In: Nursing
Using 500 words and scholarly sources to Examine why it is crucial for the EHR to be nationally interoperable. Who should be held accountable for mistakes in diagnosis and treatment when there are several parties involved including (but not limited to) the on-site physician, remote specialist and other medical personnel, and the telecommunications equipment manufacturer?
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Answer:
The electronic health record (EHR) is expected to improve the quality and efficiency of health care. Many novel functionalities have been introduced in order to improve medical decision making and communication between health care personnel.
Electronic health record (EHR) systems are expected to make health care services more efficient, reduce the workload of the clinician and prevent medical errors . They can document diagnostic investigations and medical treatment, provide clinical decision support and facilitate communication between health care personnel. In addition, there is a growing demand to extract large data sets from the EHR for administrative reporting, clinical audits and research . In the Nordic countries the EHR has become a standard tool for clinicians .
A patient's EHR must also include long-term data and information about the patient's daily life. This information will be useful not only in the planning and delivery of progressive care, but will also provide evidence for assessing different clinical interventions. Systems-engineering tools and techniques are available for modeling and determining the information needs of a “system” that can deliver progressive care and evaluate that system's performance.
Patient-centered health care delivery in the broadest sense must also focus on what the patient really wants from the entire health care community—the best physical and mental function in daily living possible within the constraints of the patient's physical condition. The key word here is “system,” that is, coordinated care, including care in the clinic, the hospital, home, rehabilitation facility, skilled nursing facility, long-term care facility, hospice, and perhaps social and societal programs. NHII is a first step toward obtaining data and information necessary for coordinating care in the clinic and hospital.
The management of large databases, which are essential to comprehensive core clinical applications for information/ communications systems, remains a critical determinant. Although databases are effectively managed in select locations, efforts must continue to develop secure, dispersed, multiagent databases that can serve both providers and patients effectively and efficiently.
In recent years, improved EHR versions with an increasing number of functionalities have been implemented at Norwegian hospitals. According to the EHR vendors, these new releases are comprehensive and capable of providing all the features needed to support clinical work, patient administration and to facilitate research .
EHR records are now being created, used, edited, and viewed by multiple independent entities including primary care physicians, hospitals, insurance companies, and patients. EHRs are increasingly being used in primary-care examination rooms to document and access patients’ records along with online medical information and decision-making tools, and prescribe medications. They have changed the dynamics of the patient-clinician interaction through clinician-patient email, virtual consults, and telemedicine.
Hundreds of government-certified EHR products are in use across the country, each with different clinical terminologies, technical specifications, and functional capabilities. These differences make it difficult to create one standard interoperability format for sharing data. In fact, not even those EHR systems built on the same platform are necessarily interoperable because they are often highly customized to an organization’s unique workflow and preferences.
Still, healthcare providers are under increasing pressure to enable widespread access to their EHRs for the patients they serve. The meaningful use incentive program in the U.S. has been a significant driver encouraging this access. Elsewhere, the cloud has become extremely efficient and successful at establishing digital identities for individuals and making EHRs interoperable across heterogeneous systems. As the healthcare industry contemplates providing patients more access to their EHRs, the solution could leverage existing cloud technology .
EHR data generated in the care of patients are also widely used to support clinical research and quality improvement . The enormous amount of data being collected by EHRs has generated additional value when integrated and stored in enterprise data warehouses (EDWs). The EDW allows all data from organizations with numerous inpatient and outpatient facilities to be integrated and analyzed . These data are not only an essential tool for management and strategic decision making, but also for enhanced data exploration, cohort identification, population management, and patient specific CDS. Patient data that was previously stored on removable disk packs or tape are now stored online; birth to death.
Interoperability itself is complex. The term refers to more than just the ability to exchange information. For two EHR systems to be truly interoperable, they must be able to exchange and then use the data. For this to occur, the message transmitted must contain standardized coded data so that the receiving system can interpret it. However, lack of standardized data is an issue that has plagued the U.S. health care system for decades and now certainly limits the ability to share data electronically for patient care.
EHR interoperability refers to the digital health record systems’ ability to openly communicate with each other, allowing providers to access and exchange patient healthcare information. The systems must process the data and present the information in an easily accessible manner to qualify as truly interoperable.
The Office of the National Coordinator (ONS) diligently works alongside standards development organizations (SDOs) to develop consistent interoperability standards amongst various healthcare systems. They have created a number of helpful guidelines that ensure the systems can speak to each other and present the data in a user-friendly manner.
Interoperability can be classified into three levels:
Foundational—One EHR system can receive data from another system but does not need to be able to interpret it.
Structural—Data can be exchanged between information technology systems and interpreted at the data field level.
Semantic—This is the highest level of interoperability, where two or more systems can exchange information, and the exchanged information can be used.
Perhaps the biggest obstacle facing EHR interoperability is not technological but cultural. As in other industries, interoperability in health care requires the close coordination and collaboration of various stakeholders, including patients, providers, software vendors, legislators, and health information technology (IT) professionals.
Yet the U.S. health care delivery system continues to have a culture defined by silos, fragmented processes, and disparate stakeholders, and where data have become more of a commodity and competitive advantage than a basis for coordinated care.
Needless to say, there has been plenty of finger-pointing over interoperability issues. Both providers and vendors have been accused of “information blocking” or intentionally interfering with the flow of information between different EHR systems.
Along with providing recommendations to CMS for improving incentive programs, Dr. Gurman says the AMA is also working on a number of fronts with the EHR vendor community and other stakeholders to improve the usability and interoperability of these products. There are many uses for the clinical data contained within an EHR, he says, including valuable insights for direct patient care as well as research and population health.
In response to the previously mentioned study that found physicians spend nearly half their day entering data into EHRs and handling other administrative tasks, the AMA said poorly designed EHRs were part of the problem. Among the capabilities that vendors need to improve or develop, the AMA says, are reducing cognitive workload, facilitating digital and mobile patient engagement, and expediting user input into product design and post-implementation feedback.
“The AMA is focused on reducing and reimagining EHR use and design regulation,” Dr. Gurman says. “Until that is addressed, EHR vendors will continue to develop products that meet federal requirements rather than patient and physician needs.”
Why it is crucial for the EHR to be nationally interoperable?
With industrywide EHR interoperability, all clinics, hospitals and other healthcare facilities could access and update their patients’ full medical records. Sections of the patients’ records would no longer remain veiled behind the standalone systems. They can easily exchange health information data from within the clinical workflow and at the point of care.
Through EHR integration, healthcare providers would no longer have to go the extra mile in retrieving or updating these records. With just a few clicks of a button, each patient’s records would quickly populate and display the vital information needed to make wise healthcare decisions. This information could be then shared with other healthcare providers, labs and pharmacies. The accessibility of patient data by various providers through Interoperability greatly helps the movement of patients between different healthcare facilities.
Healthcare systems can together provide a holistic view of patient data, promoting value-based care. In fact, studies show that interoperability has the power to cut hospitals’ costs by eliminating redundancies and readmission through improved communication. Eventually, it helps achieve improved care coordination, patient safety, and positive patient outcome.
Interoperability creates incentives for healthcare practices through the Promoting Interoperability Program offered by the Centers for Medicare & Medicaid Services (CMS). As you use interoperability to benefit your patients, your clinic will receive payments from CMS for as long as you adhere to the program guidelines.
BENEFITS OF EHR:
1. Improved data accessibility
Before EHRs, access to medical charts required a fair amount of
physical labor. For example, every time a patient visited the
office or hospital, their file had to be physically pulled from a
storage space, transported, delivered (batch processing), stamped
and sorted all in one visit. As a result of this back and forth,
there was a greater chance of human error and charts would
sometimes be missing information or be chronologically out of
order. In my experience, it was not unusual for five out of 15
charts for a clinic day to be unavailable at any given time, which
ultimately resulted in wasted time, space, motion and frequent
defects to care.
EHRs, on the other hand, have eliminated the physical transporting, sifting and filing of charts, making data available at all times. Additionally, for systems that allow remote access to charts, clinicians can even be off site and still securely access patient files. Storage and inventory is also reduced, freeing up physical space within the hospital or office, and allowing the redeployment of human resources. Unnecessary movement is eliminated, ultimately eliminating batch delivery and improving the flow of patients and information. Most importantly, the culmination of the reduction in waste is improved quality of care for the patient.
2. Computerized physician order entry
CPOE allows physicians to place lab and imaging orders,
prescriptions and other notices electronically, reducing the error
of hand-written orders and allowing the patient's other physicians
within the EHR network access to the order. That means, if a
patient is prescribed a drug from his/her cardiologist and they are
on the same EHR, the primary care physician will have access to the
prescribing information. This not only reduces time, but also
dramatically reduces errors — such as duplicate prescriptions or
drug interactions — and potential harm to the patient.
3. Charge capture
Healthcare organizations keep track of ("capture") a patient's use
of hospital resources, such as equipment, medical supplies,
diagnostic testing, medication and hospital staff. These charges
are recorded and then billed to patients and third-party payers.
Often, the use of a resource may be overlooked. The process behind
"charge capture" can be complex, making it very important that that
a system is in place to capture charges completely and correctly,
maximizing the potential reimbursement for revenue.
With an EHR system, at least one diagnosis must be captured along with a level of service that documents what was done for the patient at the end of every encounter. Additionally, the EHR includes a list of selectable Current Procedure Terminology codes that allows for easy input and helps reduces errors, ensuring the right code is used.
4. Preventative health
EHRs allow for prompts for preventative health screenings. During
routine doctor or urgent care visits, the physician has access to
preventive health records conveniently in one place. If the patient
is due for a cancer screening (such as mammogram or colonoscopy),
or blood pressure testing, the doctor can set easily look this up
via the EHR system and schedule an appointment for the patient.
What's more is EHRs allow data analysts to mine the entire system for say, all patients with diabetes who haven't had their hemoglobin A1C and cholesterol check within the past year. From there, the analysts can provide the physician with a list that allows practice management to contact the patients to schedule these preventative health appointments. This type of data mining cannot be done through paper records.
5. Ease sign off for PAs and NPs
While this varies from state-to-state by law, physician assistants
and nurse practitioners are typically required to have their notes
approved and signed off on by their supervising physician. EHRs
allow the revision and cosigning of notes to happen electronically
as opposed to physically moving and signing paper.
6. e-messaging between providers
As any physician can attest, telephone tag between providers can be
common, and is a big time-waster. With EHR software, physicians can
e-message across practices. One situation that benefits in
particular from e-messaging is referrals. Rather than playing
telephone tag to get an appointment scheduled, the physician
electronically send a message to schedule the appointment.
LIMITATIONS OF EHR:
1. Lack of interoperability between information
technologies/EHRs
With more accountable care organizations emerging across the U.S.,
technology plays an essential role in developing an ACO, allowing
primary care physicians to track and follow the patient flow
throughout the healthcare system. Part of the driving force behind
the model stemmed from the need to integrate EHRs throughout the
health system and share information with network of referring
hospitals. However, this sharing of information is often not
possible. Finding a hospital partner that is willing to open the
lines of communication is critical to the success. For example,
Simpler Consulting client Atrius Health worked closely with Beth
Israel Deaconess Medical Center and Epic Systems to develop a web
portal that allows the two provider organizations to access each
other's EHR systems for shared patients.1 If this
planning and integration is not put into place, communication can
become a serious problem and result in additional follow up, time
and waste.
2. Cost of set-up and maintenance
The cost associated with EHRs is often a deterrent. Not only must
the provider pay for the physical hardware and/or software, the
organization must also put forth a considerable dollar amount for
setup, maintenance, training, IT support and system updates. For
many smaller practices with lower cash flow, cost alone prohibits
the ability to properly implement and maintain the system.
3. Productivity
A study conducted by the University of California-Davis found a
25-33 percent drop in physician productivity in the initial
implementation phases of the EMR.2 While ultimately the
goal is to increase productivity in the office or hospital, expect
to see a significant drop in productivity, and ultimately revenue,
in the first several weeks, and perhaps longer.
4. Delays in documentation
This may come as a shock to many, however, EHRs actually increases
the physician workload. With written notes, documentation tended to
be briefer and straight to the point. With EHRs, much more
documentation is required of physicians before, during and after a
patient visit. This has its pros and cons. For example, a benefit
of more robust documentation is that it provides additional
information for the coders that may justify a higher level of
service being billed. On the negative, it can cause further delays
and errors as physicians often wait to close notes until the end of
the day or, sometimes, days later. Thus they rely on memory to
enter correct information. Additionally, if a patient is seeing a
different provider, others will not be able to access this updated
information until the note is closed.
As with most systems, however, shortcuts can be built into and
customized for the physician to reduce some documentation. Standard
work is needed to ensure provider support and learning.
5. e-Messaging between providers
While e-messaging is listed above as a benefit, it can also be a
drawback as it can result in a lack of face-to-face or
phone-to-phone conversation. With EHRs, there are no give-and-take
conversations or question-and-answer scenarios. There is no way to
express emotion, nuances or voice your concerns or fears. Rather,
physicians must trust that the information they are providing is
what the other physician needs, interpreted without confusion and
read at all. This is not always the case.
6. Continuous need for updates and lack of
accountability for doing so
For every task large or small — whether it's a basic wellness
visit, a diagnosis, a procedure, a treatment or a prescription —
the EHR system requires a corresponding update. For example, when
you have an active "problem list" for a patient (e.g., diabetes,
hypertension, high cholesterol, etc.) someone has to be responsible
for updating his or her medication and keep the problem list
accurate.
However, in my experience, I've seen a significant lack of accountability for making constant updates which needs to be addressed across all health systems. For example, when patient has a surgical procedure, this needs to be added to the health record so that all those with access to the EHR can see the work that has been done. The question is, however, who is responsible for updating? The primary care physician or the surgeon? There needs to be a clear, communicated system between all of the patient's doctors and nurses so that updates are made efficiently and by the right persons.
MISUSE OF EHR:
1. HIPAA violations
Since EHRs allow for easier access to sensitive information, there
is an increased risk of privacy violations. These may include
intentional "snooping" or may be accidental by using improper
security measures. Thankfully, many systems have implemented a
forensics piece to track what files are accessed when and by
whom.
2. Empty data fields
While this issue varies by the proprietary nature of the system
being used, many EHR systems allow for auto-population of data for
new records. While these shortcuts save some time and effort on
behalf of the physician, they can also result in inaccurate new
records if the previous auto-populated record is not current. For
example, if a patient went in for surgery in June and this was not
or improperly documented, a "no data available" empty data field
error message or, even worse, inaccurate information could be
displayed. Once again, the creation of standard work and managing
to these standards is critical to prevent this type of problem.
3. Copy and paste
Copy and paste is by and large the biggest ugly of all the
shortcomings of EHRs. Because documentation is more involved with
EHRs, physicians may rely on the copy and paste function as a
shortcut, particularly for routine or follow-up visits. While this
may save time for the physician, this puts the patient's safety at
risk and impairs quality of care as updates or changes between
visits can be overlooked or not documented properly.
NEXT-GENERATION EHR
For all health care stakeholders—from patients and physicians to software vendors and hospital systems—driving digital change often requires a major shift of organizational culture. There is probably no better example of this than the Department of Veterans Affairs (VA), the largest integrated health care system in the United States, which has relied on its homegrown EHR system known as VistA (Veterans Information Systems and Technology Architecture) for nearly 30 years. On June 5, 2017, the new Secretary of Veterans Affairs, David Shulkin, MD, announced that, after years of trying to modernize the system and years of urging by Congress, the VA would replace it with Cerner’s MHS Genesis, the same commercial off-the-shelf product used by the Department of Defense (DoD).
THE PATH TO EHR INTEROPERABILITY
Whether it’s a solo practice, a rural hospital, or a massive health system such as the VA, EHR interoperability is a huge, complex, and ongoing undertaking in health care delivery, involving the interplay of a range of stakeholders both within and across care settings. And while physicians, hospital administrators, and other stakeholders in the health care community seem to support interoperability—believing it will improve patient care, reduce medical errors, and lower costs—it has yet to become a reality for most of them.
“The future of EHR and its ability to be an important tool in care coordination and team-based care will depend on the action taken by the EHR vendor industry and the federal government to ensure interoperability is a major focus,” Dr. Gurman says.
So, how long will it be before we achieve true interoperability? In its October 2015 report, “Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap,” the ONC predicted it would be 2021 to 2024 before the nation’s health system achieves interoperability. But for this to happen, many barriers will need to be addressed, including physician dissatisfaction with EHRs, overregulation, and cost. The government will need to provide stronger incentives to both providers and EHR vendors to promote interoperability. And all health care stakeholders will need to be a part of the interoperability effort in order to break down health data silos and allow patient health information to be available across all settings of care.
Who should be held accountable for mistakes in diagnosis and treatment when there are several parties involved including (but not limited to) the on-site physician, remote specialist and other medical personnel, and the telecommunications equipment manufacturer?
Medical knowledge doubles approximately every eight years, so a physician’s knowledge base is outdated very quickly after graduation from medical school. Keeping up with current knowledge by reading journal articles is impractical due to the volume of material and lack of time for reading it.
Computerization of the knowledge (and implementation into EHRs of recommended clinical guidelines) means the physician only has to enter a suspected diagnosis or result, click “accept” or “ignore” on a recommended guideline — and in many cases, not thinking they know more than the software, having not had time to keep up with the current knowledge, may click on “accept” just to complete the transaction and move on.
But if the recommendation turns out to be incorrect, precedent says, the physician should still be held responsible. After all, they used their professional judgment to evaluate the recommendation before accepting.
Conclusion
The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.