Microbiology Pathology Radiology Ancillary Nursing Supplies Consults HIMA 4160 Fall 2009 11/2/2020 46

Decision Support Access to knowledge sources Drug alert ◦ Domain knowledge ◦ Patient education ◦ ◦ ◦ ◦ Drug dose defaults Drug dose checking Allergy checking Drug interaction checking Drug-lab checking Drug-condition checking Drug-diet checking HIMA 4160 Fall 2009 11/2/2020 47

Decision Support Other rule-based alert (e. g. , significant lab trends, lab test) Reminders ◦ Preventive services Clinical guidelines and pathways ◦ Passive ◦ Context-sensitive passive ◦ Integrated Chronic Disease Management HIMA 4160 Fall 2009 11/2/2020 48

Decision Support Clinician work list Incorporation of patient and/or family preference Diagnostic decision support Use of epidemiologic data Automated real-time surveillance ◦ Detect adverse vents and near misses ◦ Detect disease outbreaks ◦ Detect bioterrorism HIMA 4160 Fall 2009 11/2/2020 49

Electronic Communication and Connectivity Provider to provider Team coordination Patient-provider ◦ Email ◦ Secure web messaging Medical Devices Trading partners (external) ◦ ◦ Integrated medical record ◦ Within setting ◦ Cross-setting Inpatient-outpatient Other cross-setting ◦ Cross-organizational Outside pharmacy Insurer Laboratory Radiology HIMA 4160 Fall 2009 11/2/2020 50

Patient Support Patient education ◦ Access to patient education materials ◦ Custom patient education ◦ Tracking Family and informal caregiver education Data entered by patient, family, and/or informal caregiver ◦ Home monitoring ◦ Questionnaires HIMA 4160 Fall 2009 11/2/2020 51

Administrative Processes Scheduling management ◦ Appointments ◦ Admissions ◦ Surgery/procedure schedule Eligibility determination ◦ ◦ Insurance eligibility Clinical trial recruitment Drug recall Chronic disease management HIMA 4160 Fall 2009 11/2/2020 52

Reporting and Population Health Management Patient safety and quality reporting ◦ Clinical dashboard ◦ External accountability reporting ◦ Ad hoc reporting Public health reporting ◦ Reportable diseases ◦ Immunizations De-identifying data Disease registry HIMA 4160 Fall 2009 11/2/2020 53

EHR adoption Ambulatory (NEJM 2008) ◦ 4% fully functional EHR ◦ 13% basic system ◦ Small and solo practices struggle HIMA 4160 Fall 2009 11/2/2020 54

EHR Adoption HIMA 4160 Fall 2009 11/2/2020 55

Barriers Standardization of Clinical Information Cost of implementation and maintenance Physicians' readiness to adopt the EHR Privacy issues and patients’ concerns with information sharing. Legal liability HIMA 4160 Fall 2009 11/2/2020 56