EHR Adoption and Vision for HIM

Transcription

1 EHR Adoption and Vision for HIM Christina M. Janus, MBA, RHIA EOHIMA Spring Seminar April 14,

2 Content Covered Key EHR Functions Adoption Model Group Share of Current Technologies & Vision for the Future AHIMA EHR Practice Council Update EHR Certification 2

3 Key EHR Functions for HIM Involvement Electronic Dictation Support digital dictation, speech recognition, electronic signature Results Reporting trending/graphing capability or view only Electronic Document Management System document imaging, COLD-fed print forms, management of efax and Patient Care Charting free text, template-entry (H&P, RN assessment, progress notes, etc.) other documentation exclusive of order entry & medication administration recording 3

4 Key EHR Functions for HIM Involvement Electronic Medication Administration Record (emar) automating processes of administering & documenting the right dose & route of the right medication at the right time Computerized Provider Order Entry (CPOE) for all orders or medication orders with reminders & alerts Health Information Exchange with external sources (secure provider portal, , or patientcarried device) 4

5 Key EHR Functions for HIM Involvement Personal Health Record (PHR) patients may contribute information to their record, access information from their record, update their demographic & insurance information or request/schedule an appointment Data Mining for development of site specific electronic or paper-based clinical guidelines/protocols, quality improvement and/or decision support 5

6 EHR Adoption Model Data on EHR Adoption Model is from 2005/2006 HIMSS Analytics database & from HIMSS document titled EMR Sophistication Correlates to Hospital Quality Data Stage 0 Some clinical automation may be present, but all 3 major ancillary clinical systems (pharmacy, laboratory, & radiology) are not implemented Stage 1 All 3 major ancillary clinical systems are installed Stage 2 Major ancillary clinical systems feed data to a CDR that provides physicians access for retrieval & reviewing results. CDR contains a controlled medical vocabulary & clinical decision support/rules engine for rudimentary conflict checking. Information from document imaging systems may be linked to the CDR at this stage 6

7 EHR Adoption Model Stage 3 Clinical documentation (vital signs, flow sheets, RN notes, care plan charting, emar) & general order entry are implemented & integrated with CDR for 1 or more service in the hospital. First level of clinical decision support & some level of medical image access from PACS is available via internet Stage 4 CPOE for all clinicians, CDR & second level of clinical decision support capabilities related to evidence-based medicine protocols Stage 5 Closed loop medication administration environment fully implemented in at least 1 service area. emar & autoidentification technology are implemented & integrated with CPOE and pharmacy 7

8 EHR Adoption Model Stage 6 Full physician documentation & charting is implemented for at least 1 patient care service area. Level 3 of clinical decision support provides guidance for all clinician activities related to protocols & outcomes in the form of variance & compliance alerts. PACS displaces film-based images Stage 7 This is 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 (other hospitals, ambulatory clinics, sub-acute environments, employers, payers and patients) 8

9 EHR Adoption Model Sept % of US Hospitals Stage 7 Medical record & processes fully electronic 0.0% Stage 6 Physician documentation, full CDSS, full PACS 0.1% Stage 5 Closed loop medication administration 0.5% Stage 4 CPOE, CDSS (clinical protocols) 2.7% Stage 3 Stage 2 Clinical documentation (flow sheets) CDDS (error checking) PACS available outside of radiology CDR, CMV, CDSS inference engine, may have document imaging 14.2% 42.9% Stage 1 Ancillaries installed (radiology, lab, pharmacy) 21.8% Stage 0 None of the 3 ancillaries installed 17.9% 9

10 Interoperability Interoperability is the ability of different information technology systems & software applications to communicate, to exchange data accurately, effectively, consistently & to use the information that has been exchanged Data becomes exceptionally mobile; personal health information entered into a system once, becomes available to patients wherever they are and whenever they need it. 10

11 Group Discussion Describe the EHR technologies implemented at facility today and any plans you are aware of for the future What is the current EHR Adoption Stage for your facility? What is the vision for HIM as adoption increases for the EHR? 11

12 AHIMA EHR Practice Council Update Charge is to advise & provide AHIMA with expertise related to HIM practices in an electronic environment & EHR best practices across all practice settings Resolution on the Legal Health Record approved by the 2006 AHIMA House of Delegates Process of creating Legal EHR Policy Template (late spring 2007) AHIMA is drafting RFP Process for EHR Systems and providing a RFP Template (June 2007 Practice Briefs) 12

13 EHR Certification Certification Commission for Healthcare Information Technology (CCHIT) CCHIT is the recognized certification authority for electronic health records and their IT networks/infrastructure CCHIT is a voluntary, private-sector initiative whose mission is to accelerate the adoption of robust, interoperable Health Information Technology throughout the US healthcare system 13

14 EHR Certification US Dept of Health and Human Services awarded CCHIT a 3 year contract in Sept 2005 to develop & evaluate certification criteria & an inspection process for ambulatory EHRs, inpatient EHRs, and the networks through which they interoperate. CCHIT will help guide the industry by publishing current certification criteria & a roadmap describing expected requirements one & two years in the future Certification is a pass/fail indication that the product meets criteria in every area 14