© 2018 American Health Information Management Association© 2018 American Health Information Management Association

Electronic Health Records

The Value and Importance of

Managing Health Information

Marcie Wright, RHIA, CHDA, CCS

ILHIMA Education Director

© 2018 American Health Information Management Association

How is the Technological Progress of

Phones Like Health Information

Technology?

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The Transition of Health Information

More than a digital version of a patient’s paper chart

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Transition Driven by Organizational Needs

• Paper Health Records.

• Hybrid Health Records use both paper medical records and selectively uses portions of an electronic record.

• Electronic Health Records offers a suite of information systems.

• Commercial EHR systems vary in capability in turn clinics’ needs vary in how extensively they may need to use those capabilities.

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Veterans Affairs’ VistA System

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Clinical Benefits of an EHR

• Enhanced patient care.

• Access patient’s chart remotely.

• Alerts to avoid medication error.

• Alerts to critical lab values and allergies.

• Reminders for preventive care needs (vaccines, cancer screening).

• Facilitates communication with patient.

• Provides clinical guidelines for chronic conditions.

• King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: national findings. Health services research, 49(1pt2), 392-404.

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Administrative Benefits of an EHR

• Maintains patient demographic information and insurance information.

• Able to report to state registries (vaccines to VCF).

• Manages scheduling appointments.

• Problem list (infectious disease contact tracking).

• Medications list.

• Electronic prescription software.

• Billing transaction software.

• Provides structured data for statistics.

• Viewing information and improved legibility.

• Electronic ordering referrals, labs and radiology tests.

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More Accessible

• Electronic access to health information allows multiple people to view the same information at the same time.

• Cloud-based EHR makes the information available by log-in from anywhere.

• Reports are easily compiled for audits, grants, research.

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Beneficial Alerts

• Ability to flag a patients’ chart to

provide alerts to providers (suicide

risk, violent patient).

• Clinical reminders to assist clinical

decision making (vaccination due).

• Drug interaction alerts.

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Data Mining

• Structured data collection for statistical reporting, billing, and workload calculation.

• Compiling and reporting of data from structured data fields within the EHR allows for accurate bio-surveillance, public health reporting, research, quality improvement projects and performance measurement.

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The Voice of Public Health

• Data supports public health’s

mission to improve the current

state of health through health

initiatives.

• Illinois’ First Maternal Morbidity

and Mortality Report

• http://dph.illinois.gov/news/201801

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Case Study- Helping Hands’ New EHR

Small community based clinic, majority

of patient base is Medicaid, has an

office manager, front desk clerk, a

physician assistant, a nurse and a biller

each with separate needs from an

EHR. Hybrid system using both paper

and an EHR product. Purchased a new

system with Meaningful Use funds.

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Helping Hands Problems Encountered

• Did not verify that the EHR product was nationally certified.

• Inexperienced staff did not know how to shop for an EHR product (please don’t Google it).

• Failed to fully consider a product that supported processes for each position.

• Office manager didn’t realize master patient index information from old system would need to manually be re-entered for each patient into the new system.

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Helping Hands Solutions

• Verify the product is nationally certified (slide 16 resources).

• Take time to define the needs of each person’s processes, work with vendors to find the best fit (Columbus, 2006).

• Contact other facilities to get recommendations, view their system, compile a list of positives and negatives for each user.

• Consider how the information you currently use will integrate with the new system. May need a lot of work to transition. Map out solutions.

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Common Challenges of Transition

from Paper to EHR

• Cost.

• New processes can initially increase normal daily workload.

• Interoperability- like a telephone it is only useful if it can communicate with others.

• Cybersecurity.

• Certified EHR products.

• Technology / infrastructure. 15

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Interoperability

• "Interoperability means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data such that clinical or operational purpose and meaning of the data are preserved and unaltered.”

Health Level Seven (HL7). Coming to Terms: Scoping Interoperability for Health Care. White Paper. 2007. Retrieved from https://www.hln.com/assets/pdf/Coming-to-Terms-February-2007.pdf

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Resources – Certified EHR

• The Office of the National Coordinator for Health Information Technology (ONC).

• HealthIT.gov -https://www.healthit.gov/topic/health-it-basics/benefits-ehrs.

• Certified electronic health records -https://www.healthit.gov/topic/certification-ehrs/certification-process.

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Resources

• American Academy of Family Physicians, Center for Health Information Technology. Assistance adopting health IT, ranging from planning to financing, is available at www.centerforhit.org.

• Columbus, S. (2006). Small practice, big decision: selecting an EHR system for small physician practices. Journal of AHIMA, 77(5), 42-46.

• American Health Information Management Association www.ahima.org.

• Illinois Health Information Management Association www.ilhma.org.

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