Princess Sumaya University for Technology
The King Hussein School for Computing Sciences
Course 13768: Health information systems
Topic 3: Electronic Health Records
Dr. Rafat Hammad
Acknowledgements: Most of these slides have been prepared by Robert Hoyt, Elmer V Bernstam, and William Hersh
and adopted for our course. Additional slides have been
1 added from the mentioned references in the syllabus
Learning Objectives
After reading this chapter the reader should be able to:
∗ State the definition and history of electronic health records (EHRs)
∗ Describe the limitations of paper-based health records
∗ Identify the benefits of electronic health records
∗ List the key components of an electronic health record
∗ Describe the ARRA-HITECH programs to support EHRs
∗ Describe the benefits and challenges of computerized order entry
and clinical decision support systems
∗ State the obstacles to purchasing, adopting and implementing an
electronic health record
∗ Enumerate the steps to adopt and 2
implement an EHR
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Introduction
∗ There is no topic in health informatics as important, yet
controversial, as the electronic health record (EHR)
∗ In spite of fledgling EHRs being around for the past 35-40
years they are still controversial in the eyes of many
∗ Due to the federal government reimbursement programs
for EHR use by physicians and hospitals, EHRs are now part
of the healthcare landscape
∗ Some of the famous early EHRs are listed on the next slide
Early EHRs
∗ The Problem Oriented Medical Information System (PROMIS)
∗ American Rheumatism Association Medical Information
System (ARAMIS)
∗ Regenstrief Medical Record System (RMRS)
∗ Summary Time Oriented Record (STOR)
∗ Health Evaluation Through Logical Processing (HELP)
∗ Computer Stored Ambulatory Record (COSTAR)
∗ De-Centralized Hospital Computer Program (DHCP)—
forerunner of VistA (Veterans Health Administration)
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Definition
∗ Electronic Health Record: “An electronic record of
health-related information on an individual that
conforms to nationally recognized interoperability
standards and that can be created, managed and
consulted by authorized clinicians and staff across more
than one healthcare organization”
∗ While the “experts” can debate the difference between
EHR and EMR, we will not and will stick with EHR
throughout the textbook and slides
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Why do we need EHRs?
∗ Paper records are severely limited: less legible, more difficult
to retrieve, store and share and unstructured data. Also,
electronic records less likely to be missing and available 24/7
from multiple locations. Paper records do not permit clinical
decision support
∗ Need for improved efficiency and productivity: clinicians are
more productive if charts are available and retrieval of results is
faster. EHR access from home while on call helps productivity
∗ Quality of care and patient safety: the factors already described
in last two bullets plus clinical decision support, quality reports
and secure messaging as part of an EHR
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Why do we need EHRs?
∗ Public expectations: EHRs may increase patient
satisfaction through faster results, messaging, patient
portals, electronic patient education, e-prescribing and
online scheduling
∗ Governmental expectations: federal government
considers EHR to be transformational and hence why they
support reimbursement for use
Why do we need EHRs?
∗ Financial savings: EHRs may save money by eliminating
transcription and improving coding. Decreased file room
storage and faster chart pulls and info retrieval may result in
cost savings
∗ Technological advances: computers are much faster, the
Internet is more prevalent, wireless and mobile
technologies are ubiquitous; all supporting EHRs
∗ Need for aggregated data: healthcare data must be
electronic to be shared, stored and analyzed. Research
depends on large study populations and data sets which
EHRs can provide 8
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Why do we need EHRs?
∗ Need for integrated data: electronic data permits
integration with health information organizations,
data analytics, public health reporting, artificial
intelligence and genomic information
∗ EHR as a transformational tool: select organizations
such as the VA and Kaiser Permanente made huge
investments in EHRs to standardize care and
transform delivery and analysis of healthcare
Why do we need EHRs?
∗ Need for coordinated care: with an aging population
with multiple physicians and medications, care
coordination is important. Sharing electronically has
great potential, but barriers exist as we point out in
the chapter on health information exchange
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Electronic Health Record Key
Components
∗ Clinical decision support ∗ Electronic encounter notes
∗ Secure messaging ∗ Multiple input methods
∗ Computerized physician order ∗ Access via mobile technology
entry ∗ Remote access from home
∗ Practice management ∗ Electronic prescribing
∗ Manage care module ∗ Integration with images
∗ Referral management ∗ Integration with physician and
∗ Results retrieval patient education
∗ Prior encounter retrieval ∗ Public health reporting
∗ Patient reminders ∗ Quality reports
11∗ Problem summary lists
Electronic Health Record Key
Components
∗ Ability to scan in data ∗ Preventive medicine
∗ Evaluation and tracking
management help ∗ Privacy/security compliance
∗ Ability to graph and track ∗ Robust backup systems
results ∗ Ability to generate
summaries of care (CCD)
∗ Ability to create patient
∗ Support for client server or
lists application service provider
∗ Ability to create registries (ASP) modes
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Computerized Physician Order Entry
(CPOE)
∗ CPOE is an EHR feature that processes orders for
medications, lab tests, imaging, consults and other
diagnostic tests. It is not the same as electronic
prescribing
∗ CPOE has many potential benefits (next slide)
∗ CPOE has the potential to reduce medical errors but
the literature is mixed. Most early studies came from
a select number of academic institutions with home
grown EHRs and large IT departments
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Potential Benefits of CPOE
Koppel et al
∗ Overcomes the issue of illegibility ∗ Able to avoid medication errors
∗ Fewer errors associated with like trailing zeroes
ordering drugs with similar names, ∗ Creates data that is available for
∗ More easily integrated with decision analysis
support systems than paper, ∗ Can point out treatment and
∗ Easily linked to drug-drug drugs of choice
interaction warning ∗ Can reduce under and over-
∗ More likely to identify the prescribing,
prescribing physician, ∗ Prescriptions reach the
∗ Able to link to adverse drug event pharmacy quicker
(ADE) reporting systems
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CPOE
∗ One study suggested cost savings from reduced
length of stay, compared to paper based orders
∗ Some studies have shown improved standardized
care with EHRs, but this is not universal
∗ CPOE is difficult to implement in hospitals because it
disrupts workflow and slows physicians down. They
often don’t realize, however, that CPOE benefits
others on the team, such as nurses and pharmacists
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Clinical Decision Support Systems
(CDSSs)
∗ With CPOE you can embed a variety of tools to assist
in decision making. Traditionally, this meant
medication alerts and patient reminders. In reality,
any software that assists decisions is a CDSS:
∗ Knowledge support: programs embedded into the EHR
that educate clinicians or patients
∗ Calculators: part of the EHR
∗ Flow charts and graphs: to look at lab or vital sign
trends over time
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Clinical Decision Support Systems
(CDSSs)
∗ CDSS (continued)
∗ Order sets: inpatient clinical practice guidelines for specific
scenarios (e.g. pneumonia), standardizing care
∗ Reminders: remind clinician or patient about pending tests, etc.
∗ Differential diagnosis: software exists that helps clinicians
analyze symptoms and signs, to arrive at a diagnosis
∗ Lab and Imaging decision support: what tests are indicated
and at what costs?
∗ Public health alerts: primarily infectious disease alerts for new
outbreaks, e.g. MERS virus
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Electronic Prescribing (eRx)
∗ Currently, the vast majoring of eRx occurs as part of
an EHR and not a standalone program
∗ 69% of office-based prescriptions are now electronic
∗ 93% of community pharmacies are connected to the
Surescripts network
∗ The next slide lists the potential advantages of eRx
over paper-based prescriptions
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eRx Potential Benefits
∗ Legible and complete ∗ Ability to check formulary status
prescriptions and copays
∗ Abbreviations+ unclear decimal ∗ Can interface with practice and
points are avoided drug management software
∗ The process is secure and HIPAA
∗ The wait to pick up scripts shorter compliant
∗ Fewer duplicated prescriptions ∗ Associated with CDDSs
∗ Better compliance with fewer ∗ Digital records improve data
drugs not filled or picked up analysis of prescribing habits
∗ Potential to reduce workload for ∗ Batch refills can save time
pharmacists ∗ Better use of generic or preferred
∗ Timely notification of drug alerts drugs
and updates
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eRx Clinical Decision Support
∗ Details about drug allergies
∗ Drug-drug interaction alerts
∗ Formulary alerts to tell you drug is either not
recommended or not reimbursed
∗ Alerts can exist to ask about pregnancy, kidney or liver
function and safety in the elderly
∗ Dosing alerts can arise based on age or size of patient
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eRx Challenges
∗ Alert fatigue: too many alerts result in deletions, some
justified, others not. Hot topic and area of much future
research
∗ Prescribing errors still occur with eRx but they are
different; wrong drug or wrong dose
∗ There are still issues at the pharmacist’s end but these
should improve over time
∗ Still not clear how many adverse drug events are
prevented with eRx; perhaps too soon to know
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EHR Registries
∗ Chronic disease: track e.g. diabetes
∗ Research registries: high volume allows research
questions to be answered
∗ Safety registries: issues reported to e.g. FDA
∗ Public health registries: immunizations, cancer and
biosurveillance
∗ Quality: data could be stored in registry and later
forwarded to e.g. CMS
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Practice Management Systems
(PMSs)
∗ Prior to EHR adoption, most medical practices used an
electronic PMS. Now most are part of their EHR
∗ PMSs are essential to run any practice: for billing, dealing
with insurance companies, evaluating physician
performance and practice trends
∗ Typical office workflow is shown in next slide
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EHR Adoption
∗ The US has been behind many other “developed” countries up until
the HITECH ACT that included reimbursement for EHRs
∗ Ambulatory EHR adoption (2015): roughly 86% have EHRs, but some
are much more advanced than others. Larger practices adopt at a
higher rate due largely to stronger finances
∗ Inpatient (hospital) EHR adoption (2015): perhaps as many as 96% of
US hospitals have EHRs and most are participating in the Meaningful
Use program. Smaller urban and rural hospitals lag
∗ Just because you own an EHR doesn’t mean you are maximizing the
features and benefits (next slide)
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EHR Challenges
∗ Financial: in spite of government reimbursement, some
practices will gain and some will lose money. What will the
long term annual costs be after reimbursement ends? Will
some stop using EHRs?
∗ Physician resistance: complying with meaningful use has
been onerous and may not result in any immediate and
direct benefit to clinicians and patients
∗ Loss of productivity: there is almost always initial loss of
productivity and if the practice doesn’t change workflow
habits there will be a long term
26 losses as well
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EHR and Meaningful Use Challenges
∗ Workflow changes: everyone must adapt to doing business
differently but some seek strange workarounds
∗ Reduced physician-patient interaction: without careful
forethought and planning, there will be less eye contact and
interaction with patients
∗ Usability issues: some EHRs are not user friendly and require
too many mouse clicks or illogical steps, impeding workflow
∗ Integration with other systems: practices may need to build
expensive interfaces to communicate with HIOs, practice
management systems, etc. 27
EHR and Meaningful Use Challenges
∗ Lack of interoperability: EHRs are not capable of
communicating with each other without additional
technology, thus an impediment to data sharing
∗ Privacy concerns: hacking into EHRs could result in loss of
privacy for thousands, rather than a single paper chart
∗ Legal: It is not known if EHRs will increase or decrease
malpractice over the long haul
∗ Inadequate proof of benefit: in spite on many published
studies, there is not adequate proof that EHRs improve
quality of care
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EHR and Meaningful Use Challenges
∗ Patient safety and unintended consequences: not only
are studies suggesting improved patient safety mixed,
there is evidence that new medical errors may occur (at
least in the short term) with EHR use. “E-iatrogenesis”
means medical errors due to technology
∗ Situation worsened by alert fatigue, frequent software
upgrades, usability issues, stress to meet meaningful use
objectives
∗ Several sentinel failures of major EHRs in large healthcare
systems have highlighted EHR vulnerability
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HITECH ACT and EHR Reimbursement
∗ The US federal government (along with the IOM) has opined
that EHRs are an important part of healthcare reform
∗ A program for reimbursement for EHR use by clinicians and
hospitals under Medicare and Medicaid (HITECH Act) was
established in 2009
∗ Clinicians had to: (1) be eligible, (2) register for reimbursement,
(3) use a certified EHR, (4) demonstrate and prove Meaningful
Use, and (5) receive reimbursement.
∗ As of December 2017, $24.8 billion was spent by Medicare and
$12.54 by Medicaid on EHR reimbursement to clinicians
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Eligible Professionals (EPs)
∗ Medicare defines EPs as doctors of medicine or osteopathy,
doctors of dental surgery or dental medicine, doctors of
podiatric medicine, doctors of optometry and chiropractors
∗ Medicaid defines EPs as physicians, nurse practitioners,
certified nurse midwives, dentists and physician assistants
(physician assistants must provide services in a federally
qualified health center or rural health clinic that is led by a
physician assistant). Medicaid physicians must have at least
30% Medicaid volume (20% for pediatricians)
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Meaningful Use Goals
∗ The goals of MU are the same as the national goals
for HIT: (a) improve quality, safety, efficiency and
reduce health disparities; (b) engage patients and
families; (c) improve care coordination; (d) ensure
adequate privacy and security of personal health
information; (e) improve population and public health
∗ EHRs must be certified by several organizations as
capable of meeting meaningful use objectives
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Meaningful Use
∗ Users must meet required core measures and
multiple menu measures (textbook for more details).
Quality measures are a major part of meaningful use
∗ There are penalties for hospitals or EPs that don’t
comply with Medicare Meaningful Use
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Small EHR Example
Amazing Charts
∗ Low cost that includes 3 month free trial
∗ Fully featured and compliant with Meaningful Use
∗ Available as a client or web based (ASP) model
∗ Appeals to small practices, particularly primary care
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Medium EHR Example
eClinicalWorks
∗ Medium priced for medium sized practices of
multiple specialty types
∗ More clinician and patient features to include mobile
and a health information exchange (HIE) solution
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Large EHR Example
Epic
∗ Intended for very large practices such as Kaiser-Permanente
∗ Includes every aspect of Meaningful Use and numerous
innovations such as a comprehensive patient portal and
several mobile solutions
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Implementing an EHR Steps
∗ Develop an office strategy: why are you considering EHRs? Is
your entire staff onboard? Don’t do it just for reimbursement.
Plan, plan, plan
∗ Do Research: take advantage of courses, books, articles, EHR
survey results, regional extension centers, HIT consultants,
etc.
∗ List features: be sure to include inputting methods, backup,
warrantees, mobile presence, etc.
∗ Analyze and re-engineer workflow: consider all processes
likely to change when you transition from paper to electronic
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Implementing an EHR Steps
∗ Use project management tools: these will improve your
organization for tasks
∗ Choose client versus ASP model: the web based model will be
easier with less of the need for in house IT support
∗ Practice management system needs: should you purchase a
combination or build an interface?
∗ Survey your hardware and network needs: will you need
more bandwidth? Wireless? How many computer stations and
will they require upgrades?
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Implementing an EHR Steps
∗ Develop a vendor strategy: create request for
proposals (RFPs) for vendors to outline all of your
needs, to include price, maintenance, etc. Obtain
commitments in writing.
∗ Select a vendor: develop a contract and have it
reviewed by legal
∗ Develop a paper to EHR conversion strategy: it is
likely you will initially run a dual paper and electronic
practice. Textbook discusses this in more detail
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Implementing an EHR Steps
∗ Training: you can’t train to much and be sure to
discuss the details with your vendor early on
∗ Implementation: decide whether you will phase in
implementation or have a “go live” date. Be prepared
to decreased productivity for several months and a
new glitches along the way
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Conclusions
∗ EHRs are felt to be critical for US healthcare reform
∗ Paper based health records are severely limited
∗ EHR reimbursement has greatly increased US adoption
∗ In spite of many potential benefits of EHRs, multiple
challenges are associated with adoption
∗ Planning, training and strategizing about EHRs is more
important than the actual EHR brand purchased
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