Section 1.1 Adopt - Assess
                                          Vision and Strategic Planning
optimized to manage transactions for a given resident. For example, a CDR may enable
               the development of a g...
8. Telehealth, personal health records (PHR), and health information exchange (HIE)
             services are yet other fo...
Conceptual Model of EHR
      This diagram illustrates the
      many HIT components
      described above. While this
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1.1.6 HIT Vision and Strategic Planning doc.doc

  1. 1. Section 1.1 Adopt - Assess Vision and Strategic Planning for HIT in Nursing Homes (see accompanying handouts and Webinar) Health information technology (HIT) refers to the broad class of information technology that aids health care organizations in achieving efficient and effective care delivery. Electronic health record (EHR) refers to the specific application of HIT to capture data at the point of care and use it in making clinical decisions. All HIT encompasses software applications and hardware, as well as requisite people, policies, and processes. Software Applications Within HIT are many types of information system applications. In general, these include: 1. Financial, administrative systems include at a minimum, resident registration-admission, discharge, transfer (R-ADT) and billing systems. R-ADT includes the ability to maintain an index to all residents you have treated; document their demographic, contact, and insurance information; and manage the census of current residents, and other associated functions. Billing systems will support charge capture, accounts receivable, collections, trust accounts, general ledger, accounts payable, etc. 2. Departmental, or ancillary, systems support the operations of various departments or types of staff. For a nursing home, these may include a clinical laboratory information system (LIS), radiology information system (RIS), nutrition and food services (N&FS), therapy department systems (e.g., rehabilitation, physical therapy, occupational therapy, speech and language therapy, respiratory therapy, and others), human resources, time and attendance, staffing, materials management/ procurement, and executive decision support. The minimum data set (MDS), if it is a standalone software system, may be treated as an ancillary system. Some nursing homes may also have health information management (HIM) functions that are automated, such as a master person index if not included in the R-ADT module, dictation/transcription and electronic signature, encoder, chart tracking, and deficiency analysis. 3. Clinical information systems support health care professionals in direct care delivery. When these clinical systems work together, they are often described as an electronic health record (EHR) system. Clinical information systems in nursing homes may be all inclusive in a single suite of functions, or may be several distinct modules (which may not necessarily be implemented in a specific sequence). A suite of applications for nursing documentation may include nurse assessments, interdisciplinary care plans, clinical pathways, vital signs documentation, and workflow support. More-sophisticated clinical systems depend on significant connectivity with the departmental systems. These typically include computerized provider order entry (CPOE) and electronic/barcode medication administration records (EMAR/BC-MAR). Although clinical decision support (CDS) is generally included in CPOE and EMAR applications as relating to medication management, more sophisticated CDS and point-of-care (POC) charting for providers are applications that frequently are implemented after most others. 4. Clinical data repository (CDR) is the means by which data from the various applications come together for various forms of processing. A CDR is essentially a database that is Section 1.1 Adopt – Assess – Vision and Strategic Planning for HIT in Nursing Homes- 1
  2. 2. optimized to manage transactions for a given resident. For example, a CDR may enable the development of a graph showing a resident’s vital signs in comparison to medication administration. Clinical decision support is greatly enabled by a CDR. For example, when an order for a drug for a given patient is placed via a CPOE application, the order (a transaction) is placed in the CDR. In the CDR, the ordered drug is compared with drug knowledge information and maybe the patient’s lab results. (The patient’s lab results have been entered into the CDR by the laboratory information system, also considered a transaction.) If the drug being ordered is contraindicated for poor liver function and if the lab results for the specific patient for whom the drug is ordered indicate poor liver function, an alert will display stating a potential contraindication. The alert may also suggest a lower dose, alternative drug, or closer monitoring, as applicable. The ordering provider may accept the recommendation (this is another transaction), and the finalized prescription is then transmitted to a pharmacy. The recommendation may also be rejected, in which case the original prescription is transmitted to a pharmacy. The ordering provider may be asked by the CPOE application to identify the reason for the rejection, which then is another transaction held in the CDR as part of the resident’s EHR. Some EHR vendors fully integrate their clinical components with a data repository. This is generally true for nursing home EHR vendors, though not necessarily all do this. Many nursing homes acquire all their applications from a single vendor that provides a well- integrated solution via a clinical data repository structure, which may not be evident as it operates behind the applications. If you have to buy different applications from different vendors, you may be faced with also buying a clinical data repository or managing multiple interfaces between the applications. Although a clinical data repository is primarily designed to integrate discrete data, some repositories also include pointers to documents and images. 5. Electronic document management system (EDMS) is often used where a bridging strategy is needed to achieve a paperless environment during the time clinical systems are being implemented. EDMS allows document scanning and indexing to archive documents until all data collection aspects of the health record are automated. Later EDMS supplements the EHR when external documents are received in paper or digital form (e.g., email, e-fax, or digital dictation). 6. Portals are another important application to connect different providers to one another, such as physicians to your home, or your home to a hospital or multiple hospitals. In general, a portal is a Web interface that serves as a secure door to related sets of data and services. For example, a physician from a home or office may gain access to the nursing home’s EHR and obtain resident vital signs and enter orders. Patient portals allow a resident or family member to complete intake forms and perform other functions. 7. Data warehouse is also a database, but one that has been optimized to collect and manage data on which complex queries and analysis, such as data mining, can be performed. Such databases may also be called translational or analytical databases. While you can do some analysis and reporting from any database, including the databases in individual applications or the CDR, very complex analyses on large quantities of data will significantly slow down the system in performing its operations. Most nursing homes contribute data to external data warehouses, such those as held by the Centers for Medicare & Medicaid Services (CMS), their corporation, or various other payers, quality registries, etc. Section 1.1 Adopt – Assess – Vision and Strategic Planning for HIT in Nursing Homes- 2
  3. 3. 8. Telehealth, personal health records (PHR), and health information exchange (HIE) services are yet other forms of HIT which are rapidly evolving and being adopted by large and small health care delivery organizations. Many hospitals use services for remote reading of x-rays. Many small and rural communities have extensive telehealth implementations, connecting to their closest tertiary care facility or to reach out to very remote areas for patient monitoring and to supplement care delivery. Nursing homes will certainly find using a referral management system that reaches out to a variety of other organizations to be advantageous. PHR are just starting to be recognized as important adjuncts to health care delivery. CMS is developing a PHR system for Medicare beneficiaries to keep track of their medications. Several health plans (including a number of Blue Cross Blue Shield plans) also are doing this. The U.S. Department of Veterans Affairs has created myHealtheVet, a PHR systems for veterans. Some vendors are supplying various forms of PHRs, from patient-friendly summaries of care to access to lab results and even self-administered medical history systems that reduce the documentation burden for providers. Many families of chronically ill patients or elderly residents in nursing homes find that PHR is the only way they can keep track of all the medications, physician visits, etc. 9. Middleware is a final type of software that is important to include in HIT. While often not a concern to end users, various report writing applications, presentation layer utilities, interfaces, database management systems, and other software is required to make all of the end-user applications work. Hardware Of course, information system applications require computer hardware. Hardware includes the various processing devices and servers to run the applications. If you are using a hosted application, application service provider, software as a service (SaaS), or an on-demand application, you will need to acquire servers in house. Otherwise, the vendor maintains these and you pay a monthly fee for their use. Data entry requires various input devices (e.g., desktop computers, tablets, personal data assistants [PDAs], speech microphones, etc.) and output devices (monitors, display screens, printers, fax machines, speakers, etc.); they are all hardware elements you will need to purchase. Data also must be archived, so storage functionality is needed. Again, this may be part of your remote hosting, or something you need in-house. This may include various forms of storage devices, each with their associated media (such as magnetic disks, optical disks, flash drives, etc.). Various storage area networks and storage management systems are used to manage large volumes of archived data. As the HIT becomes more mission critical, backup storage and redundant processing devices are necessary, often with middleware applications to provide automatic failover. All of these devices must connect to one another in a network, so various network devices and their associated media (including various forms of cable for wired networks and wireless network capability) must be acquired and maintained. If you are using any form of hosted application, your network capabilities will be critical. You must have sufficient speed and bandwidth, and have some form of redundancy, or backup, in the event your primary network connection fails. For instance, you will very like need a T1 line from the telephone company, but you also may keep a DSL account for emergencies. Section 1.1 Adopt – Assess – Vision and Strategic Planning for HIT in Nursing Homes- 3
  4. 4. Conceptual Model of EHR This diagram illustrates the many HIT components described above. While this diagram may seem overwhelming, recognize that as clinical computing requirements are addressed, the complexity of applications, technology, and operational elements to support them increase in complexity, as do the capabilities for use of the resultant information and knowledge. For support using the toolkit Stratis Health  Health Information Technology Services 952-854-3306  Copyright © 2009, MargretA Consulting, LLC. Used with permission of author. This toolkit was funded by Aging Services of Minnesota and its subsidiary, Alliance Purchasing for use by nursing homes in Minnesota. Produced by Stratis Health. Section 1.1 Adopt – Assess – Vision and Strategic Planning for HIT in Nursing Homes- 4