1 1 Health Information Management Systems Technology and Analysis Domain 3: Assessment, System Selection and Implementation Module 3A: Purpose, Adoption and Use of Health Information Systems Lecture #1: System Adoption and Administrative Information Systems Developer: Suzanne A. Boren, PhD, MHA Slide 1: This is Module 3.A: Purpose, Adoption, and Use of Healthcare Information Systems Slide 2: The module developer is Dr. Suzanne Austin Boren, Associate Professor and Director of Graduate Studies in the Department of Health Management and Informatics, in the School of Medicine at the University of Missouri.
2 Slide 3: 2 The following topics will be discussed in this lecture: Stages of adoption Meaningful Use for HER s Determinants of EHR adoption Barriers to the adoption of outpatient HER s Associating health information system features and metrics with effects
3 Slide 4: 3 There are 7 levels of adoption of electronic health records according to the EMR Adoption Model crafted by HIMSS Analytics. All application capabilities within each level must be operational before that stage is achieved. All lower levels must have been achieved before a higher level will be considered as achieved. A hospital can achieve Levels 3 to 6 if it has met all of the application requirements for a single patient care service. In Level 0, some clinical automation may exist; however, laboratory, pharmacy or radiology systems are not installed. To achieve Level 1, all three major ancillaries (laboratory, pharmacy and radiology) are installed. To achieve Level 2, major ancillary clinical systems feed data to a clinical data repository (or C-D-R) that provides physician access for retrieving and reviewing results. The CDR contains a controlled medical vocabulary (or C-M-V) and the clinical decision support system and rules engine for rudimentary conflict checking. To earn extra points toward designation in the EMR Adoption Model, information from document imaging systems may be linked to the C-D-R.
4 Slide 5: 4 To achieve Level 3, clinical documentation is installed. This includes, for example, vital signs, flow sheets, nursing notes, care plan charting, and/or the electronic medication administration record (e-m-a-r) system are implemented and integrated with the CDR for at least one service in the hospital. The first level of clinician decision support is implemented to conduct error checking with order entry. These include drug-to-drug, drug-to-food, drug-to-lab interaction conflict checking which is normally done in the pharmacy. Some level of medical image access from the PACS (Pr: Packs) is available for access by physicians via the organization s intranet or other secure networks. Slide 6: To achieve Level 4 in the EMR Adoption Model, computerized practitioner order entry (C-P-O-E) for use by any clinician is added to the nursing and CDR environment. The second-level of clinical decision support related to evidence-based medicine protocols are implemented. If one patient service area has implemented CPOE and completed previous stages, this stage is determined to have been achieved. To achieve Level 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 (R-F-I-D), are implemented and integrated with C-P-O-E and pharmacy to maximize point-of-care patient safety processes for medication administration.
5 Slide 7: 5 To achieve Level 6, full physician documentation or charting using structured templates is implemented for at least one patient care service area. At this level, a full complement of radiology PACS systems is implemented. This includes, all images, both digital and film-based, are made available to physicians via an intranet or other secure network. To achieve Level 7, clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a regional health network. This includes hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients.
6 Slide 8: 6 The United States Congress supports the promotion of Health IT and health information exchange, and enacted the Health Information Technology for Economic and Clinical Health Act (or HI-TECH Act) in This act directs the Secretary of the Department of Health and Human Services to adopt standards, implementation specifications, and certification criteria for Health I-T that will include specific requirements for information exchange. All eligible healthcare professionals or hospitals that participate in Medicare or Medicaid will eventually be required to implement Health IT that makes meaningful use of electronic health records. Where there are specific standards that are widely accepted, meaningful use requires their use for representing information in an EHR; for example, storage of lab results using LOINC (pr: Loink) which is a common standard for storing that kind of information. Requiring use of common standards will facilitate easier movement of this information between different systems. Under the Health Information Technology for Economic and Clinical Health (HI-TECH) Act, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified E-H-R technology and use it to achieve specified objectives. These objectives, called "meaningful use" objectives, are the measurable benchmarks providers must meet to qualify for the incentive payments. Meaningful use of electronic health record technology is broken down into three components: 1. The use of certified EHR technology for electronic exchange of health information to improve quality of health care
7 7 2. The use of certified EHR technology to submit clinical quality and other measures 3. The use of a certified EHR in a meaningful manner (such as e-prescribing) Slide 9: There are three stages in the meaningful use incentive program for implementation of electronic health records. Stage 1 to be achieved between relates to Data Capture and Sharing. During Stage 1, the concentration is on electronic capture and sharing of health information in a structured format. Providers must meet certain objectives or measures and 80% of patients must have electronic records in the certified EHR technology. The reporting period for the first year is 90 days, and one year for each subsequent year. Stage 2 is to be achieved in 2013 and requires Advanced Clinical Processes. Stage 2 builds upon the Stage 1 objectives and is focused on data aggregation and quality improvement at the point of care and on electronic exchange of information. Stage 3 is scheduled for completion in 2015 and is focused on improving outcomes. In this final stage of the meaningful use incentive program, data use to impact outcomes is the major focus. Providers will demonstrate improvements in quality, safety, and efficiency, and clinical decision support and patient self-management tools.
8 Slide 10: 8 A study using a non-experimental cross sectional design was used to examine hospital EMR use in 4,606 acute care hospitals. A logistic regression approach was used to determine the correlations between hospital EMR use and organizational and environmental characteristics. The study found that hospital EMR adoption is significantly associated with four variables: rural or urban, environmental uncertainty, size, and type of system affiliation. On this slide, these four characteristics have an asterisk after them. Most urban hospitals are more likely than most rural hospitals to use EMRs. As the level of environmental uncertainty increases, for example as occurs in changes in unemployment rates, the likelihood of hospital EMR use also increases. Larger hospitals are more likely than smaller hospitals to use EMRs. Hospitals in centralized health systems are more than 16 times as likely as hospitals not in systems to use EMRs. The effects of competition, munificence, ownership, teaching status, public payer mix, and operating margin were not statistically significant in this study. If certain hospitals are more likely than others based on environmental and organizational characteristics to use EMRs, it is possible that these significant predictors also represent barriers to EMR implementation and use for some hospitals. According to this analysis, hospitals that are small, non-system affiliated and rural are less likely to use EMRs. Small, independent hospitals in rural areas are unlikely to have the financial or human resource means to implement and use an EMR system.
9 Slide 11: 9 A national survey on the use of electronic health records in ambulatory care was sent to 2,758 physicians and completed in 2008 with a 62% response rate. The survey reported that among physicians who did not have access to an electronic-records system, the most commonly cited barriers to adoption were capital costs, not finding a system that met their needs, uncertainty about their return on investment, and concern that a system would become obsolete. Physicians with EHRs tended to highlight the same barriers, but less frequently than did non-adopters. The factor that was most frequently cited as a facilitator of adoption was financial incentives for the purchase of an EHR system.
10 Slide 12: 10 Despite the barriers, it is important that electronic medical record systems are adopted by physicians and hospitals. The clinical and administrative applications in those systems can facilitate patient-centered care in a variety of ways. For example: Clinical decision support can lead to improved care processes and intermediate disease outcomes. Registries can provide opportunities for better patient and outcome tracking, as well as improved workflow efficiency for patients with chronic illnesses. Electronic health record functionality that enables real-time communication among team members is likely to promote the team care approach. Care transitions, such as from the hospital to a rehabilitation facility or to home, are vulnerable times for patients. It is possible to manage care transitions more effectively using information and communication technologies. Personal health records are portable and provide real-time information for patients. They can lead to increased patient engagement and self-efficacy. Telehealth can be used by health care practitioners to check-in with moderately to severely ill patients at a distance to assess vital signs and symptoms or to check-in with patients with stable chronic conditions who require regular preventive monitoring. For electronic health records to transform care, they will need to include much better measurement capabilities than they do today, for the purposes of both improving care and exporting data for transparency. Quality process measures can include whether or not a practice has provided preventive care, such as
11 11 immunizations or cancer screenings, and assessed treatment goals for chronic diseases such as diabetes or chronic heart failure. Slide 13: In another research report, a review of health information system studies used a benefits evaluation framework to make sense of the findings and consolidate evidence from 50 published systematic reviews. The benefits evaluation framework includes factors on (1) health information system quality (including system quality, information quality, and service quality); (2) health information system use as reflected in usage and satisfaction, and (3) net benefits measured by care quality, productivity, and access. The most effective health information system features were computer based reminder systems in preventive care which were 100% successful, CDSS reminders or alerts in medication management, disease management orders or alerts, CPOE medication orders, reminders in printed form, and finally, reminders combined with other interventions. Slide 14 Let s transition now to our discussion of administrative information systems.
12 Slide 15: 12 A hospital information system (or H-I-S) is a computer system that is designed to manage all of the hospital s medical and administrative information in order to enable health professionals to perform their jobs effectively and efficiently. Hospital information systems were first developed in the 1960s and have been an essential part of hospital information management and administration. Early systems consisted of large central computers connected to dumb terminals, which have generally been replaced by networked microcomputers. The early systems were used to manage patient finance and hospital inventory. Hospital information systems now focus on the integration of all clinical, financial, and administrative activities. Slide 16: The following topics will be discussed in this lecture: Financial information systems Medical accounting and billing systems Supply chain and materials management systems Medical appointment scheduling and registration. and Human resource management systems
13 Slide 17: 13 Financial information systems are computer systems that manage the business functions of a hospital. Healthcare business activities can be quite complex and the financial information systems are designed to ease the financial work and improve efficiency, timeliness and accuracy. Financial information systems include a number of different types of applications. Payroll handles all the recurring and non-recurring payments and deductions for employees. All recurring transactions can be automatically generated each payroll period with non-recurring transactions such as overtime added to the payroll upon approval. It is also possible to maintain employee pay rates, entitlements, salary movements and payroll histories. Accounts payable handles the processing of invoices and payments within the hospital. Accounts receivable provides support for, and the maintenance of, the records of all clients, invoices and payments. General ledger systems handle the collection, processing and reporting of financial data generated by all transactions, enabling a current, accurate and instant view of the financial status of the hospital at any point in time. (continues next page)
14 14 Fixed asset management deals with asset data retention and depreciation forecasting. The transfer of fixed assets between locations, cost centers or departments, reclassification of assets, and reassessments of asset values are functions that can be performed by the fixed asset management application. Claims management software manages all claims that are made to insurance companies and the contract management system keeps track of all ongoing contracts. Slide 18: Medical accounting and billing systems facilitate the process of submitting, and following up on claims to insurance companies and patients in order to receive payment for services rendered by a healthcare provider. Key functions and features include: Tracking and viewing outstanding payments and past-due payments, matching charges to payments, storing multiple prices for each service or procedure, storing medical billing information for every type of healthcare insurance, error checking claims, electronically sending claims, verifying patient eligibility status in a healthcare insurance plan, and printing patient statements with collection messages.
15 Slide 19: 15 Supply chain management software (S-C-M-S) refers to a whole range of software tools or modules used in executing supply chain transactions, managing supplier relationships and controlling associated business processes. Key functions and features of supply chain management applications include: Customer requirement processing Purchase order processing Inventory management Goods receipt and warehouse management Supplier management/sourcing A requirement of many S-C-M-S includes forecasting. Such tools attempt to balance the disparity between supply and demand by improving business processes and using algorithms and consumption analysis to better plan future needs. S-C-M-S also often includes integration technology that allows organizations to trade electronically with supply chain partners.
16 Slide 20: 16 The purpose of a medical appointment scheduling system is to manage appointment scheduling and streamline patient flow. Key functions and features include: Centralized scheduling of multiple sites and appointment templates. The latter allows the staff to reserve timeslots for certain types of appointments, and organize appointments to make efficient use of the practitioner s time, and coding types of appointments for quick identification. Other functions and features include searching capabilities, wait list function, various view options (for example by day or week or month, for by multiple providers and exam room), tracking, which allows staff to know who created, modified, and rescheduled appointments, patient appointment status such as unconfirmed and confirmed appointments, and whether the patient is checked in, being seen, checked out, or missed or cancelled the appointment. Automated patient reminders by text, phone, or are typically a function of these systems, as are the patient history, and online patient registration forms.
17 Slide 21: 17 The purpose of a human resource information system is to track existing employee data. Key functions and features include: payroll, work time, benefits administration, HR management information system, recruiting, learning management and training, performance record, and employee self-service. The benefits administration module provides a system for organizations to administer and track employee participation in benefits programs such as insurance, compensation, profit sharing, and retirement. The HR management module is a component covering many other HR functions from job applications to retirement. Employee demographic and address data, selection, training and development, capabilities and skills management, compensation planning records, and other related activities are all recorded in the HR system. The employee self-service module allows employees to query HR related data and perform some HR transactions over the system
18 Slide 22: 18 In summary, this lecture focused on adoption of electronic health record systems and discussed levels of adoption, the meaningful use incentive program, barriers to adoption, and the use of systems to improve patient-centered care and its quality. We also discussed administrative information systems and identified the major applications that are offered in these systems. This concludes the first lecture in Module 3A. Thank you!.