1. Building a Consensus for an EHR Wendy Jean, Jamie Kalina, Kristen Mangia NUR 353 Jacksonville University October 2013

2. A New Health System for the 21st Century The IOM listed six aims in improving health care quality: To make healthcare environments more safe for their patients. To provide more effective healthcare. To make health care more patient centered - that is ensure that the patient is more involved in the decision making process and that the patient has a better understanding of the healthcare choices available to him or her. To improve the timeliness of healthcare service. To make the process of providing healthcare, as a whole, more efficient. To work toward the elimination of healthcare disparities among diverse populations...ensuring that all patients have equal access to healthcare. 3. Executive Mandate Within ten years, every American must have a personal electronic medical record... by computerizing health records we can avoid dangerous medical mistakes, reduce costs and improve care. - President George W. Bush, April 26, 2004 According to Executive Order 13410 signed by President George W. Bush in August 2006, federal agencies administering or sponsoring federal health programs must implement any and all relevant recognized interoperability standards. These standards also become part of the certification process for electronic health records and networks. www.hitsp.org/government.aspx 4. EHR Defined EHR- an electronic health record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization ( Hebda & Czar, 277) EHRs are, at their simplest, digital (computerized) versions of patients' paper charts. But EHRs, when fully up and running, are so much more than that. EHRs are real-time, patient-centered records. They make information available instantly, "whenever and wherever it is needed". And they bring together in one place everything about a patient's health. EHRs can: Contain information about a patient's medical history, diagnoses, medications, immunization dates, allergies, radiology images, and lab and test results Offer access to evidence-based tools that providers can use in making decisions about a patient's care Automate and streamline providers' workflow Increase organization and accuracy of patient information Support key market changes in payer requirements and consumer expectations One of the key features of an EHR is that it can be created, managed, and consulted by authorized providers and staff across more than one health care organization. A single EHR can bring together information from current and past doctors, emergency facilities, school and workplace clinics, pharmacies, laboratories, and medical imaging facilities. healthit.gov 5. Not to be Confused with EMR EMR- legal records created in hospitals, clinics, and ambulatory environments that are the source of the data for the EHR Building block in the creation of EHR A single encounter Limited ability to carry information across subsequent visits Components Clinical messaging, email Results reporting, data repository Decision support Clinical documentation Order entry (Hebda & Czar, 276) 6. www.ncrr.nih.gov/publications/informatics/ehr.pdf 7. www.ncrr.nih.gov/publications/informatics/ehr.pdf 8. Why the Call for Change? Cause Decreasing Reimbursement Increasing cost Increasing healthcare regulations and notices Effect Example with EHR Supports pay for performance as quality measures are gathered Supports disease management, lowering costs for expensive diagnosis Instant notice of authorization for procedures with integration with payer- based health records 9. How of EHR Stage 0 Some clinical automation exists but the laboratory, pharmacy, and radiology systems are not all operational Stage 1 The major ancillary clinical systems-the laboratory, pharmacy, and radiology-are all installed Stage 2 Major ancillary clinical systems send data to a clinical data repository (CDR) that allows physicians to retrieve and review results Stage 3 Basic clinical documentation (vital signs, flow sheets) is required Stage 4 Computerized provider order entry (CPOE) and a second level of clinical decision support for evidence-based practice are added to the previous stages Stage 5 At least one service area has the closed loop medication administration process where barcode medication administration (BCMA), radio frequency identification (RFID), or other identification technology is in place and integrated with CPOE and the pharmacy to maximize patient safety Stage 6 At least one service area has full physician documentation, third-level clinical decision support for protocols and outcomes with variance and compliance alerts, and a full PACS system Stage 7 This is a paperless environment where all information is shared electronically and the electronic health record can produce a continuity of care document (CCD) (Hebda & Czar, 277) 10. How Do We Get There? Meaningful Use emphasizes using technology with a meaningful manner to exchange electronic health data to improve care quality and it emphasizes submittal of care quality measures to HHS. In addition, hospitals and doctors will need to meet these requirements within a specified time frame. As per law, eligible providers will be treated as a Meaningful User of EHR technology if they meet the following three criteria: Use a certified EHR in a meaningful manner, which includes the use of electronic prescribing (e-prescribing). Use a certified EHR that can accommodate the electronic exchange of health information to improve quality of health care. Submit information on clinical quality measures, as chosen by the HHS Secretary, for the reporting period. 11. http://electronicmedicalrecordsmandate.org/electronic-medical-records-mandate/emr-mandate-2014-deadline 12. Meaningful Use Requirements Record demographic information Computerized provider order entry Clinical decision support and the ability to track compliance with rules Automatic, real-time drug-drug and drug-allergy interaction checks based on the medication list, allergy Maintain an active medication/allergy list Record and retrieve vital signs Record smoking status for patients 13 years old and older Mechanisms to protect information created or maintained by the certified electronic health record technology that include access control Electronically exchange key clinical information among providers and patient-authorized entities Supply patients with an electronic copy of their health information upon request Supply patients with a electronic copy of their discharge instructions upon request Report required clinical quality measures to CMS Maintain up-to-date problem lists of current and active patient diagnosis (Hebda & Czar, 281) 13. Attributes of the EHR with Continuity of Care Provides secure, reliable real-time access to client health record information where and when it is needed to support care Records and manages episodic and longitudinal electronic health record information Functions as clinicians primary information resources during the provision of client care Assists with the work of planning and delivery of evidence-based care to individual and groups of clients Captures data used for continuous quality improvement, utilization review, risk management, resource planning, and performance management Captures the patient health-related information needed for medical record and reimbursement Provides longitudinal, appropriately masked information to support clinical research, public health reporting, and population health initiatives Supports clinical trials and evidence-based research (Hebda & Czar, 278) 14. Considerations of the EHR Cost Initial land ongoing costs for deploying and maintaining IT systems were cited as the greatest barrier to IT. According to recent CMS estimates, eligible providers will spend an average of $54,000 to purchase and implement a certified electronic health record for their offices and eligible hospitals will spend an average of $5,000,000 for the purchase and installation; those figures do not include annual maintenance costs Downtime Rushed implementation process that can negate many of the potential benefits associated with electronic health records and potentially sacrifice patient safety The enormity of switching from a paper process to a new electronic health record system must fully be considered (Hebda & Czar, 288) Training, maintenance and enhancements are additional moneys. Estimated cost per healthcare provider practice implementing an EMR is $40,000 to $100,000. The process of developing, implementing and maintaining EHRs requires adequate funds and the involvement of many individuals, including clinicians, information technologists, educators, and consultants (Bostrom, Schafer, Dontje, Pohl, 2006). 15. Considerations of EHR Caregiver Assistance Resistance by caregivers such as physicians and nurses can delay the development and use of the electronic health record This resistance is, in part, attributed to the fact that many electronic health records, lack essential features or are perceived as awkward or inconvenient to use CPOE error and Data integrity Incorrect data entry the client data found in the electronic health record are only as accurate as the person who enters them and the systems that transfer them Data correction an effective audit trail procedure permits the tracking of who entered or modified each data element, allowing appropriate follow-up measures (Hebda & Czar, 288) Selection of a system and software capable of meeting the current and anticipated needs of the providers and healthcare system is critical to the cost investment and return on investment, ROI. Maintenance costs include ongoing system enhancements as well as innovations in the pipeline. All costs, after the initial investment, can be expected to be transferred to the business costs of patient care. The ROI should reflect savings, including malpractice insurance and malpractice claims for patient care errors, particularly as a result of the reduction in medication errors. Cost savings in conjunction with positive revenue gains from meaningful use are included in the ROI calculation. Initial financial investment to convert to an electronic record format, even for a small system, can range upward of tens of thousands of dollars (Kopla, Mitchell 2011). 16. Benefits of EHR with Nursing Maximize the time nurses spend on direct patient care, improve the accuracy of documentation, decrease medication errors, and promote patient safety Can provide clinical alerts and reminders, identify abnormal parameters of laboratory and assessment data, and prompt clinicians on important tasks and protocols Supports all ongoing record of the clients education and learning response across encounters or visits Provides universal data access to all who have access to the electronic health record Improves documentation and quality of care Vital signs can be collected directly from monitors attached to the client and fed into the system (Hunter 2002). Clinical documentation systems have the advantage of collecting data to use in planning and research. (Hebda & Czar, 2009) 17. Benefits of the EHR with Providers Providing accurate, up-to-date, and complete information about patients at the point of care Enabling quick access to patient records for more coordinated, efficient care Securely sharing electronic information with patients and other clinicians Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care Improving patient and provider interaction and communication, as well as health care convenience Enabling safer, more reliable prescribing Helping promote legible, complete documentation and accurate, streamlined coding and billing Enhancing privacy and security of patient data Helping providers improve productivity and work-life balance Enabling providers to improve efficiency and meet their business goals Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health Improved eligibility for reimbursement Simultaneous record access by multiple users More comprehensive information is available Healthit.gov/providers-professionals/faqs/what-are-advantages 18. Benefits of EHR with Consumers Places the patient at the center of his/her care The EHR is connected to all the patients health care providers Reduces the patient paperwork. As information is added the EHR, the doctor and hospital will have more of that data available as soon as the patient arrives EHRs get the information accurately into the hands of people who need it, and enables the providers to make the best possible decisions Help the doctors coordinate your patient and protect patient safety Reduce unnecessary tests and procedures, which results in higher costs to the patient in the form of bigger bills and increased insurance premiums EHR give the patient direct access to their health records Decreased wait time for treatment Improved access and control over health information Increased use of best practices with incorporation of decision support Healthit.gov/patients-families/benefits-health-it 19. Looking Forward to Tomorrow This transformation may not occur as quickly as desired; it will take longer for some consumers and practitioners to make the transition since changes must also be seen in attitudes. EHR systems have the capability to improve communication between physicians, nurses and patient by making information more readily available. The electronic health record has tremendous potential to support nurses and advance nursing knowledge in the following ways: elimination of redundant efforts, redesigning the workflow, demonstrating the contributions that nurses make to patient care and outcomes, and contributing to the body of nursing knowledge through the incorporation of standardized nursing language 20. References Bostrom AC, Schafer p, Dontje K, Pohl JM, Nagelkerk J, Cavanagh SJ. Electronic health record: Implementation across the Michigan academic consortium. Comput Inform Nurs. 2006:24(1):44-52. Hebda, T., & Czar, P. (2013). Handbooks of Informatics for nurses & healthcare professionals (5th ed.). Upper Saddle River, New Jersey, USA: Pearson. Kopla, B. & Mitchell, ME. (2011). Use of digital health records raises ethics concerns. Jonah's Healthcare Law, Ethics, and Regulation, Vol. 13, No 3 pp.84-89. McNickle, M. (2012). 7 attributes next-generation EHRs will need to support . Healthcare it news.com. Thede, L. (2003). Informatics and nursing: Opportunities and challenges (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. http://electronicmedicalrecordsmandate.org/electronic-medical-records-mandate/emr-mandate-2014-deadline www.healthit.gov/patients-families/benefits-health-it www.healthit.gov/providers-professionals/faqs/ what-are-advantages www.hitsp.org/government.aspx www.ncrr.nih.gov/publications/informatics/ehr.pdf