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Legal Nurse Consultant Sandra Krug

This is fundamentals of the electronic document management system (EDMS)

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Every healthcare organization that moves to an electronic health record (EHR) system must be ready with a strategy to deal with their existing paper patient records. Many healthcare organizations have moved into hybrid medical records, where data is recorded on a combination of paper, scanned and electronic forms. Electronic document management system (EDMS) technology provides a method to scan and archive paper document images, and track and store electronic documents.

 

Healthcare organizations struggle with challenges of managing paper-based health information in conjunction with electronic health records (EHRs).

 

EDMS is a set of computer programs that includes technologies for capturing paper-based documents as scanned images. EDMS embody a wide array of functionality and may be employed by a wide range of departments. Frequently, the health information management (HIM) department oversees the EDMS for the medical records. Independent EDMS may be found in areas like emergency department, radiology, PFS, and human resources.

 

Document imaging systems (DIMS) only capture images of forms for storage in a computer system for future retrieval. EDMS also consist of technologies for receiving and storing digital documents such as computer output laser disk (COLD) documents (electrocardiograms [EKGs], lab results, transcribed reports, voice files) generated by other internal computer systems.

 

The scanned data is essentially locked within the scanned document and is not available for reporting, preventive reminders, or decision support. In contrast, much of the data in EHRs, such as lab values, vital signs, and medications, are stored in a searchable database.

 

While you can retrieve information from scanned documents, it is a labor intensive, manual process. Reports are much easier to compile with EHRs.

 

EDMS functionality is frequently integrated into electronic document/content management (ED/CM) systems. These systems combine added functionality such as website management with workflow tools, standard templates and access rights.

 

The automated capability of EHRs makes them powerful tools for pulling together the right information at the right time in the service of patient care.

 

EDMS can also be integrated with workflow technology.

 

Workflow technology guides work on documents. It can govern when a record is ready for coding and put it into the suitable coder’s work queue. At the same time, the PFS department may access the documents for reference to generate a claims attachment.

 

The EDMS consist of tools that enable the scanning of paper medical records and capture of data already in an electronic format (faxes, Word documents, PDFs, and more) for scalable storage, swift retrieval, standardized workflow routing, commanding search capabilities, flexible access, archiving options and final disposition.

 

The EDMS system has strong security management capabilities based on customizable user permissions.

 

The capacity to select blocks of text to view is great, while work distribution for processing is effortless. Keep in mind that EDMS chiefly affords access to what was originally paper record content from multiple locations.

 

EDMS is frequently utilized as an interim technology or bridge strategy (Rhodes and Dougherty 2003) along a migration path to the EHR or as a supplemental technology to achieve a totally paperless situation.

 

Several EDMS rely on a comprehensive process for data storage, including metadata.

 

The metadata of a medical record will provide straightforward access to vital details that will help those who are searching archives. In many cases, the specific documentation for original storage protocols is a major part of what makes an EDMS so valuable to a healthcare organization.

 

Reference
Rhodes, H., and M., Dougherty. 2003. Practice brief: Document imaging as a bridge to the EHR. Journal of AHIMA 74(6):56A-56G.

Here is EHR Technologies Behind the Scenes

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An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all the key administrative clinical data relevant to that persons care under a provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.

 

EHR technologies automate access to information and streamlines the clinician’s workflow.

 

EHR technologies support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.

 

At present, healthcare organizations are taking on the innovative transformations required to implement EHR technologies. These EHRs must include hardware, software, individuals, procedure, and process components in order to make this implementation effective.

 

Types of data systems that EHR technologies contain include:

 

Source systems

for gathering data. They are information systems that populate the EHR. Administrative, clinical and financial data are encompassed in this system.
 

Source systems include:


ancillary department information systems

dietary/food service information systems

emergency department information systems

laboratory information systems (LIS)

pharmacy information systems (PIS)

physical therapy information systems

radiology information systems (RIS)
 
Source systems are sometimes differentiated by clinical specialties (like oncology or neurology), or type of services (like emergency department or cath lab). Source systems consist of smart peripherals, such as smart infusion pumps or robotics as well.
 

Clinical systems

for using data at the point of care. Their purpose is providing for specific clinical functionality. Core clinical systems are frequently thought of as the applications that comprise an EHR. These systems define whether a healthcare organization has an EHR. They include:

Clinical decision support (CDS)

provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.

CDS encompasses a variety of tools for EHR technologies to enhance decision-making in the clinical workflow.

These tools include computerized alerts and reminders to care providers and patients; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.

Medication management systems

like computerized physician order entry (CPOE) which refers to any system in which clinicians directly place orders electronically with the orders transmitted directly to the recipient, electronic medical administration record (eMAR) – technology that automatically documents the administration of medication into certified EHR technology using electronic tracking sensors, and bar code medication administration record (BC-MAR) – pairs implementation of eMAR with item-specific identification (bar-coding).

Point-of-Care (POC) systems

clinicians enter data as they care for patients utilizing POC charting systems. These POCs are used for documentation including
taking a patient’s history, detailing physical exams and assessments, and composing physician progress notes or nurses’ notes.

Results management systems

diagnostic study results can be trended with other data, like medication administration.
 

Support systems

combine data from applications internal to a healthcare organization. Supporting infrastructure include:

clinical data repositories (CDRs)

a database that captures and sorts data in one location,

clinical data warehouses (CDWs)

a database allowing advanced data analysis for every service within the organization,

rules engine

controls reminders, order sets and protocols, and supplies CDR with programming logic for CDSS,

knowledge source

supplies data from external sources to rules engine,

presentation layer software and human-computer interfaces

facilitate data capture at POC,

report writers

assemble data into reports,

storage systems

(like storage area networks [SANs]) – back up and archive data.
 

Connectivity systems

support combination of data across different organizations and with patients or caregivers. A growing use of the EHR across the continuum of care, for quality measurement and reporting and for population health, is necessitating hardware and software that allows transmission of data across local and wide area networks in a secure and privacy-protected manner. The result has been the creation of various forms of health information exchange (HIE) among disparate organizations:

Continuity of care records (CCRs) and continuity of care documents (CCDs)

are standard specifications developed by different groups of organizations to achieve similar goals: improved continuity of healthcare, a reduction in medical errors, and improved health information transportability between patients, providers, and health care institutions.

It is particularly important to note that the CCD or CCR is not the underlying personal health record itself; rather it is an interchange.

The CCD and CCR provide the ability for one record to extract information, and for the next record to insert the information extracted into its own system.

Personal health records (PHRs)

to which providers and individuals contribute data and which assist individuals in managing consent for disclosure of information.

Technology for connectivity

like portals offering remote access to medical records for physicians or patients.
 
HIEs may include the ability for health plans to contribute comprehensive problem lists and medication lists to provide or individuals’ PHRs and for providers to add data to public health departments.

 

Source systems, Core clinical systems and Supporting infrastructure systems can be standalone systems within a hospital. But in the ambulatory care environment, they tend to be connected.

 

Clinical information systems ensure maximum effectiveness when the data is cohesive across all the systems and with data from all sources. Technical elements of the EHR systems, consistent with policy, must be present for individuals to utilize for the numerous processes they carry out.

 

EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians. The data, and the timeliness and availability of it, will enable providers to make better decisions and provide better care.

Point-of-care (POC) in a system delivered improved charting

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Point-of-care (POC) documentation has been identified as a patient safety measure for improving accuracy and timeliness of charting healthcare data.

 

POC Charting Systems

Clinicians enter data as they care for patients utilizing POC charting systems. These POCs are used for documentation including taking a patient’s history, detailing physical exams and assessments, and composing physician progress notes or nurses’ notes.

 

When first presented, POCs required substantial deviations in clinician workflow. The POCs were time-consuming and problematic to use. Bedside terminals soon began to be employed, because returning to a few terminals at the nursing station was insufficient.

 

Health Insurance Portability and Accountability Act/privacy concerns, and perceptions of the patients’ response to charting on computers in patient rooms were all barriers to point-of-care documentation.

 

Changes in both nursing practices and hospital infrastructure occurred to overcome these barriers to point-of-care documentation.

 

Today, POCs are more sophisticated.

 

Data entry is completed using wireless laptops or tablets fastened to carts. These POCs were originally referred to as computers on wheels (COWs) but are now called workstation on wheels (WOWs).

 

Within hospital settings, POCs centered mainly on nursing staff documentation in the past. But they are now increasingly supporting other clinicians and physicians, although to a more limited extent. Within the ambulatory setting, electronic health records (EHRs) are used by all clinicians, though particularly the physicians and nurses.

 

Data entered into POC systems may be structured or unstructured

  • Structured or discrete data are predefined in a table or checklist for charting the patient’s information from a drop-down menu or a checklist. This enables standard values to be supplied for specific variables. The data can be applied to clinical decisions and provide standard denotation for reporting purposes.
  • Unstructured or narrative data are typed or dictated reports. This is problematic to use in searches or for reporting purposes and generally are not converted into tabular or graphic form. Because the clinician is not limited to the boxes and drop-down lists, this data can be vital to guarantee comprehensive charting.

 

Structured data capture can transpire in a variety of ways. Very commonly, drop-down menus or checkboxes are applied to select data points on templates. Smart text is a code representing a whole phrase, sentence, or paragraph. Voice commands, touchscreen or the standard keyboard can initiate any of these methods.

 

A clinician may type the first few letters of the word, and “Type ahead” function can present a list of words to choose. Several EHR’s track data frequently used by the clinician and assemble a list of favorites to decrease the time it would take if selecting from a long, generic list.

 

Unstructured data capture transpires by the dictation processes, often using word processing functions such as copy and paste and drag-and-drop. Unstructured data entry aids can be helpful but can lead to errors and compliance issues.

 

The most sophisticated systems apply natural language processing to unstructured data, which permits the narrative text to be converted to structured data for processing by the computer.

 

Pros and Cons of POC

POC charting in patients’ rooms is a recent shift in technology use in hospitals, reducing inefficiencies, decreasing the probability of errors, promoting information transfer, and encouraging the nurse to be at the bedside.
POC charting has the potential to distract the nurse’s attention away from the patient and compromise the nurse-patient interaction.

Will EHR Technology Help Overcome Medical Errors?

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In 1991 the Institute of Medicine (IOM) issued a report on improving patient records which has proven to be a landmark for the many individuals and institutions involved in the development of computer-based patient records (CPRs). The report called Computer-based Patient Records: An Essential Technology for Health Care, recommended that CPRs become the primary form for patient records, and urged widespread implementation of CPRs within a decade.

 

The IOM coined the phrase CPR, which is now referred to as EHR (electronic health record).

 

Regardless of the ever-greater demands of information capabilities called for in the IOM patient records report, advancement was sluggish until 1999. That was the year the IOM published another landmark work that shocked the nation into true action.

 

To Err Is Human was the first in a series of reports portraying the U. S. “healthcare quality chasm.”

 

This report emphasized two studies. One study approximated that medical errors kill 44,000 people in U. S. hospitals yearly and the other study approximated the number was closer to 98,000 deaths per year.

 

Headlines in national newspapers opined that even in view of the lower estimate, these deaths exceeded those from highway accidents, breast cancer, or AIDS. The media further declared that these deaths were comparable to a 747 aircraft crashing and killing all its passengers every day – without the culpability for investigation that the Federal Aviation Agency completes on every crash.

 

The report stressed that there were no “magic bullets” to correct this tragedy but building a culture of safety – without attaching blame to individuals – was vital.

 

The report recommended that well-understood safety standards should be implemented, such as planning jobs and working conditions for safety: standardizing and simplifying equipment, supplies, and procedures; and avoiding reliance on memory through automated information and decision support systems (IOM 1999, 22, 34).

 

Sadly, a more recent study by HealthGrades (2008) found nearly double the number of deaths from medical errors. This further serves as a wake-up call for embracing technology to improve patient safety. It has also been discovered that care delivery organizations with EHR’s are more likely to report adverse events (Merrill 2009).

 

The IOM has not stopped encouraging use of “computational technology for effective health care,” the title of the 2009 research study conducted in conjunction with the National Research Council. Where the IOM’s series of reports on medical errors described the need to cross the “healthcare quality chasm,” this report describes the need to cross the “healthcare IT chasm.”

 

The study included onsite visits to eight medical centers around the country recognized as leaders in joining IT with healthcare. Even with finding several successes and substantial money expended on IT, the report detected that “today’s healthcare fails to deliver the most effective care and suffer substantially as a result of medical errors. In addition, many medical interventions undertaken today are in fact not necessary” (Stead and Lin 2009, 3).

 

The report comments that “these persistent problems do not reflect incompetence on the part of healthcare professionals, rather they are a consequence of the inherent intellectual complexity of healthcare taken as a whole and the medical care environment that is not adequately structured to help clinicians avoid mistakes or to symptomatically improve their decision-making and practice” (Stead and Lin 2009, 3).

 

Legal nurse consultants (LNCs) assist attorneys with the high stakes field of medical errors litigation. We help attorneys negotiate the most complicated medical aspects of their cases with insider knowledge grown from years on the front lines of the healthcare community.

Our LNCs can also recognize breaches in the standard of care in a medical malpractice case. They help attorneys identify their strong cases and stop them from taking on weak cases. Our LNCs also provide many other valuable functions, such as determining proximate cause for client injuries, assessing damages, and assisting with case strategy.

 

Call Krug Consulting today to review your cases involving EHRs.
Click to call us at 1 (844) LNC-KRUG • or Contact Us via email

 

References and Resources

Institute of Medicine. 1999. To Err is Human: Building a Safer Health System, edited by L.T. Kohn, J.M. Corrigan, and M.S. Donaldson. Washington, DC: National Academies Press.

HealthGrades. 2008. Fifth Annual Patient Safety in American Hospitals Study. Golden, CO: HealthGrades.

Merrill, M. 2009 (December 9). Doctors with an EMR are more likely to report adverse events. Healthcare IT News. http://www.healthcareitnews.com.

Stead, W.W., and H.S. Lin, eds. 2009. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Research Council of the National Academies. Washington, Dc: National Academy Press. P. 3.

History of the Useful Electronic Health Record Technology

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In 2004 President George W. Bush suggested that all Americans should have have an electronic health record (EHR) by the year 2014.  

A key component of these EHRs was the improvement of medication management.

In 2006 the Healthcare Information Management and Systems Society (HIMSS) Analytics began tracking the rate of adoption of EHR mechanisms in hospitals. They found that only 3.6% of hospitals had computerized provider order entry (CPOE) and electronic medication administration records (EMARs).

 

Electronic health records can be implemented in a variety of ways, provide many different functions, and achieved a multiplicity of purposes. In 2008, the federal government requested the development of definitive definitions for electronic health records.

These definitions are:

  • Electronic medical record – an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.
  • Electronic health record – an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.

 

In 2008, HIMSS Analytics found an increase of only 5.8% of hospitals using the applications. Therefore, in 2009 President Barack Obama incorporated incentives for hospitals and physicians to make meaningful use of certified EHR technology into his legislation (the American Recovery and Reinvestment Act [ARRA] of 2009 and Health Information Technology for Economic and Clinical Health Act [HITECH]. This incentive program is referred to simply as meaningful use (M.U.).

 

In 2010, the federal government published regulations that illustrated prerequisites to receiving incentives for M.U. of certified EHR technology. They implemented the term EHR, but also added a definition of qualified EHR (45 CFR 170 Subpart B):

      A qualified EHR is an electronic record of health-related information on an individual that –

1. includes patient demographic and clinical health information, such as medical history and problem list, and

2. has the capacity to –

a. provide clinical decision support;

b. support physician order entry;

c. capture and query information relevant to healthcare quality; and

d. exchange electronic health information with and integrate such

information from other sources (ARRA 2009).

 

By 2012, HIMSS Analytics acknowledged that 25% of hospitals had adopted CPOE systems and other essential EHR tools. HIMSS Analytics also began tracking ambulatory care facilities for their implementations of EHRs in 2012 and estimated that fewer than half of physicians used any form of automation. But when using automation, the majority were at least basic EHR systems (HIMSS Analytics 2012).  

 

Certified EHR Technology (CEHRT) is the name used to describe EHR products meeting specified standards and criteria. The M.U. criteria integrated stronger functionality than typically employed in the past but excluded some functionality necessary for implementation of EHRs.

The federal government acknowledged functionality issues in two ways:

1. they permitted EHR products to have one of two certifications-

complete: all functionality that would enable users to earn the M.U. incentives were included, or

modular: only certain functionality was included in the product. To be able to earn incentives the organization had to use a set of modular products that, together, address all required criteria.

2. they observed that the M.U. certification criteria represented the minimum capabilities EHR technology needed to include and have properly implemented to achieve certification for the purposes of earning incentives and that these criteria do not preclude complete EHR vendors from including additional capabilities not required for certification (Federal Register 2010, 44595).

A data brief made available on the HealthIT.gov Dashboard showed hospital adoption of basic EHR technology rose from 75.5% in 2014 to 83.8% in 2015 but put the percentage of hospitals with CEHRT at 96% in 2015, down nearly a full percentage point from 2014’s figure of 96.9%.

In 2017, 96 percent of all non-federal acute care hospitals possessed certified health IT. Small rural and critical access hospitals had the lowest rates at 93 percent. Ninety-nine percent of large hospitals (more than 300 beds) had certified health IT, while 97 percent of medium-sized hospitals (more than 100 beds) had certified health IT.

As of July 2017, 684 health IT developers supply certified health IT to 354,395 ambulatory primary care physicians, medical and surgical specialists, podiatrists, optometrists, dentists, and chiropractors participating in the Medicare EHR Incentive Program.

Of those 354,395 providers, over 82% have 2014 certified edition technology. Epic Systems, Allscripts, eClinicalWorks, athenahealth, and NextGen Healthcare supply 2014 certified technology to 60% of all providers that have reported 2014 edition technology. Epic Systems, alone, supplies 2014 certified technology to over 30% of all those providers.

Adoption of EHR systems has steadily increased since HITECH. Basic EHR adoption represents a minimum use of core functionality determined to be essential to an EHR system. Moreover, since the passage of the HITECH Act in 2009, state EHR adoption rates have increased.

In addition to growth in EHR adoption overall, hospital adoption of technology with advanced functionality increased significantly. While fewer hospitals used Basic EHR systems without clinician notes, significantly more adopted systems with clinician notes.

Finally, a vast majority of acute care hospitals (97%) possess EHR technology certified to meet federal requirements. These hospitals should have the technology needed to meet EHR Incentive Program objectives.

These systems are also certified to be secure and able to work with other certified systems to share information. Thus, the increase in the rate of adoption for certified EHR technology shed a positive light on hospitals’ progress towards the interoperable exchange of health information.

If you are an attorney, please contact Krug Consulting to assist with all of your cases involving EHRs.

Click to call us at 1 (844) LNC-KRUG • or Contact Us via email

Our Legal Nurse Consultants will review all the relevant documents, prepare reports, research injuries and locate experts for plaintiff or defense.

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References and Resources

45 CFR 170 Subpart B. 2010 (July 28). Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, Final Rule.

Federal Register, 2010 (July 28). 45 CFR 170: Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for EHR Technology; Final Rule, p. 44595. 

Healthcare Information Management and Systems Society. 2006-2013. HIMSS Analytics US EMR Adoption Model. Chicago, IL:HIMSS.

National Alliance for Health Information Technology. 2008 (April 28). Report to the Office of the National Coordinator for Health Information Technology on Defining Key Health Information Technology Terms.