HM311

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Introduction to Information Systems
for Health Information Technology
Chapter 9: Electronic Health Records
© 2020 American Health Information Management
Association

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Learning Objectives, 1
Create a development and implementation plan for an electronic
health record (E H R)
Explain the role of clinical vocabularies in the E H R
Support the need for and address issues related to the E H R

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Learning Objectives, 2
Educate the provider on benefits of the E H R
Identify the need for the multiple information systems required to
support the E H R
Support the need for the personal health record

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Electronic Health Records (E H R), 1
An electronic record of health-related information on an individual
that conforms to nationally recognized interoperability standards
Authorized clinicians and staff across more than one healthcare
organization can create, manage, and consult

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Electronic Health Records (E H R), 2
To Err Is Human: Building a Safer Health System
I O M now the National Academy of Medicine (N A M)
Advocated for use of health information technology (H I T) to help
prevent many mistakes that regularly occur in delivery of healthcare
and lead to injuries and deaths of tens of thousands of patients

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Health Information Technology (H I T), 1
Hardware
Software
Integrated technologies
Related licenses
Intellectual property

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Health Information Technology (H I T), 2
Upgrades/packaged solutions
Designed for or support use by healthcare facilities or patients for
electronic creation, maintenance, access, or exchange of health
information

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Electronic Health Records (E H R)
Longitudinal health record
• Permanent record
• Significant information listed in chronological order
• Maintained across time, ideally from birth to death
• Not be limited to the healthcare facility but be accessible remotely for
providers and consumer

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Electronic Medical Record (E M R)
Electronic collection of all patient’s health information and clinical
care
Stored, managed, and referred to by authorized members of single
healthcare facility
Much like the actual paper health record only in digital or electronic
form

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Interoperability, 1
Ability of different information technology systems and software
applications to communicate
Exchange data accurately, effectively, and consistently
Use the information that has been exchanged

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Electronic Health Record (E H R), 1
Reimbursement, diagnostic and procedural coding
Claims processing
Computerized provider order entry (C P O E) and results reporting
for laboratory, radiology, etc.
E-prescriptions sent to patient’s pharmacy
Medication management

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Electronic Health Record (E H R), 2
Population health reporting
Quality improvement activities
Clinical decision support
Healthcare facility administrative reports and analytics
Other additional authorized activities

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Source Systems
Information systems that capture and feed data into the E H R
Source systems include:
• Electronic medication administration record (E M A R)
• Laboratory information system
• Radiology information system
• Hospital information system
• Nursing information systems
• Not just clinical systems, but include administrative and financial systems

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Continuity of Care Record (CCR), 1
A core data set
Most relevant administrative, demographic, and clinical information
about a patient’s healthcare
Covers one or more healthcare encounters
Is not the minimum dataset for the E H R
Is information deemed most important for continued care of patient
who is transferred to or seen by another healthcare practitioner

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Continuity of Care Record (CCR), 2
ASTM International: Standards development organization
• Established a core data set defining the minimum requirements for the CCR
Data in CCR can be presented to care providers in
• Electronic format
• Extensible mark-up language (XML)
• Health Level 7 (HL7) International formats
• Paper format

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Continuity of Care Record (CCR), 3
HL7: Not-for-profit, A N S I-accredited standards-developing
organization (SDO) dedicated to providing comprehensive
framework and related standards for exchange, integration, sharing,
and retrieval of electronic health information that supports clinical
practice
• Important SDO focused on data exchange standards across health information
systems

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Personal Health Record (PHR)
Is an electronic or paper health record
Maintained and updated by individuals
Used to collect, track, and share past and current information about
their health
Or the health of someone in their care

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Status of E H R Adoption, 1
Office of the National Coordinator for Health Information
Technology (O N C): Lead federal agency spearheading this
national effort
Responsible for advising the secretary of the Department of Health
and Human Services (HHS)
Establishing guidelines and requirements for the adoption of H I T

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Status of E H R Adoption, 2
Coordinates all efforts to develop and implement the nationwide
health information exchange (H I E)
Infrastructure to help improve healthcare in the United States

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Meaningful Use (M U) Program, 1
Monetary incentives
Spur the acceptance and adoption of H I T and E H R usage
Certified E H R technology (C E H R T) is used to
• Improve quality, safety, and efficiency
• Reduce health disparities
• Engage patients and family
• Improve care coordination and population and public health
• Maintain privacy and security of patient health information

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Meaningful Use (M U) Program, 2
Also incorporated quality of care indicators
Reporting requirements to evaluate the impact of E H R adoption on
• Healthcare quality
• Patient safety measures
• Provider efficiency

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Obstacles to E H R/M U Implementation, 1
Many healthcare providers are not eligible
Interoperability
Standards for E H R systems and implementation
Lack specificity

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Obstacles to E H R/M U Implementation, 2
Best practices have yet to be refined, publicized, and consistently
implemented
Health information blocking: Persons or entities knowingly and
unreasonably interfere with the exchange or use of electronic health
information

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Certified E H R Technology (C E H R T), 1
Product has been evaluated by a member of the Office of the
National Coordinator–Authorized Certification Bodies (O N C-A C
Bs)
Verified that it meets the criteria set by the M U incentive program

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Certified E H R Technology (C E H R T), 2
Testing of the E H R product is performed by Accredited Testing
Laboratories (ATLs)
Once the testing confirms that all standards have been met, the O N
C-A C B awards the certification status

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Certified E H R Technology (C E H R T), 3
All certified products are subject to surveillance to ensure product’s
capabilities are maintained by vendor
Capable to perform its functions “in the real world” and not just in
testing laboratory
Surveillance is required and must be completed by O N C-A C Bs
Surveillance activities can be randomized or in reaction to a specific
issue

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Components of E H R, 1
Registration—admission, discharge, transfer (R-ADT)
Patient financial services
Order communication and results retrieval
Ancillary, clinical, and department applications
Patient monitoring systems

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Components of E H R, 2
Document management system
Clinical messaging and provider-patient portals
Results management
Point-of-care charting
Computerized physician or provider order entry system (C P O E)

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Components of E H R, 3
Electronic medication administration record
Clinical decision support system
Health information exchange (H I E)
Population health

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Benefits of E H Rs, 1
Easier access to clinical information
Provides current information
Tools such as reminders and alerts
Enhance the documentation captured
Allows healthcare providers to spend more time with patients

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Benefits of E H Rs, 2
Test results can also be available immediately upon completion
Supports various data analytics functions

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Benefits of E H Rs, 3
Economic and administrative benefits:
• More coordinated, efficient care
• Securely sharing electronic information
• Enabling safer, more reliable prescribing
• Enhancing privacy and security of patient data
• Reducing costs through decreased paperwork, improved safety, reduced
duplication of testing, and improved health

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Barriers to the E H R
Prohibitive cost of many E H R systems and limited access to capital
and infrastructure
Limited access to E H R vendor information and technical assistance
Suitability of E H R products for practice and rural health care
settings
Difficulty connecting to or obtaining broadband service

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Signatures, 1
Record the identity of the individual who performed the entry
Authentication: The corroboration that a person is who he claims to
be
Digitized signature: A scanned image of an individual’s actual
signature

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Signatures, 2
Electronic signature: Requires at least a password but can use a
two-factor authentication method
Digital signature: Similar to electronic signature except it uses
encryption to provide nonrepudiation to prove authenticator’s identity
• Makes it the most secure

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Copy and Paste Concerns, 1
Copying: The process of moving information from an existing health
record
Pasting: The process of entering the copied data into the current
record
Saves time, but process is not without problems

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Copy and Paste Concerns, 2
Nullifying an entry
Causing entire record to be suspect
Healthcare practitioner may not notice additional information
Healthcare practitioner may not notice missing information
Entry may misrepresent the case

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Copy and Paste Concerns, 3
Possible fraudulent claim for reimbursement
Results in harm to the patient
There might be a sentinel event that must be reported

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Audit Log, 1
Also called audit trail
• An electronic footprint of the actions that occurred in a particular file in an I S
Performed by a specific individual

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Audit Log, 2
Maps
• When a file was accessed
• Who accessed it
• How long they were in the file
• What was done to the file (including printing and saving)
• Which terminal or device was used to access the file

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E H R Tools, 1
Data retrieval
Graphical user interface
Color and icons
Data entry
Unstructured data

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E H R Tools, 2
Structured data
Template-based entry
Natural language processing

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Legal Issues
State laws vary as to what is acceptable in a court
Documentation provided must be in a usable and readable format
• Not screen prints or other unformatted data
Subpoena may require production of audit trails, decision support
rules, clinical guidelines, etc.
Other legal issues: retention, storage, security, privacy, signatures,
and data quality

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Unanticipated Issues in E H R Use, 1
Increased work for clinicians
Unfavorable workflow changes
Ongoing demands for system changes
Conflicts between electronic and paper-based systems
Unfavorable changes in communications

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Unanticipated Issues in E H R Use, 2
Negative user emotions
Generation of new kinds of errors
Unexpected and unintended changes in institutional power structure
Overdependence on technology

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Interoperability, 2
Basic
• A computer can send data to another computer but the receiving computer is
unable to interpret the data
Functional
• Defines the structure of messages so that the receiving computer can interpret
the data
Semantic
• Most advanced level; allows the information to be used in a meaningful way

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Transition Period—Hybrid Record
Hybrid record: A combination of paper and electronic health
records
Information system and implementation life cycle
Hospitals need policies and procedures to define sources of
components of patient’s health information and ensure easy and
accurate access, use, and disclosure

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Impact on Health Information Management
Functions performed by H I M change significantly and evolve
• Assembly and processing
• Transcription
• Coding
• R O I
Paper health records do not cease to exist immediately