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

Transcription

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

2 TABLE OF CONTENTS COMPUTERIZED SYSTEM IMPLEMENTATION... 4 Bar Coding... 4 Computerized Provider Order Entry... 4 Decision Support... 4 Disaster Recovery Plan Electronic Clinical Documentation For:... 4 Other Functionalities... 4 Results Viewing Of:... 4 DEPARTMENT/AREA IMPLEMENTATION... 5 Emergency department... 5 General Medical/Surgical Wards... 5 ICU... 5 Non-clinical IT Application Areas... 5 Offsite ambulatory practices... 5 Onsite Ambulatory Practices... 5 Specialty Wards... 5 ELECTRONICALLY EXCHANGING PATIENT DATA... 6 With Ambulatory Providers Inside System... 6 With Ambulatory Providers Outside System... 6 With Hospitals in System... 6 With Hospitals Outside of System... 6 ELECTRONIC HEALTH RECORD... 7 General

3 Capability for Patients... 7 Level of Barrier to Implementing EHR... 7 Method of Providing Patient Info... 7 Orders Written Electronically for Inpatients... 7 Planned Changes... 7 ELECTRONIC SYSTEM CAPABILITIES... 8 Discharge Summaries... 8 Lab Results... 8 Patient/Medication Lists... 8 Public Health Reporting/Submitting per Meaningful Use Standards... 8 Quality Reporting... 8 MEANINGFUL USE... 9 Medicare/Medicaid Incentive Payments... 9 Most Challenging Criteria... 9 Reason Not Pursuing Payment... 9 Other

4 Computerized System Implementation Bar Coding Laboratory specimens Tracking pharmaceuticals Pharmaceutical administration Supply chain management Patient ID Computerized Provider Order Entry Laboratory tests Radiology tests Medications Consultation requests Nursing orders Decision Support Clinical guidelines Clinical reminders Drug allergy alerts Drug-drug interaction alerts Drug-Lab interaction alerts Drug dosing support Advice on diagnosis Implement drug formulary checks Disaster Recovery Plan Disaster recovery plan for electronic network Annual test electronic network recovery plan Redundant networks Back-up data source to ensure clinical continuity Remote Site Electronic Clinical Documentation For: Patient demographics Physician notes Nursing assessments Problem lists Discharge summaries Advanced directives Other Functionalities Telemedicine Radio frequency Physician use of personal data assistant Review & update of privacy & security measures Results Viewing Of: Graphical display of patient lab results over time Lab reports (view) Radiology reports (view) Radiology images (view) Diagnostic test results (view) Diagnostic test images (view) Consultant reports (view) Gender and Date of Birth Race Ethnicity Preferred language for communication with providers of care Vital signs Height and weight and BMI displayed Smoking status Comprehensive list of allergies (including medication) Summary care record for relevant transitions in care Identify and provide patient specific education resources 4

5 Department/Area Implementation Emergency department General Medical/Surgical Wards ICU Non-clinical IT Application Areas Patient accounts department Patient scheduling systems Pharmaceuticals supply chain management Medical-surgical supply chain management Offsite ambulatory practices Onsite Ambulatory Practices Specialty Wards 5

6 Electronically Exchanging Patient Data With Ambulatory Providers Inside System Patient Demographics Clinical Care Record in any format Laboratory Results Radiology Reports Clinical Care Record in CCR or CCD format With Ambulatory Providers Outside System Patient Demographics Clinical Care Record in any format Laboratory Results Radiology Reports Discharge Summaries Clinical Care Record in CCR or CCD format With Hospitals in System Patient Demographics Clinical Care Record in any format Laboratory Results Radiology Reports Discharge Summaries Clinical Care Record in CCR or CCD format With Hospitals Outside of System Patient Demographics Clinical Care Record in any format Laboratory Results Radiology Reports Discharge Summaries Clinical Care Record in CCR or CCD format 6

7 Electronic Health Record General EMR/EHR initial year EMR/EHR initial year is N/A Level of HIE or RHIO participation Hospital uses an EHR System Electronic health system is CCHIT Electronic sharing of patient-level clinical data IT supports two factor authentication Development framework/set-up of EHR Primary provider of inpatient EHR Other primary provider of inpatient EHR Primary provider of outpatient EHR Other primary provider of outpatient EHR Hospital uses an EMR/EHR system(s) Capability for Patients View discharge summary online View test results online View operative notes online View medication lists online Provides an electronic copy of all health info. Method of Providing Patient Info. PHR Patient portal Secure message USB drive or other physical device Other method None Other method description Orders Written Electronically for Inpatients Medication orders (percentage of) Lab orders (percentage of) Clinical documentation (percentage of) Planned Changes Initial deployment Major change in vendor Major change in architecture Significant additional functionalities Do not know No major changes planned Enterprise architecture to best-of-breed Best-of-breed to enterprise architecture Level of Barrier to Implementing EHR Capital needed to purchase & implement EHR Uncertainty of ROI from an EHR Ongoing cost of maintaining an EHR Physician resistance to implementation Other provider resistance to implementation Lack of capacity to select, contract & implement HER Disruption in clinical care during implementation Lack of adequate IT staff Concerns of inappropriate disclosure of patient info. Legal concerns of donating a system to associated physician Concerns about illegal record tampering Finding an EHR system that meets your organization's needs Lack of interoperable IT systems in the market place Concerns about a lack of future vendor support 7

8 Electronic System Capabilities Discharge Summaries Proportion of summaries sent electronically to ambulatory care providers Length taken to send summary to ambulatory care providers after discharge Lab Results Incorporated as structured data lab results for >40% of patients admitted Patient/Medication Lists List of patient's current meds. Compare patient's impatient & preadmission med. list Provide updated med. list at discharge Auto-generate Hospital Quality measures Auto generate Physician Quality Reporting Initiative Check insurance eligibility Submit electronic claims for payment Send patient reminders Capture electronic patient consents Check inpatient prescriptions against internal formulary Generate lists of patents by condition Perform medication reconciliation Public Health Reporting/Submitting per Meaningful Use Standards To immunization registries or information systems Reportable lab results to public health agencies Syndromic surveillance data to public health agencies Quality Reporting Auto generate HQA measures for Medicare inpatient prospective payment system update Auto generate hospital meaningful use quality measures by electronic data extract Auto generate physician meaningful use quality measures calculated directly from EHR 8

9 Meaningful Use Medicare/Medicaid Incentive Payments Intent to apply for incentives Year planning to apply Year planning to apply for Medicaid incentives Year planning to attest as a meaningful user or certified EHR technology Most Challenging Criteria Implement clinical decision support (CDS) rules Implement computerized provider order entry (CPOE) at specified level of sophistication Exchange clinical information with other providers Perform medication reconciliation across settings of care Give patients access to their data in electronic form Generate problem lists used codified data sets Generate numerator and denominator data for quality reporting directly from EHR Upfront capital costs, or lack of capital Ongoing costs of maintaining/upgrading Obtaining physician cooperation Obtaining other staff cooperation Decision made at a system leadership level Generate numerator/denominator data for quality reporting Reason Not Pursuing Payment Cost - including acquisition and maintenance Lack of access to capital Resistance to implementation Concerns about security/liability for privacy breaches Uncertainty about certification process Lack of vendor capacity Lack adequate hospital IT staff for implementation/maintenance Meeting all meaningful use criteria on time Other reason Other reason description Single largest barrier Other Posses a certified system for meeting meaningful use requirements 9