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Electronic Health Records
Overview

 

An Integrated Electronic Physician Practice


 

In 2007, 85% of
small physician practices and 75% of medium and large
physician practices in
the United States still use paper medical records. Over the next
few years, the wide-spread adoption of Electronic Health Records
across all physician practices, regardless of size, will
increasingly improve as EHRs become a necessity.

Physicians need to be more aggressive about improving both the
efficiency and the effectiveness of their practices. It is
imperative to use appropriate process improvement techniques and
technology tools. Automating a bad process only makes things worse.
Technology tools by themselves will not sufficiently improve the
care setting.

The best approach for a physician practice is to first improve
processes, where necessary, and then install  a system that would create an
Integrated Electronic Practice that addresses both the clinical and
business needs of the practice in as seamless a fashion as possible.
Most vendors have products to do both. EHR software addresses the
clinical side and Practice Management software provides tools for
the business needs of billing and collections, scheduling (patient,
provider, equipment), and productivity and revenue analysis.

The vision for the Integrated Electronic Physician Practice is to
have seamless interoperation between all offices of the physician
practice and with the systems at the practice’s affiliated
hospitals, clinics, laboratories, etc. This holistic environment
produces an up-to-date, accurate, and complete clinical picture of
the patient that enables the best quality care to be provided
regardless of where the patient is treated. It also allows the
business side of the practice to run in a more effective and
profitable manner.




Definitions


There are several terms
used for the electronic tools that replace paper medical
records. The most common ones are: Computer-based
Patient Record (CPR), Electronic Health Record (EHR),
and Electronic Medical Record (EMR). The following
definitions are contained in the EHR vs. CPR vs. EMR튉 article in the May 2003 issue of Healthcare Informatics:
     


Acronym



Term


Definition

EHR
Electronic
Health Record

Generic term for all
electronic patient care systems

CPR

Computer-based Patient Record

Lifetime patient record
that includes all information from all specialties (even
dentist, psychiatrist) and requires full
interoperability (potentially internationally)

EMR
Electronic
Medical Record

Electronic record with full
interoperability within an enterprise (hospital, clinic,
practice)


Electronic Health Records Synergy


The key to delivering
quality care and maximum profitability is
Electronic Health Records (EHRs),
where synergy is achieved by effectively integrating:

Provider/Patient, Processes, and Technology.


horizontal rule

8 Core Functions of an EHR1



Health
Information and Data

Patientsä©¡gnoses, allergies, and lab results

Results
Management

New and past test results by all clinicians involved in
treating a patient

Order
Management

Computerized entry and storage of data on all medications,
tests, and other services

Decision
Support

Electronic alerts and reminders to improve compliance with
best practices, ensure regular screenings and other
preventive practices, identify possible drug interactions,
and facilitate diagnoses and treatments

Patient
Support

Tools offering patients access to their medical records,
interactive education and the ability to do home monitoring
and testing

Administrative
Processes

Tools, including scheduling systems, that improve
administrative efficiencies and patient service


Reporting

Electronic data storage that uses uniform data standards to
enable physician offices and healthcare organizations to
comply with federal, state and private reporting
requirements in a timely manner


Electronic Communication and Connectivity

Secure and readily accessible communication among clinicians
and patients

1Key
Capabilities of an Electronic Health Record System
é¾¼br>
Institute of Medicine (IOM), July 2003


Typical Phases of an EHR Implementation



Analysis
Study healthcare provider’s work environment, including work
flow, and create
report;
Develop project plan

Selection
Use functional requirements to create a Request for Proposal
(RFP);
Establish the business case for the initiative (e.g.,
project Return on Investment [ROI] and Total Cost of
Ownership [TCO]);
Select vendors for hardware, software, and network

Procurement

Negotiate acquisition of hardware, software, and network;
Purchase hardware, software, network

Installation
Install hardware, software, network;
Fully document configurations and System Administration
functions;
Customize EHR system, as needed (e.g., additional forms and
templates);
Integrate EHR system with existing embedded system, as
needed (e.g., billing, scheduling);
Perform data conversions (e.g., paper to digital, digital
from existing system to digital of new system), as needed;
Test new environment

Training
Initially train all staff users;
Evaluate, on an ongoing basis, staff’s feature usage and
retrain/coach, as needed;
Train new staff users

Maintenance
Arrange for HELP desk for all issues (e.g., user questions,
repair, outages, new installations) with dispatch
capabilities – 24×7 (e.g., 24 hours/day, 7 days/week) or
limited, as required;
Install hardware, software, network upgrades;
Arrange for routine daily maintenance (e.g., backups,
preventive maintenance);
Develop and test disaster recovery plans


 

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