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Archived Report:
Developing the
Standard Electronic Health Record
Copyright 2015, Faulkner Information Services. All Rights Reserved.
Docid: 00011305
Publication Date: 1511
Report Type: STANDARD
Preview
Efforts to develop standards for storing patient medical information so that it
can be electronically shared among multiple providers could
revolutionize healthcare data management. These efforts are progressing
at a measured pace, however, and there are numerous hurdles to
overcome. Even though the widespread adoption of a standard
electronic health record may be years off, providers should start
monitoring trends and making plans now in order to be prepared for what
will be a major change in their practices.
Report Contents:
Executive Summary
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The goal of an
electronic health record (EHR) is to digitally store a
patient’s entire medical history – regardless of who provided the
service or
when it was delivered – and then make this information universally and
conveniently
shareable among hospitals, pharmacies, medical laboratories, and other
organizations that need to view and update it.
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An electronic health record contains patient
health information such as: administrative and billing data, patient
demographics, progress notes, vital signs, medical histories, diagnoses,
medications, immunization dates, allergies, radiology images, and lab and test
results
The vision of a complete,
universal EHR has not yet been realized, and it will
likely take several years at least if it is ever to come to fruition.
But there are numerous EHR initiatives underway, both nationally and
internationally, each contributing to the process of rationalizing healthcare
delivery in a digital age.
EHR and EMR
The terms electronic health record and electronic medical record [EMR] are often used interchangeably. When a distinction is made
between the terms, “EHR" typically refers to a universal record while “EMR" is a
record that is maintained by a single provider and includes only the information
related to that provider’s interaction with the patient.
PHR
One possible
alternative to the electronic health record is the personal health record (PHR),
which is maintained and controlled by individual patients. A few years ago, this
concept was thought to have strong potential, but some assessments
have found consumer interest to be tepid.1,2
Description
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An electronic health record (EHR) contains a
patient’s complete medical history in a format that enables it to be
viewed and updated by any authorized party such as doctors’ offices, pharmacies,
and hospitals.
There
are three primary benefits that EHRs are intended to deliver:
- Increased
Efficiency – Rather
than going through the time-consuming process of recording a patient’s
medical history through a verbal interview each time the patient goes
to a new doctor, or mailing hardcopy records, a doctor would be able to
quickly access the patient’s history electronically. - Cost Reductions – The
overall streamlining of administrative tasks associated with EHRs could
reduce labor costs. These benefits may not be realized quickly,
however, and there may be some short-term cost increases. Also, any
potential benefits may be realized unevenly by different types and
sizes of providers. - Enhanced Patient Safety – The current system places a
heavy burden on patients to remember and correctly describe their
medical histories for each doctor they visit. This creates the
possibility of oversights and errors that could lead to problems such
as dangerous drug interactions or allergic reactions. An EHR would help
to prevent such errors.
A complete, universal EHR is not
yet logistically feasible, but there are
significant public sector and private sector efforts to bring this idea
to
fruition. Achieving this goal will require the following:
- A
reliable network for transferring data. - A standard data format that enables records to be shared among
different systems. - Methods to ensure the security and privacy of data in compliance
with HIPAA and other regulations. - A standard nomenclature for naming treatments, conditions, and
other medical factors. For instance, if a particular facility uses a
three-letter abbreviation to identify a certain medication, other
facilities would need to understand without ambiguity what the
medication was. - A way to uniquely identify a patient. One facility might list a
certain patient as “John Smith,” but another might call him “Jonathan
Smith.” There would need to be a way to reliably determine that this
was the same person and to prevent the records of anyone with a similar
name from also being included.
The
obstacles to meeting these requirements are
not primarily technological. Most of the technology has already been
developed
and would need only moderate customization and enhancement, if any, to
serve as
the foundation of a system for storing and sharing EHRs. For example,
the
Internet and the existing WANs and LANs in place at hospitals could
provide the
networking capabilities, and current medical records software provides
a useful model of how to store medical
information electronically.
Instead,
the most difficult obstacles involve
getting all interested parties to agree on which of these existing
technologies and
standards to use, determining how to apply the agreed upon methods to
form an
effective and cost-efficient EHR infrastructure, and getting relevant
parties to
comply.
Current View
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National Initiatives
In
the US, the initiative to develop a universal EHR program
was spearheaded by the Office of the National Coordinator for Health
Information Technology (ONC), which was created when
President George W. Bush set the goal of having EHRs for most Americans.
(Originally, the goal was to be reached by 2014.)
And in the
American Recovery and Reinvestment Act of 2009,
the Obama administration targeted $2 billion toward the development of
a nationwide network and $17 billion toward increasing Medicare and
Medicaid payments to doctors who use the system. (The portion of the
stimulus spending dedicated to electronic medical records is also
referred to as the Health Information Technology for Economic and
Clinical Health Act, or HITECH.)
In collaboration with ONC, the National Institute
of Standards and Technology (NIST) is developing the necessary functional and
conformance testing requirements, test cases, and test tools in support of the
health IT certification program.
International Initiatives
Globally, the International Organization for
Standardization (ISO) has, over the past decade, developed and promoted
numerous electronic health record standards, most prominently, ISO/TR
20514:2005, ISO 18308:2011, and ISO 10781:2015.
ISO/TR 20514:2005
Health informatics — Electronic health record — Definition, scope and
context: ISO/TR 20514:2005 describes a pragmatic
classification of electronic health records, provides simple definitions
for the main categories of EHR and provides supporting descriptions of
the characteristics of electronic health records and record systems.
ISO 18308:2011 Health informatics —
Requirements for an electronic health record
architecture: ISO 18308:2011
defines the set of requirements for the
architecture of a system that processes, manages
and communicates electronic health record (EHR)
information: an EHR architecture. The
requirements are formulated to ensure that these
EHRs are faithful to the needs of healthcare
delivery, are clinically valid and reliable, are
ethically sound, meet prevailing legal
requirements, support good clinical practice and
facilitate data analysis for a multitude of
purposes. ISO 18308:2011
does not specify the full set of requirements
that need to be met by an EHR system for direct
patient care or for other use cases, but the
requirements defined by ISO 18308:2011 do
contribute to the governance of EHR information
within such systems.
ISO/HL7 10781:2015
Health Informatics — HL7 Electronic Health Records-System Functional
Model, Release 2 (EHR FM): ISO 10781:2015 provides a reference list
of functions that may be present in an Electronic Health Record System (EHR-S).
The function list is described from a user perspective with the intent
to enable consistent expression of system functionality. This EHR-S
Functional Model, through the creation of Functional Profiles for care
settings and realms, enables a standardized description and common
understanding of functions sought or available in a given setting (e.g.
intensive care, cardiology, office practice in one country or primary
care in another country).
Outlook
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The near future will see
continued expansions of
existing EHR programs and the introduction of new ones, with new
funding accelerating the pace of adoption. It is not certain that a
truly universal and
complete EHR will ever come to fruition. In order to fully succeed, an
EHR program would have
to consolidate all the information about a patient that is currently
stored.
This data would have to be pulled together from multiple providers and
multiple
types of systems, which despite years of technological work remains a
highly difficult process.
A short list of systems that
store electronic data about patients includes the
following:
- Barcode-Enabled
Point-of-Care Systems – Designed to be used at the time of
administering a medication, these systems read barcode labels on the
medication’s packaging to verify its contents. The clinician then uses
the barcode reader to scan a patient’s wristband to determine what drug
he or she is scheduled to receive. - Medication Cabinets – Some medication cabinets have wheels
that enable clinicians to push them around a facility to dispense
medications in various care areas. Today’s cabinets have integrated
computers that store information about which medications and doses
individual patients are to receive. (Depending on their configuration,
cabinets can restrict access to their storage compartments to limit
doses or to only allow certain users to access particular drugs.) These
computers receive patient information – such as by connecting to a
network to receive prescription information from a hospital’s pharmacy
– and generate data by tracking when patients receive medications. - Picture Archiving and Communications Systems (PACS) –
These systems store diagnostic images such as X-rays. They are
connected to hospital networks to enable them to exchange data with
imaging devices and with other information systems, whether in the same
facility or another. In recent years, PACS devices have been upgraded
to enhance their integration with other systems. For instance, in many
systems, a patient’s images can automatically be transferred to the
right place based on a schedule stored in a hospital information
system. - Pharmacy Information Systems – Pharmacy information
systems enable pharmacists to set schedules for patients’ medications
and doses, and then to electronically transmit this data to the
clinicians who will dispense the medication. These systems maintain a
patient-by-patient medication delivery history and can provide alerts
if they detect a potentially dangerous drug combination or an allergy
to a medication.
Manufacturers
have made significant strides in
getting their information systems to integrate with those from other
manufacturers, but such interoperability is not universally complete or
seamless. Achieving
such a level of universal interoperability would require substantial
negotiations
regarding standards and might demand a great deal of labor on the
behalf of
healthcare facilities, which would need to consolidate and organize
their data
and upgrade or replace any information systems that were inoperable
with others.
In particular, the volumes of paper records now in place would either
have to be
manually keyed into an electronic system, scanned to create non-machine
readable
(and hence marginally beneficial) records, or left out of the
new EHR system.
Recommendations
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While the goal of establishing a universally-accepted standard for
electronic health records remains elusive, organizations are nonetheless
encouraged to proceed with the implementation of an Electronic Health Record
System that suits their particular needs. To that end, HealthIT.gov provides a
wealth of information on EHR implementation, from practice assessment to EHR
training.
Assess Your Practice Readiness
Key questions include:
- Are administrative processes organized,
efficient, and well documented? - Are clinical workflows efficient, clearly
mapped out, and understood by all staff? - Are data collection and reporting processes
well established and documented? - Are staff members computer literate and
comfortable with information technology? - Does the practice have access to
high-speed internet connectivity? - Does the practice have access to the
financial capital required to purchase new or
additional hardware? - Are there clinical priorities or needs that
should be addressed? - Does the practice have specialty specific
requirements?
Plan Your Approach
Specific steps include:
- Analyze and map
out the practice’s
current workflow and
processes of how the
practice currently
gets work done (the
current state). - Map out how EHRs
will enable desired
workflows and
processes,
creating new
workflow patterns
to improve
inefficiency or
duplicative
processes (the
future state). - Create a
contingency plan –
or back-up plan – to
combat issues that
may arise throughout
the implementation
process. - Create a project
plan for
transitioning from
paper to EHRs, and
appoint someone to
manage the project
plan. - Establish a
chart abstraction
plan, a means to
convert or
transform,
information from
paper charts to
electronic charts.
Identify specific
data elements that
will need to be
entered into the new
EHR and if there are
items that will be
scanned. - Understand what
data elements may be
migrated from your
old system to your
new one, such as
patient demographics
or provider schedule
information.
Sometimes, being
selective with which
data or how much
data you want to
migrate can
influence the ease
of transition. - Identify
concerns and
obstacles regarding
privacy and security
and create a plan to
address them. It is
essential to
emphasize the
importance of
privacy and security
when transitioning
to EHRs.
Select an EHR System
After establishing the
practice’s objective(s)
and planning how EHRs
will affect
workflows, the
leadership team and
staff can determine what
to look for when
considering and
selecting an EHR system.
The following are
several considerations
for EHR software
comparison:
- Understand if
and how a vendor’s
product will
accomplish the key
goals of the
practice.
Essentially, a test
drive of your
specific needs with
the vendor’s
product. Provide the
vendor with patient
and office scenarios
that they may use to
customize their
product
demonstration. - Clarify start-up
pricing before
selecting an EHR
system (hardware,
software,
maintenance and
upgrade costs,
option of phased
payments, interfaces
for labs and
pharmacies, cost to
connect to health
information exchange
(HIE), customized
quality reports). - Define
implementation
support (amount,
schedule,
information on
trainer(s) such as
their communication
efficiency and
experience with
product and company). - Clarify roles,
responsibilities,
and costs for
data migration
strategy if desired.
Sometimes, being
selective with which
data or how much
data to migrate can
influence the ease
of transition. - Server options
(e.g., client
server, application
service provider
(ASP), software as a
service (SaaS)). - Ability to
integrate with other
products (e.g.,
practice management
software, billing
systems, and public
health interfaces). - Privacy and
security
capabilities and
back-up planning. - Linking payments
and EHR incentive
rewards to
implementation
milestones and
performance goals. - Vendor’s
stability and/or
market presence in
region. - Cost to connect
to HIE. - Consider costs
of using legal
counsel for contract
review verses open
sources through
medical associations.
Conduct Training & Implement an
EHR System
EHR implementation involves the
installation of the EHR
system and associated
activities, such as
training, mock
"go-live", and pilot
testing. The EHR
implementation plan and
schedule (developed
during the planning
phase) should be
followed and executed
during this phase, in
addition to execution of
the following:
- Chart abstraction
plan and other data
migration plans in
conjunction with
your EHR vendor. - Execution of an
EHR implementation
training plan that
includes practice
specific goals and
needs, as well as
compliance with
Meaningful Use
objectives. - Privacy and
security risk
management
mitigation plan.
References
1 P. Cerrato. "Why Personal Health
Records Have Fopped." Information Week. January 2012.
2 A.
Vecchione. "Slow Start for Personal Health Records in New Jersey." NJ
Spotlight. August 2012.
Web Links
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- ISO: http://www.iso.org/
- Office of the National Coordinator for Health Information Technology: http://www.healthit.gov/
- US Department of Health and Human Services: http://www.hhs.gov/
- US National Institute of Standards and Technology: http://www.nist.gov/
About the Author
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James G. Barr is a leading business continuity analyst
and business writer with more than 30 years’ IT experience. A member of
"Who’s Who in Finance and Industry," Mr. Barr has designed,
developed, and deployed business continuity plans for a number of Fortune 500
firms. He is the author of several books, including How to Succeed in
Business BY Really Trying, a member of Faulkner’s Advisory Panel, and a
senior editor for Faulkner’s Security Management Practices. Mr.
Barr can be reached via e-mail at jgbarr@faulkner.com.
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