This document provides an overview of electronic health record systems (EHRs). It discusses how EHRs are used by various healthcare professionals and departments to longitudinally collect and share patient health information. Key features of EHRs discussed include providing access to patient data, clinical decision support, supporting efficient healthcare processes, and enabling remote access to patient records. Several examples of early EHR systems developed by the VA, DoD, and IHS in the 1970s are provided. The role of government agencies and standards organizations in facilitating EHR adoption is also summarized.

1. By: Mikhaela Ripa

2. Electronic Health Record
System

3. 
Is often used interchangeably with
computerized patient record clinical
information system, electronic medical –
record, and many others. Yet the choice of
the words in the term EHR – S reflects the
boarder focus on the health of the consumer
or patient and indicates that the EHR – S may
be used by all participants in the process of
achieving health, including all disiplins of
clinical, family caregivers and the patient.

4. 
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Longitudinal collection of electronic health
information for and about persons, where health
information is defined as information pertaining
to the health of an individual or healthcare
provided to an individual.
Immediate electronic access to person and
population – level information by authorized, and
only authorized, users.
Provision of knowledge and decision support that
enhances the quality, safety, and efficiency of
patient care.
Support of efficient process for healthcare
delivery.

5. 
Different departments exert different
influence towards the common goal of an
EHR for most Americans. Other agencies
provide leadership by offering monetary
incentives; finding research, development and
demonstration projects; and shaping
regulations and policy.

6. 
The Veterans Health Administration in the
Department of Veterans Affairs (VA) and the
National Institutes of Health (NIH) in the
Development of Health and Human Services
(HHS) are two examples of the initiation of
system in the 1970’s that were activity used
by clinicians.

7. 
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The Veterans Health Information System and Technology Architecture (VISTA)
support day – to – day clinical and administrative operations at local VA healthcare
facilities. All electronic records are password protected to guarantee patients
privacy other features include the following:
A checking system that alerts clinicians if an order they are entering could cause a
problem.
A notification system that immediately alerts clinicians to clinically significant
events.
A visual posting system that alerts healthcare providers to issues specifically
related to the patient on the opening of the patients electronic chart, including
crisis notes, adverse reactions, and advance directives.
A template system that allows the healthcare provider to automatically create
reports.
A clinical reminder systems that electronically alerts clinicians when certain
actions, such as examinations, patien education, and laboratory test, need to be
performed.
Remote data viewing to allow clinicians to see the patient medical history at all the
VA facilities where the patient was seen.

8. 
Within DoD, providers have had a
computerized physician order entry capability
that enables them to order lab test and
radiology examinations and issue
prescriptions electronically for over 10 years.

9. 
The IHS has long been pioneer in using
computer technology to capture clinical and
public health data. RPMS was developed in
1970 and many facilities have access to
decades of personal health information and
epidemiologic data local populations.

10. 
The government is also pursuing the
development of a public – private national
health information network to facilitate EHR –
S deployment.

11. 

The executive order of April 2004, mentioned
earlier in the chapter, created the ONCHIT to
coordinate HIT efforts in the federal sector and to
collaborate with the private sectors in driving HIT
adoption across the healthcare system.
The National Committee on Vital and Health
Statistics in 2000 and 2001, the National
Committee on Vital and Health Statistic (NCVHS)
which advises the secretary of HHS on health
information policy, held a series of national
hearings to develop a consensus vision of the
national Health Information Infrastructure
(NHCII).

13. 
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Inform Clinical Practice: Informing clinical
practice
Is fundamental to improving care and making
healthcare delivery more efficient. Three
strategic for realizing goal are:
Incentivize EHR adoption
Reduce risk of EHR investment
Promote EHR diffusion in rural and under
segued areas

14. Interconnect Clinicians: will allow information
to be portable and to more with consumer.
The three strategies for realizing this goal
are:
 Foster regional collaboration
 Develop national health information systems.
 Coordinate federal health information
systems.

15. Personalize care: consumer – centric
information helps individuals manage their
own wellness and assist with their personal
healthcare decisions. The three strategies for
realizing this goal are:
 Encourage use of personal health records
 Enhance informed consumer choice
 Promote use of telehealth systems

16. Improve Population Health: Requires the collection
of timely, accurate, and detailed clinical
information to allow for the evaluation of
healthcare delivery and the reporting of critical
findings to public health officials, clinical trials
other research and feedback to clinicians:
 Unify public health surveillance architecture
 Streamline quality and health status monitoring
 Accelerate research and dissemination of
evidence

17. 
In addition AHRQ funded demonstration
grants to establish and implement
interoperable health information systems and
data effectiveness of healthcare for patients
and populations on a specific state or
regional level.

18. 
Several large pilot programs were authorized
in the 2003 Medicare Modernization Act
(MMA) the 3 – year is intended to promote
continuity of care, help stabilize medical
conditions and reduce adverse health
outcomes, such as adverse drug interactions.

19. 
Among these private sector organizations are
those formed specifically to address issues of
connectivity, HIT, and standards
development.

20. 
Is addressing the barriers to development of
an interconnected health information
infrastructure. It brings together several
dozen of the leading healthcare provider and
prayer organizations, HIT vendors and
representatives of federal and state agencies.

21. 
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Is an independent, nonprofit affiliated
organizations established to foster improvement
in the quality safety, and efficiency of healthcare
through information and IT. Shares its mission
and providers funding for its initiatives.
Is Connecting Communities for better, a nearly
$4miillion program that provides seed funding
and technical support to multi stakeholder
collaborative within communities that are using
electronic health information exchange and other
HIT tools to drive improvements in healthcare
quality, safety and efficiency.

22. 
As an independent adviser to the nation with
the goal of improving health, the 10M has
championed the advantages of use of IT to
improve healthcare since its 1991
foundational work: the report created a
framework for identifying core functions of
an EHR – S, along with the primary and
secondary uses of these systems.

23. 
The goal of this group is to support Goal 1,
strategy 2, “Reduce risk of EHR investment” of
the strategic framework. Twelve
commissioners serve on the certification
group, with two ex – officio representing the
federal government.

24. Is known for its large body of work in the
production of technical specifications for the transfer
of healthcare data. This transport mechanism known
as messaging, is widely used domestically and
internationally.
The HL7 EHR –s functional model contains a list
of functions in three categories: direct care,
supportive, and information infrastructure.
 Direct care functions are familiar to clinicians.
 Supportive functions involves secondary use of the
data captured via the direct care functions.
 Information infrastructure section is the “backend” of
the systems.
Functional Model is the Creation of a Profile.

25. Dependable
System for Quality
Care

26. 
In this section we discuss five fundamental
guidelines that can help increase the
dependability of healthcare systems.

27. 
The infrastructure level, features that are
transparent to software applications should
be implemented to detect faults are detected
and to recover from failures before they
become catastrophic. To handle exceptions in
the execution of specific software
applications, application – specific feature
should be implemented security feature to
detect, disable and recover from malicious
attacks, while preserving system stability and
security, should be implemented.

28. 
Fundamental Principle of System architecture
is that an enterprise system architecture
should be developed from the bottom up so
that no critical component is dependent on a
component less trustworthy than itself. At the
bottom of the architecture are the physical
and logical networks that support the
enterprise and provide the “pipes“ that carry
data from system to system.

29. 
The system planning process should
anticipate business success and the
consequential need for larger networks more
system, new applications, and additional
integration. Such models can provide valuable
input into planning for scalability and future
integration.

30. 
Managing and keeping complex network and
integrated system available and responsive
requires meticulous overseers – individuals
who know that failures will occur and accept
that failures are most likely to occur when
they are least expected.

31. 
Imagine that small start – up company called
Cute Chutes has announced the availability of
a new parachute unit that promises to
revolutionize the sport of sky diving.

32. 
This system provides an informal assessment
of how well healthcare provider organizations
follow the guidelines discussed above.

33. 
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Healthcare Organizations build – or perhaps
“compose” their systems from the top down rather
than from the bottom – up. The healthcare
professionals select the user interfaces they like, and
the IT team negotiates terms with the vendors who
offer the systems that generate those interfaces these
systems are familiarly known as “departmental”
system because they generally are used only in one
department, such as registration laboratory, or
pharmacy.
The healthcare Portability and Accountability Act
(HIPAA) security regulation prescribes administrative.
Physical and technical safeguards for protecting the
confidentially and integrity of health information and
the availability of critical systems services.

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Security management, including security analysis and risk
management.
Assigned security responsibility.
Information access management, including the isolation of
clearinghouse functions from clinical function.
Security awareness and training.
Security incident procedures, including response and
reporting.
Contingency planning, including data back up planning
disaster recovery planning, and planning for emergency
mode operation.
Evaluation.
Business associate contracts that lock in the obligations of
business partners in protecting health information to
which they may have access.

35. 
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Access control, including unique user
identification and an emergency access
procedure.
Audit control.
Data integrity protection.
Person or entity authentication.
Transmission security.

36. 
Healthcare organization definitely expect
their software applications, computer system,
and networks to work.

37. 
Medical technology and prescription drugs,
as well as clinical treatment protocols, are
required to undergo extensive validation
before they can be used in clinical practice.

38. 
These organization have hired IT manager
who appreciate the important role of IT in a
healthcare environment and who recognize
the need for dependable systems that can
anticipate and recover from failures.

39. Chapter 16

40. 
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Nursing care
Patient or client demographics
Service Elements
The NMDS was develop by building on the
foundation establish by the United State
uniform hospital discharge.

41. 
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Nursing diagnosis
Nursing intervention
Nursing outcomes
Intensity of nursing care

42. 
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The NMDS identifies essential, common and
core data elements to be collected for all
patients/client receiving nursing care.
Is a standard approach that facilitates that
abstraction of these minimum, common,
essential care data elements to describe
nursing practice.
The NMDS was conceptualized through a
small group work at the nursing information
system (NISS) conference help in 1977 at the
University of Illinois College of Nursing.

43. 
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Personal identification
Date of birth
Sex
Race and ethnicity
Residence

44. 
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Unique facility or service agency number
Unique health record number or
patient/client
Unique number of principle registered nurse
provider
Episode admission or encounter date
Discharge or termination date
Disposition of patient/client
Expected payer for most of this bill

45. 
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The NMDS influenced the work of the professional
nurses association. In 1991, the Americans Nurses
Association (ANA) recognized the NMDS as the
minimum data elements to be included in any data
set or patient record.
The NMDS servers as a key component of the
standards developed by the Nursing Information and
Data Set Evaluation Center (NIDSEC).
NIDSEC develops and disseminates standards
related to nomenclature, clinical associations, clinical
data repositories, and system characteristics/
decision support/contextual variable pertaining to
data sets in information system that supports the
documentation of nursing practice (NMDS).

47. 
The Early NMDS work in the United States
spurred the development of NMDS in
numerous other countries. A perusal of these
data set reveals a definite consensus on the
importance of the nursing care elements
across all countries which identified NMDS’s.

48. 
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Several countries across most continents
beyond North America are exploring
development of NMDS systems.
It is clear that there is major work being
accomplished across the globe to ensure that
nursing essential data will be more
comprehensively available in the future.
NMDSs relationship to International Nursing
Minimum Data Set (I – NMDS).

49. 
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The i – NMDS includes the core,
internationally relevant, essential, minimum
data elements to be collected in the course
for providing nursing care.
These data can provide information to
describe compare and examine nursing
practice around the globe.
i-NMDS is intended to build on the efforts
already underway in individual countries.

50. 
The i-NMDS Research Center is lead by a
steering committee of international
representative of countries with existing and
emerging NMDS as well as professional
cosponsor ship and areas of informatics
expertise.

51. 
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Describing the human phenomena
Improving the performance of healthcare
system
Enhancing the capacity of nursing
Addressing the nursing shortage
Testing credence based practiced
improvements
Empowering the public internationally

52. 
The i-NMDS elements are organized into
three categories, subjects of care, and
nursing elements.

53. 
The power of NMDS to describe nursing
practice from international perspective is
daunting.

54. Chapter 17

55. 
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In 2001, the American Nurses Association
(ANA) published the code of Ethics for nurses
with Interpretive statements, a complete
prevision and interpretive statements that
guide all nurses in practice, be it in the
domain of direct patient care, education,
administration, or research.
Nursing informatics is the nursing specialty
that endeavors to make the collection, and
knowledge easier for the practitioner,
regardless of the domain and setting.

56. 
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Informatics is a science that combines a
domain science, computer science,
information science, and cognitive science.
Healthcare informatics may be defined as
the integration of healthcare information.
Healthcare informatics address the study
of management of healthcare information.
Nursing informatics reflects this duality as
well, moving in and out of integration and
separation as situations and needs demand.

57. 
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In 1985, Kathryn Hannah proposed a
definition that nursing informatics in the use
of informatics technologies in relation to any
nursing function and action of nurses.
Nursing sciences, computer science and
information, and knowledge to manage and
communicate data, information, and
knowledge in nursing practice.

58. 
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In early 1992, the ANA established nursing
informatics as a destine specialty in nursing
with a distinct body of knowledge.
The scope of nursing informatics practice
includes activities such as developing and
evaluating applications, tools, processes, and
strategies that assist registered nurses in
managing data to support decision – making.

59. 
Models are representation of some aspect of
the real world. Models show particular
perspectives of a selected aspect and any
illustrate relationships. Models evolve as
knowledge about the selected aspect changes
and are dependent on the “world view” of
these developing the model.

60. 
Data, information and knowledge are defined
as current met structures or overarching
concepts for nursing informatics with specific
definitions in the scope and standards of
Nursing Informatics Practice. Data are
“discrete entities that are described
objectively without interpretation” and would
include some value assigned to a variable.

61. 
Knowledge worker is the exercise of specialist
knowledge and competencies.

62. 
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Registered nurses are consumable twenty
first century knowledge workers.
Knowledge work of course, depends on
access to data, information and knowledge.

63. 
This desired change in skills involves the
evolution from novice level to advanced
beginner to competent to proficient to finally
an expert level.

64. 
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Healthcare environment is characterized by
significant emphasis on establishing the EHR
in all settings.
The concept of EHR emerged, initially, as a
computer – based patient record or CPR and
was given significant impetus ba a 1991
report from the institute of medicine that
advocate the adoption of the CPR as the
primary source of client healthcare data and
information.

65. 
This is best accomplished by using standard
communication formats and terminologies
and recognized convention for describing the
concepts being presented. Concept
representation involves the set of terms and
relationship that describe the phenomena,
processes, and practices of a discipline, such
as nursing.

66. 
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Has evolved from alphabetical listing in the
mid – 1980’s to a conceptual system that
guides the classification of nursing diagnoses
in a taxonomy and includes definitions and
defining characteristics.
Includes 167 recognized diagnoses that
every different from the pathology and
mortality focus of the ICD – 9 CM terms used
for medicine and third party payment claims.

67. 
The fourth edition of NIC contains 514
nursing interventions that describe the
treatments nurses perform updated linkages
with NANDA diagnoses and core interventions
identified for 44 specialty practice areas.
There terms differ from the surgically biased
CPT – 4 code set terms used by medicine and
third party programs.

68. 
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To provide standardization of expected
patient, caregiver, family and community
outcomes for measuring the effect of nursing
interventions.
Clinical Care Classification (CCC) Formerly
Home Health Care Classification (HHCC)
CCC system is a research – based
nomenclature designed to standardize the
terminologies for documenting nursing care
in all clinical care settings.

69. 
Was released in November 2004, originally
developed for use un home practice, the
Ohama system is now used in all clinical
settings.

70. 
Is a core clinical terminology containing over
357,000 healthcare concepts with unique
meanings and formal logic – based
definitions organized into multiple
hierarchies.

71. 
The PNDS provides a universal language for
peri – operative nursing and education and a
framework to standardize documents.

72. 
Provide a mechanism for coding integrative
health interventions by clinician by state
location for administrative billing and
insurance claims.

73. 
Includes terms and codes for patient
problems, therapeutic goals, and patient care
orders. This data set was developed by Dr.
Judith Ozbolt from research data from nine
acute care hospitals throughout the United
State.

74. 
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Originated as a database of standardized
laboratory term for result reporting for
chemistry, hematology, serology,
microbiology, and toxicology.
Includes about 32,000 terms including a
clinical portion with codes for observations at
key stages of the nursing process, including
assessments, goals and outcomes.

75. 
Is a combinational terminologies for nursing
practice developed by the international
nursing community under sponsorship of the
International council of Nurses (ICN).

76. 
Includes terms to describe the context and
environment of nursing practice, and includes
terms for nursing delivery unit/service,
patient/client population, care delivery
method, personnel characteristics and
financial resources.

77. 
Provide information resources and value –
added membership benefits that support
those individuals interested in healthcare and
nursing informatics.