Electronic Medical Record

Features

Electronic Medical Record Definition

An Electronic Medical Record is a computer based information system that includes data and functionality with the following characteristics.

Provide secure, reliable and real-time access to patient health information where and when it is needed to support care.

Capture and manage episodic and longitudinal electronic health record information.

Function as clinicians’ primary information resource during the provision of patient care.

Assist with planning and delivering evidence-based care to individuals and groups of patients.

Support continuous quality improvement, utilization review, risk management and performance management.

Capture information necessary for reimbursement.

Provide longitudinal, appropriately masked information to support clinical research, public health reporting and population health initiatives.

Support clinical trials.

As defined by HIMSS (July 9, 2003)

Electronic Medical Record Key Components

Order Entry Data Dictionaries Order Management Clinical Data Repository Order Communications Results Reporting

Clinical Documentation Drug Database Clinical Pathways Customer Relation

Management Clinical Decision Support Interfaces

As defined by HIMSS (July 9, 2003)

•Lab Results

•Radiology Reports

•Radiology images

•Medications

•Operative Notes

•E.R. Notes

•Encounter History

•Appointment

•Scanned Order Scripts

•Progress Notes

•Therapy Notes

•History & Physical

•Allergies

•Demographics

•EKGs

•Scanned Advanced Directives

•Patient Lists

EMR Data Types

Electronic Medical Record System Features (page 1)

Order EntryDesigned for use by physicians/clinicians

Includes:Order sets

Checking for:Duplicate ordersDrug interactions

AllergiesDose-range

Online medication administration record (MAR)Work lists (task generation from orders)

Clinical Pathways

Practice guidelines and protocolsStandardsWork lists

Order Management

Knowledge-based orders (KBO)Advanced order entry and advanced clinical

decision supportIncludes:

Alerting with a rules engineLinks to knowledge basesClinical pathway ordering

Prescription ordering

Order Communications

Capture and transmission of ordersIncludes:

Single ordersMulti-disciplinary orders

Order setsCharging

Requisitions

Customer Portal

Health:Content and mall item searches

Personal health:Diary and reminders

Online questionnaires for the medical record

Physician Portal

Reference librarySecure messaging

Results viewerPrescription management

Referral managementHand-held wireless solutions

Employee Portal

Personalized work viewsWork flow tools

Content management/publishingSearch/calendar/directories

Hand-held wireless solutions

Data Dictionaries

Enterprise-wideCoherent data, even if data sources are in

different nomenclatures

Customer Relation Management

Customer Relationship Management (CRM)portals:

CustomerPhysicianEmployee

Integrated Clinical Information System Features

Electronic Medical Record System Features (page 2)

Clinical Documentation

Includes:Flow sheets

Intake and outputChart audit trail

History of access to patient chartsWhoWhatWhen

Results Reporting

Structured data from:Flow sheets

Ancillary systemsLaboratory, Radiology, Pharmacy, etc.

Knowledge Based Orders

Medical knowledge embedded into anapplication to guide practitioners providing

patient careArden syntax rules engine/editor

Arden syntax = industry standard for writing“rules”

Real-time interactive knowledge engineMulti-dimensional real time alerts

Initiated by the application:Synchronous – at the time of the order

Asynchronous – after the order has been placed

Clinical Data Repository

Health Data Repository (HDR)Automates the process of:

Gathering,Translating,

Organizing, andStoring all the patient’s data.(clinical, financial, and administrative)

Ensures quick access to the patient’s data

Clinical Decision Support

Prospective evidence-based careMeasure variance

Predict actionable informationAutomated aggregation of data

Measure work flow and operational efficiencyRetrospective analysis

Cost versus quality of careLength of stay versus outcomeRetrospective efficacy review

Pathways built from historical dataTrend Analysis

ResearchAnalysis across populations

Disease management analysisKnowledge-driven alerts

Arden syntax rules engine/editorMulti-dimensional real time alerts

Alerting across the continuum of care

Drug Database

Provide clinical content, e.g., Multum, First DataBank

Includes:Drug names and product information

Disease namesCoding systems

Side effect informationTherapeutic duplication checking

Interfaces

Systems feeding into the CDR (via interfaces) toautomate results reporting, e.g.,

Admission/registrationLaboratoryRadiologyPharmacy

Other ancillary systemsTranscription

Document imaging and PACSPatient accounting/billing

Devices feeding into the CDR (via interfaces) toautomate results reporting and/or collection of

device data, e.g.,IV pumps

Blood gas analyzersVitals (blood pressure, respiratory rate)

Heart rate monitorsVentilators

Infusion pumps

Integrated Clinical Information System Features

Electronic Medical Record Environment

Functionality that is recommended to be integrated into an EMR

Functionality that can be interfaced or integrated

Healthcare industry experts recommend that all hospitals integrate several core EMR functions through a single product.

Electronic Signature

Clinical Data Repository

Clinical Decision Support

Physician Inbox

Alerts and Reminders

Charting Information Clinical Documentation

Patient History and Physical

Problem List

Vital Signs

Order Management

Pharmacy

Context Systems

Laboratory ResultsRadiology Reports

PACS - ImagesOperative Notes

Drug InformationPatient Encounter Information

Patient SchedulesPhysician Schedules

EKGsInpatient / Outpatient Progress

NotesDischarge Summaries

Medical RecordsEMPI

Billing

Technology Enablers

Voice Recognition

Mobile - Wireless Access

Workflow Engine

Web - Remote Access

Electronic Medical Record

Electronic Medical RecordBenefits & Costs

Benefits Reduction in time used documenting clinical encounters (enabling more patient visits) Improvements in encounter coding (resulting in increased reimbursement) Eliminating paper charts and their associated costs Reduction in dictation and transcription costs Reduction in time and effort to locate and assemble paper chart information Automated charge capture Lower malpractice & risk of embezzlement Optimization in the utilization of non-physician providers Elimination of duplicate data entry Ability to attract caregivers through state-of-the-art systems and access to patient

information Increased patient satisfaction through improved patient care

Costs Initial costs for the application, implementation effort, and computer hardware Infrastructure costs associated with implementing and expanding the system Additional technical staff to support increased complexity in the application and environment Initial and ongoing training costs associated with set up and usage of the EMR Ongoing maintenance costs for vendor support and system upgrades

Electronic Medical RecordImplementation Options

Medium Size Hospital - Integrated EMR

High End, Large Hospital - Integrated EMR

Multiple Vendors (Best of Breed) EMR

Integrated front end for multiple back-end systems

Integrated EMR products that are lower in cost than industry leaders target small and medium sized hospitals. They tend to have all of the critical core features needed by most hospitals and several niche features that distinguish their product from others in the marketplace. Risks are increased for financial stability and product longevity. They tend to have adequate resources to provide excellent support to end users.

Integrated EMR products that lead the industry target large to medium sized hospitals. They tend to devote resources to develop the best features for all clinical components of an EMR. Costs to purchase, implement, and support the systems are significant. Customizing the system to meet an institutions specific needs is costly.

Selecting separate vendors and products to build an EMR can result in securing the best functionality for each clinical area, however the end result of integrating these functions may not result in a cohesive system. The initial costs of all components as well as the ongoing maintenance and operations is generally higher than an integrated solution. The complexity of coordinating the implementation, interfaces, and ongoing support of this type of solution is higher than an integrated solution.

EMR functionality may be achieved by utilizing software that provides an integrated EMR look and feel while accessing existing multiple back end systems. Costs and functionality will vary depending upon the availability and platforms for existing back-end systems. This option can provide a low cost solution to implement, however may be complex to implement and support. The level of functionality may be limited and depends upon the capabilities of the existing back-end systems.

Misys, Meditech, Quadramed, CPSI, Dairyland, HMS

Cerner SiemensEpicMcKesson

Several InterSystems - Ensemble, CacheMcKesson - Horizon PortalHealthvision

$$

$1.5 - 5M

$$$

$6-15M

$$$

$10-15M

$

$1-3M

Description / Main Characteristics

Major Vendors / Products

Electronic Medical Record Implementation Options - Advantages

Medium Size Hospital - Integrated EMR

High End, Large Hospital - Integrated EMR

Multiple Vendors (Best of Breed) EMR

Integrated front end for multiple back-end systems

Lower cost than High-end to implement

Typically have best functionality and integration

Best functionality for each functional need

Potential low cost to implement

Single vendor reduced complexity of install and support

Stability of large company Can implement in stages Leverages existing investments

Core functions of EMR available Proven mature software using industry standard tools

Most vendors have mature interfacing capabilities

May be customized for specific hospital needs

Reduced complexity of infrastructure and technology pieces

Large install base with most end-users

Will only purchase functions that are needed

Can leverage existing historical data

Seamless integration results in ease of use for end-users

Scalable solutions for medium and large hospitals

Can implement in stages - as areas become ready

Excellent reporting capabilities through a single repository

Seamless integration results in ease of use for end-users

Potential to implement some key features quickly

Most vendors provide good end user support

Excellent reporting capabilities through a single repository

Will not pay for unnecessary functions

Leaders in the industry often introduce new features

Most provide adequate functionality to meet specific needs of all areas.Possible to implement all new core functions together

Pros

Electronic Medical Record Implementation Options - Disadvantages

Medium Size Hospital - Integrated EMR

High End, Large Hospital - Integrated EMR

Multiple Vendors (Best of Breed) EMR

Integrated front end for multiple back-end systems

Potentially less functionality than higher end system

High cost to implement and support

High cost to implement a fully functional solution

Depends upon existing data to be accurate and in certain formats.

Dependence upon single vendor may be a risk if not satisfied

May implement un-needed features High complexity in implementing and supporting multiple vendors

Integration may not be as seamless as integrated EMR

Some smaller companies not financially stable

Systems typically not able to be customized

May be incompatibilities between vendor products

May not provide all EMR type features easily

Scalability may issue if system grows significantly

Dependence upon single vendor may be a risk if not satisfied

Large effort to research and select systems for all affected areas

May need to purchase other 3rd party pieces to provide all required functionality

Smaller companies have more potential to merge with other companies

Availability and cost for support resources may be an issue

Increased support issues by using multiple vendors

Can be complex to implement and support

If proprietary technologies - integration may be limited

High range in cost depending upon what exists and what functionality is requiredWill not replace need to upgrade core systems as issue occur with them

Cons / Risks

Electronic Medical Record Major Vendor Comparisons

Selection Criteria

Vendor (Integrated Suites) Total Installs % of Installs301-400 Bed Size

Target Markets Vision Cost Functionality Technology Risk

Meditech 487 23.87% 39 Middle $ $$ $$$ $ $McKesson 365 17.89% 62 Mid -HI $ $$ $$ $$ $Siemens (not Soarian) 340 16.67% 35 Mid-HI $$ $$$ $$ $$ $$Cerner 274 13.43% 30 High End $$$ $$$ $$$ $$$ $$$IDX 109 5.34% 15 Mid-HI $ $$ $$ $$ $$$CPSI 103 5.05% 3 Low End $ $ $$ $$ $Eclipsys 97 4.75% 17 High End $$ $$$ $$ $$$ $$Self Developed 97 4.75% 12 Low-MidEpic 69 3.38% 6 High End $$$ $$$ $$$ $$$ $$$Misys 62 3.04% 26 Middle $$$ $$ $$ $$ $$Quadramed 37 1.81% 6 Middle End $ $$ $$ $ $$$

Subtotal Of top 10 vendors 204042 VENDORS WITH < 37 INSTALLS 203Vendor Unknown 24Sample size=3970 Acute hospitals

Source: HIMSS Analytics 2005EmergisoftPyxis

Best of Breed VendorsIdocCDR Web

Electronic Medical RecordIndustry Trends - Priorities

Healthcare Industry Priorities - Most Important Applications (Next Two Years)

38%40%

43%46%

50%52%52%52%

ElectronicMedicalRecord

ClinicalInformation

Systems

Bar CodedMedicationsManagement

ComputerizedPhysician

Order Entry

Clinical DataRepository

PACS EnterpriseWide

InformationSharing

Point of CareDecisionSupport

Based Upon Hospital Leadership Identifying Top Several Priorities.Source: HIMSS 15th Annual Leaderhip Survey - 2004

Electronic Medical RecordIndustry Trends – Current Status

Electronic Medical Record - Current Healthcare Industry Status

No plans20%

Fully Operational19%

Partially Operational

37%

Plan to Implement23%

Unknown1%

Source: 15th Annual HIMSS Leadership Survey, Sponsored By Superior Consulting (2004)

Electronic Medical Record EMR Implementation Stages

EMR Stage Definition / Systems

% of all hospitals in

stage 0-100 Beds

No Stage Lack lab, radiology, and pharmacy reqd. for stage 1 29.39 45

Stage 1 Major ancillary systems installed (Lab, Rx, Radiology) 20.47 18

Stage 2

Major systems feed to Clinical Data Repository (CDR) that provides physicians access for retrieving and viewing results. Information from document imaging systems may be linked to CDR at this stage. 47.54 35

Stage 3

Nursing documentation, charting, care plans, and eMAR is implemented and fed to the CDR. The first level of Clinical Decision Support (CDSS) is implemented to conduct error checking. Some level of PACS is available for access by physicians via intranet. 1.73 1

Stage 4CPOE for use by any clinician is added to the nursing and DCR environment along with second level CDSS related to evidence based medicine protocols. 0.84 1

Stage 5

Closed loop medication administration environment is fully implemented. The eMar and bar coding, RFID are implemented and integrated with CPOE and Pharmacy to maximize point of care patient safety processes for medication administration. 0.03

Stage 6

Full physician documentation/charting is implemented with all of the above. Level 3 of clinical decision support provides guidance for all clinician activities related to protocols and outcomes in the form of variance and compliance alerts. A full compliment PACS system provides medical images to physicians via an intranet and displaces all film based images. 0

Stage 7

Clinical information can be readily shared via electronic transactions or exchange of electronic records with all entities within a regional health network. The medical record is completely electronic/paperless. This stage allows the Care Delivery Organization to support the true electronic health record. 0

* Source HIMSS Analytics 2005 - based upon input from 3927 hospitals

HIMSS Analytics Clinical Transformation Stages

Electronic Medical Record Electronic Medical Record (EMR) vs. Electronic Health Record (EHR)

Electronic Medical Records Electronic Health Records

The legal record of the Care Delivery Organization (CDO)

Subset (ie. Continuitiy of Care Record (CCR) or Care Record Summary (CRS) from various CDOs where patient has had an encounter

A record of clinical services for patient encounters in a Care Delivery Organization Owned by the patient

Owned by the CDOCommunity, state, or regional emergence today - or nationwide in the future

These systems are being sold by enterprise vendors and installed by hospitals, health systems, clinics, etc.

Provides interactive patient access as well as the ability for the patient to append information

May have patient access to some results information through a portal, but it is not interactive

Connected by National Health Information Network (NIHN)

Does not contain other CDO encounter information

Electronic Medical RecordPotential Implementation Approach

Implementation Modules

TimeFrameDefine Requirements / Business CaseSystem Evaluation and SelectionAcquire Clinical Repository Acquire EMR Hardware + 3rd party softwareInstall Base EMR componentsIntegrate ADT/Reg, Patient InformationIntegrate Lab ResultsIntegrate Radiology ReportsIntegrate Meds / Pharmacy InformationResults Reporting (Load data from existing sources)Add scanned documentsOrder ManagementElectronic SignatureChartingNursing DocumentationAdd order types Order EntryPatient SchedulingData Warehouse + Clinical Decision SupportPhysician PortalPhysician Office Base System IntegrationEKGsER integrationOR IntegrationCPOE

Short Term PhaseFoundation &

IntegrationAddition of Key

Functions

Continue Development & Evaluation -->

Year 1 Year 2 Year 3 Year 4