challenges & prospects for ehrs final nov 2012

HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria

Challenges & Prospects for Electronic Health Records

Lorraine NicholsonImmediate Past President

IFHIMA


Challenges & Prospects for Electronic Health Records

HIMSS http://www.himss.org/asp/topics_ehr.asp


The Electronic Health Record

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. (HIMSS http://www.himss.org/asp/topics_ehr.asp)

EHRs can be made up of different types of records held on a variety of media e.g. text, images, audio, video, machine outputs etc.


Examples of EHRs Around the World (i)

Australia is dedicated to the development of a lifetime electronic health record for all citizens.

Canada Health Infoway (Infoway) is an independent, not-for-profit organization funded by the federal government which jointly invests with every province and territory to accelerate the development and adoption of electronic health information systems in Canada.

The European Commission wants to boost the digital economy by enabling all Europeans to have access to online medical records anywhere in Europe by 2020.

UK - The NHS in the England began deployment of EHR systems in 2005 - the goal was to have 60 million patients with a centralized electronic health record by 2010. The plan was greatly delayed and frequently criticised and as an overarching program it was stopped in 2011. There are other EHR initiatives in Wales, Scotland and Northern Ireland.


Examples of EHRs Around the World (ii)

USA - In a 2008 survey by DesRoches et al. of 4484 physicians (62% response rate), 83% of all physicians, 80% of primary care physicians, and 86% of non-primary care physicians had no EHRs. The American Medical Association (AMA) provides fundamental rules in embracing the electronic medical record system

Estonia is the first country in the world that has implemented a nationwide EHR system, registering virtually all residents' medical history from birth to death.

In November 2011 a planned national electronic patient record for The Netherlands was shelved due to privacy concerns and budget cuts. The Netherlands are now developing regional solutions.

Abu Dhabi is using national EHR data as a live longitudinal cohort in the assessment of risk of cardiovascular disease.

Arab Health Awards 2010 recognizes Saudi Arabia National Guard Health Affairs for advancement in EHR development

There are more!


The Challenges


Implementation Issues & Challenges

There are a number of issues and challenges surrounding the implementation of EHRs including:

Managing & Supporting Users Usability & User Acceptance Capital & Revenue Costs Fear of Failure & the Costs of Failure Interoperability of Systems is crucial

Lets look at these challenges in a bit more detail


Managing & Supporting Users

Historic practice in record-keeping has been largely paper-based - in the Daily Times NG on 25th April 2012 in his article HIMAN calls for e-health record keeping, Mr. Wole Ajayi stated that the paper-based record keeping system was the most common method of recording patient information in most hospitals

Top-down approach to system selection & implementation does not engage users

Peoples resistance to change Effectiveness of user training is crucial Support for users is important Data sharing issues can cause privacy concerns


Usability & User Acceptance

There must be engagement with all users, particularly clinical users, from the very beginning

All users need effective training and good systems support

Systems need to be intuitive and user friendly

Systems also need to be easy to navigate Systems need to be tailored to meet the specific

needs of different organizations and users


Capital & Revenue CostsThe procurement, implementation and use of EHR systems is expensive both in terms of capital costs and revenue consequences. These include

Training & administration costs Licensing costs Connectivity costs Interoperability costs Costs of effective back-up systems Systems support costs Ongoing maintenance, upgrade & replacement costs Governance costs to ensure systems and data security Costs of tailoring systems to meet the specific needs of

different organizations and users


Fear of Failure and the Costs of Failure

To build confidence and protect against failure users need effective training in necessary computer skills in addition to systems-specific training backed-up by good systems support when they experience problems

Infrastructure Issues e.g. unreliable power supply or poor systems maintenance & support this can mean down-time in commerce and industry but in the healthcare sector it can mean the difference between life and death!


Interoperability of Systems

Interoperability between multiple heterogeneous systems and compatibility between various platforms and software packages is crucial for a fully functional fit for purpose EHR to facilitate the electronic exchange of health information between disparate systems to enable the delivery of safe and effective patient care


Another challenge! How do we move from paper to EHRs

?


The Transition from Paper to Electronic Health Records

The transition from a paper-based health record to an electronic health record (EHR) must be addressed and managed on many different and complex levels: administratively, financially, culturally, technologically, and institutionally.

The EHR consists of many components that work together to create the foundation of the legal health record (US terminology) including software applications such as computerized physician order entry; integration with laboratory, radiology, and cardiology systems; an electronic document management system; or other solutions.

The transition may take many years and require many change-management dynamics that will challenge each of those involved with the transition process.


Making the Transition

A challenge for the organization! Learn lessons from other organizations which

have made the transition and avoid making the same mistakes

A focus on patient safety, best practices, and return on investment and ease of end-user adoption has driven healthcare organizations to adopt solutions that support workflow performance improvement rather than those that simply automate existing processes or system dysfunctions.


Managing the transition from paper-based records to EHRs

This is a complex process due to the multitude of systems, functionality, and rapid technological advances.

No single standard approach exists for solving the transitional process issues.

Each healthcare organization must determine the steps and policies that are needed as it evolves into using a fully functioning EHR.

Many healthcare organizations have some degree of hybridizationthat coincides with the implementation plan.

There are many decisions to consider when determining steps and guidelines for managing the transition process from paper to hybrid records and then hybrid to electronic records PLAN CAREFULLY!

Healthcare organizations must ensure that the quality and integrity of the health record remains intact during the transition process.AHIMA. "Managing the Transition from Paper to EHRs." (Updated November 2010). http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048418.hcsp?dDocName=bok1_048418


Transition via Hybrid Heath Records

Because of the slowness of adoption of EHRs, funding barriers, competing technical priorities, strained human resources, and the lack of industry education, many healthcare providers are finding themselves maintaining a combination of paper and electronic records i.e. the hybrid health record


Examples of Hybrid Health Record Scenarios

Dictation, laboratory & X-ray results available electronically BUT progress notes, ancillary care, provider information, graphic sheets, and doctors orders are on paper.

Patient health information is stored on various other media types such as film, video or an imaging system.

Patient information may be stored as scanned images in a separate part of the system rather than integrated in a chronological health record.

Hospital records are electronic but out-patient clinic records are on paper which is processed & stored in the clinic & never become part of the core EHR.


Hybrid Health Records (i)A hybrid health record is a system with functional components that include any of the following: Where there are both paper and electronic

documents without a central electronic document management system where all patient information is maintained

Where there are manual and electronic processes to compile components of the medical record

Where there are multiple repositories of information (paper or electronic) that need to be accessed by the end user to compile the health record for a single episode of care


Hybrid Heath Records (ii) Having a hybrid health record is not ideal for any

facility for any extended length of time. Avoiding hybridization, or minimizing the effect

of hybrid components, will decrease the risk to patient safety and it will be more cost-effective and efficient.

Therefore, it is imperative for organizations to identify and address the challenges related to the hybrid record and implement solutions to mitigate potential risks.


Managing the Change: Top 10 Paper/Hybrid/EHR Principles (i)

1. The EHR must be part of an organizations vision and strategic plan & there should be a standard definition for the legal health record.

2. There must be adequate leadership, consultation, staff training, equipment, policies & procedures, & funding or other resources are in place to support EHR development.

3. Establish a legal health record steering committee to guide the organization from a paper to an electronic environment which is empowered to make proactive and constructive changes.


Managing the Change: Top 10 Paper/Hybrid/EHR Principles (ii)

4. The steering committee must develop and publish policies and procedures for operating in the paper state, hybrid state, & electronic state & include long-term archive, purge, retention, & destruction guidelines.

5. HIM professionals must participate actively in the development and implementation of the EHR.

6. Establish a formal process for approving EHR software and hardware to ensure that it can adequately support the organization's operational needs for paper, hybrid, and electronic health records.

7. Establish a formal process for managing forms, paper, electronic, hybrid, and system-generated records.


Managing the Change: Top 10 Paper/Hybrid/EHR Principles (iii)

8. Establish a formal process and written guidelines addressing access, confidentiality, security, print control, disclosure, & e-discovery.

9. Complete and maintain a full inventory of all existing storage & management of paper, hybrid, shadow (duplicate), and electronic record.

10. Develop a policy for retention & destruction of all health records (paper, hybrid, or electronic health records).


Evolving Roles for HIM Professionals in the Electronic Environment

A professional challenge for HIMs!The 2010 AHIMA practice brief e-HIM Practice Transformation identified several additional roles for the HIM professional. HIM roles should be reviewed & updated when planning the transition from a paper-based environment to a hybrid or completely electronic environment.


The Future.

What are the prospectslikely to be for HIMs & EHRs in the future?


eHealth eHealth promotes, empowers & facilitates health

& wellbeing for citizens, families & communities It supports & enhances professional practice

through the use of ICT & eHealth information management (eHIM)

eHealth is not just technology - it is about finding, using, recording, managing, and transmitting information to support health care, in particular to make decisions about patient care

Computers (and other ICT devices) are merely the technology that enables this to happen


eHealth also encompasses:

Virtual healthcare teams M-Health use of mobile devices to

support treatment & care Tele-Health e.g., tele-dermatology,

remote patient monitoring etc. Medical research Health knowledge management Health Information Systems


Health information Management (HIM)

is the practice of maintenance & care of health records by traditional (paper-based) and electronic means in hospitals, clinics, primary healthcare facilities, and other organizations that provide health care or maintenance of health records.

Effective sharing of patient information using only paper-based systems is ineffective


I want to share with you.

. An e-Health integrated care model for a Patient-Centred Approach

Apologies that my diagram is a very European one!!


GP

CommunityNurse

HospitalCare/NursingHome

Physiotherapy

Pharmacy

Laboratory

DentistOpticianSpecialist Clinics

HealthCare

Personal Support

Housing

Community ServicesHome Safety

SocialCare

LearningNeeds

Leisure

Voluntary Services

Private sector support

Diagram after P. Hill

Chiropody

eHealth integrated care modelHofdijk, Jacob, Casemix Advisor, Ministry of Health, Introduction to the Silo Crossing Integrated Care Approach, Presentation at eHealth Week 2012, Copenhagen, Denmark, 8th May 2012 - Session MR18, OC4 Continuity of Care


In order to support the Patient-Centred Approach

HIM must become e-HIM

The e-Health integrated care model requires the sharing of data from multiple sources keeping an electronic record for the patient

These records must come together (THE BLUE LINE in the diagram) to facilitate the delivery of high quality safe and effective care in the patients own environment


Data Integrity & e-HIM In this model ownership of the data

belongs to the patient Patients will have full access to their data

engagement & empowerment They can choose who the data is shared

with BUT With ownership comes responsibility! The Patient-Managed Health Record

may become a reality!


Benefits of Using Health IT Effectively to Improve Care Delivery

Supports citizens to manage their own health and well-being

Supports citizens to become more active participants in their own care & the services provided

Supports citizens with long-term conditions Improves availability of information for health & social

care workers to improve the safety & quality of care Improves safety for citizens taking medication

(eliminates errors) Supports the integration of care for patients like Mary


Interoperability & Use of a Common Language between Care Providers

There is a need to link electronic systems from multiple health and social care providers (using interoperable systems) to support the integrated care approach.

Interoperability requires the use of common data standards and definitions and a common terminology such as SNOMED


Data Sharing & Information ExchangeIssues for eHealth & eHIM

Privacy concerns regarding patient records, mainly confidentiality of data, with data sharing amongst multiple providers of care

Standards & definitions must be standardised to ensure that information is shared effectively

Standardisation of terminology is crucial to facilitate effective communication, information exchange & data sharing SNOMED will help

There must be a sound infrastructure for data sharinge.g. data sharing protocols, codes of practice etc.

Risk assessment (liability issues) for tele-health is under development


What does all this mean for HIMs?The challenges for our Profession!

The transition from HIM to e-HIM is a big professional issue for Health Information Managers around the world

AHIMA has been undertaking work in this area since 2003 when an e-HIM Task Force was established (Bloomrosen, Meryl. "e-HIM: From Vision to Reality." Journal of AHIMA 76, no.9 (October 2005): 36-41)

IFHIMA & AHIMA will work collaboratively on the management of health information in the age of eHealth


Challenges for HIM Professionals in the Transition from HIM to eHIM

AHIMAs e-HIM Task Force established in 2003 identified 7 major issues affecting healthcare (rising costs, ageing & mobile population, lack of data standards, growth of technology, shrinking HIM work force, the need for consumer (citizen) education, & changing public imperatives

All 7 still remain central but former taskforce members identified 3 that are still in the forefront today i.e. The HIM Workforce, Technology & Data Standards

The transition from HIM to e-HIM is a big professional issue (a challenge) for Health Information Managers around the world, which IFHIMA will be taking forward globally.


Challenges for the Future Top 10 Trends Impacting HIM in 2016

(Linda Kloss, HIM in 2016, Precyse Solutions)1. Clinical and business process leaders must own the EHR and other

technologies in order for them to be successful.2. Some level of Information Management is a basic competence for most

who work in healthcare.3. HIM functions are distributed and embedded throughout healthcare

organizations.4. Greater recognition of the importance of managing the Records

Management/Information Management aspects of digital information through its life cycle

5. Health systems need to be overall cost effective6. Health systems are working to reducing overall costs by 20%7. The link between data quality and financial performance is well

documented8. Many people rely on technology and information to assist in self-

management e-Health, m-Health etc9. Clinicians need tools and information to anticipate the outcomes and cost

consequences of clinical decisions at the point of care.10. The design of ICD-11 is being evaluated, and planning for

implementation is projected for 2020.


Education & Support for HIM ProfessionalsTo Make the Transition

Identification of core e-HIM competencies Development of applied and interactive ways of

learning Ensure that HIM educators can access

advanced education focused on e-HIM Attract the right calibre of students through

targeted recruitment strategies Develop & deliver e-HIM conferences & other

educational opportunities to assist existing HIM professionals make the transition from traditional practice to new ways of working


What is IFHIMA doing??!!!! IFHIMA is working around the world to support

HIMs I am leading out-reach work in Africa to help

take HIM forward in the region My visit to Nigeria is a VERY important step for

IFHIMA to help HIMAN to raise the profile of HIM in your country

The congress in Montreal in May 2013 is a unique opportunity for us all to work together to play our part in dealing with the challenges for HIM. Between now and then let us work on the challenges together and then meet to discuss and share our experiences in Canada


IFHIMAs 4 Strategic Initiatives1. HIM EDUCATION IFHIMA Education Modules are on the website (free of charge),

International Educators Day in Montreal on Saturday 11th May 2013 (free of charge)2. NEEDS OF DEVELOPING COUNTRIES - IFHIMA Education Modules on the

website (free of charge), Needs of Developing Countries project and a White Paper to be published on the website before the congress in Montreal

3. DATA QUALITY/DATA MANAGEMENT - Joint working with WHO on the International Training & Certification Program for mortality & morbidity coders, free coding information sheets on the website, IFHIMA contributed to the FREE WHO ICD-10 training tool, IFHIMA is providing input to the development of ICD-11, working with WHO on a 3-year project to provide training in ICD 10 to all countries in Africa

4. THE ELECTRONIC HEALTH RECORD (EHR) White Paper to be published on the website before the congress in MontrealThe IFHIMA Executive Board is currently preparing a strategic plan for presentation at the IFHIMA General Assembly on Sunday 12th May 2013 in Montreal. Join the discussion groups at the IFHIMA General Assembly and contribute to IFHIMAs Strategic Planning Process. Its free of charge to attend and your input will be greatly valued.


What can YOU do?Your professional challenges!

Contribute to IFHIMAs Global News Reach out across country, regional and

international borders Communicate & share best practices Be professional in your working practices

at all times


Other things for you to doYour personal challenges!

Embrace & be proud of your profession Embrace change, dont resist it Be focused Take responsibility and initiative Commit to continuous learning Communicate effectively Be the best that you can be!


Thank you all very much

for inviting me to Nigeria, for your very warm welcome and for asking me to contribute to your meetings!

Being here means a great deal to me! Lorraine


Contact DetailsLorraine Nicholson FHRIM

Immediate Past President of IFHIMA141 Leander Drive,

Castleton,Rochdale OL11 2XE,

Lancs., UKTel: +44 1706 355957

E-mail:[email protected]: http://www.ifhima.org


References HIMSS http://www.himss.org/asp/topics_ehr.asp Daily Times NG, 25th April 2012, HIMAN calls for e-health record keeping,

Mr. Wole Ajayi http://dailytimes.com.ng/article/himan-calls-e-health-record-keeping

American Health Information Management Association (AHIMA) "Managing the Transition from Paper to EHRs." (Updated November 2010). http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048418.hcsp?dDocName=bok1_048418

Hofdijk, Jacob, Casemix Advisor, Ministry of Health, Introduction to the Silo Crossing Integrated Care Approach, Presentation at eHealth Week 2012, Copenhagen, Denmark, 8th May 2012 - Session MR18, OC4 Continuity of Care

Bloomrosen, Meryl. "e-HIM: From Vision to Reality." Journal of AHIMA 76, no.9 (October 2005): 36-41

Linda Kloss, Health Information Management in 2016, Precyse Solutions http://www.precyse.com/resources/HIM%20in%202016%20White%20Paper

_042412.pdf

challenges & prospects for ehrs final nov 2012

Documents

electronic health record

national ehr data

ehr development

arab health awards

canada health infoway

ehr initiatives

nigeriaexamples of ehrs

deployment of ehr systems