Electronic Health Records for Quality Nursing and Health Care

498 Pages·2016·10.457 MB·English

by  Tiffany Kelley

ELECTRONIC HEALTH RECORDS for QUALITY NURSING & HEALTH CARE
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E
LECTRONIC
H R

EALTH ECORDS for
Q N
UALITY URSING

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& EALTH ARE
Tiffany Kelley, Ph.D., MBA, RN
Founder & CEO, Nightingale Apps LLC
Affiliate, Duke University
Adjunct Associate Professor, Northeastern University
Electronic Health Records for Quality Nursing & Health Care
DEStech Pub li ca tions, Inc.
439 North Duke Street
Lanc as ter, Penns ylv an ia 17602 U.S.A.
Copy right © 2016 by DEStech Pub li ca tions, Inc.
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No part of this pub lic at ion may be re prod uced, stored in a
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10 9 8 7 6 5 4 3 2 1
Main ent ry un der tit le:
Electronic Health Records for Quality Nursing & Health Care
A DEStech Pub lic at ions book
Bib lio gr ap hy: p.
Inc ludes in dex p. 471
ISBN: 978-1-60595-071-6
Table of Contents
Foreword xi
Preface xv
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1. The Nursing Profession and Electronic Health
Records 1
1.2. Format of Electronic Health Records for Quality
Nursing Care 3
1.3. Overview of Chapter 2–Chapter 12 4
1.4. References 9
2. How it All Began: Electronic Health Records
in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1. Overview of the First Electronic Health Records
and Initial Stages of EHR Development
(1960s–1990s) 12
2.2. Emergence of National Involvement and Advocacy
for EHRs (1990s–2000s) 20
2.3. Continued National Advocacy (2000s–Present) 28
2.4. Chapter Summary 31
2.5. Discussion Questions 32
2.6. References 33
3. Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . 37
3.1. Defining CPR, EMR, EHR, and PHR 38
v
vi Table of Contents
3.2. Components of Electronic Health Records 43
3.3. Electronic Medical Record Adoption Models 58
3.4. Electronic Health Record Adoption Models 65
3.5. Benefits of Adoption and Use of Electronic
Health Records 68
3.6. Challenges of Adoption and Use of Electronic
Health Records 71
3.7. Certification of Electronic Health Records 74
3.8. Chapter Summary 75
3.9. Discussion Questions 75
3.10. References 76
4. Functions of Electronic Health Records . . . . . . . . . . 81
4.1. What is an Electronic Health Record Function? 82
4.2. Patient Searches 83
4.3. Patient Lists 83
4.4. Computerized Provider Order Entry Functions 85
4.5. Problem Lists 92
4.6. Structured Data Fields 93
4.7. Unstructured Data Fields and Notes 96
4.8. Copy and Paste 97
4.9. Device Integration 99
4.10. Electronic Medication Administration Record 103
4.11. Smart Infusion Pumps 104
4.12. Trending of Data 104
4.13. Scanning of Images and Documents 105
4.14. Calculations 106
4.15. Voice Recognition 108
4.16. Electronic Transmission of Data and Information 108
4.17. Security Settings in an Electronic Health Record 110
4.18. Chapter Summary 112
4.19. Discussion Questions 112
4.20. References 113
5. HITECH Federal Regulations and Requirements
from ARRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
5.1. Overview of HITECH Provisions within ARRA 118
5.2. Expansion of the Office of the National Coordinator
for Health Information Technology 119
Table of Contents vii
5.3. Funding Provisions to Expand the Health Information
Technology Workforce 120
5.4. Privacy and Security Regulation Expansion 121
5.5. Regional Extension Centers to Support Providers with
Electronic Health Records 123
5.6. Electronic Health Record Incentive Program 123
5.7. Chapter Summary 165
5.8. Discussion Questions 166
5.9. References 167
6. Privacy and Security Concerns with Electronic
Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
6.1. Relationship between Privacy and Security 172
6.2. Privacy 172
6.3. Security 177
6.4. Privacy and Security Federal Regulations
and Requirements 184
6.5. Privacy and Security Steps for Health Care
Organizations 188
6.6. Chapter Summary 192
6.7. Discussion Questions 192
6.8. References 193
7. Standards, Interfaces, and Interoperability
in Electronic Health Records . . . . . . . . . . . . . . . . . . . 197
7.1. Relationship between Standards, Interfaces, and
Interoperability 198
7.2. Standards 198
7.3. Interfaces 213
7.4. Interoperability 216
7.5. Chapter Summary 218
7.6. Discussion Questions 219
7.7. References 220
8. Selecting and Planning for an Electronic
Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
8.1. System Development Life Cycle for an Electronic
Health Record 226
8.2. Selecting an Electronic Health Record 228
8.3. Planning for an Electronic Health Record 260
viii Table of Contents
8.4. Chapter Summary 274
8.5. Discussion Questions 275
8.6. References 275
9. Designing, Building, and Testing an Electronic
Health Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
9.1. Designing an Electronic Health Record 280
9.2. Building an Electronic Health Record 299
9.3. Testing an Electronic Health Record 302
9.4. Chapter Summary 314
9.5. Discussion Questions 315
9.6. References 315
10. Implementing and Maintaining an EHR . . . . . . . . . . 317
10.1. Implementing the Electronic Health Record 318
10.2. Maintaining an Electronic Health Record 332
10.3. Chapter Summary 340
10.4. Discussion Questions 340
10.5. References 341
11. Outcomes Evaluation with Electronic
Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
11.1. Importance of Evaluating Outcomes from the
Use of Electronic Health Records in Health Care
Organizations 344
11.2. Evaluating Outcomes from a Quality Perspective 346
11.3. Chapter Summary 353
11.4. Discussion Questions 353
11.5. References 354
12. Future Directions of Electronic Health Records . . . 357
12.1. Mobile Health Technologies 358
12.2. Big Data and Advanced Analytics 372
12.3. Enhanced Electronic Communication 380
12.4. Increased Patient Engagement 384
12.5. Expansive Efforts Toward Nationwide Electronic
Health Record Interoperability 385
12.6. Increased Use of Cloud-based Electronic Health
Records and Other Clinical Information System
Solutions 387
Table of Contents ix
12.7. Opportunities for Nurses in Informatics 388
12.8. Chapter Summary 390
12.9. Discussion Questions 391
12.10. References 392
Appendix A—Acronyms used in Electronic Health Records
for Quality Nursing Care 399
Appendix B—List of Regional Extension Centers 403
Appendix C—Alternate Clinical Quality Measures for
Eligible Providers in Stage I of the Electronic Health Record
Incentive Program (2011–2013) 407
Appendix D—Clinical Quality Measures for Eligible Providers
in 2014 for Stage I and Stage II of the Electronic Health
Record Incentive Program 411
Appendix E—HIPAA Privacy Rule Protected Health
Information Identifiers 415
Appendix F—Steering Committee Membership List 417
Appendix G—Electronic Health Record Project Sample Timeline 419
Appendix H—Workflow Process Map Example 421
Appendix I—Functional Test Script Examples 423
Appendix J—Integrated System Test Script Examples 427
Appendix K—Workflow Test Script Examples 431
Glossary 435
Index 471