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- 1. Electronic Health Records Proposal University of Phoenix Kem Prince April 23rd, 2012 Learning Team C Danielle Garbe Taryn Heyler Heather Holcomb Lori Pearson
- 2. Introduction Benefits of Health Information Systems Privacy & Security Component Selection Implementation Role of Management & Stakeholders Evaluating Effectiveness
- 3. Health Information Systems Functions Benefits Manage Health Improved Quality & Information Safety Order Entry Improved Track Patient Visits Efficiency Communication Cost Reduction Patient Support Improved Service Administrative Support
- 4. Electronic Medical Record • Health related information gathered and managed in one health care organization. Electronic Health Record • Health related information gathered and manages across two or more health care organizations. Personal Health Record • Health information compiled from multiple sources about an individual that is kept by an individual. (Wager, Lee, Glaser, & Burns " Chapter 5: Current and Emerging Use of Clinical Information Systems," 2009).
- 5. Privacy The right to limit access to health care information. Same HIPAA laws apply as paper documentation. Organizations responsible for physical and technological protection of information. Access to information must be limited to specific viewers.
- 6. Security Implications Threats to security HIPAA mandates for security/privacy Administrative safeguards Physical safeguards Technical safeguards Image: emrsoftwarecompany.com
- 7. Systems Development Life Cycle Requirement Analysis Support and System Analysis Evaluation Implementation Design
- 8. Component Selection What Do We Need? Cost Vs. Benefit Components Computerized Physician Order Entry (CPOE) Clinical Data Management Patient Documentation & Scheduling Financial Support Administrative Support
- 9. 1 • Planning 2 • Selection 3 • Implementation 4 • Evaluate 5 • Improve
- 10. Major Steps in Implementation Organize Support Team Establish Project Plan Install System Train Staff Activate system Image: ehrpmc.com Conduct Workflow Analysis
- 11. Role of Management Manage Change Expansion or Contraction of Roles Training Implementation Manage Projects Educate Staff on Goals and Vision Oversee Committees Communicate with Stakeholders
- 12. Alignment with Strategic Goals • IT Plans Linked With Organizational Goals • Comprehensive Alignment • Tactical Planning • Clear Communication Tools
- 13. Stakeholders Health Care Professionals Patients Labs & Vendors Insurance Companies Investors Government Agencies
- 14. Evaluating Effectiveness Governance Budget & Resource Allocation System Acquisition System Implementation IT Service Levels
- 15. Conclusion Privacy and security System selection, stakeholders, organizational alignment Implementation process Management roles Benefits measurement
- 16. References Gordon, M. (2002, March 15). How to succeed in strategic planning. Retrieved from http://www.cio.com/article/ 30948/How_to_Succeed_in_Strategic_Planning? page=3&taxonomyId=3154 NYEC. (2011). Electronic health records (EHR). Retrieved March 28, 2012, from New York eHealth Collaborative: http://www.nyehealth.org/rec/index.php/education-a- resources/electronic-health-records Parush, G. V. (2008, July 1). Electronic medical records. Retrieved March 28, 2012, from PubMed: http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2464463/
- 17. References 2 Rodriguez, L. (2011, December 12). Privacy, security, and electronic health records. Retrieved March 28, 2012, from Health IT Buzz: http://www.healthit.gov/buzz-blog/privacy -and-security- of-ehrs/privacy-security-electronic-health-records/ Stephens, J. H., & Parrillo, A. V. (2011). HIPAA's Role in E-Mail Communications between Doctors and Patients: Privacy, Security, and Implications of the Bill. Health Educator, 43(1), 31-39. Sutherly, B. (2012, October 23). Electronic health records raise fresh privacy fears. Retrieved March 28, 2012, from Dayton Daily News: http://www.daytondailynews.com/news/dayton- news/electronic-health-records-raise-fresh-privacy- fears-984037.html Wager, K. A., Lee, F. W., & Glaser, J. P. (2009). Health care information systems: A practical approach for health care management (2nd ed.). San Francisco, CA: Jossey-Bass
Editor's Notes
- The information and data collected during a health care visit is very important. There is a saying in health care, “If it is not documented, it didn’t happen.” It is not uncommon to fill out pages of forms before even seeing the health care practitioner regarding demographics, history, and billing information. The nurse or assistant might record vital signs and other important baseline information. The physician will also need to document the experience as well as referrals, treatment options, prescriptions, and anything else discussed, reviewed, or considered during the appointment. After leaving the facility, someone must process the information and submit for payment. One individual medical record will often have many documents like identification sheets, medication list, history, problem lists, consultation andprogress notes, physician orders, lab reports, authorization forms, surgical reports, as well asadmit and discharge summaries. Now consider a hospital full of patients and how much information there is to process. Almost every type of health care practitioner must document patient interactions in one way or another. Documentation is how health care organizations record and justify care, receive payments, and do further research. Health care information is why weneed health care information systems. Health care information systems are electronic systems designed to manage all the data and information collected during a health care visit by an organization. Health care systems can vary in size and capabilities depending on what the organization needs. Health care information systems also have the potential to improve quality of care, improve efficiency, and reduce costs. Protected health information, in electronic form or paper form, is coveredby the Health Insurance Portability and Accountability Act (HIPAA). Health care information systems must maintain the highest level of digital security. The organization must implement additional safety protocols like password protection and limited access points to ensure that health information is protected. System acquisition is a very important and detailed process used to plan and select the various components of the health care information system. Equal amounts of time and resources need to go into the planning process as well as the the actualimplementation process. Project steering committees and project leaders establish the organizations specific needs. The mission and goals of the organization should be reflected in the information technology acquired.Once the organization decides on the health information system, implementation can start. The process begins by selecting a system champion and creating a detailed project plan. Organizations usually have better success when they initiate the system in phases. Once a system is ready to be used, the process is far from over. Health care information systems require constant upkeep and changes as organizations change and grow. Health care organizations must keep the role of management and stakeholders in mind during the entire process. Stakeholders are people who hold some type of value in the organizations, like employees. The employees of the facility are those who will be using the system the most and are who run the day-to-day activity. Opinions, ideas, andconcerns from stakeholders can be very valuable to the process. Management employees must have clear roles established throughout the process as well. Once a system is in place, evaluating its effectiveness is very important. These evaluations can be based on a cost-benefit analysis, or on patient andemployee satisfaction. The point is that the organizations follows up to see how well the system is or is not working. Each of these areas will be discussed in this presentation.
- Implementing a health information system can be very beneficial to an organization. The most important benefit is through organizing information and data. The systems themselves do not cause the improvement; they create the environment for high quality and efficient information use. Some of the functions of a health information system are to manage health information, to provide computerized order entry support, to track patient visits and progress, and to facilitatecommunication between health care providers, patient support systems, and administrative processes. Every organization does not have to use every component, butan organization could potentially run most daily work-flows through a health information system. Health information systems also have a potential for multiple benefits if implemented successfully. Improved safety and quality of care is one benefit. Once again it is important to understand that the system is not improving the care, it is improving workflow. Improving the process leads to higher efficiency, lower costs, and better service. Organizations that want the most benefit from their health information system prepare information initiatives that reflect the organizations goals. If the organization’s goal is research and education, the organization should choose patient data registries and grant management software. To improve efficiency and care, a facility can install quality measurement programs, order entry, and need specific electronic health records. If thelong-term goal isto save money,implementing a health information system with components that can evaluate how money isbeing put to best use would be a benefit.
- Health information systems open upthe opportunity for the organization to be involved in using the latest technologies in electronic health information. An electronic medical record (EMR) is the basic building block of health information systems. An EMR is an electronic record of an individual’s health information kept by a specific organization. “An EMR is able to electronically collect and store patient data, supply that information to providers on request, permit clinicians to enter orders directly into a computerized provider order entry system, and advise health care practitioners by providing decision-support tools such as reminders, alerts, and access to the latest research findings or appropriate evidence-based guidelines. These decision-support capabilities make the EMR far more robust than a digital version of the paper medical record.” (Wager, Lee Glaser, & Burns 2009, " Chapter 5: Current and Emerging Use of Clinical Information Systems ").An electronic health record (EHR) is ahealth record kept between at least two organizations. Electronic health records are sometimes kept between several hospitals and between hospitals and local physician offices. Personal health records (PHRs) are the newest technology in the health care information world. Personal health records are extensive health records kept in one place by the consumer. One example would be a data stick kept by a patient whichcould be interoperable wherever the patient might go. According to Wager, Lee, & Glaser(2009), personal health records have the potential to put consumers back in the “co-pilot seat”. Patients can receive customized content based on their needs, values, and preferences. PHRs should be lifelong, comprehensive, and should support information exchange and portability. Patients are often seenby multiple health care providers in different settings and locations over the course of a lifetime. In our fragmented health care system, this means patients are often left to consolidate information from the various participants in their care. A PHR brings together important health information across an individual’s lifetime and is safe, secure, portable, and easily accessible. PHRs can reduce costs by avoiding unnecessary duplicate tests and improve health care communication. PHRs may be particularly helpful to patients with chronic illnesses by enabling them to track their diseases in conjunction with their providers, prompting earlier intervention when they encounter a deviation or problem.In addition, PHRs may make it easier for caregivers to care for their loved ones by providing those caregivers with access to complete information. Research in this area is in its early stages; however, experts agree that the value of the PHR is greatest when the PHR is integratedwith the provider’s EMR” (Wager, Lee, & Glaser, 2009).
- Many patients have reservations about their information being located in an EHR because they worry that their information will not be kept private. What these patients do not realize is that an EHR is protected by the same laws that protects their paper records. Among the privacy laws that protect all patient information is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA requires all covered entities, such as clinics, hospitals, insurance companies, and billing departments, to keep patient health information secure (Wager, Lee, & Glaser, 2009). According to Rodriguez (2011), HIPAA outlines many rights that patients have, such as access to copies of their medical records, the right to request that any mistakes in their record be fixed, to receive notice of how their information is used and who gets to see it, and to be particular about how and when they would like to be contacted. Furthermore, if patients believe any of their rights have been violated, they reserve the right to file a complaint (Rodriguez, 2011). It is also a concern of many patients that any of the professionals in the building with system access permission can view their health information. While this may be true, the same can be said about paper records; any professional allowed access to the records room technically has access to any patients’ files. HIPAA and other privacy laws only permits health care professionals to access patient files if necessary to complete their day’s duties (Sutherly, 2010). For example, if Joe has scheduled an appointment with his primary care physician to have a mysterious bump on his arm evaluated, only his nurse and physician should be accessing his file. If any other professionals are accessing his file, they are violating HIPAA. In the event that Joe’s physician wants a trusted coworker to give a second opinion, Joe should give consent before the other physician is filled in on Joe’s situation and access to Joe’s health record.
- When an organization decides to implement a HIS they need to look at the various threats to health care information and ensure that security regulations mandated by HIPAA are part of the system. A thorough security assessment evaluates administrative, physical, and technical safeguards. Threats to security might include viruses, fire in the computer room, untested software, and employee theft of clinical and administrative data. Threats may also involve intentional or unintentional damage to hardware, software, or data, or misuse of the organization’s hardware, software, or data (Wager, Lee, & Glaser, 2009).It is essential for the organization to understand how privacy is related to security. Whether intentional or unintentional, the unapproved release of patient identifiable information is a misuse of the information system. The system’s security program should be designed to protect patient information and the organization’s IT assets. IT assets include networks, hardware, software, and applications (Wager, Lee, & Glaser, 2009).The HIPAA security rule spells out specific standards that are broken down into three areas (Wager, Lee, & Glaser, 2009): Administrative safeguards, physical safeguards, and technical safeguards. Administrative safeguards include security management functions, assigned security responsibility, workforce security, information access management, security awareness training, security incident reporting, a contingency plan, evaluation, and business associate contracts and other arrangements. Physical safeguards include facility access controls, workstation use, workstation security, and device and media controls. Technical safeguards look at access control, audit controls, integrity, person or entity authentication, and transmission security.
- When an organization makes the decision to investigate acquiring a new health information system (HIS) they most likely will want the system to be in alignment with their strategic goals. Incorporating a design that has a strong foundation, fosters high-quality care, and has the potential for growth is also an important part of choosing a HIS (Wager, Lee, & Glaser, 2009). The decision to obtain a new HIS usually means a significant investment for a health care organization. According to Wager, Lee, and Glaser (2009), in addition to the initial cost, there are a host of long-term costs associated with maintaining, supporting, and enhancing the system. Health care professionals need access to reliable, complete, and accurate information in order to provide effective and efficient health care services. The systems-development life cycle (SDLC) is the process that an organization goes through when planning, selecting, implementing, and evaluating a health care information system. The SDLC normally consists of four stages 1) planning and analysis 2) design 3) implementation, and 4) support and evaluation (Wager, Lee, & Glaser, 2009). The planning and analysis phase should involve widespread participation of end-users to establish what the organizations specific needs are and to facilitate buy-in. The design phase considers factors such as whether the system will be designed in-house or if an outside vendor will be utilized. The implementation phase entails creation of workflows, installing the system, testing the system, training employees, converting data, and preparing the organization for the go-live of the new system (Wager, Lee, & Glaser, 2009). The support and evaluation phase provides opportunity for fixing glitches, installing updates or upgrades, and assessing if resources are available for proper maintenance of the system chosen. This phase is the longest in a HIS life cycle and often encompasses the largest part of the I.T. budget (Wager, Lee, & Glaser, 2009). Each phase of the SDLC is essential for an organization in order to maximize the total investment. A skipped step could result in choosing a system that may not align with an organizations needs and strategic goals, costing time, money, and indirectly, lives.
- When deciding what health information system to use, it is fist important toselect what components are needed. Most times each component adds to the cost, therefore component selection must be methodical.The system selection process includes:establishing a project steering committee and appointing a strong project manager to lead the effort,defining project objectives,screening the vendor marketplace,determining system goals,establishing system requirements,developing and administering a request for proposal or request for information,evaluating vendor proposals, andconducting a cost-benefit analysis on the various options.(Wager, Lee, & Glaser, 2009, " Chapter 6: System Acquisition").Conducting a cost-benefit analysis is important to make sure budget requirements are met and costs do not out weigh potential benefits. The project steering committee has to take the overallcosts into account. “The capital cost analysis may include software, hardware, network or infrastructure, third-party, and internal capital costs. The total cost of ownership should factor in support costs and the costs of the resources needed (including personnel) to implement and support the system. Once the initial and ongoing costs are identified, it is important to weigh them against the benefits of the systems being considered. Can the benefits be quantified? Should they be included in the final analysis?” (Wager, Lee, & Glaser, 2009, " Chapter 6: System Acquisition").Health care information systems are growing to include more every day. Some of the components include:Registration systems for patient demographic information, health insurance or payer, provider’s name, date, reason for visit or encounter;Communication networks so thathealth care workers can communicate with each other; Accounting systems for patient billing information such asfinal diagnosis and procedure codes, charges, and dates of services provided;Ancillary servicessuch as laboratory, radiology, and pharmacy; CPOE for physician’s orders, date, time, and status; Medication administration systems for medications ordered, dispensed,and administered; Other clinical and administrative systems such as nursing, physical therapy, and nutrition education documentation, and scheduling information;Knowledge-based reference systemsfor access to Medline, the latest research findings, and practice guidelines;Telemedicine and tele-health systems for documentation of provision of health care services, online communication with patients and providers(Wager, Lee, Glaser, & Burns " Chapter 5: Current and Emerging Use of Clinical Information Systems," 2009).” The component selection process should not be takenlightly. Success of a health information system can depend on the choices made during this process. Once components are officially reviewedand selected, system implementation can begin.
- There are many steps involved when implementing a new electronic health record system. The first step in the process is planning. The organization needs to decide what they want, establish expectations, and assemble a request for proposal (RFP). Once this is completed, the organization proceeds to the selection process. It is best to select the five top vendors and interview them, making sure that these vendors have the most up-to-date systems (Wager, Lee, & Glaser, 2009). Once the most appropriate vendor is chosen, the implementation process can begin. During this process it is imperative that regular meetings to review the process and progress are conducted with the project champion. This is part of the evaluation process. The project champion ensures that the project is on track and moving forward as expected. The project champion can address any improvements that need to be made (Wager, Lee, & Glaser, 2009).
- Implementation begins with organizing a support team that is responsible for establishing expectations and collaborating on a RFP (Request for Proposal). In the beginning stages it must be determined what is expected from this IT system and what the end results will bring. Understanding the goals, mission, and expectations of the organization and ensuring they align with each other in order to promote a clear concise statement about the organization are key elements. Then a project plan is established before interviewing possible IT vendors and narrowing the list down to five. Once the vendor has been approved, and the contracts are signed, the system can be installed and employees trained. Training of end-users should be thorough so that every employee understands and are not fearful. Once training is completed, the system can be activated. In the following months, workflow analyses should be conducted to test for compatibility issues and other glitches (Wager, Lee, & Glaser, 2009).During the implementation stage, it is expected that there will be changes within the workflow. During this part of the implementation process, training is crucial to the staff. The implementation process can be very stressful and the more training the staff receives, the better the transition will be. A stable and secure IT infrastructure should be in place to ensure minimal downtime and adequate response time. A formal feature should be in place for reporting and correcting errors and glitches in the system (Wager, Lee, & Glaser, 2009). Once the system is up and running, a workflow analyses should be conducted. Failing to analyze and manage can lead to increased costs, dissatisfied users, project delays, and system sabotage. Healthcare organizations cannot afford to mismanage their implementation process as this can lead to financial ruin of the organization.
- During the implementation of the EHR, management has two main responsibilities: managing change and managing projects (Wager, Lee, Glaser, & Burns, 2009). When managing change, management must pay attention to the change in the roles and responsibilities of their staff. While the implementation is in progress, there is a chance that certain tasks may be limited or completely stopped for a period of time. It is the manager’s responsibility to implement an alternative method so that daily tasks are still completed and the workload does not accumulate. Managers are also responsible for ensuring that the new system will work well with staff responsibilities. This means that they should be kept in the loop on all project decisions and what to expect from the final project. Part of ensuring successful staff transition is ensuring that all employees are trained adequately. Even if managers are not a part of an implementation team, they can still ensure that staff are undergoing training and understand the new system. Sometimes implementing an information system is only one part of a series of changes for a health care institution. It is the responsibility of managers to ensure that staff are aware of the goals and vision aligned with the project as a whole as well as the information system. This can include providing staff with knowledge of the means by which the institution is paying for the project. They might also oversee project committees. Managers can also be responsible for ensuring that stakeholders are kept in the loop on project progress and changes. Regardless of the particular responsibilities the manager has during an implementation, they are absolutely a large part of ensuring the successful implementation of a system.
- According to Wager, Lee, & Glaser (2009), the goal of IT alignment is to ensure a strong and clear relationship between IT investment decisions and the health care organizations overall strategies, goals, and objectives. IT offers strength in looking at how to apply technology to make the organization easier to do business with, more efficient internally, and how to better utilizecapital assets. The Chief Information Officer (CIO), in collaboration with other stakeholders, should be expected to develop an assessment of the IT ramifications of strategic options and to identify areas where IT can enable new approaches to strategy (Wager, Lee, & Glaser, 2009). The following steps reflect a comprehensive plan for IT to capture and communicate alignment with the organization:Scope: High-level goals and plans for all areas of information technology that affect the organization, not just the infrastructure. Strategic goals: A road map for IT is useful in illustrating overall strategy. Lay out the specific organizational goals, assumptions and plans that populate the IT strategic plan. For example, the organizations goal is financial stability and IT initiatives support this goal by providing revenue system enhancement and cost accounting. Metrics: Put measurements of progress in place when you create the strategic plan instead of waiting for review time to figure it all out. The goal is not precision, but the ability to measure appropriate progress toward goals. Evaluate: The IT department will review the plan and revise it as necessary at least once during the fiscal year.By creating an IT strategic initiative that reflects a comprehensive alignment plan, the organization will have a clear communication tool for supporting IT plans and projects.
- Stakeholders include anyone the EHR is in contact with. The people who are most directly affected by EHRs are health care professionals (NYEC, 2011). People who work at hospitals, clinics, and long term care facilities are directly affected by the implementation of EHRs because they are then forced to utilize it constantly throughout the day. Patients are another huge stakeholder in EHRs because their information is stored within these systems (Viner & Parush, 2008). Not only that, but their visit is generally driven by their EHR. For example, notes are typed into a patient’s file and accessed by each professional assisting the patient. In order to have complete knowledge of the patient’s medical history and current concerns, professionals must refer back to the EHR constantly. Sometimes when a patient gives a specimen, such as blood or urine, it must be sent to another facility to be tested. These laboratories are also affected by the implementation of an EHR at their coordinating health care facility because it can change the way they submit their results back to the facility (NYEC, 2011). Also, insurance and billing companies are affected by the implementation of an EHR (NYEC, 2011). When entering a patient’s diagnosis information into an EHR, professionals utilize codes. These codes must be translated for insurance and billing companies to process the information.
- It is extremely important to evaluate HIS performance to assess function, service, opportunity for new developments, and ability to meet organizational goals. By evaluating HIS effectiveness, leadership can explore problems and identify opportunities for improvement. Evaluation of HIS effectiveness can be performed by in-house employees or by outside vendors. Regardless of whom performs the assessment, governance, budget and resource allocation, system acquisition, system implementation, and IT service levels should be addressed.Governance drives HIS strategies, budget, resource allocation, and assesses for effective alignment with the organization. The CIO should be an active member of annual strategic planning for the organization. The CIO can synchronize the organization’s goals with the pace of technological change and bridge the gap between IT and operations. Gordon (2002) states that IT and finance share a deep cultural commitment to process, making them complementary teammates in strategic planning. While CFOs could take tips from CIOs on the importance of technological innovation, he says, CIOs also have a lot to learn from their colleagues on the money side of the house: "IT has to be driven by a basic understanding of business and fundamental appreciation of economics.“ When IT and finance work together, they can determine if too much or too little is being spent on the IT budget.Other metrics to evaluate effectiveness of HIS include assessing if the selection process was effective, how long did it take to acquire the system, if applications were delivered on time, if they were within budget, and if they were to specification (Wager, Lee, & Glaser, 2009).
- The decision to acquire, implement, and then maintain a health information system is not one to be taken lightly or made quickly. An organization considers a HIS for the potential to improve quality of care, improve efficiency, and reduce costs. In addition to these factors, the organization will also want the HIS to align with their specific organizational goals. By clearly evaluating potential systems for their functionality and their proposed benefits, the organization can narrow down selection. Privacy, security, EMR, EHR, and PHR interfacing, should also be part of system assessment. Engagement of a systems life cycle model will ensure an organization follows a structured process that considers all factors and has a clearly defined plan for implementation and evaluation. No one step in the process is more important than another, but implementation may require the most resources. Management needs to be included from the beginning to ensure that the stakeholders they represent are included in all phases of HIS acquisition, implementation, and evaluation. When all of these considerations are put into place, an organization stands a high chance of implementing a HIS successfully.