© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 2 Standards and Features of...

© 2013 The McGraw-Hill Companies, Inc. All rights reserved.

Chapter 2

Standards and Features of Electronic Health Records

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. 2-2

• 2.1 History of EHR Standards• 2.2 EHR Functionality• 2.3 Privacy and Security of the EHR• 2.4 EHR Implementation and Technology• 2.5 Electronic Health Record Competencies

Chapter 2 Learning Outcomes


• Application Server Provider (ASP)• Certification Commission for Health

Information Technology (CCHIT)• Computer on Wheels (COW)/Workstation

on Wheels (WOW)• Computerized provider order entry (CPOE)• Consolidated Health Informatics (CHI)• Current Procedural Terminology (CPT)

codes• Drug Formulary• Eligible Professional (EP)• Encrypting • Health Insurance Portability and

Accountability Act (HIPAA)• Health Level Seven (HL7)

• Healthcare Common Procedure Coding System (HCPCS) codes

• Institute of Medicine (IOM)• International Classification of Diseases (ICD)

codes• Intranet• Local Area Network (LAN)• Meaningful Use (MU)• National Committee on Vital and Health

Statistics (NCVHS)• Protected Health Information (PHI)• Server• Structured Data• Tablet• Telehealth Services• Template• Test Script• Wireless Connectivity

Chapter 2 Key Terms


LO 2.1 History of EHR Standards


• Passed in 1996• To establish standards for accountability and

criteria for protection and confidentiality of electronically transported health information

• In 2000, the National Committee on Vital and Health Statistics proposed national standards to improve patient care

Health Insurance Portability and Accountability Act (HIPAA)

LO 2.1


• An initiative of the U.S. Office of Management and Budget (OMB)

• Released the first set of EHR standards– Common vocabulary– Standard methods for transmission

• Goal was to make 20 agencies interoperable• Not legally required, but heavily suggested

Consolidated Health Informatics (CHI)

LO 2.1


• Health Level Seven (HL7)• The National Council on Prescription Drug

Programs (NCPDP)• The Institute of Electrical and Electronic

Engineers 11073 Medical Device Communication Standard (IEEE)

• Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT)

Notable Adopted Standards

LO 2.1


• Determined eight main functions of the EHR• Four most notable:

1. Health Information and Patient Data2. Results Management3. Order Entry/Management4. Medical Decision Support

Institute of Medicine (IOM)

LO 2.1


• Organized in July 2004• Supported by AHIMA, HIMSS, and NAHIT• Work focused in three main HIT areas:– Ambulatory healthcare EHRs for office-based

healthcare providers– Inpatient EHRs for hospitals and health systems– Network components through which EHRs

interoperate and share information

The Certification Commission for Health Information Technology (CCHIT)

LO 2.1


• Established in 2004• Within the Office of the Secretary for HHS• Purpose:

– To serve as a resource for the entire health system– To support HIT adoption– To promote a nationwide health information exchange

• Goal:– Improving healthcare in the United States

• Authorized several testing centers to certify EHR products• Created the American National Standards Institute (ANSI)

Healthcare Information Technology Standards Panel (HITSP) in 2005 to continue efforts of interoperability in healthcare

Office of the National Coordinator for Health Information Technology (ONC)

LO 2.1


LO 2.2 EHR Functionality


• Provides financial incentives, assistance, online tools, and resources for providers to implement, use, and prove meaningful use (MU) of electronic health record

• ATCB certification signifies to each eligible professional (EP) and hospitals that the EHR technology has the capabilities to meet MU goals and objectives

HITECH Act

LO 2.2


• Defined: – Demonstrably effective use of an EHR

program, determined via tangible, ONC-established functionalities

• ARRA specifies three main components:– Use of a certified EHR in a specified

significant manner– Use of certified EHR technology for

electronic exchange of health information to improve healthcare quality

– Use of certified EHR technology to submit clinical quality reports and other measures

• EPs must demonstrate use of 15 core objectives via use of certified EHR for 90 days

Meaningful Use

LO 2.2


1. Create computerized physician order entry (CPOE).2. Generate and transmit permissible prescriptions electronically (eRx).3. Report a total of 6 ambulatory clinical quality measures to CMS.4. Implement one clinical decision support rule.5. Provide patients with an electronic copy of their health information, upon request.6. Provide clinical summaries for patient for each office visit.7. Perform drug–drug and drug–allergy interaction checks.8. Enable a user to electronically record, modify, and retrieve patient demographic data, including preferred language, gender, race, ethnicity, and date of birth.9. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9 or SNOMED CT.

Core Objectives

LO 2.2


10. Maintain the patient’s active medication list.11. Maintain the patient’s active medication allergy list.12. Record and chart changes in patient’s vital signs:

– Height– Weight– Blood pressure– Calculate and display BMI– Plot and display growth charts for children 2–20 years (including BMI)

13. Record smoking status for patients 13 years old or older.14. Exchange key clinical information among providers of care and patient-authorized entities electronically.15. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.

Core Objectives, continued

LO 2.2


Five of the following objectives have to be selected to qualify for incentives:1. Perform drug-formulary checks.2. Document clinical lab test results as structured data.3. Generate lists of patients by specific conditions.4. Send reminders to patients per patient preference for preventive/follow-up care.5. Provide patients with timely electronic access to their health information.6. Use certified EHR technology to identify patient-specific education resources and provide to patient.7. Perform medication reconciliation.8. Create summary of care record for each transition of care/referrals.9. Submit electronic data to immunization registries/systems (public health objective).10. Provide electronic surveillance data to public health agencies (public health objective).

Menu Set Objectives

LO 2.2


• Defined: – Means by which a physician or clinician

electronically transmits instructions for a patient’s treatment or the ordering of tests to a testing facility

• CPOE is one of the core objectives for Meaningful Use

• Benefits of the CPOE function in EHRs – more expedient order completion– reduction in errors related to handwriting– opportunity to check for duplicate or

incorrect tests

Computerized Provider Order Entry (CPOE)

LO 2.2


LO 2.3 Privacy and Security of the EHR


Regulated under HIPAA, PHI includes any information (past, present, or future) about

health status, provision of healthcare (including mental health), and payment for healthcare that can be linked to a specific

individual

Protected Health Information

LO 2.3


• Allows for the disclosure of PHI in relationship to terrorism

• HIPPA allows for disclosure of information to law enforcement under certain limited circumstances

USA Patriot Act and Homeland Security

LO 2.3


HIPAA’s Core Regulations for the EHR Industry

LO 2.3


• Introduced the first federally mandated “data breach notification requirement” which expanded HIPAA to include “business associates”

• Increases compliance obligations and privacy regulations

• Specified methodology for encrypting PHI

Health Information Technology for Economic and Clinical Health (HITECH) Act

LO 2.3


Other Privacy Concerns

LO 2.3


LO 2.4 EHR Implementation and

Technology


• Data Entry Methods• Templates• Portability• Network• Internet and Intranet• Web-based EHRs

EHR Implementation and Technology

LO 2.4


LO 2.5 Electronic Health Record Competencies


• MAERB and CAAHEP are developing core curricula for EHR competencies within health professional education programs

Electronic Health Record Competencies

LO 2.5


• Critical Work Functions for EHR Competencies:– Understand the use of technology in maintaining electronic health

records.– Create and update documents within the EHR using electronic tools

and applications (including portable computing devices, word processing, spreadsheets, databases, and desktop presentation applications).

– Locate and retrieve information in the electronic health record for various purposes.

– Understand the ONC’s mission and functions as they pertain to EHRs’ application, certification, and meaningful use.

– Utilize mainstream software to complete job-specific tasks, and understand the interaction between mainstream and EHR technology.

– Follow security and privacy policies and procedures for the use of networks, including intranet and Internet.

Competency Model Clearinghouse (CMC)

LO 2.5


• Critical Work Functions for EHR Competencies – Follow confidentiality and security measures to protect electronic

health information.– Differentiate between primary and secondary health data sources

and databases.– Identify classification and systematic health-related terminologies

for coding and information retrieval.– Know the policies and procedures related to populating and using

the health data content within primary and secondary health data sources and databases.

– Resolve minor technological problems associated with using an EHR.– Utilize basic IT troubleshooting processes to identify the root cause

of an IT-related problem.– Utilize IT help desk for problem resolution where necessary to

maximize efficiency and effectiveness.

Competency Model Clearinghouse (CMC)

LO 2.5


LO 2.1 Identify major events in the development of standards for the EHR• HIPAA• CHI• IOM• CCHIT• ONC

Chapter 2 Summary


LO 2.2 Describe meaningful use (MU) criteria, including specific EHR functions that meet MU requirements.• 5-year incentive program• EHR certification program• Meaningful Use incentive program• CPOE standard feature in EHR

Chapter 2 Summary


LO 2.3 Describe key privacy and security issues related to EHRs.• USA Patriot Act and Homeland Security• HIPAA and Privacy/Security• Health Information Technology for Economic and Clinical Health Act (HITECH)• Other Privacy Concerns

Chapter 2 Summary


LO 2.4 Explain the basic technology used in EHR implementation.• Modes of Data Entry• Network Technologies

Chapter 2 Summary


LO 2.5 List EHR competencies identified by the Competency Model Clearinghouse.• Core curricula are being developed

Chapter 2 Summary

© 2013 The McGraw-Hill Companies, Inc. All rights reserved. Chapter 2 Standards and Features of...

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