Custom Report Data Elements: 2012 IT Database Fields. Source: American Hospital Association IT Survey

Transcription

1 Custom Report Data Elements: 2012 IT Database Fields Source: American Hospital Association IT Survey

2 COMPUTERIZED SYSTEM IMPLEMENTATION 3 Bar Coding 3 Computerized Provider Order Entry 3 Decision Support 3 Electronic Clinical Documentation For: 3 Other Functionalities 3 Results Viewing Of: 3 MEANINGFUL USE FUNCTIONALITIES 4 Automated Quality Reporting 4 Discharge Instructions and Care Summary Documents 4 Electronic Clinical Documentation 4 Medication Management 4 Other Functionalities 4 Population Health Management 4 Public Health Reporting 4 HEALTH INFORMATION EXCHANGE FUNCTIONALITIES 5 Clinical/Summary Care Record 5 Laboratory Results 5 Medication History 5 No Patient Data Exchange 5 Other Types of Patient Data 5 Patient Demographics 5 Radiology Reports 5 Other 5 PATIENT ENGAGEMENT FUNCTIONALITIES 6 Method of Providing Patient Info. 6 Patient Access to Health/Medical Records 6 EHR SYSTEM AND IT VENDORS 7 General Information 7 Planned Changes 7 Primary Implementation Challenges 7 Vendors 7 2

3 Computerized System Implementation Bar Coding Caregiver verification Patient verification Medication administration Pharmacy verification Computerized Provider Order Entry Consultation requests Medications Radiology tests Laboratory tests Nursing orders Decision Support Clinical guidelines Drug allergy alerts Drug-drug interaction alerts Clinical reminders Drug dosing support Drug-lab interaction alerts Electronic Clinical Documentation For: Advanced directives (doc.) Medication lists (doc.) Patient demographics (doc.) Problem lists (doc.) Discharge summaries (doc.) Nursing notes (doc.) Physician notes (doc.) Other Functionalities Ability to connect mobile devices to EHR Telehealth Bard coding or Radio Frequency (RFID) Results Viewing Of: Consultant reports (view) Diagnostic test results (view) Radiology images (view) Diagnostic test images (view) Lab reports (view) Radiology reports (view) 3

4 Meaningful Use Functionalities Automated Quality Reporting Auto generate hospital meaningful use quality measures by electronic data extract Auto generate physician meaningful use quality measures calculated from EHR Auto generate HQA measures for Medicare inpatient update Discharge Instructions and Care Summary Documents Electronic copy of discharge instructions upon request Electronically exchange key clinical information with providers Summary of care record for relevant transitions of care Electronic copy of record upon request Include care teams and plan of care in care summary record Transition of care summaries to unaffiliated org using different certified EHR vendor Electronic Clinical Documentation Family health history as structured data Incorporated as structured data lab results for >40% of patients admitted Preferred language for communication with providers of care Smoking status Vital signs Gender and date of birth Medication allergy lists Race and Ethnicity Time and preliminary cause of death Medication Management Automatically track medications with emar Compare patient's inpatient & preadmission med. list Provide updated med. list at discharge Check inpatient prescriptions against internal formulary erx of discharge medication orders Other Functionalities Implement at least 5 Clinical Decision Support interventions related to 4 or more clinical quality measures Security risk analysis and implement security updates Population Health Management Generate lists of patients by condition Identify and provide patient specific education resources Public Health Reporting Reportable lab results to public health agencies To immunization registries or information systems Syndromic surveillance data to public health agencies 4

5 Health Information Exchange Functionalities Clinical/Summary Care Record Clinical Care Record in any format (HIS) Clinical Care Record in any format (AIS) Clinical Care Record in any format (HOS) Clinical Care Record (DNK) Clinical Care Record in any format (AOS) Laboratory Results Laboratory Results (AIS) Laboratory Results (AOS) Laboratory Results (DNK) Laboratory Results (HIS) Laboratory Results (HOS) Medication History Medication history (AIS) Medication history (AOS) Medication history (DNK) Medication history (HIS) Medication history (HOS) No Patient Data Exchange Do not exchange patient data (AIS) Do not exchange patient data (AOS) Do not exchange patient data (DNK) Do not exchange patient data (HIS) Do not exchange patient data (HOS) Other Types of Patient Data Other types of patient data (AIS) Other types of patient data (AOS) Other types of patient data (DNK) Other types of patient data (HIS) Other types of patient data (HOS) Patient Demographics Patient Demographics (AIS) Patient Demographics (AOS) Patient Demographics (DNK) Patient Demographics (HIS) Patient Demographics (HOS) Radiology Reports Radiology Reports (AIS) Radiology Reports (AOS) Radiology Reports (DNK) Radiology Reports (HIS) Radiology Reports (HOS) Other CCR, CDA or CCD format capability Electronic notification to primary care physician when patient visits ED (DNK) Electronic notification to primary care physician when patient visits ED (IS) Electronic notification to primary care physician when patient visits ED (OS) Electronic sharing of patient-level clinical data Level of HIE or RHIO participation Provide electronic notification to primary care physician when patient visits ED Providers able to query electronically for patient health info from sources outside Sharing of clinical/summary care records with other providers 5

6 Patient Engagement Functionalities Method of Providing Patient Info. None Other method Other method description Patient portal PHR Secure message Patient Access to Health/Medical Records Download information from their health/medical record Health medical records DNK None Pay bills online Request an amendment to change/update their health/medical record Request refills for prescriptions online Schedule appointments online Submit patient-generated data View information from their health/medical records online 6

7 EHR System and IT Vendors General Information Two factor authentication Hospital uses EMR/EHR system EMR/EHR initial year EMR/EHR initial year - unknown EHR Description Certified EHR for Meaningful Use Planned Changes Best-of-breed to enterprise architecture Enterprise architecture to best-of-breed Initial deployment Major change in vendor Significant additional functionalities Changes Unknown No major changes planned Primary Implementation Challenges Concerns about security/liability for privacy breaches Lack adequate IT staff Lack of vendor capacity Meeting all meaningful use criteria on time Obtaining other staff cooperation Obtaining physician cooperation Ongoing costs of maintaining/upgrading Other reason Other reason specified Uncertainty about certification process Upfront capital costs, or lack of capital Difficulty reaching system-level decision Vendors Primary inpatient EHR/EMR vendor Primary inpatient EHR/EMR vendor - other Primary outpatient EHR/EMR vendor Primary outpatient EHR/EMR vendor - other 7