B Y : C A S S I D Y W H I T E , S A N D Y P A R K , N I C H O L E
R O D R O C K , & M E A G H A N B O L A N D
OVERVIEW-WHAT IS A
• McGonigle and Mastrain (2009) state that a clinical
information system (CIS) is a assemblage of
applications, medical equipment and technologies
working together to collect patient data to enhance
• Clinical information systems are utilized at the point
of care with data recorded in real time and allow for
interventions to be made immediately.
• Patient care data is stored in a centralized location
and includes history of present illness, treatment
options and wellness activities.
WHAT IS A CLINICAL DECISION
• A clinical decision making system is a support
system that “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” (Farukhi).
• A clinical decision making system can alert
healthcare workers to possible drug interactions
and patient complications (Farukhi).
HOW SHOULD A CLINICAL DECISION
MAKING SYSTEM BE STRUCTURED?
• There is an easy way for nurses to see how a clinical
decision making system should be structured, because it
is similar to a process a nurse uses before giving a med.
• The “Five Rights” of clinical decision making systems for
• The clinical delivery system should “provide the Right information to
the Right person in the Right format through the Right channel at
the Right time” (Berner, 2009)
• So a clinical decision making system should make sure
that the right person receives the alert about the patient
before an action is taken.
• this can prevent duplicate tests and med errors
• It also can alert a health care worker to critical lab results
HOW OFTEN SHOULD THE EVIDENCE
BASED PRACTICE (EBP) GUIDELINES BE
• Clinical decision making systems should provide
“new relevant studies, identify those that are of high
quality, and then incorporate the best evidence
into patient-specific assessments or practice
recommendations” (Sim, et al., 2001).
• EBP guidelines should be updated frequently to
ensure that patients are receiving the best standard
WHAT COMPANIES CREATE CLINICAL
DECISION MAKING SYSTEMS?
• There are many companies that create clinical
decision making systems.
• RADARmed http://www.radarmed.com/
• Zynx Health http://www.zynxhealth.com/
• Webmedx http://corpweb.webmedx.com/
• Anvita Inc. http://www.anvitahealth.com/
• You can visit Health Tech JAZD markets healthcare
directory for more companies.
DEFINING THE ELECTRONIC
• Clinical information systems come in many applications
and contribute to the formation of the electronic health
record (EHR) or electronic medical record (EMR).
• The EHR is an indispensable tool in patient care and
functions to replace the paper medical record.
• The EHR serves as a systematic documentation of a
patient’s care including current and past health status.
• EHRs allow for patient data to be recorded in a digital
format, stored securely, and accessible by all disciplines
providing patient care (McGonigle & Mastrain, 2009).
1. Health Information
3. Order Entry
4. Decision Support
6. Patient Support
8. Reporting and
8 COMPONENTS OF EHR
• Patient data required to make sound clinical
• Medical and nursing diagnosis
• Medication lists
• Test results
• Patient, and clinicians need access to this
information as well as registration and case
manager/social worker for any outpatient set
HEALTH INFORMATION AND DATA
• Ability to manage results of all types
• Lab reports
• Radiology procedure reports
• Current & historical
• Physicians and clinicians caring for a patient
need access to these information for vital
information for care
• Ability of a clinician
to enter orders into a
• Supply orders
• Ancillary services
• Clinicians and
need access to
place an order
for tests or
supplies for a
ORDER ENTRY MANAGEMENT
• Computer reminders and alerts to improve the
diagnosis and care of a patient
• Screening for correct drug selection and dosing
• Medication interaction with other medications
• Preventive health reminders i.e. vaccinations
• Health risk screening and detection
• Clinical guidelines
• Alerts clinicians, physicians, pharmacists and nurses to
important information such as an allergy, indication
and interaction of meds for patient safety
• Online communication along with healthcare
team members, their care partners, and patient
• Web messaging
• Integrated health record within and across
settings, institutions, and telemedicine
• Access required for healthcare members for
referrals and consultation and availability of
records to prevent delay in recommendations
ELECTRONIC COMMUNICATION AND
• Interactive computer based patient
• Home telemonitoring
• Telehealth systems
• Patient and clinical staff should have
access so education can be provided
and supported for successful outcome of
• Electronic scheduling, billing, and claims
• Electronic scheduling for inpatient and
outpatient visits & procedures
• Electronic insurance eligibility validation
• Claim authorization and prior approval
• Identification of possible research study
• Drug recall support
• Receptionist, case managers, social
workers, billings, and pharmacist should
have access. Data are populated
throughout the record and generally remain
constant. For clinical researchers, alerts can
be established to assist with recruitment
efforts by identifying eligible research
participants ("Electronic health records,"
ADMINISTRATIVE PROCESSES CONT.
• Data collection tools to support public and private reporting
requirements including data represented in a standardized
terminology and machine readable format
• Assigned Information Technology sector would need access
to these info to built the most appropriate EHR for different
setting, i.e. child health, cardiology, and ER.
REPORTING AND POPULATION
IMPLEMENTING AN EHR
• Choosing to implement an EHR has many benefits
for both patients and clinicians including:
-improvements in quality, safety and
-reduction in health disparities
-engagement of patients and families
in their healthcare
-improvements in care coordination and
-ensure adequate privacy and security of
protected health information (Woodrock,
IMPLEMENTING AN EHR, CONT.
• Effective implementation of an EHR depends solely on who is
• “End-users” are the key players involved and consist of the
staff nurses, nurse managers and physicians that will be utilizing
• Ancillary staff such as respiratory therapy and physical therapy
also play a key role in the design and execution of a CIS.
• By involving all areas of the health care staff, consistency is
created which leads to better patient outcomes.
• Input from clinicians is critical to the success of the system
construction and application (McGonigle & Mastrain, 2009).
EDUCATION AND TRAINING
• Jeffery Grant(2010) states that any organization that has made
the transition to the HER has met challenges along the way.
“Not enough training and not enough time for training” are two
pitfalls that can be avoided with proper planning.
• Conducting an in house assessment to gauge each staff
member’s strengths and weaknesses is beneficial to a
successful EHR software launch.
• Consider the amount of training that will be required prior to
implementation of the EHR and the costs associated with the
training (Jain, 2010).
EDUCATION AND TRAINING, CONT.
• Grant (2010) also emphasizes the benefit of bringing in the EHR
vendor to train staff with considerations being made for
employee numbers and facility size.
• “Power Users” are individuals who display exceptional
knowledge in the EHR and have received additional training
with the vendor.
• These advanced users can be available to train and assist
other basic users.
• Practice sessions simulating patient visits are conducive to the
learning process and allow for the recognition of problem
EDUCATION AND TRAINING, CONT.
• After initial training is complete, a mock program could be
utilized before the “go live” period takes place to assess needs
• Practice computers should be made available to physicians
and staff utilizing vendor supplied online and tutorial training.
• Having a power user and project manager present during the
“go live” process will help the transition go smoothly.
• Implementing an EHR is “a process, not an event” (Grant,
2010)and education and training will be a continuous process.
• President Bush’s executive order given to develop
nationwide interoperable EHR within 10 yrs in 2004
• “Annual spending on Health Care IT will reach $10.8
billion by 2012” (INPUT, 2008a)
• It could cost at least $75 billion to $100 billion over
the ten years for hospitals to implement program
• The biggest cost will be paying and training the
labor force needed to create the network
COST OF IMPLEMENTING EHR
CONCERNS OF PATIENTS AND THE EHR
• Privacy and
remain the biggest
concern for people
and the EHR
• Consumers believe
“they should have a
say in how their
data is shared and
used” (Conn 2010)
CONFIDENCE IN PRIVACY DATA
• A 2009 survey done
by National Public
School of Public
Health shows how
feel that their data
is protected in an
SECURITY OF EHR
• Security is improved with the EHR
• By computerizing the EHR, protected
health information (PHI) is more
• “The EHR, when maintained according
to the HIPAA Privacy and Security
Rules, actually offers more safeguards
than the paper record” (The EHR:
Benefits for Privacy and Security, 2008)
CONTROLLING WHO VIEWS THE
• Hospitals should
implement policies on
who is allowed to
records (Conn 2010)
• Administration should
offer classes and
educate on policies
• Ultimately the patient
should control who can
view and access their
SECURING THE INFORMATION
• Systems need to be physically inaccessible to any
• “Contingencies in place to recover or restore lost
data in case of a disaster or emergency” (The EHR:
Benefits for Privacy and Security, 2008)
• Everyone accessing the EHR should have a unique
user name and password that only they will know
• “Strong” passwords should be implemented
• Access control lists give specific users certain or
specific privileges to particular information
• For example: a physical therapist would not be able to
access the same information that a physician would have
PROTECTING INFORMATION IN THE
• Workstations should be
• No records should be left
unattended on the screen
• Staff should stay alert for
over the shoulder readers
• Each hospital should have a
team who audits the
information, making sure of
no unnecessary viewing of
patient information (The
EHR: Benefits for Privacy and
• Especially important in high
• Identifying weaknesses in a system
before a major breach is always
• Intrusion detection not only identifies
attempts at unauthorized access, but
also looks at traffic patterns of users
(The EHR: Benefits for Privacy and
• Auditing users and transaction logs
on a regular basis is also
fundamental to privacy and security
• It is important for each health care
system to educate users on the
consequences of looking at
• Implementation of an EHR not only allows for better
care of the patient but also allows information to be
shared among different physicians
• The EHR allows for easy access to patient’s past and
present medical history
• With proper security the EHR, is safer than paper
Berner, E. S. (2009, June). Clinical decision support systems: State of the
art. Retrieved October 14, 2010, from Agency for healthcare research and quality:
Conn, J. (2010). Yet another study: HHS plans survey on IT privacy, security issues.
Modern Healthcare, 40(15), 34. Retrieved from CINAHL Plus with Full Text database.
Electronic health records overview. pdf (2006, April). Retrieved from
Farukhi, F. (n.d.). Clinical Decision Support Systems. Retrieved October 14,
Goldman, D. (n.d.). Obama's health care challenge - Jan. 12, 2009 . Business,
financial, personal finance news - CNNMoney.com. Retrieved October 17, 2010,
Grant, J.T. (2010, March). EHR: from paper to electronic.
Opthamology Times, 35(6), 44-46.
Grant, J.T. (2010, April). Allow time to implement ehr.
Ophthalmology Times, 35(7), 54-56.
INPUT, (2008a). State & local health care technology spending to
reach $10.8 billion by 2012. Retrieved Oct 20, 2010, from
Jain, V. (2010). Evaluating ehr systems. Health Management
Technology, 31(8), 22-24.
McGonigle, D., & Mastrain, K. (2009). Nursing Informatics and the Foundation of
Knowledge. Sudlbury, MA: Jones and Bartlett Publishers, LLC.
Sim, I., Gorman, P., Greenes, R., Haynes, R. B., Kaplan, B., Lehmann, H., et
al. (2001, July 11). Clinical decision support systems for the practice of
evidence-based medicine. Retrieved October 19, 2010, from Journal of the
American Medical Informatics Association:
The EHR: Benefits for Privacy and Security. (2008, September). Retrieved October 25, 2010,
Woodrock, E. (2010). Ehr criteria. Dermatology Times, 31(2), 68- 70.
Wainer, J. (2008, December 24). Security Requirements for a Lifelong Electronic Health
Record System: An Opinion. Retrieved October 25, 2010, from PubMed Central: