MOS: Chapter 1 An Overview

The working definition for this textbook is as follows: -The portions of a patient's medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record.

Acceptable answers include: -Simultaneously accessible at multiple locations by multiple providers -Searchable by computer -Data are more likely to be standard medical terms -Capable of being transferred electronically to another system -Additional benefits realized from having codified EHR data: Health maintenance Trend analysis Alerts Decision support

-Health information and data -Result management -Order management -Decision support -Electronic communication and connectivity -Patient support -Administrative processes and reporting -Reporting and population health

•Capture data at the point of care •Integrate data from multiple sources •Provide decision support

• Electronic health records overcome the many drawbacks of paper records by offering improved legibility, and the ability to find, share, and search patient records. Multiple providers can see the same chart simultaneously; charts do not have to be transported from location to location. • Additional benefits from an EHR include trend analysis, alerts, health maintenance, and decision support that take the practice of medicine to levels that cannot be achieved with paper records.

Here is a summary of key differences: -Both workflows started with the patient calling for an appointment. -Astute students may point out that an alternative for some EHR offices is to allow scheduling over the Web; give extra points to those students. Paper: The night before the visit paper charts are pulled. -EHR: Pulling charts is not necessary; however, some EHR systems can automatically verify the patient's insurance eligibility. -Paper: The patient updates his or her history on a paper form. -EHR: The patient completes his or her medical history and reason for today's visit using a computer in a private area of waiting room. -Paper: The patient describes symptoms and reason for the visit to the nurse; vital signs are recorded in the paper chart by the nurse. The doctor enters and the patient repeats description of symptoms and reason for the visit. -EHR: The nurse reviews patient-entered data with the patient and edits for clarification if necessary. Vital signs can be electronically transferred from instruments into chart. •The clinician performs the physical exam and makes a clinical assessment and a plan of treatment. -Paper: The clinician makes a few notes and retains the observations and physical exam in his or her memory. -EHR: The clinician records the findings at the time of the exam or shortly thereafter; has access to previous problems and reviews those; makes the clinical assessment and plan of treatment. -Paper: The clinician handwrites prescriptions and orders, makes a note of them in the paper chart, and marks billing codes and diagnoses codes on the paper encounter form. The clinician creates the exam note from memory, either handwriting in the chart or dictating. -EHR: The clinician enters the findings directly into the EHR while the patient is still present. Orders create tasks for lab personnel to obtain a specimen, which is subsequently transmitted directly to the lab. •Prescriptions are written as part of the chart and transmitted to the pharmacy. -Paper: Dictated notes must be transcribed and subsequently reviewed and signed by the clinician and then filed in the paper chart. -EHR: When the exam is finished, the note is finished. A copy of the completed note can be printed and given to the patient with other patient education materials. Patient checks out. -Paper: Billing information is manually keyed into the computer from the encounter form. The codes circled by the clinician are only a best guess and may require a coding specialist to verify them. -EHR: The billing codes can be automatically calculated from the completed note and electronically transferred from the EHR into the billing system. -Paper: Results from tests are returned and the chart is pulled again. The doctor must review and sign the results, staff must notify the patient, and the chart must be re-filed. -EHR: Results received electronically are merged directly into the patient chart and immediately available for clinician review and patient notification.

Documenting a visit at the point of care ensures a more accurate record, provides the most benefits from the system, and allows the note to be completed before the patient ever leaves the office. •The clinician can sign the note immediately. Dictation time is saved and the need for personal dictation aides is eliminated. Patient care is improved because the patient can leave with a complete copy of the medical record, a step that stimulates compliance. •The delivery process is improved with point of care documentation because referrals can be accomplished with full information available at the time that the referral is needed.

-Medical specialization (patients no longer have just one doctor) -Increasingly mobile society (patients relocate and change doctors often) -Internet (patients are researching their conditions and demanding access to their own records) -New methods of diagnostic and preventative medicine require the ability to share exam records. -Health safety (deaths as a result of medical errors that could have been prevented by electronic records) -Employers (The Leapfrog Group) -Government initiatives

•Computerized Provider Order Entry or •Computerized Physician Order Entry

The Health Information Technology for Economic and Clinical Health (HITECH) Act authorizes CMS to pay incentives for providers to use a certified EHR.

The patient can leave with a complete copy of the medical record, and/or it stimulates patient compliance with the plan of care.

-Electronic results for better interpretation -Quicker recognition and treatment of medical problems -Reduces redundant testing -Improves care coordination among multiple providers.

►Started studies in 1991 that paved the way for EHR. At the technology evolved, the name has changed several times, but they all mean essentially the same thing - EHR. ►IOM outlined eight core functions that EHR should be capable of performing: • Health Information Data • Results Management • Order Management • Decision Support • Electronic Communication and Connectivity • Patient Support • Administrative Processing and Reporting • Reporting and Population Health ►Ideas from the Computer-based Patient Record Institute and the Health Insurance Portability and Accountability Act help us define EHR.

A defined data set including diagnoses, a medication list, allergies, demographics, clinical narratives, laboratory test results, and easy access to the information when the provider needs it.

Ability to access results of computerized reports whenever and wherever needed. - quicker access allows for quicker recognition and treatment of conditions - display of previous tests reduces redundancy and avoid additional testing - allows for better interpretation, ensuring appropriate follow-up - allows coordination amount multiples providers and between provider and patient

Computerized provider order entry (CPOE) eliminates lost order and ambiguities caused by illegible handwriting, generates related orders automatically, monitors duplicate orders, and reduces time required to fill orders - CPOE system reduces errors in dosage, frequency, allergies and interactions.

- Computerized provider order entry (CPOE) eliminates lost order and ambiguities caused by illegible handwriting, generates related orders automatically, monitors duplicate orders, and reduces time required to fill orders - CPOE system reduces errors in dosage, frequency, allergies and interactions.

- Computerized decision support systems help healthcare providers manage issues of prevention, diagnosis, drug prescriptions, and detection of adverse events and disease outbreaks. - Computerized reminders and prompts improve preventative practices in areas such as vaccinations, breast cancer screening, colorectal screening, and cardiovascular risk reduction.

E-communication can enhance patient safety and quality of care, especially for patients with multiple providers or service settings • E-connectivity is essential for creating and populating EHR systems • Secure e-mail and web messaging facilitate communication among providers and with patients, allowing for greater continuity of care • Automatic alerts regarding abnormal lab results reduce the time until treatment can be administered • E-communication is fundamental in creating an integrated health record

Computer-based patient education improves control of chronic illness, such as diabetes • Patients can use home devices to conduct home monitoring. Examples: spirometry for asthma, glucose monitors for diabetes, Holter monitors for heart conditions.

Electronic scheduling systems increase efficiency and provide timelier service to patients • Communication and content standards are important in billing and claims management • Electronic authorizations and prior approvals can eliminate delays and confusion; immediate validation of insurance eligibility results in more timely payments and less paperwork • EHR data can be analyzed to identify patients who are eligible for clinical trials or chronic disease management programs • Reporting tools support drug recalls

Public-and private-sector reporting requirements at the federal, state, and local levels and public health, are more easily met with computerized data. • EHRs eliminate the time consuming abstraction of data from paper records which reduces errors errors that occur in the manual process • They facilitate the reporting of key quality indicators used for the internal quality improvement efforts of healthcare organizations • Improve public health surveillance and timely reporting of adverse reactions and disease outbreaks

Another contributor to EHR systems; CPRI identified three key criteria for EHR: • Capture data at point of care • Integrate data from multiple sources • Provide decision support

In 1996 HIPAA strengthened the privacy of patient health records. The security rule broadened the definition of EHR. It protects all personally identifiable health information stored in electronic format.

EHR are the portions of a patient's medical/dental records that re stored in a computer system as well as the functional benefits derived form having an EHR.

The combination of several important reports brought public awareness to the benefits of EHRs. • Health Saftey - the IOM report pointed out that between 44,000 and 98,000 people die each year from preventable medical errors. Also, the errors cost $17 - $29 billion dollars a year. Often the errors result from a disconnection between a patients providers. • Health Costs - Rising costs health insurance programs prompted 150 employers to form the Leapfrog group. The goal was to tie the purchase of group health insurance benefits to quality care standards. Leapfrog also promoted CPOE as a means of reducing errors and adverse drug reactions. • Government Response - was positive beginning under Clinton. Congress gave $50 million to the Agency for Healthcare Research and Quality (AHRQ) to support a variety of efforts targeted at reducing medical errors. Bush established the Office of the National Coordinator for Health Information (ONC) under HHS to develop and direct implementation. Obama signed Health Information Technology for Economic and Clinical Health (HITECH) Act to promote adoption of EHRs and provide incentives to providers using EHR for a few years, then the penalties begin for providers who do not use EHRs.

Changes in the mobility of the population and in specialization of medical care, make it advantageous to have EHRs. Patients (customers) have become used to being able to access information on the internet and want to be able to do the same with their health records.

►Both paper and electronic providers' exam notes are documented using SOAP notes: • Subjective • Objective • Assessment • Plan ►Historically, a patients medical records were stored at each location where the patient was examined or treated. ►Paper records have drawbacks: • abbreviations or illegible handwriting • time-consuming to compile and fax records from one office to another • access to charts when patients receive care at a different branch of the same practice is inconvenient • paper records are difficult to search ►Improved legibility and the ability to find, share, and search patient records are strong points for EHR. Other advantages, like trend analysis, alerts, health maintenance, and decision support, are barely possible with paper records. ►EHR requires computers, software, and changes to the way providers work.

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►One way EHR systems improve accuracy and completeness of the patient \"chart\" is to record it at the time the interaction is happening. ►In a physician's office, point-of-care documentation means the SOAP notes are completed before the patient ever leaves the office. In an inpatient setting, the notes are completed at the patient's bedside instead of at the end of the shift. ►POC documentation is efficient, saves dictation time and eliminates the need for transcriptionists. Patient care is improved because the patient can leave with the complete copy of the medical record, which stimulates compliance. Referrals can be completed easily. These benefits lower the cost of healthcare.

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