1. COmPUTER INFORMATION SYSTEMS AND THE ELECTRONIC HEALTH RECORD Meeting at intersection of technology and life Team 2

2. CIS & ehr: A love story Paper-based records have been in existence for centuries and are rapidly being replaced by computer-based records. Health systems, insurance companies and the Federal government are jumping on board to this newest development to help expedite patient care through the electronic medical record systems or EHR. EHRs are at the center of any computerized health information system.

3. Clinical Information System This is a “technology based system that is applied at the point of care and is designed to support the acquisition and processing of information as well as providing storage and processing capabilities” (Mastrain and McGonigle).

4. What is CIS? “CIS or Clinical Information System is a collection of various information technology applications that provides a centralized repository of information related to patient care across distributed locations.” CIS makes patient information such as medical history, charting, and physician instruction and plan of care easily accessed. (McGonigle and Mastrian, 2009)

5. Key players in choosing CIS “critical need for the end users to be intimately involved in choosing and/or developing the CIS.” Anyone that will use this system needs to give input to people choosing the system, such as nurses, PCA’s, physicians, lab workers, social workers, etc. Key players in choosing the CIS are usually involved in implementing and revising the system as well.(McGonigle and Mastrian, 2009)

6. Who should implement CIS? Whoever is involved in implementing CIS needs to “pay attention to the human-technology interface.” “Implementation should involve those who work with patients to improve the interface, accuracy, and security.” A team of people who are familiar with all aspects of the process of patient care. (McGonigle and Mastrian, 2009)

7. Who should revise the CIS? Executive, medical staff, clinicians, system administrator, project manager, tech support, educators, and anyone that accesses the system. Input from all the key players that use the CIS daily is key to having a successful CIS for your organization. (McGonigle and Mastrian, 2009)

8. So how do you choose? All clinicians should be involved in the selection process. This includes lab, pharmacy, radiology, nursing, and physicians (Ciott and Swab, 2010). Users can attend trade shows, vendor promotions, and investigate on the internet to select the proper CIS for their area (Clopas, 2010). Clopas also suggests checking out social networking sites to see other healthcare professionals’ opinions of various systems, perhaps getting information vendors may not disclose (2010)

9. Choosing a CIS Due to the new stimulus plan, Centers for Medicaid and Medicare Services will provide reimbursement for healthcare providers who become “meaningful users” of “certified EHR technology”. $19 billion has been allocated for these financial incentives (Murphy, 2010). Therefore, the facility would probably like to choose a system that meets these standards of “meaningful use”.

10. Choosing a CIS It is “increasingly essential to the success of today’s health care reform movement that informatics nurses are involved in every aspect of selecting, designing, testing, implementing, and developing health information systems” (Murphy, 2010). Healthcare providers need to be careful to choose programs appropriate to the size of the facility, instead of getting caught up on cost. Higher cost doesn’t always equal best performance for one’s facility.

11. Cost First tier of vendors (less than 100 beds): Expect to pay $1-$2 million spent on hardware, software, and implementation, then around $100,000 a year on maintenance fees. This tier is made for a smaller hospital with only one full time IT person (Ciotti and Swab, 2010). Second tier (100-300 beds): Expect to pay $3-$10 million on hardware, software, and implementation fees, then another $200,000 to $300,000 per year for maintenance. Third tier (300+ beds): Expect to pay $10 million to $1 billion dollars for hardware, software, and implementation, then around $1 million per year for maintenance. These hospitals usually have an entire IT department with at least 100 full time employees, and informaticists who work alongside the nurses (Ciotti and Swab, 2010).

12. Other Cost Considerations Hospitals should avoid systems made for larger hospitals, because more money would have to be spent hiring IT personnel and possibly informaticists. Additionally, travel cost of the vendor to come to the hospital can be up to “six figures”, and training for personnel can be “thousands per trainer” (Ciotti and Swab). There are also file conversion fees and other required interfaces (Ciotti and Swab).

13. Remember, “the proposal of earning a few million dollars in government incentives for demonstrating meaningful use of such systems should be placed in perspective of the total cost of these systems” (Ciotti and Swab).

14. The clinical decision making system in a CIS – How should it be structured? The greatest tool to increase the standard of care, reduction of practice pattern variation, successful diagnosis, and correct care path choice will result from the clinical decision support domain of the clinical information system. Clinical decision support software offers the possibility to improve the quality and reduce the cost of care by influencing medical decisions at the time and place that these decisions are made. Clinical decision support systems are intended to receive patient data and utilize that data to propose a series of possible diagnoses and a course of action. It would alert physicians when results are returned from data entry of lab and the data attained can be compared to the general population to indicate whether the data is within the normal limit or may require further analysis A physician may also enter a possible diagnosis into the system and then receive feedback from the system regarding the plausibility of such a diagnosis being true. A clinical decision support system can recognize drug-drug interaction and patient complications that would otherwise be unrecognized by the physician to provide a valid, efficient, and “best practice” solution to the patient diagnosis process.

15. How often should it be updated with new EBP guidelines? The system has to be updateable to constant changes that accompany the scientific development that is a result of the extensive research.

16. Any companies out there that design clinical decision making systems for the CIS? Numerous clinical information system vendors have developed such decision support systems, including; HBOC, IBM, Siemens Medical Systems, and Health VISION. These systems have been implemented within numerous care delivery sites, including; Columbia-Presbyterian Medical Center, JFK Medical Center, Ohio State University, and Meridian Health Systems.

17. Education Users are generally educated on new systems by employees of the vendor who are hired to educate. Also, coworkers may go to classes to learn new systems, and are then in charge of educating others in classes set up by the hospital. Like all computer systems, a CIS must be updated. Users should be educated with each update to learn what is new or what has changed. This can be done in classes or by competencies demonstrated through email or scheduled competency demonstration times.

18. Education All new employees must be educated on the CIS system. At some places, emails of updates are sent by educators, and a receipt confirming the coworker has read the update is returned to the educator.

19. Safeguarding our patient’s information:Back Up/Storage of Data Healthcare systems need to be vigilant in the way that they secure information and manage network security. The system needs to be backed up often in another area to store and keep the information safe. There should be a police clearly stating what data is confidential and how the data should be handled.

20. protection of files from viruses/worms/hackers The most common threat to a network is hackers, worms and viruses. Either antivirus software or a hardware tool such as a proxy server will help fight against worms and viruses. Firewalls are a common tool used to protect networks. The examine incoming messages from the internet.

21. Who should have access? Intrusion detection systems block against hackers. Those allowed access to information should have their user name and password. Passwords are enforced to be strong, which could include numbers and symbols, and not be names or dates close to the individual. Individuals who have access should know not to use portable storage devices to store data because it can be taken out of the facility.

22. ethical considerations in design People should be aware of “shoulder surfing” or watching over someone’s back. It is a major way confidentiality is compromised.

23. HIPAA became the first national rules that enforce standards for health information to secure the privacy and confidentiality of patients. HIPPA provides the patient with a greater access and control over their protected health information (PHI).

24. ELECTRONIC HEALTH RECORD

25. Electronic Health Record (EHR)- a computer-based data warehouse or repository of information regarding the health status of a client, replacing the former paper-based medical record; it is the systematic documentation of a client’s health status and health care in a secured digital format, meaning It can be processes, stored, transmitted, and accessed by authorized interdisciplinary professionals for the purpose of supporting efficient, high quality health care across the client’s healthcare continuum.

26. EHR & ITS COMPONENTS Health Information and Data- is the patient data required to make sound clinical decisions including demographics, medical and nursing diagnosis, medication lists, allergies, and test results(IOM, 2003). Results Management- is the ability to manage results of all types electronically, including laboratory and radiology procedure results, both current and historical (IOM, 2003). Order Entry Management-is the ability of a clinician to enter medication and other care orders, including laboratory, microbiology, pathology, radiology, nursing, supply orders, ancillary services, and consultations directly into a computer (IOM, 2003). Decision Support- is the computer reminders and alerts to improve the diagnosis and care of a patient including screening for correct drug selection and dosing, medication interactions with other medication, preventive health reminders in areas such as vaccinations, health risk screening and detection, and clinical guidelines for patient disease treatment (IOM, 2003).

27. Electronic Communication and Connectivity- is the online communication among healthcare team members, their care partners, and patients including e-mail, Web messaging, and an integrated health record within and across setting, institutions, and telemedicine (IOM, 2003). Patient Support- is the patient education and self-monitoring tools, including interactive computer-based patient education, home telemonitoring, and telehealth systems (IOM, 2003). Administrative Processes- are the electronic scheduling, billing, and claims management systems including electronic scheduling for inpatient and outpatient visits and procedures, electronic insurance eligibility validation, claim authorization and prior approval, identification of possible research study participants, and drug recall support (IOM, 2003). Reporting and Population Health Management- are the data collection tools to support public and private reporting requirements including data represented in a standardized terminology and machine-readable format (IOM, 2003).

28. Protecting health records It is generally accepted that the information maintained in an EHR should only be accessible by physicians and healthcare providers, who have a “need to know.” Due to the ubiquitous nature of the EHR it becomes more challenging to define which individuals should have access to what information and how security protocols should be utilized to limit individual access. Whether through privacy legislation or the common law, patients should have a right of access to their personal health information and a right to ensure that their information remains confidential. The CIS and EHR come together by taking control of digital health data, trying to improve healthcare quality and lower costs. They have worked hard to try and establish a digital exchange of data, personal records related to billing and services, health system data such as inventory, productivity, and accessibility.

29. In closing….. Information technology promises many benefits to healthcare. By helping to make accurate information more readily available to providers, payers, administrators, researchers and patients, advanced computing and communications technology can help improve the quality and lower the costs of healthcare (“For the Record,” 1997).

30. References Ciotti, V. & Swab, J. (2010). What to consider when purchasing an EHR system. Healthcare financial management, 64(5): 38-41. Cinhal plus with Full Text. Clopas, P. (2010). Digital delimma: Experts provide tips on purchasing electronic health records. Health Management Technology, 31(6): 12-14. Cinhal Plus with Full Text. Farukhi, F. (2010). Clinical decision support systems. Retrieved from http://www.cwru.edu/med/epidbio/mphp439/Clinical_Decision.htmhttp:// www.cwru.edu/med/epidbio/mphp439/Clinical_Decision.htm For the Record, Protecting Electronic Heatlh Information. (1997). In NetLibrary. Retrieved from http://eagle.sbuniv.edu:2086/Reader. Mastrian, K. & McGonigle, D. (2009). Nursing informatics and the foundation of knowledge. Jones and Bartlett: Sudbury, MA. 193-197. Murphy, J. (2010). The journey to meaningful use of electronic health records. Nursing Informatics, 28(4): 283-286. Cinhal Plus with Full Text.