Electronic Health Records: Trends, Issues, Regulations & Technologies

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1 New September 2010 Critical Report! Electronic Health Records: Trends, Issues, Regulations & Technologies A Management Primer & Update Including: EHR Definition and Role EHR vs. EMR The New Momentum in EHR HITECH and ARRA Rules Meaningful Use Standards Medical Identity Theft Risks Kaiser Permanente EHR Implementation A Management Primer & Update by Robert F. Smallwood, MBA E-Health Records Primer & Update 2010 R. F. Smallwood Do Not Copy 1

2 Who we are IMERGE Consulting is North America's largest and most experienced team of experts in the fields of enterprise content management (ECM) and business process optimization. IMERGE is also a leading provider of education courses in records management, electronic document capture and e-discovery. IMERGE has offices in major cities including Boston, San Francisco, Toronto, Chicago, Houston, Los Angeles, Minneapolis, Seattle, New Orleans and Washington, DC. Our track record speaks for itself: We have completed more successful projects, published more articles and given more expert presentations than any other enterprise content management consulting firm in the world. Learn more about us at imergeconsult.com or contact an IMERGE professional today to discuss putting our expertise to work for you. About the Author Robert Smallwood, MBA, Master of Information Technology, Laureate of Information Technology is a founding Partner of IMERGE Consulting has an extensive background in e-records and electronic patient records. He has been recognized as one of the industry s 25 Most Influential People and Top 3 Independent Consultants by KM World magazine. Some of his past clients include Ochsner Medical Center & Clinic, Children s Hospital of Philadelphia, LSU Medical Center, St. Agnes Medical Center, Clarksville Memorial Hospital, General Health System, and Baton Rouge Medical Center. He has published more than 100 articles and given more than 50 conference presentations on document, records and content management. He is the author of the book, Taming the Tiger, and several others. Disclaimer The references provided in this book should not be considered as legal advice, and is only provided as a resource and starting reference point for further foundation to your own research. All cited references should be verified and updated with your own organization s legal counsel and findings as applicable. 2

3 E-Health Records Primer & Update Table of Contents Executive Summary... 4 Electronic Health Records: Detailed Definition and Role... 5 E-Health Record vs. E-Medical Record: What s the Difference?... 6 The New Momentum Behind Electronic Health Records... 7 Advantages of Implementing EHRs...10 Disadvantages of EHRs...11 More U.S. Doctors Moving to E-Rx...12 Government Stimulus Money for Meaningful Use of EHRs...14 Patients Want Health Data Too...16 Risks of Medical Identity Theft...18 Electronic Health Records: What's Taking So Long?...21 EHR Implementation May Help Reduce Malpractice Claims...25 Standards Issued for Electronic Health Records...25 The ARRA Final Rules...27 Kaiser Permanente Completes E-Health Record Implementation...29 E-Health Records Primer 2010, R. F. Smallwood Do Not Copy 3

4 Executive Summary Electronic health records (EHR) have moved into the forefront of health care IT priorities due to changes in government regulations that encourage their use through financial incentives. According to the U.S. Department of Health and Human Services, an Electronic Health Record (EHR) is an electronic version of a patient s medical history, which is maintained by the provider over time. The EHR can improve patient care by: Reducing the incidence of medical error by improving the accuracy and clarity of medical records. Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions. Many healthcare professionals, and often the government, and the press use the terms electronic medical record (EMR) and electronic health record (EHR) interchangeably. But EHR and EMR are NOT one in the same. The EHR is actually a subset of the EMR, and contains only computerized structured data, such as patient demographics, lab results, and prescriptions, but not unstructured data, like scanned handwritten provider notes. Under the Recovery Act, providers will be able to earn substantial bonus payments if they adopt electronic records: up to $44,000 in Medicare or almost $64,000 in Medicaid for individual providers, and millions of dollars for hospitals The use of online personal health records (PHR), like Microsoft HealthVault and Google Health for assembling and storing personal medical information are catching on. This Management Primer & Update will assist health care IT executives, health information managers, compliance managers and others involved in electronic health records to make intelligent, informed decisions. 4

5 Electronic Health Records: Detailed Definition and Role According to the U.S. Department of Health and Human Services, an Electronic Health Record (EHR) is an electronic version of a patient s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. 1 The EHR automates access to information and has the potential to streamline the clinician's workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting. EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care. For example, the EHR can improve patient care by: Reducing the incidence of medical error by improving the accuracy and clarity of medical records. Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions. According to HIMSS (Healthcare Information Management Systems Society), an electronic health record (EHR) is defined as: A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting. 1 https://www.cms.gov/ehealthrecords/ 5

6 E-Health Record vs. E-Medical Record: What s the Difference? Many healthcare professionals, and often the government, and the press use the terms electronic medical record (EMR) and electronic health record (EHR) interchangeably. But EHR and EMR are NOT one in the same. The EHR is actually a subset of the EMR, and contains only computerized structured data, such as patient demographics, lab results, and prescriptions, but not unstructured data, such as scanned H&P forms, scanned insurance cards, scanned handwritten charts and notes, and also letters and documents (e.g. from the insurance company or patient). EHR and EMR describe completely different concepts, both of which are crucial to the success of healthcare organizations to improve patient care, avoid mistakes, and reduce the cost of delivering healthcare. The EMR is the all inclusive legal record created in the healthcare setting that is the source of data for the EHR. The EHR allows caregivers to share medical information and to have a patient s information available throughout their encounters in the healthcare delivery setting. EMR vs. EHR: Definitions The definitions that proposed for these terms are as follows: 2 Electronic Medical Record: An application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. This environment supports the patient s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO). The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO. Electronic Health Record: A subset of each care delivery organization s EMR, presently assumed to be summaries like ASTM s Continuity of Care Record (CCR) or HL7 s Continuity of Care Document (CCD), is owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a 2 6

7 In February, 2010, the Healthcare Information and Management Systems Society honored Kaiser Permanente for their hospital-based implementation. HIMSS Analytics created the EMR Adoption Model to measure health IT adoption across all 2400 hospitals in the US. By the end of 2009, 39 hospitals were recognized for achieving the highest state of implementation; 24 of those are Kaiser Permanente hospitals. With the final implementation of KP HealthConnect, it is expected that many, if not all, of the remaining Kaiser Permanente hospitals will be recognized as Stage 7 hospitals in The full implementation of KP HealthConnect in both inpatient and outpatient settings paves the way for further information sharing that will improve the future of health care for years to come. Integrated electronic disease registries already draw on KP HealthConnect data to provide a patient-centered view of various chronic conditions that helps to facilitate the delivery of recommended care, and researchers are looking to the data as they embark on comparative effectiveness studies funded by the America Recovery and Reinvestment Act. Kaiser Permanente is also working with other health care organizations, such as the U.S. Department of Veterans Affairs, to determine ways to securely share patient information from KP HealthConnect through the National Health Information Network when patients are under the care of multiple health systems, and provide permission for record sharing. This data sharing helps reduce redundancies and ensures that each care team treating the patient has the complete, up-to-date clinical information necessary to provide quality care. 31

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