Special Topics in Vendor-Specific Systems: EHR Functionality

Audio Transcript

Slide 1: EHR Functionality

This lecture is for Component 14, Special Topics in Vendor-Specific Systems.
Unit 4 is on Electronic Health Record Functionality. Electronic Health Records
EHRs provide functionality that is important to clinical care. Many of these
functionalities are critical to ensure safe and efficient care of patients.

Slide 2: Lecture Objectives

At the end of this lecture you will be able to describe five EHR functionalities.
These are: results review, computerized provider order entry (CPOE),
documentation, messaging among different vendor systems, and billing
supported by EHR vendor systems.

Slide 3: Outline
During this lecture we will define and discuss the EHR functionalities of results
review, computerized provider order entry, the various forms and types of
documentation, billing, and messaging.

Slide 4: Results Review

Results review functionality within an electronic health record refers to the
reviewing of results for laboratory tests as well as imaging tests. In the clinical
setting, laboratory tests are drawn and collected by a clinician and sent to the
laboratory to be processed. The results of that laboratory test are entered into the
laboratory information system which links to the electronic health record to
display the result to the clinician. Examples of laboratories include bacterial
cultures, complete blood cell counts, and the monitoring of therapeutic drug
levels. Imaging results are processed in the EHR in a similar way. The results of
imaging tests and studies, such as radiology reports and x-ray, CAT scan, and
MRI images, are linked from the radiology imaging information system into the
electronic health record to be viewed by a clinician. The imaging information
system uses picture archiving communication system, or PACS, which processes
and manages digital radiography. There may be differences in how different
EHRs present results for review by clinicians. Some systems have different
processes to notify a clinician of a critical lab result. If the lab result is abnormally
high or abnormally low, then there may be functionality within the EHR to alert
the clinician. Additionally, the format for presented results may differ. Results may
be presented in a table or a flow sheet format, which may show all of the
laboratory test and imaging results at one point in time. An alternative view is a
graph that displays the trend for one type of laboratory value. This view allows
the clinicians to assess how one particular laboratory value has changed

Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems

Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
overtime. Some vendor systems may have the functionality to display results in
multiple formats and allow the clinician to choose their preference.

Slide 5: Computerized Provider Order Entry (CPOE)

Computerized Provider Order Entry, which is also referred to as CPOE is another
functionality within the electronic health record. The American Hospital
Association definition of CPOE is: a system used for direct entry of one or more
types of orders by a provider into a system that transmits those orders
electronically to the appropriate department. An example of the use of CPOE is
ordering medications. A physician orders a medication for a hospitalized patient
using the CPOE system. Next, the information is transmitted to the pharmacy for
processing and is then delivered to the hospital floor in which the patient is
located. When the nurse administers the medication to the patient he or she will
document it as administered in the EHR. Other types of orders that may be
entered into a CPOE system are nursing orders, laboratory orders, radiology or
imaging orders, provider referrals, blood bank orders, physical therapy or
occupational therapy orders, respiratory therapy orders, rehabilitation therapy,
dialysis orders, provider consults and discharge and transfer orders.

Slide 6: CPOE (cont.)

CPOE is an important functionality of electronic health record. It has been shown
to have the potential to alleviate many different patient safety problems by
limiting illegible handwriting of medication and medication doses, the use of
dangerous abbreviations and verbal orders which may be misinterpreted, and
transcription errors from handwriting an order from one clinical document to
another. The Joint Commission has issued a do not use list of dangerous
abbreviations and these should not be part of any CPOE system. Verbal orders
typically occur during a telephone call between a nurse and a physician when a
physician is not present on the patient care floor. CPOE prevents verbal orders
because it allows a provider to electronically enter an order from any location in
which they can access the electronic health record. However, these workflow
changes may have some unintended consequences on patient care. CPOE
systems often present lists of patients or medication for a clinician to select from.
In a busy clinical environment, which is often rich with distractions, a clinician
may inadvertently select the wrong patient, the wrong medication, or the wrong
medication dose from a list. Additionally, the implementation of CPOE drastically
changes the clinical workflow. The ability of a physician to enter an order from
any location within or outside of the hospital or clinic setting may decrease
communication between clinical disciplines by limiting the opportunity for face-to-
face discussions to occur. Different EHRs will also have different workflow
configurations for interfaces with other systems, such as separate labs and
imaging systems. The interfaces attempt to provide the user with a seamless
workflow for viewing and entering data.

Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems

Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
Slide 7: CPOE: Vendor System Differences
Vendor systems may have different CPOE online formularies. A formulary is a
list of medications that reflects the medications that are available from a hospital
or clinic pharmacy. ePrescribing is closely related to CPOE. It is a functionality
for ambulatory or clinic settings that allows a provider to electronically prescribe a
medication. The prescription is electronically transmitted to the patients
pharmacy. An ePrescribing system may have a formulary of the medications that
are covered by the patient's health insurance.

Slide 8: CPOE: Vendor System Differences (cont.)

CPOE systems may also differ by the types of decision support functionalities.
Some systems may provide medication dosing recommendations and
calculations. Often these calculations are based on a patients weight or
laboratory values. A CPOE system may have customized order sets based on a
patients diagnosis. For example, an order set for a patient diagnosed with
pneumonia may indicate specific laboratory tests and x-rays that should be
performed and medications that should be prescribed. Some systems may have
bar coding scanning technology to decrease medication errors during the
medication administration process. A medication order entered into the CPOE
system is electronically transmitted to the pharmacy. When the pharmacy
processes that order, a bar code will be printed out and placed on the
medications packaging. When the nurse administers the medication to the
patient he or she will scan the bar code on the medication and scan the patient's
ID band. The system will verify that it is the correct medication for the correct
patient. Another form of decision support is alerts. For a patient with an allergy to
penicillin, an alert will be displayed if the clinician attempts to prescribe Penicillin.
A similar type of alert is drug interaction checking. There are instances in which
two drugs should not be prescribed together because the combination may
cause side effects or an adverse reaction. The system will check all of a patients
medication prescriptions to ensure that none of them interact with each other. A
final type of alert is one that we discussed earlier, laboratory alerts. If a laboratory
value is critically abnormal the system will notify the clinician of the value so that
he or she can take action. Vendor systems may have different functionalities to
support the medication reconciliation process. Reconciling a patients
medications at each transition of care is a Joint Commission requirement. This
means that when a patient is admitted to the hospital the provider checks to
make sure that the medications that the patient had been taken at home are also
ordered, as clinically appropriate, for the patient while they are in the hospital.
This process should be performed throughout the patients hospital stay, at
discharge from the hospital and during other health care encounters.

Slide 9: CPOE
CPOE functionalities within an electronic health record are an essential part of
meaningful use criteria. In the non-hospital setting, such as outpatient or
Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems
Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
ambulatory clinics, to be deemed a meaningful user of electronic health records
CPOE must be used for at least 80 percent of all orders and ePrescribing must
be used for at least 75 percent of all orders. Within the hospital setting, it's
required that CPOE is used for at least 10 percent of all orders. And as
mentioned in the previous slide, medication reconciliation is required to be
performed for at least 80 percent of relevant encounters and transitions of care.

Slide 10: Documentation: Multiple Disciplines

Now we are going to talk about documentation functionalities within the electronic
health record. Documentation is used by multiple disciplines including physicians,
nurses, social workers, physical therapists, respiratory therapists, as well as
other types of clinicians.

Slide 11: Documentation: Electronic Capture of Clinical Information

Documentation within the electronic health record is the electronic capture of
clinical information. One type of this is a clinical note, such as a visit note written
by a primary care provider about a patients visit in an outpatient setting. Another
example of a clinical note is a discharge summary written by a provider when a
patient is being discharged from the hospital. A third example of a clinical note is
the pre-operative note written for a surgical patient before they have surgery.
Another type of documentation is a patient assessment such as a vital sign
flowsheet where the patients vitals signs such as blood pressure and heart rate
are entered. Clinical reports are a third type of documentation. An example of a
report is the medication administration record, and this is a record of all of the
medications that have been administered to a patient. Finally, documentation
includes a patient's advanced directive and any informed consent forms that they
may have signed for various procedures or inpatient admissions. This information
may be paper based and scanned into the electronic health record.

Slide 12: Documentation: Methods of Information Capture

We just discussed the different types of documentation, and now we will discuss
the three different methods for representing clinical documentation within the
electronic health record. The first is unstructured information. Unstructured
information refers to narrative free text notes written by a clinician. The second
method of representing clinical documentation is semi-structured. This refers to
notes that have structured headings followed by free text entry. For example, a
clinician may write a progress note on a patient during their stay within the
hospital and it may have a heading for the patient assessment, below which the
clinician may type a narrative description of the patient's assessment information.
Finally, information may be represented in a completely structured format, such
as checkboxes. For example, on the medication administration record the nurse
checks off if a patient received a medication. Flow sheets are another example
of structured documentation. A vital sign flowsheet is a grid of vital sign
measurements such as blood pressure and heart rate. The rows indicate the type

Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems

Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
of vital sign and the columns indicate the time a vital sign measurement was
taken.

Slide 13: Documentation: Potential Barriers to Implementation

Documentation within the electronic health record may have some potential
implementation barriers related to workflow implications. Documenting in an
electronic health record, as opposed to on paper, may increase the amount of
time required for documentation. Additionally, the overuse of structured data or
poorly structured data may lead to inaccurate data selections for a patient that
may persist within a patients electronic record.

Slide 14: Documentation: Vendor System Differences

Vendor systems offer a variety of options for creating clinical notes. Some
systems provide semi-structured templates for note generation. A template may
be designed for use by a specific clinical discipline such as physicians or nurses,
or it may be for a specific specialty. For instance, a template for a note for a
dialysis clinic visit will include different information than a patient visit at an
orthopedic clinic. Additionally, notes templates may be specific to the type of
procedure or care given. For example, when administering blood products to a
patient a nurse will complete a blood administration note and upon admission of
a patient to the hospital a nurse will complete a hospital admission note. Some
vendor systems include macros. Macros are a functionality that allows clinician to
use a combination of keystrokes to generate user-predefined text. For example,
a physician may not want to type out all of the required information to state that a
patient's neurological exam was normal because this is a lot of extra typing for a
large volume of patients. Therefore, the physician can use a macro to generate
text that states: "The neurological exam is within normal limits. The patient is
alert and oriented to person, place, and time". Some vendor systems may have
voice recognition software and embedded dictation functionalities which allow the
clinicians recorded voice to be automatically transcribed into text that generates
a semi-structured note. Additionally, some electronic health records have a copy
and paste function. For example, this functionality will allow a clinician to copy
and paste a patient's past medical history from a previous note into his or her
current note instead of typing the same unchanged information again. Finally,
structured documentation within the electronic health record may have tailored
assessments. A structured assessment tool may be presented to the clinician for
a clinical issue such as assessing neurological status or a patients risk for falling,
and using this information the EHR may generate a clinical note.

Slide 15: Legal Issues

There are legal issues related to the information entered into the electronic health
records and if it is considered a part of the legal health record. The discovery of
information within the electronic health record for legal purposes has been
defined by the Centers for Medicare and Medicaid and The Joint Commission.

Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems

Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
The HIPAA Privacy and Security Rules which are enforced by the Office for Civil
Rights, states that organizations are responsible for identifying the designated
legal record set. This definition is applied to all patients who receive care at that
organization. The criteria for designating information within the electronic health
record as being a part of the legal health record is how that information was used
in providing care for the patient, not where it actually resides within the electronic
health record.

Slide 16: Billing

Billing is also an important functionality with electronic health records. All vendor
systems support the codes that are used for billing purposes. These codes are
ICD-9-CM codes, which stands for the International Classification of Diseases,
9th Revision, and Clinical Modifications. The transition to ICD-10 codes, referring
to the 10th Revision, has been delayed beyond the previously established
deadline of October 2013 and as of February 2012 a new deadline has not yet
been announced. ICD-10 coding consists of ICD-10-CM Diagnosis codes, and
ICD-10-PCS, the procedure coding system. Another type of codes are CPT
codes, or Current Procedural Terminology codes. We will discuss these codes in
more detail in the following slide.

Slide 17: Billing

Professional billing is done by providers such as physicians and nurse
practitioners. These providers use of ICD-9 codes and CPT codes. For example,
within a hospital discharge summary or an outpatient visit note, a provider will
enter an ICD-9 code that is specific to the patients diagnosis. CPT codes are
used to bill for procedures, such as surgery, or the level of evaluation and
management performed by the provider in the outpatient setting. Hospital billing,
such as for supplies used during surgery, is done using ICD-9-CM. After the
transition to ICD-10, hospital billing will be done using ICD-10-PCS codes, but,
as of February 2012, a deadline for the transition to ICD-10 has not yet been
announced.

Slide 18: Messaging

The last functionality that we are going to talk about today is messaging internally
within the EHR. An EHR may provide internal e-mail for clinicians and staff and
secure e-mail between providers and patients. Additionally, an electronic health
records may allow a clinician to send a text page to another clinician through the
EHR. Furthermore, an EHR may support interoffice group communication
messages.

Slide 19: Messaging (cont.)

Additionally, an EHR may allow a provider to copy a patients chart or laboratory
results or an x-ray image and send those results to another provider with a note.
Telephone messages may be documented within the EHR. Scheduling of patient
Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems
Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
appointments may be supported by the EHR. Additionally, a provider may attach
a referral letter or a consultation report to a message to be sent to the
appropriate provider. Finally, an EHR may generate messages for patient follow-
up deficiency alerts for patients that have not made an appointment for a follow-
up appointment or routine checkup.

Slide 20: Summary

In summary, we discussed five important functions that EHRs perform. These
were: results review, CPOE, documentation, messaging, and billing. WE
discussed the implications of many of the functionalities on clinical care. As you
learn more about these functionalities it is important to consider their impact
on clinical workflow, patient safety, information retrieval, legal issues, billing, and
communication.

Slide 21: References

No audio.

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Health IT Workforce Curriculum Special Topics in Vendor-Specific Systems

Version 3.0 / Spring 2012 EHR Functionality

This material (Comp14_Unit4) was developed by Columbia University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.