Health Information Technology for Nursing: The Future is Now

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1 Original Release Date: 9/15/2014 Expiration Date: 9/15/2017 Audience The audience for this course includes al health care professionals that must use information technology in providing care for patients. Purpose statement Health information is generated with each and every patient encounter, and the management of this information has changed enormously in the past century. What was previously documented in paper charts or microfiche and stored away in a locked room can now be recorded and stored solely on computers. Constant changes in technology require Learning objectives Explain the purpose of the HITECH Act. Compare and contrast the characteristics of electronic health records vs electronic medical records. Discuss the benefits of electronic health records for patient care outcomes. Describe how electronic health records can decrease medical errors and improve efficiency in healthcare practices. Explain the criteria for meaningful use of electronic health records. Describe the process for certifying electronic health record systems. List the steps for implementing an electronic health record system. Discuss the implications of the HIPAA Security Rule for health information technology. List the administrative, technical, and physical safeguards required by the HIPAA Security Rule to protect patient information. How to receive credit Read the entire course, which requires a 6-hour commitment of time. Depending on your state requirements you will asked to complete either: An attestation to affirm that you have completed the educational activity. Accreditation and approvals Elite is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider of continuing education in nursing by: Alabama, Provider #ABNP1418 (valid through April 30, 2017); California Board of Registered Nursing, Provider #CEP15022; District of Columbia Board of Nursing, Provider Health Information Technology for Nursing: The Future is Now 6 CE Hours healthcare professionals to remain diligent in managing this protected information appropriately. This course provides the background of electronic health information technology as well as current trends and strategies for its use. Describe the ten cybersecurity practices recommended by the Office of the National Coordinator for Health Information Technology to protect patient information. List e-prescribing system requirements. Explain the significance of regulations issued by the DEA s interim final rule on the use of e-prescribing systems to prescribe controlled substances. Describe the functional standards used to guide the nationwide use of immunization information systems. Explain the role of the NASPER Act in the implementation and improvement of prescription drug monitoring programs. Explain the Institute of Medicine s operational guidelines for telehealth services. OR completed the test and submit (a passing score of 70 percent is required). Note: Test questions link content to learning objectives as a method to enhance individualized learning and material retention. Provide required personal information and payment information. Complete the MANDATORY Self-Assessment, and Print the Certificate of Completion. # ; Florida Board of Nursing, Provider # ; Georgia Board of Nursing, Provider # ; and Kentucky Board of Nursing, Provider # (valid through December 31, 2017). Faculty Katie Ingersoll, Pharm D, RPh Dr. Ingersoll graduated from Northeastern University with a Doctor of Pharmacy degree in She works for a national chain pharmacy and has a certificate in Pharmacy-Based Immunization Delivery from the American Pharmacists Association. She is actively involved Page 60 in many aspects of health care including the use of technology as a communication, care, and educational tool. Her interest in information technology has expanded to the education of peers and other health care professionals.

2 Content Reviewer June D. Thompson, DrPH, MSN, RN, FAEN Activity Director June D. Thompson, DrPH, MSN, RN, FAEN Lead Nurse Planner Disclosures Resolution of Conflict of Interest In accordance with the ANCC Standards for Commercial Support for CNE, Elite implemented mechanisms, prior to the planning and implementation of the CNE activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the CME activity. Disclaimer The information provided at this activity is for continuing education purposes only and is not meant to substitute for the independent Sponsorship/Commercial Support and Non-Endorsment It is the policy of Elite not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient s medical condition. 2016: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction Health information is generated with each and every patient encounter, and the management of this information has changed enormously in the past century. What was previously documented in paper charts or microfiche and stored away in a locked room can now be recorded and stored solely on computers. Constant changes in technology require healthcare professionals to remain diligent in managing this protected information appropriately. Health information technology (health IT or HIT) refers to the technology used to store, manage, or share health information [i]. Managing health information through technology can be challenging, due to the sensitivity of the data and a lack of uniformity among computer systems. Improving the efficiency of storing and accessing health information through technology has been a priority since the turn of the century and remains a priority today. The potential advantages of an efficient health information technology system are substantial. Online system information management, such as the use of shared computerized patient records to facilitate communication among doctors, patients, and other members of the patient s healthcare team, can positively affect patient care and treatment outcomes. Health IT also gives patients the opportunity to take a more active role in their healthcare [i]. This course provides an overview of health information technology systems. Because state laws vary in their regulation and enforcement, individuals using health information technology must ensure their activities are in compliance with all applicable local, state, and federal laws. History Records of patient health conditions and treatments were not routinely maintained until the 1920s. By this time, many healthcare providers realized documentation of patient treatment helped them provide better care. Patient s health records became increasingly common as providers learned their beneficial effects on healthcare safety and quality. Physicians found the patient record provided a more comprehensive picture of the patient s condition, in a more efficient manner than simple notes or discussion. Not all medical records were equally useful. Many healthcare personnel did not know the principles of good recordkeeping. In 1928, the American College of Surgeons (AMC) established a standardized medical recordkeeping procedure, for health information management in the form of paper records. The AMC also established the American Association of Record Librarians, now known as the American Health Information Management Association (AHIMA), a professional organization dedicated to improving medical recordkeeping systems. Medical records were printed on paper from the 1920s until the 1990s. As early as the 1960s and 1970s, several universities partnered with hospitals to explore the use of computers to house medical records. These experiments were confined to a small number of facilities, however, due to the prohibitive price of computers, which limited use until the early 1990s. At this time, it became common to store master patient lists on computerized systems, providing services such as computerized check-in procedures in hospitals. Computerized records gained popularity in the 1990s. Many different hospital departments developed applications for the technology, but a number of factors limited the utility of electronic records at that time. While laboratory and radiology test results were stored electronically, the data was not linked in any way to other patient information or previous lab results. Additionally, information could not be shared by different departments. In 2000, this limitation in the healthcare computer system was identified as a possible reason for an increase in medical errors, emphasizing the need for change. President George W. Bush emphasized the importance of electronic medical records in his State of the Union address, in January 2004, explaining, By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care [ii]. He established the Office of the National Coordinator for Health InformationTechnology (ONCHIT or ONC), the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information [iii].the ONC is housed within the Department of Health and Human Services (HHS) and is dedicated to supporting the adoption of health information Page 61

3 technology and the promotion of nationwide health information exchange to improve health care. In 2009, under the Obama Administration, the Senate passed the American Recovery and Reinvestment Act (ARRA), earmarking more than $19 billion to increase the use of electronic health records, specified in a section of the ARRA called the Health Information Technology for Economic and Clinical Health Act, or the HITECH Act. It was created with the objective of improving the delivery of healthcare through increased investment in health information technology. Funds from this act were allocated to: Support the infrastructure of the ONC. Create incentives for providers who become meaningful users of electronic health record systems. Terminology Electronic health record (EHR) In the simplest definition, an electronic health record (EHR) is a computerized version of the paper charts previously used to track a patient s health care. They are real-time records of a patient s medical condition that bring information from current and past providers, clinics in schools or workplaces, laboratories, pharmacies, radiology clinics, and emergency departments, together in one streamlined record for optimal patient care. The key identifying feature of electronic health records is that they can be created, managed, and shared by healthcare providers across multiple healthcare organizations or systems. This means the patient has one record accessible and transferrable to all his or her various providers across different organizations, locations, and state lines [vi]. Electronic medical record (EMR) The electronic medical record contains the computerized records of the patient s medical chart from a single practice or facility, including laboratory, radiology, and pharmacy records from that provider. EMR benefit patients who meet all their healthcare needs from providers in one practice, but they do not follow patients to different facilities. It is generally difficult to transfer electronic medical record information to another facility; if information must be transferred, it may need to be printed and mailed to other members of the patient s care team [vii]. Interoperability Interoperability is the capability of multiple systems to exchange information and be able to use the information that was exchanged. Electronic medical records must not only communicate information from one source to another, they must be able to read and use the information imported from another system. Since different information management systems may not be designed to communicate with one Electronic health records (EHR) Why should healthcare providers adopt EHR? Interdisciplinary teamwork is a critical tool in patient healthcare management, as the ability to share information with other members of a patient s healthcare team effects the safety and quality of patient care. Healthcare professionals who use electronic health records recognize the relationship between comprehensive medical records and an improved ability to make sound clinical decisions. ECR allow healthcare providers to: Access complete, up-to-date, and accurate patient s health information, regardless of the care setting. Provide care more quickly in a crisis, due to increased availability of allergy, medical, and medication histories in one, easy-to-access system. Improve coordination of care in patients with multiple chronic medical conditions. Share information with patients, families, and caregivers, and empower patients to take a more decisive role in their healthcare. Page 62 Implement health IT within the Indian Health Service. Research the effects of health IT on health outcomes. Support the secure exchange of health information. The HITECH Act authorized the Office of the National Coordinator to adopt health information technology standards and create two committees, the HIT Policy Committee and the HIT Standards Committee, to assist the National Coordinator for Health Information Technology in making informed decisions [iv]. This legislation provided incentives to adopt the technology, both through financial means and the creation of Regional Extension Centers (REC) to support healthcare providers establishing their own electronic health record systems. The legislation established a deadline of 2014 to implement a national electronic health record system [v]. another, the Office of the National Coordinator (ONC) for Health Information Technology sets nationwide standards and guidelines for electronic health records, to improve communication among computer systems and ensure efficient and seamless management, utilization, and transfer of medical data. Personal health record (PHR) The personal health record (PHR) is similar to the electronic health record (ECR), except the information is controlled by the patient instead of the medical provider. Some healthcare facilities and insurance companies have systems that allow patients to monitor, review, and access services through the facility s software or an online system. These systems (sometimes known as health portals ) help patients manage information such as prescription and over-the-counter medications, history of immunizations and allergies, lab results, and emergency contact numbers. Some of these programs even have applications (apps) that can be used in conjunction with smartphones to track sleeping patterns or exercise routines. Some facilities are capable of linking an individual s PHR and EMR, if both are housed within the same system, but this technology was not widespread at the time of this writing. Electronic prescribing Electronic prescribing allows providers to send prescriptions directly into a pharmacy s computer system, instead of by phone, fax, or handwritten order, which might need deciphering by pharmacy staff. While an electronic order, like any prescription, must be verified by a pharmacist, it provides more protection than other types of prescriptions against data entry and interpretive errors, safeguarding patient care. While this system is not completely foolproof, simplifying the prescribing process helps decrease error potential and saves both the patient and pharmacy precious time [vi]. Recognize potentially serious drug interactions before they affect the patient. Verify that medications and dosages are accurate and appropriate. Improve preventive care and decrease the necessity of risky procedures [ix]. Evidence based practice: A recent study conducted by the National Center for Health Statistics (NCHS) showed over 70% of all physicians who purchased an electronic health record system would purchase it again, and half of all physicians who did not have a system in place planned to purchase one within a year [ix]. Nearly twenty years ago, the Department of Veterans Affairs (DVA) established one of the first computerized health IT systems. Since that time, EHR have been associated with improvements in quality of care, significant financial savings, and even increased patient satisfaction. The VA further improved health outcomes and healthcare efficiency by adding capabilities to HER, including bar code technology and computerized ordering for electronic imaging, medications, and laboratory tests, all of which streamline patient management and reduce the risk of medical error.

4 Research conducted over a ten-year period at the VA by the Center for IT Leadership (CITL) studied the VA s investment in information technology (IT) and its costs and benefits to the organization. The study concluded the VA spent nearly $4 billion on health information technology, but saved more than $7 billion due to improvements in safety, healthcare quality, and patient satisfaction. The study found over 86% of savings were related to a reduction in unnecessary duplicate testing and decreased incidence of medical errors. The remaining 14 percent savings were associated with a reduction in operating costs and workload. This study also explored the EHR system s potential to improve the use of clinical guidelines for treating chronic illnesses. Research focused on the treatment of diabetes (an illness that affects approximately 25% of patients in the VA health system) among VA patients versus those in the private sector. VA patients with diabetes were found to have better cholesterol levels, better glucose testing compliance, and retinal exams conducted at more appropriate intervals as compared to Medicare patients. The study found the DVA preventive treatment of diabetic patients averaged a score 15% higher on average than that of diabetic patients in the private sector [viii]. Improvements in convenience and quality of healthcare EHC have the potential to improve the convenience and quality of healthcare, which are important to patients and healthcare providers alike. Healthcare professionals are likely to see all the following changes in healthcare quality and convenience with an electronic health record system: Simplified access to patient records from both inpatient and remote locations. Improved decision-making support with the use of systemintegrated alerts and reminders. Tools to improve performance and report information in real time. Improvements in documentation, billing, and coding procedures. Efficient transfer of EHR and other data from external healthcare facilities, laboratories, and disease registries. Safer prescribing practices. Patients are likely to see the following improvements in the quality and convenience of their care: Less time spent filling out forms. More accurate and reliable information at the point of care. Electronic prescriptions that can be sent directly to the pharmacy. Online portals used by patients to access personal healthcare information, such as lab results, and communicate with healthcare providers. Electronic referrals for faster and easier access to specialists. Nursing consideration: Providing the most complete medical history possible at the point of care was shown to contribute to higher quality care, leading to better patient outcomes. EHR enable providers to be more informed and efficient decision makers throughout patient care [x]. Patient participation through PHR Ideally, patients and healthcare providers work together to make the best decisions for the patient s care. PHR support this strategy, as they make collaboration and communication between the patient and provider more convenient and efficient, enabling patients to be better informed and take more active roles in their healthcare decisions. Patients and their family members can use the information in their PHR to keep track of, lab test results, and medications, and any other personal healthcare information desired by the patient [xi]. A patient s PHR is a simplified version of the EHR, accessed through the EHR system or externally used as a mode of communication between the provider and patient. The personal health record can be used by patients to services such as paying bills or scheduling appointments with the provider using an online system. Messaging systems, such as texting or , are typically integrated into the system to ease communication and ensure it is sufficiently frequent that providers identify potentially health issues as possible. PHR also provide important discharge information and medical instructions for patients following appointments and hospital stays. Patients able to access an electronic record showing and/or explaining the results of a health exam are more likely to discuss the information with their provider, particularly if the provider takes an opportunity to review the information with the patient and provide additional information about their care. Providers can send information to patients about past and future appointments, directions for follow-up care, taking prescription medication, proper wound care, or any other instructions for patient care, even referral to online resources for relevant medical information. There are two main types of PHR: Stand alone PHR require patients to fill in health information forms relying on their own records or memory, then store the information digitally. Connected or tethered PHR are those linked a provider s or insurance company s EHR. This type of health record allows patients to log on to their records and view information, such as lab test results. Improvements in diagnosis and safety for patients EHR systems are poised to improve patient outcomes by enabling providers to diagnose medical conditions more accurately. Prescribers surveyed in 2012 reported that electronic health records were available at the point of healthcare for 94% of prescribers, with 88% of EHR users reporting clinical benefits from the system, and 75% concluding EHR improved the delivery of patient care [xii]. EHR enhance a provider s ability to accurately and efficiently diagnose patients ailments because systems can consolidate, organize, and present the information in a useful, easily interpreted manner more likely to bring meaningful information to the provider s attention. EHR help providers reduce errors by: Maintaining a record of the patient s current medication list, as well as allergies to medications, and automatically checking for drug interactions or contraindications when the prescriber adds new medications. Allowing providers in the emergency department to gather information on a patient s medications, allergies, and medical conditions in a timely fashion, which is especially helpful if the patient is uncooperative or unconscious. Alerting the provider to potential safety issues before they become serious problems. Helping identify the source of problems when they occur, simplifying problem resolution. Liability issues can also be resolved more easily with use of an electronic health record. When information is contained in a single electronic file, outsiders can more easily review a case to determine the order of events and whether the provider s decision-making process is grounded in evidence-based practices. Informed Consent and other patient-provider agreements can be stored in the EHR, and provided upon request of legal personnel [xiii]. Improving patient health outcomes EHR can improve patient health outcomes because the electronic data within each record can be sorted and analyzed to provide a more complete picture of an individual s health status, or compare and contrast characteristics within and among groups. Looking at patient with specific characteristics (such as those who share the same medical condition, or are taking the same medication) as a group can help providers evaluate their patients quality of care and decide the best course of treatment for each individual. For example, providers can look at all of their patients with asthma who are taking Budesonide (Pulmicort), assess the beneficial and detrimental effects of the medication for each individual, and use this Page 63

5 growing patient database to determine the most effective treatments and the direction for future patient care. Several studies have assessed the benefits of EHR on patient outcomes. In 2010, a survey conducted to examine attitudes toward EHR found patients were highly satisfied with practices in which doctors implemented EHR-assisted services. The primary perceived benefit to patients, according to 92 percent of respondents, was streamlining the prescription-filling process, with 76% considering the e-prescribing process easier, and 90% reporting that when e-prescribing was used, only rarely was a prescription not already filled when they went to the pharmacy to pick up their order. Patients also reported a 63% reduction in medication errors. Providers in the study expressed satisfaction with the EHR system, reporting it decreased the number of calls to their medical offices after hours [xiv]. Quality of healthcare often improves with the implementation of electronic health records. A 2013 study conducted to assess the effects of an EHR system within community-based clinics in the New York State Hudson Valley found providers using EHR showed increased numbers of screenings for diabetes (A1C testing), chlamydia, breast cancer, and colorectal cancer. The higher screening rates gave providers the ability to identify and treat potential health concerns earlier than might otherwise have been possible [xv]. Research in Philadelphia examined the care of children with asthma to determine whether integrating clinical decision support programs into health records might improve adherence to the national guidelines for asthma treatment in children. Providers across twelve primary care pediatric offices used either passive clinical decision support methods, or active pop-up alerts to assist them in making clinical decisions for children with persistent asthma. Several areas showed significant improvements in both intervention groups: Use of maintenance asthma medication increased by 6% overall; asthma care plan usage increased by 14%, and patient spirometry results (e.g., pulmonary function testing) also showed improvement. Findings provide good evidence that the integration of active clinical decision support programs into electronic health records can promote greater adherence to national guidelines for the treatment of chronic illnesses [xvi]. A similar study examining the effects of an electronic health record system at Fletcher Allen Health Care Medical Center in Vermont showed a 60 percent reduction in reports of near-miss medication events, and a 20 percent increase in the completion of daily fall assessments, used for the purpose of preventing prolonged hospital visits due to falls; both changes translated into safer and improved medical care [xvii]. Improving care coordination Managing chronic medical conditions often requires the efforts of a team of healthcare providers who help the patient maintain optimal health. Primary care providers, nurses, pharmacists, specialists, and other mental and physical care practitioners making up the healthcare team, tend to be more attuned to aspects of the patient s health that fall within their specific area of care. While some providers may have overlapping information about a patient s history or condition, without a single system for collecting all of the information on a single patient in one place, and a plan of care that coordinates communication among team members, treatment becomes segmented, to the patient s possible detriment. EHR implementation facilitates coordination of care and the sharing of patient information among providers, resulting in improved treatment care and outcomes. For example, a master medication and allergy list can be updated by any of the patient s providers, to ensure records contain current accurate patient information. Computer programs are chosen and adapted to the needs of each specific healthcare environment to allow the greatest ease in transition to the system, data entry, and searching procedures. The system can be programmed to notify other team members if the patient was in the hospital or emergency room, or any other issues or events calling for checking in or medical follow-up. Page 64 Shared information and communication improve the coordination of care, which can decrease the risk of medical errors and prevent unnecessary testing and medical procedures. Every member of the patient s medical team can access and review the patient s history of medical conditions, procedures, tests, and medications, resulting in higher quality care and better health outcomes for patients [xviii]. Efficient practices In addition to improving patient care, EHR increase efficiency in the following ways: Integrated scheduling systems connect appointments to claims, automatic coding systems, and progress notes. Shortcuts, such as improved search functions and chart management functions, that save time. Improved communication among providers, insurance plans, and laboratories. Providing links to the patient s health plan in the patient record, enabling providers to choose treatments that provide the best insurance coverage up front. Simplified ordering systems for lab and imaging studies. Links to public health registries, adverse event reporting systems, and communicable disease databases. Streamlining the billing process, allowing providers and their staff to spend less time filling out forms and handling billing requests. Streamlining the process of ordering tests and procedures, reducing potential for duplication. Improved documentation of clinical events, such as eliminating the need for traditional medical transcription, or pulling patient charts, as well as additional factors that reduce lag times and increase billing accuracy. Seventy-nine percent of healthcare providers who implemented an EHR system reported a more efficient working environment, according to a recent survey [xiii], with 82% of all respondents saving time with an e-prescribing system, and 75% of all respondents receiving lab results more quickly [xix]. Cost savings for health care practices Although installing an EHR system comes with an initial investment of time and money, the financial benefits associated with its implementation can be significant and far-reaching, as the benefits of optimal patient care extend beyond the patient to networks of family members, friends, healthcare providers, and beyond. EHR systems bring immediate and direct cost savings associated with automating labor-intensive procedures such as transcription, pulling, storing, and re-filing charts, or any other time-consuming tasks previously recorded on paper [ix]. Savings are also attributable to improved accuracy in billing, which enables medical centers to obtain reimbursement from insurance companies more quickly and easily. Initial costs and resulting savings for hospitals implementing electronic health record systems vary based on their size. Large hospitals can experience savings of $37 to $59 million over a 5-year period, before collecting incentive payments [xviii]. A study conducted in 2006 assessed the costs and benefits of several aspects of HIT systems to determine their value in various healthcare settings. The study reviewed available literature focusing on pediatric care. Findings from review and analysis of 256 cases electronic medical record use, decision support, and computerized order entry in the outpatient and inpatient setting showed substantial savings from EHR implementation. Benefits outweighed the cost of investment, with a financial break-even point ranging from three to thirteen years. The study concludes HIT has the potential to dramatically alter the delivery of healthcare, creating a safer, more effective, and more efficient environment, but its widespread use is limited by a lack of knowledge regarding the types of HIT that provide the most costeffective results [xx].

6 Incentive programs for electronic health record implementation In 2009, the American Recovery and Reinvestment Act (ARRA) earmarked money for the Centers for Medicare & Medicaid Services (CMS) to provide up to $27 billion for incentive payments to eligible professionals, hospitals, and other facilities adopting, implementing, or upgrading certified electronic health record systems, and demonstrating their meaningful use. Eligible healthcare professionals can qualify for incentive payments of up to $44,000 through Medicare, or $63,750 through Medicaid, and eligible hospitals can qualify for incentive payments of $2 million or more [xxi]. These incentives are provided to offset the high costs of implementing this technology, to improve the value, reliability, and quality in the nation s health records. The program established two separate incentive payment systems, one through Medicare and one through Medicaid. The Medicare incentive payment system is regulated by the federal government, and requires proof of meaningful use of a certified electronic health record system in the first year to receive incentive payments. The Medicaid incentive payment system functions on the state level, with payments issued for implementing, upgrading, or adopting a certified electronic health record system in the first year of participation. In order to qualify for the Medicare incentive payment system, the system must demonstrate meaningful use. This means that certified electronic health record technology is used for: Improving quality, safety, and efficiency of healthcare. Reducing treatment and service disparities. Engaging patients and family in patient care. Improving coordination of care. Maintaining privacy and security of patient health information. The positive effects of EHR systems are demonstrated by improved: Clinical outcomes. Population health outcomes. Transparency of healthcare. Efficiency of healthcare. Patient empowerment. Research data on health systems. Regional extension centers Because small practices that provide essential preventive care and are not electronically linked to larger hospitals and healthcare systems are more likely to lack the resources needed to implement HIT, the Office of the National Coordinator founded 62 Regional Extension Centers (REC). REC are support and resource centers located throughout the country staffed with experts to assist healthcare providers develop HIT systems to improve patient care. Transition to an EHR system, and ensuring adherence to incentive regulations can be challenging; REC experts can provide advice to healthcare facilities and providers, or assist with an entire EHR implementation process, from choosing an EHR system through development of meaningful use. Healthcare providers and facilities seeking funds are strongly encouraged to work with their local REC to ensure they understand the criteria for demonstrating meaningful use of EHR, as multiple specific objectives must be met to qualify for incentive payments [xxii]. Regional Extension Centers are financially supported by the providers they assist, collecting one-third of the incentive payment that each provider earns. This fee structure ensures REC are financially able to continue supporting providers through HIT. REC personnel can assist providers with project management, health IT training and education, selecting an EHR vendor, financial consultations, incorporating health IT into workflow, security and privacy issues, connecting with state and federal health information exchanges, and continued technical assistance after implementation. Support is geared to the needs of each individual practice, and is provided after implementation as well. Of the more than 147,000 healthcare providers enrolled with REC as of July 2013, over 124,000 providers have implemented EHR systems. Of those providers implementing EHR, more than 70,000 (56 percent) demonstrated meaningful use of their system. Regional Extension Centers were initially designed to assist primary care providers (PCP), who showed a national rate of REC enrollment of 41 percent as of July 2013, with 51% of those PCP located in rural areas [xxiii]. Certification of EHR systems The process for certifying electronic health record technology was established by the Office of the National Coordinator for Health Information Technology. In 2011, ONCHIT introduced an HIT certification program for certifying EHR technologies, to ensure they follow established standards and achieve meaningful use. The Health and Human Services (HHS) Secretary is responsible for the development of specific rules for testing and certifying EHR systems, and standards and certification criteria are updated on a regular basis. Certifying EHR systems assures providers and healthcare facilities that the software they plan to purchase is capable of meeting meaningful use requirements and other objectives established by the CMS. System certification also assures providers and patients that the information in electronic systems is secure and interoperable. The certification process starts with vendors creating EHR systems that meet the HHS Secretary s defined standards and criteria. After system development, Accredited Testing Laboratories (ATLs) test the product and evaluate it according to HHS-defined standards and criteria. Upon successful completion, the Office of the National Coordinator-Authorized Certification Bodies (ONC-ACB) certifies that the EHR meet the necessary standards and criteria. After certification, the product qualifies for inclusion on the Office of the National Coordinator s List of Certified Health IT Products. The National Voluntary Laboratory Accreditation Program (NVLAP), administered by the National Institute of Standards and Technology (NIST), accredits testing facilities, develops testing requirements and tools, and produces test cases to support ONCHIT certification programs by ensuring electronic health record systems are compliant with meaningful use requirements [xxiv]. Implementing an electronic health record system Nurses are integral to the implementation of electronic health record systems. Whether the system is being implemented in a small medical practice or a large hospital system, it is one of the most complicated and resource-intensive projects that any establishment can undertake. It requires a significant investment in financial and human resources, as well as time and patience. Despite advances in technology, complications along the way are inevitable. Medical facilities interested in EHR should contact an expert at the REC for technical and logistical support, especially if implementing large-scale computer software systems, as they can provide invaluable expertise throughout the entire process. The following steps can be used in conjunction with Regional Extension Center support to guide providers through the EHR implementation process. Step one: Assessment of current practices The first step in implementing an electronic health record system is assessing whether the facility is ready to change from a paper recordkeeping system to a computerized one, or upgrade an existing electronic system to one that meets certification requirements. To make this determination, management should evaluate the extent to which the facility s practice goals are being met, if an EHR system is affordable for the practice, and the time transitional time required until the staff and systems can effectively utilize the new technology [xxv]. Page 65

7 A thorough assessment of the current practice of recordkeeping is necessary to determine what processes are working well, and what need improvement. The assessment should include the following questions, recommended by HealthIT.gov, to assist the organization in evaluating its level of productivity and efficiency: Are administrative processes organized, efficient, and fully documented? Are clinical workflows efficient, clearly designed, and understood by all staff? Are data collection and reporting processes established and documented? Are staff members computer literate and comfortable with information technology? Does the practice have access to secure high-speed Internet connectivity? Does the practice have access to financial capital required to purchase new or additional hardware? Are there clinical priorities or other needs that should be addressed first? Does the practice have specialty-specific requirements [xxvi]? The assessment should help management envision the future of the practice, including how implementation of the EHR system will affect providers and staff members, and change the quality of care experienced by patients. Goals for guiding program implementation should be established once an organization decides to install an electronic health record system. Goals should be meaningful to the practice setting, relevant to clinical and financial goals, or the workplace environment. Using the SMART system for setting goals helps ensure they are reasonable and attainable. SMART goals are: Specific, Measureable, Attainable, Relevant, and bound by Time. This last factor means goals must be reassessed frequently to ensure decisions are based on current, accurate information to achieve the established goals as quickly and efficiently as possible. During the assessment phase, the organization should establish a team to lead the EHR implementation process. Individuals in the organization advocating conversion to an electronic system may be candidates for this position as they can help guide staff members through the transition, but should only be selected if they are can manage other responsibilities of the position as well. The assessment should provide the implementation team with a clear understanding of the process for implementing an ERH system, including specific steps necessary to complete the program [xxvii]. Step two: Create a plan An EHR implementation plan can assist team leaders in identifying tasks necessary for system setup and in what order those tasks must be completed, and stimulates discussion of the plan among team members. The team must decide which elements and processes from the old system will transfer to the new, which will no longer be used, and what new practices will replace them. This allows the implementation team to determine the characteristics of the new working environment and prioritize various plan tasks. An implementation plan should include the following steps: Analyze current workflow and assess the strengths and weaknesses of the current recordkeeping system. Determine how the EHR system can address the facility s weaknesses and improve workflow and efficiency. Create a backup plan to address possible contingencies and complications that can arise when implementing the EHR system. Plan the transition from paper or an uncertified electronic recordkeeping system to a certified system, including how and when each phase will proceed, and the name of the people managing the process. Discuss what data, such as demographic or scheduling information, will need to transfer to the new system. Page 66 Determine and document exactly how information will transfer from the old recordkeeping system to the certified EHR system, including which data elements will need manual entry, and if scanning paper records will be necessary. Discuss potential obstacles to transferring information, such as risks to the privacy of patient health information, and develop a plan for handling these issues [xxvii]. Step three: Selecting a certified electronic health record system Choosing a specific electronic health record system is one of the most important decisions in the implementation process, and people disagree about the optimum time to take this step. It is best when a practice has sufficient time to identify its healthcare goals before trying to choose an EHR system that will achieve those goals. REC produced the following list of considerations to help providers identify deficits and strengths when comparing EHR software options: Assess products from several different companies/vendors, and determine whether the system in question will help the practice accomplish the goals determined in Step 1. Discuss the practice s goals with the vendors, and discuss how these goals can be addressed to achieve meaningful use. A list of vendors that sell certified EHR systems is available at ehrcert?q=chpl [xxvii]. Clarify and confirm costs associated with purchasing and implementing the electronic health record system, including software, hardware, maintenance, upgrades, different interfaces for various departments, connecting to the health information exchange, customized report creation, potential legal fees, and any costs related to establishing or guaranteeing meaningful use. Discuss what level and type of support the provider can expect from the vender during implementation, such as the availability and scheduling of support sessions, or the educational credentials and experience of the person who will be training staff on the new system, as well as options for extended or ongoing support from the company after installation. Discuss the process of moving information from the previous recordkeeping system to the new one, who will be responsible for each task, and costs associated with this phase of the process. Clarify how information will be stored, including the location and format of the files (e.g., using a server housed on location in the medical office or offsite; web-based or text format), and assess risks related to privacy of patient information stored in this manner. Determine the ability of the prospective EHR system to integrate other, more current software or databases, such as public health registries, scheduling systems, or billing software, that will need to be installed or used after the system is in place. Discuss a primary and backup plan for information storage that ensure privacy and security. Examine and assess the factors used to determine when incentives have been earned, and how to manage payments. Evaluate the reputation of the software vendor to determine if there are any characteristics that might negatively affect their product in regard to its use or implementation, future maintenance, or support of the product [xxvii]. Vendors can help providers decide if the product will meet the provider s needs by conducting a product demonstration, or providing a list of previous customers who have successfully implemented a similar EHR system. REC can be consulted about any questions or issues that arise in selection of an EHR vendor [xxvii]. Step four: Implement the electronic health record system and train personnel The actual implementation of the electronic record system includes the physical installation of software and hardware, and pilot testing in sections of the facility to anticipate and address potential problems before system-wide installation. The implementation plan developed in step two guides this phase.

8 This step also involves the physical movement of health information from the old to the new system using data migration software or manual data entry, if necessary. Personnel must maintain the privacy and security of patient health information throughout the implementation process. Security software should be programmed to scan the system regularly to identify and address potential vulnerabilities before they become security breaches [xxvii]. Step five: Ensure the EHR system achieves meaningful use Since the CMS has an incentive program for organizations that demonstrate meaningful use of their certified electronic health record systems, the implementation process should confirm the system qualifies for meaningful use, as defined by CMS. Their primary criteria for assessing meaningful use are the extent to which they enable the practice to: Improve healthcare quality, safety, and efficiency. Engage patients and families in healthcare decisions. Improve healthcare coordination. Improve public health due to a decrease in communication wait times that therefore allow healthcare providers to address issues more quickly. Ensure privacy and security of personal health information. Each of these criteria is associated with its own set of requirements that affect a provider s eligibility for incentive payments. For example, Improving healthcare quality, safety, and efficiency, is demonstrated by ensuring there is a medication list for each patient, and, Improving Public Health, requires immunizations are submitted to national immunization registries. REC and system vendors can provide indispensable assistance in meeting meaningful use criteria [xxvii]. Step six: Continue to improve quality After implemention, the electronic health record system requires review and testing to ensure the facility s goals have been met and determine areas for improvement. During this step, team leaders should assess the need for additional training, adjustments in staffing, whether the technology is appropriate for the facility, and if it is functioning as it should. Since the actual implementation process may diverge greatly from that described in the initial plan, the facility should assess to how well the final product meets the provider s needs, and what changes, if any, are required to fulfill the EHR originally outlined in the plan. Measures of healthcare quality should be reassessed at regular intervals to ensure the system continues to meet facility objectives and expectations [xxvii]. Privacy and security Major changes in health information technology, such as greater use of electronic health information, have created an increased need for information security. Information security is the protection of information from unapproved use, access, disclosure, or modification. The information s integrity, availability, and confidentiality, as defined below, must be maintained at all times: Integrity: Health information must not be modified or destroyed by unauthorized personnel. Availability: Health information must be accessible by authorized personnel when necessary. Health Insurance Portability and Accountability Act of 1996 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established legal standards for the use and disclosure of patient health information. HIPAA requires healthcare professionals acknowledge the basic privacy rights of all patients, and explain those rights to patients. It ensures the confidentiality of protected health information (PHI), requires the use of the minimum amount of PHI necessary, and gives patients the right to see who has accessed their PHI. It also requires that all healthcare professionals who have access to PHI receive formal training on HIPAA. HIPAA establishes that healthcare workers have a professional responsibility to protect a patient s PHI. Confidentiality: Health information must not be disclosed to unauthorized personnel or systems. Federal law protects health records and ensures confidentiality of personal health information. Creating awareness of these regulations can help create an understanding of the importance of supporting the security of this information. Maintaining the privacy and security electronically stored personal information is crucial to building the trust in patients necessary to appreciate the benefits of electronic health records. It applies to all covered entities, defined as any person or group who provides healthcare services to a patient, bills for healthcare services, or receives payment for healthcare services. Examples of PHI include: Name, address, and other demographic information. Date of birth. Social Security Number. Payment history. Account, license, and record numbers. Prescription and medical history. address. Device identifiers, such as IP addresses. Genetic information. HIPAA Security Rule The HIPAA Security Rule established national standards to ensure protection of electronically communicated health information [xxviii]. Electronically transmitted health information must use HIPAAcompliant channels of communication and secure storage to protect patient records from unauthorized access. The Security Standards for the Protection of Electronic Protected Health Information (SSPEPHI), known as the HIPAA Security Rule (HSR or Security Rule), focuses on the application of HIPAA to electronic protected health information (e-phi). Since the increased use of electronic health records increases the risk of disclosing patient information, the HIPAA Security Rule was created to protect patient information in this format while encouraging the use of new technology to enhance patient care. While the HSR designates the requirements to ensure e-phi protection, the Office for Civil Rights (OCR) within the Department of Health and Human Services (DHHS) is responsible for enforcement of the HIPAA Security Rule. The HIPAA Security Rule specifies the administrative, technical, and physical security procedures that anyone who transmits health information in an electronic format must use to ensure e-phi confidentiality. Under this Security Rule, covered entities must: Ensure the confidentiality, integrity, and availability of all e-phi they create, receive, maintain, or transmit. Identify and protect against reasonably anticipated threats to the security or integrity of data. Identify and protect against reasonably anticipated impermissible uses or disclosures of data. Ensure employee compliance [xxix]. The Security Rule is designed to be flexible, since covered entities range from single provider practices to large healthcare systems, and Page 67