Current Electronic Health Record Research Articles

A call to action for optimizing the electronic health record in the parenteral nutrition workflow

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

Diabetes Educators' Insights Regarding Connecting Mobile Phone- and Wearable Tracker-Collected Self-Monitoring Information to a Nationally-Used Electronic Health Record System for Diabetes Education: Descriptive Qualitative Study.

BackgroundDiabetes educators are integral to a clinical team in providing diabetes self-management education and support; however, current mobile and Web-based self-management tools are not integrated into clinical diabetes care to support diabetes educators’ education efforts.ObjectiveThe objective of our study was to seek diabetes educators’ insights regarding the development of an interface within the Chronicle Diabetes system, a nationally used electronic health record (EHR) system for diabetes education documentation with behavioral goal-setting functions, to transfer mobile phone- and wearable tracker-collected self-monitoring information from patients to diabetes educators to facilitate behavioral goal monitoring.MethodsA descriptive qualitative study was conducted to seek educators’ perspectives on usability and interface development preferences in developing a connected system. Educators can use the Chronicle Diabetes system to set behavioral goals with their patients. Individual and group interviews were used to seek educators’ preferences for viewing mobile phone- and wearable tracker-collected information on diet, physical activity, and sleep in the Chronicle Diabetes system using open-ended questions. Interview data were transcribed verbatim and analyzed for common themes.ResultsFive common themes emerged from the discussion. First, educators expressed enthusiasm for and concerns about viewing diet and physical activity data in Chronicle Diabetes system. Second, educators valued viewing detailed dietary macronutrients and activity data; however, they preferred different kinds of details depending on patients’ needs, conditions, and behavioral goals and educators’ training background. Third, all educators liked the integration of mobile phone-collected data into Chronicle Diabetes system and preferably with current EHR systems. Fourth, a need for a health care team and a central EHR system to be formed was realized for educators to share summaries of self-monitoring data with other providers. Fifth, educators desired advanced features for the mobile app and the connected interface that can show self-monitoring data.ConclusionsFlexibility is needed for educators to track the details of mobile phone- and wearable tracker-collected diet and activity information, and the integration of such data into Chronicle Diabetes and EHR systems is valuable for educators to track patients’ behavioral goals, provide diabetes self-management education and support, and share data with other health care team members to faciliate team-based care in clinical practice.

A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

A Call to Action for Optimizing the Electronic Health Record in the Parenteral Nutrition Workflow.

Parenteral nutrition (PN) is a complex therapeutic modality provided to neonates, children, and adults for various indications. Surveys have shown that current electronic health record (EHR) systems are in need of functionality enhancement for safe and optimal delivery of PN. This is a consensus statement from the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, and the American Society of Health-System Pharmacists outlining some of the key challenges to prescribing, order review/verification, compounding, and administration of PN using EHRs today and is a call to action for clinicians and vendors to optimize their EHRs regarding the PN build and workflow.

Data standards for interoperability of care team information to support care coordination of complex pediatric patients

ObjectiveSeamless access to information about the individuals and organizations involved in the care of a specific patient (“care teams”) is crucial to effective and efficient care coordination. This is especially true for vulnerable and complex patient populations such as pediatric patients with special needs. Despite wide adoption of electronic health records (EHR), current EHR systems do not adequately support the visualization and management of care teams within and across health care organizations. Electronic health information exchange has the potential to address this issue. In the present study, we assessed the adequacy of available health information exchange data standards to support the information needs related to care coordination of complex pediatric patients. MethodsWe derived data elements from the information needs of clinicians and parents to support patient care teams; and mapped them to data elements in the Health Level Seven (HL7) Consolidated Clinical Document Architecture (C-CDA) standard and in the HL7 Fast Healthcare Interoperability Resources (FHIR) standard. We also identified additional C-CDA data elements and FHIR resources that include patients’ care team members. ResultsInformation about care team members involved in patient care is generally well-represented in the C-CDA and FHIR specifications. However, there are gaps related to patients’ non-clinical events and care team actions. In addition, there is no single place to find information about care team members; rather, information about practitioners and organizations may be available in several different types of C-CDA data elements and FHIR resources. ConclusionThrough standards-based electronic health information exchange, it appears to be feasible to build patient care team representations irrespective of the location of patient care. In order to gather care team information across disparate systems, exchange of multiple C-CDA documents and/or execution of multiple FHIR queries will be necessary. This approach has the potential to enable comprehensive patient care team views that may help improve care coordination.

A survey of chiropractic intern experiences learning and using an electronic health record system.

Previous research has discussed various challenges to introducing an electronic health record (EHR) to first-time health professional students. Chiropractic interns face similar challenges. Interns' perceptions about learning and using an EHR were assessed. An anonymous electronic survey was sent to interns of our outpatient chiropractic clinic requesting their relative agreement or disagreement to statements in nine domains. Since perceptions of EHR have been shown to change with increased time spent using an EHR, the survey also sought to compare more experienced users (8th semester) to novices (7th semester). Data were analyzed for relative agreement to statements related to learning the use of the EHR. Interns also provided other written comments. There was a 51% overall response rate, evenly divided between 7th and 8th semester interns. Interns generally concurred that they were adept at using the current EHR and those with more experience responded they were more adept than those with less EHR familiarity. Interns strongly agreed that the EHR facilitated gathering information about patients through the ability to review previous clinical notes, tests, and medication lists. Experienced interns were more likely to enter data after the encounter was over and novice users more commonly entered data during the encounter. This information regarding interns' EHR experiences may provide strategies that lead to improvements in intern EHR education. Having insight into learners' experiences can provide important input to the EHR features that should be considered carefully by institutions and individual purchasers alike.

Moving From Problem-Oriented to Goal-Directed Health Records

Electronic health records (EHRs) have been in place for decades; however, most existing systems were designed in the prevailing disease- and payment-focused care paradigm that often loses sight of the goals, needs, and values of patients and clinicians. The goal-directed health care model was proposed more than 20 years ago, but no design principles have been developed for corresponding electronic record systems. Newly designed EHRs are needed to facilitate health care that is anchored by patient life and health goals. We explore the limitations of current EHRs and propose a blueprint for a new EHR design that may facilitate goal-directed health care. To reflect patient goals as a thread through the care continuum, we propose 5 major system functions for goal-directed health records based on the 8 characteristics of primary health care defined by the Institute of Medicine. We also discuss how new EHR functions could support goal-directed health care and how payment and quality measurement systems will need to be transformed. It may be possible for patient life and health goals to drive health care that is reinforced by a corresponding health record design; however, synchronized shifts must occur in the models of providing, documenting, and paying for health care.

Archetype modeling methodology

Clinical Information Models (CIMs) expressed as archetypes play an essential role in the design and development of current Electronic Health Record (EHR) information structures. Although there exist many experiences about using archetypes in the literature, a comprehensive and formal methodology for archetype modeling does not exist. Having a modeling methodology is essential to develop quality archetypes, in order to guide the development of EHR systems and to allow the semantic interoperability of health data. In this work, an archetype modeling methodology is proposed. This paper describes its phases, the inputs and outputs of each phase, and the involved participants and tools. It also includes the description of the possible strategies to organize the modeling process. The proposed methodology is inspired by existing best practices of CIMs, software and ontology development. The methodology has been applied and evaluated in regional and national EHR projects. The application of the methodology provided useful feedback and improvements, and confirmed its advantages. The conclusion of this work is that having a formal methodology for archetype development facilitates the definition and adoption of interoperable archetypes, improves their quality, and facilitates their reuse among different information systems and EHR projects. Moreover, the proposed methodology can be also a reference for CIMs development using any other formalism.

Using a Best Practices Advisory (BPA) Alert Tool to Identify and Enhance Outpatient Palliative Care (OPC) Referrals for Stage 4 Cancer Patients (FR461B)

•Understand the present state of oncology referrals to outpatient palliative care•Understand a way to enhance integration of palliative care in the outpatient oncology clinic setting by using active prompting system to help oncologist assess need for OPC OPC referrals from oncology clinics using the current electronic health record (EHR) are significantly under-utilized and do not meet national cancer guidelines. To develop a BPA Alert tool in the Epic® HER to identify appropriate patients for OPC referral. To use that tool to increase Oncology-OPC integration. In a first phase silent pilot study without health care provider knowledge, BPA Alert criteria were used to trigger an OPC referral that included:•stage IV or metastatic disease and•no palliative visit in last six months and•not on hospice In a second phase live study, the BPA Alert tool was activated in the Thoracic Oncology Clinic. In two oncology clinics over a six-week period using the silent BPA alert, the following results were:•Number of patients seen: 1,654.•Number of total patients meeting criteria 17% (284/1654).•Number of patients meeting criteria who were referred to OPC: 5% (14/284).•At five weeks using the active BPA Alert, the following results were available:•One-hundred-fifty-nine patients met criteria for OPC referral.•Sixteen/159 or 10% were referred to OPC, a doubling compared with the silent pilot.•Twenty-two/159 or 13.8 % provided acknowledgment of palliative care plans already in place (by clicking the appropriate button within the BPA Alert drop-down menu). Using this electronic BPA Alert, 38/159 or 23.9% of patients had documentation that palliative needs were addressed. In the next step phase, it will be introduced in the GI Oncology clinic. Data collection is ongoing.

Electronic Health Records: Patient Care and Ethical and Legal Implications for Nurse Practitioners

Electronic health records (EHRs), with their adoption incentivized as part of the American Recovery and Reinvestment Act of 2009, are now a ubiquitous part of the health care landscape. Although these systems promised to improve the quality of patient care, increase efficiency, and reduce costs, health care providers are finding that current EHRs instead require time-consuming data entry, can interfere with patient interactions, and cause medical errors. Nurse practitioners should implement practical tips and best practices for navigating and successfully using EHRs, as well as risk management strategies to ensure better patient care and avoid malpractice litigation or licensing issues.

Usability Evaluation of Electronic Health Record System around Clinical Notes Usage-An Ethnographic Study.

Background A substantial gap exists between current Electronic Health Record (EHR) usability and potential optimal usability. One of the fundamental reasons for this discrepancy is poor incorporation of a User-Centered Design (UCD) approach during the Graphical User Interface (GUI) development process. Objective To evaluate usability strengths and weaknesses of two widely implemented EHR GUIs for critical clinical notes usage tasks. Methods Twelve Internal Medicine resident physicians interacting with one of the two EHR systems (System-1 at Location-A and System-2 at Location-B) were observed by two usability evaluators employing an ethnographic approach. User comments and observer findings were analyzed for two critical tasks: (1) clinical notes entry and (2) related information-seeking tasks. Data were analyzed from two standpoints: (1) usability references categorized by usability evaluators as positive, negative, or equivocal and (2) usability impact of each feature measured through a 7-point severity rating scale. Findings were also validated by user responses to a post observation questionnaire. Results For clinical notes entry, System-1 surpassed System-2 with more positive (26% vs. 12%) than negative (12% vs. 34%) usability references. Greatest impact features on EHR usability (severity score pertaining to each feature) for clinical notes entry were: autopopulation (6), screen options (5.5), communication (5), copy pasting (4.5), error prevention (4.5), edit ability (4), and dictation and transcription (3.5). Both systems performed equally well on information-seeking tasks and features with greatest impacts on EHR usability were navigation for notes (7) and others (e.g., looking for ancillary data; 5.5). Ethnographic observations were supported by follow-up questionnaire responses. Conclusion This study provides usability-specific insights to inform future, improved, EHR interface that is better aligned with UCD approach.

Interoperable informatics for health enterprise transformation

ABSTRACTThe U.S. healthcare system is arguably undergoing its most significant transformation since the introduction of Medicare and Medicaid in the 1960s. As then, covering more citizens is a motivation, but the larger effort now is toward creating a high-quality, safe, precise, and cost-effective system. There is broad agreement that accomplishing these objectives requires widely adopted, interoperable digital health records and related clinical tools, including those used by patients. In parallel, sophisticated analysis of the data from these systems and tools is required to gain deeper understanding of care processes and optimal care delivery. Current electronic health record systems and tools are in need of innovative approaches to increase their usability and impact on care. Health Level Seven's (R) rapidly emerging Fast Healthcare Interoperability Resources standard may provide a practical solution to interoperability and for innovation to feedback new knowledge gained from past care to support bet...

Electronic Health Records: Then, Now, and in the Future.

Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved. Literature search based on "Electronic Health Record", "Medical Record", and "Medical Chart" using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review. By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today's rapidly changing healthcare environment. The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

Testing electronic health records in the "production" environment: an essential step in the journey to a safe and effective health care system.

Thorough and ongoing testing of electronic health records (EHRs) is key to ensuring their safety and effectiveness. Many health care organizations limit testing to test environments separate from, and often different than, the production environment used by clinicians. Because EHRs are complex hardware and software systems that often interact with other hardware and software systems, no test environment can exactly mimic how the production environment will behave. An effective testing process must integrate safely conducted testing in the production environment itself, using test patients. We propose recommendations for how to safely incorporate testing in production into current EHR testing practices, with suggestions regarding the incremental release of upgrades, test patients, tester accounts, downstream personnel, and reporting.

Development and significance of automated history-taking software for clinical medicine, clinical research and basic medical science.

Development and significance of automated history-taking software for clinical medicine, clinical research and basic medical science.

Provider Adherence to Evidence-Based Asthma Guidelines in a Community Health Center.

Background: Improved outcomes for patients with asthma have been proven with the use of the Expert Panel Report 3 (EPR-3) evidence-based asthma guidelines. These clinical guidelines are tools developed for providers to direct appropriate high-quality patient care that leads to positive outcomes. However, research has shown health care providers do not routinely follow the evidence-based asthma guidelines adequately. Objective: To develop and implement an evidence-based asthma protocol in a community clinic and improve provider adherence and attitudes/beliefs to the EPR-3 guidelines resulting in improved asthma outcomes, asthma control, and self-management for patients with asthma. Methods: The study was conducted in 2 parts over a period of 3 months. First, all medical providers at a community clinic were invited to participate in the research study. The intervention included implementing the asthma protocol within the current electronic health record (EHR). A pre- and postintervention questionnaire measuring provider's adherence and attitudes to evidence-based practice was administered. In addition, pre- and postclinic aggregate data for International Classification of Diseases codes specific to asthma that correlate to 7 identified aims based on the EPR-3 guidelines were collected. Results: Results show statistical significance among the provider attitudes/beliefs with the intervention, the greatest effect being found for the medical doctors. Four of the 7 aims showed improvement. Conclusions: The findings of this application research quality improvement study indicate that providing necessary tools and resources needed to adhere to evidence-based asthma guidelines can positively affect providers' adherence and attitudes/beliefs toward evidence-based guidelines.

Identifying opportunities in EHR to improve the quality of antibiotic allergy data.

Antimicrobial resistance is a growing, global public health crisis, due in large part to the overuse and misuse of antibiotics. Understanding medication allergy data and allergy reactions that are documented in electronic health records (EHRs) can help to identify opportunities to improve the quality of documentation of beta-lactam allergies, thus potentially reducing the prescribing of alternative antibiotics. Medication allergies and allergy reactions recorded in the EHR for 319 051 patients seen across 32 community health centers were reviewed. Patients with a beta-lactam allergy recorded in their EHR were identified. Free text, as well as standardized allergy and allergy reaction fields, were analyzed. Among patients, 9.1% (n = 29 095) had evidence of a beta-lactam allergy recorded in their EHR. Women, white, and non-Hispanic patients were more likely to have a documented allergy compared to men, black, and Hispanic patients. Among all patients with a documented beta-lactam allergy, 36.2% had an empty or missing allergy reaction description in their EHR. Findings suggest that current EHR documentation practices among the health centers reviewed do not provide enough information on allergic reactions to allow providers to discern between true allergies and common, but anticipated, drug side effects. Improved EHR documentation guidance, training that reinforces the use of standardized data and more detailed recording of allergic reactions, combined with initiatives to address patient barriers including health literacy, may help to improve the accuracy of drug allergies in patients' records. These initiatives, combined with antimicrobial stewardship programs, can help to reduce inappropriate prescribing of alternative antibiotics when beta-lactam antibiotics are first-line and can be tolerated.

Development of a Hospital Outcome Measure Intended for Use With Electronic Health Records: 30-Day Risk-standardized Mortality After Acute Myocardial Infarction.

Electronic health records (EHRs) offer the opportunity to transform quality improvement by using clinical data for comparing hospital performance without the burden of chart abstraction. However, current performance measures using EHRs are lacking. With support from the Centers for Medicare & Medicaid Services (CMS), we developed an outcome measure of hospital risk-standardized 30-day mortality rates for patients with acute myocardial infarction for use with EHR data. As no appropriate source of EHR data are currently available, we merged clinical registry data from the Action Registry-Get With The Guidelines with claims data from CMS to develop the risk model (2009 data for development, 2010 data for validation). We selected candidate variables that could be feasibly extracted from current EHRs and do not require changes to standard clinical practice or data collection. We used logistic regression with stepwise selection and bootstrapping simulation for model development. The final risk model included 5 variables available on presentation: age, heart rate, systolic blood pressure, troponin ratio, and creatinine level. The area under the receiver operating characteristic curve was 0.78. Hospital risk-standardized mortality rates ranged from 9.6% to 13.1%, with a median of 10.7%. The odds of mortality for a high-mortality hospital (+1 SD) were 1.37 times those for a low-mortality hospital (-1 SD). This measure represents the first outcome measure endorsed by the National Quality Forum for public reporting of hospital quality based on clinical data in the EHR. By being compatible with current clinical practice and existing EHR systems, this measure is a model for future quality improvement measures.

Impact of the HITECH Act on physicians' adoption of electronic health records.

The Health Information Technology for Economic and Clinical Health (HITECH) Act has distributed billions of dollars to physicians as incentives for adopting certified electronic health records (EHRs) through the meaningful use (MU) program ultimately aimed at improving healthcare outcomes. The authors examine the extent to which the MU program impacted the EHR adoption curve that existed prior to the Act. Bass and Gamma Shifted Gompertz (G/SG) diffusion models of the adoption of "Any" and "Basic" EHR systems in physicians' offices using consistent data series covering 2001-2013 and 2006-2013, respectively, are estimated to determine if adoption was stimulated during either a PrePay (2009-2010) period of subsidy anticipation or a PostPay (2011-2013) period when payments were actually made. Adoption of Any EHR system may have increased by as much as 7 percentage points above the level predicted in the absence of the MU subsidies. This estimate, however, lacks statistical significance and becomes smaller or negative under alternative model specifications. No substantial effects are found for Basic systems. The models suggest that adoption was largely driven by "imitation" effects (q-coefficient) as physicians mimic their peers' technology use or respond to mandates. Small and often insignificant "innovation" effects (p-coefficient) are found suggesting little enthusiasm by physicians who are leaders in technology adoption. The authors find weak evidence of the impact of the MU program on EHR uptake. This is consistent with reports that many current EHR systems reduce physician productivity, lack data sharing capabilities, and need to incorporate other key interoperability features (e.g., application program interfaces).

Can Health Care Survive Current Electronic Health Record Usability?

Can Health Care Survive Current Electronic Health Record Usability?