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Chapter 1
An Introduction to Electronic Health Records
© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill
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Chapter 1 Content
1.1 Brief history of electronic health records (EHRs)
1.2 History of standards development for the EHR and nursing’s role in their development
1.3 Certification bodies for the EHR1.4 Benefits of the EHR1.5 Government involvement in the EHR1.6 Role of nursing informatics in healthcare
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L.O. 1.1 The EHR History
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L.O. 1.1 The EHR History
• Impetus for development– Quality patient care
• 1960s– First EMR programs– First electronic databases
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L.O. 1.1 The EHR History
• Terms and Definitions– CPR: Computer-Based Patient Record– EMR: Electronic Medical Record– EHR: Electronic Health Record– CCD: Continuity of Care Document– PHR: Personal Health Record
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L.O. 1.1 The EHR History
• Point of care documentation• Modes of Data Entry– Keyboard– Voice recognition– Handwriting recognition– Templates and data selection– Touch screens
• COWs/WOWs
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L.O. 1.1 The EHR History
• Security and reliability– Local area network (LAN)– Internet– Intranet– Data encryption– Application server provider (ASP)
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L.O. 1.2 Development of EHR Standards
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L.O.1.2 Development of EHR Standards
• Barriers to EHR adoption– Cost– Organization– Lack of unified standards, functionality, and
interoperability
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L.O.1.2 Development of EHR Standards
• IOM’s Committee on Data Standards for Patient Safety – 2003– Identified key competencies– Became foundational benchmark for EHR
development and programming• Consolidated Health Informatics (CHI) standards -
2004– Enabled agencies to share information– Common clinical vocabularies– Standard methods of transmission
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L.O.1.2 Development of EHR Standards
• Role of nursing in standards development– Promotes standardization to identify nursing’s
contribution to patient care– Promotes research– Promotes identification of relationships among
nursing interventions and outcomes
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L.O.1.2 Development of EHR Standards
• Technology Informatics Guiding Educational Reform (TIGER) Initiative– Goal to ensure nursing input into the
standardization process for EHRs– Calls for agreement on the standardized nursing
terminology to promote interoperability• Standardized nursing language examples– NANDA-I, NOC, NIC– ICNP
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L.O. 1.3 EHR Certification Agencies
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L.O. 1.3 EHR Certification Agencies
• The Certification Commission for Health Information Technology (July 2004)– Mission: To accelerate the adoption of health
information technology by creating an efficient, credible, and sustainable product certification program
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L.O. 1.3 EHR Certification Agencies
• CCHIT– Creates inspection process for:• Ambulatory care EHRs for the office-based
healthcare provider• Inpatient EHRs for hospitals and health systems• Network components through which EHRs
interoperate and share information
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L.O. 1.3 EHR Certification Agencies
• Office of the National Coordinator for Health Information Technology (ONC) - 2004– Purposes• Serve as a resource to the entire health system• Support the adoption of health information
technology• Promote a nationwide health information
exchange in order to improve healthcare in the United States
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L.O. 1.4 Benefits of The EHR
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L.O. 1.4 Benefits of The EHR
• Enhanced accessibility to clinical information• Patient safety• Quality patient care• Efficiency and savings
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L.O. 1.5 Government Involvement in the EHR
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L.O. 1.5 Government Involvement in the EHR
• President George W. Bush (2004)– Called for universal EHRs by 2014
“By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.”
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L.O. 1.5 Government Involvement in the EHR
• Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)– Positive incentives for practitioners who use e-
prescribing– Penalties for practitioners who do not e-prescribe
after 2014
• Surescripts– National clearinghouse for e-prescribing
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L.O. 1.5 Government Involvement in the EHR
• American Recovery and Reinvestment Act (ARRA) - 2009– The Health Information Technology for Economic
and Clinical Health (HITECH) Act• $20 billion to aid in the development of a healthcare
infrastructure and to promote adoption and use of health information technology, including EHRs• Requires “meaningful use” of a “certified” EHR• Provides bonus/incentive payments
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L.O. 1.6 Nursing Informatics
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L.O. 1.6 Nursing Informatics
• Florence Nightingale – Recognized the need for standardization of
nursing language to facilitate communication and enhance quality care
• Harriet Werley – first provided nursing input for computer use in
the healthcare arena in the 1950s• 1970s: Nursing applications for computers
began to be developed
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L.O. 1.6 Nursing Informatics• 1973– North American Nursing Diagnosis Association (NANDA)– Developed initial set of nursing diagnoses• 1980s– Development of personal computers– Nursing informatics courses• 1994– Nursing informatics recognized as nursing specialty – Scope and standards of nursing informatics practice
developed
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L.O. 1.6 Nursing Informatics
• Nursing informatics – Supports quality of nursing decisions by enhancing
access to nursing knowledge and patient information– Promotes development and use of tools compiled
from a variety of sciences– Assists with managing and communicating
information and knowledge between healthcare team members
– Promotes access to current evidence-based nursing practice
