EHR Interoperability and Nursing Systems

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Questions and Answers

What is required for EHR data to reach level 7 of shareable EHR adoption?

High-cost infrastructure

Data interoperability (correct)

Data encryption techniques

Increased data storage capacity

Which of the following best describes the role of a Nursing Information System?

To facilitate clinical decision-making and improve patient care (correct)

To manage financial records in healthcare settings

To track inventory and supply chain logistics

To store medical histories exclusively for physicians

What does Computerized Physician Order Entry (CPOE) primarily enhance in a healthcare environment?

Storage of patient data

Patient diagnostic accuracy

Communication among healthcare providers

Efficiency of medication ordering and prescription (correct)

How does integrating Electronic Health Records (EHR) contribute to patient care?

By standardizing data formats across systems Signup and view all the answers

What is a significant barrier to achieving EHR data interoperability?

Diverse data formats and systems used by providers Signup and view all the answers

What does EHR data interoperability primarily ensure?

Clear, shared expectations about the contents of EHR data. Signup and view all the answers

Which aspect is NOT a part of EHR data interoperability?

Strict confidentiality protocols for all medical records. Signup and view all the answers

In terms of EHR integration, what is essential for achieving interoperability?

Shared language and standards for data exchange. Signup and view all the answers

Which of the following is a primary function of a Nursing Information System in relation to EHR interoperability?

Facilitating the exchange of nursing care data with other systems. Signup and view all the answers

What is a primary benefit of Computerized Physician Order Entry (CPOE) in the context of EHR data interoperability?

Enabling real-time order processing and data sharing. Signup and view all the answers

What is one function of the Patient Registration System (PRS)?

Manage and store patients' admission, transfer, and discharge details Signup and view all the answers

How does the PRS contribute to the availability of patient data?

By making patients' data available to all departments of the healthcare institution Signup and view all the answers

What is a key aspect of the integration between PRS and Electronic Health Records (EHR)?

PRS and EHR share workflows to enhance patient management Signup and view all the answers

Which role does a healthcare receptionist play in the PRS and EHR workflow?

They search for incoming patients via the PRS user interface Signup and view all the answers

What function could a Computerized Physician Order Entry (CPOE) system provide in relation to PRS?

It allows physicians to enter orders directly into the healthcare system Signup and view all the answers

Study Notes

Medical Records and HIS/EHR Systems

Health Information Systems (HIS) are systems for capturing, storing, managing, analyzing, or transmitting information related to individual health.
HISs also administer and manage organizational activities within the healthcare sector (financial, personnel, payroll, bed census).
HISs also evaluate hospital performance and cost, and project long-term forecasts.
HIS systems are categorized into four categories: Clinical Information Systems, Administrative Information Systems, Management Support Information Systems, and Research and Data Analysis Information Systems.
Each category contains multiple HISs.
Each HIS system interacts with Electronic Health Records (EHR).

Health Information Systems Workflow and Functions

Learning objectives include describing the types and functions of HISs, identifying the roles of HIS systems in generating, managing, and using EHR data, and understanding the common workflows.

Administrative HIS

Support business functions of the healthcare organization.
Primarily contain administrative and financial data about patients, healthcare providers (staff), healthcare materials, and equipment.
Patient Registration System (PRS) captures pertinent patient information upon entry to a healthcare institution (like a hospital).
- It tracks patient encounters across data input points.
- It's the core HIS in any healthcare institution, providing required information for other HISs.
- PRS functions include searching and retrieving patient demographic and care data from the most recent visit, registering patient identification information (unique ID, age, name, contact), and registering detailed information about a patient needing treatment.
PRS coordinates and manages patient admission, transfer, and discharge.
PRS makes patient data available to all healthcare institution departments.

PRS and EHR Workflow

Healthcare receptionist searches for incoming patients via the PRS user interface.
PRS accesses the EHR repository to search and retrieve data on the incoming patient from the most recent visit (if one exists).
Healthcare receptionist adds identification information for patients not already registered through the PRS user interface.
PRS stores the patient's data in his/her related EHR.
A healthcare receptionist adds detailed information about a patient requiring treatment or admission.
PRS updates the patient's related EHR.
Other HISs notify PRS of transfer or discharge requests.
Healthcare receptionist accesses EHR for handling the unified transfer or discharge request via PRS user interface.
PRS updates the patient's related EHR.
Other HISs can view the status of the transfer/discharge request.

Clinical HIS

Designed to support patient care.
Healthcare providers can access timely, complete, and relevant clinical information.
Healthcare providers use clinical information to diagnose, treat, and manage patient care.
Clinical ISs directly feed the EHR.

Computerized Provider Order Entry (CPOE)

Designed to replace clerical paper-based ordering systems.
Enables healthcare providers (physicians) to electronically write, maintain, and review orders.
Changes to orders are tracked by responsible personnel.
Functions include order entry, electronically transmitting orders to the correct department for fulfillment, decision support (alerts and reminders for healthcare providers).

CPOE and EHR Workflow

Physician or other authorized healthcare provider enters order data via the CPOE user interface.
CPOE checks order data against patient data and medication contradiction data.
If appropriate, CPOE sends a reminder or alert.
Order data is stored in EHR related to the patient.
CPOE sends a notification to the relevant IS to handle the order (e.g., lab, pharmacy, or radiology).
The order is sent to the relevant IS for handling.

Nursing Information System (NIS)

Helps nurses provide better patient care.
Facilitates nursing activities and provides tools for managing the delivery of nursing care.
NIS Functions:
- Register, view, and update patient vital signs (body temperature, blood pressure, heart beats, oxygen percentage).
- Register, view, and update patient care plans (admission and nursing assessments, required treatment tests, nursing notes).
- Register, view, and update patient condition (undetermined, good, fair, serious, critical, treated and released, or confirming patient's death).
- Access order information (drug order, lab order, radiology order).
- Access procedure guidelines

NIS and EHR Workflow

Nurse profession records/views/updates patient plan via NIS user interface.
EHR stores/updates patient's plan.
Nurse profession periodically records/views/updates patient vital signs via NIS interface.
EHRs periodically stores multiple copies of vital signs.
Nurse profession records/views/updates patient condition via NIS interface.
EHRs retrieve/updates patient's plan.
CPOE or other HIS sends a notification alert to the NIS (medication order, lab order, patient's serious or critical condition alert, etc.)
Nurse profession handles patient's situation by viewing and handling notification alerts.
EHR retrieves/updates patient info.
Nurse profession views procedure guidelines.
EHR retrieves procedure guidelines.

Laboratory Information System (LIS)

Effectively manages lab samples and associated data.
Integrates lab instruments to improve lab efficiency.
Functions include:
Patient and sample management (admission date, admitting physician, ordering department, specimen type, specimen & container registration, tracking chain of custody, sample & sample location).
Instrument and application integration (accepting input from bedside devices, controlling operations of physical instruments, extracting, storing, and reporting results).
Decision support (notify alert or reminder when lab test contradicts patient situation or medication, notify alert when the requested test is done soon, notify alert when the result of such lab test is serious or critical).
Electronic data exchange (management of instruments' input and output data, importing of remote data and exporting of test result to remote system or to EHR, send test results to other clinical systems).

LIS and EHR Workflow

Lab profession receives lab test request (paper or electronic) and manages it as follows:
Records/views patient information and requested lab type; generates and stores a barcode identifier for test samples and test containers.
Handles the requested lab test (manually/automatically prepares test instruments, executes and controls the test, extracts and reports the result, stores the test's result in the patient's EHR).
LIS notifies lab profession and other HISs of alerts or reminders.
Lab profession and other healthcare providers handle the LIS notification or reminder.

Radiology Information System (RIS)

Manages medical images and associated data, and tracks radiology imaging orders.
Alternative name is Picture Archiving and Communication Systems (PACS).
Functions include:
Allows direct order entry or accepts orders from other HIS systems.
Generates, analyzes, and manages medical images.
Allows health provider reporting of image results.
Provides picture archiving and transmission of images and tracking of film.

RIS and EHR Workflow

Radiology professions handles the requested radiology image as follows:
Prepares imaging instruments and machines manually or automatically; executes and controls the image.
Extracts and reports the image result; stores the image result in the patient's EHR.

Pharmacy Information System (PIS)

Simplifies and streamlines medication dispensing, inventory control, and drug orders comparison to appropriate dosages for patients.
Receiving medication orders from other HISs (like CPOE and NIS).
Monitoring drug interactions, drug allergies and medication-related complications.
Managing prescriptions for patients.
Tracking all prescriptions through the system.

Clinical Decision Support System (CDSS)

Assists healthcare providers in accurate diagnosis and treatment of patients.
Integrates data from a number of systems to aid charting, CPOE, and identification of drug contraindications.

EHR-based HIS Trends

Not all healthcare institutions (doctors' clinics, healthcare & radiology centers, medical labs, hospitals) adopt a shareable EHR.
EHR requires institutions to share information generated and managed to provide meaningful use.
Information sharing needs to be across multiple levels, including institutions, nationally, and internationally.
The Healthcare Information & Management Systems Society (HIMSS) has an EHR adoption model consisting of eight stages (0-7) that measures the adoption and utilization of shared EHR functions, aiming to promote and support healthcare institutions to adopt EHR and HISS to improve healthcare delivery.
Level 0: No key ancillary clinical information systems installed. Paper-based records are used.
Level 1: All three key ancillary clinical information systems (laboratory, pharmacy, radiology) are installed; electronic storage of healthcare notes (usually as free text) are stored in patient records.
Level 2: Major clinical systems feed data to a clinical data repository (CDR); CDR provides physician access; CDR contains a controlled vocabulary and a clinical decision support/rules engine. Information from document imaging systems may be linked to the CDR. The hospital may be health information exchange (HIE) capable.
Level 3: Nursing/clinical documentation (e.g., flow sheets, nursing notes) is required, implemented, and integrated with CDR. Care plan charting is scored with extra points. The electronic Patient Registration System (PRS) or Patient Master Index system is implemented. Medical image access from radiology information system (RIS) is available for physicians outside the radiology department.
Level 4: CPOE (Computerized Practitioner Order Entry) for use by clinicians is added to the nursing, laboratory, radiology, and CDR environment. Related clinical decision support capabilities are used for evidence based medicine protocols.
Level 5: A full complement of radiology information system (RIS) systems provides medical images to physicians via an intranet and displaces all film-based images.Cardiology RIS and document imaging are scored with extra points.
Level 6: Full physician documentation (structured templates). Progress notes, consult notes, discharge summaries, or problem list & diagnosis list maintenance is implemented. Level 3 clinical decision support provides activities related to protocols and outcomes in the form of variance & compliance alerts. The closed loop of medication administration with bar coded unit dose medications environment is fully implemented.
Level 7: Hospital no longer uses paper-based records. A mixture of discrete data, document images, and medical images within EMR environment. Data warehousing is used for clinical data analytics; data is sharable with entities allowed to treat patients (other hospitals, ambulatory clinics, payers, and patients.) Summary data continuity for inpatient, outpatient, ED, and all owned or managed ambulatory clinics is demonstrated; blood products and human milk are included in the closed-loop medication administration process. EHR data interoperability is required to successfully achieve Level 7. A number of standard coding systems (SCS) are developed and practically used for EHR data interoperability. Most common standard coding systems in healthcare include ICD-X codes, SNOMED codes, HL7 terminology, and EHR communication standards (CEN 13606).

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Description

This quiz explores the critical elements required for Electronic Health Record (EHR) adoption and interoperability. It delves into the roles of Nursing Information Systems and the significance of Computerized Physician Order Entry (CPOE) in enhancing patient care. Assess your understanding of the challenges and benefits associated with EHR integration.