3rd edition electronic guide health organization practical professional record

The implementation team can help minimize time spent on data entry by thoughtfully triaging work away from the physician when developing new workflows see Expanded Rooming and Discharge Protocols module. Setting expectations about the new workflows see Expanded Rooming and Discharge Protocols module will benefit the care team in the long run and help them transition more smoothly to the EHR.

If our needs are too complicated for practice staff to manage, where else can we find help? RECs provide education, outreach and technical assistance to physicians in their service areas and help them implement and demonstrate meaningful use of certified EHR technology. Employ consultants who can guide practice leadership to make thoughtful decisions. Practice leadership can ask colleagues for referrals and recommendations to find the right consultants. EHR software can be modified to create specialty- or physician-specific templates, which are used to support documentation.

Discuss customization options and cost with your EHR vendor. Quiz Ref ID The right hardware can save an organization time and money.

Some clinics find that a printer in every room saves 30 minutes of physician time per day and a large monitor saves 20 minutes of physician time per day. Furthermore, some practices reduce the time spent logging into the system multiple times each day by providing every worker with their own laptop or tablet to carry from room to room.

System hardware i. Physician practices may hire an IT service company to help them with their system hardware needs. Typically, IT service companies are independent from the EHR vendor and may not even specialize in the health care industry.

Both the IT service company and EHR vendor can be helpful in finding the right equipment at the best possible price. The IT service company may also supply, install and troubleshoot all devices, including the local area network and routers.

What should I look for in an IT service company? It is ideal to select an IT service company that can monitor the system remotely to detect problems before they become critical. Ask colleagues about the IT support company that they use. They may be able to make a referral and confirm that your rate is competitive. A practice can assign existing staff to assist with this process. Prepare a checklist of items to be entered into the EHR. This will ensure that no critical information is missed during the transfer.

Establish the amount of time required to transfer information for the average patient. This can help the practice properly distribute workload and set realistic dates of completion among staff transferring data.

Do I need to transfer all paper documentation into the EHR? During implementation, should the practice create paper duplicates of clinical records? Creating two repositories for medical information will only create more work. It will also lead to confusion because of the lack of version control, as some information may be available on paper that may not be available in the EHR or vice versa. If the practice team is uncomfortable using the EHR for daily clinic tasks, invest time in designing and practicing future patient encounters and other important workflows.

This will help the physician and staff gain comfort with the new EHR without the fear of something falling through the cracks. It is best to optimize workflows before EHR implementation. Does this require the skills and training of a physician? See the Expanded Rooming and Discharge Protocols and Team Documentation modules for more ideas about task-sharing with the clinical team. Placement of the computer in the exam room impacts patient care. If the staff and physician must look over their shoulder to see the patient while using the computer, patient communication and engagement suffer.

One way to create this triangular configuration is to use a semicircular desk, which allows the patient and physician to face each other and, as needed, to each turn slightly and include the electronic information source in their discussion. Another option is to place the computer on a cart that can be wheeled into a position anywhere in the exam room to accommodate patient and physician communication. This has the advantage of minimizing the time spent managing both a paper record and the new electronic system simultaneously.

It can also be highly disruptive and small glitches can be amplified. Other practices implement their EHR incrementally, turning on certain functions in a step-wise approach i.

Another incremental approach is to implement the EHR in certain sites or departments and slowly roll out to the rest of the organization, learning and tweaking the process along the way see Table 2. Once physicians and staff decide on the launch approach, they can begin to acclimate to the new system in the practice.

Different implementation strategies can be used depending on the approach see Table 3. Comparison of the immediate and incremental approaches to EHR implementation. Strategies for immediate and incremental EHR implementation. Can you give an example of an EHR implemented according to visit type? A multispecialty practice or a practice that cares for obstetric patients may use the EHR only for new patients for the first week.

The second week, they may expand to using the EHR for all patients. Can you give an example of an EHR implemented according to the number of patient visits per day? On the first day of implementation, the practice may use the EHR for the first patient every hour and use the EHR for the entire visit from check-in to check-out. After the first day, they may increase the number patients being entered into the system to two per hour. Starting the second week, the practice may feel comfortable using the EHR for all patients in the morning session and could use a hybrid system during the afternoon session.

By the third week, the practice should feel comfortable enough to document all patient visits in the EHR. How can I ensure that patients understand the changes in the practice? Communicate with your patients about changes in the practice. They will appreciate the transparency.

For example, staff can contact the patient and let them know to arrive a few minutes early for their appointment and that the visit may be lengthier than they are used to because staff are still getting acclimated to the EHR. Setting expectations prior to a visit lets patients plan ahead and prepare for any delays. In addition, some practices provide informational brochures or place signs in the office to increase awareness about changes in the practice and how they impact the patient.

I am interested in the incremental approach. Which EHR functions should I start with? Typically, physician practices that choose the incremental approach start with a specific function such as: Physician orders e.

Physician visit documentation e. Certain modules or functions should always be implemented at the same time to reduce or eliminate confusion among physicians and staff. For example, staff can enter all referrals and phone calls into the EHR. This ensures that all information is centralized in one location. Similarly, the e-prescribing module should be used for all patients when activated.

We anticipate that the launch will be stressful despite our best efforts. Is there anything else we can do to make it easier? For the first week or two of launch, it is helpful to have super users or vendor-supplied trainers in every clinical area to answer questions.

If possible, decrease physician schedules for the first few weeks following go-live to allow the physician and care team to adjust to the new system without having a negative impact on the quality of care they are giving to patients. Super users can have scheduled monthly check-ins with the team for the first year after implementation to help the physicians and staff acclimate and improve over time.

Despite the higher interoperability of EHR data and standardization of phenotyping protocols, fine details of EHR data may affect the selection results. Some of the challenges include: Process of Care : different providers or clinical workflows generate different data values for the same event or fact; hence, the same fact or event might be represented differently in the same EHR.

Nature of Intervention : different interventions with different levels of risk may be encoded similarly, meaning EHR does not contain the true risk factors for those interventions. As a basic good practice, registries should use some form of data curation to review and assess data quality.

In the context of EHR-based registries, data quality issues stem from the fact that data extracted from EHRs often requires extensive cleaning and preparation before being imported into registries. EHRs are designed to manage the transaction of healthcare and support clinical workflow and documentation for billing.

The purpose of an EHR is not to conduct research, and EHRs are not designed to systemically collect research-grade longitudinal data. As a result, data captured by EHRs are of variable quality. Thus, EHR data may not be appropriate for some research purposes. Data quality can be defined in various perspectives. The most impactful aspects of data quality for registries are: 14 Accuracy: the extent to which data captured in EHR accurately reflects the state of interest, which is often complex to measure because the true value of a given variable remains unknown.

Completeness : the level of missing data for a particular data element in the EHR for the population of interest; this is commonly measured as a data quality indicator for EHR-integrated registries. Timeliness: the length of time between the initial capture of a value and the time the value becomes available in the EHR. It is important to note that data quality varies across EHRs used by different healthcare organizations. For example, upgrades intended to improve performance or add features may inadvertently result in poor record linkage or may require updating record extraction protocols.

Evaluating data quality, completeness and accuracy should be conducted as an on-going process and not a one-time exercise. EHRs contain a considerable amount of unstructured data, such as progress notes.

The unstructured data may contain key patient information missing in structured data, extra information complementing structured data, or even data that may contradict information represented by structured data.

The complexities of unstructured data, along with the fact that existing text mining tools and natural language processing applications have limited accuracy in extracting information from free text, 67 have prompted some registries to ask for a manual chart review of individual patients before final inclusion in the registry.

Unstructured data limits the application of automated computational phenotyping methods and increases the likelihood of low data quality e. Many EHRs also allow a choice of places where important data may be entered. Interoperability is defined as the ability of a system to exchange electronic health information with, and use electronic health information from other systems without special effort on the part of the user. Lack of interoperability is a major limiting factor for the extraction, integration, and linkage of EHR data for registries.

Most EHRs are not fully interoperable in the core functions that would enable them to participate in various registries without a significant effort. Data sharing and interoperability challenges are not limited to incoming EHR data for a registry. In a learning health system, a bidirectional registry shares its findings with providers that have shared their EHR data.

In such a reciprocal model, the findings are turned into knowledge and can effectively be used to change the delivery of care and improve outcomes across all participating providers.

Currently, there are no common standards on how to distribute registry findings while protecting the identity of individual healthcare providers.

Sharing the findings about data quality issues with data providers is challenging as well as it may result in legal ramifications e. Linking and integrating various EHR data sources for registries also requires matching patients across databases. Developing and utilizing an MPI is a complex process and may introduce error and bias in registries despite many tools being available to accomplish this process. EHRs may provide IT infrastructure and tools to support the development of an EHR-based registry, but they typically do not provide turnkey solutions for functional registries.

Over the last decade, a variety of EHR tools have been developed that could form the building blocks of EHR-based registries. These system-wide data warehouses often serve as the backbone of data products that eventually support an EHR-integrated registry see Chapter 2.

However, challenges with updating, maintaining, scaling, and sharing such tools across healthcare providers still hinders development of registries. In addition, the architecture of an EHR deployment within a healthcare delivery system may influence the usefulness of EHR for different registry applications. For example, a health system that lacks an enterprise-level EHR architecture may find it challenging to develop a system-wide EHR-integrated registry, as each of its entities operates a standalone EHR with no interoperable solution to share data among them.

Data access and privacy challenges are complex in multi-site EHR-based registries. Data sharing is an additional concern in the context of EHR-based registries.

Decisions must be made about whether a single institutional review board IRB will suffice or whether all sites will require local IRB approval. Governance is also challenging as the rules around sharing of data identifiable or de-identified vary depending on the organizations involved and the purpose of the research.

Scientific — what question is important? Research design — how do we answer the question? Clinical — do the data mean what we think they mean? Informatics — do the data maintain their epistemological integrity from clinical collection to analysis? Information technology IT — how do we curate and manage the data? Statistics and epidemiology — how do we answer the question with the data obtained?

In addition, although EHRs may offer cost-effective solutions for registry use, the need to capture comprehensive data for registries may counter this cost-effectiveness balance e. Assuming that all data objectives for a registry can be met within an EHR, data collection for EHR-based registries hypothetically could be achieved at the time of a clinical encounter, thus reducing the cost of data collection; however, this has yet to be achieved on a widespread basis.

These include challenges with collecting patient consent within clinical workflows, incorporating patient-reported data, and safeguarding the security of the data. Some international registries are derived from national data collected in the context of national health insurance programs. In the Nordic countries, the unique constellation of universal coverage, a network of population-wide registries and databases, and individual-level linkage 72 make registries optimally suited for observational medical research in multiple clinical domains 73 and, increasingly for pragmatic trials.

For example, Nordic countries maintain a wide network of continuously updated databases, which collectively cover most health events, which can be linked on individual level in combinations dictated by the needs of a given study. The data undergo a set of built-in data checks before being available for research. In some instances, additional data are linked e.

All patients registered with the participating practices, regardless of their disease, are included in the resulting dataset as long as they are enrolled in a participating practice. Similarly, routine records are also being collected in some form in many countries in Europe though generally with less national coverage than in England, with non-exhaustive list including Netherlands, 78 , 79 Italy, 79 , 80 Scotland, 81 Germany, 82 France, 83 and Spain.

The true promise of EHRs for registries is in facilitating the achievement of a practical, scalable, and efficient means of collecting registry data for multiple purposes. Scalability constraints on patient registries can be dramatically reduced by using digitized information. Despite the challenges and barriers of using EHRs for registries, EHRs will likely play a key role in expanding and developing existing and future registries.

Multiple factors are poised to increase the role of EHRs in registries in the near future such as: increasing adoption of light-weight and efficient interoperability standards e. EHRs can be linked or integrated with registries in many formats or various purposes. Future research should focus on developing and disseminating additional guidelines and technical documentations about registry integration with EHRs for public use.

Finally, achieving a fully interoperable EHR-based registry, so that EHRs and patient registries function seamlessly with one another, is unlikely to be accomplished in the near future.

This chapter uses both terms interchangeably. All rights reserved. The Agency for Healthcare Research and Quality AHRQ permits members of the public to reproduce, redistribute, publicly display, and incorporate this work into other materials provided that it must be reproduced without any changes to the work or portions thereof, except as permitted as fair use under the U.

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When parts of this work are used or quoted, the following citation should be used:. Turn recording back on. National Center for Biotechnology Information , U. Search term. Introduction There is growing interest in using data captured in electronic health records EHRs for patient registries. Patient Identifiers EHRs are designed to facilitate the identification of individual patients in clinical workflows. Diagnoses Diagnosis often is a key variable to evaluate a patient for inclusion in a registry.

Medications In addition to diagnosis, registries often use medication data as eligibility criteria. Procedures Procedure data include clinical procedures such as surgery, radiology, pathology, and laboratory. Laboratory Data Currently, the best sources of laboratory data are the information systems used by standalone laboratories, which are frequently but not always incorporated into the EHR.

Vital Signs EHRs are a primary source of vital sign data. Surveys Survey data are usually collected from self-reported questionnaires; however, clinical data captured by surveys are increasingly stored within EHRs for various purposes.

Social Data Social data include variables ranging from individual-level factors to community-level elements e. Patient-Generated Data Patient-generated data can include a wide array of variables e. Figure Common architecture of EHR-integrated registries to support clinical care.

Technical Issues and Operational Challenges of EHR-Based Registries EHR-based registries fulfill different purposes and use different IT system architectures, but many technical issues and operational challenges are common across the range of registries. Identifying Eligible Patients Retrieval protocols and phenotyping methods are commonly applied against EHR data to define the denominator of interest and identify eligible patients for screening, clinical trials, and inclusion in registries.

Data Quality As a basic good practice, registries should use some form of data curation to review and assess data quality. Unstructured Data EHRs contain a considerable amount of unstructured data, such as progress notes. Interoperability Interoperability is defined as the ability of a system to exchange electronic health information with, and use electronic health information from other systems without special effort on the part of the user.

International Perspective on EHR-Based Registries Some international registries are derived from national data collected in the context of national health insurance programs. The Future of EHR-Based Registries The true promise of EHRs for registries is in facilitating the achievement of a practical, scalable, and efficient means of collecting registry data for multiple purposes.

References for Chapter 4 1. Third edition. Two volumes. April Institute of Medicine of the National Academies; Third ed. Online Journal of Public Health Informatics. PMID: DOI: Accessed August 15, Meaningful Use. Core Data for Interoperability. Version 1. Accessed June 18, Patient Identification and Matching: Final Report. Part Security and Privacy. Accessed August 16, Am J Manag Care. Fed Regist. Medicare Learning Network. December 21, Review: electronic health records and the reliability and validity of quality measures: a review of the literature.

Med Care Res Rev. Within this context, the main objectives of this document are as follows: To generate knowledge related to information systems and immunization registries for immunization program managers at the national and subnational levels; »» To provide teams, EPI managers, and experts in health information systems with relevant background and experiences for development, implementation, maintenance, monitoring, and evaluation of EIR systems, so as to support planning of their implementation; »» To provide technical, functional, and operational recommendations that can serve as a basis for discussion and analysis of the standard requirements needed for development and implementation of EIRs in countries of the Region of the Americas and other regions; »» To serve as a platform for documentation and sharing of lessons learned and successful experiences in EIR implementation.

This document is structured into three major sections: background; EIR planning and design; and EIR development and implementation, taking into account the relevant processes and their structure. The content of the chapters is supported by a literature review of aspects related to EIR requirements, and summarizes the experiences of the countries of the Region of the Americas and other regions that already have EIRs in place or are at the development and implementation stage.

Citation Pan American Health Organization. Washington, D. Related items Showing items related by title, author, creator and subject.