HIMT 204 2024-2025 Lecture 4 Electronic Health Information System PDF

College of Applied Medical Sciences in Dammam Academic Year 2024-2025 Health Information (HIMT 204) Electronic Health Information & Record System Core Clinical Applications (Part I) Lec tu re 4...

College of Applied Medical Sciences in Dammam Academic Year 2024-2025 Health Information (HIMT 204) Electronic Health Information & Record System Core Clinical Applications (Part I) Lec tu re 4 Nouf Alassaf  Learning Objectives At the end of this session, you should be able to: Identify the core clinical applications of EHRs. Explain the benefits of each core clinical application. Describe the five-rights for success in implementing EMAR and CDSS. Evaluate the challenges and key capabilities of EHRs.  EHR: Structure The following are components found in most commercial EHRs available today POC EMAR CPOE CDSS Robotics Copyright © 2008, Margret\A Consulting, LLC.  Core Clinical Applications Overview - It is an essential component of the EHR - Used by physicians, nurses and other providers to perform “core business” of healthcare i.e., taking care of patients - EHR alone, without any additional tool, are electronic filing cabinets of healthcare data.  Core Clinical Applications Overview (Cont.) - There are many core clinical applications, the most used are: o Point of Care (POC) Charting o Computerized Provider Order Entry (CPOE) o Electronic Medication Administration Record (EMAR) o Clinical Decision Support System (CDSS) Point of Care (POC) Charting  POC: Definition - Point of Care (POC) charting from the name, it implies the importance of using the application at the same time the patient is taking care of in order to take advantage of real time alerts and reminders - Applies to any clinical role o Different role have different preferences for input methods o Types of data input  POC: Type of Data 1. Structured Data - Refers to data that has been predefined in a table or checklist - Examples o Drop-down menu options o Check boxes/radio buttons - Allows for accurate and distinct elements of documentation to be captured precisely and used in subsequent processing by computer Example of structured data  POC: Types of Data (Cont.) 2. Unstructured Data - Refers to narrative data entered via o Keyboard in a comment field o Dictation/transcription o Speech recognition o Scanning of handwritten documents - Individual data elements not able to be processed by computer - Example o If allergies are documented in a comment field, the system will not provide any suggestion  POC: Types of Documentation 1. Provider Documentation 1. History & Physical (H&P) - Basic document for all patients - The starting point of the patient's "story" as to why they are seeking medical attention - Includes o Chief complaint, history of present illness, history (medical, surgical, psychological), social and family history, medication list, physical exam, assessment & plan Example of H&P form  POC: Types of Documentation (Cont.) 1. Provider Documentation 2. Progress note - Daily notes on hospitalized patients to provide an account of their illnesses for all of those who share in their care - Typically, written in Subjective, Objective, Assessment and Plan (SOAP) note format Example of progress note in SOAP format  POC: Types of Documentation (Cont.) 1. Provider Documentation 2. Progress note - EHR can help in filling the information and import it from different section in the patient file Example of progress note with imported data  POC: Types of Documentation (Cont.) 1. Provider Documentation 3. Discharge summary - Summarizes the patient’s hospitalization - Includes o Final diagnoses o Consultations (if any) o Summary of labs, x- rays and procedures o Final day note o List of discharge medications o Recommendations and follow-up Example of discharge summary form appointments  POC: Types of Documentation (Cont.) 1. Provider Documentation 4. Medication reconciliation - It is the process of comparing a patient's medication orders to all the medications the patient has been taking - It is done to avoid medication errors such as omissions Example of medication reconciliation form  POC: Types of Documentation (Cont.) 2. Nursing Documentation - Depend upon EHR configuration for structured and unstructured data - Requirements vary by specialty and care setting - Examples 1. Notes (shift note, infusion note, nursing note, etc.) 2. Assessment (admission/intake, “head to toe”/system review 3. IV/lines/drains 4. Risk screening 5. Interventions  POC: Types of Documentation (Cont.) 2. Nursing Documentation 6. Medication administration record Ways to filter the medications Example of medication administration record from Cerner EHR  POC: Types of Documentation (Cont.) 2. Nursing Documentation 7. Care plan Example of care plan form  POC: Benefits 1. Access o multiple users o onsite and remote o no need for employee to request another employee to pull the record 2. Legibility 3. Better organization of data o easy to navigate 4. Reduced data entry o re-use data o aggregation of data  POC: Benefits (Cont.) 5. Electronic conveniences o spell check o prompts to user o range check above/below normal range o format check mg instead of ml o consistency check ordering normal saline more than the patient expected length of stay o delta check a comparison of two sets of results from the same patient mainly used with laboratory results POC: Benefits (Cont.) An example of format check Computerized Provider Order Entry (CPOE)  CPOE: What is an Order? - An order is a documented instruction from the treating physician to anything that must be done to or with the patient - Example o Diet o Activity o Medication o Laboratory test o Nursing intervention o Radiology test o Treatment (ex: wound care) o Procedure o Discharge  CPOE: Order’s Elements - Basic components of an order 1. Patient’s full name 2. Date/time of the order 3. Instructions of the order o Medication order instructions: name, dosage, route, frequency 4. Signature of the treating provider  CPOE: Pre-implementation - Any verbal order using paper-based health record will have the following steps 1. Telling nurse what orders are needed 2. Transcribing dictated instructions 3. Conversation with another provider 4. Handwritten prescriptions or order slips 5. Note in the patient’s chart CPOE: Pre-implementation (Cont.)  CPOE: Pre-implementation (Cont.) - Can you read this? - Or this? Example of handwritten medication order and CPOE  CPOE: Pre-implementation (Cont.) - What about this? 17/09/2024, 0900: Acetaminophen (Tylenol), 650mg, PO, Q 4h, PRN Temp >100°F. Routine. Dr. Nora. Stop 24/09/2024, 0900. - Or this? Give 650mg of Tylenol by mouth every four hours as needed for a temperature greater than 100 degrees Fahrenheit for a week starting from today September 17th, 2024, at 09:00 a.m. to September 24th, 2024, at 09:00 a.m. Ordered by Dr. Nora - Abbreviations PO = by mouth (from Latin Per Os) Q = every (from Latin quaque) 4h = 4 hours PRN = as needed for (from Latin pro re nata)  CPOE: Definition - It is a system enabling care providers to enter orders directly through EHR - Integral part of EHR, cannot stand-alone - Originally developed to improve safety of medication orders then added electronic ordering of tests, procedures, and consultations - It affects almost all departments in the hospital  CPOE: Definition (Cont.) - Mainly, it o Provides capability of transmitting orders to various ancillary departments (order management) o Provides capability of viewing results of laboratory tests, other diagnostics studies, and status of orders (result management) o Standardizes verbal, faxing, and telephone processes - Other terms o Computerized physician order entry o Computer-based provider order entry o Care provider order entry  CPOE: Example Example of verbal order using CPOE  CPOE: Example (Cont.) Example of how orders are shown in CPOE  CPOE: Benefits 1. Prevent, reduce, or eliminate medical errors and adverse drug events (ADEs) in prescribing phase - According to Elden & Ismail study (2015), ordering phase was the highest in medication errors - Also, Kuo et al. (2008) concluded that 70% of medication errors were related to prescribing and that 57% of errors might have been prevented by electronic prescribing - CPOE can help in reducing the percentage by o Overcoming illegibility o Notifying similar name medications o Reaching pharmacy quicker o Decreasing under and over-prescribing (range check)  CPOE: Benefits (Cont.) 2. Improve efficiency of healthcare delivery - CPOE can improve the process through –for example- o Reduction in order verification and processing times o Increase productivity (provides pre-defined orders) o Electronic communication both directions Order entered electronically Order sent electronically Order received electronically Status returned electronically 3. Reduce costs - Study compared CPOE to paper records, CPOE can save, on average between $11.6 and $170 million per hospital (Nuckols et al., 2015) o Through identifying duplicate orders  Electronic Medication Administration Record (EMAR) EMAR: Definition  EMAR: Definition (Cont.) - Automation of many of the medication administration processes in the hospital - Called bar-code medication administration record system - Uses a barcode or radio frequency identification technology (RFID)  EMAR: Uses - Aids in making sure the 5 rights: right patient, right meds, right dose, right time, and right route  EMAR: Benefits 1. Reduce medication errors in administration phase Errors are reduced by CPOE Errors are reduced by EMAR Medication management process  EMAR: Benefits (Cont.) 1. Reduce medication errors in administration phase - According to a study in 2015, medication errors were higher during o Ordering/prescription stage (38.1%) o Followed by (20.9%) during administration phase - EMAR can help in reducing phase four errors  EMAR: Benefits (Cont.) 2. Positively identify patient, drug, and person administering the drug 3. Access patient information 4. Real time documentation and billing 5. Audit trail (date and time-stamped, sequential record) 6. Alerts and warning messages (if merged with CDSS) THANK YOU