Electronic Data Management

8/12/2019 Electronic Data Management

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Electronic Data Management:Electronic Health Record Systems

and CPOE Systems


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Introduction

Electronic Data Management

Two forms of technology:

Electronic Health Record (EHR) Systems

Computerized Provider Order Entry (CPOE) Systems


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Electronic Health Record (EHR) Systems

Computer based-applications

Designed to acquire, store, manage, and displayhealth care related records


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Reasons for limited adaptation of EHR Systems

High cost of developing and maintaining suchsystems

Unclear return of EHR investments

Physician resistance Inadequate number of individuals trained in IT


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Computerized Provider Order Entry (CPOE)

System

It is a process by which health care providers placeclinical orders using a computerized system.

Only 17% of hospitals use CPOE systems


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Electronic Health Record Systems


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Terminologies:

Electronic Health Records

Electronic Medical Records

Personal Health Records


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History of EHR

Began in the 1960s

The Medical Record developed in 1970 at DukeUniversity

The Regenstrief Medical Record System developed in1972


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EHR SYSTEMS

Tools that provide secure, real-time, point-care andpatient centered information for all health careproviders

Remind and advise health care providers Provide easy retrievable information about care

given days or years before

Coordinate the efforts of all parts of the health care

system


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Good EHR systems standards:

Can help clinicians manage multiple aspects ofpatient care

Promote better decision making

Enabled patient to be coordinated across differentsites of health care delivery, support administrativefunctions related to scheduling patients admissionsand appointments, and organize information


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Comprehensive EHR systems components:

DATA REPOSITORY

A type of database that contains patientinformation, including list of medications, allergies,

lab and radiology testing results, and etc.


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USER INTERFACES

Point of communication between clinicians andthe system. These are essential for the basic work of

medicine including the entry of new orders orprescriptions, viewing of lab reports, schedulingclinical visits or admission, and managing lists ofdiagnoses.


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CLINICAL DECISION SUPPORT

A tool which guide and advise clinicians as theyinterface with the system. It provides feedback aboutthe best available evidence from nation professionalsociety clinical guidelines and other experts sources.


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COMPUTER-BASED DOCUMENTATION SYSTEMS

Assist health care providers in documentingtheir clinical decision making and patient

interactions.


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Benefits of EHR Systems

Electronic Health Record Systems

Provide a number of direct benefits to health careproviders; physicians, nurses, pharmacist and

therapist. Data can be automatically captured as a part of the

overall workflow.

Errors can be reduced because information enteredat keyboards or other data capture devices goesright into an HER system.


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Clinical Documentation Tools

Improve legibility and reduce medication anddocumentation errors.

Aggregate performance information by disease, byhealth care providers and patient-care area.

Can be connected directly to medical devices.

Improve compliance with regulatory societystandards.


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Support Research Efforts

Researchers can download informationelectronically from diverse locations quickly and

economically. Designed to improve the quality of data received by

prompting clinicians to provide complete medicaldata.

Data can be made available shortly afterwards.

I f ti C t t d D t I ith


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Information Content and Data Issues with anEHR System

List of potential functionalities that could be incorporated in anEHR system:

Clinical Documentation Medication administration records Nursing assessments Physician notes Problem list Test an Imaging Diagnostic test imaging

Diagnostic test result Laboratory reports Radiographic images and reports


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CPOE Laboratory tests

Medications

Decision Support

Clinical guidelines

Clinical reminders

Drug-allergy alerts

Drug-drug interaction alertsDrug-laboratory interaction alerts

Drug dose support

bl l f


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Two Common Problems Occur in Real LifePractice

Difficulties in data input

System information sharing limit the ability tocollect and access good data


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Different Ways to Input Patient Data

Manual Punch Card

Patient Entered Data (electronic questionnaire)

Keyboard (handheld key pad)

Direct interfaces with other computers that generate data(digital laboratory test analyzers, some glucose monitors)

Point and click entry

Drawing (digital tablet)

Scanning of handwritten documentsBut each method of data input has a relative strength and

weaknesses

Li it d S t I t ti it /


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Limited System-Interconnectivity/Interoperability

Problem arose when different systems/ tools within asingle system encode the same information usingdifferent words, codes or narrative structure.

Vendors of EHR systems have customized theirproduct resulting in differing data categories andformats.


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Data Standardization

Defines a regular format for the data, the terms used torepresent it and the configuration it should take.

Example:

Weightmust includeName (e.g., weight), Value (e.g.,175), and the Units

(e.g., pounds)


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Health Level 7 (HL-7)

Defines standards for data formatting andconfiguration.

Data from two HL-7 compliant systems can

communicate with relative ease and minimaladditional programming.

United Stated National Committee on Health and


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United Stated National Committee on Health andVital Statistics (NCVHS)

Identified several core clinical vocabularies asterminology standards.


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Enterprise Information Architecture

Describes a structure fro implementing informationsystems that takes a holistic view of system design.

Simplifies the overall EHR system by designing

interoperability into the system with compatible,logical suites of application programs.


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EHR systems are expensive to purchase, implement,and maintain.

SOLUTION: Incentives that can help offset the EHRsystem purchasing costs include reimbursement

from third-party payers and/ or governmentalsupport.

High expectations from: U.S. Department of Health and Human services, (HHS)

Congress Food and Drug Administration, (FDA)

Centers for Medicare and Medicaid Services (CMS)


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Computerized Provider Order Entry

Promoted as a major solution to the problem of medical error. In 2000, Institute of Medicine- first report on medical error,

To Err is Human.

Crossing the Quality Chasm: A New Health System for the

21

st

Century- importance of EHR systems and CPOE. CPOE have been designed with an emphasis on functions for

reducing adverse drug events

Leapfrog Group- made CPOE one of the three recommendedgoals to improve quality in hospitals.


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CPOE vs. E-prescribing

CPOE describes orderentered electronically intoa health systems EHRanywhere within thesystem

Includes orders forlaboratory, dietary,radiology, nursing, andpharmacy services.

Electronic prescribing or e-prescribing refers only toCPOE in ambulatory caresettings.

Typically describes

electronic transmission ofprescription data betweenprescribers, pharmacies,pharmacy benefitmanagers, and insurance

plans.


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Computerized Provider Entry

mid- 1970s Early systems allowed health care providers to enter

orders directly into the system but provided littledecision support to alert drug-drug interactions, allergy,

warning, etc. System functionality, hardware limitations, and

readiness of institutions limited early adoption Over subsequent years, technical advancement and the

necessity for tools to assist professional in deliveringever-increasing complex care to patientsfurtheradoption of CPOE.


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CPOE for medications has only been fully implemented in17% of all U.S hospitals with 45% of hospitals having noCPOE or plans for CPOE in the near future.

REASONS FOR NOT ADOPTING CPOEs1. Belief that physicians would not use computerized ordering2. Products available from vendors have not been perfected3. Technical and process complexities of implementing CPOE

translate into a significant investment with no guarantee ofsuccess.

4. Lack of standardization in practice across health care facilities.


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Implementing CPOE Systems


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CPOE Systems

Promote their potential to reduce adverse eventsrelated to prescribing

Alerting health care providers to potential errors includingdrug interactions and patient allergies


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Goals

Improve patient safety

Increase timeliness of care

Facilitate use of current medical knowledge via

clinical decision support Improve the process and coordination of care

Limit the missed opportunities for preventive care

Provide research capability for epidemiologicalstudies

Control or reduce costs


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Disadvantages

While its implementation impacts every hospitaldepartment, the pharmacy often becomesdisproportionately involved in the process

Complexity of the medication CPOE module

Volume of transactions

Perceived value of CPOE on the medication order process

CPOE implementation is generally too massive for thepharmacy to initiate but the pharmacy must be prepared and

positioned to provide leadership in the medication componentof these systems


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Process of CPOE (Prescriber)

Prescriber signs in to a computerverifies identity andprescribing privileges of the prescriber therebypreventing any prescribing outside ones scope ofpractice

A patient is selectedpatients medical record isreviewed for any medication therapy

Prescriber chooses drugdosage, route ofadministration, and other options are presented along

with any alerts or advisories relevant to the situation

Prescriber authorizes orderorder is then sent to thepharmacy electronically, or sometimes, in print form


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Process of CPOE (Pharmacy)

Order is reviewed against the patients medicationprofile or medical record and entered into the system

Alerts and advisories are flagged for the

pharmacistthis helps resolve any potentialproblems with prescriber

Medication is dispensed with directions and sent tothe nursing unit for administration to the patient


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Clinical Decision Support System

Set of tools that facilitates the decision-makingcapabilities of the prescriber at the decision point ofCPOE

Ranges from simple (reminder) to complex(algorithms) to recommend or change therapy


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Goals and Advantages

Checks allergies

Duplicate therapies

Drug interactions

Abnormal dosage ranges


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Disadvantages

Not always effectively utilized in CPOE systemsbecause many alerts are clinically insignificant whileimportant alerts are often inadequately addressed

Pharmacists are not allowed access to patientdemographics information, disease information, andlaboratory values


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Passive CDS Intervention

Present relevant patient-specific information to theprescriber without recommending a change intherapy

Examples: nonformulary alerts, drug shortages, andorder tests


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Active CDS Intervention

Utilize specific patient information combined withother content knowledge to recommend or changetherapy

Examples: recommendation of dosing, allergywarnings, and safer therapy, or less expensivetreatment options


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Drug-Content Modules

Provided by CPOE vendors with their productswhich serve as the core of medication CDS

Provide alerts for drug-drug, drug-allergy, drug-pregnancy, and other drug-related problems

This ensures that majority of alerts are clinicallysignificant and actionable while only minimalnumber are time wasters

Examples: First Data Bank, Multum, Micromedex


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Alerts

Should only be generated for clinically significantproblems

Causes the problem of alert fatigue where the clinician isdesensitized to warnings

Pharmacists have an important role to play here inidentifying nuisance alerts from relevant alerts anddeveloping strategies for reducing them

Pharmacists can also update systems to reflect the bestavailable evidence on therapy

Most commercial systems allow pharmacists todeactivate nuisance alerts and add new alerts deemedclinically important for an institutions patientpopulation


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Outcomes for any CDDS Alert

Alert Generated No Alert Generated

Correct Alert Alert for clinicallysignificant problem

No alert generatedbecause of no error

Incorrect Alert Alert generated for aclinically insignificant

problem

No alert generated fora clinically significant

problem


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Assessing the Impact

Medication safety and adverse drug events

Response time for medication processing

Pharmacy resource needs

Drug cost reductions and achieving financial targets Downtime and availability of systems

Response time of system

Clinical alerts and action taken by provider


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Importance of Systems

By monitoring the performance, make neededadjustments, and provide feedback to the user, thisencourages support of the system and continuousimprovement of the system

This will introduce new opportunities for error, thusintroducing new opportunities for better change


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Documents

Electronic Data Management