Electronic Health Record Products Research Articles

A Brief History of Public Health Informatics-Lessons for Leaders and a Look Into the Future.

A Brief History of Public Health Informatics-Lessons for Leaders and a Look Into the Future.

Pilot Testing of Simulation in the Evaluation of a Novel, Rapidly Deployable Electronic Health Record for use in Disaster Intensive Care.

The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training. We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX). A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed. Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.

Improving Student Confidence With Electronic Health Record Order Entry.

Despite near-universal utilization of electronic health records (EHRs) by physicians in practice, medical students in most ambulatory settings gain limited experience with placing EHR orders. In this study, an individual preceptor site investigated the usefulness of a targeted curriculum in improving students' EHR confidence and clinical reasoning skills. Family medicine clerkship students assigned to one community health center were invited to participate in this prospective, survey-based study. In their first week, students observed a preceptor performing EHR tasks. For the remainder of the 4-week clerkship, students utilized decision support tools, assigned a working diagnosis, entered unsigned orders in the EHR, proposed an assessment, and discussed a plan with a preceptor. Students completed weekly questionnaires to self-report confidence across several EHR domains while preceptors synchronously evaluated students' accuracy with entering orders correctly. From February 2017 to March 2020, all 49 eligible students completed the study. One hundred percent of students reported that placing EHR orders was beneficial to their medical education. The difference over time in learner confidence with placing EHR orders was statistically significant across every domain (eg, writing prescriptions, ordering labs and imaging). Preceptors' evaluations of students' accuracy with placing orders also showed significant improvement between each week. Clerkship-wide EHR training may be limited by multiple sites with multiple EHR products. This pilot study suggests that committed faculty at an individual preceptor site can offer a targeted curriculum to help students develop EHR confidence. We propose other preceptors similarly offer students this opportunity to maximize clerkship education.

Multidisciplinary Sprint Program Achieved Specialty-Specific EHR Optimization in 20 Clinics.

The objective of the study was to highlight and analyze the outcomes of software configuration requests received from Sprint, a comprehensive, clinic-centered electronic health record (EHR) optimization program. A retrospective review of 1,254 Sprint workbook requests identified (1) the responsible EHR team, (2) the clinical efficiency gained from the request, and (3) the EHR intervention conducted. Requests were received from 407 clinicians and 538 staff over 31 weeks of Sprint. Sixty-nine percent of the requests were completed during the Sprint. Of all requests, 25% required net new build, 73% required technical investigation and/or solutions, and 2% of the requests were escalated to the vendor. The clinical specialty groups requested a higher percentage of items that earned them clinical review (16 vs. 10%) and documentation (29 vs. 23%) efficiencies compared with their primary care colleagues who requested slightly more order modifications (22 vs. 20%). Clinical efficiencies most commonly associated with workbook requests included documentation (28%), ordering (20%), in basket (17%), and clinical review (15%). Sprint user requests evaluated by ambulatory, hardware, security, and training teams comprised 80% of reported items. Sprint requests were categorized as clean-up, break-fix, workflow investigation, or new build. On-site collaboration with clinical care teams permitted consensus-building, drove vetting, and iteration of EHR build, and led to goal-driven, usable workflows and EHR products. This program evaluation demonstrates the process by which optimization can occur and the products that result when we adhere to optimization principles in health care organizations.

Association of Electronic Health Record Use Above Meaningful Use Thresholds With Hospital Quality and Safety Outcomes

By 2018, Medicare spent more than $30 billion to incentivize the adoption of electronic health records (EHRs), based partially on the belief that EHRs would improve health care quality and safety. In a time when most hospitals are well past minimum meaningful use (MU) requirements, examining whether EHR implementation beyond the minimum threshold is associated with increased quality and safety may guide the future focus of EHR development and incentive structures. To determine whether EHR implementation above MU performance thresholds is associated with changes in hospital patient satisfaction, efficiency, and safety. This quantile regression analysis of cross-sectional data used publicly available data sets from 2362 acute care hospitals in the United States participating in both the MU and Hospital Value-Based Purchasing (HVBP) programs from January 1 to December 31, 2016. Data were analyzed from August 1, 2019, to May 22, 2020. Seven MU program performance measures, including medication and laboratory orders placed through the EHR, online health information availability and access rates, medication reconciliation through the EHR, patient-specific educational resources, and electronic health information exchange. The HVBP outcomes included patient satisfaction survey dimensions, Medicare spending per beneficiary, and 5 types of hospital-acquired infections. Among the 2362 participating hospitals, mixed associations were found between MU measures and HVBP outcomes, all varying by outcome quantile and in some cases by interaction with EHR vendor. Computerized provider order entry (CPOE) for laboratory orders was associated with decreased ratings of every patient satisfaction outcome at middle quantiles (communication with nurses: β = -0.33 [P = .04]; communication with physicians: β = -0.50 [P < .001]; responsiveness of hospital staff: β = -0.57 [P = .03]; care transition performance: β = -0.66 [P < .001]; communication about medicines: β = -0.52 [P = .002]; cleanliness and quietness: β = -0.58 [P = .007]; discharge information: β = -0.48 [P < .001]; and overall rating: β = -0.95 [P < .001]). However, at middle quantiles, CPOE for medication orders was associated with increased ratings for communication with physicians (τ = 0.5; β = 0.54; P = .009), care transition (τ = 0.5; β = 1.24; P < .001), discharge information (τ = 0.5; β = 0.41; P = .01), and overall hospital ratings (τ = 0.5; β = 0.97; P = .02). At high quantiles, electronic health information exchange was associated with improved ratings of communication with nurses (τ = 0.9; β = 0.23; P = .03). Medication reconciliation had positive associations with increased communication with nursing at low quantiles (τ = 0.1; β = 0.60; P < .001), increased discharge information at middle quantiles (τ = 0.5; β = 0.28; P = .03), and responsiveness of hospital staff at middle (τ = 0.5; β = 0.77; P = .001) and high (τ = 0.9; β = 0.84; P = .001) quantiles. Patients accessing their health information online was not associated with any outcomes. Increased use of patient-specific educational resources identified through the EHR was associated with increased ratings of communication with physicians at high quantiles (τ = 0.9; β = 0.20; P = .02) and with decreased spending at low-spending hospitals (τ = 0.1; β = -0.40; P = .008). Increasing EHR implementation, as measured by MU criteria, was not straightforwardly associated with increased HVBP measures of patient satisfaction, spending, and safety in this study. These results call for a critical evaluation of the criteria by which EHR implementation is measured and increased attention to how different EHR products may lead to differential outcomes.

10 Years of INTERACT: The Push for Better SNF Care

10 Years of INTERACT: The Push for Better SNF Care

Trends in Use of Electronic Health Records in Pediatric Office Settings

To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs. An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012. The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care. Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.

Are all certified EHRs created equal? Assessing the relationship between EHR vendor and hospital meaningful use performance.

The federal electronic health record (EHR) certification process was intended to ensure a baseline level of system quality and the ability to support meaningful use criteria. We sought to assess whether there was variation across EHR vendors in the degree to which hospitals using products from those vendors were able to achieve high levels of performance on meaningful use criteria. We created a cross-sectional national hospital sample from the Office of the National Coordinator for Health Information Technology EHR Products Used for Meaningful Use Attestation public use file and the Centers for Medicare & Medicaid Services Medicare EHR Incentive Program Eligible Hospitals public use file. We used regression models to assess the relationship between vendor and hospital performance on 6 Stage 2 Meaningful Use criteria, controlling for hospital characteristics. We also calculated how much variation in performance is explained by vendor choice. We found significant associations between specific vendor and level of hospital performance for all 6 meaningful use criteria. Epic was associated with significantly higher performance on 5 of the 6 criteria; relationships for other vendors were mixed, with some associated with significantly worse performance on multiple criteria. EHR vendor choice accounted for between 7% and 34% of performance variation across the 6 criteria. A nontrivial proportion of variation in hospital meaningful use performance is explained by vendor choice, and certain vendors are more often associated with better meaningful use performance than others. Our results suggest that policy-makers should improve the certification process by including more "real-world" scenario testing and provider feedback or ratings to reduce this variation. Hospitals can use these results to guide interactions with vendors. Vendor choice accounts for a meaningful proportion of variation in hospital meaningful use performance, and specific vendors are consistently associated with higher or lower performance across criteria.

Information Blocking: Is It Occurring and What Policy Strategies Can Address It?

Policy Points: Congress has expressed concern about electronic health record (EHR) vendors and health care providers knowingly interfering with the electronic exchange of patient health information. These “information blocking” practices would privately benefit vendors and providers but limit the societal quality and efficiency benefits from EHR adoption. We found that information blocking is reported to frequently occur among EHR vendors as well as hospitals and health systems, and that it is perceived to be motivated by opportunities for revenue gain. Because information blocking is largely legal today, the most effective policy response likely involves a combination of direct enforcement and the altering of market conditions that promote information blocking. ContextCongress has raised concerns about providers and electronic health record (EHR) vendors knowingly engaging in business practices that interfere with electronic health information exchange (HIE). Such “information blocking” is presumed to occur because providers and vendors reap financial benefits, but these practices harm public good and substantially limit the value to be gained from EHR adoption. Crafting a policy response has been difficult because, beyond anecdotes, there is no data that captures the extent of information blocking.MethodsWe conducted a national survey of leaders of HIE efforts who work to enable HIE across provider organizations. We asked them about the frequency of information blocking, its specific forms, and the effectiveness of various policy strategies to address it. We received responses from 60 individuals (57% response rate). We calculated descriptive statistics across responses.FindingsHalf of respondents reported that EHR vendors routinely engage in information blocking, and 25% of respondents reported that hospitals and health systems routinely do so. Among EHR vendors, the most common form of information blocking was deploying products with limited interoperability. Among hospitals and health systems, the most common form was coercing providers to adopt particular EHR or HIE technology. Increasing transparency of EHR vendor business practices and product performance, stronger financial incentives for providers to share information, and making information blocking illegal were perceived as the most effective policy remedies.ConclusionsInformation blocking appears to be real and fairly widespread. Policymakers have some existing levers that can be used to curb information blocking and help information flow to where it is needed to improve patient care. However, because information blocking is largely legal today, a strong response will involve new legislation and associated enforcement actions.

Barriers to comparing the usability of electronic health records.

Despite the widespread adoption of electronic health records (EHRs), usability of many EHRs continues to be suboptimal, with some vendors failing to meet usability standards, resulting in clinician frustration and patient safety hazards. In an effort to increase EHR vendor competition on usability, recommendations have been made and legislation drafted to develop comparison tools that would allow purchasers to better understand the usability of EHR products prior to purchase. Usability comparison can be based on EHR vendor design and development processes, vendor usability testing as part of the Office of the National Coordinator for Health Information Technology certification program, and usability of implemented products. Barriers exist within the current certified health technology program that prevent effective comparison of usability during each of these stages. We describe the importance of providing purchasers with improved information about EHR usability, barriers to making usability comparisons, and solutions to overcome these barriers.

A framework for evaluating electronic health record vendor user-centered design and usability testing processes.

Currently, there are few resources for electronic health record (EHR) purchasers and end users to understand the usability processes employed by EHR vendors during product design and development. We developed a framework, based on human factors literature and industry standards, to systematically evaluate the user-centered design processes and usability testing methods used by EHR vendors. We reviewed current usability certification requirements and the human factors literature to develop a 15-point framework for evaluating EHR products. The framework is based on 3 dimensions: user-centered design process, summative testing methodology, and summative testing results. Two vendor usability reports were retrieved from the Office of the National Coordinator's Certified Health IT Product List and were evaluated using the framework. One vendor scored low on the framework (5 pts) while the other vendor scored high on the framework (15 pts). The 2 scored vendor reports demonstrate the framework's ability to discriminate between the variabilities in vendor processes and to determine which vendors are meeting best practices. The framework provides a method to more easily comprehend EHR vendors' usability processes and serves to highlight where EHR vendors may be falling short in terms of best practices. The framework provides a greater level of transparency for both purchasers and end users of EHRs. The framework highlights the need for clearer certification requirements and suggests that the authorized certification bodies that examine vendor usability reports may need to be provided with clearer guidance.

Developing a communitywide electronic health record disease registry in primary care practices: lessons learned from the Western new york beacon community.

Background and Introduction:Disease registries, as part of electronic health records (EHRs), have shown promise in improving care and outcomes. However, little is known about how best to implement them across communities, especially in communities that are not highly integrated. The Western New York (WNY) primary care community consists largely of independent practices using at least 20 different EHR products. This paper discusses the processes undertaken to develop a communitywide EHR disease registry in WNY, improvements it engendered, barriers overcome, and the lessons learned.Methods:HEALTHeLINK, under the Office of the National Coordinator for Health Information Technology Beacon Community Initiative, reached out to 98 primary care practices in the WNY region to establish EHR-based diabetes registries. Working with practices, community partners, and vendors, registry specifications were created. The registry was piloted with practices using one local vendor’s EHR product and then rolled out to other practices, including five other EHR products. Using identified and de-identified registry datasets, quality benchmarking within and between practices and population health management were undertaken.Findings:From 2011 to 2013, the WNY Beacon Community assisted 98 practices (344 providers) serving over 50,000 adult diabetic patients. A major focus was on EHR registry development across diverse systems, and overcoming the challenges this presented. The Beacon diabetes registry was implemented at 85 of the 98 targeted practices. Of these registries, 65 met the criteria described in a later section for quality benchmarking and population health management purposes. Practices received quarterly benchmark reports summarizing their performance on key diabetes quality metrics and were compared to community practice averages. Practices used their registries for population health management by identifying and targeting patients in need of follow-up or specific diabetes-related care.Discussion and Conclusion:The creation of the registry infrastructure required unified registry technical specifications as well as close collaboration between all parties involved. The WNY experience showed that a useful disease registry can be established in a community largely consisting of numerous disparate primary care practices. This laid the groundwork for the future use of EHR data for a variety of purposes in the community. The methods used and lessons learned through this endeavor may benefit other communities in a similar position, with several disconnected EHRs, to establish unified registries.

An interoperable HL7 document standard to improve the quality of cancer care across multiple locations.

12 Background: Cancer care is by nature interdisciplinary and increasingly depends on seamless electronic transmission of clinical data. Health information exchange and semantic understanding are critical for improved outcomes, personalized medicine, comparative effectiveness research, and cost control. While there is a growing focus on this, sharing patient information remains difficult due to a lack of standardization and general incompatibility between electronic health record products. There is a need for well-designed, oncology-specific interoperability standards. Thus ASCO is developing standards to improve the quality and insight of cancer care. Methods: ASCO volunteers formed a Standards Work Group (Standards WG) in 2012, and ASCO engaged an independent consulting firm to perform the technical work. The Standards WG first developed an interoperable standard with broad application that would also be a foundation for future standards work. They adapted ASCO’s Breast Cancer Adjuvant Treatment Plan and Summary (Breast TPS), which was originally developed as a paper-based form. This adaptation required extensive work involving input from medical and surgical oncologists, ASCO staff, and the consultants. This preparatory work was vital to define and disambiguate clinical concepts. Some value sets in the original Breast TPS were replaced with National Cancer Institute value sets. Multiple oncology and standards stakeholders reviewed the draft to ensure accurate representation of the data and harmonization with related standards. Results: The standard was developed using the Health Level Seven International (HL7) Clinical Document Architecture, a widely used XML-based markup standard with national and international recognition. The draft Breast Cancer Adjuvant Treatment Plan and Summary Standard was successfully balloted through HL7 in May 2013 and will subsequently be published for trial use in late 2013. Conclusions: The Breast Cancer Adjuvant Treatment Plan and Summary Standard will improve quality by allowing providers to efficiently transmit clinical data with semantic meaning to health professionals, patients, quality improvement initiatives, and registries.

APA to Survey Members About EHR Use

Back to table of contents Previous article Next article Professional NewsFull AccessAPA to Survey Members About EHR UseMark MoranMark MoranSearch for more papers by this authorPublished Online:4 Jan 2013https://doi.org/10.1176/appi.pn.2013.12b18AbstractThe survey should help inform the design of future electronic health record (EHR) systems for psychiatrists and minimize or avoid pitfalls associated with EHRs.Are you using an electronic health record (EHR), and if so what kind? APA wants to know and will be surveying its members early this year to find out.In conjunction with AmericanEHR Partners and the American College of Physicians (ACP), APA is participating in a nationwide survey of physicians from every major specialty group. The survey, which is being e-mailed to members this month, is designed to ascertain the extent to which physicians are using electronic health records, the kinds of products they use, and their opinions about them.Members who complete the survey will be entered into a drawing for a new Apple mini-tablet computer.Robert Plovnick, M.D., M.S., director of APA’s Office of Quality Improvement and Psychiatric Services, said the survey will take approximately 50 minutes to complete. It consists of a set of questions that every physician, regardless of specialty, will be asked; a second set of questions targeting those who are currently using some kind of EHR product; and a third set of questions specifically for psychiatrists.Responses to the survey will be confidential, and physician identities will not be used in reporting survey results.“The goal is to get a sense of EHR usage and collect detailed information on the products currently used by psychiatrists,” Plovnick told Psychiatric News. “This is directly responsive to requests we have received from all areas of the organization. Everyone wants to know which EHRs psychiatrists are using and what they think of them, so we can have a sense of the state of the EHR market and help our members make their own purchasing decisions.“So far we have had to rely on anecdotal evidence, so the survey is an opportunity to provide more-robust information about available EHR products to our members,” he said. “The more feedback we get, the more useful it will be to the field.”(According to its Web site, AmericanEHR Partners has been developed by Cientis Technologies and ACP; it provides physicians, state and federal agencies, vendors, and funding organizations with tools to identify, implement, and effectively use electronic health records and other health care technologies.)The psychiatry-specific questions gauge clinician satisfaction with the ability of an EHR to use DSM diagnoses and coding; ability to create or customize templates for psychiatry specific documentation; ability to manage separate psychotherapy notes; ability to create and share records with members of a treatment team, including other physicians, psychologists, and social workers; and ability to record substance use, among other issues.Psychiatrist Daniel Balog, M.D., a member of APA’s Committee on Electronic Health Records, said psychiatrist participation in the survey can also help influence the design of EHR products in the future.“The majority of current EHR systems were designed with a predominance of medical input, so APA’s involvement in this clinical survey provides member psychiatrists a platform to share their EHR experiences,” Balog told Psychiatric News. “The survey includes specialty questions designed by the APA EHR Committee to target information relevant to member psychiatrists who are shopping for EHR systems or who are in a position to influence purchasing decisions made by larger organizations.” ■More information about EHRs is posted on the APA Web site at http://www.psychiatry.org/ehr. Information about American EHR Partners, including information about EHR products derived from responses from physicians who have completed the survey, is posted at http://www.americanehr.com. ISSUES NewArchived

Family Physicians Provide Feedback On Electronic Health Records In FPM'S User Satisfaction Survey

It’s official. Family Practice Management garnered the largest response ever—3,088 family physician participants—for the fifth iteration of its electronic health record (EHR) survey. This year’s offering, titled “The 2012 EHR User Satisfaction Survey: Responses From 3,088 Family Physicians,” at http://www.aafp.org/fpm/2012/1100/p23.html (members/paid subscribers only) appears in the November/December issue of Family Practice Management. And as authors of the survey noted up front, “Where else can you get EHR advice from a few thousand colleagues?” Kenneth Adler, MD, coauthor of the survey report and FPM’s new medical editor, confirmed to AAFP News Now that this was the fifth EHR user satisfaction survey undertaken by FPM. The timing of the 2012 survey came just 16 months after what is usually a biennial project. “We did it sooner this time given the rapidly accelerated EHR adoption that has occurred since the CMS EHR incentive programs got underway last year,” said Adler. Adler, a practicing family physician, is medical director of information technology for Arizona Community Physicians in Tucson, Arizona and a certified professional in health care information and management systems. He noted that more than 200 EHR products are currently on the market. “We want to help family physicians zoom in on the products that their fellow family physicians both use and have found most satisfying,” said Adler. The survey itself fulfills multiple needs. For example, it contains critical information to help FPs select their first EHR system or replace an existing system that’s underperforming. “We’d like to help folks choose well. Making a poor choice can have a hugely negative impact on a practice,” said Adler. The information gathered in the survey also provides feedback to EHR vendors whose products—at least in the eyes of physician users—could use some adjustments. Adler pointed out that only 38% of users participating in the survey were highly satisfied with their EHRs. “Usability issues and negative impact on physician productivity continue to be concerns,” said Adler. “Vendor support remains an area of weakness for EHR vendors.” Survey authors focused on the 31 specific EHR systems that had enough physician response to represent a reasonable variety of opinions. Practices of various sizes were represented in the survey. Nearly one-half of survey respondents hailed from practices with 10 or fewer physicians and almost as many came from practices of more than 20 physicians. In one portion of the survey, participants were asked to note their level of agreement or disagreement with 19 statements about EHRs using these terms: strongly agree, agree, neutral, disagree, strongly disagree, and unsure. For example, family physicians were asked about the ease of documentation, clarity of information display, help in avoiding mistakes, ability to create notes that promote better patient care, availability of useful preventive medicine tools, and ability of the system to process electronic prescriptions. Survey takers also were asked their general satisfaction with their system and if they enjoyed using their EHRs. Physicians supplied answers that helped study authors make some overall observations based on positive responses. For example, regarding top areas of satisfaction, users were most happy with the way their EHRs: facilitated intra-office messaging and tasking (60%) found information (58%) documented data (57%) facilitated electronic prescribing (56%) On the other hand, areas of lowest satisfaction based on positive responses were effect on productivity (16%) effect on the physician’s ability to focus on patient care (24%) vendor support (36%) The authors noted that only 38% of users agreed or strongly agreed that they were highly satisfied with their EHR systems. In addition, 37% of respondents—1,131 family physicians—agreed or strongly agreed with the statement, “I enjoy using this EHR.” Authors noted that, as in past surveys, their goal was not to pick EHR system winners in terms of user satisfaction.

Duelin' Registries

Duelin' Registries

Developing an electronic clinical decision support system to promote guideline adherence for healthy weight management and cardiovascular risk reduction in children: a progress update

Overweight and obesity are common challenges facing pediatric clinicians. Electronic health records (EHRs) can impact clinician behavior through the presentation of relevant, patient-specific information during clinical encounters, potentially improving clinician recognition and management of overweight/obesity in children. Little research has been published evaluating the impact of EHR-facilitated decision support on the treatment of obesity in children. The main objectives of our community clinician-led project are: 1) to build customized, evidence-based decision support into an EHR; 2) To evaluate the impact of decision support on the identification and treatment of overweight and obese children; and 3) to improve behavior around screening for obesity-related comorbidities. Through a clinician-led consensus process, we customized end user templates in the commercially-available EHR at an urban community health center with a known high prevalence of childhood overweight and obesity. Evidence based decision support was build into the screens to prompt clinicians to identify and address overweight and obesity, as well as for related comorbidities. Pre/post measures will be used to evaluate the impact of these tactics on clinician behavior. The customized EHR templates took longer than anticipated to develop, but are now being used by pediatric clinicians at the health center. Feedback to date suggests that clinicians find the evidence based decision support useful at the point of care, especially around ordering recommended screening tests. Clinicians must be active participants in the design of decision support in order for it to impact their behavior. Off-the-shelf EHR products do not automatically come with comprehensive functionality to support evidence-based interventions around clinician behavior. Modifications are needed to achieve the full promise of health information technology as it relates to delivering high quality, patient-centered, for underserved populations.

Experts Urge Hospitals to Act on Integration

Hospitals have nearly five years to integrate medical devices with electronic health record (EHR) technology, in order to receive money from the federal government. But it’s important that biomeds and clinical engineers take steps now to ensure effective implementation. That was the main message from experts at a symposium during AAMI’s 2010 Annual Conference & Expo in Tampa, FL, in June. Nearly $20 billion in financial incentives was included in the 2009 American Recovery & Reinvestment Act to entice hospitals and physician offices to adopt “meaningful use” of EHRs. The Office of the National Coordinator for Health Information Technology (ONC) recently adopted a temporary certification program that authorizes organizations to test and certify EHR products. The first stage of meaningful use is scheduled to begin in 2011 with a set of objectives for hospitals and physicians to meet, with further goals coming in 2013 and 2015. In 2015, the meaningful-use requirements will include medical devices, with testing and technical standards to be released the year before, according to Elliot Sloane, research professor and director of the Health Systems Engineering Program at Drexel University in Philadelphia, and a speaker at the symposium, which was sponsored by the American College of Clinical Engineering (ACCE). “Use your purchasing programs to insist on interoperable technologies,” Sloane said. “Put EHR and software engineering topics on your reading list. Get to know the standards and deploy them.” Also, be ready to anticipate change. “Look at your structures and business model to see whether you are flexible enough to both proactively anticipate change that is coming and react to it,” added Linda Chan, information services manager at New Jersey-based Virtual Health Information Services. “We expanded our help desk to 24x7. We also spent over a year working with biomed and information technology (IT) departments to look at organization structure in support of device integration work, and a lot cross-training is needed.” “Know your systems,” stressed Erin Sparnon, senior project engineer at ECRI Institute. “If you are talking about meaningful use of integrating infusion pumps, think about what systems you have in your hospital right now.” Focus, Sparnon suggested, on some “easy wins” to get the ball rolling. “Maybe some things you can implement by 2011 with little fuss,” Sparnon said. “There might be an easy way to say to hospital administration, ‘Here is what we can Robert King is the editor of AAMI News. E-mail: rking@aami.org Experts Urge Hospitals to Act on Integration

The Progression of Electronic Health Records and Implications for Psychiatry

The Progression of Electronic Health Records and Implications for Psychiatry

Archetype-based conversion of EHR content models: pilot experience with a regional EHR system

BackgroundExchange of Electronic Health Record (EHR) data between systems from different suppliers is a major challenge. EHR communication based on archetype methodology has been developed by openEHR and CEN/ISO. The experience of using archetypes in deployed EHR systems is quite limited today. Currently deployed EHR systems with large user bases have their own proprietary way of representing clinical content using various models. This study was designed to investigate the feasibility of representing EHR content models from a regional EHR system as openEHR archetypes and inversely to convert archetypes to the proprietary format.MethodsThe openEHR EHR Reference Model (RM) and Archetype Model (AM) specifications were used. The template model of the Cambio COSMIC, a regional EHR product from Sweden, was analyzed and compared to the openEHR RM and AM. This study was focused on the convertibility of the EHR semantic models. A semantic mapping between the openEHR RM/AM and the COSMIC template model was produced and used as the basis for developing prototype software that performs automated bi-directional conversion between openEHR archetypes and COSMIC templates.ResultsAutomated bi-directional conversion between openEHR archetype format and COSMIC template format has been achieved. Several archetypes from the openEHR Clinical Knowledge Repository have been imported into COSMIC, preserving most of the structural and terminology related constraints. COSMIC templates from a large regional installation were successfully converted into the openEHR archetype format. The conversion from the COSMIC templates into archetype format preserves nearly all structural and semantic definitions of the original content models. A strategy of gradually adding archetype support to legacy EHR systems was formulated in order to allow sharing of clinical content models defined using different formats.ConclusionThe openEHR RM and AM are expressive enough to represent the existing clinical content models from the template based EHR system tested and legacy content models can automatically be converted to archetype format for sharing of knowledge. With some limitations, internationally available archetypes could be converted to the legacy EHR models. Archetype support can be added to legacy EHR systems in an incremental way allowing a migration path to interoperability based on standards.