lesson 5 - electronic health record and clinical informatics.ppt student copy

Sheila Lyn U. Recidoro,RN

Electronic Health Record and Clinical Informatics


Introduction• January 2004

President George W. Bush raised the profile of electronic health records in his State of the Union address by outlining a plan to ensure that most Americans would have an electronic health record by 2014.


Electronic Health Record (EHR)• A data warehouse or repository of

information regarding the health status of a client, replacing the former paper-based medical record.

• It is the systematic documentation of a client’s health status and healthcare in a secured digital format


Electronic Health Record (EHR) • also known as an Electronic Medical

Record

• can be used to collect and look up patient data by physicians or health professionals at various locations such as doctor’s offices or hospitals.


Information included in EHR :• demographics

• patient problems

• medication

• allergies

• laboratory results, etc.

(Certification Commission for Healthcare Information Technology [CCHIT], 2007).


Components• The definition of an EHR is evolving.

• A survey of the literature reveals that there are many different definitions, each with its own terminology and developed with a different audience in mind.

• The IOM definition is the most widely referenced, however, and provides a good starting point.

* IOM – Institute of Medicine


Components• Health information and data is the patient data required to make sound clinical decisions

• Results management is the ability to manage results of all types electronically including laboratory and radiology procedure reports, both current and historical


Order Entry management• is the ability for a clinician to enter

medication and other care orders directly into a computer including laboratory, microbiology, pathology, radiology, nursing, supply orders, ancillary services and consults.

Components


Decision support

• is the computer reminders and alerts to improve the diagnosis and care of a patient.

Components


Electronic communication and connectivity

• is the online communication among healthcare team members, their care partners and patients including e-mail, web messaging, and an integrated health record within and across settings, institutions and telemedicine

Components


Patient support• is the patient education and self-

monitoring tools including interactive computer based patient education, home telemonitoring and telehealth systems

Components


Administrative Processes :• electronic scheduling

- inpatient and outpatient visits

- procedures• billing and claims management systems

- electronic insurance eligibility validation

- claim authorization and prior approval• identification of possible research study

participants • drug recall support


Reporting and population health management

• is the data collection tools to support public and private reporting requirements including data represented in a standardized terminology and machine-readable format


Office of the National Coordinator for Health Information Technology

(ONCHIT)• was established after President Bush’s

state of the union address in 2004 the to address these nuances and gaps in defining an EHR.

• Primary Mission of ONCHIT : - is to assure users of health information

technology systems that those systems “provide needed capabilities, securely manage information and protect confidentiality and work with other systems without reprogramming” (Department of Health and Human Services, 2007).


Advantages : • no longer having to interpret poor

penmanship and handwritten orders• to reduce turn-around-time for lab results

in an emergency department• For prompt administration of the first dose

of antibiotics in an inpatient nursing unit


Advantages : In the ambulatory care setting :• evidence of improved management of

cardiac related risk factors in patients with diabetes

• effective patient notification of medication recalls


Advantages

• Despite limited standards and published studies, there is enough evidence to warrant pursuing widespread implementation of the EHR (Halamka, 2006)

• To further study of the EHR’s use and benefit.


Ownership

• The process of becoming a successful owner of an EHR has multiple steps and requires integrating the EHR into both the organization’s day to day operations and long term vision, and the clinician’s day to day practice.


Ownership1. Vendor selection process.• Pre-acquisition phase

- understanding the current state of the health information technology industry


Ownership2. Select a system based on the organization’s

current and predicted needs. • The criteria should include both subjective

and objective items :

common clinical workflows

decision support

reporting

usability

technical build

maintenance of the system.


Ownership• Implementation planning should

occur concurrently with the selection process, particularly the assessment of the scope of the work, initial sequencing of the EHR components to be implemented and resources required.

• The implementation plan should also account for the long term optimization of the EHR.


Flexibility and Expandability

• At a very basic level, there is as yet no electronic health record system available that can provide all functions for all specialties to a degree that all clinicians would successfully adopt.

• Most healthcare organizations do not yet have the capacity to implement and maintain systems in all care areas.


Flexibility and Expandability• Financial and patient privacy hurdles

must also be overcome to achieve an expansive EHR.

• The Department of Health and Human Services recently loosened regulations so that physicians may now be able to receive healthcare IT software, hardware and implementation services from hospitals in an effort to alleviate the cost burden on individual providers and foster adoption of the EHR.


Flexibility and Expandability• Patient privacy is a pivotal issue to determining how far and how easy it will be to share data across healthcare organizations.

• For health exchanges such as these to reach their full potential the public must be able to trust that their privacy will be protected, or else risk that patients may not share a full medical history or worse yet may not seek care, effectively making the exchange useless.


Incentives to Invest in EHRs“The value of electronic health records …

as tools to improve access, quality and comprehensiveness of care should be reinforced so that the public clearly understands the benefits and demands of their introduction.

We recommend that providers, governments and the public jointly commit to the rapid adoption of these tools.”

(Health Council of Canada, Report to Canadians, 2005)


Concerns with EHRs“issue of privacy, confidentiality and

protection of personal health information in the context of an EHR system is perhaps the most sensitive one raised”

“Currently, there is significant variation in privacy laws and data access policies across the country that poses a challenge for EHR systems that are dependent on inter-sectoral and inter-jurisdictional flows of personal health information. …”

Senator Kirby, Senate Report on the Health of Canadians (2002)


Privacy, Confidentiality & Security

• Privacy: one’s right to control who has access to information about oneself

• Confidentiality: a duty owed by one to preserve the secrets of another

• Security: mechanisms put in place to safeguard privacy and ensure confidentiality is maintained


Professional Duties• Hippocratic oath– “Whatsoever I shall see or hear concerning

the life of men, in my attendance on the sick, or even apart there from, which ought not to be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets.”


Health Info Privacy Code• right of privacy fundamental in a free and

democratic society• includes patient's right to determine with

whom he or she will share information and to know of and exercise control over use, disclosure and access concerning any information collected about him or her

• right of privacy and consent are essential to trust and integrity of the patient-physician relationship.


Legislative Developments• public sector information and privacy laws

• health information laws– Manitoba (1997)– Alberta (2001)– Saskatchewan (2003)– Ontario (2004)

• private sector privacy laws


Need for legal framework• EHRs “potentially conflict with privacy principles unless patients control how the record is shared and appropriate security measures are in place.”

• “A coherent legal framework to appropriately

protect the privacy and confidentiality of personal health records is therefore an essential first step for successful EHRs”

Amanda Cornwall, “Connecting Health: A review of electronic health record projects in Australia, Europe and Canada” (2003)


Consent

• Should individual consent be required before information is included in EHR or disclosed through EHR?

• To be legally valid, consent generally must be informed:– Who will have access to info?– For what purposes?– What security mechanisms are in place?– What are risks of unauthorized access?


Saskatchewan HIPA• comprehensive health records

• initially gave individuals right to refuse consent

• removed in 2003

• retain right to restrict access to comprehensive health record by giving written instruction


Alberta HIASection 59: required individual consent before information could be disclosed electronically authorization for custodian to disclose purpose for disclosure identity of recipient acknowledgement of reasons, risk, benefits date effective statement that consent may be revoked

Removed in 2003


Practical Experience• “in facilitating a province wide electronic health record, practical experience made it apparent that getting consent from Albertans was going to be difficult and costly”

• not “possible to inform people in a meaningful way of all the specific disclosures by electronic means, which might ever be made of their health information”Frank Work, QC, Alberta Information & Privacy Commissioner


Australian Example• patient consent required to include information in EHR

• pilot project in Tasmania (2004):– many patients were not asked for consent– identified need for simple consent process

• discussion about moving to presumed consent / opt-out model


United Kingdom exampleNational Health Service “care record

guarantee” published May 2005

consent for sharing patient information in EHR is generally presumed

but “You can choose not to have information in your electronic care records shared”

consistent with 2006 BMA statement


Security Obligations• maintain administrative, technical and physical safeguards to protect confidentiality and privacy

• measures to guard against risks associated with EHRs

• audit logs• privacy impact assessments


ConclusionsBenefits and Risks of EHRs

1. professional obligations– ethical and legal

2. patient rights– consent and control

3. achieving an appropriate balance


Future• Despite the challenges, the future

of EHRs is an exciting one for patient and clinician alike.

• Benefits may be realized by stand-alone EHRs as described here, but the most significant transformation will come as interoperability is realized between systems.


Future• There is a wealth of descriptive

data available pointing to the benefits of an EHR.

• Nursing must stay engaged in this evolution and help shape its direction, as it has already proven to have a significant impact on our practice and our patients.


Thought Provoking Questions1. What are the implications for nursing

education as the electronic health record (EHR) becomes the standard for caring for patients?

2. What are the ethical considerations related to interoperability and a shared electronic health record?

lesson 5 - electronic health record and clinical informatics.ppt student copy

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