CHAPTER 14

•ELECTRONIC HEALTH RECORD•SYSTEMS: U.S FEDERAL•INITIATIVES AND PUBLIC/ PRIVATE PARTNERSHIPS

OBJECTIVES: Define the terms electronic health record(EHR-S). Summarize the history of use of health information

technology (HIT) by federal health provider communities.

Discuss how federal agencies that do not provide direct patient care play a leadership role in healthcare.

Describe the creation of the office of the National Coordination for health Information Technology(ONCHIT).

Identify key public/ private partnerships and the focus of their efforts.

KEY WORDS:

ELECTRONIC HEALTH RECORD ELECTRONIC HEALTH RECORD

SYSTEM FEDERAL AGENCIES FEDERAL HEALTHCARE

PROVIDERS PUBLIC/ PRIVATE PARTNERSHIPS

In April 2004, the president of the United States issued an executive order that called for action to put EHR in place for most Americans in 10 years.

This order gave new momentum to efforts across the healthcare community to use HIT to improve healthcare

For over a decade, the Institute of Medicine has been calling for the use of information technology(IT) to improve the efficiency, safety, and quality of the healthcare Americans receive in a series of groundbreaking reports.

OVERVIEW:

An early adopter of EHR-S, the US government is currently advancing initiatives to accelerate the use of HIT in both the public and private sectors.

Private groups have been instrumental in promoting awareness of the benefits of EHR-S architecture, messaging, and functions.

Both sectors have done considerable EHR-S innovation and some notable benchmark implementation over the past decade.

Defining Electronic Health Record System

The term EHR-S is often used interchangeably with computer and patient record, clinical information system, electronic medical record, and many others.

EHR-S reflects the broader focus on the health of the consumer or patient and indicates that the EHR-S may be used by all participants in the process of achieving health, including all discipline of clinicians, family caregivers and the patient.

By including the word system, the term forces a distinction between an EHR, which is a physical or logical(virtual) repository of data, and an EHR-S, which can be made up of one or more applications

International Organization for Standardization (ISO) had drafted its standard for EHR definition, scope and context, ISO 20514; the final version was expected in 2005 or 2006.

The IOM’s 1991 definition of computer- based patient record system is currently the basis for domestic and international definitions of an EHR-S

IOM modified this definition in its report, key capabilities of an EHR-S, reiterating the new definition in a report on patient safety. An EHR-S includes the ff.

1. Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or healthcare provided to an individual.

2. Immediate electronic access to person and population level information by authorized and only authorized, users.

3. Provision of knowledge and decision support that enhances the quality, safety, and efficiency of patient care.

4. Support of efficient processes for healthcare delivery.

Federal Initiatives

Within the federal government, different departments exert different influences toward the common goal of an EHR for most Americans.

Agencies providing direct healthcare offer evidence that the use of EHR-S across a multifacility enterprise is a realistic goal with measurable, repeatable positive outcomes.

Government as provider and early adopter

Federal agencies that provide direct care have been early adopters of EHR-S. The Veterans Health Administration in the Department of Veterans Affairs(VA) and the National Institutes of Health(NIH) in the Department of Health and Human Services(HHS) are 2 examples of the initiation systems in the 1970s that were used by clinicians

The Department of Defense and the Indian Health services in the Department of HSS both acquired the VA’s original clinical information system year ago, customizing it to meet their clinical and business needs.

Department of Veterans Affairs

The Veterans Health Information Systems and Technology Architecture(VistaA) supports day-to-day clinical and administrative operations at local VA healthcare facilities.

Computerized Patient Record System(CPRS) new interface provided a single place for healthcare providers to review and update a patient’s health record and order medications, special procedures, x-rays, nursing orders, diets, and laboratory test.

In 2004 VA began implementing MyHealtheVet as an internet tool for personal health management. It permits veterans to voluntarily interact with subsets of their VistaA health record and ultimately, manage their own personal health record

Department of Defense

Within DoD, providers have had a computerized physician order entry capability that enables them to order lab tests and radiology examinations and issue prescriptions electronically for over 10 years. In January 2004, DoD began a worldwide rollout of the next generation system, the composite health care system II (CHCS II) a secure, scalable, patient centric EHR-S.

Indian Health Services

The IHS has long been a pioneer in using computer technology to capture clinical and public health data. Its Resource and Patient Management System(RPMS) was developed in 1970s, and many facilities have access to decades of personal health information and epidemiologic data on local populations.

Office of the National Coordinator for Health Information Technology

The executive order of April 2004, mentioned earlier in the chapter, created the ONCHIT to coordinate HIT efforts in the federal sector and to collaborate with the private sector in driving HIT adoption across the healthcare system.

David Brailer MD PhD was named to fill the subcabinet-level post

In July 2004 HHS secretary Tommy Thompson and D. Brailer released a framework for strategic action. Intended to guide collaborative efforts to promote progress toward a consumer- centric and informationrich healthcare industry.

Goals of the Strategic Framework

Goal 1: Inform Clinical Practice Goal 2: Interconnect Clinicians Goal 3: Personalize Care Goal 4: Improve Population Health

The National Committee on Vital and Health Statistics

In 2000 and 2001 the (NCVHS), w/c advises the secretary of HHS on health information policy, held a series of national hearings to develop a consensus vision of the National Health Information Infrastructure.

As envisioned by NCHVS, PHRs are a core component of the NHII, enhancing the ability of each individual to control his or her health data and the access by healthcare providers to those data.

Agency for healthcare Research and Quality

In 2003- 2004, AHRQ unveiled a major HIT portfolio, with grants, contracts, and other activities to demonstrate the role of HIT in improving patient safety and the quality of care.

About $24 million funded new implementation grants for healthcare organizations; of this amount, $14 million was targeted for small and rural hospitals and communities.

The 3 dimensions of the National Health Information Infrastructure

Centers for Medicare and Medicaid Services

Within HHS the CMS has initiated several pilot project to promote health IT. In May 2004, CMS awarded a $100,000 grant of American Academy of Family Physicians (AAFP) for pilot projects to provide comprehensive, standardized EHR software to small- and medium-sized ambulatory care practices

Several large pilot programs were authorized in the 2003 Medicare Modernization Act(MMA).

Cont....

The 3 year Care Management Performance Demonstration Program is intended to promote continuity of care, help stabilize medical conditions, prevent or minimize acute exacerbations of chronic conditions, and reduce adverse health outcomes, such as adverse drug interactions.

Public- Private Partnership

A number of collaborative efforts are focused on the use of EHR-Ss and HIT to improve care.

Among these private sector organizations are those formed specifically to address issues of connectivity, HIT, and Standards development.

Connecting for Health

A large private collaborative with federal participants supported by the Markle and the Robert Wood Johnson Foundations, connecting for health is addressing the barriers to development of an interconnected health information infrastructure.

More recently in July 2004, connecting for health released an incremental “roadmap” that laid out nearterm actions necessary to achieving electronic connectivity.

eHealth Initiatives

Is an independent, non profit affiliated organization established to foster improvement in the quality, safety, and efficiency of healthcare through information and IT

The major program of the foundation for eHealth Initiative is Connecting Communities for Better Health, a nearly $4 million program that provides seed funding and technical support to multistakeholder

Cont....

Collaboratives within communities (both geographic and nongeographic) that are using electronic health information exchange and other HIT tools to drive improvements in healthcare quality, safety, and efficiency.

Institute of Medicine

As an independent advisor to the nation with the goal of improving health, the IOM has championed the advantages of use of IT to improve healthcare since its 1991 foundational work, The computer- based patient record, which was revised and published in 1997.

The IOM continues to illuminate the importance for the use of IT in Healthcare.

Health Level Seven

An international, not-for-profit, volunteer standards organization, Health Level Seven is known for its large body work in the production of technical specifications for the transfer of healthcare data.

This transport mechanism known as messaging is widely used domestically and internationally.

HL7& continues to have technical specifications for messages as the primary body of its work product but is changing to address additional technical solutions for the transport of healthcare data.

Cont.....

Supported by public and private groups, the HL7s EHR Technical Committee developed a draft standards for trial use, known as a DSTU, for EHR-Ss and made it available for public comment prior to being reballoted as a standard.

The HL7 EHR-S functional model contains a list of functions in three categories: direct care, supportive, and information infrastructure

Looking to the Future

The year 2004 was a year of amazing growth, in federal initiatives and in public- private partnerships.

Federal agencies that had been early adopters of EHR-Ss continued to launched new programs and new capabilities; others offered new incentives to the healthcare community to embrace EHRs and the creation of the ONCHIT provided new leadership at a time public- private partnerships for common solutions were already increasing across federal and community environments.

Cont...

Over the next 10 years, as the nation moves toward the goal of EHRs for most Americans, nurse informaticists will have increased opportunities to participate in the activities of these formative groups, using the growing body of tools available to them. This time of great change brings grand opportunities for nursing informaticist and the entire nursing profession.

WALAAAANGGG FOREEEVEEERRRRRRRR!!!!