Unit 3: Electronic Health Records

Lecture A defines an electronic medical record (EMR) and electronic health record (EHR) and explains their similarities and differences, identifies attributes and functions of an EHR, discusses the issues surrounding EHR adoption and implementation, and describes the impact of EHRs on patient care. Lecture B links EHRs to the Health Information Exchange (HIE) and the Nationwide Health Information Network (NHIN) initiatives, discusses how HIE and NHIN impact health care delivery and the practice of health care providers, summarizes the governmental efforts related to EHR systems including meaningful use of interoperable health information technology and a qualified EHR, describes the Institute of Medicine’s vision of a health care system and its possible impact on health management information systems, and lists examples of the effects of developments in bioinformatics on health information systems.

Lectures

Lecture A Notes

Slide 1

Welcome to Health Management Information Systems: Electronic Health Records.  This is Lecture a.

The component, Health Management Information Systems, is a “theory” component that provides an introduction to health care applications and the systems that use them, health information technology standards, health-related data structures, and enterprise architecture in health care organizations. 

Lecture a will define an electronic medical record (EMR) and electronic health record (EHR) and explain their similarities and differences, identify attributes and functions of an EHR, discuss the issues surrounding EHR adoption and implementation, and describe the impact of EHRs on patient care. 

Slide 2

The Objectives for this unit Electronic Health Records are to:

  • State the similarities and differences between an electronic medical record (EMR) and electronic health record (EHR); 
  • Identify attributes and functions of an EHR;
  • Describe the perspectives of health care providers and the public regarding acceptance of or issues with an EHR, which can serve as facilitators of or major barriers to its adoption; and
  • Explain how the use of an EHR can affect patient care safety, efficiency of care practices, and patient outcomes;

Slide 3

Additional Objectives for this unit, Electronic Health Records are to:

Discuss how Health Information Exchange (HIE) and Nationwide Health Information Network (NHIN) impact health care delivery and the practice of health care providers;

Outline issues regarding governmental regulation of EHR systems, such as meaningful use of interoperable health information technology and a qualified EHR;

Summarize how the Institute of Medicine’s Vision for 21st Century Health Care and Wellness may impact health management information systems; and Identify how ongoing developments in biomedical informatics can affect future uses and challenges related to health information systems.

Slide 4

As a way of introduction to electronic health records, let’s identify why a patient or medical record exists in the first place. According to Dr. Reiser, the purpose of a patient record is “to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions” (Reiser, 1991, p. 902). 

The medical record is a way of communicating between staff managing patient care. It also allows for an integrated view of patient data. 

The patient medical record is also the legal business record for a health care provider, as the American Health Information Management Association (AHIMA) e-HIM Work Group on Maintaining the Legal EHR, pointed out in the article Maintaining a Legally Sound Health Record—Paper and Electronic. In this same article, the Work Group states “As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards” (AHIMA, 2005, para. 1). 

Slide 5

Historically, patient records have been paper-based. However, more and more health care providers are moving away from paper-based to adoption of an electronic form. There are two terms associated with the electronic form. They are electronic medical record (or EMR) and electronic health record (or EHR).

The report, Defining Key Health Information Technology Terms defines an EMR as “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization” (NAHIT, 2008, p. 6). This same report stated “health-related information encompasses health, wellness, administrative data, and information derived from public health and scientific research. It includes past and present observations and facts documented in the provision of health care that may be related to preventing illness and promoting wellness or that may be used in the process of informing consent” (NAHIT, 2008, p. 10).

An electronic medical record is a record of medical care created, managed, and maintained by one health care organization. This does not mean a single physical location. There may be instances when information is shared among multiple facilities and still be within one EMR. For example, an electronic record used in a physician practice with several offices is still an EMR when all sites are using the same proprietary data structure and architecture and the information is not moving outside the confines of the organization. 

EMRs are the electronic equivalent of an individual’s legal medical record for use by providers and staff within one health care organization.

Slide 6

The purpose of an EMR is to provide an electronic equivalent of an individual’s legal medical record for use by providers and staff within one health care organization.

The EMR is understood to meet specific business needs for care, reimbursement, and disclosure, follow regulation and rules promulgated by Federal, State, or accrediting entities, and contain information as defined by the provider organization.

The electronic medical record encapsulates a record of medical care provided in a single health care organization, i.e., an intra-organizational medical record. 

Slide 7

The other term associated with electronic records is electronic health record, or EHR.

The report Defining Key Health Information Technology Terms also provided a definition for electronic health record. An EHR is “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization” (NAHIT, 2008, p. 6).

Being a repository of individual health records that reside in numerous information systems and locations, EHRs are intended to support efficient, high-quality integrated health care, independent of the place and time of health care delivery. Consequently, EHRs are part of a health information technology infrastructure.

Slide 8

The purpose of an EHR is to provide an electronic equivalent of an individual’s health record for use by providers and staff across more than one health care organization. An EHR is inter-organizational, that is, two or more unrelated health care organizations contribute to the record which becomes an aggregation of one record focused around a person’s comprehensive health history rather than being one provider’s record. However, to arrive at this level of information aggregation, all contributors must be able to send and receive information using standards that facilitate the interoperable exchange of health-related information.

An EHR is intended to support efficient, high-quality integrated health care, independent of the place and time of health care delivery. 

It encapsulates an electronic equivalent of an individual’s health record for use by providers and staff in multiple unrelated facilities.

As the National Alliance for Health Information Technology’s report Defining Key Health Information Technology Terms explained, “The principal difference between an EMR and an EHR is the ability to exchange information interoperably. An EMR aligns with the prevailing state of electronic records today (whether the record is branded an EMR or an EHR). However, the movement of the industry is toward electronic records that are capable of using nationally recognized interoperability standards, which is a key defining component of an EHR” (NAHIT, 2008, p. 5).

Slide 9

Adding to NAHIT’s principle difference, other comparisons illustrating similarities and differences between an EMR and EHR are shown in Table 3.1.

The first row in Table 3.1 states an EMR is a record of medical care created, managed, and maintained by one health care organization (intra-organizational) while an EHR is a repository of individual health records that reside in numerous information systems and locations (inter-organizational). 

The second row explains an EMR is an integration of health care data from a participating collection of systems from one health care organization in contrast to an EHR which is an aggregation of health-related information into one record focused around a person’s health history, i.e., a comprehensive, longitudinal record. 

The third row points out an EMR is consulted by authorized clinicians and staff within one health care organization while an EHR is consulted by authorized clinicians and staff across more than one health care organization.

The fourth and final row reiterates NAHIT’s principle difference, that is, in an EMR, data continuity exists throughout one health care organization but in the case of an EHR, data interoperability across different organizations occurs.

While these distinctions can be made between an EMR and EHR, many regard the two terms as synonymous.

Slide 10

According to a Centers for Medicare and Medicaid Services Fact Sheet, Electronic Health Records at a Glance, electronic health records improve care by enabling functions that paper records cannot deliver.

These include:

“EHRs can make a patient’s health information available when and where it is needed – it is not locked away in one office or another.

EHRs can bring a patient’s total health information together in one place, and always be current – clinicians need not worry about not knowing the drugs or treatments prescribed by another provider, so care is better coordinated.

EHRs can support better follow-up information for patients – for example, after a clinical visit or hospital stay, instructions and information for the patient can be effortlessly provided; and reminders for other follow-up care can be sent easily or even automatically to the patient.

EHRs can improve patient and provider convenience – patients can have their prescriptions ordered and ready even before they leave the provider’s office, and insurance claims can be filed immediately from the provider’s office” (CMS, 2010, para. 5)

Slide 11

Additionally, “EHRs can link information with patient computers to point to additional resources – patients can be more informed and involved as EHRs are used to help identify additional web resources.

EHRs don’t just “contain” or transmit information, they also compute with it – for example, a qualified EHR will not merely contain a record of a patient’s medications or allergies, it will also automatically check for problems whenever a new medication is prescribed and alert the clinician to potential conflicts.

EHRs can improve safety through their capacity to bring all of a patient’s information together and automatically identify potential safety issues -- providing “decision support” capability to assist clinicians” (CMS, 2010, para. 5).

Slide 12

The final group of ways in which EHRs can improve care according to CMS are: 

“EHRs can deliver more information in more directions, while reducing “paperwork” time for providers – for example, EHRs can be programmed   for easy or automatic delivery of information that needs to be shared with public health agencies or quality measurement, saving clinician time.

EHRs can improve privacy and security – with proper training and effective policies, electronic records can be more secure than paper.

EHRs can reduce costs through reduced paperwork, improved safety, reduced duplication of testing, and most of all improved health through the delivery of more effective health care” (CMS, 2010, para 5).

With regards to improving privacy and security, EHRs can be encrypted and stored on password-protected systems thereby restricting their access to only those authorized. In addition, systems can track who accessed a record, when it occurred and for what purpose. Firewalls and other physical security measures can be put in place to prevent unauthorized users from gaining access to patient records.

Overall EHRs have the potential for improvements in patient safety and quality. However, improvements are not an automatic result of implementing an EHR. 

Slide 13

Thus, an electronic health record is not an electronic version of the paper record. An electronic health record has additional attributes or properties that a paper record does not.

The Healthcare Information and Management Systems Society or HIMSS described eight attributes of an electronic health record in their report HIMSS Electronic Health Record Definitional Model. The first two attributes are that the EHR: 

“Provides secure, reliable, real-time access to patient health record information, where and when it is needed to support care

Captures and manages episodic and longitudinal electronic health record information” (Handler, et al., 2003, p. 3).

Slide 14

The next three attributes as described in the HIMSS report are the EHR:

“Functions as clinicians’ primary information resource during the provision of patient care

Assists with the work of planning and delivering evidence-based care to individual and groups of patients and

Supports continuous quality improvement, utilization review, risk management, and performance monitoring” (Handler, et al., 2003, pp. 4-5).

Slide 15

The final three attributes listed in the HIMSS report are the EHR

“Captures the patient health-related information needed for reimbursement

Provides longitudinal, appropriately masked information to support clinical research, public health reporting, and population health initiatives 

Supports clinical trials” (Handler, et al., 2003, pp. 6-7).

In addition to those identified in the HIMSS report, two additional attributes are the EHR supports timely access to patient information and by more than one person at a time and provides the ability to generate reports that can help measure activity and determine levels of compliance with policies and evidence-based medicine protocols.

Slide 16

In addition to the HIMSS report, Health Level Seven International, or HL7, published an EHR System Functional Model. According to HL7’s web site, HL7 is “an ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation of health services” (HL7, 2011, para. 1).

The HL7 EHR System Functional Model establishes EHR systems (EHR-S) standards that will enable the development of EHRs based on one set of functional requirements. The model contains three sections. They are Direct Care functions, Supportive functions, and Information Infrastructure functions.

Slide 17

According to the HL7 EHR-S Model (2007), direct care functions are functions employed in the provision of care to individual patients. Direct care functions are the set of functions that enable delivery of healthcare or offer clinical decision support. Subsets of direct care functions include care management, clinical decision support, and operations management and communication. 

Some examples of the Care Management subset are the capability to identify and maintain a patient record, manage patient demographics, and manage problem lists.

For the Clinical Decision Support subset, examples of direct care functionality include support for standard care plans, guidelines, protocols; support for medication and immunization administration; and orders, referrals, results and care management.

Examples for the Operations Management and Communication subset are clinical workflow tasking, support clinical communication, and support for provider-pharmacy communication.

Slide 18

The HL7 EHR-S Model (2007) describes supportive functions as functions that support the delivery and optimization of care, but generally do not impact the direct care of an individual patient. These functions assist with the administrative and financial requirements associated with the delivery of healthcare, provide support for medical research and public health, and improve the global quality of healthcare. 

Slide 19

The final section, Information Infrastructure Functions, define the heuristics of a system necessary for reliable, secure and interoperable computing (HL7 EHR-S Model, 2007). These functions are not involved in the provision of healthcare, but are necessary to ensure that the information system provides safeguards for patient safety, privacy and information security, as well as operational efficiencies and minimum standards for interoperability.

The functions for this section include security, health record information and management, registry and directory services, standard terminologies and terminology services, standards-based interoperability, business rules management, and workflow management.

Slide 20

In addition to HL7’s EHR systems (EHR-S) standards, the Office of the National Coordinator for Health Information Technology published The Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology Final Rule (2010) which includes the following standards for the certification of EHR technology: 

Content exchange standards for exchanging electronic health information. For example, the National Council for the Prescription Drug Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT standard or the HL7 Clinical Document Architecture (CDA) Release 2, Continuity of Care Document (CCD)      

Vocabulary standards for representing electronic health information. Two examples of vocabulary standards are the Systematized Nomenclature of Medicine Clinical Terms and Logical Observation Identifiers Names and Codes.

Standards for health information technology to protect electronic health information created, maintained, and exchanged. For example one standard is any encryption algorithm identified by the National Institute of Standards and Technology (NIST) as an approved security function in Annex A of the Federal Information Processing Standards (FIPS) Publication 140–2. Another example is a hashing algorithm with a security strength equal to or greater than SHA–1 (Secure Hash Algorithm (SHA–1) as specified by the NIST in FIPS PUB 180–3. (p. 44650)

Slide 21

With more and more health care providers moving away from paper-based to adoption of an electronic medical record, with the ultimate goal of implementing an electronic health record, it stands to reason a question one might ask is “why aren’t we there yet?” To answer that question, the perspectives of health care providers and the public regarding acceptance of, or issues with, an EHR will be explored.

First from the standpoint of the provider, EHR acceptance is on the rise throughout the health care community as more and more research supports the benefits far outweigh the costs.

Regarding costs to implement, monetary incentives have been put in place by the Federal Government to stimulate EHR adoption. Momentum for widespread adoption and implementation has picked up since the American Recovery and Reinvestment Act, or ARRA, was signed into law February 2009. ARRA provides many different stimulus opportunities, one of which is $19.2 billion for health IT. The Health Information Technology for Economic and Clinical Health, often referred to as HITECH, is a provision of the American Recovery and Reinvestment Act. The funding is expected to assist providers and states in adopting and utilizing health IT in order to achieve widespread adoption of health IT and enable electronic exchange of health information.

Providers have also begun to accept EHRs since the establishment of the Certification Commission For Health Information Technology or CCHIT. With certification, a certain comfort level exists with regards that the EHR purchased and implemented will have longevity and meet specific requirements. In addition to CCHIT, ONC-Authorized Testing and Certification Bodies are Drummond Group, InfoGard Laboratories, SLI Global Solutions, ICSA Labs, and Surescripts. The American National Standards Institute (ANSI) has been approved as the ONC-Approved Accreditor (AA) for the Permanent Certification Program. 

Slide 22

As cited in IHE Moves EHR Goals Forward, “The public has mixed feelings about EHRs. A national Harris Interactive survey found that 45 percent of adults believe that tools to track and maintain their own personal medical information with an EHR system are very important, but they worry that computerization could increase rather than decrease medical errors and that federal health privacy rules will be reduced in the name of efficiency” (RSNA, 2005, para. 9).

Slide 23

A more recent poll conducted by Harris Interactive (2010) online from June 8-10, 2010, among 2,035 U.S. adults, showed little change from 2009 to 2010 with regards to adults attitudes of electronic medical records.

Seventy-eight percent in both 2009 and 2010 answered "Strongly/Somewhat Agree“ that all physicians treating me should have access to information contained in my EMR.

Seventy-two and seventy-one percent in 2009 and 2010 respectively answered "Strongly/Somewhat Agree“ that an EMR would be a valuable tool to track the progress of my health.

Slide 24

Even with acceptance on the rise, barriers still exist. An editorial Stimulating the Adoption of Health Information Technology describes barriers to adoption  as “their substantial cost, the perceived lack of financial return from investing in them, the technical and logistical challenges involved in installing, maintaining, and updating them, and consumers’ and physicians’ concerns about the privacy and security of electronic health information” (Blumenthal, 2009). 

Each one of these has its own complexities. For example, logistical challenges would include resources issues, training and re-training, resistance by potential users, and development of new workflow processes. The possibility of poor clinical system performance would impact provider productivity and also become a significant barrier to adoption. Privacy and security concerns include identity theft and widespread exposure of personal health information with the risk of it being seen by unauthorized personnel if it is sent electronically. Breeches through stolen laptops or hacking is also a concern.

Another barrier to adoption is the perceived lack of return on investment to the practitioner

Slide 25

Even though perceived or bona fide barriers do exist, potential benefits to adopting and implementing EHRs are surfacing. With respect to having an effect on patient care safety they include: 

  • Reducing the need to repeat tests,
  • Reducing the number of lost reports, and
  • Supporting provider decision making 

Slide 26

EHRs also have an effect on efficiency by

Improving accessibility of patient information, e.g., being able to access reports anytime/anywhere,

Integrating data from multiple internal and external sources, e.g., improving charge capture, and

Facilitating coordination of health care delivery, e.g., no need to retrieve and copy paper charts.

Slide 27

The final effect of EHR adoption and implementation is on patient outcomes. An EHR has the potential to improve the quality of patient care and help providers practice better medicine. Being a repository of individual health records that reside in numerous information systems and locations, EHRs are intended to support efficient, high-quality integrated health care, independent of the place and time of health care delivery. An EHR also has the potential to provide seamless exchange of information among providers.

Slide 28

This concludes Lecture a of Electronic Health Records. This lecture defined an electronic medical record (EMR) and an electronic health record (EHR) and explained their similarities and differences, identified EHR attributes and functions, discussed the issues surrounding EHR adoption and implementation, and described the impact of EHRs on patient care.

Lecture B Notes

Slide 1

Welcome to Health Management Information Systems: Electronic Health Records.  This is Lecture b.

The component, Health Management Information Systems, is a “theory” component that provides an introduction to health care applications and the systems that use them, health information technology standards, health-related data structures, and enterprise architecture in health care organizations.

Lecture b will link EHRs to the Health Information Exchange (HIE) and the Nationwide Health Information Network (NHIN) initiatives, discuss how HIE and NHIN impact health care delivery and the practice of health care providers, summarize the governmental efforts related to EHR systems including meaningful use of interoperable health information technology and a qualified EHR, describe the Institute of Medicine’s vision of a health care system and its possible impact on health management information systems, and list examples of the effects of developments in bioinformatics on health information systems.

Slide 2

The Objectives for this unit, Electronic Health Records are to:

State the similarities and differences between an electronic medical record (EMR) and electronic health record (EHR); 

Identify attributes and functions of an EHR;

Describe the perspectives of health care providers and the public regarding acceptance of or issues with an EHR, which can serve as facilitators of or major barriers to its adoption;

Explain how the use of an EHR can affect patient care safety, efficiency of care practices, and patient outcomes;

Slide 3

Additional Objectives for this unit, Electronic Health Records are to: 

Discuss how Health Information Exchange (HIE) and Nationwide Health Information Network (NHIN) impact health care delivery and the practice of health care providers;

Outline issues regarding governmental regulation of EHR systems, such as meaningful use of interoperable health information technology and a qualified EHR;

Summarize how the Institute of Medicine’s Vision for 21st Century Health Care and Wellness may impact health management information systems;

and Identify how ongoing developments in biomedical informatics can affect future uses and challenges related to health information systems. 

Slide 4

A definition of health information exchange begins our discussion. The report, Defining Key Health Information Technology Terms defines health information exchange as the electronic movement of health-related information among organizations according to nationally recognized standards” (NAHIT, 2008, p. 6).

According to the report, “the process of health information exchange enables the sharing of health-related information among health care organizations and with individuals on a local, regional, and national basis” (NAHIT, 2008, p. 23).

The EHR is a central component of HIE.

Slide 5

The report Defining Key Health Information Technology Terms goes on to state “HIE supports the sharing of health-related information to facilitate coordinated care through the utilization of EHRs…. This interplay of electronic records and health information exchange is an important component in establishing the basics of an infrastructure that will become the Nationwide Health Information Network (NHIN)” (NAHIT, 2008, p. 23).

The paper, Health Information Exchanges: Similarities and Differences, identifies three models of HIE.

“A federated model allows the data source organization to maintain custodianship and control over the patient’s medical record and indices. When requested, data is queried from the data source organization.

A centralized model has organizations sending patient demographic and clinical information to a shared repository. This centralized repository is queried to obtain a patient’s clinical results and other information.

A hybrid model is a mixture of the federated and centralized models” (HIMSS, 2009, p. 15). 

Some HIE requirements include policies and procedures for exchanging health information, security utilities, matching algorithm, and record locator service.

Slide 6

Given what is known about HIEs, what potential impact does health information exchange have on health care delivery and the practice of the health care provider?

From a health care delivery viewpoint, HIEs may have both a clinical and financial impact. Health care quality is affected by the ability to exchange electronic heath records across multiple payers and providers. HIEs, enabled by technology, are expected to improve the quality of care and patient safety and reduce health care costs of health care delivery.

The practice of health care providers may also be impacted by having real-time patient care data at the point-of-care and access to patients’ longitudinal test results may facilitate coordination of care and improve clinical decision making, such as the prevention of errors of omission by enabling automated reminders when follow-up studies are indicated. Streamlined information flows may allow for productivity gains by providers who have access to the electronic HIE network.

Slide 7

External influences, specifically the Federal government, are having a major influence on the adoption and implementation of electronic health records and health information exchange. The national agenda for HIT is twofold: increase adoption of Electronic Health Records (EHRs) and build a framework that enables these EHRs to be sharable and interoperable. The Nationwide Health Information Network or NHIN, is part of this national agenda.

According to the Office of the National Coordinator for Health Information Technology, “The Nationwide Health Information Network is the set of standards, services and policies that enable the secure exchange of health information over the Internet” (ONC, 2011, para. 1)

Think of the Nationwide Health Information Network as a collection of standards, protocols, legal agreements, specifications and services overseen by the Office of the National Coordinator for Health Information Technology to support the secure exchange of health information over the Internet. The NHIN has been referred to as a "Health Internet," which is intended to involve consumers, providers, government organizations, and others in its fabric. 

Slide 8

The image is entitled “Nationwide Health Information Network (NHIN)” and consists of a map of the United States with two rings.  The red outer ring is labeled “The Internet.”  The blue dotted inner ring is labeled “Standards, Specifications, and Agreements for Secure Connections.”  Outside the rings starting in the upper left corner and going counterclockwise are the labels, Community #1, Integrated Delivery System, Community #2, various Federal agencies, Community Health Centers, and Health Bank or Personal Health Record or PHR Support Organization. 

What is the reason behind the development of the Nationwide Health Information Network? It is “…to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. This critical part of the national health IT agenda will enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of healthcare information beyond direct patient care so as to improve health” (DHHS, 2008. para. 1).

Slide 9

The NHIN is a key component of the nationwide health IT strategy and is expected to provide a common platform for health information exchange across diverse entities, within communities and across the country, helping to achieve the goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act (Section 3001(b)) calls for the Office of the National Coordinator for Health Information Technology (ONC) to develop “a nationwide health information technology infrastructure that allows for the electronic use and exchange of information and that…ensures that each patient’s health information is secure and protected, in accordance with applicable improvements in health care quality, reduces medical errors, reduces health disparities, and advances the delivery of patient centered medical care” among other goals.

NHIN is a critical part of the national health IT agenda. The goal is to enable health information to follow the consumer, be available for clinical decision making, and support appropriate use of health care information beyond direct patient care and, as a result, improve population health.

The role of the NHIN is to provide means by which health and health care entities are able to securely exchange interoperable health information.

Slide 10

The Office of the National Coordinator for Health IT (ONC) believes that with broad implementation, the secure exchange of health information using NHIN standards, services and policies will help improve the quality and efficiency of healthcare for all Americans. Driven by emerging technology, users, uses, and policies, the NHIN is evolving to meet emerging needs for exchanging electronic health information securely over the Internet.

One example is the initiative, the NHIN Direct Project. The NHIN Direct Project is being launched to explore the NHIN standards and services required to enable secure health information exchange at a more local and less complex level, such as a primary care provider sending a referral or care summary to a local specialist electronically.

The report The Direct Project Overview states “The Direct Project specifies a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet. The Direct Project focuses on the technical standards and services necessary to securely push content from a sender to a receiver and not the actual content exchanged. However, when these services are used by providers and organizations to transport and share qualifying clinical content, the combination of content and Direct-Project-specified transport standards may satisfy some Stage 1 Meaningful Use requirements” (The Direct Project, 2010, p. 4).            

This may include for example communication of summary care records in support of continuity of care.

NHIN Direct will also provide an easy "on-ramp" for a wide set of providers and organizations.

Slide 11

At its most fundamental level the NHIN is a network. Networks for exchanging health related information are essential to aggregating patient-focused information into EHRs.

Health care delivery may be impacted by the NHIN by establishing a standards-based infrastructure which will increase the ability to collect and store aggregated data. The practice of health care providers may be impacted by the NHIN by providing a care coordination platform.

Other NHIN architecture requirements may impact health care delivery and the practice of health care providers including the ability to

  • Discover and exchange healthcare information among participant entities,
  • Match patients to their data without a universal or national patient identifier,
  • Support patient preferences regarding their data exchange,
  • Support secure data exchange,
  • Support harmonized standards,
  • Support diverse sets of organizations, technologies, and approaches, and
  • Support a common trust agreement. 

Slide 12

In addition to the Nationwide Health Information Network, there are State-Level Health Initiatives. These are initiatives designed to ensure that states and regional efforts to achieve health information exchange (HIE) are aligned with the national agenda. The Office of the National Coordinator for Health Information Technology (ONC, 2010) initiatives describes these initiatives in the following manner:

State Health Policy Consortium. The SHPC is responsible for working with groups of states to address policy issues to enable the electronic exchange of health information across state lines.

State-Level Health Information Exchange Consensus Project - The purpose of this initiative is to provide a forum for ONC to work with and disseminate information to states and for the states based efforts to inform the federal government to ensure all health information exchange activities throughout the Unites States align.

State Alliance for e-Health is also a forum consisting of an executive-level body of state elected and appointed officials with the responsibility of working together to facilitate the adoption of interoperable electronic HIE, to identify new inter- and intrastate-based policies and best practices, and explore solutions to programmatic and legal issues related to the exchange of health information.

Health Information Security and Privacy Collaboration (HISPC) are multi-state collaboratives that are addressing privacy and security challenges related to the electronic exchange of health information with the intended outcome to develop common, replicable multi-state solutions that have the potential to reduce variation in and harmonize privacy and security practices, policies, and laws. 

Slide 13

Additional key federal initiatives related to the adoption and implementation of electronic health records tied to HITECH programs include the meaningful use of interoperable health information technology and qualified EHRs and the HIT Advisory Committees.

The Health Information Technology for Economic and Clinical Health Act, or the "HITECH Act" established programs under Medicare and Medicaid to provide incentive payments for the "meaningful use" of certified EHR technology.  According to the Centers for Medicare and Medicaid Services (CMS), “The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals, eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology” (CMS, 2011, para. 1)

On July 13, 2010, the Secretary of HHS published in the Federal Register a final rule that adopted standards, implementation specifications, and certification criteria for HIT. The final rule was released in conjunction with the Medicare and Medicaid EHR Incentive Programs final rule. The CMS regulations specify the objectives that providers must achieve in payment years 2011 and 2012 to qualify for incentive payments. The ONC regulations specify the technical capabilities that EHR technology must have to be certified and to support providers in achieving the “meaningful use” objectives.

Slide 14

The Department of Health and Human Services (HHS) issued a final rule on June 18, 2010 establishing a temporary certification program for EHR technology and included information on how organizations can become ONC-Authorized Testing and Certification Bodies (ONC-ATCBs). According to the Office of the National Coordinator for Health Information Technology, ONC-ATCBs “…test and certify that certain types of EHR technology (Complete EHRs and EHR Modules) are compliant with the standards, implementation specifications, and certification criteria adopted by the HHS Secretary and meet the definition of “certified EHR Technology” (ONC, 2010).

The Temporary Certification Program Final Rule specifically establishes a temporary certification program to assure the availability of Certified EHR Technology prior to the date on which health care providers seeking the incentive payments would begin to report demonstrable meaningful use of Certified EHR Technology.  

The final rule to establish the Permanent Certification Program for Health Information Technology was issued in January 2011. The American National Standards Institute (ANSI) was approved as the ONC-Approved Accreditor (AA) for the Permanent Certification Program which instills the responsibility of accrediting organizations who will certify electronic health record technology. Implementation of the permanent certification program is expected to occur in mid 2012. 

The certification program provides a way for developers of EHR technology to have their EHR technology tested and certified so that it can be subsequently adopted by health care providers who seek to achieve meaningful use. Eligible professionals and eligible hospitals who seek to qualify for incentive payments under the Medicare and Medicaid EHR Incentive Programs are required by statute to use Certified EHR technology. 

Slide 15

The Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology Final Rule (2010) states certified EHR technology means:            

            (1) A Complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary; or

            (2) A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in accordance with the certification program established by the National Coordinator as having met all applicable certification criteria adopted by the Secretary, and the resultant combination also meets the requirements included in the definition of a Qualified EHR.           

Complete EHR means EHR technology that has been developed to meet, at a minimum, all applicable certification criteria adopted by the Secretary. (p. 44649)

Slide 16

The HITECH Act (Section 3001(13)) defines a qualified EHR as:

“An electronic record of health-related information on an individual that:

(A) Includes patient demographic and clinical health information, such as medical history and problem lists; and

(B) has the capacity:

     (i) To provide clinical decision support;

     (ii) to support physician order entry;

     (iii) to capture and query information relevant to health care quality; and

     (iv) to exchange electronic health information with, and integrate such information from other sources” (p. 229).

Slide 17

The American Recovery and Reinvestment Act of 2009 (ARRA) also provided for the creation of two Federal advisory committees under the auspices of the Federal Advisory Committee Act (FACA). These committees are the Health IT Policy Committee and the Health IT Standards Committee.

Per the ONC, the Health IT Policy Committee makes “recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information. The American Recovery and Reinvestment Act of 2009 (ARRA) provides that the Health IT Policy Committee shall at least make recommendations on standards, implementation specifications, and certifications criteria in eight specific areas” (ONC, 2011, para. 1)

The other Federal Advisory Committee is the Health IT Standards Committee. This group is “charged with making recommendations to the National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. Initially, the Health IT Standards Committee is focusing on the policies developed by the Health IT Policy Committee’s initial eight areas…. In developing, harmonizing, or recognizing standards and implementation specifications, the Health IT Standards Committee also provides for the testing of the same by the National Institute for Standards and Technology (NIST)” (ONC, 2011, para. 1) 

Slide 18

Another external influence on the future of health management information systems, electronic health records, and the process of building a framework that enables these EHRs to be sharable and interoperable, is the Vision for 21st Century Health Care and Wellness. As cited in chapter two of Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, “The IOM vision calls for a health care system that is systematically organized and acculturated in ways that make it easy and rewarding for providers and patients to do the right thing, at the right time, in the right place, and in the right way. This vision entails many different factors (e.g., systemic changes in paying for health care, an emphasis on disease prevention rather than disease treatment)” (Stead & Lin, 2009, p. 20)

The principal factor in the Institute of Medicine’s vision of a health care system is the effective use of information.

Slide 19

The report identified information-intensive aspects of the IOM’s vision for 21st century health care. These important health care IT capabilities include: 

  • “Comprehensive data on patients’ conditions, treatments, and  outcomes;
  • Cognitive support for health care professionals and patients to help integrate patient-specific data where possible and account for any uncertainties that remain;
  • Cognitive support for health care professionals to help integrate evidence-based practice guidelines and research results into daily practice; and
  • Instruments and tools that allow providers to manage a portfolio of patients and to highlight problems as they arise both within individual patients and within populations;” (Stead & Lin, 2009, pp. 4-5)

As the Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions report explains “cognitive support” refers to IT-based tools and systems that provide users (clinicians and patients) with the information, abstractions, and models needed to achieve the IOM’s vision of health care quality” (Stead & Lin, 2009, p. 21)

Slide 20

Three additional important health care IT capabilities identified in the IOM’s vision for 21st century health care are:

“Rapid integration of new instrumentation, biological knowledge, treatment modalities, and so on, into a “learning” health care system that encourages early adoption of promising methods but also analyzes all patient experience as experimental data;

Accommodation of the growing heterogeneity of locales for the provision of care, including home instrumentation for monitoring and treatment, lifestyle integration, and remote assistance; and

Empowerment of patients and their families in effective management of health care decisions and execution, including personal health records (as contrasted to medical records held by care providers), education about the individual’s conditions and options, and support of timely and focused communication with professional health care providers” (Stead & Lin, 2009, p. 5)

Slide 21

Ongoing developments in biomedical informatics can affect future uses and challenges related to health information systems and electronic health records. The report listed five principles related to evolutionary change and four principles related to radical change as guidance towards successful use of health care IT to support a 21st century vision of health care.

The five principles related to evolutionary change are:

  1.  “Focus on improvements in care—technology is secondary
  2.  Seek incremental gain from incremental effort
  3.  Record available data so that today’s biomedical knowledge can be used to interpret the data to drive care, process improvement, and research
  4.  Design for human and organizational factors so that social and institutional processes will not pose barriers to appropriately taking advantage of technology
  5.  Support the cognitive functions of all caregivers, including health professionals, patients, and their families” (Stead & Lin, 2009, p. 6)

Accordingly, those in the field of biomedical informatics can affect future developments related to health information systems by, for example, creating technology that address organizational factors, supporting the cognitive functions of caregivers, and designing software for human factors. 

Slide 22

The four principles related to radical change are:

“Architect information and workflow systems to accommodate disruptive change.

Archive data for subsequent re-interpretation, that is, in anticipation of future advances in biomedical knowledge that may change today’s interpretation of data and advances in computer science that may provide new ways of extracting meaningful and useful knowledge from existing data stores.

Seek and develop technologies that identify and eliminate ineffective work processes and

Seek and develop technologies that clarify the context of data” (Stead & Lin, 2009, p. 6).

Slide 23

This concludes Electronic Health Records.  

Lecture a defined an electronic medical record (EMR) and an electronic health record (EHR) and explained their similarities and differences, identified EHR attributes and functions, discussed the issues surrounding EHR adoption and implementation, and described the impact of EHRs on patient care.

Lecture b linked EHRs to the Health Information Exchange (HIE) and the Nationwide Health Information Network (NHIN) initiatives, discussed how HIE and NHIN impact health care delivery and the practice of health care providers, summarized the governmental efforts related to EHR systems including meaningful use of interoperable health information technology and a qualified EHR, described the Institute of Medicine’s vision of a health care system and its possible impact on health management information systems, and listed examples of the effects of developments in bioinformatics on health information systems.

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Comments

  • Great lecture!
  • Wow this is an impressive structure ,..I can see the future !
  • Agreed
  • Quite a bit of info to digest here.
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