EHR Chapter 1

Chapter 1

Overview of

Electronic Health Records

Chapter Topics

Distinctions between electronic medical records and electronic health records

Role of interoperability and computer protocols in facilitating communication between electronic health record systems

Federal regulations influencing the implementation of electronic health records

Benefits of electronic health record use

Barriers to electronic health record implementation

Current and future workforce considerations

Objectives

• Define the terms electronic medical record (EMR) and electronic health record (EHR) and understand their distinctions.

• Explain the concept of interoperability and its importance in the EHR environment.

• Define the terms syntactic interoperability level and semantic interoperability level.

• Define computer protocol and discuss the most common communication protocol, HL7.

• Describe the Health Information Technology for Economic and Clinical Health Act and the federal incentive programs for implementing EHRs.

• Understand the concept of meaningful use and identify its three main components.

• List and discuss the benefits and barriers to implementing EHRs.• List and discuss the evolving roles of the health information

manager in the EHR environment.

Electronic Health Records

• Historically patient records were paper-based

• U.S. is entering a new era in which electronic health record (EHR) use is expected from providers

• Incentive programs are in place to influence and expedite EHR implementation

• Beginning January 1, 2015, provider reimbursement will be reduced if EHRs are not used

• Rationale for EHR implementation includes: • Operational/administrative efficiency benefits• Improved patient outcomes• Enhanced population health

Electronic Health Records

• This image depicts the broad range of data collection, reporting, and sharing capabilities within EHRs

Electronic Medical Record v. Electronic Health Record• EMR and EHR are incorrectly used synonymously

• EMR • Electronic version of patient record for use within one facility• Is considered the legal record of care for that facility

• EHR• Contains patient information gathered from multiple EMRs• Is a longitudinal collection of patient information from multiple sources• Is considered interactive• Allows for interoperability with various health information systems

Checkpoint: Your Turn

A longitudinal collection of patient information from multiple sources is depicted in which of the following: • Electronic medical record• Electronic health record

True or false: Eventually, providers will see reducations to reimbursement if they opt to not use EHRs• True• False

Interoperability

• Interoperability is the ability of one computer system to communicate with another

• Six recognized levels of interoperability exist

Level of Interoperability Description

Level 0 Standalone system; no interoperability

Level 1 Infrastructure allowing for exchange of bits and bytes of data

Level 2* Syntactic interoperability introduces common data format for information exchange, but meaning of the data is not interpreted

Level 3* Semantic interoperability occurs, allowing the meaning of data to be shared and information interpreted

Level 4 – 6 The higher the level, the greater amount of data manipulation and conceptualization occurs

*Most focus on interoperability in EHRs is in relation to levels 2 and 3

Interoperability

• Research at the Virginia Modeling, Analysis and Simulation Center defined the hierarchy of interoperability and led to the development of Levels of Conceptual Interoperability Model in 2003

• The general concept of the six levels remains the same, but greater clarity is provided in the Model

Computer Protocols

• Computer protocol is a standardized method of communicating or transmitting data between two computer systems

• For EHRs to be useful and beneficial, all EMRs need to use standardized computer protocols, thus allowing for interoperability and data exchange

• Computer protocols allow for various systems to talk to one another

• The goal is for universal standards related to computer protocols be used in EMRs

• Health Level 7 (or, HL7) is the most commonly used computer protocol in the domain of EMRs and EHRs

• HL7 allows for seamless exchange of clinical and administrative data between various systems

• HL7 is developed and maintained by an organization of the same name, comprised of healthcare experts and information scientists

Computer Protocols

• This image depicts an example of HL7• Without standard use of HL7, a complex schema of protocols would exist, making

communication and interoperability impossible

Computer Protocols

• The U.S. Department of Health and Human Services is also developing Consolidated Health Informatics (CHI) standards; these are not required by law, but have been voluntarily adopted by agencies and vendors to allow for seamless interactions between industry, vendors, and the government

• Some of the CHI standards include the following:• HL7

• Institute of Electrical and Electronics Engineers 1073 (IEEE 1073)• Protocols related to medical devices

• Logical Observation Identifiers Names and Codes (LOINC)• Protocols related to clinical laboratory data

• Digital Imaging and Communications in Medicine (DICOM)• Protocols related to imaging results and related information

Computer Protocols

• The Office of the National Coordinator for Health Information Technology (ONC) supports various health IT endeavors in the U.S.

• The ONC is also concerned with universal protocols to allow for systematic information exchange

• One ONC effort is to establish a Nationwide Health Information Network (NwHIN)

• A NwHIN would allow for sharing of patient data from previous encounters and admissions at the point of care, regardless where in the country the patient is seen

• The concept of this type of information sharing relies on standardized computer protocols

Checkpoint: Your Turn

Which communication protocol relates to clinical laboratory data? • LOINC• HL7• DICOM• IEEE 1073

True or false: Consolidated Health Informatics standards are mandated by law• True• False

Federal Regulations

• EHR implementation and use in the U.S. recently became a legislative focus

• The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in February 2009

• The HITECH Act was funded via the American Recovery and Reinvestment Act (ARRA), which was signed into law by President Barack H. Obama

• This legislation allocated $19.2 billion dollars related to the following goals: • Establish incentive payment programs for providers and facilities that see Medicare and

Medicaid patients; allowing eligible providers and hospitals to receive incentive payments if they adopt certified EHR technology and depict usage in a meaningful way

• Create the Health Information Technology Extension Program, which provides support to small and medium sized physician practices with their goals of implementing EHR technology

• Establish national Health Information Technology Research Centers and Regional Extension Centers; these entities work together to identify and share best practices in the implementation of EHRs and serve as a resource to physicians and other providers

Federal Regulations

• Meaningful Use is a set of standards created by the Centers for Medicare and Medicaid Services (CMS)

• The Meaningful Use standards must be met by healthcare providers participating in the Medicare and Medicaid EHR Incentive Programs

• Meaningful Use consists of a three stage approach, consisting of these general goals:

Meaningful Use Stage General Focus

Stage 1 Standards focus on data capture and sharing

Stage 2 Standards focus on advancing clinical processes

Stage 3 Standards focus on improved patient outcomes

Federal Regulations

• Stage 1 of Meaningful Use was the first phase of the EHR incentive programs

• During 2011 – 2012 Stage 1 was first implemented

• Three main components of Stage 1 included:

1. Use of certified EHRs in meaningful ways, such as to e-prescribe

2. Use of certified EHRs to exchange health information to improve quality of care

3. Use of certified EHRs to report various quality indicators and measures

Federal Regulations

• The Medicare and Medicaid EHR Incentive Programs allow for participation from hospitals and eligible providers

• Eligible providers are specifically defined to depict eligibility to participate in the Medicare and Medicaid incentive programs

• Payments for the Medicare incentive program include up to $44,000/provider for up to five years

• Payments for the Medicaid incentive program include up to $63,750/provider for up to five years

• Medicare reimbursement will be reduced in gradual increments beginning in 2015 for providers not using EHR technology

Benefits of EHRs

• The transition toward EHRs has been a period of adjustment for providers

• Despite the learning curve associated with EHRs, EHRs are capable of producing a variety of benefits related to care processes, administrative efforts, and patient safety

• Three examples of benefits include:

1. Improved documentation

2. Streamlined and rapid communication

3. Immediate and improved access to patient information

Benefits of EHRs

• Improved documentation can occur when EHRs are effectively utilized; improved documentation depends on provider commitment to quality documentation

• In a paper-based environment, patient safety risks existed due to illegible physician handwriting

• Illegible handwriting was found in documentation such as progress notes, orders, prescriptions, and patient instructions

• EHRs provide various standardized options to capture documentation, thus eliminating handwriting from the record

• Documentation options in the EHR may include: • Typewritten entries (aka unstructured data )• Dropdown menus, check boxes, arial buttons

(aka structured data)• Scanning capability, when appropriate

Benefits of EHRs

• Easily decipherable clinical documentation is a necessary component of safe care

• Compare this progress note to the handwritten progress note to the on the previous slide

Benefits of EHRs

• EHRs can facilitate communication among providers

• Healthcare delivery involves a variety of providers; paper-based records do not allow for the record to be interactive, readily available for all users, and linked to communication devices

• Examples of EHR communication capabilities: • A physician orders lab work; when the

results are finalized, the physician can be automatically notified of available results via messaging

• When a radiology image becomes available, the ordering physician is notified via messaging and may have immediate access on their hand held device or computer to the film image and radiologist documentation

Benefits of EHRs

• EHRs allow for patient information to be readily available for providers

• In paper-based environments, access to medical records was dependent on the ability to locate where in a facility or clinic the record was stored and if the record was or was not already checked out or in use by another member of the healthcare team

• Value added elements of readily available EHRs include these examples:• Providers are able to view patient records from any secure location• When a medical report is completed, it becomes immediately available in the system in

draft or final status• Clinical documentation necessary for coding, billing, or other processes is immediately

available

Consider This: Discussion

Barriers to EHR Implementation

• Various stakeholders have a vested interest in the use of EHRs–this includes patients, providers, staff, payers, vendors, government, etc.

• Variables can influence personal comfort level with EHRs

• Some criticisms of this technology include: • EHR systems are expensive, and require a long-term financial commitment

• Because the use of this technology is relatively new in the U.S., concerns related to privacy and security of patient information exist

• Providers and health systems struggle with an inadequate applicant pool of potential employees to support implementation and training related to EHRs

• EHRs require modification of workflow and processes, which will not feel comfortable to all stakeholders

Checkpoint: Your Turn

Which of the following may be a benefit to implementing an EHR? • Less staff turnover• Improved documentation• Increased time for doctors to spend with patients

Which of the following may be barriers to EHR implementation? • Concerns related to long-term expenses• Concerns related to privacy and security of health information • Concerns related to workflow changes• All of the above are potential barriers to EHR implementation

Moving Forward

• While initial investment in EHRs seems great, the long-term result will produce savings if systems are leveraged to their potential• Savings include human life (i.e., reducing medical errors) and financial (i.e., conducting

administrative processes more efficiently)

• Privacy and security risks are legitimate concerns• Issues related to privacy and security, as well as concerns related to medical identity

theft, are a top priority for industry and government

• A continued need for qualified staff–in both provider and vendor settings–will be essential to long-term success• Students studying in areas related to health information management and technology

will remain in high demand

Consider This: Discussion

Evolving Roles in the EHR Environment

• According to the U.S. Bureau of Labor Statistics, a need for health information management (HIM) professionals will increase 20% by 2018

• American Health Information Management Association (AHIMA) is the premiere organization representing the HIM profession, with over 71,0000 members

• AHIMA offers various certification exams for HIM professionals; three are significantly valuable to employers in the EHR environment

RHIT: Registered Health Information Technician

(Associate’s Degree)

RHIA: Registered Health Information

Administrator (Bachelor’s Degree)

CHTS: Certified Healthcare Technology

Specialist

Evolving Roles in the EHR Environment • Health Information and Management

Systems Society (HIMSS) is another professional organization representing health IT professionals and software vendors

• HIMSS also offers a certification exam -Certified Professional in Healthcare Information and Management Systems (CPHIMS)

• The CPHIMS is a popular credential option for chief information officers or similar vice president level information executives in healthcare; approximately 37% of the nearly 2,000 professionals with the credential work on those capacities

Summary

• The road toward universal EHR adoption will be a long one, but the benefits are worth the effort

• EHRs support reliability and efficiency in clinical, administrative, and operational processes

• Exciting career opportunities for those interested in EHRs exist and will continue to exist

• Professionals in various capacities related to EHRs make an important contribution to patient care