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CHAPTER 6
HOSPITAL INFORMATION SYSTEM
INTRODUCTION
● A century ago as a paper record intended to contain the universe of care provided to a patient in a given setting has transformed into an electronic portal that describes not only local care but also the interactions between health providers and their patients ● The record encompassess the broadest possible definition of data aggregation centered on the patient ● This chapter aims to define the evolution of this record from its paper origins to its current state and explain the transition from traditional models of systems generated by healthcare entities to more commercially available products that define the “state-of-the-art” functionality ● The computer is the equivalent of the stethoscope in healthcare; the ubiquitous, necessary tool that enables providers to embark on their diagnostic and therapeutic journeys. There will be a period of adjustment as the Electronic Health Record (EHR) reaches maturity in the marketplace, in the quality of the product, and in the science of correct implementation ● One of the key transformations in the EHR is that, in place of static presentation of data for review by healthcare practitioners or even a venue in which to order pharmacologic or diagnostic interventions. The EHR provides a place of record for communications and places them in the correct context of the record HISTORICAL DEVELOPMENT OF THE ELECTRONIC HEALTH RECORD ● The first electronic records were aggregations of observations laid down on paper, either through full narrative entries or scanned copies of notes ● The initial term for these records was “electronic medical records” (EMRs) in that they dealt with the record of disease and interventions to cure them ● However, as the repository came to include elements of healthcare maintenance and preventative care items, it became a full “health record” spanning the continuum of care, hence becoming an “electronic health record”, or EHR
ELEMENTS IN THE FOLLOWING KEY AREAS
MADE ONLINE RECORDS MORE
ADVANTAGEOUS:
1. Accessibility. - By making records available through applications distributed on desktops across an enterprise linked to a central server or by using an Internet-based application, patient data became available at any time and nearly any location, without the need for medical records file rooms and file clerks, thereby diminishing the specter of a lost record 2. Legibility. - The high degree of variability in provider handwriting has often been identified as among the root causes of medication errors. The EHR circumvents this by 3. Use of Discrete Data. - By forcing the use of discrete data elements in representation of the elements of history, medical problems, medications, and even social history documentation, the record allows for aggregation of data across populations and the creation of association with other findings such as laboratory values or radiological findings The first use of EMRs occurred in single institutions that sought to develop systems to support the “business enterprises” of hospitals namely, the capture of physician orders and their appropriate routing to departments such as laboratory, pharmacy, and radiology and then to processing the associated fees that should be charged for those services. The side benefits of these systems is that they often provided clinicians with access to results (e.g., laboratory and radiology reports) electronically, allowing them to move beyond paper printouts. The manner by which these results were aggregated formed the basis of the first tenet of comprehensive electronic records: an integrated view of patient data across time and specialty Individual systems used proprietary formats to display laboratory and radiology values, which were very useful and tailored for their own systems but were not
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understandable to a larger interface. Drawing on the experience of early programmers who leveraged the application programming interface (API) and standards initially created by the American Society for Testing and Materials (ASTM), developers learned to create universal messaging protocols to allow for interchange of these data among different computer systems. Individual hospitals integrate individual departmental systems to their core EMR. This standard, now called health level 7 (HL-7), references the highest level of integration of information and is the industry leader. It is in use at over 1,500 healthcare institutions in the United States. This allowed providers to see relevant clinical information for a particular inpatient stay. Terminologies were created to control the representation of data, each for its own individual area: diagnoses, procedures, psychiatric diagnoses, clinical observations (e.g., laboratory values, vital signs), and medications. It is helpful to outline the most common standards used to represent these elements in electronic health records. DIAGNOSES ● Managed by the International Classication of Diseases and its Clinical Modifications (ICD-9-CM), which serves as the “lingua franca” of diagnostic terms in U.S. hospitals. ● Used for clinical decision support and for billing support purposes. ● Now out of sync with the rest of the world, which has moved to ICD version 10, which is slated to be implemented in the United States by 2013. ● To aggregate a group of related diagnoses, the concept of diagnosis-related groups (DRGs) was created; this allows for a smaller number of diagnostic groups to define a given hospitalization, facilitating reimbursement for similar care across hospitals. For example, there are many ICD-9 terms for bacterial pneumonia (e.g., 482.83: pneumonia secondary to Gram-negative organisms, and 482.31: pneumonia secondary to streptococcus). However, many of them are rolled up into larger groups to create a more rational basis for compensating hospitals (e.g., DRG 89: pneumonia with complications, and DRG 90: pneumonia without complications) UTILIZATION AND PROCEDURES ● The American Medical Association keeps a master dictionary of procedures (Current Procedural Terminology) that encompasses the universe of diagnostic and therapeutic procedures done by providers to patients. ● It has uses among health services researchers to understand patterns of care. ● Often the way in which requests for procedures (i.e., a laboratory or radiology test) are “ordered” by the core electronic medical record to the recipient ancillary system. LABORATORY FINDINGS AND OBSERVATIONS ● Researchers at the Regenstrief Institute in Indianapolis, Indiana, developed a system of structured data for laboratory indings and later for other observations (e.g., vital signs, electrocardiographic indings). ● This came to be known as the Logical Observation Identiier Names and Codes (LOINC) terminology NURSING TERMINOLOGIES ● North American Nursing Diagnosis Association (NANDA) ● Nursing Outcomes Classiffication (NOC) ● Nursing Interventions Classiication (NIC) ● There is no correlation between the more classical “medical” diagnoses utilized in ICD-9-CM and these nursing diagnoses ● Inpatient records have two problem lists at ● any time: ○ those identiied by the physician providers and ○ those laid out by the nursing professionals DRUG CODES ● The current standard from the U.S. Food and Drug Administration (FDA) is a dictionary entitled the National Drug Codes (NDCs) that is driven by the manufacturer and not unique to a speciic drug, dose, and route. Rather, it is very much inluenced by manufacturer and packaging ● The National Library of Medicine (NLM) has sought to create a universal standard for transmitting medication information (RxNorm) ● Most hospital systems rely on commercially prepared, proprietary drug databases with attached clinical decision support information
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problems. This structured approach allows for a common space where multiple ancillary providers (e.g., respiratory therapists, case managers, social workers, dietitians, physical therapists) can interact in one area to describe the ongoing progress of the patient toward health ● The greatest challenge to this approach to documentation is that physician providers, who are required to provide discreet “notes” of their individual encounters for fiscal reasons, have found it challenging to adopt this more problem–intervention-based methodology for charting ORDER MANAGEMENT ● To understand the EHR’s real impact on order management, one first has to start with an understanding of the previous paper-based order management system ● The first hospital systems focused on clerk order entry to mitigate the rewriting of physician orders onto requisitions. Having clerks enter these orders into a core system that would then route the orders to the appropriate system (e.g., laboratory, radiology, or, less often, pharmacy) ofered at least a controlled vocabulary of tests and procedures from which to choose and increased likelihood of appropriate test ordering ● To eliminate this step, a small number of hospitals in the late 1980s developed computerized provider order entry (CPOE) modules to attach to their EMR products ● The goal of CPOE was to provide structure to physician orders and to allow for the rendering of decision support tools at the moment of ordering ● The development of CPOE in subsequent years has been to extend the tools of standardized vocabulary and passive and active decision support to all areas of physician ordering (described more fully in Chapter 15). This development came to include areas such as medication ordering and study ordering, and it went on to cover specific directions to nurses for bedside care ● The other key distinguishing feature of CPOE is that it ensures that the correct provider received the result
CPOE AND MEDICATION ORDERING IN THE EHR
● Medication ordering is a unique subset of orders that has received the most attention because most sources identify medication management as the most error-prone element of both inpatient and ambulatory care ● It is the best described and represents the largest penetration of CPOE in the inpatient environment Complete order life cycle for medications in an inpatient EHR INPATIENT DRUG ORDERS ● The physician initiates the order, entering a series of discrete elements such as dose, frequency, route, priority (e.g., “stat”), start and stop times, and other key instructions picked from a structured drug dictionary ● Sent across an interface, the order is received in a work queue by a pharmacist, who might see additional alerts to help him or her determine the clinical safety and validity of an order ● Within their own pharmacy systems, pharmacists are oten in a position to modify the order according to local policy or on drug availability, provided that it is an approved therapeutic equivalent to the original order ● In a small percentage of hospitals, the order goes forward to a medication administration system ater validation ● The system then provides the bedside nurses with an active work list of medications to be administered—the medication administration record ● In combination with a bar coding system to identify the patient and the medication to be administered, the administration is checked for correctness of time, patient, route, dose, and frequency one more time ● This step of checking the administration one more time before drug administration reduces the risk of preventable adverse drug events ● Finally, in some systems, the loop is fully closed as documentation of the medication administration is passed to another view for the physician provider so that he or she can see the precise time at which the medication was given ● In this manner, the EHR leverages the use of structured terminology, decision support at the
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time of ordering, and validation to improve the safety of the order and the quality of the documentation OUTPATIENT DRUG ORDERS ● The life cycle of a medication order in an ambulatory EHR replicates many of the physician ordering steps, but often has a diferent fate when it is sent to an outpatient pharmacy ● The ambulatory physician must consider not only the medication dosage information, but also whether a given medication is covered by the patient’s insurance ● It is much less likely that the ambulatory medication order will be transmitted directly to a pharmacy, so a paper or facsimile intermediary is produced ● Increasingly, the U.S. government is interested in promoting electronic prescribing with physician order entry as well as direct links to pharmacies. ● The EHR plays a role because it has the capacity to maintain the patient’s inancial information in a structured format as well as the list of preferred pharmacies to promote electronic transmission DECISION SUPPORT ● A growing body of literature examines the unintended consequences of provider order entry, such as new work for clinicians, unfavorable work lows, new errors through the presentation of inconsistent data, and impaired communication between co-workers because of excess reliance on computerized communication SECONDARY USE OF THE EHR TO PROMOTE QUALITY ● Now that the functional components of the electronic record have been deined, it is vital to understand the way in which the record has come to be used to drive forward initiatives in overall quality of care. ● Much as in clinical decision support associated with medication ordering, the judicious use of alerts and reminders is intended to prompt the physician to take action (to order) in a manner consistent with established, evidence-based guidelines ● These schema have been well studied in the ambulatory arena where key quality indicators exist in the domain of cancer screening, glycemic management for persons with diabetes, and lipid management for those with coronary artery disease ● On a more global level, the record provides an aggregation of all care delivered and can target speciic providers or practices that appear to be delivering care less consistent with national guidelines ● Many institutions embark on the creation of a “clinical data warehouse” to capture all clinical data derived from an electronic record for later analysis ● The beneit of analyzing data after they have been moved out of the EHR is that the data can be reviewed without afecting the performance of the database used to care for patients. his also allows for merging clinical data with inancial, genomic, or other data not in the EHR ● In one review of care delivered at ambulatory sites in 2003 and 2004 in which 18% of visits were associated with an EHR, no statistical diference was found in 14 of 17 nationally established quality indicators between visits with and without EHR use SUMMARY ● The EHR is now the established communication tool for healthcare delivery in the twentyirst century ● Electronic health records are based on structured healthcare terminology, accommodate the practices of documentation and provider–provider and patient–provider communication, and provide for order management ● To date, the EHR has a proven track record of improving medication safety and record accuracy, legibility, and completeness
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PHARMACY INFORMATICS
The use and integration of data, information, knowledge, technology, and automation in the medication process for the purpose of improving health outcomes 10 FACTS ABOUT PHARMACY INFORMATICS According to University of Illinois Chicago
- The Healthcare Information and Management Systems Society (HIMSS) defines pharmacy informatics as “the scientific field that focuses on medication-related data and knowledge within the continuum of healthcare systems - including its acquisition, storage, analysis, use and dissemination”
- The American Society of Health-System Pharmacists describes the clinical informatics pharmacist as “an expert in human factors, patient safety, and the use of technology to optimize care delivery processes and effectively communicate patient care activity”
- A thorough understanding of the pharmacy technology language used by National Council for Prescription Drug Programs (NCPDP) is essential for success in a pharmacy career in the health informatics field
- Pharmacy informatics play an important role in achieving the goals of many of their high-level colleagues including the Chief Medical Information Officer (CMID), pharmacy director, pharmacy operations manager, medical safety leaders, and physician informaticists
- Examples of pharmacy informatics include Computerized Provider Order Entry (CPOE), e-prescribing, telepharmacy, bedside barcoding, electronic medication administration records (eMARs), automated dispensing cabinets, inventory management systems, smart pumps and robotic IV automation
- Several Stage 2 requirements for meaningful use relate to medication use, including CPOE, clinical decision support, patient access to personal pharmacy records, and medication order tracking
- While most providers have embraced e-prescribing, it does not mean that the pharmacy on the receiving end has processed the prescription electronically. Many pharmacies receive electronic prescriptions via fax because it is less expensive 8. Becoming fluent in reporting analytics is a powerful measure of success for pharmacy informatics who want to valid results within their respective pharmacy operation. This includes metrics related to pharmacy data, clinical data, cost data, and functional data that can be applied to improve clinical outcomes, cost control, and overall system usage 9. Pharmacy informatics are improving medication use and patient safety by making it easier for prescribers to reduce patient risk by providing layers of data related to prescribing habits, patient compliance, drug equivalents, and cost-savings potential 10. Intelligent pills that can deliver targeted drug therapy to specific areas of the body, monitor the body’s environment (e.g, pH levels, temperature), and otherwise support informatics efforts by transmitting data via wireless technology. Other pharmacy technologies like mobile apps, sensors on medication caps, and skin patches can also gather patient information send it out to their care team via the cloud
