Computer physician order entry

The ethical issues addressed in this paper are the various reasons healthcare industry administrators and other entities choose to delay updating and enhancing outdated Hospital Information Technology (HIT). Even though their responsibility to provide the best care and information/ education to the patients and staff is very important, it does not seem like a priority just until the recent years. Also discussed are the resources and benefits they will inevitably gain by implementing the recommended solutions provided.

I have chosen this topic because I myself have always had an interest in many types of technology, especially if I can use it to improve my performance. I have been working in healthcare for almost 7 years now and realize that this is important because we are now in an era of technology being implemented in every part of our lives and how more efficient we can be with information technology. This just doesn’t apply to the healthcare industry, but this essay is in regards to why most of the healthcare industry as a whole has been slow to adapt to modern information technology in their daily business operations and health records keeping.

The subjects that will be discussed are the criteria for a healthcare facility/organization to implement a health information technology system, what has been the industry trends over the past 10 years, what software examples and types are available and of course, the benefits of implementing these systems. We will also be discussing the implementation of the Virtual Lifetime Electronic Record program, in the Department of Defense and the Dept. of Veterans Affairs; and how this is a perfect example, of how the healthcare industry is working on a solution to the above mentioned issues.

Background About 595,800 establishments make up the healthcare industry; they vary greatly in terms of size, staffing patterns, and organizational structures. About 76 percent of healthcare establishments are offices of physicians, dentists, or other health practitioners. Although hospitals constitute only 1 percent of all healthcare establishments, they employ 35 percent of all workers (table 1) (Bureau of Health Professions, 2012). Table 1. Percent distribution of employment and establishments in health services by detailed industry sector, 2008

The healthcare industry includes establishments ranging from small-town private practices of physicians who employ only one medical assistant to busy inner-city hospitals that provide thousands of diverse jobs. In 2008, around 48 percent of non-hospital healthcare establishments employed fewer than five workers. In contrast, 72 percent of hospital employees were in establishments with more than 1,000 workers (Bureau of Health Professions, 2012). Healthcare organizations of all sizes face a critical need to manage and integrate clinical, financial and operational information.

Reimbursement models are changing; competition is increasing; margins are getting tighter; and the emphasis on patient care and good outcomes has never been higher. As these needs evolve, the industry will require a Hospital Information Technology (HIT) that can keep pace (McKesson, 2012). Define the Problems The issues addressed in this paper are the various reasons healthcare administrators and other entities choose to delay updating and enhancing outdated Hospital Information Technology (HIT).

This affects the delivery of healthcare in that the information needed by providers, physicians, medical staff, and the patients themselves, may not be delivered correctly, timely, and of course securely. Various systems will be discussed and each how they affect healthcare delivery, in particular Electronic Health Record (EHR), Electronic Medical Records (EMR) and Computerized Physician Order Entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry). Electronic Medical Records (EMRs) are a digital version of the paper charts in the clinician’s office.

An EMR contains the medical and treatment history of the patients in one practice. EMRs have advantages over paper records. For example, EMRs allow clinicians to: * Track data over time * Easily identify which patients are due for preventive screenings or checkups * Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations * Monitor and improve overall quality of care within the practice (Garret and Seidman, 2011). But the information in EMRs doesn’t travel easily out of the practice.

In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record (Garret and Seidman, 2011). Electronic Health Records (EHRs) do all those things—and more. EHRs focus on the total health of the patient—going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information.

They are built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization” (Garret and Seidman, 2011). The information moves with the patient—to the specialist, the hospital, the nursing home, the next state or even across the country.

In comparing the differences between record types, HIMSS Analytics stated that, “The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual. ” EHRs are designed to be accessed by all people involved in the patients care—including the patients themselves (Garret and Seidman, 2011). The above is what makes all the difference.

Because when information is shared in a secure way, it becomes more powerful. It is our duty as healthcare administrators to provide the patients healthcare information in this fashion. Health care is a team effort, and shared information supports that effort. After all, much of the value derived from the health care delivery system results from the effective communication of information from one party to another and, ultimately, the ability of multiple parties to engage in interactive communication of information (Garret and Seidman, 2011).

Electronic Health Record (EHR) adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. They are dehumanizing by the fact that when working with these systems doctors inevitably spent more time on the computer than with their patients and this is not effective healthcare delivery. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social

etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods (Jones, 2009). While EHRs are increasingly essential for healthcare providers, their efficiency can be constricted by the nature of their design, their use and the interpretation of data. Jerry Buchanan, Program Manager and Scrum Master at eMids Technologies, Inc. , an IT and BPO consulting company, weighs in on some features that are missing from EHRs: 1.

Information, not data – While EHRs hold data, that’s not the same as holding information, Buchanan notes. Data needs to be converted into relevant information to be of practical use. However, there’s also the possibility that EHRs can get overloaded with information. The goal, Buchanan says, is technology that organizes data in a way that assists healthcare providers most efficiently and effectively in making clinical decisions. This includes EHRs capable of providing alerts and alarms about patient conditions, given to caregivers in real time. 2.

Comprehensive health history- Buchanan says that clinical data is usually entered into an EHR after a health episode. He notes that a history of recorded episodes is not the same as an overview of someone’s health history. Some health systems are beginning to change this feature, propelled by the needs of chronic disease management, Buchanan says. Ultimately, it may be the standard for all patients. 3. Information tailored for various users- Who is the audience for the EHR’s information? Buchanan says information is most useful when it matches the needs of various recipients.

For example, a cardiologist, a primary care physician and a nurse might have different needs when it comes to the type of information and the level of detail they seek about a patient. Ideally, an EHR would be configured to the needs of the individual end-user. 4. Tracking the transition of care- Appropriate patient care is not static — it must flow from one caregiver to another, from one facility to another. An EHR works better for a patient if it includes features that track tasks — such as giving medications, monitoring conditions and administering medical tests — to completion, and then reassigns them, if necessary.

5. Patient-side management of information- The ultimate EHR would give the patient — the consumer — the ability to manage just what health-related information (HRI) is available to which practitioners (McCallum, 2010) In the EHR article, “The Perfect EHR,” states that the reason behind the resistance to install or upgrade to Complaints about usability, speed of documentation, training, performance, and personalization limitations are typical. The government has been trying to get doctors to use these systems for some time, but many physicians remain skeptical.

In 2004, the Bush administration issued an executive order calling for a universal “interoperable health information” infrastructure and electronic health records for all Americans within 10 years. And yet, in 2011, only a fraction of doctors use electronic patient records. In an effort to change that, the Obama economic stimulus plan promised $27 billion in subsidies for health IT, including payments to doctors of $44,000 to $64,000 over five years if only they would use EHRs.

The health IT industry has gathered at this multibillion-dollar trough, but it hasn’t had much more luck getting physicians to change their ways (Jones, 2009). Legacy systems such as the Computerized Physician Order Entry (CPOE) (also sometimes referred to as Computerized Provider Order Entry) are a process of electronic entry of medical practitioner instructions for the treatment of patients (particularly hospitalized patients) under his or her care. These orders are communicated over a computer network to the medical staff or to the departments (pharmacy, laboratory, or radiology) responsible for fulfilling the order.

CPOE decreases delay in order completion, reduces errors related to handwriting or transcription, allows order entry at point-of-care or off-site, provides error-checking for duplicate or incorrect doses or tests, and simplifies inventory and posting of charges. Although manufacturers use the term Computerized Physician Order Entry, a more accurate term would be Computerized Prescriber Order Entry or Computerized Pharmacist Order Entry. Order Entry is in the domain of the pharmacist because it is the pharmacist’s responsibility to verify any entry into the system concerning the use of medications within the hospital or health care system.

Order clarification requests will be enhanced by improved communication and collaboration amongst the health care team. CPOE is a form of patient management software (Koppel, et al. 2005). CPOE presents several possible dangers by introducing new types of errors (Koppel, et al. 2005) (Lahr, 2005). Prescriber and staff inexperience may cause slower entry of orders at first, use more staff time, and is slower than person-to-person communication in an emergency situation. Physician to nurse communication can worsen if each group works alone at their workstations.

Automation causes a false sense of security, a misconception that when technology suggests a course of action, errors are avoided. These factors contributed to an increased mortality rate in the Children’s Hospital of Pittsburgh’s Pediatric ICU when a CPOE system was introduced (Yong, 2005). In other settings, shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses. (Yong, 2005). Frequent alerts and warnings can interrupt work flow, causing these messages to be ignored or overridden due to alert fatigue.

CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the United States Pharmacopoeia. (Santell, 2004). Introducing CPOE to a complex medical environment requires ongoing changes in design to cope with unique patients and care settings, close supervision of overrides caused by automatic systems, and training, testing and re-training all users (Santell, 2004). CPOE systems can take years to install and configure.

Despite ample evidence of the potential to reduce medication errors, adoption of this technology by doctors and hospitals in the United States has been slowed by resistance to changes in physician’s practice patterns, costs and training time involved, and concern with interoperability and compliance with future national standards (Kaufman, 2005). Several high profile failures of CPOE implementation have occurred, so a major effort must be focused on change management, including restructuring workflows, dealing with physicians’ resistance to change, and creating a collaborative environment (Connolly, 2005).

An early success with CPOE by the United States Department of Veterans Affairs (VA) is the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s record at any computer in the VA’s over 1,000 healthcare facilities. CPRS includes the ability to place orders by CPOE, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests. Privacy and Security Concerns

Widespread HIT must also confront the issues of privacy and security. In order to be used effectively for comparative effectiveness research, medical records must be amassed in a distributed health data network (Wilson, 2009). However, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is an impediment to the creation of integrated health information networks. For instance, HIPAA standard 270/271 limits communications between health plans and providers. Navigating this process can also be expensive (Inside Health Reform, 2010).

Making EMRs available to far-flung health care providers necessarily makes them more accessible to the world at large. Given the frequency and costs associated with identity theft, medical record security is a big issue. There are also legitimate concerns about government access to data. Proper privacy protections must be implemented before patients will trust an integrated information-sharing system (Greenberg, 2009). Who owns patient information and who should have the authority to change it is another issue. There is an age-old assumption that providers — not patients — own medical records, but this is debatable (McGraw et al.

, 2009). Sharing records runs the risk of replicating incorrect information, making it harder for patients to track down and correct. Current privacy laws require providers and insurers to give patients access their records and provide them with a process to correct errors. Certainly, patients should be allowed to opt out of data collection they believe to be intrusive (Wilson, 2009). The best-known privacy and security breaches concern sports figures and celebrities. In October 1994, Dallas Cowboys Pro Bowl defensive tackle Erik Williams suffered a season-ending knee injury when he lost control of his car late at night (Mason, 2010).

Although Williams refused to make his medical records available to the media or authorities, rumors quickly surfaced that his blood alcohol level was well above the legal limit. Curiosity was high as Williams was integral to the Dallas Cowboys bid to reach the Super Bowl. According to a former Parkland Hospital computer records specialist, during a seven-day period while Williams was hospitalized, his electronic records were viewed online by 1,754 separate Parkland employees. It is unknown how many of these employees had a legitimate reason to view Williams’ records, but it was likely to be less than a few dozen.

After several high-profile breaches of privacy, the California Health Department conducted an investigation on incidents of patient record “snooping” at the UCLA Medical Center. It found that, from 2003 to 2008, more than 100 hospital workers had inappropriately accessed the records of 1,041 patients — including California first lady Maria Shriver. Some of those hospital workers were passing information on hospitalized celebrities to the tabloid media. (Dolan, 2008). Moreover, between January 2009 and May 2009 alone, California hospitals reported over 300 instances where patient records were inappropriately accessed (Ornstein, 2009).

In 2009, Kaiser Permanente fired 15 employees for reading the records of Nadya Suleman, the much publicized mother of octuplets (Monegain, 2009). High Level Solution & Suggestions The purpose of this paper is to show how for each application or organization that there is a high level solution that can meet the customer’s requirements. When developing the high level solution, the IT company doing the job must review the customers proposal that identifies what issue the customer is having so they know what to address.

An example of this would be back in 2008, the Veterans Affairs and Department of Defense established a program to oversee the completion of interoperability of Electronic health Records (EHR) or capabilities. This was a result of the National Defense Authorization Act, Section 1635, 2008. VA/VHA currently uses Veterans Health Information Systems and Technology Architecture (VistA)/Computerized Patient Record System (CPRS). DoD/MHS uses AHLTA/Composite Health Care System (CHCS). VHA and the Department of Defense Military Health Services (DoD/MHS) have been working on EHR Information Technology (IT) issues together for decades.

Both departments have been working with their own EHR system daily and have come to rely on their own systems. This “working-together” effort has resulted in products such as the Bidirectional Health Information Exchange (BHIE) and the Clinical and Health Data Repositories (CHDR). This has also resulted in systems and capabilities that allow for full interoperability for healthcare delivery between the two Departments (Felton, 2010). Another example, but still similar, would be a physician’s private practice/ clinic converting from the old style of medical charts/ medical record to an

electronic format. Electronic medical records (EMR), is a computerized medical record created in an organization that delivers care, such as a hospital or physician’s office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records. Physicians still find that their old method of paper-based records is very easy and low cost but requires a lot of actual physical storage and can be time consuming is searching for a particular record.

And another issue that arises to these organizations is when a copy of a particular record or set of records needs to me in more than one location. EMR can solve these issues and by drastically reducing the actual physical space that the records take up, making it much easier for the information to have the capability to be in multiple locations. Also the costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media.

When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records. Also with a physician’s private practice, a new developing trend is the low-overhead, solo physician practice. Solo providers rely on technology to fill the void of little or no support staff.

Patients often schedule their own appointments online and patient records are stored electronically. This arrangement offers the personalized care doctors provided before third-party payment and the low-overhead costs allow physicians to spend more time with their patients (Herrick and Gorman, 2010). To reach the high level solution, the various health care establishments must identify the causes and effects created by the lack of action needed to remain competitive, relevant, efficient, which therefore improves the quality of service in today’s healthcare environment.

Utilizing HIT resources and subject matter experts we will analyze and determine if there are a set of universal answers to this problem or is there a need to peal this issue apart and breakdown the solution to its lowest common denominator by looking at the various segments of the healthcare industry. For example, is there a difference between why a nursing home, an Obstetrician, or large hospital (public and private) would delay installing and upgrading their IT infrastructure? What are the limitations? What if anything can be done to positively facilitate change? Will installing new HIT systems create more problems than they will solve?

In analyzing these factors we will develop a framework of solutions which best suits the problems at hand (Frisse, 2009). Problem Analysis According to a study by RAND Health, the US healthcare system could save more than 81 billion dollars annually, reduce adverse medical events and improve the quality of care if it were to widely adopt CPOE and other health information technology. (RAND Healthcare 2011). As more hospitals become aware of the financial benefits of CPOE, and more physicians with a familiarity with computers enter practice, increased use of CPOE is predicted.

A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years. (Hospital Quality & Safety Survey, 2004). The passage of the American Recovery and Reinvestment Act (ARRA) provides incentives to encourage physicians in their practice and healthcare organizations to tap into the power of electronic health records (EHRs) and other healthcare IT solutions that reduce costs by improving quality, safety and efficiency. Physicians who demonstrate “meaningful use” of “certified” EHRs could be eligible for up to $64,000 in incentives over six years.

(McKesson, 2012). With fully functional HIT systems, all members of the team have ready access to the latest information allowing for more coordinated, patient-centered care. With HITs: * The information gathered by the primary care provider tells the emergency department clinician about the patient’s life threatening allergy, so that care can be adjusted appropriately, even if the patient is unconscious. * A patient can log on to his own record and see the trend of the lab results over the last year, which can help motivate him to take his medications and keep up with the lifestyle changes that have improved the numbers.

* The lab results run last week are already in the record to tell the specialist what she needs to know without running duplicate tests. * The clinician’s notes from the patient’s hospital stay can help inform the discharge instructions and follow-up care and enable the patient to move from one care setting to another more smoothly. (Garret and Seidman, 2011). Solution Implementaion Early information system support for utilization management was quite limited, with most hospital information system vendors providing fields for utilization reviewers to document information necessary for the patient billing process.

Information system applications to support provider utilization management have been evolving and have become commercially available in the marketplace over the past seven to ten years. (Culp, 2005). Today, a number of vendors offer specialty products and applications that have been designed as data collection and reporting tools for the myriad clinical review functions being performed by providers. These applications include utilization, quality, infection, risk, and outcomes monitoring.

The systems also may include physician credentialing functionality, either as an integrated application, or as an interface to other niche credentialing products. (Culp, 2005). In the aptly named article, ‘Stalking the perfect EHR’, veteran healthcare consultant analyst Anne Zieger says, “In all seriousness, virtually every EHR installation seems to involve systems integration problems, workflow requirements, user interface design or a baker’s dozen of additional problems that hang like a cloud of smoke over even the more successful rollouts.

In theory, you might be able to resolve these disputes by letting the staff choose which EHR they’d like to see in place. ” But in reality, that doesn’t work either, argues John Halamka, MD, MS, whose many titles include CIO of Beth Israel Deaconess Medical Center and CIO at Harvard Medical School. “I’ve heard from GE users who want Allscripts, eClinicalWorks users who want Epic, Allscripts users who want AthenaHealth, and NextGen users who want eClinicalWorks,” he notes.

Worse, if you let every department and clinical constituency pick what they want to include in their EMR, you end up with “an unintegrated melange of different products that make care standardization impossible,” Dr. Halamka suggests. (Zieger, 2012). As nice as it would be to satisfy everyone, there’s really only one approach that works, Dr. Halamka says. IT leaders need to pick an EMR for their enterprise that meets the enterprises overall strategic goals, one “providing the greatest good for the greatest number. ” Then, follow up

with substantial training, education, collaboration, user engagement support and healthcare information exchange, he says. (Zieger, 2012). Business process changes The best way to examine business process changes, for the purpose of this paper, is to focus on change management and getting the buy-in from users. “It’s all about the people! ” • A structured process design is needed to deal directly and intentionally with the human factors involved in not just planning and implementing any HIT system but through behavior change, achieving the anticipated benefits that justified the project in the first place.

• Desired behavior change is achieved by helping people understand and internalize change and by preparing them to be successful contributors in the future state. In the case of HIT system implementations, effective change management delivers users who are willing and able to use a HIT system in a way that satisfies the requirements of the job, the needs of the patient, and the health of the organization. (Wangler, 2012). The assumption is that the software that is being implemented works. If the software doesn’t work, you have another kind of problem; one that even the best change management won’t resolve.

Well-designed, integrated, people-focused work builds logically over time in a way that makes sense to the user. It brings users along, guiding and supporting them so they arrive at where you want them to be. This is about willingness and ability, hearts and minds. One will not work without the other. (Wangler, 2012). The overarching purpose of change management is to accelerate the speed at which people move successfully through the change process so that anticipated benefits are achieved faster. And there are additional benefits to change management.

Through optimizing the efficiency and efficacy of users, an effective EMR change management program will also: * Improve organizational outcomes and performance (effective use of the system generates value to patients and the organization). * Enhance employee satisfaction, morale, and engagement (when people learn new skills, meet performance expectations, and contribute to a greater good they feel pride in their accomplishments). * Improve service quality (users feel valued and supported by an organization that makes an investment in them; this positively impacts how they treat patients).

* Help achieve hoped-for benefits (benefits that include EMR value realization, reduction of errors, return on investment). * Create higher levels of openness, trust, involvement, and teamwork (develop an engaged workforce). * Build change capability and capacity in the organization, resulting in improved ability to respond quickly and effectively to new situations (create organizational nimbleness through embedded change management knowledge, structure, and process). (Wangler, 2012). In other words, it really is all about the people.

Intentionally managing the cultural, behavioral, and organizational changes that need to take place to make the desired EMR future not only a reality but a sustainable reality pays off on many levels in that it also facilitates organizational transformation. Building on individual capability and organizational capacity, change management results in a change capable culture—a huge advantage in today’s competitive and fast changing world. (Wangler, 2012). Process oriented IT support makes possible a number of improvements: * Documented changes to a patient’s health status are available resulting in increased security for the patient.

* The risk for misunderstanding or forgetting planned treatments is minimized due to improvement in communication between healthcare providers. * The patient will be met by personnel who have been able to prepare their work. * Current information is always easi