The Electronic Health Record and Clinical Informatics Essay

Now that you understand middle range theory, look through the list of middle range theories in your text. Find 2-3 that are related to concepts that you are interested in and read about them. Can you determine what type of theory it is? What are the concepts? How could this theory be used for research or practice?The Electronic Health Record and Clinical Informatics Essay

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Theory is made up of concepts and propositions about a phenomenon.

Concept = word or phrase that captures the essence of something such as functional status or mood.

For example: a single dimension might be physical energy. On the other hand, a multidimensional might be functional status which would include several factors.

A proposition is a statement about one or more concepts. For example, Functional status is defined as performance of usual activities of daily living. A proposition about two or more concepts states an association between the concepts, including the relation between the concepts or the effect of one or the other. So, nursing theory focuses on experiences of health conditions and health related events.The Electronic Health Record and Clinical Informatics Essay

Types of middle range theory

Descriptive: describe a phenomenon. Typically comprise one concept and one proposition that is a definition or description of the concept.
Examples include “Theory of Functional Status”. The concept is functional status. The proposition is that it is a multidimensional concept that is defined as performance of usual family care activities, household activities, social activities, community activities, person care activities and of occupational activities.

Explanatory: Specify how concepts are related to one another, they provide explanations about a phenomenon. They consist of two or more concepts, the propositions that are definitions or descriptions of each concept, and the propositions that specify the relations between the concepts.
Example: The theory proposition that specifies the relation between concepts is as follows: chronic pain, physical disability, social support, age, and gender are related to perceived daily stress, which is related to depression.The Electronic Health Record and Clinical Informatics Essay

Predictive: Specifies how a concept affects one or more other concepts. They are made up of two or more concepts the propositions that are definitions or descriptions of each concept, and the propositions that specify the effect(s) of one concept on one more other concept.
Example: A theory about the effects of cancer support groups with coaching on symptom distress, emotional distress, functional status and quality of the relationship with a significant other. Women with breast cancer who participate in a cancer support group with coaching would have less symptom distress, less emotional distress, greater functional status, and higher quality of relationship with a significant other than women who participated in a cancer support group without coaching and women who did not participate in any support group.

To understand the complexities of the emerging electronic health record system, it is helpful to know what the health information system has been, is now, and needs to become. The medical record, either paper-based or electronic, is a communication tool that supports clinical decision making, coordination of services, evaluation of the quality and efficacy of care, research, legal protection, education, and accreditation and regulatory processes. It is the business record of the health care system, documented in the normal course of its activities. The documentation must be authenticated and, if it is handwritten, the entries must be legible.The Electronic Health Record and Clinical Informatics Essay

In the past, the medical record was a paper repository of information that was reviewed or used for clinical, research, administrative, and financial purposes. It was severely limited in terms of accessibility, available to only one user at a time. The paper-based record was updated manually, resulting in delays for record completion that lasted anywhere from 1 to 6 months or more. Most medical record departments were housed in institutions’ basements because the weight of the paper precluded other locations. The physician was in control of the care and documentation processes and authorized the release of information. Patients rarely viewed their medical records.

A second limitation of the paper-based medical record was the lack of security. Access was controlled by doors, locks, identification cards, and tedious sign-out procedures for authorized users. Unauthorized access to patient information triggered no alerts, nor was it known what information had been viewed.

Today, the primary purpose of the documentation remains the same—support of patient care. Clinical documentation is often scanned into an electronic system immediately and is typically completed by the time the patient is discharged. Record completion times must meet accrediting and regulatory requirements. The electronic health record is interactive, and there are many stakeholders, reviewers, and users of the documentation. Because the government is increasingly involved with funding health care, agencies actively review documentation of care.The Electronic Health Record and Clinical Informatics Essay

The electronic health record (ERC) can be viewed by many simultaneously and utilizes a host of information technology tools. Patients routinely review their electronic medical records and are keeping personal health records (PHR), which contain clinical documentation about their diagnoses (from the physician or health care websites).

The physician, practice, or organization is the owner of the physical medical record because it is its business record and property, and the patient owns the information in the record [1]. Although the record belongs to the facility or doctor, it is truly the patient’s information; the Office of the National Coordinator for Health Information Technology refers to the health record as “not just a collection of data that you are guarding—it’s a life” [2]. There are three major ethical priorities for electronic health records: privacy and confidentiality, security, and data integrity and availability.

Privacy and Confidentiality
Justices Warren and Brandeis define privacy as the right “to be let alone” [3]. According to Richard Rognehaugh, it is “the right of individuals to keep information about themselves from being disclosed to others; the claim of individuals to be let alone, from surveillance or interference from other individuals, organizations or the government” [4]. The information that is shared as a result of a clinical relationship is considered confidential and must be protected [5]. The information can take various forms (including identification data, diagnoses, treatment and progress notes, and laboratory results) and can be stored in multiple media (e.g., paper, video, electronic files). Information from which the identity of the patient cannot be ascertained—for example, the number of patients with prostate cancer in a given hospital—is not in this category [6].The Electronic Health Record and Clinical Informatics Essay

Patient information should be released to others only with the patient’s permission or as allowed by law. This is not, however, to say that physicians cannot gain access to patient information. Information can be released for treatment, payment, or administrative purposes without a patient’s authorization. The patient, too, has federal, state, and legal rights to view, obtain a copy of, and amend information in his or her health record.

The key to preserving confidentiality is making sure that only authorized individuals have access to information. The process of controlling access—limiting who can see what—begins with authorizing users. In a physician practice, for example, the practice administrator identifies the users, determines what level of information is needed, and assigns usernames and passwords. Basic standards for passwords include requiring that they be changed at set intervals, setting a minimum number of characters, and prohibiting the reuse of passwords. Many organizations and physician practices take a two-tier approach to authentication, adding a biometrics identifier scan, such as palm, finger, retina, or face recognition.

The user’s access is based on preestablished, role-based privileges. In a physician practice, the nurse and the receptionist, for example, have very different tasks and responsibilities; therefore, they do not have access to the same information. Hence, designating user privileges is a critical aspect of medical record security: all users have access to the information they need to fulfill their roles and responsibilities, and they must know that they are accountable for use or misuse of the information they view and change [7].The Electronic Health Record and Clinical Informatics Essay


Under the HIPAA Privacy and Security Rules, employers are held accountable for the actions of their employees. In 2011, employees of the UCLA health system were found to have had access to celebrities’ records without proper authorization [8]. UCLA failed to “implement security measures sufficient to reduce the risks of impermissible access to electronic protected health information by unauthorized users to a reasonable and appropriate level” [9]. The health system agreed to settle privacy and security violations with the U.S. Department of Health and Human Services Office for Civil Rights (OCR) for $865,000 [10]. Controlling access to health information is essential but not sufficient for protecting confidentiality; additional security measures such as extensive training and strong privacy and security policies and procedures are essential to securing patient information.

The National Institute of Standards and Technology (NIST), the federal agency responsible for developing information security guidelines, defines information security as the preservation of data confidentiality, integrity, availability (commonly referred to as the “CIA” triad) [11]. Not only does the NIST provide guidance on securing data, but federal legislations such as the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act mandate doing so. Violating these regulations has serious consequences, including criminal and civil penalties for clinicians and organizations.The Electronic Health Record and Clinical Informatics Essay

The increasing concern over the security of health information stems from the rise of EHRs, increased use of mobile devices such as the smartphone, medical identity theft, and the widely anticipated exchange of data between and among organizations, clinicians, federal agencies, and patients. If patients’ trust is undermined, they may not be forthright with the physician. For the patient to trust the clinician, records in the office must be protected. Medical staff must be aware of the security measures needed to protect their patient data and the data within their practices.

A recent survey found that 73 percent of physicians text other physicians about work [12]. How to keep the information in these exchanges secure is a major concern. There is no way to control what information is being transmitted, the level of detail, whether communications are being intercepted by others, what images are being shared, or whether the mobile device is encrypted or secure. Mobile devices are largely designed for individual use and were not intended for centralized management by an information technology (IT) department [13]. Computer workstations are rarely lost, but mobile devices can easily be misplaced, damaged, or stolen. Encrypting mobile devices that are used to transmit confidential information is of the utmost importance.The Electronic Health Record and Clinical Informatics Essay

Another potential threat is that data can be hacked, manipulated, or destroyed by internal or external users, so security measures and ongoing educational programs must include all users. Some security measures that protect data integrity include firewalls, antivirus software, and intrusion detection software. Regardless of the type of measure used, a full security program must be in place to maintain the integrity of the data, and a system of audit trails must be operational.

Providers and organizations must formally designate a security officer to work with a team of health information technology experts who can inventory the system’s users, and technologies; identify the security weaknesses and threats; assign a risk or likelihood of security concerns in the organization; and address them. The responsibilities for privacy and security can be assigned to a member of the physician office staff or can be outsourced.The Electronic Health Record and Clinical Informatics Essay

Audit trails. With the advent of audit trail programs, organizations can precisely monitor who has had access to patient information.

Audit trails track all system activity, generating date and time stamps for entries; detailed listings of what was viewed, for how long, and by whom; and logs of all modifications to electronic health records [14]. Administrators can even detail what reports were printed, the number of screen shots taken, or the exact location and computer used to submit a request. Alerts are often set to flag suspicious or unusual activity, such as reviewing information on a patient one is not treating or attempting to access information one is not authorized to view, and administrators have the ability to pull reports on specific users or user groups to review and chronicle their activity. Software companies are developing programs that automate this process. End users should be mindful that, unlike paper record activity, all EHR activity can be traced based on the login credentials. Audit trails do not prevent unintentional access or disclosure of information but can be used as a deterrent to ward off would-be violators.The Electronic Health Record and Clinical Informatics Essay

The HIPAA Security Rule requires organizations to conduct audit trails [12], requiring that they document information systems activity [15] and have the hardware, software, and procedures to record and examine activity in systems that contain protected health information [16]. In addition, the HITECH Act of 2009 requires health care organizations to watch for breaches of personal health information from both internal and external sources. As part of the meaningful use requirements for EHRs, an organization must be able to track record actions and generate an audit trail in order to qualify for incentive payments from Medicare and Medicaid. HIPAA requires that audit logs be maintained for a minimum of 6 years [13]. As with all regulations, organizations should refer to federal and state laws, which may supersede the 6-year minimum.

Integrity and Availability
In addition to the importance of privacy, confidentiality, and security, the EHR system must address the integrity and availability of information.

Integrity. Integrity assures that the data is accurate and has not been changed. This is a broad term for an important concept in the electronic environment because data exchange between systems is becoming common in the health care industry. Data may be collected and used in many systems throughout an organization and across the continuum of care in ambulatory practices, hospitals, rehabilitation centers, and so forth. This data can be manipulated intentionally or unintentionally as it moves between and among systems.The Electronic Health Record and Clinical Informatics Essay

Poor data integrity can also result from documentation errors, or poor documentation integrity. A simple example of poor documentation integrity occurs when a pulse of 74 is unintentionally recorded as 47. Whereas there is virtually no way to identify this error in a manual system, the electronic health record has tools in place to alert the clinician that an abnormal result was entered.

Features of the electronic health record can allow data integrity to be compromised. Take, for example, the ability to copy and paste, or “clone,” content easily from one progress note to another. This practice saves time but is unacceptable because it increases risk for patients and liability for clinicians and organizations [14, 17]. Another potentially problematic feature is the drop-down menu. Drop-down menus may limit choices (e.g., of diagnosis) so that the clinician cannot accurately record what has been identified, and the need to choose quickly may lead to errors. Clinicians and vendors have been working to resolve software problems such as screen design and drop-down menus to make EHRs both user-friendly and accurate [17].The Electronic Health Record and Clinical Informatics Essay

Availability. If the system is hacked or becomes overloaded with requests, the information may become unusable. To ensure availability, electronic health record systems often have redundant components, known as fault-tolerance systems, so if one component fails or is experiencing problems the system will switch to a backup component.

The Future
Some who are reading this article will lead work on clinical teams that provide direct patient care. Some will earn board certification in clinical informatics. Others will be key leaders in building the health information exchanges across the country, working with governmental agencies, and creating the needed software. Regardless of one’s role, everyone will need the assistance of the computer.The Electronic Health Record and Clinical Informatics Essay

Medical practice is increasingly information-intensive. The combination of physicians’ expertise, data, and decision support tools will improve the quality of care. Physicians will be evaluated on both clinical and technological competence. Information technology can support the physician decision-making process with clinical decision support tools that rely on internal and external data and information. It will be essential for physicians and the entire clinical team to be able to trust the data for patient care and decision making. Creating useful electronic health record systems will require the expertise of physicians and other clinicians, information management and technology professionals, ethicists, administrative personnel, and patients.

need for Electronic Health Records (EHR)
The following are the most significant reasons why our healthcare system would benefit from the widespread transition from paper to electronic health records.The Electronic Health Record and Clinical Informatics Essay

Paper records are severely limited
Much of what can be said about handwritten prescriptions can also be said about handwritten office notes. Figure 4.2 illustrates the problems with a paper record. In spite of the fact that this clinician used a template, the handwriting is illegible and the document cannot be electronically shared or stored. It is not structured data that is computable and hence shareable with other computers and systems. Other shortcomings of paper: expensive to copy, transport and store; easy to destroy; difficult to analyze and determine who has seen it; and the negative impact on the environment. Electronic patient encounters represent a quantum leap forward in legibility and the ability to rapidly retrieve information. Almost every industry is now computerized and digitized for rapid data retrieval and trend analysis. Look at the stock market or companies like Walmart or Federal Express. Why not the field of medicine?

Figure 4.2: Outpatient paper-based patient encounter form Outpatient paper based patient encounter form

With the relatively recent healthcare models of pay-for-performance, patient centered medical home model and accountable care organizations there are new reasons to embrace technology in order to aggregate and report results in order to receive reimbursement. It is much easier to retrieve and track patient data using an EHR and patient registries than to use labor intensive paper chart reviews. EHRs are much better organized than paper charts, allowing for faster retrieval of lab or x-ray results. It is also likely that an EHR will have an electronic problem summary list that outlines a patient’s major illnesses, surgeries, allergies and medications. How many times does a physician open a large paper chart, only to have loose lab results fall out? How many times does a physician re-order a test because the results or the chart is missing?The Electronic Health Record and Clinical Informatics Essay  It is important to note that paper charts are missing as much as 25% of the time, according to one study.10 Even if the chart is available; specifics are missing in 13.6% of patient encounters, according to another study.11 Table 4.1 shows the types of missing information and its frequency. According to the President’s Information Technology Advisory Committee, 20% of laboratory tests are re-ordered because previous studies are not accessible.12 This statistic has great patient safety, productivity and financial implications. Table 4.1: Types and frequencies of missing information The Electronic Health Record and Clinical Informatics Essay

EHRs allow easy navigation through the entire medical history of a patient. Instead of pulling paper chart volume 1 of 3 to search for a lab result, it is simply a matter of a few mouse clicks. Another important advantage is the fact that the record is available 24 hours a day, seven days a week and doesn’t require an employee to pull the chart, nor extra space to store it. Adoption of electronic health records has saved money by decreasing full time equivalents (FTEs) and converting records rooms into more productive space, such as exam rooms. Importantly, electronic health records are accessible to multiple healthcare workers at the same time, at multiple locations. While a billing clerk is looking at the electronic chart, the primary care physician and a specialist can be analyzing clinical information simultaneously. Moreover, patient information should be available to physicians on call so they can review records on patients who are not in their panel. Furthermore, it is believed that electronic health records improve the level of coding. Do clinicians routinely submit a lower level of care for billing purposes because they know that handwritten patient notes are short and incomplete? Templates may help remind clinicians to add more history or details of the physical exam, thus justifying a higher level of coding (templates are disease specific electronic forms that essentially allow a user to point and click a history and physical exam). A study of the impact of an EHR on the completeness of clinical histories in a labor and delivery unit demonstrated improved documentation, compared to prior paper-based histories.13 Lastly, an EHR provides clinical decision support such as alerts and reminders, which will be covered later in this chapter.The Electronic Health Record and Clinical Informatics Essay

Need for improved efficiency and productivity
The goal is to have patient information available to anyone who needs it, when they need it and where they need it. With an EHR, lab results can be retrieved much more rapidly, thus saving time and money. It should be pointed out however, that reducing duplicated tests benefits the payers and patients and not clinicians so there is a misalignment of incentives. Moreover, an early study using computerized order entry showed that simply displaying past results reduced duplication and the cost of testing by only 13%.14 If lab or x-ray results are frequently missing, the implication is that they need to be repeated which adds to this country’s staggering healthcare bill. The same could be said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trillion dollar healthcare bill is for administration.15 EHRs are more efficient because they reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically. Consider what it takes to simply get the results of a lab test back to a patient using the old system. This might involve a front office clerk, a nurse and a physician. The end result is frequently placing the patient on hold or playing telephone tag. With an EHR, lab results can be forwarded via secure messaging or available for viewing via a portal. Electronic health records can help with productivity if templates are used judiciously. The Electronic Health Record and Clinical Informatics Essay As noted, they allow for point and click histories and physical exams that in some cases may save time. Embedded clinical decision support is one of the newest features of a comprehensive EHR. Clinical practice guidelines, linked educational content and patient handouts can be part of the EHR. This may permit finding the answer to a medical question while the patient is still in the exam room. Several EHR companies also offer a centralized area for all physician approvals and signatures of lab work, prescriptions, etc. This should improve work flow by avoiding the need to pull multiple charts or enter multiple EHR modules. Although EHRs appear to improve overall office productivity, they commonly increase the work of clinicians, particularly with regard to data entry. We’ll discuss this further in the Loss of Productivity section.


Quality of care and patient safety
As previously suggested, an EHR should improve patient safety through many mechanisms: (1) Improved legibility of clinical notes, (2) Improved access anytime and anywhere, (3) Reduced duplication, (4) Reminders that tests or preventive services are overdue, (5) Clinical decision support that reminds clinicians about patient allergies, correct dosage of drugs, etc., (6) Electronic problem summary lists provide diagnoses, allergies and surgeries at a glance. In spite of the before mentioned benefits, a study by Garrido of quality process measures before and after implementation of a widespread EHR in the Kaiser Permanente system, failed to show improvement.16 To date there has only been one study published the authors are aware of that suggested use of an EHR decreased mortality. This particular EHR had a disease management module designed specifically for renal dialysis patients that could provide more specific medical guidelines and better data mining to potentially improve medical care.The Electronic Health Record and Clinical Informatics Essay The study suggested that mortality was lower compared to a pre-implementation period and compared to a national renal dialysis registry.17 It is likely that healthcare is only starting to see the impact of EHRs on quality. Based on internal data Kaiser Permanente determined that the drug Vioxx had an increased risk of cardiovascular events before that information was published based on its own internal data.18 Similarly, within 90 minutes of learning of the withdrawal of Vioxx from the market, the Cleveland Clinic queried its EHR to see which patients were on the drug. Within seven hours they deactivated prescriptions and notified clinicians via e-mail.19 Quality reports are far easier to generate with an EHR compared to a paper chart that requires a chart review. Quality reports can also be generated from a data warehouse or health information organization that receives data from an EHR and other sources.20 Quality reports are the backbone for healthcare reform which are discussed further in another chapter.The Electronic Health Record and Clinical Informatics Essay

Public expectations
According to a 2006 Harris Interactive Poll for the Wall Street Journal Online, 55% of adults thought an EHR would decrease medical errors; 60% thought an EHR would reduce healthcare costs and 54% thought that the use of an EHR would influence their decision about selecting a personal physician.21 The Center for Health Information Technology would argue that EHR adoption results in better customer satisfaction through fewer lost charts, faster refills and improved delivery of patient educational material.22 Patient portals that are part of EHRs are likely to be a source of patient satisfaction as they allow patients access to their records with multiple other functionalities such as online appointing, medication renewals, etc.

Governmental expectations
EHRs are considered by the federal government to be transformational and integral to healthcare reform. As a result, EHR reimbursement is a major focal point of the HITECH Act. It is the goal of the US Government to have an interoperable electronic health record by 2014. In addition to federal government support, states and payers have initiatives to encourage EHR adoption. Many organizations state that healthcare needs to move from the cow path to the information highway. CMS is acutely aware of the potential benefits of EHRs to help coordinate and improve disease management in older patients.The Electronic Health Record and Clinical Informatics Essay

Financial savings
The Center for Information Technology Leadership (CITL) has suggested that ambulatory EHRs would save $44 billion yearly and eliminate more than $10 in rejected claims per patient per outpatient visit. This organization concluded that not only would there be savings from eliminated chart rooms and record clerks; there would be a reduction in the need for transcription. There would also be fewer callbacks from pharmacists with electronic prescribing. It is likely that copying, faxing and mail expenses, chart pulls and labor costs would be reduced with EHRs, thus saving full time equivalents (FTEs). More rapid retrieval of lab and x-ray reports results in time/labor saving as does the use of templates. It appears that part of the savings is from improved coding. More efficient patient encounters mean more patients could be seen each day. Improved savings to payers from medication management is possible with reminders to use the drug of choice and generics. It should be noted that this optimistic financial projection assumed widespread EHR adoption, health information exchange, interoperability and change in workflow.23 EHRs should reduce the cost of transcription if clinicians switch to speech recognition and/or template use. Because of structured documentation with templates, they may also improve the coding and billing of claims. It is not known if EHR adoption will decrease malpractice, hence saving physician and hospital costs. A 2007 Survey by the Medical Records Institute of 115 practices involving 27 specialties showed that 20% of malpractice carriers offered a discount for having an EHR in place. Of those physicians who had a malpractice case in which documentation was based on an EHR, 55% said the EHR was helpful.The Electronic Health Record and Clinical Informatics Essay

Technological advances
The timing seems to be right for electronic records partly because the technology has evolved. The internet and World Wide Web make the application service provider (ASP) concept for an electronic health record possible. An ASP option means that the EHR software and patient data reside on a remote web server that users can access via the internet from the office, hospital or home. Computer speed, memory and bandwidth have advanced such that digital imaging is also a reality, so images can be part of an EHR system. Personal computers (PCs), laptops and tablets continue to add features and improve speed and memory while purchase costs drop. Wireless and mobile technologies permit access to the hospital information system, the electronic health record and the internet using a variety of mobile technologies. The chapter on health information exchange will point out that health information organizations can link EHRs together via a web-based exchange, in order to share information and services.The Electronic Health Record and Clinical Informatics Essay

Need for aggregated data
In order to make evidence based decisions, clinicians need high quality data that should derive from multiple sources: inpatient and outpatient care, acute and chronic care settings, urban and rural care and populations at risk. This can only be accomplished with electronic health records and discrete structured data. Moreover, healthcare data needs to be combined or aggregated to achieve statistical significance. Although most primary care is delivered by small practices, it is difficult to study because of relatively small patient populations, making aggregation necessary.25 For large healthcare organizations, there will be an avalanche of data generated from widespread EHR adoption resulting in “big data” requiring new data analytic tools.The Electronic Health Record and Clinical Informatics Essay

Need for integrated data
Paper health records are standalone, lacking the ability to integrate with other paper forms or information. The ability to integrate health records with a variety of other services and information and to share the information is critical to the future of healthcare reform. Digital, unlike paper-based healthcare information can be integrated with multiple internal and external applications:

Ability to integrate for sharing with health information organizations (another chapter)
Ability to integrate with analytical software for data mining to examine optimal treatments, etc.
Ability to integrate with genomic data as part of the electronic record. Many organizations have begun this journey. There is more information in the chapter on bioinformatics 26
Ability to integrate with local, state and federal governments for quality reporting and public health issues
Ability to integrate with algorithms and artificial intelligence. Researchers from the Mayo Clinic were able to extract Charlson Comorbidity determinations from EHRs, instead of having to conduct manual chart reviews The Electronic Health Record and Clinical Informatics Essay
EHR is a transformational tool
It is widely agreed that US Healthcare needs reform in multiple areas. To modernize its infrastructure healthcare would need to have widespread adoption of EHRs. Large organizations such as the Veterans Health Administration and Kaiser Permanente use robust EHRs (VistA and Epic) that generate enough data to change the practice of medicine. In 2009 Kaiser Permanente reported two studies, one pertaining to the management of bone disease (osteoporosis) and the other chronic kidney disease. They were able to show that with their EHR they could focus on patients at risk and use all of the tools available to improve disease management and population health.28-29 In another study reported in 2009 Kaiser-Permanente reported that electronic visits that are part of the electronic health record system were likely responsible for a 26.2% decrease in office visits over a four year period. They posited that this was good news for a system that aligns incentives with quality, regardless whether the visit was virtual or face-to-face.30 Other fee-for-service organizations might find this alarming if office visits decreased and e-visits were not reimbursed. Kaiser also touts a total joint registry of over 100,000 patients with data generated from its universal EHR. As a result of their comprehensive EHR (KP HealthConnect) and visionary leadership they have seen improvement in standardization of care, care coordination and population health. They also have been able to experience advanced EHR data analytics with their Virtual Data Warehouse, use of artificial intelligence and use of computerized simulation models (Archimedes). In addition they have begun the process of collecting genomic information for future linking to their electronic records.The Electronic Health Record and Clinical Informatics Essay

Need for coordinated care
According to a Gallup poll it is very common for older patients to have more than one physician: no physician (3%), one physician (16%), two physicians (26%), three physicians (23%), four physicians (15%), five physicians (6%) and six or more physicians (11%).33 Having more than one physician mandates good communication between the primary care physician, the specialist and the patient. This becomes even more of an issue when different healthcare systems are involved. O’Malley et al. surveyed 12 medical practices and found that in-office coordination was improved by EHRs but the technology was not mature enough to improve coordination of care with external physicians.34 Electronic health records are being integrated with health information organizations (HIOs) so that inpatient and outpatient patient-related information can be accessed and shared, thus improving communication between disparate healthcare entities. Home monitoring (telehomecare) can transmit patient data from home to an office’s EHR also assisting in the coordination of care. It will be pointed out in a later section that coordination of care across multiple medical transitions is part of Meaningful Use.The Electronic Health Record and Clinical Informatics Essay

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