Electronic Health Record

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Electronic Health Record

• By Jackie Patel Brendan
  Noto

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Objectives

• List and describe Hardware used with E
• List, Describe, and Evaluate Software used with
  her
• Describe and Review the Information System
• Describe Advantages and Disadvantages of using
  her
• Examine Ethical/Legal issues related to the use
  of her
• Describe the Technology Related Competencies of
  the Professional Nurse Working with The
  Electronic Health Record
• Describe the Function of The Informatics Nurse is
  working with EHR

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Definition of Electronic Health Record

• An electronic health record is a longitudinal
  electronic record of patient health data that is
  generated by one or more encounter.
• Included in the information are
• patient demographics, progress notes,
  medications, problems, immunizations, vital
  signs, past medical history, radiology lab
  reports.

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Electronic Health Record (cont)

• The her automates and steamlines the clinicians
  workflow.
• The her has the ability to generate a
• complete re a clinical patient
• Encounter.
• Supports other care-related activities directly
  or indirectly via interface.
• This includes evidence-base decision, support,
  quality management, and outcomes reporting.

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Hardware

• The hardware used with the electronic health
  record is any desktop, laptop, computer that is
  integrated into a network associated with
  electronic health record software.
• Computer access is required to use an electronic
  health record system.

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Hardware (con't)

• A sufficient number of workstations, laptops, or
  other mobile computers must be available to
  accommodate the number of healthcare providers at
  any one facility.

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Software

• There are numerous software used for electronic
  health records.
• Most software share common features which include
  the ability to enter pertinent patient data.
• The main feature of choosing an electronic health
  record software is system compatibility.
• We will cover a few of these software programs in
  our presentation as the list is extensive.

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Software (view website)

• http//en.wikipedia.org/wiki/Electronic_health_rec
  ord

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Advantages of EHR

• Gives information and improves risk management
• Provides outcome assessment
• Provides clinical alerts, expert systems, and
  reminders
• Offers great capabilities for storing data in a
  small amount of space.
• Is accessible from remote sites to many people at
  the same time.
• Information is retrieved instantaneously

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Disadvantages of EHR

• Confidentiality, privacy, and security are
• serious concerns
• Requires great technical understanding to
  maintain the system
• There are many high startup costs
• The learning curve for documenting a new system
  is great
• There are too many issues concerning data entry
  that needs to be addressed

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Description of trend in information system

• Major commitments have been made toward the
  construction of an electronic health information
  highway
• Federal government believes major investment in
  health information system will lead to better
  quality care, better access to health services,
  improved patient safety, and efficiencies in the
  delivery of health services.

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Trend (Med Series4 HIS) Criterion

• The trend utilized for ehr is Siemens Med
  Series4 HIS.
• This is a Clinical/General IS
• The health care professionals that use HIS
• are financial officers, data collection and
  management, and
• billing and collections departments.
  
• There are many functions that the IS
• enables the users to perform, such as
• Scheduling, registration, clinical and
  charge, documentation,
• coding, billing, accounts receivable,
  clinical data entry,
• expected reimbursement to name a few.

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Trend (Med Series4 HIS) Criterion

• The configuration used for this IS is
• Workstation.
• The data standards used with this system
• are workgroup for electronic data exchange,
  self directed
• workteams, and HC7 Interfaces are
  formulas for success
• The disease and procedure classification
• system is not applicable for this system.
• The nursing practice standards
• classification scheme used is RPS COTS
• Systems.

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Trend recommendation

• There is a lot of information and data out there
  for this particular trend.
• I would recommend this trend to others who are
  implementing it in their facility.
• This trend may allow a hospital/facility to
  accomplish it's goal.

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Legal barriers to EHR

• Paper-era state regulations may not permit her
• The anti kickback statute
• The Stark anti-referral rules
• Concerns about enhanced malpractice exposure
• HIPPAA privacy and security regulations
• Anti-trust laws

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Legal barriers to EHR

• Law lags behind technology
• State regulation of medical records
• based on rules created in era of paper records
• No mention of electronic records
• Department of health rules applicable to records
  written in 1970s
• Cannot determine authetification of original
  record with EHR

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Legal barriers to EHR

• Anti-kickback statute is a barrier to
  implementing her
• Prohibits remuneration in exchange for referral
• Statute assumes that if hospital
• Makes equipment and software of its EHR available
  to physicians
• Physician may make referrals to hospital
• In-kind value referrals illegal

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Legal barriers to EHR

• Stark rules refer to compensation relationships
• Offer two exceptions
• Wholly dedicated hardware does not equal
  remuneration
• Protects remuneration in form of
• Hardware and software used for community wide HIS
• Party providing technology may not take

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Legal barriers to EHR

• Referrals into account of who gets support
• Community wide system must
• Be available to all providers who want to
  participate
• Arrangement cannot violate Anti-kickback statute

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Legal barriers to EHR

• Many provider believe that EHR will
• Enhance medical liability exposure
• No current case addresses standard of care
• requires use of her
• Current case law does not require physician to
• Obtain or consult a patients prior medical
  record

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Legal barriers to EHR

• HIPPA privacy and security standards
• Allow for down stream use of information along
  familial lines
• Does not anticipate wide open unrestricted use
• Information sharing among unrelated health care
  providers
• Technological challenges of authentification of
  parties

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Legal barriers to EHR

• Anti trust laws
• Prohibit anti-competitive behavior
• Involves content of her
• EHR expected to include payment information
• Payment information could allow providers to
• Collude on prices and violate Anti-trust laws

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Competencies of the professional nurse using EHR

• Use E-mail
• Operate Windows applications
• Search data bases
• Know institution specific nursing software
• Should be educated on core Nursing informatics
  competencies

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Function of the informatics nurse working with EHR

• Data entry
• Communication with interdisciplinary teams
• Ensuring patient adherence to medical advise
• Improving patients outcomes through monitoring
  of health problems

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References

• The MITRE Corporation, (2006, April). National
  Institute of Health-National Center for Research
  Resources/Electronic Health Records Overview.
  Retrieved April 2006 from http//www.ncrr.nih.gov/
  publications/informatics/EHR.pdf
• Wikipedia, The Free Encyclopedia (2008, January
  25). Electronic Health Record. Retrieved
  January 25, 2009 from http//en.wikipedia.org/wiki
  /Electronic_health_record

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References

• East, T. D. (2005, June 28). Lessons
• learned interfacing RPMS and COTS billing
  systems from www.ihs.gov/misc/links_gateway/downlo
  ad.cfm?doc_id
• CMA.CA (2004, January 18). Electronic Health
  Record from http//www.cma.ca/index.cfm/ci_id/8433
  /la_id/1.htm

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References

• East, T. D. (2005, June 28). Lessons
• learned interfacing RPMS and COTS billing systems
  from www.ihs.gov/misc/links_gateway/download.cfm?d
  oc_id
• CMA.CA (2004, January 18). Electronic Health
  Record from http//www.cma.ca/index.cfm/ci_id/8433
  /la_id/1.htm

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References

• Shay, F.(2005). Legal Barriers to Electronic
  Health Records. Physicians News Digest.
  Retrieved February 11,2009 from
  http//www.physiciansnews .com/law/505.html

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References

• McGonigle, D. Mastrian, K. (2009).Nursing
  Informatics and the Foundation of Knowledge.
  Sudbury, MA. Jones and Bartlett Publishers