Understanding Features & Functions of an EHR

Objectives:

  • Learn about the must-have features of an EHR
  • Learn about studying your current workflow and envisioning new workflow options for the EHR

Electronic Health Record Features & Functions

Basic EHR Functions

Projects like Health Level 7 are currently attempting to define the minimum functions an EHR should perform to help physicians practice better medicine and improve the bottom line. Some of these functions include, but are not limited to:

  • Identify and maintain a patient record
  • Manage patient demographics
  • Manage problem lists
  • Manage medication lists
  • Manage patient history
  • Manage clinical documents and notes
  • Capture external clinical documents
  • Present care plans, guidelines, and protocols
  • Manage guidelines, protocols and patient-specific care plans
  • Generate and record patient-specific instructions

HL7 List of EHR Functions

Identify and maintain a patient record - Identify and maintain a single patient record for each patient.

Manage patient demographics - Capture and maintain demographic information. Where appropriate, the data should be clinically relevant, reportable and trackable over time.

Manage problem lists - Create and maintain patient-specific problem lists.

Manage medication lists - Create and maintain patient-specific medication lists.

Manage patient history - Capture, review, and manage medical procedural/surgical, social and family history including the capture of pertinent positive and negative histories, patient-reported or externally available patient clinical history.

Manage clinical documents and notes - Create, addend, correct, authenticate and close, as needed, transcribed or directly-entered clinical documentation and notes.

Capture external clinical documents - Incorporate clinical documentation from external sources.

Present care plans, guidelines, and protocols - Present organizational guidelines for patient care as appropriate to support order entry and clinical documentation.

Manage guidelines, protocols and patient-specific care plans - Provide administrative tools for organizations to build care plans, guidelines and protocols for use during patient care planning and care.

Generate and record patient-specific instructions - Generate and record patient-specific instructions related to pre- and post-procedural and post-discharge requirements.

Place patient care orders - Capture and track orders based on input from specific care providers.

Order diagnostic tests - Submit diagnostic test orders based on input from specific care providers.

Manage order sets - Provide order sets based on provider input or system prompt.

Manage results - Route, manage and present current and historical test results to appropriate clinical personnel for review, with the ability to filter and compare results.

Manage consents and authorizations - Create, maintain, and verify patient treatment decisions in the form of consents and authorizations when required.

Support for standard assessments - Offer prompts to support the adherence to care plans, guidelines, and protocols at the point of information capture.

Support for standard care plans, guidelines, protocols - Support the use of appropriate standard care plans, guidelines and/or protocols for the management of specific conditions.

Support for drug interaction checking - Identify drug interaction warnings at the point of medication ordering.

Patient specific dosing and warnings - Identify and present appropriate dose recommendations based on patient-specific conditions and characteristics at the time of medication ordering.

Support for accurate specimen collection - Alert providers in real-time to ensure specimen collection is supported.

Present alerts for preventive services and wellness - At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.

Present alerts for preventive services and wellness - At the point of clinical decision making, identify patient specific suggestions/reminders, screening tests/exams, and other preventive services in support of routine preventive and wellness patient care standards.

Notifications and reminders for preventive services and wellness - Between healthcare encounters, notify the patient and/or appropriate provider of those preventive services, tests, or behavioral actions that are due or overdue.

Support for monitoring response to notifications regarding an individual patient's health, including appropriate follow-up notifications - In the event of a health risk alert and subsequent notification related to a specific patient, monitor if expected actions have been taken, and execute follow-up notification if they have not.

Clinical task assignment and routing - Assignment, delegation and/or transmission of tasks to the appropriate parties.

Clinical task linking - Linkage of tasks to patients and/or a relevant part of the electronic health record.

Clinical task tracking - Track tasks to guarantee that each task is carried out and completed appropriately.

Clinical task timeliness tracking - Track and/or report on timeliness of task completion.

Inter-provider communication - Support secure electronic communication (inbound and outbound) between providers to trigger or respond to pertinent actions in the care process (including referral), document non-electronic communication (such as phone calls, correspondence or other encounters) and generate paper message artifacts where appropriate.

Pharmacy communication - Provide features to enable secure bidirectional communication of information electronically between practitioners and pharmacies or between practitioner and intended recipient of pharmacy orders.

Provider and patient or family communication - Trigger or respond to electronic communication (inbound and outbound) between providers and patients or patient representatives with pertinent actions in the care process.

Patient, family and care giver education - Identify and make available electronically or in print any educational or support resources for patients, families, and caregivers that are most pertinent for a given health concern, condition, or diagnosis and which are appropriate for the person(s).

Entity Authentication - Authenticate EHR-S users and/or entities before allowing access to an EHR-S.

Entity Authorization - Manage the sets of access-control permissions granted to entities that use an EHR-S (EHR-S Users). Enable EHR-S security administrators to grant authorizations to users, for roles, and within contexts. A combination of the authorization levels may be applied to control access to EHR-S functions or data within an EHR-S, including at the application or the operating system level.

Secure Data Exchange - Secure all modes of EHR data exchange.

Enforcement of Confidentiality - Enforce the applicable jurisdiction's patient privacy rules as they apply to various parts of an EHR-S through the implementation of security mechanisms.

Data Retention, Availability and Destruction - Retain, ensure availability, and destroy health record information according to organizational standards. This includes: > Retaining all EHR-S data and clinical documents for the time period designated by policy or legal requirement; >Retaining inbound documents as originally received (unaltered); >Ensuring availability of information for the legally prescribed period of time; and >Providing the ability to destroy EHR data/records in a systematic way according to policy and after the legally prescribed retention period.

Workflow Management - Support workflow management functions including both the management and set up of work queues, personnel, and system interfaces as well as the implementation functions that use workflow-related business rules to direct the flow of work assignments.

Provider demographics - Provide a current directory of practitioners that, in addition to demographic information, contains data needed to determine levels of access required by the EHR security system.

Patient demographics - Support interactions with other systems, applications, and modules to enable the maintenance of updated demographic information in accordance with realm-specific recordkeeping requirements.

Patient's residence for the provision and administration of services - Provide the patient's residence information solely for purposes related to the provision and administration of services to the patient, patient transport, and as required for public health reporting.

De-identified data request management - Provide patient data in a manner that meets local requirements for de-identification.

Scheduling - Support interactions with other systems, applications, and modules to provide the necessary data to a scheduling system for optimal efficiency in the scheduling of patient care, for either the patient or a resource/device.

Report generation - Provide report generation features for the generation of standard and ad hoc reports.

Health record output - Allow users to define the records and/or reports that are considered the formal health record for disclosure purposes, and provide a mechanism for both chronological and specified record element output.

Specialized views - Present specialized views based on the encounter-specific values, clinical protocols and business rules.

Rules-driven clinical coding assistance - Make available all pertinent patient information needed to support coding of diagnoses, procedures and outcomes.

Rules-driven financial and administrative coding assistance - Provide financial and administrative coding assistance based on the structured data and unstructured text available in the encounter documentation.

Service authorizations - Support interactions with other systems, applications, and modules to enable the creation of requests, responses and appeals related to service authorization, including prior authorizations, referrals, and pre-certification.

Support of service requests and claims - Support interactions with other systems, applications, and modules to support the creation of health care attachments for submitting additional clinical information in support of service requests and claims.

Claims and encounter reports for reimbursement - Support interactions with other systems, applications, and modules to enable the creation of claims and encounter reports for reimbursement.


Manage Practitioner/Patient relationships - Identify relationships among providers treating a single patient, and provide the ability to manage patient lists assigned to a particular provider.

E-prescribing vs. Fax-prescribing

E-prescribing typically refers to a process that is not yet in place, or is just beginning to take hold. E-prescribing allows a physician to write a prescription that is electronically transmitted to a pharmacy in such a way that the data goes directly into the pharmacy's computer system. This means that there is no re-entry of data at the pharmacy end. This saves time and leaves much less room for human error.

Fax-prescribing is widely used today. While each state may have different laws about how faxed prescriptions are handled, most allow a physicians office to fax a prescription. This is not typically considered e-prescribing.

There are services available on the Internet where you can send the prescription electronically to the service, which then transmits it to a pharmacy. However, those prescriptions are still faxed to the pharmacy– just through the service and not directly from the physician's office.

Speech Recognition Questions

Why should I use speech recognition with my EHR?

peechrecognition save you money in terms of transcription costs, it can also improve efficiency within your practice and increase the quality of patient care you provide.

Charles Booras MD, Jacksonville, Florida, says:

"I have been using voice recognition for all my dictation over the past 5+ years. It has increased my work burden at the office, but I'm saving over $1000 a month in transcription costs and my documentation very clearly supports my level of coding. In this era of low reimbursement for primary care, any reduction in overhead is money in my pocket."

Louis Spikol, Whitehall, Pennsylvania, says:

"I use speech-recognition with my electronic record as one of a number of tools that I have; most of the time I will put in a few sentences after the patient leaves the room, sometimes as a nurse is drawing blood or taking care of something else. Sometimes I need to dictate a letter or another note for the patient and I will just excuse myself and say 'I'm dictating this letter for you.' Very few patients object to getting things done for them right now!"

What are some speech recognition products available?

ViaVoice

ViaVoice is voice recognition software made by IBM. This software allows the user to create a customizable vocabulary of over 300,000 words, compose documents and e-mail, navigate through the Internet by simply stating web addresses and use customized voice command shortcuts. ViaVoice works well with a variety of other PC applications and a medical vocabulary expansion is available. ViaVoice is a satisfactory and reasonably priced alternative to more expensive medical voice recognition software.

Paul Spilseth, MD, Stillwater, Minnesota, says:

"I have used ViaVoice to document the visit of every patient I have seen for the past three years. I tried the standard edition first, but the medical vocabulary is well worth it. It takes some dedication to get it up and running successfully."

Dragon Naturally Speaking (DNS)

Dragon Naturally Speaking (DNS) is a type of voice recognition software made by Nuance. Its ability to translate speech into text with a high level of accuracy has won DNS acclaim from many physicians who use the professional medical edition of this software. Dragon Naturally Speaking works with many EHR applications, contains a large medical vocabulary and allows users to navigate through various software applications using voice commands.

Louis Spikol, MD, Whitehall, Pennsylvania, says:

"Within Dragon there are two aspects: speech to text capability (the obvious use that most of us who use speech recognition rely upon and command and control), the ability to activate program commands, and operating system commands. Dragon is fairly good at both and, in fact, it is possible to operate the complete computer by voice."

MacSpeech

MacSpeech is the only developer of voice recognition software for Macintosh. It's newest software, iListen, has the ability to dictate, format, and edit directly in virtually any application. Although there is not a specific medical edition of this software, iListen can launch over 150 applications and has an extensive vocabulary: 30,000 native vocabulary words and close to 300,000 background words. It is relatively inexpensive and easy to train and use.

What kind of hardware do I need for speech recognition?

Voice recognition appears to work well on desktops, laptops, and tablets alike. However, there are some additional aspects of hardware to consider when using DNS or any other voice recognition system. For example, in order to optimize accuracy and speed, it is often necessary to have an up-to-date processor and a computer with a sufficient amount of RAM, usually at least one gigabyte. It is also a good idea to have an adequate sound card and a good microphone to get the most out of your voice recognition software.

Louis Spikol, Whitehall, Pennsylvania, says:

"Desktop computers: the processor should be at least a Pentium 3 (or Athlon) 800 MHz or greater with ideally 512 MB on RAM. The amount of RAM is especially important for speed and accuracy. If you have a choice between some extra processing power and extra RAM, choose extra RAM. Many of the newer speech recognition versions are optimized for the Pentium 4 processor.

"Notebook Computers: again, the processor should be at least a Pentium 3 - 800 MHz or greater with ideally 512 MB of RAM. I believe notebook computers are becoming the platform of choice for physicians and speech recognition. They have greatly matured in terms of their capabilities. In addition, laptop computers can be used quite easily in the exam room.

"Sound cards: in desktop computers the sound card should be a separate sound card. Sound cards integrated into the motherboard have too much noise and are not acceptable for speech recognition. Internal sound cards of notebook computers tend to vary; some are acceptable and some are not. Recently, external USB sound cards have become available. They are approximately $50 and are worth trying if you have difficulty with recognition either on a desktop or laptop using the internal sound card."

Paul Spilseth, Stillwater, Minnesota, recommends:

"I use a desktop Sennheiser MD431 II on a balanced spring microphone in my office and it works well. I use a Sennheiser headset microphone in one of my exam rooms, but I prefer the desktop microphone because it is faster (you don't have to put it on your head and take it off). You just pull the boom over to your mouth and start talking."

Brian Madden, MD, Santa Monica, California, says:

"My ideal would be that the patient doesn't even notice you're doing it; you switch the mic on and off during the encounter and you could quickly add in the snippets of charting as you went along. If you walk in with a tablet and a USB microphone/headset, it's still cumbersome, obvious, and hinders the encounter (take it off to put on your stethoscope, etc.). So for this situation the recommendation is usually the handheld device; it's small, fits in your pocket and you flip it out to record."

What are some drawbacks to using speech recognition?

Although voice recognition can greatly benefit your practice, there are also some drawbacks involved. Like adapting to other aspects of using an EHR, implementing voice recognition takes both practice and patience. It is often necessary to make corrections on dictation mistakes and it takes time to train your software to it's optimal ability. Another drawback is that when using voice recognition in your office, the files are not accessible to everyone and are not networkable. Voice recognition software takes up a lot of RAM and may require an ungraded computer in order to get started. Here's what some of your peers are saying about the drawbacks of voice recognition:

Dr. Bill Wade, St. Louis, Missouri, says:

"Learning to use any voice recognition product is a skill. Just like learning the art of auscultation, proficiency at voice recognition takes good training, practice and good equipment. Just buying a stethoscope does not qualify one as a cardiologist. How well it works for you will depend on your realistic expectations, the amount of training you avail yourself to, learning the correct way to make corrections and "teach" the software, and your willingness to practice."

KnowBrainer, Hermitage, Tennessee, says:

"The biggest reason physicians are giving up on voice recognition is because they have no backup. Most of them purchased their software from CompUSA, which is consumer software. They are lead to believe that their microphone and sound card were adequate when in fact, they are not."

Jim McNabb, MD, Mooresville, North Carolina, says:

"One drawback to DNS 8 is that you really can't install NaturallySpeaking on each network computer if you have more than six PC's. That's because DNS 8 is limited to six installs and must be activated over the Internet. Also, ScanSoft states that the end-user license is per user, not per system. Therefore, you need to purchase a Dragon Naturally Speaking license for each individual user."