EMR & EMR Modules

1. EMR & EMR Modules Lecture 9 Monday, February 4, 2013 Victoria Aceti Chlebus, MA

2. Agenda EMR Lecture Leftovers • Benefits of an EMR & Organization of an EMR EMR Modules • Patient Care System (Data Entry) • Computerized Physician Order Entry • Electronic Medication Management & ePrescribing • PACS • CADx • Clinical Decision Support Systems

3. Patient Care System (Data Entry) • EMR is a view-only system where entered information is accessed by a patient’s care circle. • Can be specialized to specialties (Critical Care, Ophthalmology, OB/GYN, Chronic Disease Management) • A Patient Care System (called sometimes by different names) is where information is entered through: • Progress Notes (free text or linked) • Standard templates • Assessments (Tests) • Interventions (Treatment Plans) • Scanned reports

4. Clinical Decision Support System • An interactive computer software system which assists clinicians in making decisions about a patient’s current condition and treatment. • There are many different modules which use CDSS: • Triage • Computerized Physician Order Entry • Electronic Medication Management & ePrescribing • CADx

5. Clinical Decision Support System • Clinical Decision Support Systems (CDSS) work in the background and can create alerts for: • Patient Acuity • Drug interactions • Allergies • Routine Tests • Diagnosis assistance

6. Triage Support: ePod

7. Computerized Physician Order Entry • Orders are directives from physicians as to how to care for a patient and what medications they are prescribing. • Order Entry is currently functional within many health organizations • Computerized Physician Order Entryhas been shown to decrease the number of medication errors, prescribing errors, order-to-patient time, and increase patient safety. • Some studies suggest a reduction in 18-32%

8. Computerized Physician Order Entry

9. Cancer Care Ontario • Canada’s 1st cancer-specific CPOE System • Currently used in 11 cancer centres (ADCP not included) • Largest ambulatory oncology CPOE implementation in Canada with 100% success rate & 90% physician adoption

10. Electronic Medication Management & ePrescribing Tuesday, April 3 Lecture 19

11. What’s the Difference? Electronic Medication Management Electronic prescribing, administration and dispensing of medication No connection to pharmacy or pharmacist Printed copy of prescription for patient to bring to pharmacy ePrescribing • Electronic prescribing within an electronic medical record • Pharmacist has access to patient prescription history • Pharmacist has electronic copy of pending prescriptions • Printed copy of prescription for patient, or sent directly to pharmacist

12. Electronic Medication Management Prescribing • Ordering the drug, the dose, the frequency and route of administration • Detailed list of available medications (including generic products) • Compiles all the medications that have been prescribed to that patient • Does not show which prescriptions have been filed or indicate current medications

13. Electronic Medication Management Medication Decision Support • Drug interactions • Drug-to-drug warnings • Drug-to-disease warnings • Allergy reactions • Dosing information • Complex dosing regimens (chemotherapy) • Particularly important when treating neonates or children

14. Electronic Medication Management Dispensing • Legibility of prescriptions • Legibility of doctor’s orders • Provides an effective check and balance to capture errors • Secondary identification management (Bar coding)

15. Electronic Medication Management Administration • In hospital: RN • Highly structured • Usually regulated by a form of technology • At home: patient or RN • Often not regulated by a medical professional • Can lead to complications

16. ePrescribing • Requires: • Common data language • Access to secure VPN system • Consent from patients to share data with pharmacist • Understanding between the provider and pharmacist as to responsibilities “The ability to send error-free, accurate, and understandable prescriptions electronically from the provider to the pharmacy” (ePrescribing Canada, 2012).

17. So what’s the hold up? • Data sharing and secure VPNs • Patient privacy issues • Pharmacists not wanting responsibility or liability • Ammenwerth et al. (2008): The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review • ePrescribing can reduce the risk for medication errors • Searched literature from 1976-2006, n=27 met inclusion criteria • 23 of the 27 studies found medication error risk reduction • Significant error reduction from 13% to 98% • Researchers found studies concluding 98% reduction grossly overestimated

18. Picture and Archiving Communication Systems (PACS) • Picture and archiving information system • Original PACS system integrated in 1982 in the US • Allows for sharing of diagnostic images through a centralized repository • Different types of health information available in PACS: • Radiology • Cardiovascular

19. SAH IMAGING GHC MAMMOGRAPHY RIS DI DI ARCHIVE REPORT RADIOLOGIST RIS

20. Benefits of PACS Replacement of hard copy medical images Remote access Electronic integration of information (EMR & RIS) Improvement of workflow Additional tools to improve patient diagnoses Improved collaboration Improved communication

21. PACS Challenges Technical issues impeding the delivery of images Potential loss of data or lack of data transmission Legal issues of responsibility between organizations High cost of integrating system and updating system

22. Pan-Northern Ontario PACS Project Originally the “Pan-Northern Ontario PACS Project” NEODIN is one of four Diagnostic Imaging Repositories being implemented in Ontario NW-LHIN, NE-LHIN & Champlain LHIN A total of 59 hospitals (including Group Health Centre) involved Overall goal is to link up all 4 in Ontario for one repository

23. SAH IMAGING GHC MAMMOGRAPHY RIS WS WS ARCHIVE SAH RADIOLOGIST RIS TOH DI-r REPORT HSN

24. Computer Assisted Diagnosis • Combines artificial intelligence and digital images to help diagnose irregularities • Used in the detection of cancers and heart disease at the screening stage • Introduced in 1960s who proposed the idea that computers could detect irregularities

25. Eadie et al. Systematic Review • Reviewed evidence for the effectiveness of computer-assisted diagnosis in cancer imaging • Looked at studies from 1990-2010 • N=48 from 9199 identified studies • Looked at sensitivity and specificity measures

26. Sensitivity & Specificity • Binary classification used to measure the accuracy of a diagnosis: • Sensitivity: measure of true positive and false negative diagnoses • Specificity: measure of true negative and false positive diagnoses

27. Findings Systematic review conducted in 2011 found that CADx assist in the diagnosis of breast cancers, but no evidence of overall benefit from using CADx. Further there is no evidence that CADx are a detriment to diagnosis.

28. Issues with Computer-Assisted Diagnosis • High rate of false-positives, thus still requires a Radiologist to differentiate between significant and insignificant results • Potential loss of diagnosing ability without CAD • When should your clinical judgment override that of a computer?

29. Final Thoughts • EMRs have the potential to improve patient care and decrease medical risk. • Clinicians need to be educated on the limitations of CDSSs as to understand when clinical judgment overrides system features. • There is still much to be understood about how these systems are designed and flow into clinical practice.