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LESSON 16
Transition to Electronic Health Record
LEARNING OUTCOMES
_____________________________________________________
_________________________
In this lesson, you will do the following:
Evaluate the factors that drive an organization to adopt a
strategy to create an electronic health
care record.
READINGS
The following reading assignments are for Lessons 13 through
16:

Gartee Text:
Chapter 2, pp. 27 - 41
Chapter 7, pp. 152 - 181
Chapter 8, pp. 182 - 206
ACTIVITIES / ASSESSMENTS
The following activities/assessments are for Lessons 13 through
16:
1. Read the assigned pages from the Gartee text, Unit 4
PowerPoint, and Lecture Notes.
2. Participate in the weekly discussion question.
3. Complete the written assignment.
WRITTEN ASSIGNMENTS
Research and discuss three challenges facing an organization,
and review how the conversion to

a full electronic health record could address the challenges
identified.
PLEASE NOTE: All graded assignments for the lessons in this
unit should be grouped together
and submitted as ONE document using the Assignment
Submission form accessed from your
course homepage or http://www.sjcme.edu/gps/assignments.
All activities/assignments for this unit should be as follows:
1. Should include a cover sheet for each assignment stating the
following:
2. Each individual assignment number and copy of the
assignment directions should be
included in the submission as the starting header of each lesson.
3. Carefully check grammar and spelling.

4. Use APA format for any research or sources that are being
used or quoted.
5. Email the instructor if you have questions regarding the
assignments.
http://www.sjcme.edu/gps/assignments
LESSON 16
Transition to Electronic Health Record
LECTURE NOTES
_____________________________________________________
_________________________________
The push for the conversion from paper-based to electronic
health records is clear and definite.
The mandate comes from the federal government in terms of
regulatory requirements, financial
incentives, and a desire to reduce costs and improve quality.
Research and experience has
indicated that a fully deployed electronic health record system
will achieve these desired
outcomes. The ability to enhance the productivity of personnel
is another business outcome that

health care providers will need to consider. However, there are
major challenges and barriers to
achieving full implementation of interoperable electronic health
records.
Costs of Care
The costs of health care in the United States are reported to be
almost 17% of the gross national
product (GNP), or about $7000 per capita for every person in
the country. The costs for health
care continue to rise faster than consumer inflation.
This makes the cost of health care in the United States the
highest in the world and about double
the cost of the next highest country. The perception has been
that the health care delivery system
in the United States is the best in the world, yet the outcomes
indicate otherwise.
While the costs are high, quality measures are not a priority
and, depending on the metric, the
United States is found to rank in the low teens when compared
to other developed nations. This
is not the outcome that is desired, nor are the costs sustainable.

Higher health care costs cause products made in the United
States to be higher than other
countries, simply because of these high costs, and make those
products less competitive in the
world market as well. Higher costs do not translate into better
care and outcomes.
Efforts by the government to address health care coverage and
costs go back to the 1950s when
Congress and President Eisenhower discussed the creation of a
health care program for the
country. Major legislation to reform a portion of health care
was eventually passed in 1965 in
the form of the Medicare and Medicaid programs. Medicare is
for health care payments for the
population over age 65, and Medicaid is for the poor. Both of
these programs were a step
forward in assuring coverage for these two groups.
Efforts by other public policy makers had not been successful in
assuring access to health care
services, including a plan in 1993 by President Clinton. In
2009, President Obama and Congress

finally passed a comprehensive plan for health care reform that
addresses the costs of health care,
access to health care, and outcomes to be achieved in the health
care system. Use of electronic
health care records was a significant strategy in the reform plan.
The debate over the direction for this legislation, the issue of
costs, and quality outcomes will
last for a while since the cost increase curve for health care
needs to change and access needs to
be expanded. With the United States facing other major
challenges as well, hopefully, the
commitment to improving outcomes and reducing costs will
continue.
Starting in January 2011, demographics indicate that 10,000
Baby Boomers a day are turning age
65 and becoming eligible for Medicare, which is a taxpayer-
supported health care payment
system. For the next 20 years, Boomers will continue to age
until all 77 million are enrolled in
the Medicare program, which is almost double the current
number in Medicare. This will create

even more health care costs and access challenges for the
country.
Veterans Administration Healthcare (VAH) has a perceived
reputation for providing less than
perfect health care for America’s veterans. Historically, that
might have been an accurate
observation, but no longer is that factual. Today, the VAH is
considered to be a model integrated
health care delivery system, both in terms of the cost of care
and the measurement of outcomes
to patients.
One of the root causes for this change has been the adoption of
a fully operational electronic
health record system, which started about 20 years ago. The
electronic health record software
system, called VISTA, is deployed across the country to all
VAH locations, including hospitals
and clinics. This allows veterans to be treated at any location,
and the employees of the VAH
can access any veteran’s health care record. This system
prevents duplicated services, finds
conflicts in medications, tracks outcomes, and provides
enhanced support to health care

providers in the VAH.
VISTA software was developed by the VAH and is available for
anyone to use free of charge
because it was created using federal, taxpayer funds. The tool
has been refined, developed, and
updated for the past 20 years and will continue to evolve. It is
online and can be downloaded,
yet it is not widely used outside of the VAH system. This is a
resource and model that other
providers should review, and they should consider adopting a
similar system.
As previously mentioned, the pressure caused by the high cost
of health information staff is
considered to be a challenge. Other direct care staff will also
be a problem that health care
leaders will need to address.
This high cost of health care staff is a major driving reason for
health care cost increases. If the
productivity of health care staff can be enhanced using
electronic technology, this would be an
outcome that could reduce the overall costs of care. Another

opportunity to reduce costs is to
prevent the duplication of tests. A comprehensive and fully
deployed electronic health care
record system could reduce or eliminate these unnecessary costs
of care.
Crossing the Quality Chasm
In 2001, the Institute of Medicine (IOM) continued its series of
reports on improving health care
outcomes and reducing the costs of care. Crossing the Quality
Chasm (IOM, 2001) declared that
100,000 lives could be saved each year in the health care
delivery system if certain quality
improvement processes were widely adopted by health care
providers. The recommendations
included the need for a fully integrated and interoperable
electronic health record system.
The IOM’s report in 2006, Preventing Medication Errors (IOM,
2006), continued the research
and recommendations on how to prevent avoidable errors in
dispensing medications to patients.
Again, a major recommendation was to use technology to order,

confirm, and dispense
medications in the health care setting.
For the past decade, researchers and health care professionals
have examined how quality might
be improved. A key driver is the ability to use technology to
enhance the standardization of
protocols in health care organizations. The technology
available for the electronic health care
record system has the ability to meet that need effectively and
cost efficiently.
WORKS CITED
Institute of Medicine. (2001). Crossing the quality chasm.
Washington, DC: National Academies
Press (http://www.nap.edu).
Institute of Medicine. (2006). Preventing medication errors.
Washington, DC: National
Academies Press (http://www.nap.edu).

http://www.nap.edu/
http://www.nap.edu/
LESSON 15
Hardware and Software for HIT
LEARNING OUTCOMES
_____________________________________________________
_________________________
Discuss the use of hardware and software in health information
systems.
READINGS
16:
Gartee Text:

Chapter 7, pp. 152 - 181
Chapter 8, pp. 182 - 206
16:
WRITTEN ASSIGNMENTS
Discuss how hardware, software, and the operating system are
used collectively to keep health
information confidential and private.

LESSON 15
Hardware and Software for HIT
LECTURE NOTES
_____________________________________________________
_________________________________
Introductory Comments on Hardware and Software Systems for
Health Care
Providers
It requires both hardware and software to make the health
information system function since
each has a part in the information creation process. Hardware is
the mechanical components of
the computer system such as monitors, keyboards, hard drives,

computer processing units
(CPU’s), random access memory (RAM), printers, servers,
modems, and other such physical
equipment. Most of the hardware components used by health
care providers are typical of all
businesses. However, there are some specialized pieces of
hardware unique to health care
businesses. Some of these are noted below.
Software is the programming used to make the computer
hardware function for the user. As
mentioned in a prior lesson, there are three basic functions for
software: word processing,
numbers processing (spreadsheets), and databases.
Health care providers do use some typical business software
such as accounting and financial
software. However, other software for a health care
organization needs to be highly specialized
for the electronic health record since it is required to perform
very specific tasks. While the
basic health care record is a sophisticated database system, the
format needed for the record is
significantly different from other database systems that non-

health care businesses might use for
their customers.
Special Hardware for Health Care
As electronic health care records evolved, manufacturers looked
for opportunities to upgrade and
enhance the health care equipment used with these records.
Many of these devices use wireless
connections, both Wi-Fi and Bluetooth protocols, to directly
input data into the system. Other
devices are directly wired to the computer or the network.
An example of input devices would include scales for weighing
a patient, blood pressure units,
blood monitors, imaging systems (PACS), laboratory
equipment, and point-of-care devices
(POC). The latter (POC) are devices that allow for the
inputting of information by para-
professional staff, using a handheld, dedicated kiosk or other
device that can be connected. The
POC might use a touch screen with graphic symbols as the
system for inputting. This allows for
a less-expensive input device, which is simpler to use than a

keyboard and is similar to a mouse
device with its point-and-click type of input.
Some physicians are using “smart phones” or other handheld
devices to access information on
patients, and these devices can be used to order treatments or
medications remotely. Physicians
can also access a database of the latest drugs and medications as
a reference tool, using one of
the thousands of applications developed for health care
providers.
Special Software for Health Care
The electronic health record is a database with some highly
specialized requirements and
functions. The health care record needs to have highly detailed
information that can be accessed
by a number of individuals and retrieved both as an individual
record and in combination with
other records for reporting purposes.

One very special software function that is used by physicians is
called CPOE, or computerized
provider order entry. This system gives users the ability to
enter data directly into the system,
without the need for having a clerk or other personnel transcribe
a handwritten or oral order.
This direct access to the system eliminates errors and removes
several steps from the inputting
process. Additionally, CPOEs can be created to assist
physicians in the ordering process by
using “drop down menus” of certain categories such as
medications. A sub-database of
medications allows the physician to type the first letters of the
medication, and the system then
provides several options. Dosages and other information can be
included in the setup. Some
systems can “learn” the preferred protocols of a physician and
can provide those first, and then
allow for further changes or refinement of an order.
Another specialized health-related software function is called
“decision support systems,” which
is used by physicians and other providers to look for
information when making a decision on a

treatment or condition of a patient. It allows access to the latest
research and evidence-based
practices for the diagnosis or condition being considered for
treatment. While this type of
software does not replace the professional judgment of the
provider, it can be an extremely
valuable tool that assists in the process.
One of the true values of collecting information in an electronic
format is the ability to compile
the information for research and analytical purposes. Report-
writing software allows users to
customize what information they want to extract, how it is
extracted, and how it is organized.
This provides an excellent tool for a variety of purposes,
including quality improvement,
governmental reporting, statistical review, as well as other
business functions.
LESSON 14
Paper vs. Electronic

LEARNING OUTCOMES
_____________________________________________________
_________________________
Analyze the differences in a paper-based health record and an
electronic health record.
READINGS
16:
Gartee Text:
Chapter 7, pp. 152 - 181
Chapter 8, pp. 182 - 206

16:
WRITTEN ASSIGNMENTS
Review the Case Study on page 178 of the Gartee text. What
might be the disadvantages and
challenges of transitioning to a full electronic health record, and
what might be done to overcome
those challenges?

LESSON 14
Paper vs. Electronic
LECTURE NOTES
_____________________________________________________
_________________________________
Evolution of Information Systems in Health Care
The health care profession has used paper-based record systems
since the early 1900s, first by
the health care professions as a mandate for professional
standards and then by the organizations
paying for care and by governmental entities. Since that time,
health information systems have
evolved to become highly sophisticated and specialized record-
keeping systems. However, it
took nearly 90 years to develop this level of effectiveness.
While there are limitations and issues

with paper-based systems, they certainly have been tools that
allowed for the timely and accurate
recording of the care and condition of patients.
The development of computers began in the 1940s and were
simple systems that used vacuum
tubes and were housed in boxes the size of a living room. With
the invention of the transistor,
the computer began to shrink in physical size. As electronic
engineers experimented with this
new technology, computer systems began to evolve rapidly with
the ability to put a transistor on
a micro basis in the silicon chip.
The physical size of the computer continued to be reduced, but
the cost of the hardware was still
too high for smaller organizations. Most of the software that
was available required high levels
of expertise and special knowledge. It was the creation of the
micro-computer that drove the
cost of the units down and allowed for wide-area adoption of
the technology.
Hospitals and other health care organizations began to more
widely adopt electronic technology,

primarily in the accounting and finance departments as a
solution to the information needs of the
organization. Financial software became widely available for
business purposes and was readily
adopted by health care entities since numbers are just numbers.
Little or limited specialized
software was developed and used by health care entities. Using
the technology for health records
was probably considered and even used in some settings, but
only if the software was available.
However, most of the software was customized for the
organization and was very expensive to
develop.
As the size of the hardware was reduced and software evolved
to become more user friendly, the
value of computers began to be seen by many organizations and
professions. It was the
development of software that pushed the expansion of
computers into the public mainstream.
Computers started to become a tool to manage large amounts of
data in a small space and
manipulate that data in ways that had never been done so
quickly.

The development of the Internet and broad access to that system
by the general public created the
tipping point for the further explosion of computing. The
Internet was developed as a tool for
large government and academic entities so they could transmit
information between each other.
As it became available to the general public, it was readily
adopted for home and small business
use. Access to information, e-mail, games, personal software,
etc., all came into use, and the
high demand for Internet access expanded rapidly. Connection
to the Internet transformed into a
necessity of daily life.
Use of Computerized Systems in Health Care
In the early 1990s, the Institute of Medicine (IOM), a research
and think-tank organization,
evaluated the current paper-based health record with the
potential of using electronic technology
to record, compare, and manipulate patient data. The IOM
report suggested that an electronic

health record could create a number of functions that would
enhance the care and outcomes
delivered to a patient.
The IOM report created the potential for eight core functions
that the technology could perform
that would be an enhancement to the health care delivery
system. They saw the ability to create
a defined data set of information that would give researchers the
ability to assess treatment
outcomes and create evidence-based practices. They also saw
the potential for error reduction
and enhanced productivity in recording information by using a
computerized provider order
entry (CPOE) system and a decision support system that would
provide access to best practices
(Dick & Steen, 1991).
This IOM report started three decades of research by the IOM
and other research-based
organizations on the value of the electronic health record,
including the 2009 health care reform
legislation (H.R.1, 2009) that mandates the adoption of this
technology as a means to reduce both

errors and costs. Much of the strategy to “bend the cost” curve
of health care is being driven by
the expanded adoption of electronic health information systems.
There are a number of key items that the technology will need
to consider to allow the reduction
of errors, provide enhanced productivity, and lower the costs of
health care. These functional
issues are factors that will determine how information systems
are developed.
First, a standardized and mandated protocol for the format of
patient information needs to be
created and adopted. If every health care provider is left to
determine how the information will
be recorded and saved, the ability to compile information for
separate systems will be
compromised. While it is the decision of the provider on how
the data might be used internally,
the ability to share information from provider to provider on a
patient is essential if duplicate
services are to be eliminated and conflicting treatments are to
be prevented. A number of
organizations and entities are creating standards, including HL7

and CCHIT.
Another area similar to the protocol for transmitting
information is the adoption of a standardized
coding system, which is referred to as nomenclatures. This
assures that the terminology used is
the same from location to location, which again provides the
ability to conduct comparisons.
The systems used include SNOWMED-CT and MEDCIN.
The adoption of both of these key standards provides for
consistent inputting of health
information by each entity, which is a critical factor for quality
improvement purposes and to
achieve reduced costs. This consistency allows for the accurate
transmission of health
information to other providers, third-party payers, and
governmental entities.
_____________________________________________________
_________________________

WORKS CITED
Dick, R. S., & Steen, E. B. (1991). The computer-based patient
record: An essential technology
for health care. Washington, DC: Institute of Medicine,
National Academy Press. (Revised
1997, 2000).
111
th
Congress. (2009-2010). H.R.1: American recovery and
reinvestment act of 2009. Title XIII
Health Information Technology for Economic and Clinical
Health, February 17, 2009.
LESSON 13
Health Information Staffing
LEARNING OUTCOMES
_____________________________________________________

_________________________
Differentiate the various roles of health information
professionals.
READINGS
16:
Gartee Text:
Chapter 7, pp. 152 - 181
Chapter 8, pp. 182 - 206
16:

WRITTEN ASSIGNMENTS
Interview a Health Information Specialist (or their Supervisor)
or an individual in a similar
position, and review the roles of the various positions in a
Health Information Department and
how they impact the health information system.

LESSON 13
Health Information Staffing
LECTURE NOTES
_____________________________________________________
_________________________________
Staffing and Organizing the Health Information Management
Department
The personnel needed to operate a health information
management system require specialized
training for this field of employment. Regardless of whether
the department is using a paper-
based health record, has converted to a partial electronic health
record, or has made the
commitment to a full electronic health record, health
information systems has become a highly
specialized field with many sub-specialties.
Each health care organization creates policies, procedures, and
protocols for using their health

care information records, regardless of whether it is paper-based
or electronic. While the
organization and their health information specialists follow
professional and governmental
requirements, each system is created and modified to meet the
specific needs of the organization.
As the saying goes, “If you have seen one health care
information system... you have seen only
one health care information system.” The newly hired health
care information specialist will
need to be trained and oriented to the organization’s system, the
policies and procedures, and the
other internal protocols of the organization.
For the paper-based record, the individual should possess skills
and knowledge of the structure
and organization of the health record, patient privacy and
confidentiality, state and federal laws
and regulations, storage and retention of records, organization
of the health care delivery system,
and medical terminology. The individual also needs to be
meticulous and detailed oriented since
the record is the primary legal document that supports the
services rendered to the patient. In

some positions, the ability to use statistical tools is needed,
especially for quality assurance and
other review and quality audit systems. If the individual is in a
leadership or supervisory
position, additional skills in management theory and
supervisory experience would be necessary
for success.
For the organization that uses an electronic health record, all of
the above mentioned skills are
necessary along with computer expertise. Individuals need
some technical skills on how the
electronic system operates, but not highly specific knowledge
on information technology.
Specialized training on hardware, software, and operating
systems would be critical for the
individual in the information technology (IT) department.
While the functioning of electronic health records is similar,
every system and vendor has
programs and operations that are unique to their software.
Having worked or trained on other
software systems is helpful, but most likely individuals will
need to have detailed and specific

training on their health care organization’s software and
protocols for health information.
Ongoing Training for HIM Professionals
Once individuals have been hired, orientated, and trained on the
health information system for
their employer, the training and learning process is merely a
beginning. Systems and
requirements change on a routine basis. Governmental payment
systems also change and are
updated regularly, and HMOs and insurance carriers make
changes to coding, reimbursement,
and other conditions for treatments to patients. All of these
require additional training and
knowledge.
Software vendors typically have normal maintenance changes to
their software systems to
correct bugs, malfunctions, and changes in rules or regulations.
Additionally, vendors are
constantly improving and upgrading their software giving users

the ability to enhance their use of
the system.
Health care information specialists also make suggestions to
vendors for system enhancements to
their software. This type of feedback is very valuable to
vendors since health care staff members
are using their systems on a regular basis and know the
challenges, issues, and any opportunities
for improvements.
Strategies for HIT Staffing
As health information positions become specialized, salaries
have been growing at a rapid pace,
especially for those who have skills with electronic health
records. During the past few years,
however, the recruitment for HIT and IT staff positions has not
been a major challenge for
employers, primarily due to the recession. As the recession
gradually ends, salaries for IT
positions will continue to increase and the competition for
qualified staff by employers will again
be a problem.

Some employers create programs to develop qualified HIT staff
in-house, using various on-the-
job programs to train individuals in their health information
system. This can be an excellent
strategy for addressing staffing needs and shortages. It also
provides a career path for the
organization’s staff, which can improve staff satisfaction and
enhance loyalty to the organization.
As salaries increase and competition for hiring becomes intense,
employers look for alternative
staffing strategies to consider for their HIT needs. One option
is to use temporary or contracted
staff to fill in during vacations or leaves of absence. They can
also be used to supplement
existing health care information staff when there are special
projects or when an increase in
productivity is required due to increased occupancy or other
circumstances. This strategy gives
the employer supplemental staffing when needed, and they do
not have the long-term cost of
hiring and training new staff.

Another option for HIT is to outsource much of the storage and
network function of their
electronic information system. However, this needs to be
carefully evaluated since privacy and
security issues are still the responsibility of the health care
organization. It becomes an issue of
balancing off the cost of permanent hiring with the use of
contract staffing.
Professional Organizations Representing HIM Professionals
There are a number of organizations that provide training,
advocacy, support, and certification
for health information specialists. The names of those
associations are listed in the Gartee
textbook. If you have an interest in any of the health
information positions, please go to the
website of the organization for detailed information.
There is value to the health information specialist and the
employer in having highly qualified
and competent individuals operating the HIM system. A
certification process can provide a

certain level of competency for individuals. Typically, the
process includes training sessions,
written assignments for evaluating knowledge, and the testing
of skills.
In the health care field, most of the direct care positions (i.e.,
nursing, medical, laboratory,
imaging, etc.) are required to have both a license and a
credential that demonstrate competency.
At the present time, the government and other payers have not
mandated the certification of
health information specialists. As health information
technology becomes the norm for health
care organizations, it is predicted that some form of
credentialing or certification process will be
required to assure the competency of individuals who are
operating and accessing the system.
There is currently a voluntary form of certification managed by
the American Health Information
Management Association. The certification is available at both
the administration and technical
levels.

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