What is an EHR

1
EHR RoadmapWebEx
Stratis Health, the Minnesota Quality
Improvement Organization in partnership with
other QIOs, presents . .

• What is an EHR?

2
Presenter

• Margret Amatayakul
• RHIA, CHPS, CPHIT, CPEHR, FHIMSS
• President, Margret\A Consulting, LLC,
  Schaumburg, IL
• Consultant to Stratis Health DOQ-IT Project
• Independent information management and
  systems consultant,
  focusing on EHRs and
  their value proposition
• Adjunct faculty College of St. Scholastica,
  Duluth, MN, masters program in health informatics
• Founder and former executive director of
  Computer-based Patient Record Institute,
  associate executive director AHIMA, associate
  professor Univ. of Ill., information services
  IEEI
• Active participant in standards development,
  HIMSS BOD, and co-founder of and faculty for
  Health IT Certification

3
EHR Roadmap
4
Objectives

• Recognize how strengths and weaknesses of
  paper-based medical records contribute to
  interest in and challenges regarding EHR
• Describe the concept of EHR and outline its
  benefits
• Understand how differences in processes and work
  flow require differences in EHRs for ambulatory
  care (clinics) and acute care (hospitals), yet
  also require interoperability
• Recognize key functions of an EHR for ambulatory
  care
• Appreciate the complexity of EHR design,
  implementation, and maintenance needed to achieve
  an intuitive and highly powerful system

5
What is an EHR?

• Influence of
• Paper-Based Medical Record Strengths and
  Weaknesses
• on EHR

6
Strengths of Paper Records

• Familiar
• Portable, can be carried to point of care (POC)
• Once in hand, they do not experience downtime
• Allow flexibility in recording data, especially
  subjective, narrative information
• Easily browsed by flipping through pages
• These characteristics must survive in the EHR

7
Weaknesses Content

• Often missing, i.e., not filed yet or being used
  by someone else
• Often incomplete, e.g., a lab result has not yet
  been obtained in paper form
• Often illegible expensive to dictate and have
  transcribed
• Poorly written orders for the anti-diabetic
  medication AVANDIA (rosiglitazone) can look like
  COUMADIN (warfarin), both of which are available
  as 4 mg oral tablets!
• Paper records do not provide any additional
  knowledge, such as medication contraindications
• Sometimes inaccurate (because documentation is
  put off)
• Generally not reflective of treatment rationale
• Lack of standard data definitions devalue their
  subsequent use for quality review
• Rarely are longitudinal

8
Weaknesses Format

• Can be organized in only one way at a time
• Can only be used by one person at a time, which
  often results in missing charts
• Data is static and cannot be processed with out
  abstraction (e.g., creating a lab summary from
  individual lab results)
• Records become voluminous, with lessening ability
  to review content
• There are no established forms standards, so all
  records look different

9
Weaknesses Confidentiality and Security

• While records stored in a chart room are pretty
  secure, once removed they can be easily lost,
  stolen, or otherwise left unsecured. Photocopies
  of paper records can be made easily/often are not
  destroyed
• While record processing procedures require a
  reason to retrieve a chart, there are no access
  controls to restrict people without a need to
  know from viewing data, or controlling access
  once it leaves the confines of the record
  custodian
• Because patients change their names or go by
  different names, multiple records may have to be
  reviewed to determine which is the right record
  (potentially compromising confidentiality
  of the other patients)
  
• There are no back ups of paper records
  once they are gone, they are
  gone forever

These issues must be overcome
10
Ownership is NOT an Issue

• State statutes, licensure regulations, or the
  courts generally hold that a provider owns the
  physical records created by the provider in
  delivering care to patients,
• Subject to the patients limited interest in the
  information contained in the record
• Medical records are the business records of the
  organization that compiles them. They
• Represent what was learned about the patient and
  what procedures were performed should the record
  be required in a court case
• either representing the patients interests in a
  third party lawsuit, or
• representing the organization in a suit brought
  about by the patient against it

11
Duality of Interest

• The Health Insurance Portability and
  Accountability Act of 1996 (HIPAA) establishes
  that a provider or health plan is permitted to
  use or disclose protected health information
  (PHI)
• To the individual patient
• For Treatment, Payment, and healthcare Operations
  (TPO)
• Incident to a use or disclosure
• Pursuant to authorization from patient
• Pursuant to patient being given an opportunity to
  agree or object, including inference based on
  professional judgment
• Required by law

12
Individual Rights

• HIPAA also requires individuals be given notice
  of privacy practices (NPP) outlining how their
  information will be used and disclosed, and
  identifying patients rights in the information
• In a clinically integrated care setting where
  individuals typically receive care from more than
  one provider, the providers may designate
  themselves as being an organized health care
  arrangement (OHCA)
• Patients rights to information in the medical
  record also include
• Access (i.e., view, copy)
• Request restrictions
• Request amendment
• Accounting of disclosures (except for TPO or as
  authorized

13
RHIO Model(Regional Health Information
Organization)
A record locator service identifies where
patient records exist and affords access to
legitimate users for TPO because a RHIO could be
an OHCA under HIPAA
14
What is an EHR?

• Conceptual Model of EHR

15
EHR Purposes

• Improve quality of care data availability
  links to knowledge sources
• Enhance patient safety context-sensitive
  reminders/alerts, clinical decision support,
  automated surveillance, disease management,
  drug/device recall
• Support health maintenance, preventive care, and
  wellness patient reminders, summaries, tailored
  instructions, home monitoring
• Increase productivity data capture and
  reporting formats tailored to user, streamlined
  workflow support, and patient-specific care plans
  and protocols.
• Reduce hassle factors/improve satisfaction for
  clinicians, consumers, and caregivers managing
  scheduling, registration, referrals, medication
  refills, work queues, and automatically
  generating administrative data.
• Support revenue enhancement accurate and timely
  eligibility and benefits, cost-efficacy analysis,
  clinical trial recruitment, rules-driven coding
  support, accountability reporting/outcomes
  measures, and contract management.
• Support predictive modeling and contribute to
  development of evidence-based healthcare
  guidance.
• Maintain patient confidentiality and exchange
  data securely among all key stakeholders.

16
Conceptual Model of EHR
CDSS
(Redundant) Processor(s)
Human-computer interface
17
(No Transcript)
18
Important Distinction
CDR
CDW

• Both are databases

• Optimized for
• Transactions relating to patient care
• Access lab results
• Enter order
• Post vital signs
• Record meds administered
• Etc.
• Often included in ambulatory EHR, separate
  component for acute care

• Optimized for
• Analysis relating to a population of patients
• Aggregate data to identify patterns
• Compare measures
• Data mining
• Predictive modeling
• Etc.
• Rarely included in ambulatory EHR, somewhat more
  frequent component for acute care

19
What is an EHR?

• Reality - in
• Ambulatory vs. Acute Care
• EHR

20
Reality in Ambulatory Care
LIS
PACS Images
PMS
Charges
External sources uses of data e.g.,
eRx
Operations
CDR
Fax
CDSS
Scanning
Processor
Human-computer interface
21
Reality in Acute Care
Other source systems
PACS Images
PIS
LIS
Other source systems
RIS
Operations
PFS
R-ADT
Charges
Interface Engine
EDMS
EMAR
CPOE
POC
CDR
CDW
Processor
Human- computer interface
Human- computer interface
22
Reality

• Acute care and ambulatory care are different
• Different processes and work flows
• Different sources and uses of data
• Different volume of data
• Vendors have designed EHRs for one of these
  markets
• Recognizing the need to address both markets,
  vendors have acquired or partnered with
  complementary vendors
• Such product suites are not necessarily
  integrated at all, and may only provide a free
  interface
• Vendors are beginning to recognize both the
  problems with the dichotomy, as well as the need
  for health information exchange (HIE), and are
  beginning to develop integrated suites, use
  repositories more, and use web services
  architectures

23
What is an EHR?

• Key Functions of EHR for
• Ambulatory Care

24
Login and Patient Snapshot
25
Physician In-Basket
26
Patient Summary Screen
27
Semi-Structured HP
April 4, 2005
28
Structured Note Template
29
Care Plan/Guidelines
04/12/2006
File Edit View Window Help
Jane Doe Patient

ID 99-88-77
Protocol Results

• Protocol Adult Females 18-39
• Female patients with an age of greater than
  18 years, and less than 40
• years should have the following
• Test Schedule Last Done Last Result Status
• - - - - - - - - - - - - - - - - - - - - - - - -
  - - - - - - - - - - - - - - - -
• TD BOOSTER Every 10 Y 10/16/1997 0.5 ml
  g. Due 10/06/2007
• PAP SMEAR Every 12 M 03/31/2004 Normal Due
  03/31/2006
• BREAST EXAM Every 12 M 03/30/2004 WNL Due
  03/30/2006
• CHOLESTEROL Every 5 Y 11/02/2003 146 Due
  11/02/2008
• BP DIASTOLIC Every 24 M 02/02/2005 80 Due
  02/02/2007
• BP SYSTOLIC Every 24 M 02/02/2005 120 Due
  02/02/2007

30
Results Review
Patient T. L. Smith Date
07/06/06 Time 1000 AM BASIC MET PANEL
ST. C Provider Lab Test
Value Unit H/L Range
Previous Previous Value
QST SPDOI 128
mmol/L L 137-145 01/12/06
140 QST POTASSIUM
8.2 mmol/L H
3.60-5.0 01/12/06 4.9
QST CHLORIDE 100
mmol/L 98-107 01/12/06
106 QST CO2
25 mmol/L
22-31 01/12/06 25


Close
Sign
Graph
Open Chart
I.M.
31
Instant Message
32
Prescription Writing and Warning
33
EM Coding Support
34
Retrieval of Scanned Documents
35
Generation of Reports
36
Quality Activities
37
Patient Instructions
38
Achieving EHR

• Right Data
• Data modeling
• Maintenance of data dictionary
• Controlled vocabulary
• Right Presentation
• Screen design
• Template building
• Right Decision
• Practice guidelines
• Up-to-date knowledge sources
• Software to perform analysis on data to fire
  rules correctly
• Accurate and complete data to support rules
• Right Processes
• Process mapping
• Process improvement
• Right Outcomes
• Data to support measures
• Ability to analyze data

39
Stratis Health is a non-profit independent
quality improvement organization that
collaborates with providers and consumers to
improve health care.
This presentation was created by Stratis Health
under a contract with the Centers for Medicare
Medicaid Services (CMS). The contents do not
necessarily reflect CMS policy.