HI 5001 Introduction to Electronic Health Records

Course Type: basic

Credit Hours: 3

This course is designed to provide informatics students with an overview of the key concepts regarding implementation of a clinically-oriented information system (e.g., an electronic medical record, computer-based provider order entry, nursing 5.    

The course will strive to present “best practices” in cases in which there is evidence to support such assertions.  It will rely heavily upon the published literature as well as the experiences of the instructors.

Course Objectives:
After completing this course, students should be able to:

• Create an implementation plan for a clinically-oriented information system within a healthcare organization
• Think critically about at least three issues involved in implementation and argue (orally and in writing) their position
• Critically review articles relating to clinical information systems
• Create an article and publish on ClinfoWiki.org
• Compare and contrast computer-based provider order entry systems
• Evaluate and make decisions about clinical applications presentations documentation system, etc.).  As such we will aim to focus roughly equal amounts of time on the technical and social/political issues surrounding these systems and their implementation.

◊    History of EMRs
◊    Overview of pioneering efforts:
o    Regenstrief: RMRS, gopher
o    El Camino: Technicon
o    LDS Hospital: HELP
o    Veteran’s Affairs – Vista /CPRS

◊    Making the case for EMRs to the Board of Directors
◊    Developing a business case
◊    Estimating return on investment
◊    Identifying potential benefits of the system
◊    Estimating the cost of the project
◊    Readings:
o    Kuperman & Gibson Annals of Internal Medicine on CPOE
o    Raymond Kaiser report
o    Poon / Middleton / Partners

◊    Selecting a vendor/product
◊    Creating the RFP
◊    Reviewing the vendors
◊    Conducting site visits with vendors at your institution
◊    Scoring the competitors
◊    Conducting site visits to other customers with your top x vendor’s systems
◊    Understanding CCHIT criteria
◊    Readings:
o    Kannry;
o    CCHIT ambulatory / in-patient criteria from web

◊    Building the implementation team
◊    Who is in-charge of the project, of the team, of overseeing the team
◊    Identifying champions
◊    Where do you find “bridgers”?
◊    How do you get clinicians involved?   
◊    How many committees do you need?
◊    Setting up the committee structure
◊    Who is accountable for the project, for realizing the benefits of the project
◊    Readings:
o    Stead Vandy IAIMS structure; Ash: Bridgers

◊    Building the Benefits Realization team
◊    Forming a benefits realization team with formal responsibility for analysis, education, facilitation, and measurement;
◊    Studying system design to consider requirements for benefits realization;
◊    Integrating cultural, organizational and process change plans with system implementation plans;
◊    Measuring benefits using a measurement framework that matches organizational reporting, enables multi-level sequential analysis and adjusts for bias in quantifying benefits;
◊    Assigning accountability for achieving benefits by matching every benefit with an individual and an operational group; system executives, hospital executives, and department managers are held accountable for benefits within their scope of responsibility, and expected financial benefits are part of their yearly budgets.
◊    Readings:
o    Thompson DI, et al. Benefits planning for advanced clinical information systems implementation at Allina hospitals and clinics. J Healthcare Information Management. 2005 Winter;19(1):54-62.

◊    Overcoming barriers to clinician adoption
◊    What are the key barriers to adoption?
◊    What is the current state of adoption in the US, world-wide?
◊    Readings:
o    Jha AK, Doolan D, Grandt D, Scott T, Bates DW. The use of health information technology in seven nations. Int J Med Inform. 2008 Dec;77(12):848-54.
o    Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S, Blumenthal D. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood). 2006 Nov-Dec;25(6):w496-507.

◊    Selecting the hardware
◊    Server capacity
◊    Workstation and printer placement and number
◊    Portable solutions – handhelds, COW – computer on wheels
◊    Setting up, securing and testing a wireless infrastructure
◊    Planning for the future – VoIP, RFID locators, etc.
◊    Creating a robust, redundant hardware infrastructure
◊    Readings:
o    Richardson: Vocera

◊    Developing an implementation strategy
◊    Big bang or unit by unit
◊    Identifying the pilot units
◊    Planning for temporary workload reduction
◊    Identifying criteria to be met before installing in other locations
◊    Readings:
o    Lorenzi: Pilot site selection;

◊    Handling existing medical record data/information
◊    Scan old charts
◊    Understanding different types of data
o    Coded, free-text, images
◊    Import or enter laboratory data – how much?
◊    Will you continue to deliver old paper records? For how long?
◊    Developing interfaces to existing ancillary clinical systems (e.g., laboratory, pharmacy, ADT, etc.)
◊    HL-7; CCD documents
◊    Readings:
o    Dolin: CCD specification or CDA paper
o    HL-7 RIM specification

◊    Creating a timeline and work breakdown structure
◊    Identifying key milestones

◊    Assessing existing data resources
◊    Vocabulary standards: SNOMED; ICD-9
◊    Different database designs: relational, hierarchical, object-oriented
◊    Readings:
o    Rector: Why is Vocabulary so hard?
o   

◊    Understanding and mapping existing clinical workflows
◊    Identifying key processes
◊    Re-engineering workflow to improve efficiency

◊    Configuring the system
◊    Who will be the “decider” and make all the decisions
◊    How will the decisions be made (i.e., large representative group of clinicians, small group of experts, etc.)
◊    Readings:
o    Joint-Application development papers?

◊    The User Interface
◊    User interface design principles
◊    Data display alternatives
◊    Discount usability testing
◊    Readings:
o    Discount usability testing
o    User interface design
o    Common user interface CUI standards

◊    Clinical Decision Support
◊    What will you focus on first (e.g., safety, cost, efficiency, quality)
◊    Who will create the interventions?
◊    What data is needed to drive the interventions?
◊    Where will this data come from?
◊    How will you test the interventions?
◊    How will you monitor and evaluate the interventions
◊    How many order sets, default values
◊    Readings:
o    Payne VA Order sets paper
o    Improving outcomes Guide

◊    Setting up a communication strategy
◊    For rank and file – monthly newsletters
◊    For organization leadership – project dashboards
◊    Use of “pizza parties” to gather stakeholders

◊    Developing a training strategy
◊    Train the trainer
◊    Who trains physicians?
◊    Setting up a training room
◊    Creating on-line educational materials

◊    Developing a downtime strategy
◊    Backup policy and procedures: maintaining the integrity of the data
◊    Uninterruptible power – back up generators, batteries
◊    Establishing a remote hot site
◊    Readings:
o    Campbell: AMIA downtime
o   

◊    Establishing policy and procedures
◊    Establishing roles and responsibilities for users
◊    Password strength, change frequency, remote access
◊    Modifying organizational by-laws
◊    Will system usage be required by all?
◊    Security / Privacy / Confidentiality
◊    Readings:
o    Data and system security talk from Singapore
o    IOM security book

◊    Unit, System, and Integrated testing
◊    Unit testing
◊    Testing interfaces to ancillary systems
o    Clinical laboratory, pharmacy, radiology, admitting
◊    Integrated testing
◊    User Acceptance testing
◊    Dress rehearsals
◊    Readings: Improving outcomes guide – section on testing

◊    Patient-access to the system
◊    Who “owns” the data?
◊    How do patient’s get access to the systems?
◊    What do patients want from these systems?
◊    Overview of different types of personal health records
o    Tethered, downloaded data (e.g., Google, Health Vault), free-standing
◊    Readings:
o    Christiansen data ownership essay

◊    EHR Safety
◊    Unintended consequences
◊    E-Iatrogenesis
◊    Readings:
o    Campbell JAMIA UAC paper
o    Koppel JAMA paper
o    E-Iatrogenesis paper
o    Ash, Coiera, Berg – Unintended consequences

◊    Evaluating the effects of the system
◊    Gathering feedback
◊    Monitoring system usage
◊    Measure the effects on clinical processes and outcomes
◊    Availability, Use, Effects, e-Iatrogenesis
◊    Study design and reporting
◊    Readings:
o    Talmon: STARE-HI  IJMI 2009.
o    Ash: AMIA 2008 RAP
o    Leonard Sittig: JMIR

Prerequisites

HI 5310 Foundations I or equivalent.  Basic knowledge of PowerPoint, wikis, discussion groups.  Consent of instructor.