Patient Safety Achieving a New Standard for Care (2004) / Chapter Skim
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Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report
Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report
Pages 430-470
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E Key Capabilities of an Electronic Health Record System Letter Report Committee on Data Standards for Patient Safety Board on Health Care Services 430
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Additional copies of this report are available in limited quantities from the Committee on Data Standards for Patient Safety through the Board on Health Care Services, 500 Fifth Street, N.W., Washington, DC 20001. This report is also available online at www.nap.edu.
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432 PATIENT SAFETY "Knowing is not enough; we must apply. Willing is not enough; we must do." -- Goethe Shaping the Future for Health
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Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine.
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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 health care provided to an individual; (2) immediate electronic access to person- and populationlevel information by authorized, and only authorized, users; (3)
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Likewise, the availability of complete patient health information at the point of care delivery, together with clinical decision support systems such as those for medication order entry, can prevent many errors and adverse events (injuries caused by medical management rather than by the underlying disease or condition of the patient) from occurring (Bates et al., 1998, 1999; Evans et al., 1998)
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A handful of communities and systems have established secure platforms for the exchange of data among providers; suppliers; patients; and other authorized users, such as the Veterans Health Administration, the New England Healthcare Electronic Data Interchange Network, the Indiana Network for Patient Care, the Santa Barbara County Care Data Exchange, the Patient Safety Institute's National Benefit Trust Network, and the Markle Foundation's Healthcare Collaborative Network (CareScience, 2003; Kolodner and Douglas, 1997; Markle Foundation, 2003b; New England Healthcare EDI Network, 2002; Overhage, 2003; Patient Safety Institute, 2002)
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On the private-sector side, various insurers, purchasers, and employer groups are instituting quality incentive programs for specific EHR system functionalities, such as computerized provider order entry for prescription drugs and electronic reporting of performance measures (National Health Care Purchasing Institute, 2003)
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It will be important to update the functional model from time-to-time to reflect advancements in health care technology and care delivery. PROJECT OVERVIEW In response to the request from DHHS in May 2003, the charge to the IOM Committee on Data Standards for Patient Safety was expanded as follows: Provide guidance to DHHS on a set of "basic functionalities" that an elec tronic health record system should possess to promote patient safety.
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Key EHR functionalities have been identified for four settings -- hospital, ambulatory care, nursing home, and care in the community (i.e., the personal health record)
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Although each functionality independently may not fulfill all five criteria, when taken together as part of an EHR system, the core functionalities should address all criteria. • Improve patient safety.
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It would be advisable to reassess periodically the feasibility of implementing certain EHR functionalities and modify expectations regarding timing, as appropriate. CORE EHR FUNCTIONALITIES The IOM Committee identified core functionalities falling into eight categories (see Box 2)
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It is also important to note that too much information and data may overwhelm or distract the end user, so EHR systems must have well designed interfaces. The health information and data captured by an EHR system must also evolve over time, as new knowledge becomes available,
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. The use of computerized order entry, in conjunction with an electronic health record, is also beginning to demonstrate a positive effect on clinician productivity (Overhage et al., In press)
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. A study comparing clinical decisions made by physicians in the same practice using an EHR system and traditional paper records found that the former group made more appropriate clinical decisions as a result of all the tools available in an EHR system, including decision support (Tang et al., 1999a)
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. Improved communication among care partners, such as laboratory, pharmacy, and radiology, can enhance patient safety and quality of care (Schiff et al., 2003)
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Additionally, immediate validation of insurance eligibility should add value for both providers and patients through improved access to services, more timely payments and less paperwork. Moreover, computerized decision support tools are being used in a variety of settings to identify eligible or potentially eligible patients for clinical
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and artificial neural networks that can assist in identifying candidates for chronic disease management programs (Heden et al., 1997; Kok and Boon, 1996; Petrick et al., 2002)
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, the committee believes that fully functional, comprehensive EHR systems will be available and implemented by some health systems and regions. It may take considerably longer, however, for all providers to be using a comprehensive EHR system that provides for the longitudinal collection of complete health information for an individual; immediate access to patient information by all authorized users within a secure environment; extensive use of knowledge support and decision support systems; and extensive support for applications that fall outside immediate patient care (e.g., homeland security, public health, clinical research)
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Paul C Tang, Chair Committee on Data Standards for Patient Safety Cc: Ann Marie Lynch, Acting Assistant Secretary for Planning and Evaluation (ASPE)
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– Problem list X – Procedures X – Diagnoses X – Medication list X – Allergies X – Demographics X – Diagnostic test results X – Radiology results X – Health maintenance X – Advance directives X – Disposition X – Level of service X Minimum dataset (MDS) for nursing homes – Defined MDS for nursing homes NAa – Expanded/refined MDS NA Narrative (clinical and patient narrative)
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APPENDIX E 451 Care in the Community Ambulatory Care Nursing Homes (Personal Health Record) 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 X X X X X See Minimum Dataset Below X X X X X X X X X X X X X X X X X X X NA X NA NA X NA X X X X X X X X NA X X X X X X X X X X NA NA X X X X X X NA X NA X X NA Continued
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Order Entry/Management Computerized provider order entry – Electronic prescribing X – Laboratory X – Microbiology X – Pathology X – XR X – Ancillary X – Nursing X – Supplies X – Consults X
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APPENDIX E 453 Care in the Community Ambulatory Care Nursing Homes (Personal Health Record) 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X NA X X NA X X NA X X NA X X NA X X NA X X NA X X NA X X NA Continued
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X Reminders – Preventive services X Clinical guidelines and pathways – Passive X – Context-sensitive passive X – Integrated X Chronic disease management NA Clinician work list X Incorporation of patient and/or family preferences X Diagnostic decision support X Use of epidemiologic data X Automated real-time surveillance – Detect adverse events and near misses X – Detect disease outbreaks X – Detect bioterrorism X
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APPENDIX E 455 Care in the Community Ambulatory Care Nursing Homes (Personal Health Record) 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 X X X X X X X X NA X X NA X X NA X X NA X X NA X X NA X X NA X X NA X X X X X X X X X X X NA X X X X X NA X X X X X NA X X NA X X NA X X NA X NA NA Continued
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– Outside pharmacy X – Insurer X – Laboratory X – Radiology X Integrated medical recordb – Within setting X – Cross-setting - Inpatient–outpatient X - Other cross-setting X – Cross-organizational X 6. Patient Support Patient education – Access to patient education materials X – Custom patient education X – Tracking X Family and informal caregiver education X Data entered by patient, family, and/or informal caregiver – Home monitoring NA – Questionnaires X bDefined as the extent to which a single record integrates data from different settings, providers, and organizations (e.g., Primary Care Physician, specialist, hospital)
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APPENDIX E 457 Care in the Community Ambulatory Care Nursing Homes (Personal Health Record) 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 2004–5 2006–7 2008–10 X X NA X X NA X NA X X NA X X X X X X X X X X X X NA X X NA X X NA X X X X X X X X X X X X X X X X X X X X X X NA X X NA X Continued
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Reporting and Population Health Management Patient safety and quality reporting – Clinical dashboards X – External accountability reporting X – Ad hoc reporting X Public health reporting – Reportable diseases X – Immunization X Deidentifying data X Disease registries X
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APPENDIX E 459 Care in the Community Ambulatory Care Nursing Homes (Personal Health Record)
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J Am Med Inform Assoc 6 (6)
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2003. Building the National Health Information Infrastructure for Personal Health, Health Care Services, Public Health,a Nd Research.
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J Am Med Inform Assoc 8 (3)
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J Am Med Inform Assoc 9 (5)
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2002. "Patient Safety Institute: Presentation to the Fifth National HIPAA Summit -- Beyond HIPAA: Clinical Data Standards and the Creation of an Interconnected Electronic Health Information Infrastructure." Online.
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Project: Rationale and Design. J Am Med Inform Assoc 9 (1)
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J Am Med Inform Assoc 6 (3)
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Proc AMIA Annu Fall Symp 325-9.
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JAMES, Executive Director, Intermountain Health Care Institute for Health Care Delivery Research, and Vice President for Medical Research, Intermountain Health Care KEVIN JOHNSON, Associate Professor and Vice Chair, Department of Biomedical Informatics and Associate Professor, Department of Pediatrics, Vanderbilt University JILL ROSENTHAL, Program Manager, National Academy for State Health Policy TJERK W van der SCHAAF, Associate Professor of Human Factors in Risk Control, Eindhoven University of Technology, Eindhoven Safety Management Group, Department of Technology Management
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CORRIGAN, Director, Board on Health Care Services PHILIP ASPDEN, Study Director JULIE WOLCOTT, Program Officer SHARI ERICKSON, Research Associate REBECCA LOEFFLER, Senior Project Assistant ANTHONY BURTON, Administrative Assistant The committee wishes to thank the co-chairs of the Health Level Seven (HL7) Special Interest Group (SIG)
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Detmer, Dennis Gillings Professor of Health Management, The Judge Institute of Management Studies, University of Cambridge, and Professor Emeritus, Professor of Medical Education, University of Virginia. Appointed by the National Research Council and Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered.
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