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Core clinical functionalities include a not only medication lists, allergy lists, order sets, and lab ordering, but also can include a fully integrated pharmacy/medication management interface.
== Core Clinical Features ==
In 2003, the DHHS [http://www.hhs.gov/] asked the IOM [http://www.iom.edu/] to provide guidance on the basic functionalities of electronic health records systems. The committee concluded that the core functionalities should address the following areas:
* Improvement of patient safety
* Support delivery of effective patient care
* Facilitate management of chronic conditions
* Improve efficiency
* Feasibility of implementation and
* Integration of hospital services
In the Journal of Healthcare Information Management Kranny et. al discussed the importance of an application in the EHR which will promote continuity of care. During the selection of a vendor it is imperative for the decision committee to find out if there is an integration of inpatient, clinical and outpatient interface systems. <ref name="Find-EHR-Vendor">Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23 (42), 1-4.</ref> The patient's progress in house and discharge summary should be accessible by his primary care provider upon discharge. Medications that were discontinued during hospitalization should be updated in the patient's outpatient medication profile so wrong medications are not refilled by the patient. In addition, when new medications are added to the patient medication regimen it should be accessible by the primary care provider and outpatient pharmacist.
The IOM committee decided that the core functionalities of EHR system should cover the following areas: <ref name="Johnson-Ahima-2006">Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g</ref>
* Improvement of patient safety
* Support delivery of effective patient care
* Facilitate management of chronic conditions
* Improve efficiency
* Feasibility of implementation
Jain et al. (2010), in the article Evaluating EHR Systems, describes a few criteria to look for in EHR selection. Considerations for EHR selection should include privacy of patient data, interoperability, ease of use( for physicians and support staff) and efficiency of the integrated systems. Management support during implementation is crucial. <ref name="Jain-V-2010">Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/747986471?accountid=7034</ref>
Based on these areas, the they identified eight categories of core functionalities, including: <ref name="Johnson-Ahima-2006">Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g</ref>
* Health information and data
* Results management
* [[CPOE|Order entry/management]]
* [[CDS|Decision support]]
* Electronic communication and connectivity
* Patient support; administrative processes
* Reporting and population health management
=== EHR System Feature List ===
* Information to be considered to store in the system:
** Demographics details
** Patient specific problem or CC (Chief Complaint) with [[ICD|ICD-9 or ICD-10]] numbering
*** Acute/Chronic Indicator
*** Worsening/Resolving Indicator
*** Injuries List
*** Present Illness Description
** Procedures
** Diagnoses
** Medications
** Allergies
** Family medical history
** Consultations
** Signs & Symptoms
** Vitals
** Progress Notes
** Discharge Summaries
** Appointments/Admissions/Visits
** Advance Directives
** Clinical Reminders [Immunizations, Screenings, Risks]
* Result Management (lab, imaging, other diagnostic measurements, pictures, multimedia)
** Review and search results easily by sorting test types, test time, test administers, test results and so on
** Choose one or several test types, such as HGB, and/or WBC, and/or blood sugar and chart on their results for showing trends
* Is the software configuration flexible to customize for future needs? How much customization to the EMR can the vendor offer to meet the institution’s needs? Will there be a surplus of unusable or insufficient components to the EMR? <ref name="himss-ama-pms">American Medical Association. 15 questions to ask before signing an EMR/EHR agreement. http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref>
* Is this EHR system compatible with any other systems such as adverse drug reaction system, case based reasoning system and rule based reasoning systems?
* The proposed EHR software should bring minimal to no new limitations to the existing workflows of the institution <ref name="himss-ama-pms"> </ref>
* Does the system meet all existing required operational tasks?
* Does the EHR tested in any other provider sites?
* Does the EHR allow for expandability to mobile devices, mobile medical applications and upcoming mobile technologies?
* Does the EHR have integrated practice management to avoid having to interface with a 3rd party practice management system?<ref name="himss-ama-pms"> </ref>
* Does the software provide a tool for workflow mapping/charting?
* Is it possible to migrate existing legacy EMR system institute use to the new EMR database schema?
* Can the software be easily configured/adapted to changing workflows?
* Does the EHR provide on-screen flags to indicate patient visit status?
* Does the EHR allow customization of work flows by the provider, clinician, or other health care professional?
* Does the EHR documentation method support error checking for vital sign data entry?
* Does the EHR/EMR system allow multiple terminals (physician, nurses' station, X-ray, labs, etc.) to log in to the same patient's record simultaneously? Certain systems only allow one terminal to access a patient record at a time - they must log out before any other terminal can access patient EHR/EMR. (For example, if a nurse forgets to log out at their station, the lab cannot access that patient's record.)
* Does the product have a standardized electronic patient handoff tool to facilitate physician workflow, increase physician satisfaction and ultimately potentially improve patient outcomes?
* Does the EHR package come with a fully integrated Computer Practitioner Order Entry (CPOE) system?
* If you are a large academic teaching hospital, does the EHR meet the special It requirements? Specifically, does the EHR accommodate the numerous handoffs in care that are the result of resident education and regulatory requirements?<ref name="Kannry"> Kannry, J, Mukani, S & K Myers. Using an Evidence-based
Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital, Journal of Healthcare Information Management — Vol. 20, No. 2</ref>
* An EMR at an academic medical center must be evaluated on its ability to conduct large-scale research with data capture and retrieval, as well as attaining regulatory compliance regarding billing.<ref name="Kannry"> </ref>
== CPOE ==
* [[CPOE| Computerized Physician Order Entry (CPOE)]], [[Electronic prescribing| e-Prescribing]]
* Computerized Physician Order Entry system that integrates and provides for two-way communication with the Pharmacy, Laboratory, Registration systems, and that allows for scanning and downloading of health information as needed. The EHR system should have a completely understood interface and provide for [[HIE|interoperability]] with all current and future systems and between clinics and providers.
* CPOE will generally allow for the organization to specify a default dose for a medication order. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.
* CPOE should allow for the order of all medications with options for dosage, treatment time, and if not the system should allow for the customization by the ordering physician.
* The CPOE team will need to review what happens when non-formulary items are entered. The workflow for non-formulary items will also need to be determined. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.
* The EHR should have the capabilities to interface with the various labs the hospital or physician uses to order and receive patient lab work automatically.
* Does the EHR have a referral management system so that within large organizations, specialty and primary care departments can easily communication with each other and have similar information on a patient that is using both offices to treat their illness?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.
* Does the system allow each provider to create customized order sets including laboratory order sets, procedure order sets, presurgical order sets, and postsurgical order sets? <ref>http://www.aafp.org/practice-management/health-it/product/features-functions.html</ref>
* The use of a CPOE integrated with a CDSS can greatly improve the standard of care in many hospital settings. Though if this integration is planned it will require careful planning, maintenance, and adoption of safety standards. The safety standards are required so that the potential risks with reliance on this technology can be minimized. <ref name="IT Health">http://www.healthit.gov/safer/guide/sg007</ref>
== Clinical decision support (CDS) ==
* [[Earlier Clinical Decision Support (CDS) Tools]]
* [[Historical Challenges of Clinical Decision Support (CDS) Tools]]
* [[Benefits of Various types of Clinical Decision Support(CDS) Tools]]
* [[CDS|Decision Support]] (Drug Interaction, Drug information and other Prescription Supports, Clinical Guidelines [Plans & Protocols] and disease information, Diagnosis and differential diagnosis Support, Risk Assessments, Clinical Checklists, Medical References, etc)
* Formulary Database Support
* Electronic Communication (Provider-Provider & Patient-Provider Direct Communication, Health Data Exchange, Interface to Medical Devices, Notifications, Clinical Documentation such as Nursing Notes)
* Patient Administration (ADT [Admit, Transfer, Discharge], Reservation & Scheduling, Billing, Waiting List Management, Records of Patient Activity, Master Patient Index across the Healthcare Organization)
* Querying & Reporting (Research & Analysis, Statistics [Vital Statistics, National Statistics], External Accountability Reporting)
* Telecare, Telehealth, and Telemedicine functionality. Home Monitoring device input/linking.
* [[PHR|Patient Portal for online personal health record access]]
* Clinical policies and procedures guidelines
* Produce visit summary and complete medical record printout and data export on demand for patient use.
* Electronic Health Record (EHR) systems should be capable of accommodating multiple users working concurrently within the system and within the same patient file or document. EHR systems should also be capable of protecting the integrity of data in the system so that no data loss occurs when multiple users are working concurrently with the same patient file or document.
** Provide direct decision support explanation link to [[EBM|evidence based knowledge]] (through such as "infobutton",etc) about needed test information, such as purpose and methods of conducting that test, normal range of that test, clinical indications when abnormal results occurred and suggestions what to do, etc.
** Provide abnormal alerts to providers and/or patients through various ways, such as online display, cell phone text messages, etc if the patients/doctors register for this service.
* The organization will need to strike a balance between displaying so many alerts that it causes clinical care to slow. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.
* According to Beeler (2014), the potential harms of CDS include treatment delays due to CPOE and CDS, additional workload and too many false positive alerts <ref name=" Clinical decision support systems "> Beeler, P. E., Bates, D. W., & Hug, B. L. (2014). Clinical decision support systems. Swiss medical weekly, 144.
</ref>. The terms "e-iatrogenesis" introduced by Weiner et al.<ref name=" e-Iatrogenesis "> Weiner, J. P., Kfuri, T., Chan, K., & Fowles, J. B. (2007). “e-Iatrogenesis”: the most critical unintended consequence of CPOE and other HIT. Journal of the American Medical Informatics Association, 14(3), 387-388.</ref> and "alert fatigue" were realized. The implementation of CDS needs to be carefully planned to avoid workflow interruption and CDS interventions should be thoroughly examined before implementation.
*Does the EHR have an aspect of the CPOE that can manage patient protocols and treatment plans? <ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.
* Does the software have “Clinical/Business Intelligence” capability based on local clinic medical trends, e.g. if there is above normal upper respiratory infection clinic visits, perhaps a flu season is imminent and may warrant stocking of flu vaccine in the clinic?
* Does the system support patient-specific dosing? When entering medication orders, can the system recommend dosages based on the patient's age, weight, and comorbidities? <ref>http://www.aafp.org/practice-management/health-it/product/features-functions.html</ref>
*According healthit.gov, CDS interventions for Meaningful Use is about quality improvement. To achieve the benefits of CDS, the CDS interventions must provide five rights:<ref name=" Clinical decision support CDS "> www.healthit.gov/providers-professionals/clinical-decision-support-cds </ref>.
**the right information (evidence-based guidance, response to clinical need)
**to the right people (entire care team – including the patient)
**through the right channels (e.g., EHR, mobile device, patient portal)
**in the right formats (e.g., order sets, flow-sheets, dashboards, patient lists)
**at the right times (for key decision or action).
*To achieve Meaningful Use Stage 2, the objective to use CDS defined by ONC (healthit.gov) is "to improve performance on high-priority health conditions". "The measures include:
**1) Implement 5 clinical decision support interventions related to 4 or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period.
** 2) The EP, eligible hospital, or CAH has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period". <ref name=" Clinical Decision Support Rule"> www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures-2/clinical-decision-support-rule </ref>
== Data Storage and Retrieval ==
* EHR systems should be capable of capturing, storing, indexing, retrieving and displaying externally created documents. Indexing of captured documents should include not only patient identifiers and descriptive information, but also date/time stamps and document type.
* EHR systems should be capable of retaining all system data until such data is archived or intentionally purged from the system.
* The system should load patient records in a timely manner to not interrupt workflow.
* This system should present chronological data of patients like medicine history, progress of diseases.
* Also, system provides gene information or drug allergies of patients to avoid [[Adverse drug event|ADE]].
* System should be compatible with old system to reduce re-entry time.
* System should update regularly.
* system should be able to have Patient prescription plan eligibility, prescription product formulary and external medication history.
* System should be able to have insurance retrieval capabilities (i.e. insurance firms, sum insured, premium dues, etc.).[11]
* Capability to integrate with other products such as practice management software, billing systems and public health interfaces.
== Functional Requirements ==
Functional requirements are those processes that you want a system to perform <ref name="stratishealth"> Requirements Analysis. http://www.stratishealth.org/documents/HITToolkitHospital/1.Adopt/1.3Select/1.3Requirements_Analysis.doc. </ref>.
The electronic health record’s architecture, or its relationship across any existing or future systems at the organization’s practice, directly influences what functions the EHR can support <ref name="ehrchecklist"> EHR Checklist: Functional and Technical Essentials. http://www.poweryourpractice.com/electronic-health-records/ehr-checklist-functional-and-technical-essentials/. </ref>.
The following functional requirements have been broken into the following areas that correspond to EHR functional categories:
==== Clinical Documentation Requirements ====
Clinical documentation is used throughout healthcare to describe care provided to a patient,communicate essential information between healthcare providers and to maintain a patient medical record <ref name="clindoc"> Boone,K.W. Clinical Documentation. 2011. http://www.springer.com/cda/content/document/cda_downloaddocument/9780857293350-c1.pdf?SGWID=0-0-45-1140144-p174097770. </ref>.
* Document and View Medication History
** Will the EHR have the ability to perform basic clinical documentation, including medication history?
** Will the current, active medications be viewable on demand?
** Will the system have the ability to display a complete medication history from information available within the EHR? <ref name="functional"> EHR Functional Requirements. http://www.nyehealth.org/images/files/File_Repository16/pdf/Version_2_2_EHR_Functional_Requirements-16_Nov_09.pdf. </ref>
* Treatment plan
** Will the system be able to document a treatment plan and create any new orders?
** As part of that treatment plan, will clinician have the ability to confirm previous medications and prescribe any potential new medications or make dose changes, and the ability to electronically submit orders such as labs, radiology, physical therapy, and other supportive services?
** Will the EHR be able to create structured treatment plan as part of patient encounter? <ref name="functional"></ref>
* Consult Note
** Will the system be able to document a consult note with appropriate clinical information from the medical record, including a clinical recommendation, and surgical clearance? <ref name="functional"></ref>
*Chief Complaint, Problems, Vital Sign, History, Visits, Medication List, Allergies
** Will the appropriate clinical staff be able to electronically document chief complaint, vital signs, reason for visit, new history, MD visits, problem list, and medication lists?
** Will the system permit appropriate clinical staff to document, review and update patient problems, medications, and allergies or adverse drug reactions in the EHR?<ref name="functional"></ref>
*History of Present Illness/Review of Systems/Family History/Medical History/Surgical History/Social History and Physical Exam
** Will the system allow the complete physical assessment, including all necessary examinations based on the current standards of care for the applicable condition, to be documented in a standardized manner with consistent nomenclature? <ref name="functional"></ref>
*Patient Educational Materials
** Will the system have patient education material available within the application either from the application itself or from a third party solution? <ref name="functional"></ref>
* Does the system support various methods of documentation creation? Can documents be created through traditional dictation and transcription and imported into the patient record? Does the vendor support interfaces for importing documents?
== Formulary Management ==
# Data repository for formulary information, maintain real time update of medication information with national drug information database
# Support periodic update of formulary, restricted formulary, and nonformulary medications
# Cross reference patient’s insurance formulary list to allow for generic medications to be selected when e-prescribing.
== Drug dispense and delivery ==
# Support outpatient pharmacy operation functionality:
## Maintain outpatient prescription data
## Management of prescription fill, refill and dispense activities
## Support billing protocols with governmental and private insurance
# Support inpatient pharmacy operation functionality
## Maintain inpatient medication ordering data
## Real-time monitoring of IV and oral medication compounding and delivery
## Support real-time data interface with automatic dispensing cabinet
*'''ADE - Adverse drug event detection'''
Detecting and notifying suspecious cases of potential ADE's to treating physicians is very important. To detect the "ADE's" a good inter operable HI systems are needed.This linked article show how even the OTC-over the counter drug list should also be shared. <ref name= "ADE"> ADE http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/?term=Adverse+drug+event+notification+on+a+semantic+interoperability+framework </ref>
== Nursing Functionality ==
# Supporting eMAR: supporting real-time electronic medication administration record and [http://www.ncbi.nlm.nih.gov/pubmed/20445181 bar code medication administration technology].
## Does the system track refusal of medications? <ref name="ELECTRONIC MEDICATION ADMINISTRATION RECORD (EMAR)">http://www.healthsecure-emr.com/jail-emr-emar</ref>
## Does the eMar have the ability to send encrypted messages directly to the pharmacy?
# Supporting bedside automation in medication delivery: Support data interface and real-time monitoring of [http://www.ncbi.nlm.nih.gov/pubmed/15753744 smart infusion pumps] and home infusion pumps
# Ease of use of Nursing flow sheets: Rows in the EHR to be filled by nurses for consistent patient care processes.<ref name="ICU Accept">Carayon, P. Cartmill, R. Blosky, M. Brown, R. Hackenberg, M. Hoonakker, P. Hundt, A. Norfolk, E. Wetterneck, T. Walker, J. (2011).ICU nurses’ acceptance of electronic health records. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3197984/pdf/amiajnl-2010-000018.pdf </ref>
# Ease of access and usability of EHR for nursing administration and clinical documentation for nurses. <ref name="Disputes Risks">Raasikh, . What the others haven't told you: lessons learned to avoid disputes and risks in EHR implementation.http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?action=interpret&id=GALE%7CA365889941&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&authCount=1</ref>
# Clinical decision support and risk assessment tools for issues related to nurse care delivery, such as falls, medication delivery, skin ulcers etc. <ref name="Impact Nurse">Dowding,D. Turley, M. and Garrido, T. (2012). The impact of an electronic health record on nurse
sensitive patient outcomes: an interrupted time
series analysis. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3384108/pdf/amiajnl-2011-000504.pdf</ref>
== Pharmacy Operation ==
Hospitals and physician practices need to keep their patients safe and well managed by using a pharmacy information system also called a medication management system. The system must have several core functions including in and outpatient order entry, dispensing, and inventory and purchasing management. The system must also be able to connect to other systems within the enterprise, including an EMR, computerized physician order entry (CPOE), barcode technology, and smart IV infusion pumps.<ref name="Pharmacy Information Systems">10 Popular Pharmacy Information Systems".http://www.informationweek.com/healthcare/clinical-information-systems/10-popular-pharmacy-information-systems/d/d-id/1104805?</ref>
# Connect to other systems within the enterprise including EMRs
# Computerized physician order entry (CPOE)
# Barcode technology
# Smart IV infusion pumps
back to [[Vendor Selection Criteria|home, Vendor Selection criteria]]
==Laboratory functionalities==
Ordering of test,collection of specimens,routing and tracking the specimens to the appropriate area of the laboratory,testing the specimens,resulting and notifying the critical test reports are part of major [http://www.healthit.gov/providers-professionals/achieve-meaningful-use/menu-measures/clinical-lab-test-results laboratory functions] that an EHR should have.
== Imaging functionalities ==
Providers need to be able to order imaging thru the EMR and have the capability to connect to view not only current, but also historical imaging.<ref name="Imaging">Incorporating imaging at the core of your interoperability plan. http://www.healthcareitnews.com/blog/incorporating-imaging-core-your-interoperability-plan</ref> The integration of medical images as part of the patient record has always been a critical component of documentation and information supporting clinical decisions.<ref name="Imaging2">From PACS to integrated EMR Osman Ratiba, , , Michael Swiernikb, J.Michael McCoyb http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S0895611102000757</ref>
EMR systems need to be able to display not only the exam results, but also the images for physicians review without having to utilize additional applications or credentials. In addition, clinical decision support when ordering imaging exams would be beneficial to make sure the appropriate exam is been ordered in accordance with the patient's chief complaint.
== References ==
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