chapter 5. clinical information systems ◦ electronic health record/electronic medical record ◦...

Current and Emerging Use of Clinical Information

SystemsChapter 5

Outline Clinical Information Systems

◦ Electronic health record/Electronic medical record

◦ Computerized provider order entry◦ Medication Administration◦ Telehealth and Telemedicine

Definition and Functions Current Use of Systems Factors Influencing Adoption Value of Systems Barriers to Diffusion

EMR Adoption in Hospitals

Adoption of EHR Meaningful Use of Electronic Health

Records, April 2011 through May 2012.

Electronic Medical Record MRI Five Levels of Computerization

◦ Level 1: Automated Medical Record◦ Level 2: Computerized Medical Record System◦ Level 3: Electronic Medical Record◦ Level 4: Electronic Patient Record◦ Level 5: Electronic Health Record

Five Levels of Computerization (Figure 5.1)

Value of EMR Improved quality, outcomes and safety

◦ Computerized reminders and alerts◦ Improved compliance with practice guidelines◦ Reduction in medical errors

Improved efficiency, productivity, and cost reduction

Value of EMR continued Improved service and satisfaction

◦ Patient satisfaction ◦ User satisfaction◦ Less stress◦ Improved job satisfaction◦ Quality of documentation

Other major types of CIS Computerized provider order entry (CPOE) Medication administration using barcoding Telemedicine Telehealth—for our purposes, we will focus

on online communication (e.g. email) between patients and providers

Computerized Provider Order Entry, at its most basic level, is a computer application that accepts physicians orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians with decision-support capabilities at the point of ordering.

CPOE

Electronic entry of physician orders and instructions for treatment

Order entry at point-of-care or off site Communication over a network to medical

staff Integration of various departments

(radiology, laboratory, etc..)

What is CPOE?

(Wikipedia, 2010)

Replacer of hand-written orders Immediate alerting of allergies or

contraindications at point of entry Real-time clinical decision support Supports access to patient data

What is CPOE, continued

(Open Clinical, 2006)

Desktop Computer Laptop Computer on Wheels PDA (Personal Digital Assistant) PALM Pilot

CPOE Hardware

Provider Order System Multiple manufacturers• Cerner • McKesson• Eclipsys• Siemens• Quadramed• HMS• Meditech

May be coupled with Clinical Decision Support Systems (CDSS)

CPOE Software

(MedicExchange, 2010)

Offers single solution to automate workflow

Capabilities: Enter orders Check orders Document Communicate Evaluate patient status

Cerner CPOE

(Cerner Corporation, 2010)

Benefits with Cerner: Improve patient safety Save time Save money Enhance communication Reduce errors Easy-to-use

Cerner CPOE, continued

(Cerner Corporation, 2010)

Evaluated with indicators: Ease of use Ease of learning Satisfaction Efficiency of use Error tolerance Fit of system to task

CPOE Usability

(McGonigle, D. & Mastrian, K., 2009)

Most often implemented in large academic medical centers

25-27% of U.S. hospitals over 200 beds using CPOE

11.3% of U.S. hospitals actively using CPOE (physicians entering >50% of orders)

Currently 291 hospitals that use CPOE at the 100% level

Most CPOE sites also using barcode scanning

CPOE Usability, continued

(Hess, J., 2010)

Ensures standardized and complete orders Increases patient safety by reducing errors Automates workflow Supports ready access to patient data and

assessment Improves efficiency by integrating multiple

departments Provides order sets for easier use

CPOE System

(Open Clinical, 2006)

Direct entry of orders into EMR Replaces handwritten orders Cross reference for potential drug-

interactions or allergies Reduces wait times for patients Improves compliance with best practices Ready access to patient data

CPOE Advantages

(Open Clinical, 2006)

Improves patient safety Potential to improve efficiency Cost saving benefits by:

Reducing number of duplicate tests Reducing errors

Advantages, continued

(Open Clinical, 2006)

Cost User resistance Personalization for individual hospitals Potential for integration issues with other

systems Disruption of workflow with employee

training

CPOE Disadvantages

(Open Clinical, 2006)

Basic knowledge of computer usage

Three levels of competencies: Technical Utility Leadership

Informatics Competencies

Technical: Web Expert data systems Nursing and Hospital information systems Multimedia Telecommunication devices

Informatics Competencies, continued

(Kaminski, 2009)

Utility: Process of using computers and other

technology

Leadership: Ethical issues with using computers Management issues with using computers

Competencies, continued

(Kaminski, 2009)

Barriers to CPOE use Physician entry an issue Takes longer to place order; many systems

are ‘cumbersome’, take too many steps Incentives may not be aligned with use Lack of confidence in system reliability Insufficient training Mandating use – should you?

Medication administration

Use of barcoding becoming more widespread

Aids in correctly identifying patient, drug, dose, etc.

HIMSS implementation guide—good resource

More widely accepted

Has been used successfully by many health care organizations

Again, has potential to aid in making sure the right meds, get to the right patient, at the right dose…

Fitting Pieces Together(Figure 5.9)

Barriers to Adoption Financial (acquisition and support) Organizational or Behavioral (user

acceptance) Technical (need for standards, integration)

Strategies for Overcoming Barriers What strategies are being employed to help

overcome—◦ Financial barriers?◦ Behavioral barriers?◦ Technical barriers?

Summary Examined 5 different clinical information

systems—their current use, status, and value

Discussed the three major barriers to adoption of these systems—financial, behavioral and technical and strategies to overcome them