Electronic health records (EHR) are a widespread and practical application of information technology in healthcare. They contain data about the patient in digital format while protecting the privacy of the person. Information in this form can be effectively used by providers to treat one patient and be transmitted between them to ensure the best recovery. Choosing the right EHR and its capabilities for the organization will increase efficiency, reduce costs and help to achieve their goals.
Selecting the necessary system for the organization depends on its size, goals, stakeholders and can take a long time. The studied case presents the medium-size healthcare organization Alpha, which includes 150 beds, 5 for intensive care. Key specializations include pediatrics, cardiology, women’s health, outpatient surgery, and orthopedic surgery. Its auxiliary service lines contain 13 clinics, which, in addition to mentioned specializations, also have family practice, internal medicine, neurological, and eye care clinics. Part of Alpha’s activity is also devoted to outpatient rehabilitation services and a community wellness program.
The organization is interested in ensuring that the new system will allow employees to transmit data through all service lines efficiently. The new system should also solve the problem of entering information and provide a convenient scheduling system. The main stakeholders are the staff – doctors, and nurses, as they will use the system the most. Other stakeholders include administration, managers, information technologies (IT) and health information management (HIM) department, billing department, and the EHR provider.
Applications: Health Informatics
EHR is a collection of several systems that work together. Several components should be included in the EHR for Alpha. In particular, registration – administration, discharge, transfer (R-ADT) system, continuity of care record (CCR), and a personal health record (PHR) are needed to contain patient data. Computerized provider order entry (CPOE) system, patient monitoring systems, document management system (DMS), clinical messaging, scheduling system, and electronic mediation administration record (EMAR) also support personnel activities (Sayles & Kavanaugh-Burke, 2018). Population health and patient-provider portal are necessary to provide patient support.
It is possible to set the following requirements for EHR:
- Health data – information should be collected and presented thoroughly and in a standardized form.
- Communication – the system should provide convenient and fast communication between suppliers.
- Patient support – the system should provide tools to communicate with patients. They should also be able to see personal information, like test results, and general information, like guides or health recommendations.
- Order Management – the system should enable providers to work with prescriptions and orders (Green, 2021).
- Population health – the system should support communication with society and providing it with reports and relevant information.
- Privacy and security – patient data, providers’ communication must remain confidential and protected from intruders.
The necessary components will help to solve the tasks assigned to the Alpha organization. For example, DMS will streamline paper patient records using scanning. CCR and PHR contain patient information, and authorized users can access it. In this case, doctors will have complete and accurate information collected by other specialists, which will reveal a more detailed history of the patient. R-ADT and CPOE systems are needed to collect data in a standardized form using document templates, which will then be used in the treatment and by the billing department. CPOE is created to enter orders by suppliers but also contains a reminder function important for regular patient screening and integrated clinical decision support capabilities.
EMAR simplifies the discharge of medicines, and scheduling systems are convenient for appointments. Patient monitoring systems can be effectively used for intensive care and cardiology. Patient-provider portals help customers communicate with doctors and learn the necessary information, like test results or clinical guides. Finally, population health is helpful for the community wellness program, as it is designed for reporting at the public level. For example, it can provide information about the prevalence of a virus or disease.
Secondary information is data collected by someone else, not its current user. In the case of EHR implementation, Alpha should consult with other health institutions that use the proposed systems from the particular vendor (Sayles & Kavanaugh-Burke, 2018). Organizations can be found with the help of an EHR provider, cold calls, and corporate offices (Sayles & Kavanaugh-Burke, 2018). In this case, Alpha will determine the real advantages and disadvantages and evaluate the results of other organizations. When the choice is made and the system is installed, Alpha employees must also go through training. They will also receive secondary information about the peculiarity of using the systems. Training is carried out not only before installing new systems but can also be ongoing or additional after some changes.
Applications: Health Information Exchange
People’s health depends on many factors, so it is crucial to consider all aspects that impact them. Health Information Exchange (HIE) provides different health organizations with information that their colleagues gathered about a particular patient, excluding the possibility of error if the patient does not remember accurate data. HIE involves storing customer data obtained from various institutions and EHR systems (Price, 2020). If the EHR system is connected to the HIE, its users can receive and send information there. Thus, the chance of error is reduced, and treatment becomes more effective.
Patient information, especially in electronic form, requires serious protection from the organization. Kruse et al. (2017) identify three areas of security for protection against external and internal threats:
- Administrative: risk analysis and assessment, Chief Information Security Officer, security evaluation.
- Physical: physical access control, assigned security responsibility, workstation security.
- Technical: firewalls, encryption, access control, virus checking, authentication, audit trails.
The most effective and discussed methods are firewalls and encryption. Firewalls monitor inbound and outbound traffic and block malicious traffic. When encryption occurs, the data text is converted for storage to an unreadable form. Once the provider accesses data, it is converted to the original format.
Applications: Disaster and Recovery Planning
A disaster and recovery plan is needed to protect patient data in critical situations, such as natural disasters, power outages, and other similar events. Such a plan usually involves data backup, actions procedures, and disaster recovery (Snell, 2018). Alpha can create a backup network or cloud storage for patient data. Backups help access and restore information when conventional methods are unavailable, even during cyber attacks (Snell, 2018). Thus, the prepared plan allows providing care to patients continuously.
Applications: Computer-Assisted Coding
Computer-assisted coding (CAC) improves the performance of healthcare facilities by improving the quality of reports and meeting the requirements of its customers. Using CAC, data from EHR is transferred to transcription and financial systems (“Computer assisted coding software,” n.d.). CAC uses natural language processing (NLP) to “analyze and interpret unstructured healthcare data using specialized algorithms, extracting the facts that support the codes assigned” (“Computer assisted coding software,” n.d., para. 3). Thus, with the help of CAC, the management of medical documents is simplified by embedding the correct codes into them.
The CAC capabilities required for EHR efficiency are as follows:
- Performance – fast coding speeds up processes such as search of duplicates, document sorting, and other tasks (“Computer assisted coding software,” n.d.).
- Transparency – codes must be associated with relevant data in patient records.
- Consistency between different code assets provides accuracy and confidence in data (“Computer assisted coding software,” n.d.).
- Correctness – affects the correctness and effectiveness of results and improves compliance.
Computer assisted coding software. (n.d.). Foresee Medical.
Green, J. (2021). EHR requirements and key features: Your complete guide. EHR in Practice.
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for the Electronic Health Records. Journal of Medical Systems, 41(8), 127.
Price, L. (2020). Why Health Information Exchange is important for EHR use. Patagonia Health.
Sayles, N.B., & Kavanaugh-Burke, K. (2018). Introduction to information systems for health information technology (3rd ed.). Ahima.
Snell, E. (2018). Why providers need a disaster recovery plan for EHR security. Health IT Security.