Question

Instructions

EHR Systems

As with Surveillance Systems, it is critical to understand the various systems used in healthcare to collect data in a clinical setting. It is also critical to understand the various standards, which allow the sharing of information about a patient to provide quality care.

Tasks:

Based on your reading, create a 5- to 6-page document in Microsoft Word, which includes the answers to the following questions:

Describe and explain the basic components and benefits of an EHR System.

Describe and defend your opinion on the current status of hospitals meeting the requirements of MU today and in the future?

Examine and discuss briefly the HIE and the need for standards.

Answer 1

Instructions

EHR Systems

As with Surveillance Systems, it is critical to understand the various systems used in healthcare to collect data in a clinical setting. It is also critical to understand the various standards, which allow the sharing of information about a patient to provide quality care.

Tasks:

Based on your reading, create a 5- to 6-page document in Microsoft Word, which includes the answers to the following questions:

Describe and explain the basic components and benefits of an EHR System.

Describe and defend your opinion on the current status of hospitals meeting the requirements of MU today and in the future?

Examine and discuss briefly the HIE and the need for standards.

Electronic Health Records (EHR)

EHR is the form of documenting patient’s data electronically. Which can be entered and retrieved easily. It speeds up the documentation and improves accuracy. Strict measures should be taken to maintain confidentiality. EHR helps in a standardization of care and in cooperates physician’s decision making. Community-based health care services get more advantages from EHR. EHR helps the updating of information easily, as the change in prescription.

The instant availability of real-time, patient-centered records securely to the authorized users is the main feature of EHR.

EHR contains information’s that are relevant to the patient for the entire lifetime. The EHR includes the components of paper records or file of a patient like medical history, diagnosis, medications used, plan of treatment, immunization and allergies history, imaging and other diagnostic results. In addition to the regular medical record, EHR can provide access to evidence-based tools help decisions about a patient’s care and automate and streamline provider workflow.

The collected health information can be managed and modified by the authorized providers as it is in digital format. EHR can be easily shared with other healthcare and related providers across more than one healthcare organization. The beneficiaries of EHRs other than hospitals are laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities, and school and workplace clinics. The easy availability of the Electronic health records (EHRs) is the key components of a transformation of the healthcare delivery in America. Availability of the genuine records helps in the avoidance of duplication of the procedure and easy decision making.

Electronic health record (EHR) can be stored and managed easily and can be useful for monitoring and managing the patient’s entire lifetime health status. Clinical Decision Support Systems (CDSS) is the modified IT health system that incorporates the knowledge and data which allows the access of concerned personnel. It helps CDSS (Clinical Decision Support Systems) provide health-related information to the healthcare professionals, patients and families in order to make decisions relevant to the patient care. CDS utilizes the different data sets like Clinical guidelines, EHR, computerized alerts, Reminders to health care suppliers and consumers. Information’s like drug use, allergies, care provided, history, associated conditions etc. are enrolled in the database and that can be used in CDSS.

Key components of an EHR

1. Patient Management

The patient management component is essential for patient registration, admission, transfer and discharge or the ADT functionality. After patient registration with all the relevant information such as demographics, insurance information, contact information a unique ID - Medical Record Number - is generated. For the subsequent visit or encounter with the organization, another unique “encounter” number is generated. A Master Patient Index (MPI) also can be developed by an efficient EHR system.

2. Clinical Component

A clinical component can be the subtotal of different sub-components like Computerized Provider Order Entry (CPOE), electronic documentation, nursing component etc.

The Computerized Provider Order Entry (CPOE) allows the healthcare providers to enter the patient management orders directly in the HER system and this can make use of clinical decision support tools such as drug-drug, drug-allergy, and drug-diagnoses interactions. Electronic documentation component enables the documentation of data such as history & physical, examinations, discharge summaries, operative notes etc. Multiple tools like templates, speech recognition and transcription services may be used to enable electronic documentation. The pharmacy component system maintains a medication formulary, filling prescriptions and crosschecking any orders that are placed by providers at any time. Nursing component allows for the collection of vital patient information such as vital signs, input and output data, medication administration record (MAR), barcode medication charting and nursing documentation.

3. Laboratory component:

The Lab components have mainly two parts or subcomponents such as capturing results from lab machines and integration with orders, billing and lab machines. The lab component can be kept alone or integrated with the HER. 4. Radiology Information System:

This allows managing patient workflow, ordering process, results and the images themselves.

5. Billing System

The billing system allows capturing all charges generated in the process of taking care of patients and generate claims, which can be submitted to insurance companies then tracked and completed.

Benefits of EHR

Although EHR has taken some time to be implemented and widely accepted in the healthcare industry it possesses many advantages.

1. Improved quality of care: Easy accessibility of healthcare information can help in efficient and improved healthcare decisions and thereby boost the quality of care.

2. Minimizes the time for decision: Use of HER minimizes the decision-making time as it readily provides a patient’s health information.

3. Effective use of resources

4. Provide standardized care

5. Easy accessibility

6. Easy exchange of information

7. Provider and patient satisfaction

8. Allow providers to use the evidence-based tools while making decisions about a patient’s care

9. EHR can automate and streamline the provider workflow

10. Improvement in care coordination

Meaningful use

The American Reinvestment & Recovery Act (ARRA) was enacted on February 17, 2009. ARRA includes many measures to modernize our nation's infrastructure, one of which is the "Health Information Technology for Economic and Clinical Health (HITECH) Act". The HITECH Act supports the concept of electronic health records - meaningful use [EHR-MU], an effort led by Centers for Medicare & Medicaid Services (CMS ) and the Office of the National Coordinator for Health IT (ONC). HITECH proposes the meaningful use of interoperable electronic health records throughout the United States health care delivery system as a critical national goal. Meaningful Use is defined by the use of certified EHR technology in a meaningful manner (for example electronic prescribing); ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and that in using certified EHR technology the provider must submit to the Secretary of Health & Human Services (HHS) information on quality of care and other measures.

The concept of meaningful use rested on the '5 pillars' of health outcomes policy priorities, namely:

1.     Improving quality, safety, efficiency, and reducing health disparities

2.     Engage patients and families in their health

3.     Improve care coordination

4.     Improve population and public health

5.     Ensure adequate privacy and security protection for personal health information

HIE

Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other healthcare providers and patients to appropriately access and securely share a patient’s vital medical information electronically—improving the speed, quality, safety and cost of patient care.

Despite the widespread availability of secure electronic data transfer, most Americans’ medical information is stored on paper—in filing cabinets at various medical offices, or in boxes and folders in patients’ homes. When that medical information is shared between providers, it happens by mail, fax or—most likely—by patients themselves, who frequently carry their records from appointment to appointment. While electronic health information exchange cannot replace provider-patient communication, it can greatly improve the completeness of patient’s records, (which can have a big effect on care), as past history, current medications and other information are jointly reviewed during visits.

Appropriate, timely sharing of vital patient information can better inform decision making at the point of care and allow providers to

• Avoid readmissions
• Avoid medication errors
• Improve diagnoses
• Decrease duplicate testing