A study on. EHR and exploring new business offerings for emids Technologies. Submitted by: Vijay K. Reg No: Under the guidance of

Transcription

1 A study on EHR and exploring new business offerings for emids Technologies Project submitted in partial fulfillment for the requirement of the Post Graduate Diploma in Business Management (PGDBM) of Bharathidasan Institute of Management Submitted by: Vijay K Reg No: Under the guidance of Dr. Sajan Mathew Bangalore Campus May 2009 Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 1

2 DECLARATION BY THE STUDENT This is to state that the project titled A Study on EHR and exploring new business offerings for emids Technologies is an original work carried out by me under the guidance of Prof. Sajan Mathew, BIM Bangalore towards partial fulfillment for the requirement of the Post Graduate Diploma in Business Management (PGDBM) of Bharathidasan Institute of Management. This has not been submitted in part or full towards any other degree of diploma. K Vijay Reg No: PGDBM Batch VI Bharathidasan Institute of Management Bangalore Campus Place: Bangalore Date: June 2009 Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 2

3 Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 3

4 CERTIFICATE BY THE GUIDE This is to certify that the project titled A Study on EHR and exploring new business offerings for emids Technologies is an original work carried out by K Vijay under my guidance. This has not been submitted in part or full towards any other degree of diploma. Dr. Sajan Mathew BIM, Bangalore PGP Chairperson - BIM Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 4

5 ACKNOWLEDGEMENT First of all, I extend my sincere gratitude to Ms. Suchismita Bhattacharya, emids technologies for her guidance, constructive comments and support that she offered throughout the period of the project. I would like to thank Mr. Prithwiraj Dasgupta Vice President, Business Development and Practice Management, emids technologies for providing me this excellent opportunity to work with emids technologies. I am grateful to Prof. Sajan Mathew, BIM for her continuous support and valuable comments throughout the course of this project. I am deeply indebted to all my friends and colleagues who have offered their support and help. I would like to owe my prayers to the Almighty for everything he has blessed me with. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 5

6 Executive Summary In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person, up from $2.1 trillion, or $7,026 per capita, the previous year. Spending in 2006 represented 16% of GDP, an increase of 6.7% over 2004 spending. Growth in spending is projected to average 6.7% annually over the period 2007 through Health insurance costs are rising faster than wages or inflation, and medical causes were cited by about half of bankruptcy filers in the United States in Thus in order to reduce the healthcare cost, EHR (Electronic health record) is the only solution. In 2004, President Bush established a ten-year plan as this EHR technology is essential to cut down the health care cost. In order to fasten the implementation of EHR, on February 2009, President Obama stated: "Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down cost, ensure privacy, and save lives" The 2009 economic stimulus package (HITECH Act) passed by Obama aims at incenting more physician to adopt EHR. The act promises incentive payments to those who adopt and use "certified EHRs" and, eventually, reducing Medicare payments to those who do not use an EHR. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to also show "meaningful use" of an EHR system This creates great scope for EHR vendors and physicians to use EHR for incentives. From emids Technologies perspective it also generates scope for new line of business in EHR at this point of time. Thus detailed study of EHR is carried out and final offerings are suggested in the field of EHR. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 6

7 Declaration Certificate from Organization Certificate by Guide Acknowledgement Executive Summary ii iii iv v vi TABLE OF CONTENTS 1 Introduction Healthcare in US Health care providers Medical products, research and development Health care spending Health care payment About Health Information Technology (HIT) Concepts and Definitions Implementation of HIT Types of technology About EHR EMR vs. EHR: Definitions Need for EHR Advantages of EHR Features of EHR Barriers to implement EHR Components of EHR Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 7

8 1.10 EHR Implementation models Components of EHR EHR Adoption Model Economic stimulus package and Healthcare Information Technology Organization and standards governing EHR Technology and functionality of EHR EHR Technology Product architecture Workflow of EHR Functionalities of EHR EHR Certifying body (CCHIT) About CCHIT About CCHIT criteria Functionality Interoperability Security Certification programs of CCHIT Product Attributes and Inspection Methods Impact of certification on various entities Stimulus effect on CCHIT Anticipated use of Certified EHR emids and CCHIT emids Target vendors emids offering in CCHIT Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 8

9 LIST OF FIGURES Figure 1 : Total spending on Health care Figure 2 : Health care spending per capita Figure 4 : A Sample EHR Record Figure 5 : Adoption model Figure 6 : emids offering LIST OF TABLES Table 1 : EMR Vs EHR Table 2 : ASP Vs Locally Hosted model Table 3 : Target Vendor List Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 9

10 1 Introduction The project objective involves a detailed study of the EHR systems, CCHIT and the associated processes and technologies. After assessment of the details, it was discussed if it would be strategically viable as a new line of business (LOB) for emids Technologies. 1.1 Healthcare in US Health care in the United States is provided by many separate legal entities. Including private and public spending, more is spent per person on health care in the United States than in any other nation in the world. A study of international health care spending levels published in the health policy journal Health Affairs in the year 2000, found that while the U.S. spends more on health care than other countries in the Organization for Economic Co-operation and Development (OECD), the use of health care services in the U.S. is below the OECD median by most measures Active debate over health care reform in the United States concerns questions of a right to health care, access, fairness, efficiency, cost, and quality. The World Health Organization (WHO), in 2000, ranked the U.S. health care system as the highest in cost, first in responsiveness, 37th in overall performance, and 72nd by overall level of health (among 191 member nations included in the study). The WHO study has been criticized in a study published in Health Affairs for its methodology and lack of correlation with user satisfaction ratings. A 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries. However, the U.S. is a leader in medical innovation, with three times higher per-capita spending than Europe. The U.S. also has higher survival rates than most other countries for certain conditions, such as some less common cancers, but has a higher infant mortality rate than all other developed countries Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 10

11 As a proportion of GDP, public health care spending in the United States is larger than in most other large Western countries. On top of that, there is substantial expenditure paid from private insurances. According to the Institute of Medicine of the National Academy of Sciences, the United States is the "only wealthy, industrialized nation that does not ensure that all citizens have coverage" (i.e. some kind of insurance). Source: HIMSS Analytics Figure 1 : Total spending on Health care Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 11

12 Source: HIMSS Analytics Figure 2 : Health care spending per capita Health care providers In the United States, ownership of the health care system is mainly in private hands, though federal, state, county, and city governments also own certain facilities. The non-profit hospital's share of total hospital capacity has remained relatively stable (about 70%) for decades. There is also privately owned for-profit hospital as well as government hospitals in some locations, mainly owned by county and city governments. The federal Veterans Health Administration operates VA hospitals open only to veterans, though veterans who seek medical care for conditions they did not receive while serving in the military are charged for services. The Indian Health Service operates facilities open only to Native Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 12

13 Americans from recognized tribes. These facilities, plus tribal facilities and privately contracted services funded by IHS to increase system capacity and capabilities, provide medical care to tribes people beyond what can be paid for by any private insurance or other government programs Hospitals provide some outpatient care in their emergency rooms and specialty clinics, but primarily exist to provide inpatient care. Hospital emergency departments and urgent care centers are sources of sporadic problem-focused care. Hospice services for the terminally ill who are expected to live six months or less are most commonly subsidized by charities and government. Prenatal, family planning, and "dysplasia" clinics are government-funded obstetric and gynecologic specialty clinics respectively, and are usually staffed by nurse practitioners. A research brief published in December 2008 by the Center for Studying Health System Change found that most U.S. consumers rely on word of mouth and physician referrals when choosing health care providers Medical products, research and development The United States is a leader in medical innovation. In 2004, the nonindustrial sector spent three times as much as Europe per capita on biomedical research. Companies provide medical products such as pharmaceuticals and medical devices. The nation spends a substantial amount on medical research, mostly privately funded. As of 2000, non-profit private organizations funded 7%, private industry funded 57%, and the tax-funded National Institutes of Health supported 36% of medical research in the U.S. However, by 2003, the NIH provided only 28% of medical research funding; finance from private industry increased 102% from 1994 to Research and development for applications is primarily done in commercial labs, while the government and universities fund the majority of general research. Much of this basic research is funded or conducted by governmental research institutes such as the NIH. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 13

14 1.1.3 Health care spending Current estimates put U.S. health care spending at approximately 15.2% of GDP, second only to the tiny Marshall Islands among all United Nations member nations. The health share of GDP is expected to continue its historical upward trend, reaching 19.5 percent of GDP by The Office of the Actuary (OACT) of the Centers for Medicare and Medicaid Services publishes data on total health care spending in the United States, including both historical levels and future projections. In 2007, the U.S. spent $2.26 trillion on health care, or $7,439 per person, up from $2.1 trillion, or $7,026 per capita, the previous year. Spending in 2006 represented 16% of GDP, an increase of 6.7% over 2004 spending. Growth in spending is projected to average 6.7% annually over the period 2007 through Health insurance costs are rising faster than wages or inflation, and medical causes were cited by about half of bankruptcy filers in the United States in It has found that "about half of all growth in health care spending in the past several decades was associated with changes in medical care made possible by advances in technology." Other factors included higher income levels, changes in insurance coverage, and rising prices. Hospitals and physician spending take the largest share of the health care dollar, while prescription drugs take about 10 percent. The use of prescription drugs is increasing among adults who have drug coverage. Health care spending in the United States is concentrated. An analysis of the 1996 Medical Expenditure Panel Survey found that the 1% of the population with the highest spending accounted for 27% of aggregate health care spending. The highest-spending 5% of the population accounted for more than half of all spending. These patterns were stable through the 1970s and 1980s, and some data suggest that they may have been typical of the mid-to-early 20th century as well. One study by the Agency for Healthcare Research and Quality (AHRQ) found significant persistence in the level of health care spending from year to year. Of the 1% of the population with the highest health care spending in 2002, 24.3% maintained their ranking in the Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 14

15 top 1% in Of the 5% with the highest spending in 2002, 34% maintained that ranking in 2003 Seniors spend, on average, far more on health care costs than either working-age adults or children. The pattern of spending by age was stable for most ages from 1987 through 2004, with the exception of spending for seniors age 85 and over. Spending for this group grew less rapidly than that of other groups over this period. The 2008 edition of the Dartmouth Atlas of Health Care found that providing Medicare beneficiaries with severe chronic illnesses with more intense health care in the last two years of life increased spending, more tests, more procedures and longer hospital stays is not associated with better patient outcomes. There are significant geographic variations in the level of care provided to chronically ill patients. Only a small portion of these spending differences (4%) is explained by differences in the number of severely ill people in an area; rather, most of the differences are explained by differences in the amount of "supply-sensitive" care available in an area. Acute hospital care accounts for over half (55%) of the spending for Medicare beneficiaries in the last two years of life, and differences in the volume of services provided is more significant than differences in price. The researchers found no evidence of "substitution" of care, where increased use of hospital care would reduce outpatient spending (or vice versa). Increased spending on disease prevention is often suggested as a way of reducing health care spending. Research suggests, however, that in most cases prevention does not produce significant long-term costs savings. Preventive care is typically provided to many people who would never become ill, and for those who would have become ill is partially offset by the health care costs during additional years of life. In September 2008 the Wall Street Journal reported that consumers were reducing their health care spending in response to the current economic slow-down. Both the number of prescriptions filled and the number of office visits dropped between 2007 and In one survey, 22% of Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 15

16 consumers reported going to the doctor less often, and 11% reported buying fewer prescription drugs Health care payment In the United States, doctors and hospitals are generally funded by payments from patients and insurance plans in return for services rendered. Around 84.7% of citizens have some form of health insurance; either through their employer or the employer of their spouse or parent (59.3%), purchased individually (8.9%), or provided by government programs. All government health care programs have restricted eligibility, and there is no national system of health insurance which guarantees that all citizens have access to health care. Americans without health insurance coverage at some time during 2007 totaled about 15.3% of the population, or 45.7 million people. Among those whose employer pays for health insurance, the employee also usually contributes part of the cost of this insurance, while the employer usually chooses the plan and, for large groups, negotiates with the insurance company. In 2004, private insurance paid for 36% of personal health expenditures, private out-of-pocket 15%, federal government 34%, state and local governments 11%, and other private funds 4%. Insurance for dental and vision care is usually sold separately, and prescription drugs are often handled differently than medical services, including by the government programs. Major federal laws regulating the insurance industry include COBRA and HIPAA. Individuals with private or government insurance must generally find a medical facility which accepts the particular type of medical insurance they carry. Visits to facilities outside the insurance program's "network" are usually either not covered or the patient must bear more of the cost (usually waived for emergencies). Hospitals and doctors negotiate with insurance programs Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 16

17 to set reimbursement rates; some rates for government insurance programs are set by law. The sum paid to a doctor for a service rendered to an insured patient is generally less than that paid "out of pocket" by an uninsured patient. In return for this discount, the insurance company includes the doctor as part of their "network", which means more patients are eligible for lowestcost treatment there. The negotiated rate may not cover the cost of the service, but hospitals and doctors can refuse to accept a given type of insurance, including Medicare and Medicaid. Low reimbursement rates have generated complaints from providers, and some patients with government insurance have difficulty finding nearby providers for certain types of medical services. Charity care for those who cannot pay is sometimes available from any given medical facility, and is usually funded by non-profit foundations, religious orders, government subsidies, or services donated by the employees. Massachusetts and New Jersey have programs where the state will pay for health care when the patient cannot afford to do so. The City of San Francisco is also implementing a citywide health care program for all uninsured residents, initially available to those whose incomes are below an eligibility threshold. Some cities and counties operate or provide subsidies to private facilities open to all regardless of the ability to pay, but even here patients who can afford to pay or who have insurance are generally charged for the services they use. The Emergency Medical Treatment and Active Labor Act require virtually all hospitals to accept all patients, regardless of the ability to pay, for emergency room care. This does not provide patients who cannot afford to pay for health care access to non-emergency care, nor does it provide the benefit of preventive care and the continuity of a primary care physician. This is also generally more expensive than an urgent care clinic or a doctor's office visit, especially if a condition has worsened due to putting off needed care. Emergency rooms are typically at, near, or over capacity. Long wait times have become a problem nationally, and in urban areas some ERs are put on "diversion" on a regular basis, meaning that ambulances are directed to bring patients elsewhere. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 17

18 1.1.5 Health care regulation and oversight In the federal government of the United States, the United States Department of Health and Human Services is the executive department responsible for health. It is managed by the Secretary of Health and Human Services, a member of the Cabinet. On March 2, 2009,President Obama has released $155 million in the $787 billion economic stimulus measure to support 126 new health centers, with the goal of giving people more access to primary and preventive health care services. State governments maintain state health departments, and local governments (counties and municipalities) often have their own health departments, usually branches of the state health department. Regulations of a state board may have executive and police strength to enforce state health laws. In some states, all members of state boards must be health care professionals. Members of state boards may be assigned by the governor or elected by the state committee. Members of local boards may be elected by the mayor council. In 1980 the United States Congress legislated that the Department of Welfare and Health become the Department of Health and Human Services. The agencies of the Public Health Service are the Health Administration, which regulates health care to people without health care, the Food and Drug Administration, which certifies the safety of food, effectiveness of drugs and medical products, the Centers for Disease Prevention, which prevents disease, premature death, and disability, the Agency of Health Care Research and the Agency Toxic Substances and Disease Registry, which regulates hazardous spills of toxic substances. There are government institutes such as the Centers for Disease Control and Prevention that identify threats to public health. In addition there are regulatory bodies such as the FDA that identify and approve drugs for medical use and sale. Many health care organizations also voluntarily submit to inspection and cert. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 18

19 A report issued by Public Citizen in April 2008 found that the number of serious disciplinary actions against physicians by state medical boards declined from 2006 to This was the third yearly decline in a row. The Centers for Medicare and Medicaid Services (CMS) publishes an on-line searchable database of performance data on nursing homes. CMS also publishes a list of Special Focus Facilities - nursing homes with "a history of serious quality issues." The Government Accountability Office (GAO), however, has found that state nursing home inspections understate the number of serious nursing home problems that present a danger to residents. The GAO concluded that while CMS oversight has improved, there are still weaknesses in its oversight of nursing homes. The U.S. has a joint federal/state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers. State mandates generally do not apply to the health plans offered by large employers, due to the preemption clause of the Employee Retirement Income Security Act. 1.2 About Health Information Technology (HIT) Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technologies (HIT) in general are increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system. Broad and consistent utilization of HIT will: Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 19

20 Improve health care quality; Prevent medical errors; Reduce health care costs; Increase administrative efficiencies; Decrease paperwork; and Expand access to affordable care Interoperable health IT will improve individual patient care, but it will also bring many public health benefits including: Early detection of infectious disease outbreaks around the country; Improved tracking of chronic disease management; and Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared Concepts and Definitions Health information technology (HIT) is the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making. Technology is a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 20

21 machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT. Informatics refers to the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informatics refers to the intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, and pharmacy informatics are sub disciplines that inform health informatics from different disciplinary perspectives. The processes and people of concern or study are the main variables Implementation of HIT The Institute of Medicine s (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the President s Health Information Technology Plan, established a ten-year plan as this technology is essential to put the needs and the values of the patients first and gives patients information they need to make clinical and economic decisions. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 21

22 and improve the quality of care if it were to widely adopt health information technology. The most immediate barrier to widespread adoption of technology is cost: patients benefit from better health, and payers benefit from lower costs; however, hospitals pay in both higher costs for implementation and lower revenues due to reduced patient length of stay Types of technology Electronic Health Record (EHR) Although frequently cited in the literature the Electronic health record (EHR), previously known as the Electronic medical record (EMR). However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures. Important features of modern EHR software include automatic drugdrug/drug-food interaction checks and allergy checks, standard drug dosages and patient education information, such as describing common side effects. Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient. Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise. Electronic medical record (EMR) Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 22

23 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. 1.3 About EHR EHR is defined as including: Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual Immediate electronic access to person- and population-level information by authorized, and only authorized users Provision of knowledge and decision support that enhance the quality, safety and efficiency of patient care Support of efficient processes for health care delivery Simply put, EMRs refer to all patient related data traditionally captured in the medical case file within a single provider setting. EHR refers to a collection of a patient s health information gathered across his/her lifespan. The EHR is not restricted to interactions with a provider alone, but takes into account interactions across the healthcare system ranging from payers, regulatory bodies, registries as well as devices outside the provider setting. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 23

24 The EHR attempts to promote a more holistic view of patient records where continuum of care is the key aspect, allowing access to medical information by multiple stakeholders. An EHR can be a system of multiple systems or an enterprise wide solution spanning a range of functions and departments Many people in the US healthcare industry, government, and the press use the terms electronic medical record (EMR) and electronic health record (EHR) interchangeably. However, these terms describe completely different concepts, both of which are crucial to the success of local, regional, and national goals to improve patient safety, improve the quality and efficiency of patient care, and reduce healthcare delivery costs. EHRs are reliant on EMRs being in place, and EMRs will never reach their full potential without interoperable EHRs in place. The EMR is the legal record created in hospitals and ambulatory environments that is the source of data for the EHR. The EHR represents the ability to easily share medical information among stakeholders and to have patient s information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payers/insurers, including the government. But before we can move to effective EHR environments, provider organizations must implement complete EMR solutions. At this point, few hospitals have EMR solutions that can effectively reduce medical errors or improve the quality and efficiency of patient care. The Clinical Transformation Staging Model has been developed by HIMSS Analytics to assess the status of clinical system/emr implementations in care delivery organizations Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 24

25 Figure 3 : A Sample EHR Record Source: Above record have Demographic details Schedule for hospitals visits Medicine details Lab results Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 25

26 Billing and insurance details Various imaging processes for diagnosis 1.4 EMR vs. EHR: Definitions The market has confused the electronic medical record (EMR) and the electronic health record (EHR). Government officials, vendors, and consultants have propagated this confusion, in some cases unintentionally. The definitions that HIMSS Analytics proposes for these terms are as follows: 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(cdo) EMR, 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 community, region, or state (or in some countries, the entire country). The EHR in the US will ride on the proposed National Health Information Network (NHIN). The EHR can be established only if the electronic medical records of the various CDOs have evolved to a level that can create and support a robust exchange of information between stakeholders within a community or region. While some forms of early EHRs exist today in Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 26

27 limited environments, it will be difficult to establish effective EHRs across the majority of the US market until we have established clinical information transaction standards that can be easily adopted by the different EMR application Interoperability: A Key Difference between the EHR and EMR The terms EHR and EMR are used interchangeably in part because of their common foundation (paperless method for patient charting and documentation) and many similarities in software features. As we promote the EHR, we don t negate the benefit of an EMR. EMRs allow practices to, at minimum, expedite all documentation tasks related to paper charting, while saving space and minimizing duplication in collection of information. However, a key difference with the EHR is its interoperability. HIMSS defines this as the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities. Many electronic medical records are essentially capable of (and in the process of) transforming into an EHR by reaching higher stages of utilization that include interoperability capabilities. What is so important about interoperability? Interoperability is more than a capability; it is an essential component to achieve the necessary information sharing among health care stakeholders to administer continuous, quality patient care without limitations to patient health information. In fact, interoperability has national importance, encouraged and endorsed by the Secretary of Health and Human Services (HHS). HHS supports the American National Standards Institute s Health Information Technology Standards Panel (HITSP), which is a consortium of HIT experts committed to streamlining interoperability standards, based on national and international benchmarks. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 27

28 EHR Interoperability Standards: Certification Commission for Health Information Technology National focus toward information sharing and exchange also became apparent from the creation of the Certification Commission for Health Information Technology (CCHIT). CCHIT is a body various HIT and HIE experts who developed a certification process for HIT tools. CCHIT certification is awarded to EHR products that demonstrate nationally recognized interoperability standards, along with functionality and security. With these certifications and national standards, tools deemed as EMRs today will most likely either advance/undergo upgrades to become an EHR, or eventually dissolve as their lack of interoperability capabilities makes them outdated. Table 1 : EMR Vs EHR ELECTRONIC MEDICAL RECORDS The legal record of the Providers A record of clinical services for patient encounters in a Providers Owned by the Providers These systems are being sold by enterprise vendors and installed by hospitals, health systems, clinics, etc Does not contain other Providers encounter information ELECTRONIC HEALTH RECORDS Subset (i.e. Providers) of information from various Providers where patient has had encounters Owned by patient or stakeholder Community, state, or regional emergence today (RHIOs) or nationwide in the future Provides interactive patient access as well as the ability for the patient to append information. Connected by NHIN Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 28

29 1.5 Need for EHR To share patient information among health care practitioners and professionals To improve clinical processes or workflow efficiency To improve quality of care To reduce medical errors (improve patient safety To facilitate clinical decision support To provide access to patient record at remote locations To improve clinical data capture To improve clinical documentation to support appropriate billing service levels To meet requirement of legal, regulatory or accreditation standards To reduce healthcare delivery cost To establish a more efficient and effective information infrastructure as a competitive advantage. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 29

30 1.6 Advantages of EHR 1. Increase Productivity EMR technology supports automation of clinical processes, thereby improving the productivity of organizations. Mundane tasks like manually pulling/filing paper charts are replaced by simply clicking a patient's name in the EMR system. Integration with diagnostic devices enable users to feed lab, imaging and x-ray results and other findings directly into patient records, thereby eliminating the need to manage several kind of documents/forms all coming from various locations. Financial reporting becomes a lot easier and customized as the electronic medical accounting and charting software enables generating detailed reports over few clicks. 2. Increase Revenue With successful implementation of medical office billing software, we can offer new services to patients, thereby attracting new business and reducing work load on our staff. Owing to the drastic reduction in paperwork enabled by the electronic patient record software, physicians no more require a huge physical storage space. This translates to having more office space available for treating patients or accommodating additional staff. Advanced medical billing and coding procedures lead to improved and faster insurance reimbursements. Therefore, working in close proximity with our patient/s treatment plan, in tandem with submitting claims at the right time, can help us maximize our revenue. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 30

31 3. Reduce Paper Costs Reduction in paper costs, including stationary (charts, folders, paper, etc); copying, management (pulling/filling) and storage (office space, cabinets) are the outstanding benefit of executing EMR software. Practices can also minimize their transcription costs as healthcare software provides us with easier means of documenting patient records and report writing. After becoming more familiar and efficient with our paperless medical office management software, we can save on the cost of hiring new employees. We can also maintain lower malpractice premiums by producing higher quality documentation and drug prescription alerts. 4. Boost Profits In order to increase our profits, it is essential to take into account the new expenses that we will incur as a result of an EMR implementation such as support contracts, computer maintenance and product updates. However, long term benefits promised by the integrated EMR program seem miniscule against these not-so-frequent expenses. Some benefits of medical records software are difficult to quantify - such as improved care, patient satisfaction, and office image are items that contribute to higher profits and also result in increased patient referrals and better patient retention. 5. Improve Clinical Decision Making EMR software package comes with many in-built tools that help doctors in making educated decisions. These tools range from diagnosis to prescribing medications, from automated health maintenance reminders to treatment plan recommendations. Most physician EMRs have in-house PDR-based medical dictionaries that give physicians Adverse Drug Event (ADE) alerts, generic drug and dosage recommendations. Electronic healthcare management systems also provide decision-support in making treatment recommendations based on a patient's diagnosis. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 31

32 6. Enhance Documentation Empowered with computerized technology, physician EMR charting software permits multiple users to access patient charts at the same time. This feature ensures more accuracy as all information is entered in real-time. Medical practice management systems are equipped with a security administration module enabling administrators to manage/restrict access to patient records by setting individual user permissions. Electronic health record software s allow physicians access to fairly more complete and legible patient records. One of the greatest advantages of having patient documentation digitalized is the ability to manipulate data for reporting purposes. This becomes very useful for research reports, statistics, drug recalls and patient marketing. 7. Deliver Better Patient Care & Scheduling Some medical scheduling software s support interactive features wherein patients can even schedule/cancel appointments online from home or practically anywhere. Many doctors are now using internet to conduct web consultations. Being able to access patient data from anywhere in the world via a secure internet connection allows the doctor to conduct web consultations or generate reports from home or anywhere. 1.7 Features of EHR Health information recording and clinical data repository Ability to have immediate electronic access to person- and population-level information patients diagnoses, allergies and laboratory test results that would improve the ability of clinicians to make sound decisions in a timely manner Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 32

33 Provide secure, reliable, real-time access to patient health record information where and when it is needed to support care Capture and manages episodic and longitudinal electronic health record information Sharing of information, connectivity and interoperability Ability to provide a secure and readily accessible communication among health care providers and patients to improve continuity of care and timeliness of diagnoses and treatments Provides tools to facilitate teamwork and coordination process Ability to share patient information among authorized professionals Accessing information Results management Ability of providers to have quick access of past and new test results Support interfaces from labs, standard data transfer, HL7, captures discrete data Medication management Offers access to integrated database for online ordering lab, radiology, procedures, immunizations, supplies Offer online prescription writing and patient allergies and drug-drug interactions Order entry and management Ability to entry and storage orders for all medications, tests and other services in a computerized-base system Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 33

34 Permits efficient data entry of all orders and documentation by authorized clinicians Decision support Office work flow management-standards of care Ability to use computerized reminders, prompts, electronic alerts to improve compliance with best practices, ensure regular preventive and screenings practices, identify drug interactions, and facilitate diagnoses and treatments Assists with the work of planning and delivering evidence-based care to individual and groups of patients Functions as clinicians primary information resource during the provision of patient care 1.8 Barriers to implement EHR Accenture surveyed executives of hospitals, health insurance plans, physician groups, health technology vendors and other health organizations. Feedback from 84 respondents is summarized below Capital costs are widely seen as the greatest barrier to EHR implementation More than half (58 percent) of survey respondents noted that the capital cost outlay required to implement EHRs was the area of most concern. Health organizations view up-front financial expenditures as the primary barrier to EHRs, although they recognize the ultimate financial benefits Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 34

35 Perceived barrier is physician adoption Nearly half of respondents (46 percent) identified physician adoption as a major implementation Barrier for their organizations. In particular, they identified physician resistance to change and lack of office technology as obstacles that need to be overcome. Several pointed to the need for financial incentives specifically geared toward physicians. Further development of technology standards will certainly be required for successful EHR adoption Thirty percent of respondents identified the lack of technology standards as a problem for their organizations in making progress toward implementing EHRs. The increasing of staff workloads was another area of concern The impact on IT staff was noted by 17 percent of respondents. In addition, several respondents indicated concern about further burdening staff in other departmental areas outside of IT. Some, for example, worried that EHRs will require that nurses spend time to assist physicians in accessing medical records and/or using the system. Our current health care culture poses a potential implementation barrier for EHRs Widespread EHR adoption will require a major change in attitudes, workflows, relationships between health organizations, and attitudes. It will also require major incentives to encourage Adoption in the short term, particularly for community physicians Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 35

36 1.9 Components of EHR Most commercial EHRs are designed to combine data from the large ancillary services, such as pharmacy, laboratory, and radiology, with various clinical care components (such as nursing plans, medication administration records [MAR], and physician orders). The number of integrated components and features involved in any given MEDICAL CENTERS is dependent upon the data structures and systems implemented by the technical teams. MEDICAL CENTERS may have a number of ancillary system vendors that are not necessarily integrated into the EHR. The EHR, therefore, may import data from the ancillary systems via a custom interface or may provide interfaces that allow clinicians to access the silo systems through a portal. Or, the EHR may incorporate only a few ancillaries. Administrative System Components Registration, admissions, discharge, and transfer (RADT) data are key components of EHRs. These data include vital information for accurate patient identification and assessment, including, but not necessarily limited to, name, demographics, next of kin, employer information, chief complaint, patient disposition, etc. The registration portion of an EHR contains a unique patient identifier, usually consisting of a numeric or alphanumeric sequence that is unidentifiable outside the organization or institution in which it serves. RADT data allows an individual s health information to be aggregated for use in clinical analysis and research. This unique patient identifier is the core of an EHR and links all clinical observations, tests, procedures, complaints, evaluations, and diagnoses to the patient. The identifier is sometimes referred to as the medical record number or master patient index (MPI). Advances in automated information systems have made it possible for organizations or institutions to use MPIs enterprise wide, called enterprise-wide master patient indices. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 36

37 Laboratory System Components Laboratory systems generally are standalone systems that are interfaced to EHRs. Typically, there are laboratory information systems (LIS) that are used as hubs to integrate orders, results from laboratory instruments, schedules, billing, and other administrative information. Laboratory data is integrated entirely with the EHR only infrequently. Even when the LIS is made by the same vendor as the EHR, many machines and analyzers are used in the diagnostic laboratory process that are not easily integrated within the EHR. For example, the Cerner LIS interfaces with over 400 different laboratory instruments. Cerner, a major vendor of both LIS and EHR systems, reported that 60 percent of its LIS installations were standalone (not integrated with EHRs).8 Some EHRs are implemented in a federated model, which allows the user to access the LIS from a link within the EHR interface. Radiology System Components Radiology information systems (RIS) are used by radiology departments to tie together patient radiology data (e.g., orders, interpretations, patient identification information) and images. The typical RIS will include patient tracking, scheduling, results reporting, and image tracking functions. RIS systems are usually used in conjunction with picture archiving communications Pharmacy System Components Pharmacies are highly automated in MEDICAL CENTERS and in other large hospitals as well. But, again, these are islands of automation, such as pharmacy robots for filling prescriptions or payer formularies that typically are not integrated with EHRs. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 37

38 Computerized Physician Order Entry Computerized physician order entry (CPOE) permits clinical providers to electronically order laboratory, pharmacy, and radiology services. CPOE systems offer a range of functionality, from pharmacy ordering capabilities alone to more sophisticated systems such as complete ancillary service ordering, alerting, customized order sets, and result reporting. Only four percent of U.S. hospitals reported that they are using CPOE systems. 113,000 physicians are using CPOE regularly and 75,000 of these physicians are using CPOE in teaching hospitals. Forty teaching hospitals reported in 2005 that 100 percent of their physicians were using CPOE for placing orders, an increase from eight teaching hospitals in Clinical Documentation Electronic clinical documentation systems enhance the value of EHRs by providing electronic capture of clinical notes; patient assessments; and clinical reports, such as medication administration records (MAR). As with CPOE components, successful implementation of a clinical documentation system must coincide with a workflow redesign and buy-in from all the Stakeholders in order realize clinical benefits, which may be substantial as much as 24 percent of a nurse s time can be saved. Examples of clinical documentation that can be automated include: Physician, nurse, and other clinician notes Flow sheets (vital signs, input and output, problem lists, MARs) Discharge summaries Transcription document management Medical records abstracts Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 38

39 Advance directives or living wills Durable powers of attorney for healthcare decisions Consents (procedural) Medical record/chart tracking Releases of information (including authorizations) Staff credentialing/staff qualification and appointments documentation Chart deficiency tracking Utilization management Medical devices can also be integrated into the flow of clinical information and used to generate real time alerts as the patient s status changes EHR Implementation models Application service provider(asp) ASP model involves having a practice s clinical data/information stored off site. Data is managed most via World Wide Web (internet) Locally hosted Locally hosted model has the data stored within a computer server Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 39

40 Source: Table 2 : ASP Vs Locally Hosted model Application service provider(asp) model Locally hosted model Advantage: Advantage: -System is maintained by IT professionals remotely, reducing the cost of maintenance - Faster overall operational speed - Practice has control over its data Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 40

41 -Online backup service - Accessible anywhere in the world from any computer with an internet connection - Low initial cost of ownership - No dependency on internet connection - Better integration with imaging devices (scanners, printers) and on-site resources Disadvantage: - Higher upfront cost of ownership as a server and software must be purchased upfront - Manual product updates are usually required (not in all cases) - Online backup must be purchased as add-on 3rd party software - Remote access to EMR is limited in functionality and is more complex 1.11 Components of EHR Once an organization has determined that an EHR system is worth implementing, it must decide which components to implement. There are multiple components to the EHR system including: Clinical Data Repository (CDR) Clinical Decision Support System (CDSS) Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 41

42 Clinical Documentation Module Computerized Point of Entry (CPOE) module Controlled Medical Vocabulary (CMV) Clinical Data Repository(CDR) The CDR functions as the single, comprehensive storage facility for all clinical information generated by Hospitals. It receives data from a variety of ancillary IT systems, as well as direct data entry by caregivers of information such as clinical documentation and medication administration. CDRs are quite mature in current EHR products. They can handle a variety of data types and can retrieve information rapidly for a given patient. In recent years, the breadth and depth of information in the CDR has expanded to include virtually any type of clinical information. Because the CDR represents a comprehensive and authoritative source of clinical information, it forms a critical starting point for automation support of the clinical care process Clinical Decision Support System (CDSS) A critical component of the EHR system is the CDSS, or technology that aids the clinician with the decision-making process. Specifically, a CDSS provides context-sensitive advice for clinicalcare situations by permitting the CDO to specify and revise the rules that define a significant event. The CDSS obtains the information it needs from the CDR; a CDR is thus a prerequisite for a CDSS. The CDSS monitors information within a CDO and produces an alert when noteworthy events occur. CDSS activities include: Detection of possible adverse-drug interactions Notification of severely abnormal laboratory values Reminders of alternate therapies (such as switching from an intravenous to an oral medication) Notice of overdue events Assistance in differential diagnosis Detection of potentially dangerous trends Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 42

43 Suggestion of generic alternatives to brand-name drugs The benefits of a CDSS are twofold: Reduction in medical errors and improvement in quality Potentially dangerous situations are detected quickly and brought to the attention of the caregiver, thus avoiding undesirable patient outcomes. Potential reduction in long term costs As quality improves, complications that could result in greater costs down the road are avoided. Also the risk of malpractice suits is reduced. Clinical Documentation Module The Clinical Documentation Module involves the recording of various steps in the process of caring for patients. These steps might include: obtaining patients histories, performing physical examinations, ordering tests and evaluating their results, establishing diagnoses, instituting therapies, and monitoring the course of treatment. An EHR system must be capable of recording every type of significant event that a patient had with his or her caregiver. Ideally it should permit caregivers to document data according to her or his preference (for example, speech recognition, partial or full discrete data, charting by exclusion, or patient-entered data) and should enable the creation of various types of clinician notes (such as history and physical information, procedure reports, nursing notes, admission/progress notes). There also must be a way to import data from clinical systems within the organization including pathology, radiology, laboratory, intensive care unit (ICU) monitoring systems or patient/physician Web messaging systems. The ultimate objective is to integrate clinical information from outside the care delivery organization, because it is unlikely that all of a patient s clinical encounters will take place within a given CDO. In this sense, clinical data is instrumental in nearly all healthcare processes Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 43

44 such as clinical decision support, billing/billing compliance, and health maintenance and outcomes analysis. Computerized Point of Entry Module (CPOE) The CPOE module handles the process of entering an order by a physician or caretaker. This order-management component of an EHR captures new orders, verifies them using a rules engine, communicates them to appropriate recipients and monitors order fulfillment. Often times, the CPOE works hand-in-hand with the CDSS. For example, if a caregiver prescribes a medication that conflicts with another that the patient is taking; the CDSS sends an alert through the CPOE system Controlled Medical Vocabulary A controlled medical vocabulary (CMV) supports medically relevant concepts, terms, codes and relationships. The role of a CMV is to provide a linguistic and semantic infrastructure representing a consistent framework to support the exchange of information between humans, between automation systems and across the human/machine interface. In this manner, a CMV is instrumental in enabling humans and automation systems to more-effectively use medical text to support the processes of healthcare. CMV services are delivered using a vocabulary server, which then exposes a set of CMV functions as a series of application programming interfaces (APIs). This approach makes the CMV accessible to any software component in the EHR or its environment that requires such services. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 44

45 1.12 EHR Adoption Model Understanding the level of EMR capabilities in hospitals is a challenge in the U.S. healthcare IT market today.himss Analytics has created an EMR Adoption Model TM that identifies the levels of EMR capabilities ranging from the initial CDR environment through a paperless EHR environment. HIMSS Analytics has developed a methodology and algorithms to automatically score the approximately 4,000 hospitals in the HIMSS Analytics TM Database, relative to their IT-enabled clinical transformation status. The data provides peer comparisons for CDOs as they strategize their path to a complete EMR. Source: Figure 4 : Adoption model Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 45

46 The stages of the model also referred to in this report as EMR scores rank as follows: Stage 0: Some clinical automation may be present, but all three of the major ancillary department systems (laboratory, pharmacy, and radiology) are not implemented. Stage 1: All three of the major ancillary clinical systems pharmacy, laboratory, radiology are installed. Stage 2: Major ancillary clinical systems feed data to a CDR that provides physician access for Retrieving and reviewing results. The CDR contains a controlled medical vocabulary and a clinical decision support/rules engine for rudimentary conflict checking. Information from Document imaging systems may be linked to the CDR at this stage Stage 3: Clinical documentation (e.g. vital signs, flow sheets, nursing notes, care plan charting and emar) and general order entry are required, and are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinical decision support is implemented to conduct error checking with order entry (i.e., drug-drug, drug-food and drug-lab conflict checking normally found in the pharmacy). Some level of medical image access from PACS is available via the organization s intranet or secure networks outside radiology Stage 4: CPOE for use by any clinician is added to the nursing and CDR environment along with The second level of clinical decision support capabilities related to evidence-based medicine protocols. If one patient service area has implemented CPOE and completed the previous stages, then this stage has been achieved Stage 5: The closed loop medication administration environment is fully implemented in at least one patient care service area. The emar and bar coding or other auto-identification technology, such as radio frequency identification (RFID), are implemented and integrated with CPOE and Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 46

47 Pharmacy to maximize point-of-care patient safety processes for medication administration. Stage 6: Full physician documentation and charting (structured templates) is implemented for at least one patient care service area. Level three of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance Alerts. A full complement of PACS systems displaces film-based images Stage 7: This is the ideal. The hospital has a paperless EMR environment. Clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a regional health network (i.e., other hospitals, ambulatory clinics, sub-acute Environments, employers, payers and patients). The majority of U.S. hospitals are in the early stages of EMR transformation. Currently, about 18 Percent of U.S. hospitals are at Stage 0, roughly 22 percent have achieved Stage 1, 43 percent have achieved Stage 2, 14 percent have achieved Stage 3, 2.7 percent have achieved Stage 4, and less than 1 percent of hospitals have achieved Stages 5 and 6. None in the HIMSS Analytics database is at Stage Economic stimulus package and Healthcare Information Technology The HITECH (Health Information Technology for Economic and Clinical Health) Act 2009 which is a part of the ARRA (American Recovery and Reinvestment Act) 2009 has generated huge interest among the stakeholders of the Healthcare Industry. This article gives an insight into the Medicare and Medicaid Incentives to the physicians, providers. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 47

48 Summary The ARRA 2009 provides substantial stimulus funds to incentivize the Healthcare IT industry amounting $20 billion for the development and adoption of HIT. Electronic Health Record (EHR) is emerging as the top most priority in the health information technology marketplace. Government initiatives and cost optimization are key drivers of EHR adoption and will continue to drive purchases of EHR systems in the near future. The major portion $ 17 billion (approx.) is for incentivizing providers to become a meaningful EHR user. The incentive structure in the stimulus package encourages early adoption of EHR. On the other hand, penalties are to be faced by the providers if they do not become meaningful users of EHR by Governance The ARRA 2009 insists on forming new governing bodies to assist and monitor the adoption of HIT. The following are the various bodies and their roles: Office of the National Coordinator for HIT (ONCHIT) - Established by HHS - Headed by a National Coordinator appointed by the Secretary of HHS, having responsibilities to o Develop HIT infrastructure o Update federal HIT strategic plan to address the use of EHR technology o Monitor privacy and security of EHR - Assisted by HIT Policy committee that recommends standards, compliances and certification criteria. When adopted, these standards will assess whether providers are meaningful EHR users Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 48

49 Important Terms Certified EHR For an EHR to be certified, it must - Meet standards adopted by National Coordinator under ARRA - EHR should include patient demographic and clinical health information (e.g. medical history and problem lists) Meaningful EHR User To become a meaningful EHR user - Each provider must implement a certified EHR system that enables: - Clinical decision support - Clinical physician order entry - Exchange of data - Quality reporting - EHR criteria for healthcare professionals include: - e-prescribing - Ability to exchange data Ability to conduct quality reporting Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 49

50 1.14 Organization and standards governing EHR Organization CHI (Consolidated Health Informatics Initiative) CCHIT (Certification Commission for Healthcare Information Technology) IHE (Integrating the Healthcare Enterprise) ANSI (American National Standards Institute) HIMSS (Healthcare Information and Management Systems Society) ASTM (American Society for Testing and Materials) OpenEHR Canada Health Infoway World Wide Web Consortium (W3C) Description Recommends nationwide federal adoption of EHR standards in the United States A federally funded, not-for-profit organization that evaluates and develops the certification for EHRs and interoperable EHR networks (USA) A consortium, sponsored by the HIMSS, that recommends integration of EHR data communicated using the HL7 and DICOM protocols Accredits standards in the United States and co-ordinates US standards with international standards An international trade organization of health informatics technology providers A consortium of scientists and engineers that recommends international standards Provides open specifications and tools for the 'shared' EHR A federally funded, not-for-profit organization that promotes the development and adoption of EHRs in Canada Promotes Internet-wide communications standards to Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 50

51 prevent market fragmentation Clinical Data Interchange Standards Consortium (CDISC) A non-profit organization that develops platformindependent healthcare data standards Standards HL7 DICOM ANSI X12 (EDI) ISO - ISO TC 125 CEN's TC/251 EN CONTSYS (EN 13940) HISA (EN 12967) Description A standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems An international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association) Transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data. For example: 834 (Benefit Enrollment and Maintenance), 835 (Healthcare Claim Payment/Advice), 837 (Healthcare Claim) Provides international technical specifications for EHRs. ISO describes EHR architectures Provides EHR standards in Europe Communication standards for EHR information in Europe Supports continuity of care record standardization in Europe A services standard for inter-system communication in a clinical information environment Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 51

52 2 Technology and functionality of EHR 2.1 EHR Technology EHR architecture is three tier architecture and each layer is built on different technologies and they are Business logic - J2EE framework -.NET framework Database layer - Oracle/MySQL Client layer - DHTML,javascript technologies 2.2 Product architecture Over 90% of world s browser market use IE i.e., presentation layer Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 52

53 2.3 Workflow of EHR The generic workflow of EHR in any provider organization will be like the above diagram. It starts from administration section then proceeds to documentation, scheduling, ordering, claims management and finally billing and reporting Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 53

54 2.4 Functionalities of EHR General The system links with a variety of digital and analog dictation systems The system supports the HIPAA Standards for Electronic Transactions The system supports local, regional, and national vocabularies, updates and enhancements Demographics The system has the capability of importing patient demographic data via HL7 interface from an existing Practice Management System, Patient Registration System The system has the capability to import/create, review, update, and delete patient demographic information as well as other non-clinical information from the patient record The system captures permanent patient/temporary address Medical History The system supports rapid capture of patient history and physical exam data The system captures history of received immunizations. The system documents all existing allergies, such as Drug, food... Progress notes Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 54

55 The system automatically captures the electronic signature and title of the person entering data and date/time stamps each transaction. The system includes a medical terminology dictionary and a spell checker within the progress notes data entry module. Problem lists The system automatically links problems with order and results The system archives problems complete with status history The system separates active from inactive problems. Prevention The system includes a patient tracking and reminder capability The system includes user-modifiable health maintenance templates. Alerts The system prints an alert on demand The system has the capability of forwarding the alert to a specific provider The system has the capability of capturing the alert from labs Orders The system has the capability to fax orders The system has the capability to print orders for manual transmission Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 55

56 The system accepts orders from multiple locations The system allows the user to accept, override, or cancel an order. Prescription The system stores common prescriptions for quick entry. The system stores refill and repeat prescription information The system allows storage of prescription data for retrieval by any drug name, drug code number Confidentiality and Security The system supports biosensor technology for logon. Supports industry standard electronic signatures. The system controls access to and within the system at multiple levels The system establishes patient/physician data element confidentiality Decision Support The system includes access to medical research and literature databases such as MEDLINE, JAMA The system automatically triggers and alert upon documentation of patient health data The system utilizes health data from all sections of the chart to provide decision support to providers. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 56

57 3 EHR Certifying body (CCHIT) 3.1About CCHIT The Certification Commission for Healthcare Information Technology (CCHIT) is a private notfor-profit organization that serves as the recognized US certification authority for electronic health records (EHR) and their networks. CCHIT was founded in 2004 with support from three leading industry associations in healthcare information management and technology: the American Health Information Management Association (AHIMA), the Healthcare Information and Management Systems Society (HIMSS) and the National Alliance for Health Information Technology (the Alliance). In September 2005, CCHIT was awarded a 3-year contract by the U.S. Department of Health and Human Services (HHS) to develop and evaluate the certification criteria and inspection process for EHRs and the networks through which they interoperate. In October 2006, HHS officially designated CCHIT as a Recognized Certification Body (RCB). The Certification Commission is an officially recognized certification body in the United States for EHR products a private, nonprofit organization that is to electronic health records what Underwriters Laboratories is to electrical products. The Commission is the official agency to apply standards, test products, and award a seal of compliance to EHR software. As part of a broad federal initiative to create national standards for health information technology, the U.S. Department of Health and Human Services awarded the Commission a three year contract to develop certification criteria and manage an inspection process for certifying EHRs and the health information exchanges over which they transport patient information The Certification Commission brings together panels of volunteers many of them physicians and nurses with expertise in electronic health records. After thorough exploration and debate, as well as a review of thousands of comments from the public, the Commission reached Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 57

58 consensus on standards-based criteria and other requirements that an EHR product must meet to attain certification. Certification is voluntary, but in the first year after the Commission began offering certification, nearly half of the EHR companies in the marketplace brought their products to the Commission for testing. Both large and small companies, serving practices of all sizes, now offer certified products Mission of CCHIT To accelerate the adoption of robust, interoperable HIT throughout the US healthcare system, by creating an efficient, credible, sustainable mechanism for the certification of HIT products Certification can help in reducing providers risk when they select an EHR The Certification Commission stays abreast of the new demands that practices face, and ensures that CCHIT Certified products have the capability of fulfilling those needs. For example: Certified products enable us to measure and report the quality indicators needed to satisfy payment incentive Programs that are based on levels of performance. Certified products qualify under a special exemption to the Stark and anti-kickback laws in healthcare, allowing a local hospital or health system to cover most of their cost for us. Some professional liability insurers are offering premium discounts for use of certified EHRs. How Product Certification Can Accelerate HIT Adoption Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 58

59 Increase the confidence of providers to invest in and adopt HIT Ensure interoperability of HIT products within the emerging health information infrastructure Enhance the availability of HIT adoption incentives from public and private purchasers/payers 3.2 About CCHIT criteria CCHIT inspects every product in three areas: Functionality the ability to create and manage electronic records for all of a physician practice s patients, as well as automate the flow of work in the office. Interoperability the ability to receive and send electronic data between an EHR and outside sources of information such as labs, pharmacies, and other EHRs in physician offices and hospitals. Security the ability to keep patient information safe and private Functionality For 08 CCHIT requires ambulatory EHR products to provide every function that a physician needs today to manage every patient s care efficiently, safely, and with high quality, electronically -- instead of on paper. Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 59

60 There are approximately 350 functionality criteria. The broad areas covered are: Organizing patient data demographics, clinical documentation and notes, medical history Compiling lists problems, medication, allergies, adverse reactions Receiving and displaying information test results, consents, authorizations, clinical documents from outside the practice Creating orders ordering medication or diagnostic tests; managing order sets, orders, referrals; generating and recording patient-specific instructions Supporting decisions presenting alerts and reminders for disease management, preventive services, wellness; checking for drug interactions and guiding appropriate responses; supporting standard care plans, guidelines and protocols; updating decision support guidelines Authorized sharing managing practitioner/patient relations, enforcing confidentiality, enabling concurrent use among multiple practitioners and healthcare personnel Managing workflow assigning and routing clinical tasks, managing the taking of medication and immunizations, communicating with a pharmacy Administrative and billing support using rules to assist with financial and administrative coding; verifying eligibility and determining insurance coverage While there are several dozen new Functionality criteria proposed for addition for 09 (beginning July 1, 2009), many are simply clarifications and refinements of existing criteria. There is no justification for delaying investment in EHRs for want of functionality in certified products Interoperability In the Interoperability domain, for 2008 certification CCHIT requires ambulatory EHR products to use approved standards to send and receive all forms or clinical data that are practical to exchange today, as well as demonstrate ability to support emerging areas of data exchange. There are approximately two dozen Interoperability criteria. The broad areas required are: Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 60

61 Laboratory results comply 100% with federally-approved standards to receive and store lab results, differentiate between a preliminary and final result, process corrected results, and include information on test accuracy. A basic capability to view x-ray images is also required. Electronic prescribing comply 100% with federally-approved standards to send a new prescription, approve a refill, check that a medication is on the approved formulary, check patient eligibility, and obtain medication history from the pharmacy. Exchange summary documents demonstrate first-stage compliance with federally-approved standards to receive and display a patient summary from an outside system, and send a patient summary to an external system Security Simply stated, for 08 CCHIT requires ambulatory EHR products to provide state-of-the-art technical capabilities needed to keep patient information safe and secure. There are approximately 50 Security criteria. To be certified, an EHR must meet 100% of them. The broad areas covered are: Authentication of users (proving identity) Controlling access based on the user role or the context of a care situation. Auditing every access and use of records Encryption of any data sent out of the system. Protection against viruses and other malware Backup of data to prevent loss in case of computer failure or disaster Security is another area, like Functionality, that is considered mature. Updates for 09 are minimal and there is no justification for delaying health IT investment to wait for additional criteria Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 61

62 3.3 Certification programs of CCHIT Base Domain Certification Options History/Status Ambulatory EHR - Launched May 06 Updated May 07 Updated July 08 Ambulatory Child Health Launched July 08 Ambulatory Cardiovascular Medicine Launched July 08 Inpatient EHR - Launched August 07 Updated August 08 Emergency Dept - Launched August 08 Amb+Inpatient+Emerg.dept Enterprise Launched August 08 HIE - Launched Oct 08 PHR - To be Launched July 09 Stand-alone eprescribing - To be Launched July 09 Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 62

63 3.4 Product Attributes and Inspection Methods Functionality Security and Privacy Interoperability Self-attestation (documentation review) Jury-observed demonstration Technical Testing Interoperability is tested using LYKA testing tool As the Certification Commission for Healthcare Information Technology (CCHIT) escalates its capacity to test the transmission and receipt of standard messages for interoperable transfer of clinical information, it s supplying a high-tech stand-in to play the role of an exchange partner, ensuring that any two certified systems can complete the transaction successfully. A tool known by the name LAIKA has proven its worth in the first year of deployment, and CCHIT is ready to roll out a new version, LAIKA 09, with a broader range of utility to confirm Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 63

64 to healthcare providers that certified products are prepared to deal with new waves of standards and technology innovation. LAIKA was employed in the certification of more than two dozen EHR products thus far in the 08 cycle of testing to validate the exchange of Continuity of Care Documents conforming to the HITSP C32 specification. These are the digital building blocks of structured clinical content necessary to make information understandable from one EHR to another. The specially designed tool is instrumental in both helping vendors engineer and test their products and enabling certification testers to validate data exchanges without having to rely on less-exacting traditional alternatives. LAIKA 09 is a substantial step forward in the world of health information technology interoperability testing tools. It offers: The first set of test tools that actually compare transaction data for expected results. The only set of tools for testing data exchanges on both sides: EHR systems and entities for HIE. The easiest-to-use interface to test all current components of interoperability: CCD documents in C32 form; the transport envelope for them (Cross Enterprise Document Sharing, or XDS); and the middle step of patient identification and information registry (Patient Identifier Cross-referencing, or PIX, and Patient Demographic Query, or PDQ). Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 64

65 3.5 Impact of certification on various entities Providers, payers and vendors get benefitted when an EHR product is CCHIT certified Project work by K Vijay Bharathidasan Institute Of Management Bangalore Campus Page 65