Using Technology

Electronic Data Management: Electronic Health Record Systems and CPOE Systems

Introduction
Electronic Data Management Two forms of technology: Electronic Health Record (EHR) Systems Computerized Provider Order Entry (CPOE) Systems

Electronic Health Record (EHR) Systems

Computer based-applications

Designed to acquire, store, manage, and display

health care related records

Reasons for limited adaptation of EHR Systems

High cost of developing and maintaining such

systems Unclear return of EHR investments Physician resistance Inadequate number of individuals trained in IT

Computerized Provider Order Entry (CPOE) System

It is a process by which health care providers place

clinical orders using a computerized system. Only 17% of hospitals use CPOE systems

Electronic Health Record Systems

Terminologies:
Electronic Health Records Electronic Medical Records

Personal Health Records

History of EHR
Began in the 1960s

The Medical Record developed in 1970 at Duke

University The Regenstrief Medical Record System developed in 1972

EHR SYSTEMS
Tools that provide secure, real-time, point-care and

patient centered information for all health care providers Remind and advise health care providers Provide easy retrievable information about care given days or years before Coordinate the efforts of all parts of the health care system

Good EHR systems standards:

Can help clinicians manage multiple aspects of

patient care Promote better decision making Enabled patient to be coordinated across different sites of health care delivery, support administrative functions related to scheduling patients admissions and appointments, and organize information

Comprehensive EHR systems components:

DATA REPOSITORY

A type of database that contains patient information, including list of medications, allergies, lab and radiology testing results, and etc.

 USER INTERFACES

Point of communication between clinicians and the system. These are essential for the basic work of medicine including the entry of new orders or prescriptions, viewing of lab reports, scheduling clinical visits or admission, and managing lists of diagnoses.

 CLINICAL DECISION SUPPORT

A tool which guide and advise clinicians as they interface with the system. It provides feedback about the best available evidence from nation professional society clinical guidelines and other experts sources.

 COMPUTER-BASED DOCUMENTATION SYSTEMS

Assist health care providers in documenting their clinical decision making and patient interactions.

Problem with EHR systems

Lack of interoperability (capability of information

system components to exchange and use data).

Benefits of EHR Systems

Electronic Health Record Systems Provide a number of direct benefits to health care providers; physicians, nurses, pharmacist and therapist. Data can be automatically captured as a part of the overall workflow. Errors can be reduced because information entered at keyboards or other data capture devices goes right into an HER system.

Clinical Documentation Tools Improve legibility and reduce medication and documentation errors. Aggregate performance information by disease, by health care providers and patient-care area. Can be connected directly to medical devices. Improve compliance with regulatory society standards.

Support Research Efforts Researchers can download information electronically from diverse locations quickly and economically. Designed to improve the quality of data received by prompting clinicians to provide complete medical data. Data can be made available shortly afterwards.

Information Content and Data Issues with an EHR System

List of potential functionalities that could be incorporated in an EHR system: Clinical Documentation Medication administration records Nursing assessments Physician notes Problem list Test an Imaging Diagnostic test imaging Diagnostic test result Laboratory reports Radiographic images and reports

 CPOE Laboratory tests Medications Decision Support Clinical guidelines

Clinical reminders
Drug-allergy alerts Drug-drug interaction alerts

Drug-laboratory interaction alerts

Drug dose support

Two Common Problems Occur in Real Life Practice

Difficulties in data input

System information sharing limit the ability to

collect and access good data

Different Ways to Input Patient Data

Manual Punch Card

Patient Entered Data (electronic questionnaire)

Keyboard (handheld key pad) Direct interfaces with other computers that generate data

(digital laboratory test analyzers, some glucose monitors) Point and click entry Drawing (digital tablet) Scanning of handwritten documents
But each method of data input has a relative strength and weaknesses

Limited System-Interconnectivity/ Interoperability

Problem arose when different systems/ tools within a single system encode the same information using different words, codes or narrative structure. Vendors of EHR systems have customized their product resulting in differing data categories and formats.

Data Standardization
Defines a regular format for the data, the terms used to represent it and the configuration it should take. Example: Weight must include Name (e.g., weight), Value (e.g.,175), and the Units (e.g., pounds)

Health Level 7 (HL-7)

Defines standards for data formatting and configuration. Data from two HL-7 compliant systems can communicate with relative ease and minimal additional programming.

United Stated National Committee on Health and Vital Statistics (NCVHS)

Identified several core clinical vocabularies as terminology standards.

Enterprise Information Architecture

Describes a structure fro implementing information systems that takes a holistic view of system design. Simplifies the overall EHR system by designing interoperability into the system with compatible, logical suites of application programs.

Promoting Expansion of EHR Systems: Issues and Solutions

5% to 39%- implemented EHR systems

Issues about functionality, ease of use, integration

with other health care applications, data security, and ability to conform to clinical workflow Solution: health care providers and organizations must also expend resources to manage local knowledge-based rules and guidelines for the decision support and order entry systems.

 EHR systems are expensive to purchase, implement,

and maintain. SOLUTION: Incentives that can help offset the EHR system purchasing costs include reimbursement from third-party payers and/ or governmental support. High expectations from:

U.S. Department of Health and Human services, (HHS) Congress Food and Drug Administration, (FDA) Centers for Medicare and Medicaid Services (CMS)

Computerized Provider Order Entry

Promoted as a major solution to the problem of medical error. In 2000, Institute of Medicine- first report on medical error,

To Err is Human. Crossing the Quality Chasm: A New Health System for the 21st Century- importance of EHR systems and CPOE. CPOE have been designed with an emphasis on functions for reducing adverse drug events Leapfrog Group- made CPOE one of the three recommended goals to improve quality in hospitals.

CPOE vs. E-prescribing

CPOE describes order

entered electronically into a health systems EHR anywhere within the system Includes orders for laboratory, dietary, radiology, nursing, and pharmacy services.

Electronic prescribing or e-

prescribing refers only to CPOE in ambulatory care settings. Typically describes electronic transmission of prescription data between prescribers, pharmacies, pharmacy benefit managers, and insurance plans.

Computerized Provider Entry

mid- 1970s Early systems allowed health care providers to enter

orders directly into the system but provided little decision support to alert drug-drug interactions, allergy, warning, etc. System functionality, hardware limitations, and readiness of institutions limited early adoption Over subsequent years, technical advancement and the necessity for tools to assist professional in delivering ever-increasing complex care to patients further adoption of CPOE.

 CPOE for medications has only been fully implemented in

17% of all U.S hospitals with 45% of hospitals having no CPOE or plans for CPOE in the near future.

REASONS FOR NOT ADOPTING CPOEs 1. Belief that physicians would not use computerized ordering 2. Products available from vendors have not been perfected 3. Technical and process complexities of implementing CPOE translate into a significant investment with no guarantee of success. 4. Lack of standardization in practice across health care facilities.

Implementing CPOE Systems

CPOE Systems
Promote their potential to reduce adverse events

related to prescribing

Alerting health care providers to potential errors including drug interactions and patient allergies

Goals
Improve patient safety

Increase timeliness of care

Facilitate use of current medical knowledge via

clinical decision support Improve the process and coordination of care Limit the missed opportunities for preventive care Provide research capability for epidemiological studies Control or reduce costs

Disadvantages
While its implementation impacts every hospital

department, the pharmacy often becomes disproportionately involved in the process

Complexity of the medication CPOE module Volume of transactions Perceived value of CPOE on the medication order process CPOE implementation is generally too massive for the pharmacy to initiate but the pharmacy must be prepared and positioned to provide leadership in the medication component of these systems

Process of CPOE (Prescriber)

Prescriber signs in to a computerverifies identity and

prescribing privileges of the prescriber thereby preventing any prescribing outside ones scope of practice A patient is selectedpatients medical record is reviewed for any medication therapy Prescriber chooses drugdosage, route of administration, and other options are presented along with any alerts or advisories relevant to the situation Prescriber authorizes orderorder is then sent to the pharmacy electronically, or sometimes, in print form

Process of CPOE (Pharmacy)

Order is reviewed against the patients medication

profile or medical record and entered into the system Alerts and advisories are flagged for the pharmacistthis helps resolve any potential problems with prescriber Medication is dispensed with directions and sent to the nursing unit for administration to the patient

Clinical Decision Support System

Set of tools that facilitates the decision-making

capabilities of the prescriber at the decision point of CPOE Ranges from simple (reminder) to complex (algorithms) to recommend or change therapy

Goals and Advantages

Checks allergies

Duplicate therapies
Drug interactions Abnormal dosage ranges

Disadvantages
Not always effectively utilized in CPOE systems

because many alerts are clinically insignificant while important alerts are often inadequately addressed Pharmacists are not allowed access to patient demographics information, disease information, and laboratory values

Passive CDS Intervention

Present relevant patient-specific information to the

prescriber without recommending a change in therapy Examples: nonformulary alerts, drug shortages, and order tests

Active CDS Intervention

Utilize specific patient information combined with

other content knowledge to recommend or change therapy Examples: recommendation of dosing, allergy warnings, and safer therapy, or less expensive treatment options

Drug-Content Modules
Provided by CPOE vendors with their products

which serve as the core of medication CDS Provide alerts for drug-drug, drug-allergy, drugpregnancy, and other drug-related problems This ensures that majority of alerts are clinically significant and actionable while only minimal number are time wasters Examples: First Data Bank, Multum, Micromedex

Alerts
Should only be generated for clinically significant

problems Causes the problem of alert fatigue where the clinician is desensitized to warnings Pharmacists have an important role to play here in identifying nuisance alerts from relevant alerts and developing strategies for reducing them Pharmacists can also update systems to reflect the best available evidence on therapy Most commercial systems allow pharmacists to deactivate nuisance alerts and add new alerts deemed clinically important for an institutions patient population

Outcomes for any CDDS Alert

Alert Generated Correct Alert Incorrect Alert Alert for clinically significant problem Alert generated for a clinically insignificant problem No Alert Generated No alert generated because of no error No alert generated for a clinically significant problem

Assessing the Impact

Medication safety and adverse drug events

Response time for medication processing

Pharmacy resource needs Drug cost reductions and achieving financial targets

Downtime and availability of systems

Response time of system Clinical alerts and action taken by provider

Importance of Systems
By monitoring the performance, make needed

adjustments, and provide feedback to the user, this encourages support of the system and continuous improvement of the system This will introduce new opportunities for error, thus introducing new opportunities for better change