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Electronic Health Records: Benefits, Interoperability, and Implementation

This chapter explores the basic concepts and functionalities of electronic healthcare information systems, with a focus on clinical information systems. Topics include electronic medical records, clinical documentation, electronic health records, and the benefits of electronic records. The chapter also discusses the American Recovery and Reinvestment Act and the need for interoperability in healthcare systems. The systems life cycle and project management are addressed, along with the advantages and disadvantages of paper records.

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Electronic Health Records: Benefits, Interoperability, and Implementation

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  1. Chapter 18Basic Electronic Healthcare Information Systems

  2. Clinical Information Systems • Electronic Medical Record (EMR): electronic version of traditional record • Order entry • Computerized provider order entry (CPOE) • Pharmacy • Other applications for clinical documentation • Searchable database

  3. Clinical Information Systems (Cont.) • Electronic Health Record (EHR) • Transportable subset of EMR • Use by healthcare organizations and physicians, and other providers • Use of Clinical Document Architecture (CDA) data standards • Continuity of Care Document (CCD): use of CDA architecture to provide “snapshot” of patient’s health information • Electronic Personal Health Record (ePHR)

  4. Clinical Information Systems (Cont.) • American Recovery and Reinvestment Act (ARRA) signed into law February 17, 2009 • Health Information Technology for Economic and Clinical Health (HITECH) part of the ARRA. Outlines four purposes: • Define meaningful use • Use incentives and grant programs to foster the adoption of EHRs ($27 billion) • Gain the trust of the public • Promote IT innovation

  5. Clinical Information Systems (Cont.) • Need for interoperability: ability to share data • Benefits of electronic record • Minimize decentralization and fragmentation of health care delivery system • Information privacy and security (audit trail) • Ability to search and extract information; trend information for knowledge • Real-time information • Improvement in patient care outcomes

  6. Question • Is the following statement True or False? • A key aspect of electronic records is the ability to share data.

  7. Answer • True • Rationale: Interoperability, or the ability to share data, is an essential characteristic of electronic records.

  8. Paper Records • Strengths • Light, transportable • No waiting at computer terminal, no log in • No electricity, maintenance, or down time • Weaknesses • No backup system • Easily damaged or destroyed • Legibility issues • Tedious to trend data; prone to error • Large, heavy, and difficult to store if stay is lengthy

  9. Electronic Records • Rationale for need • Safer patient care • Paper record not good enough anymore • Need for workflow redesign • Consideration of patient, work done by all care providers, organizational needs • Users’ perceptions; barriers to change; strategies to work through barriers • Purpose, goals, outcomes; tremendous work and collaboration between disciplines • Technological competencies

  10. Project Management • Essential skill of nursing informatics specialist • Management of project from start to finish • Skills • Communication • Team building • Organizational planning • Time and resource management • Systems life cycle as backbone

  11. Question • Which of the following is an advantage of paper records? • A. Safer for patient care • B. Easy to read • C. Trends easily identifiable • D. No down time

  12. Answer • D. No down time • Rationale: Paper records are advantageous because there is no down time and no electricity or maintenance is needed. Electronic records are safer for patient care. Legibility issues of paper records would be a disadvantage. Trends are more difficult to identify with paper records.

  13. Systems Life Cycle • Conception of system until implementation • Analogous to nursing process • Assessment • Multiple places for iteration • Evaluation • Never-ending; changes made based on evaluation • Wording and steps differ by agency or author (see Figure 18-3).

  14. Systems Life Cycle (Cont.) • Initiating • Project goals • Project scope • Scope creep: unanticipated project growth • Project requirements • Risks; needs assessment • Return on investment; cost benefit • Request for information (RFI) • Request for proposal (RFP)

  15. Systems Life Cycle (Cont.) • Planning • Work flow analyses • System selection • System design and testing (vanilla product) • Bugs and debugging • Regression testing • Integration testing • Training

  16. Systems Life Cycle (Cont.) • Implementation • “Go-live” • Roll-back • Contingency plan • Pilot conversion • Phased conversion • Parallel conversion • Big-bang conversion

  17. Question • Is the following statement True or False? • Debugging of the system occurs during implementation.

  18. Answer • False • Rationale: Debugging occurs during the planning step.

  19. Systems Life Cycle (Cont.) • Maintenance/Evaluation • Ongoing process • Planned at least 6 months after implementation

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