Electronic Health Record systems: U.S. Federal initiatives and Public/

private partnerships

In April 2004, the president of the United States issued an executive order that called for action to put EHRs in place for Americans in 10 years.

over a decade, the institute Of Medicine (IOM) has been calling for the use of IT to improve the efficiency, safety, and quality of the health care Americans receive

nurses are drivers in organizational planning and process re engineering to improve health care system and is therefore essential in the implementation of such efforts.

Federal initiatives continue to actively identify and target solutions that lessen the barriers and accelerate the use of EHR-s

What is Electronic Health Record Systems ?

often used interchangeably with computerized patient record, clinical information system, electronic medical record , and many others.

EHR-, which is a physical or logical repository of data

EHR-s, which can be made up of one or more applications and provides the components that support clinical and health care functions including business rules, procedures, and so forth by accessing EHR- to write and / or read patient data

Federal initiatives

Government as provider and Early adopter

Department of veterans Affair

All aspects of a patient's record are integrated, including active problems, allergies, current medications, laboratory results, vital

signs, hospitalizations, and outpatient clinic history.

All electronic records are password protected to guarantee patient privacy.

In 2004, VA began implementing MyHealtheVet as an internet tool for personal health management .

Department of Defense

can order lab tests and radiology examinations and issue prescriptions electronically for over 10 years.

In January 2004, they began a worldwide roll out of the next generation system , the composite health care system II

pharmacy data transaction service links military treatment facilities, mail order and network pharmacies.

Indian Health Service

has long been pioneer in using computer technology to capture clinical and public health data

in the 1970s -Resource and Patient management system was developed

since the early 1980s -The patient care component which is it's primary clinical component has been in place

IHS-EHR is the next phase of clinical software development of Indian health service .

Government as Leader

Office of The National Coordinator for health information technology

Steps outlined for coordinating public and private sector efforts included:

completion and adoption of standards that would allow medical information to be stored and shared electronically while assuring privacy and security

increased funding for demonstration projects on HIT

identification of opportunities where government supports , provides, or pays for healthcare to create incentives and opportunities for health care providers to use electronic records.

in July 2004 -a framework was released for strategic action.

The National committee on Vital and health statistics

presented the concept of an infrastructure that emphasizes health oriented interactions and information sharing among individuals and institution.

It further defined the National health information infrastructure (NHII )

As envisioned PHRs are a core component for the NHI

Agency for Health care Research and Quality

in 2003-2004, AHRQ unveiled a major HIT portfolio with grants, contracts, and other activities to demonstrate the role of HIT in improving patient safety and the quality of care.

AHRQ funded demonstration grants to establish and implement inter operable health information systems and data sharing

In 2004, AHQR also funded five contracts for about 1 million dollars per year for 5 years for state and regional demonstration of health IT.

Centers for medicare an medicaid services May 2004, CMS awarded a 100,000 dollar grant to the american

academy of family physicians for a pilot project to provide comprehensive, standardized EHR- software to small and medium sized ambulatory care practices.

The 3 year care management performance demonstration program is intended to promote continuity of care, help stabilize medical conditions, prevent or minimize acute exacerbation of chronic conditions and reduce adverse health outcomes such as adverse drug interactions.

In another program, MMA called for NCHVS to develop a national standard for electronic prescriptions, so that providers can share information on what medications a patient is taking and to be alerted for possible drug interactions.

AT the end of 2004, CMS launched the chronic care improvement progrram (CCIP), CCIP with pilots that offer self care guidance and support to chronically ill beneficiaries.

Public-Private partnerships

Connecting For Health

It addresses the barriers to development of an interconnected health information infrastructure.

In july 2004, connecting for health released an incremental road map that laid out near term actions necessary to achieving electronic activity.

ehealth initiative

The major program of the foundation for ehealth initiative is connecting communities for better health

is implementing activities on a national, regional and local basis that will lay the foundation for an interconnected , electronic, standards-based health information infrastructure to support patients, clinicians, and those responsible for population health.

Institute of medicine It continues to illuminate the importance for the use of IT in health care.

showcased federal programs and encouraged the development of an information infrastructure for the comparison of data to evaluate performance.

Summer 2003, at the request of of HHS, the IOM issued a report, key capabilities of an electronic health record system , which identified key functions of EHRs in four setting: hospitals, ambulatory care, nursing homes, and care in the community.

Certification Commission for health information technology

the health information and management systems, American health information management association and National alliance for health information technology have joined together to establish certification commission for health information technology.

Whose goal is to support goal1, strategy 2 “risk of EHR- investment”.

Health level seven

As an organization it continues to have technical specification for messages as primary body of it's work product

the HL7 EHR-s functional model contains a list of functions in three categories : direct care, supportive and information infrastructure.

The act of customizing the HL7 EHR-s functional model is the creation of a profile. As profile developed by clinicians to provide care to their patient population is called use profile. A list of functions customized to describe a vendor product is called a product profile

Dependable systems for quality care

As IT assumes a greater role in healthcare decision making and in the provision of care , the nurse increasingly must rely on IT to help protect the patients personal information and safety.thus ethical obligation drive requirements for system reliability, availability, confidentiality, data integrity, responsiveness and safety attributes collectively referred to as dependability.

Dependability

is a measure of the extent to which a system can justifiably be relied on to deliver the services

expected from it. Comprise six attributes:

1.system reliability: consistently behaves in the same way

2.service availability: services are present and usable when they are needed

3.confidentiality: sensitive information is disclosed only to those authorized to see it

4.data integrity: data are not corrupted or destroyed

5.responsiveness: the system responds to user input within an expected and acceptable time period

6.safety: does not cause harm

February 2003 issue of CIO

a catastrophic failure in the network infrastructure that supported CareGroup, one of the most prestigious health care organization in the US. Which resulted in 4 hour closure of the emergency room, a complete shutdown of network and 2 days of paper-based clinical operations.

March 2003

kaiser permanente learned how the lack of dependability can affect it's business, when a power outage caused a prescription system to misprint labels on prescribed medications.

August 2003

the blaster and soBig worm attacks invaded hospitals around the world. In Glasgow Scotland

10,000 computers used by city hospital and emergency services were infected, and systems at one hospital were down for 15 hours.

Guidelines for dependable systems

Five fundamental guidelines that can help increase the dependability of the health care system:

Architect for dependability

an enterprise system should be developed from bottom up

no single component should be capable of bringing the system down should that component fail

complexity should be minimized throughout the architecture

Anticipate failures

features that are transparent to software applications should be implemented to detect faults,to fail over redundant components when faults are detected, and to recover from failures before they become catastrophic

security features to detect ,disable, and recover from malicious attacks while preserving system stability and security should be implemented.

Safety critical systems should be designed and built to fail in a safe state.

Anticipate success

planning process should anticipate business success and the consequential need for larger networks, more systems, new applications and additional integration

Hire meticulous managers

takes emergency and disaster planning very seriously

develops, maintain and judiciously exercise plan and procedures for managing emergencies and recovering from disasters.

Anticipating Success Healthcare organizations do not foresee that their business success

may increase their need for processing power and networking capability.

Do not foresee the need to consolidate their systems with those of another healtcare enterprise.

Adventurous technologies in healthcare Wireless networking and handheld computers are a good example of

technologies that are not yet mature enough for safety-critical applications yet are one of the most frequently used technologies in healthcare.