This document discusses building consensus for electronic health records (EHRs) in healthcare. It begins by outlining goals for improving healthcare quality put forth by the Institute of Medicine. It then discusses executive mandates for implementing EHRs and defines EHRs and how they differ from electronic medical records. Factors driving the need for EHRs are described. The stages of EHR implementation and meaningful use requirements are outlined. Attributes of EHRs that support continuity of care are listed. Considerations for EHR implementation including costs, downtime, caregiver assistance, and data integrity are also discussed.

1. Building a Consensus
for an EHR
Wendy Jean, Jamie Kalina, Kristen Mangia
NUR 353
Jacksonville University
October 2013

2. A New Health System for the 21st Century
The IOM listed six aims in improving health care quality:
• To make healthcare environments more safe for their patients.
• To provide more effective healthcare.
• To make health care more patient centered - that is ensure that the patient is more involved in the
decision making process and that the patient has a better understanding of the healthcare choices
available to him or her.
• To improve the timeliness of healthcare service.
• To make the process of providing healthcare, as a whole, more efficient.
• To work toward the elimination of healthcare disparities among diverse populations...ensuring that all
patients have equal access to healthcare.

3. Executive Mandate
• “Within ten years, every
American must have a
personal electronic
medical record... by
computerizing health
records we can avoid
dangerous medical
mistakes, reduce costs
and improve care.”
- President George W.
Bush, April 26, 2004
• “According to Executive Order
13410 signed by President George
W. Bush in August 2006, federal
agencies administering or
sponsoring federal health programs
must implement any and all relevant
recognized interoperability
standards. These standards also
become part of the certification
process for electronic health records
and networks.”
www.hitsp.org/government.aspx

4. EHR Defined
• EHR- an electronic health record
of health-related information on an
individual that conforms to
nationally recognized
interoperability standards that can
be created, managed, and
consulted by authorized clinicians
and staff across more than one
healthcare organization
( Hebda & Czar, 277)
• “EHRs are, at their simplest, digital (computerized) versions of
patients' paper charts. But EHRs, when fully up and running, are
so much more than that.
• EHRs are real-time, patient-centered records. They make
information available instantly, "whenever and wherever it is
needed". And they bring together in one place everything about a
patient's health. EHRs can:
– Contain information about a patient's medical history,
diagnoses, medications, immunization dates, allergies,
radiology images, and lab and test results
– Offer access to evidence-based tools that providers can use
in making decisions about a patient's care
– Automate and streamline providers' workflow
– Increase organization and accuracy of patient information
– Support key market changes in payer requirements and
consumer expectations
• One of the key features of an EHR is that it can be created,
managed, and consulted by authorized providers and staff across
more than one health care organization. A single EHR can bring
together information from current and past doctors, emergency
facilities, school and workplace clinics, pharmacies, laboratories,
and medical imaging facilities.”
healthit.gov

5. Not to be Confused with EMR
• EMR- legal records created in hospitals, clinics, and ambulatory
environments that are the source of the data for the EHR
– Building block in the creation of EHR
– A single encounter
– Limited ability to carry information across subsequent visits
– Components
•Clinical messaging, email
•Results reporting, data repository
•Decision support
•Clinical documentation
•Order entry
(Hebda & Czar, 276)

6. www.ncrr.nih.gov/publications/informatics/ehr.pdf

7. www.ncrr.nih.gov/publications/informatics/ehr.pdf

8. Why the Call for Change?
Cause
Decreasing Reimbursement
Increasing cost
Increasing healthcare
regulations and notices
Effect Example with EHR
• Supports pay for
performance as quality
measures are gathered
• Supports disease
management, lowering costs
for expensive diagnosis
• Instant notice of
authorization for procedures
with integration with payer-
based health records

10. How of EHR
• Stage 0 – Some clinical automation exists but the laboratory, pharmacy, and radiology systems are not
all operational
• Stage 1 – The major ancillary clinical systems-the laboratory, pharmacy, and radiology-are all installed
• Stage 2 – Major ancillary clinical systems send data to a clinical data repository (CDR) that allows
physicians to retrieve and review results
• Stage 3 – Basic clinical documentation (vital signs, flow sheets) is required
• Stage 4 – Computerized provider order entry (CPOE) and a second level of clinical decision support
for evidence-based practice are added to the previous stages
• Stage 5 – At least one service area has the closed loop medication administration process where
barcode medication administration (BCMA), radio frequency identification (RFID), or other
identification technology is in place and integrated with CPOE and the pharmacy to maximize patient
safety
• Stage 6 – At least one service area has full physician documentation, third-level clinical decision
support for protocols and outcomes with variance and compliance alerts, and a full PACS system
• Stage 7 – This is a paperless environment where all information is shared electronically and the
electronic health record can produce a continuity of care document (CCD)
(Hebda & Czar, 277)

12. How Do We Get There?
•Meaningful Use
– emphasizes using technology with a meaningful manner to exchange
electronic health data to improve care quality and it emphasizes submittal of
care quality measures to HHS.
– In addition, hospitals and doctors will need to meet these requirements
within a specified time frame.
As per law, eligible providers will be treated as a Meaningful User of EHR
technology if they meet the following three criteria:
• Use a certified EHR in a meaningful manner, which includes the use of electronic
prescribing (e-prescribing).
• Use a certified EHR that can accommodate the electronic exchange of health
information to improve quality of health care.
• Submit information on clinical quality measures, as chosen by the HHS
Secretary, for the reporting period.

13. http://electronicmedicalrecordsmandate.org/electronic-medical-records-mandate/emr-mandate-2014-deadline

14. Meaningful Use Requirements
• Record demographic information
• Computerized provider order entry
• Clinical decision support and the ability to track compliance with rules
• Automatic, real-time drug-drug and drug-allergy interaction checks based on the medication list,
allergy
• Maintain an active medication/allergy list
• Record and retrieve vital signs
• Record smoking status for patients 13 years old and older
• Mechanisms to protect information created or maintained by the certified electronic health record
technology that include access control
• Electronically exchange key clinical information among providers and patient-authorized entities
• Supply patients with an electronic copy of their health information upon request
• Supply patients with a electronic copy of their discharge instructions upon request
• Report required clinical quality measures to CMS
• Maintain up-to-date problem lists of current and active patient diagnosis
(Hebda & Czar, 281)

15. Attributes of the EHR with
Continuity of Care
• Provides secure, reliable real-time access to client health record information where and
when it is needed to support care
• Records and manages episodic and longitudinal electronic health record information
• Functions as clinicians primary information resources during the provision of client care
• Assists with the work of planning and delivery of evidence-based care to individual and
groups of clients
• Captures data used for continuous quality improvement, utilization review, risk
management, resource planning, and performance management
• Captures the patient health-related information needed for medical record and
reimbursement
• Provides longitudinal, appropriately masked information to support clinical research,
public health reporting, and population health initiatives
• Supports clinical trials and evidence-based research
(Hebda & Czar, 278)

17. Considerations of the EHR
• Cost
– Initial land ongoing costs for deploying and
maintaining IT systems were cited as the
greatest barrier to IT.
– According to recent CMS estimates, eligible
providers will spend an average of $54,000 to
purchase and implement a certified electronic
health record for their offices and eligible
hospitals will spend an average of $5,000,000
for the purchase and installation; those figures
do not include annual maintenance costs
• Downtime
– Rushed implementation process that can negate
many of the potential benefits associated with
electronic health records and potentially
sacrifice patient safety
– The enormity of switching from a paper
process to a new electronic health record
system must fully be considered
(Hebda & Czar, 288)
• Training, maintenance and enhancements are
additional moneys. Estimated cost per healthcare
provider practice implementing an EMR is $40,000
to $100,000.
• The process of developing, implementing and
maintaining EHRs requires adequate funds and the
involvement of many individuals, including clinicians,
information technologists, educators, and consultants
(Bostrom, Schafer, Dontje, Pohl, 2006).

18. Considerations of EHR
• Caregiver Assistance
– Resistance by caregivers such as
physicians and nurses can delay the
development and use of the electronic
health record
– This resistance is, in part, attributed to
the fact that many electronic health
records, lack essential features or are
perceived as awkward or inconvenient to
use
• CPOE error and Data integrity
– Incorrect data entry – the client data
found in the electronic health record are
only as accurate as the person who enters
them and the systems that transfer them
– Data correction – an effective audit trail
procedure permits the tracking of who
entered or modified each data element,
allowing appropriate follow-up measures
(Hebda & Czar, 288)
• Selection of a system and software capable of
meeting the current and anticipated needs of
the providers and healthcare system is critical
to the cost investment and return on
investment, ROI. Maintenance costs include
ongoing system enhancements as well as
innovations in the pipeline. All costs, after the
initial investment, can be expected to be
transferred to the business costs of patient
care. The ROI should reflect savings,
including malpractice insurance and
malpractice claims for patient care errors,
particularly as a result of the reduction in
medication errors. Cost savings in conjunction
with positive revenue gains from “meaningful
use” are included in the ROI calculation.
Initial financial investment to convert to an
electronic record format, even for a small
system, can range upward of tens of thousands
of dollars (Kopla, Mitchell 2011).

20. Benefits of EHR with Nursing
– Maximize the time nurses spend on direct patient care, improve the accuracy of documentation,
decrease medication errors, and promote patient safety
– Can provide clinical alerts and reminders, identify abnormal parameters of laboratory and
assessment data, and prompt clinicians on important tasks and protocols
– Supports all ongoing record of the clients education and learning response across encounters or
visits
– Provides universal data access to all who have access to the electronic health record
– Improves documentation and quality of care
– Vital signs can be collected directly from monitors attached to the client and fed into the system
(Hunter 2002).
– Clinical documentation systems have the advantage of collecting data to use in planning and
research.
(Hebda & Czar, 2009)

21. Benefits of the EHR with Providers
• Providing accurate, up-to-date, and complete information about patients at the point of care
• Enabling quick access to patient records for more coordinated, efficient care
• Securely sharing electronic information with patients and other clinicians
• Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
• Improving patient and provider interaction and communication, as well as health care convenience
• Enabling safer, more reliable prescribing
• Helping promote legible, complete documentation and accurate, streamlined coding and billing
• Enhancing privacy and security of patient data
• Helping providers improve productivity and work-life balance
• Enabling providers to improve efficiency and meet their business goals
• Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and
improved health
– Improved eligibility for reimbursement
– Simultaneous record access by multiple users
– More comprehensive information is available
Healthit.gov/providers-professionals/faqs/what-are-advantages

22. Benefits of EHR with Consumers
• Places the patient at the center of his/her care
• The EHR is connected to all the patient’s health care providers
• Reduces the patient paperwork. As information is added the EHR, the doctor and hospital
will have more of that data available as soon as the patient arrives
• EHRs get the information accurately into the hands of people who need it, and enables the
providers to make the best possible decisions
• Help the doctors coordinate your patient and protect patient safety
• Reduce unnecessary tests and procedures, which results in higher costs to the patient in the
form of bigger bills and increased insurance premiums
• EHR give the patient direct access to their health records
• Decreased wait time for treatment
• Improved access and control over health information
• Increased use of best practices with incorporation of
decision support
Healthit.gov/patients-families/benefits-health-it

23. Looking Forward to Tomorrow
This transformation may not occur as quickly as desired; it
will take longer for some consumers and practitioners to
make the transition since changes must also be seen in
attitudes. EHR systems have the capability to improve
communication between physicians, nurses and patient by
making information more readily available.
The electronic health record has tremendous potential to
support nurses and advance nursing knowledge in the
following ways: elimination of redundant efforts,
redesigning the workflow, demonstrating the contributions
that nurses make to patient care and outcomes, and
contributing to the body of nursing knowledge through the
incorporation of standardized nursing language

24. References
Bostrom AC, Schafer p, Dontje K, Pohl JM, Nagelkerk J, Cavanagh SJ. Electronic health record: Implementation across the Michigan
academic consortium. Comput Inform Nurs. 2006:24(1):44-52.
Hebda, T., & Czar, P. (2013). Handbooks of Informatics for nurses & healthcare professionals (5th ed.). Upper Saddle River, New
Jersey, USA: Pearson.
Kopla, B. & Mitchell, ME. (2011). Use of digital health records raises ethics concerns. Jonah's Healthcare Law, Ethics, and
Regulation, Vol. 13, No 3 pp.84-89.
McNickle, M. (2012). 7 attributes next-generation EHRs will need to support . Healthcare it news.com.
Thede, L. (2003). Informatics and nursing: Opportunities and challenges (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
http://electronicmedicalrecordsmandate.org/electronic-medical-records-mandate/emr-mandate-2014-deadline
www.healthit.gov/patients-families/benefits-health-it
www.healthit.gov/providers-professionals/faqs/ what-are-advantages
www.hitsp.org/government.aspx
www.ncrr.nih.gov/publications/informatics/ehr.pdf