Healthcare Information Technologies Discussion

Healthcare Information Technologies Discussion ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Healthcare Information Technologies Discussion I’m studying for my Health & Medical class and don’t understand how to answer this. Can you help me study? Healthcare Information Technologies Discussion Instructions and assigned reading is attached below. If you have any questions, please feel free to let me know. hca_521_unit_7_read.pdf healthcare_informatio Instructions: This assignment must be done in APA format. A minimum word count of 300 words (not including references) is required. A minimum of 3 references (with in-text citations) is required. Please make sure that scholarly references are used. If you have any questions please feel free to ask. What is the definition of an EHR? Do an analysis of at least three forces driving the change to the EHR (root cause analysis). Provide research sources to support your analysis List the three criteria of an electronic signature. Why are these required? List at least two ways codified data in the EHR can be used to manage and prevent disease. Give specific examples. Please separate your answers into 4 separate sections. Book Reference: Gartee, R. (2011). Health information technologyand management. Upper Saddle River, NJ: Pearson. Instructors Notes: In professional writing avoid using first person “I” and third person “we”, as they detract from the quality and turn professional researched statements into opinions. Instead of “I” use, for example, use “the writer, the author or the researcher”. Approved sources for this course include the course textbook and scholarly articles from the Bethel library databases. No other source information is acceptable. M07_GART2674_01_SE_C07.QXD 7 8/10/09 1:58 PM Page 152 Electronic Health Records LEARNING OUTCOMES H I should be able to: After completing this chapter, you ? Define electronic health records G ? Explain why electronic health records are important G ? Discuss what forces are driving the adoption of electronic health records S ? Describe the functional benefits derived from using an EHR , EHR data ? Compare different forms of ? ? ? ? Describe different methods of capturing and recording data Explain why patient visits should be documented at the point of care S Explain how electronic signatures work Describe the workflow of H an office fully using EHRs A N ACRONYMS USED IN CHAPTER 7 I Acronyms are used extensively in both medicine and computers. The following C acronyms are used in this chapter. Q ABN Advance Beneficiary Notice HIPAA Health Insurance Portability and Accountability Act U AHRQ Agency for Healthcare Research and Quality Hx History A CDC Centers for Disease Control and Prevention CDR 1 Clinical Data Repository CMS Centers for Medicare 1 and Medicaid Services CPOE 0 Computerized Physician Order Entry; Computerized 5 Provider Order Entry T ICU Intensive Care Unit IOM Institute of Medicine of the National Academies LOINC® Logical Observation Identifiers Names and Codes OB Obstetrics PACS OR PAC SYSTEM Picture Archiving and Communication System CPRI Computer-Based Patient Record Institute S PIN Personal Identification Number CT SCAN Computerized Tomography Scan Px Physical Examination RHIO DUR Drug Utilization Review Regional Health Information Organization Dx Diagnosis Rx Therapy (Including Prescriptions) ECG OR EKG Electrocardiogram EHR Electronic Health Record HHS Department of Health and Human Services SNOMED-CT® SNOMED Stands for Systematized Nomenclature of Medicine; CT stands for Clinical Terms 152 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.qxd 8/22/09 5:09 PM Page 153 ELECTRONIC HEALTH RECORDS SOAP Subjective, Objective, Assessment, Plan Sx Symptoms Tx Tests (Performed) URI Upper Respiratory Infection 153 Evolution of Electronic Health Records The idea of computerizing patients’ medical records has been around for more than 30 years, but only in the past decade has it become widely adopted. Prior to the EHR, a patient’s medical records consisted of handwritten notes, typed reports, and test results stored in a paper file system. Though paper medical records are still used in many healthcare facilities, the transition to H electronic health records is under way. I Beginning in 1991, the IOM (which stands for the Institute of Medicine of the National Academies) sponsored studies and created reports that led the way G toward the concepts we have in place today for electronic health records. Originally, the IOM called them computer-based G names including electronic medpatient records.1 During their evolution, EHRs had many other ical records, computerized medical records, longitudinal patient S records, and electronic charts. All of these names referred to essentially the same thing, which in 2003, the IOM renamed as the , electronic health record or EHR. Institute of Medicine S The IOM report2 put forth a set of eight core functions that an EHR should be capable of performing: H ? ? A Health Information and Data: Providing a defined data set that includes such items as N medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results; I providers when they need it. providing improved access to information needed by care C Result Management: Computerized results can be accessed more easily (thanQ paper reports) by the provider at the time and place they are needed. U Reduced lag time allows for quicker recognition and treatment of medical problems. Healthcare Information Technologies Discussion Ait possible to reduce redundant The automated display of previous test results makes and additional testing. Having electronic results can allow for better interpretation and for easier detection of abnormalities, thereby ensuring appropriate follow-up. 1 Access to electronic consults and patient consents can 1 establish critical links and improve care coordination among multiple providers, as well as between provider and 0 patient. 5 ? Order Management: Computerized provider order entry (CPOE) systems canTimprove workflow processes by eliminating lost orders and ambiguities caused by illegible S handwriting, generating related orders automatically, monitoring for duplicate orders, and reducing the time required to fill orders. CPOE systems for medications reduce the number of errors in medication dose and frequency, drug allergies, and drug–drug interactions. The use of CPOE, in conjunction with an EHR, also improves clinician productivity. 1 R. S. Dick and E. B. Steen, The Computer-Based Patient Record: An Essential Technology for Health Care (Washington, DC: Institute of Medicine, National Academy Press, 1991, revised 1997, 2000). 2 Ibid. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 154 8/10/09 1:58 PM Page 154 CHAPTER 7 ? ? ? FIGURE 7-1 Data from digital spirometer transfers to EHR. (Courtesy of Midmark Diagnostics Group.) Decision Support: Computerized decision support systems include prevention, prescribing of drugs, diagnosis and management, and detection of adverse events and disease outbreaks. Computer reminders and prompts improve preventive practices in such areas as vaccinations, breast cancer screening, colorectal screening, and cardiovascular risk reduction. Electronic Communication and Connectivity: Electronic communication among care partners can enhance patient safety and quality of care, especially for patients who have multiple providers in multiple settings that must coordinate care plans. Electronic connectivity is essential in creating and populating EHR systems with data from laboratory, pharmacy, radiology, and other providers. Secure e-mail and web messaging have been shown to be effective in facilitating H communication both among providers and with patients, thus allowing for greater contiI nuity of care and more timely interventions. Automatic alerts to providers Gregarding abnormal laboratory results reduce the time until an appropriate treatment is ordered. G Electronic communication is fundamental to the creation of an integrated health record, both within a setting andSacross settings and institutions. , Patient Support: Computer-based patient education has been found to be successful in improving control of chronic illnesses, such as diabetes, in primary care. S is accomplished by means of electronic devices; examHome monitoring by patients ples include self-testing by patients H with asthma (spirometry), glucose monitors for patients with diabetes, and Holter monitors for patients with heart conditions. Data from monitoring A devices can be merged into the EHR, as shown in Figure 7-1. N I C Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 155 ELECTRONIC HEALTH RECORDS ? ? 155 Administrative Processes and Reporting: Electronic scheduling systems increase the efficiency of healthcare organizations and provide better, timelier service to patients. Communication and content standards are important in the billing and claims management area. Electronic authorization and prior approvals can eliminate delays and confusion; immediate validation of insurance eligibility results in more timely payments and less paperwork. EHR data can be analyzed to identify patients who are potentially eligible for clinical trials, as well as candidates for chronic disease management programs. Reporting tools support drug recalls. Reporting and Population Health: Public and private sector reporting requirements at the federal, H state, and local levels for patient safety and quality, as well as for public health, are more easily met with I computerized data. Eliminates the labor-intensive and time-consumingG abstraction of data from paper records and the errors that often occur in a manual process. G Facilitates the reporting of key quality indicators used for the internal quality improvement efforts of many healthcare organizations. S Improves public health surveillance and timely reporting of adverse reactions and , disease outbreaks. In addition to the IOM, ideas from CPRI and HIPAA help us define the EHR. S H Another early contributor to the thinking on EHR systems was the Computer-based Patient A an EHR: Record Institute (CPRI), which identified three key criteria for N ? Capture data at the point of care.Healthcare Information Technologies Discussion I ? Integrate data from multiple sources. ? Provide decision support. C Q HIPAA Security Rule The HIPAA Security Rule did not define an EHR, but perhaps U it broadened the definition. The Security Rule established protection for all personally identifiable health information stored in A electronic format. Thus, everything about a patient stored in a healthcare provider’s system is Computer-based Patient Record Institute protected and treated as part of the patient’s EHR. 1 1 In Electronic Health Records: Changing the Vision, authors Murphy, Waters, Hanken, and Pfeiffer define the EHR to include “any information relating to the past, present or future physical/mental 0 health, or condition of an individual which resides in electronic system(s) used to capture, transmit, 5 the primary purpose of providing receive, store, retrieve, link and manipulate multimedia data for health care and health-related services.”3 EHRs can include dental T health records as well. The core functions defined by the IOM and CPRI suggest that the EHR is not just what data is stored, but what can be done with it. In the broadest sense, S EHRs are the portions of a patient’s EHR Defined medical records that are stored in a computer system as well as the functional benefits derived from having an electronic health record. Social Forces Driving EHR Adoption Visionary leaders in medical informatics have been making the case for EHRs for a long time. However, the combination of several important reports caught the public’s attention and set in motion economic and political forces that are driving the transformation of our medical records systems. 3 Gretchen Murphy, Kathleen Waters, Mary A. Hanken, and Maureen Pfeiffer, eds., Electronic Health Records: Changing the Vision (Philadelphia: W. B. Saunders Company, 1999), 5. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 156 8/10/09 1:58 PM Page 156 CHAPTER 7 HEALTH SAFETY The IOM published a report stating: “Health care in the United States is not as safe as it should be—and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Beyond their cost in human lives, preventable medical errors exact other significant tolls. They have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. A variety of factors have contributed to the nation’s epidemic of medical errors. One oft-cited problem arises from H the decentralized and fragmented nature of the health care delivery system—or ‘non-system,’ to some observers. When patients see multiple providers in different settings, Inone of whom has access to complete information, it becomes easier for things to go G wrong.”4 These statements got the attention G of the press and public. They also got the attention of 150 of the nation’s largest employers. S Employers who sponsored employee health insurance programs had become , frustrated by the increasing costs of health insurance benefits for which they had little or no say about the quality of care. Following the release of the IOM report, these employers formed the Leapfrog group. Healthcare Information Technologies Discussion S A study by the Center for Information Technology Leadership found more than 130,000 lifeH drug reactions alone. The study suggested that $44 billion threatening situations caused by adverse could be saved annually by installingAcomputerized physician order entry systems in ambulatory settings. Leapfrog created a strategy thatN tied purchase of group health insurance benefits to quality care standards. It also promoted CPOE I as a means of reducing errors. HEALTH COSTS GOVERNMENT RESPONSE The response C to the IOM report was swift and positive, within both the government and private sectors. Almost immediately, President Bill Clinton’s administration Qgovernment agencies that conduct or oversee healthcare issued an executive order instructing programs to implement proven techniques U for reducing medical errors, and creating a task force to find new strategies for reducing errors. Congress appropriated $50 million to the Agency for A Healthcare Research and Quality (AHRQ) to support a variety of efforts targeted at reducing medical errors. President George W. Bush followed through by establishing the position of the National 1 Coordinator for Health Information Technology, under the U.S. Department of Health and Human Services (HHS) to “develop,1maintain, and direct the implementation of a strategic plan to guide the nationwide implementation 0 of interoperable health information technology in both the public and private health care sectors that will reduce medical errors, improve quality, and produce greater value for health care5expenditures.”5 President Barack Obama identified T the EHR as a priority for his administration and signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act. S of EHRs and authorizes Medicare incentive payments The act promotes the widespread adoption to doctors and hospitals using a certified EHR and eventually financial penalties for physicians and hospitals that don’t.6 4 Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, 1999). 5 President George W. Bush, Executive Order #13335, April 27, 2004. 6 H. R. 1 American Recovery and Reinvestment Act of 2009, Title XIII Health Information Technology for Economic and Clinical Health, February 17, 2009. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 8/10/09 1:58 PM Page 157 ELECTRONIC HEALTH RECORDS 157 Changes in the way we live have also made paper medical records outdated. In an increasingly mobile society, patients relocate and change doctors more frequently and thus need to transfer their medical records from previous doctors to new ones. Additionally, many patients no longer have a single general practitioner who provides their total care. Increased specialization and the development of new methods of diagnostic and preventive medicine require the ability to share exam records among different specialists and testing facilities. The Internet, one of the strongest forces for social change in the past decade, also affects healthcare. Consumers are becoming accustomed to being able to access very sensitive information securely over the web. They are beginning to ask “Why can’t I access my health records online?” Additionally, there are literally millions of health-related pieces of information on the web. Patients are arriving at their doctor’s office armed with questions and sometimes answers. Medical information previously unavailable to the average consumer is now as easy to access as searching Google™ or WebMD®. Healthcare Information Technologies Discussion CHANGING SOCIETY H I Functional Benefits of an EHR G The ability to easily find, share, and search patient records G makes an EHR superior to a paper record system. However, remember the definition of EHR S as not just stored data but the functional benefits that can be derived from having that data accessible. Four benefits derived , from EHR data that cannot easily be achieved with paper records are health maintenance, trend analysis, alerts, and decision support. These will be described in a moment. First it is necessary to review the various forms in which EHR data is stored before exploring how these and other S functional benefits are derived from it. H Form Affects Functionality A An EHR with any form of data offers improved accessibility Nover a paper chart, but to achieve its full functional benefits, the computer must be able to quickly and accurately identify the information in the record. The form in which the data isI stored determines to what extent the computer can use the content of the EHR to provide additional functions that improve the C quality of care. Chapter 4 discussed various forms in which medical Q records are stored in the database. These may be broadly categorized into three forms: U ? Digital images: This category includes scanned documents, A diagnostic images, digital ? ? x-rays, and even annotated drawings or sound recordings. Images can be retrieved and displayed by the computer, but a human is required to interpret the meaning of the content. 1 Text: The second type of data includes word processing 1 files of transcribed exam notes and also text reports. It is principally obtained in the EHR by importing text files from outside 0 sources. The text files are useful for doctors and nurses to read 5 and can be searched by the computer for research purposes. However, text data is seldom used for generating alerts, trend analysis, decision support, or other real-time EHRTfunctions, because the search capability is slow and the results often ambiguous. S Discrete data: This third form of stored information in an EHR is the easiest for the computer to use. It can be instantly searched, retrieved, and combined or reported in different ways. Discrete data in an EHR may be subcategorized into fielded data and coded data. Coded data is fielded EHR data that goes a step further. By associating a code with each medical term and storing the appropriate code in the medical record, ambiguities about the clinician’s meaning are eliminated. Within medicine, many different terms are used to describe the same symptom, condition, or observation. Additionally, clinicians often use short abbreviations to document their observations in a patient chart. This makes it difficult for a computer to compare notes from one physician to CODED DATA Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M07_GART2674_01_SE_C07.QXD 158 8/10/09 1:58 PM Page 158 CHAPTER 7 another. For example, exam notes by two different providers might phrase a knee injury problem differently: Dr. 1: “knee injury” Dr. 2: “knee trauma” A search of medical records for “knee injury” might not find the second record. To realize the full benefits of an EHR, it is necessary to record a code identifying the clinical information in add … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10