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Real-World Case
Community Hospital has a single-vendor hospital information system (HIS) that provides typical financial and administrative information systems services, including laboratory, radiology, and pharmacy information systems, and order-entry/results review. Other ancillary departments such as nutrition, physical therapy, and nursing are not online. The hospital, however, is considering acquiring a CPOE system to reduce medication errors and to earn the MU incentives. The hospital participates in a cardiac care registry but abstracts data from their paper charts to contribute to the registry. The health plans serving the community are starting to offer incentives for use of health information technology if positive patient outcomes can be identified.
Physicians who are affiliated with Community Hospital have expressed interest in acquiring EHR systems for their practices but are waiting for the hospital to make a vendor decision concerning CPOE. They believe that if they acquire an EHR from the same vendor as the hospital, they will be able to write orders from their practices for patients who are in the hospital, have better access to the information they need to monitor their 10131014patients, and be able to tap into other providers’ EHR systems when they are covering in the emergency department.
The hospital and representative physicians are reviewing vendor products but are confused by what various vendors are telling them. One vendor has suggested that the hospital does not have the type of pharmacy information system that would support CPOE and thus would have to also buy a new pharmacy system. A vendor selling EDMS has suggested scanning and COLD feeding all the current chart forms from all provider settings into one repository so that they would be readily available when needed in an emergency. In the meantime, a couple of physicians purchased a standalone electronic prescribing device. They can send prescriptions to the major chain pharmacies in the community, but not to the community pharmacy, nor can they get an interface written between the device and the clinical pharmacy in the hospital that would be needed for CPOE.
Summary
Many hospitals and physician practices are in the throes of analyzing their current information systems environment and assessing how to move forward to achieve an electronic health record (EHR). An EHR is a major investment, a complex undertaking, and involves all the organization’s stakeholders, especially clinicians. The EHR also is touching others in the healthcare community, including payers, employers, and, most important, patients who are learning that EHRs contribute to increased patient safety and quality healthcare. The federal government is now taking a significantly greater role in promoting adoption of EHR through incentive programs, training initiatives, and other funding opportunities—all tied to improving quality and patient safety.
Ensuring that data can be collected from all the various source systems and that there are applications to provide reminders and alerts when needed most by the clinician is a laudable goal and may seem easy. However, such an undertaking requires hardware and software that adhere to standards for interoperability and data comparability, as well as active engagement of all potential users, appropriate policies for adoption and use, and change management to use the computer to improve processes. Implementing an EHR is a clinical transformation; it truly changes how clinicians think and act—indeed, how they practice medicine.
Most hospitals cannot migrate to such systems overnight, which results in hybrid records that challenge the HIM professional’s skills in managing the two worlds of paper and computer. Moreover, some are concerned that the electronic systems may not be receiving the data quality attention previously given paper records, which is even more acutely needed in the electronic environment. Many physician practice systems are highly sophisticated, but its users less informed about how to effectively use the systems. Such challenges point to the enhanced need for HIM professionals to understand and lead their organization’s adoption of health information technology.
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