CHAPTER 2 Functional EHR Systems

CHAPTER 2 Functional EHR Systems Chapter Overview Chapter 2 of the student text describes the various forms of storing EHR data and the value of using standardized codes for those data. The chapter covers the prominent nomenclature standards and their history, purpose, and relationships to each other. The chapter s hands- on exercises allow students to explore a common component of most EHR systems the document imaging system. Additional topics in this chapter include the potential uses of EHR for patient health management, decision support, and the electronic interchange of data between systems. Learning Outcomes 1. Explain how the format of EHR data determines functional benefits. 2. Compare different EHR data formats. 3. Discuss the limitations of certain types of data. 4. Describe the importance of codified electronic health records. 5. Have an understanding of prominent EHR code sets, such as Systematized Nomenclature of Medicine Clinical Terms (SNOMED- CT ), MEDCIN, and Logical Observation Identifiers Names and Codes (LOINC ). 6. Name different methods of capturing and recording EHR data. 7. Describe the functional benefits derived from using an EHR. 8. Provide examples of the EHR functions of trend analysis, alerts, health maintenance, and decision support. Resources Instructor Resource Guide Instructor Test Generator PowerPoint (PPT) slides for Chapter 2 18

Textbook MyHealthProfessionsKit website LEARNING OUTCOMES AND LESSON PLANS Lesson 1 Learning Outcomes 1. Explain how the format of EHR data determines functional benefits. 2. Compare different EHR data formats. 3. Discuss the limitations of certain types of data. 4. Describe the importance of codified electronic health records. 5. Have an understanding of prominent EHR code sets such as SNOMED- CT, MEDCIN, and LOINC. PPT Slides: 1 9 Textbook pages: 16 36 Classroom Activities: Consider the following topics for class discussion: Why would a healthcare facility choose to use a picture archiving and communication system (PAC) for diagnostic images rather than store them in a document image system? What advantages might the PAC offer that the document image system does not? If you had the option of scanning exam notes from a paper record or uploading a word processor file of the same notes, which option would you choose? Why? Complete Guided Exercise 3: Exploring a 19

Document Image System. If you have not done so already, have students sign in and register for MyHealthProfessionsKit website access. Homework Have students compare and contrast the different lab data in Figures 2-13, 2-14, and 2-15 and discuss what each shows about the trends among the different tests. Teaching Tips Obtain examples of data in each of the EHR data formats and bring them to class for students to review. If possible, obtain both diagnostic images and scanned documents as examples of digital images and fielded and coded data for examples of discrete data. Did You Know? Discrete data use a year- month- day system for recording dates. For example, if a fielded entry includes the date 20101128, the information was obtained on November 28, 2010. Storing dates in this format makes it 20

easy for the computer to sort data chronologically. Instructor Notes Lesson 2 Learning Outcomes 6. Name different methods of capturing and recording EHR data. PPT Slides: 10 15 Textbook pages: 27 33 Classroom Activities: Complete Guided Exercise 4: Importing and Cataloging Images Homework If students have Internet access outside of class, have them work through Exercise 4 again for additional practice. Did You Know? Drug formularies can do more than alert a clinician about insurance coverage related to prescriptions. They can provide decision support through comparisons of alternative brands of the same drug and information about the therapeutic classes of drugs. Instructor Notes 21

Lesson 3 Learning Outcomes 7. Describe the functional benefits derived from using an EHR. 8. Provide examples of the EHR functions of trend analysis, alerts, health maintenance, and decision support. PPT Slides: 16 22 Textbook pages: 33 43 Classroom Activities: Complete Critical Thinking Exercise 5: Retrieving a Scanned Lab Report Homework Have students answer the Testing Your Knowledge of Chapter 2 questions located on page 44 of the text. If in- class time does not permit students to work on Exercise 5, assign this to them as homework. Teaching Tips Tie the functional benefits of codified records back to the IOM core functions discussed in Chapter 1. Instructor Notes LEARNING OUTCOMES 1 AND 2 Explain how the format of EHR data determines functional benefits. 22

Compare different EHR data formats. Concepts for Lecture: I. Format of data determines potential benefits A. Medical records data stored within a database can be categorized as one of three types. 1. Digital images: image data retrieved and displayed by a computer; can be divided into two types. a. Diagnostic images, like x- rays, computed tomography scans, and drawings. b. Scanned documents, like paper forms, old paper records, and dictated notes. 2. Text files: data obtained by importing text files from outside sources; include word processing files of exam notes and text reports. 3. Discrete data: data that can be instantly searched, retrieved, combined, or reported in different ways; can be divided into two types. a. Fielded data, in which each piece of information is assigned its own position, or field, in the record. Meaning is inferred based on the position of information. b. Coded data, or fielded data that contain a code in addition to or in place of descriptive text. LEARNING OUTCOME 3 Discuss the limitations of certain types of data. Concepts for Lecture: I. Limitations of certain types of data A. All three data types have certain limitations that hinder the functional benefits of EHRs. 1. Digital image data require human interpretation in order for the content to have meaning. This is especially limiting if the bulk of the EHR is scanned paper documents. 2. Text data search capabilities tend to be slow, making the EHR of limited usefulness for generating alerts or providing decision support and trend analysis. 23

3. Discrete data that is fielded but not codified tend to be ambiguous due to the fact that many terms can describe the same symptom, condition, or observation. This complicates the process of comparing notes from different physicians. Even if data are codified, use of nonstandard codes limits its functionality. LEARNING OUTCOME 4 Describe the importance of codified electronic health records. Concepts for Lecture: I. Definition of codified electronic health records A. Coded data refer to data that are stored in the medical record with both a code and a text description. 1. Such a record is considered a codified record. B. Benefits of codified records include the following: 1. They can instantly find and match the desired information by code, regardless of the clinician s choice of words. 2. They are more useful than text- based records because they precisely identify the clinician s finding or treatment. C. Considerations for codified records 1. Codified records that do not use proprietary codes instead of standard codes make it difficult to exchange medical record data between different EHR systems or facilities. a. Note: Exchange of data is one of the eight core functions defined by the IOM. 2. Using a national standard code set will meet the following objectives: a. Improve the exchange of medical records among systems b. Improve the accuracy of the content c. Open the door to the other functional benefits derived from having an electronic health record. 24

LEARNING OUTCOME 5 Have an understanding of prominent EHR code sets such as SNOMED- CT, MEDCIN, and LOINC. Concepts for Lecture: I. Standard EHR coding systems A. EHR coding systems, or nomenclatures, codify details and observations of the patient clinician encounter. B. Nomenclatures are more granular, or contain more codes, than other classification systems because of the level of detail they describe. C. Nomenclatures differ from billing codes, which only record the type and complexity of a visit or exam. D. Three main nomenclatures are used for EHRs. 1. SNOMED- CT: Systemized Nomenclature of Medicine Clinical Terms was developed by the College of American Pathologists and the United Kingdom s Health Service to merge two previous code systems. 2. MEDCIN: Developed by Medicomp Systems, Inc., in collaboration with staff physicians at Cornell, Johns Hopkins, and Harvard, this system is designed to be used at the point of care. 3. LOINC: Logical Observation Identifiers Names and Codes was developed by the Regenstrief Institute Indianapolis, Indiana, to standardize codes for laboratory test orders and results. E. Many hospitals and labs have developed their own internal coding systems rather than adopted one of the standard formats, which is problematic when information must be exchanged between systems. LEARNING OUTCOME 6 Name different methods of capturing and recording EHR data. Concepts for Lecture: I. Capturing and recording EHR data A. Digital image systems 25

1. Scanned documents and diagnostic images may be added to the EHR via a digital image system that catalogs images through ID field and keyword associations. 2. Remind students that EHRs will always include some paper documents, such as referral letters or paper medical documents from outside sources 3. Guided Exercise 3: Exploring a Document Image System a. This exercise has nine steps. Its function is to help students become familiar with an imaging system. It simulates many of the features typically found in an EHR document image management system. Students will need access to the Internet and should have completed the student registration for the MyHealthProfessionsKit website. You will find that information located on the inside cover of the student text. b. Before students begin, point out the following alert: All instructions in these exercises refer to the simulation window. Because you are running this simulation inside a browser, be careful to use the Menu bar and Toolbar inside the simulation window, not the Menu bar or Toolbar of your Internet browser program. c. Lead students through the exercise. As students work through this exercise, encourage them to check the figures displayed in Chapter 2 of their text to ensure they are following each step correctly. B. Cataloging images 1. The process of associating these fields and keywords with images is called cataloging the image. a. Catalog data add the ability to search an EHR for the electronic document images in multiple ways. 2. Quality control during scanning and cataloging is important because original documents are stored offsite or shredded after they are added to the system. Poor scans or improper cataloging make the image difficult to read or locate. 26

3. Cataloging may be manual or automated. Automated cataloging may utilize barcodes that identify the patient and document type. (Figure 2-7 on page 26 of the text is an example of a document created for automated cataloging.) It may also utilize optical character recognition (OCR) software that recognizes text characters in images. 4. Guided Exercise 4: Importing and Cataloging Images a. This exercise has eight steps. Its function is to take students through the steps of cataloging a scanned report and a diagnostic image. Students will again need access to the Internet for this exercise. b. As students work through this exercise, encourage them to check the figures displayed in Chapter 2 of their text to ensure they are following each step correctly. C. Picture archiving and communication system (PAC) 1. Diagnostic images may be stored in a PAC, which is a separate system that houses and links them to the EHR. A PAC may be used because file sizes of diagnostic images are generally much larger than those of document images and would take up too much space in the EHR system. D. Importing text into the EHR 1. Text files can be directly imported into an EHR and text data can be searched or reformatted for different display devices, unlike digital image data. E. Importing coded EHR data 1. Discrete data can also be imported directly into an EHR, often through interfacing between the EHR and data collection devices like glucose and Holter monitors. In other circumstances, data are entered into the EHR by users as part of a workflow. F. Other, more specialized programs can be used to interface with EHR data in different ways. 1. Patient- entered data: Instant Medical History and programs like it collect information entered into the computer by the patient and merge it with the EHR. 27

2. Health Level 7 (HL7) translates and interfaces data from different computer systems within a healthcare organization into the main EHR system. 3. Regional health information organizations (RHIOs) are networks that enable the transfer of EHRs between healthcare providers. 4. With provider- entered data, the healthcare provider, such as the physician, nurse, or medical assistant, enters coded EHR data during the patient encounter. Note that this is the focus of the remainder of the chapters in the student text (Chapters 3 to 8). LEARNING OUTCOMES 7 AND 8 7. Describe the functional benefits derived from using an EHR. 8. Provide examples of the EHR functions of trend analysis, alerts, health maintenance, and decision support. Concepts for Lecture: I. Functional benefits from codified records A. Four functional benefits can be derived from EHR codification: trend analysis, alerts, health maintenance, and decision support. B. Trend analysis, or the comparison of lab tests for the same patient over a period of time, is simplified through record codification. Codification eliminates the need to scroll through and interpret pages of scanned data and leads to more- specific search results than are possible with text files. Compare lab results stored in each of the data formats discussed in Lesson 1. 1. Lab data as scanned image. Have students perform Critical Thinking Exercise 5: Retrieving a Scanned Lab Report. This exercise applies what students learned during their completion of Guided Exercise 3. Here, they will locate information from a scanned lab report for a patient. (Answer key is provided at the end of this lesson.) 28

2. A lab results report that was received as a text file it might resemble Figure 2-13 on page 34 of the text. 3. Codified data can be used to create cumulative summary reports that compare results for multiple tests across multiple categories, as shown in Figure 2-14 on page 35 of the text. 4. Codified data can also be extracted and graphed via computer software to determine trends. An example is provided in Figure 2-15 on page 36 of the text. C. Alerts, or automatic messages and reminders, are based on programmed rules that notify a healthcare provider when certain conditions are met within the patient record. When records are not codified, clinicians must monitor records manually and identify these conditions on their own. 1. Drug utilization review alerts are common with electronic prescriptions because the EHR can check allergies, current medications, and other relevant information for conflicts. 2. Drug formulary alerts also notify the clinician whether the prescribed medication is not covered by the patient s insurance. 3. Alerts can also be tied to lab orders, test values, and nonaction on the part of clinicians or administrators. D. Health maintenance, or preventive care, incorporates annual checkup reminders and preventive service recommendations based on expert opinion within a codified system. Standard rules regarding immunization and testing requirements can be set up within the EHR. E. Decision support, or medical literature and other information that enable clinician analysis and diagnosis of symptoms, is simplified in a codified system. Materials can more quickly be sorted and analyzed for information pertinent to a particular case. 29

1. In addition to references and drug information, electronic decision support utilizes protocols, or standard plans of therapy established for different conditions. These plans can be accessed and orders placed through the patient s chart. 2. Medication dosing decisions can be tied to lab results in a codified system for more precise medication adjustments. Answer Key to Critical Thinking Exercise 5: Retrieving a Scanned Lab Report Caption: Answer Key for Critical Thinking Exercise 5: Retrieving a Lab Report The Answer is 150 (see red rectangle below). PATIENT INFORMATION Patel, Raj REPORT STATUS Final ORDERING PHYSICIAN QUEST DIAGNOSTICS INCORPORATED DOB: 03/05/1932 Age: 80 Dr. Rice CLIENT SERVICE 813.972.7100 GENDER: M SPECIMEN INFORMATION SS: 587-36-4569 CLIENT INFORMATION SPECIMEN: TP016756T ID: PATID-10 97504017 REQUISITION: 0005290 LAB REF NO: Physician Account MINDY SMITH 4225 E FOWLER AVE COLLECTED: 02/08/2012 10:00 TAMPA, FL 33617-2026 RECEIVED: 02/08/2012 14:02 REPORTED: 02/08/2012 08:48 Lab Test In Range Out of Range Reference Range Lab LIPID PANEL 30

TRIGLYCERIDES 150 H <150 MG/DL TP CHOLESTEROL, TOTAL 195 <200 MG/DL TP HDL CHOLESTEROL 40 >OR=40 MG/DL TP LDL-CHOLESTEROL 98 <130 MG/DL (CALC) TP CHOL/HDLC RATIO 4.9 <5.0 (CALC) TP PROTHROMBIN TIME WITH INR INTERNATIONAL NORMALIZED 2.7 RATIO (INR) SUGGESTED THERAPEUTIC RANGES USING INR FOR STABLY ANTICOAGULATED PATIENTS: ROUTINE ORAL ANTICOAGULANT THERAPY = 2.0-3.0 ORAL ANTICOAGULANT THERAPY FOR PATIENTS WITH THROMBOEMBOLIC EVENTS ON STANDARD DOSES OF COUMADIN AND THOSE WITH MECHANICAL HEART VALVES = 2.5-3.5 INR REFERENCE INTERVAL APPLIES TO PATIENTS NOT ON ANTICOAGULANT THERAPY: 0.9-1.1 SUGGESTED INR THERAPEUTIC RANGE FOR ORAL ANTICOAGULANT THERAPY (STABLY ANTICOAGULATED ANTICOAGULANT THERAPY (STABLY ANTICOAGULATED PATIENTS) ROUTINE THERAPY: 2.0-3.0 31

RECURRENT MYOCARDIAL INFARCTION OR MECHANICAL PROSTHETIC VALVES: 2.5-3.5 PROTHROMBIN TIME 25.0 H 9.0-11.5 SECONDS PROSTATE SPECIFIC ANTIGEN TP TOTAL PSA 3.6 < OR = 4.0 NG/ML Performing Laboratory Information: TP QUEST DIAGNOSTICS-TAMPA 4225 E. FOWLER AVE TAMPA FL 33617 Laboratory Director: Thomas Brian, MD Answer Key to Testing Your Knowledge Questions 1. What is the advantage of codified data over document imaged data? ANSWER: When EHR data are coded, they can be used for trending, alerts, health maintenance, and decision support; they can be accurately identified and electronically compared by computer. Document imaged data require a person to read the information. 2. What does the acronym SNOMED- CT stand for? ANSWER: Systematized Nomenclature of Medicine; CT stands for Clinical Terms. 3. What university is closely affiliated with the development of LOINC? ANSWER: University of Indiana Give examples for the following terms: 4. Trend analysis ANSWER: Acceptable answers include the following: graphs or comparison of data from different dates, tests, or events; cumulative summary reports; comparison of changes in medications or dosage to changes in blood tests. 32

5. Decision support ANSWER: Providing reference information just when the clinician needs it. Examples from the text include prescription drugs, drug formularies, generic or therapeutic equivalents to brand- name drugs, evidence- based guidelines, and online medical references. The text also describes protocols as standard plans of therapy that can be used for treatment of different conditions. 6. Alerts ANSWER: Acceptable answers include a message or reminder that is automatically generated from the data. Students might also cite the example of two or more conflicting medications. 7. Health maintenance ANSWER: Acceptable answers include the following: reminders to make the patient aware when it is time for a preventative procedure or a checkup, a flu shot, or another immunization. Some students may list specific items referenced in the textbook, such as mammograms or prostate- specific antigen (PSA) screenings. The example of a reminder from the dentist was also used. 8. List at least two ways codified data in the EHR can be used to manage and prevent disease. ANSWER: Any two of the following: disease management, graphic analysis, trending, preventative screening, interactive alerts. 9. What is a nomenclature? ANSWER: A nomenclature is a system (or list) of names used in a field of science, typically created by a recognized group or authority. In an EHR the term is used for organized lists of medical phrases that can be codified to help to standardize the way in which clinicians record information. EHR nomenclatures are also called clinical vocabularies or clinical terminologies. 10. What does the phrase cataloging an image refer to? 33

ANSWER: Using a computer program to enter scanned or imported images in a document image system and associate various ID information and keywords with the image. 11. What does the acronym DUR stand for? ANSWER: Drug utilization review 12. Name at least four things that a DUR checks. ANSWER: Any four of the following: A conflict with any drug the patient is already taking. Ingredients that make up the drug are checked against the ingredients of current medications to see whether they conflict with or would hinder the effectiveness of the drug. Drugs are checked for duplicate therapy, which occurs when a patient is taking a different drug of the same class that would have the effect of an overdose. Allergy records are checked for food and drug allergies that would be aggravated by the new drug. The patient s diagnosis history is checked to see whether the patient has a medical condition that the drug would negatively affect. A patient education alert is created when the drug might be affected by certain foods or alcohol interactions. If the Sig has been entered at the time of the DUR, then it is also checked to see whether it matches recommended guidelines for the drug. Too much, too little, too many days, or too many refills could cause overdosing, underdosing (causing the drug to be ineffective), or abuse. 13. What is a RHIO? ANSWER: A Regional Health Information Organization; it facilitates the interchange of electronic patient records among participating healthcare facilities. 14. Name a type of alert other than prescription or drug alerts. ANSWER: Any one of the following: Ordered tests that require an Advance Beneficiary Notice. An alert that monitors changes in values of certain blood tests and pages a doctor whenever the value is outside of a certain range. Alerts for a pending test order that have not been received within the time frame 34

normally required for that type of test. Alerts that notify an administrator when medical items are not handled in a timely fashion. Alerts that detect a finding with a value above or below the desired limit. 15. Name a type of decision support. ANSWER: Any one of the following: defined protocols; drug formularies; medication dosing; results of case studies; standard care guidelines prepared by specialists, medical societies, or government organizations; evidence- based guidelines or medical literature. 35