EHR Technical Overview

The model for the IHS·EHR is the Veterans Health Administration (VHA) electronic medical record, the Computerized Patient Record System (CPRS). CPRS has been successfully deployed across the VHA hospital network over the past several years.

The IHS·EHR utilizes a technical infrastructure originally developed for the VHA that displays various clinical functions in a graphical user interface (GUI) format. A private corporation, Clinical Informatics Associates, under contract to IHS, owns the framework technology for IHS·EHR, called VueCentric. VueCentric is not an end user application, but is a technical infrastructure that supports graphical presentation of data from applications in the M environment (MSM, DSM or Caché). Within the VueCentric GUI framework, clinical functions are visually and operationally integrated in a way that is accessible and intuitive to users comfortable with Windows® programs. All data generated in IHS·EHR is stored in the RPMS database.

By using a component-based architecture, the IHS·EHR enables implementation of a variety of clinical functional components, including IHS-developed components, components adapted from VHA software, and, potentially, commercial products (COTS) that have been adapted to framework technology. Among the advantages of componentization is the ability to add or modify GUI components without reinstalling the entire application.

Hardware and Network Requirements

A thorough review of the local technology environment will be required at any facility implementing the IHS·EHR. Facilities will need to evaluate hardware needs in or near exam rooms and provider offices to ensure that providers and other users of the EHR have access to the system at the point of service. Deploying the EHR will create additional demands on the RPMS server and network at each facility because of the new group of system users - providers and other clinical staff.

Because IHS-EHR is a client/server application, it does not require a separate server to run. The VueCentric framework resides on each client (user) computer, and all data resides on the RPMS server. A single object library folder is maintained on the RPMS server (or another central computer). Updates to the framework application or GUI components are deposited in this folder, which automatically updates the client computers each time the application is launched.

I/T/U health care facilities vary greatly in size, services provided, and in a number of other factors. For this reason it is difficult to provide a single set of recommendations for hardware and network infrastructure that will fit all sites. The IHS Office of Information Technology in Albuquerque is available to provide consultation on questions regarding these requirements. The principal contact in Albuquerque on these issues is Rick Pullen ().

EHR Clinical Overview

The IHS Electronic Health Record (IHS·EHR) is intended to help providers manage all aspects of patient care electronically, by providing a full range of functions for data retrieval and capture to support patient review, encounter and follow-up. By moving most (and eventually all) data retrieval and documentation activities to the electronic environment, patient care activities and access to the record are able to occur simultaneously at multiple locations without dependence on availability of a paper chart. Moreover, point-of-service data entry ensures that the record is always up to date for all users.

The IHS·EHR combines the powerful database capabilities of the Resource and Patient Management System (RPMS) with a familiar and comfortable presentation layer, or graphical user interface (GUI). Integration of various RPMS components into the user interface allows providers to obtain a more comprehensive view of the clinical process. Access to patient information is available via "point and click", rather than the user having to log in and out of separate RPMS applications to retrieve different types of data.

Installation of the most current RPMS applications and/or patches is required for optimal functionality of the IHS·EHR (see Technical Overview). With the appropriate "back end" RPMS components, EHR supports such functions as:

  • Patient lookup and management of personalized patient lists
  • Problem list management
  • Order entry for laboratory, radiology, medications
  • Results notification and retrieval
  • Report retrieval
  • Health maintenance and disease state management reminders
  • Clinical encounter documentation
  • Clinical decision support
  • Documentation of immunizations, patient education, health and reproductive factors, etc.
  • Coding support (ICD and CPT)
  • Consult/referral generation and tracking

Most of these functions will be available in the first version of IHS·EHR, while others (such as image viewing) will be developed for future deployment. Although implementation of EHR requires installation of the full suite of RPMS applications (plus a number of VA applications), facilities may turn on or off these components according to local preferences. The availability of a variety of solutions will allow the system to be flexible in meeting the needs of different facilities, which offer various levels of clinical services. The aim is to develop technology solutions that are easily extensible to tribes and other rural communities.

Preparing for EHR

Transitioning to an electronic healthcare record requires substantial changes in an organization's business processes, as well as in the computer hardware and software needed to support and run the EHR. Moving from the paper to the electronic environment will force changes in routine for every employee connected with clinical services or activities.

Rolling out an electronic record system will require a considerable training effort at the time of implementation, as well as an ongoing program of training and support in anticipation of staff turnover and application upgrades. Most facilities should expect to add a full time Clinical Applications Coordinator position for support and training of the product, and should consider whether additional Information Technology staff will be needed to support increased demand on this department.

Because medical providers and other users of the EHR will need access to the system at the point of service, many facilities will need to extensively upgrade their network infrastructure and install new computer hardware. In addition, the latest versions of and patches to RPMS applications will need to be installed.

There is something of a learning curve for providers using EHR for the first time, so most organizations should expect to see decreased provider productivity during the first few months of EHR implementation. On the other hand, improved efficiencies in other areas (fewer chart pulls, decreased data entry, improved coding, more timely billing, and reductions in medication errors) may be anticipated as well.

"Electronic health records are one of the keys to modernizing the healthsystem and improving access and outcomes for Canadians."

An electronic health record (EHR) provides each individual in Canada with a secure and private lifetime record of their key health history and care within the health care system. Today, health records are largely paper-based and often not easily accessible to the right health care professional at the right time. An EHR would be available electronically to authorized health care providers and the individual anywhere, anytime in support of high quality care.

An EHR solution is a combination of people, organizational entities, business processes, systems, technology and standards that interact and exchange clinical data. A network of interoperable EHR solutions—one that links clinics, hospitals, pharmacies, and other points of care—will help enhance quality of care and patient safety, improve Canadian's access to health services, and make the health care system more efficient.

Interoperability for electronic health records is the capability of computer and software systems to seamlessly communicate with each other. It is central to Infoway's mission, making clinical data available across the continuum of care and across health delivery organizations and regions, promoting reusable and replicable solutions that can be aligned with jurisdictional priorities and deployed across the country more cost-efficiently. Without a common framework and sets of standards, EHR systems across Canada would be a patchwork of incompatible systems and technologies.

Overview

The vision of a pan-Canadian solution for the interoperable EHR is emerging amid a convergence of will, and a commitment to building the necessary capacity and capability. In meeting the EHR challenge, it is clear that uniform adoption of sustainable standards in support the EHR will be a key to success.

Standards facilitate information exchange and are a critical foundation for the EHR. They create the opportunity for future cost reduction as systems converge on pan-Canadian and international standards. In addition, standards can ease the effort required for replication.

While few definitive standards exist today, Standards Collaboration clearly presents an opportunity to establish an EHR based on robust, sustainable standards. With Standards Collaboration, the process of researching and establishing standards that meet the diverse needs of the EHR will be guided by a set of principles that ensure relevance, accuracy, completeness and timeliness. These principles ensure that as an agent of change, the Standards Collaboration Process continues to maintain a clear focus on our ultimate objectives.

Principles for Establishing Pan-Canadian EHR Standards

  1. Standards initiatives must be driven by the business of healthcare with a clearly defined business need
  2. Existing standards work must be leveraged wherever possible and practical with an approach that includes adoption, or adaptation of existing standards, before development
  3. The Health Level 7 version 3 messaging standard is required for all new message development related to the EHR
  4. Infoway investments are predicated on a commitment to implement pan-Canadian EHR standards
  5. Standards will be established, tested, refined and evaluated within the context of early adopter implementations
  6. Infoway will support early adopter investment projects that have as their goal the establishment of pan-Canadian standards
  7. Establishing standards is an evolutionary process and may not be perfect the first time, we may need to implement standards that are not fully balloted
  8. Infoway is committed to supporting Canada’s leadership role in influencing EHR international standards
  9. Infoway will work with other countries undertaking similar EHR initiatives to leverage their work and bring synergies to Canadian projects as they move toward internationally balloted standards
  10. Infoway will partner with CIHI, HL7 Canada, IHE Canada and other standards organizations in the establishment of pan-Canadian EHR standards
  11. Establishment of pan-Canadian EHR standards is coordinated via an open, transparent and inclusive stakeholder collaboration process as defined by our stakeholders

The diagram (opposite) provides a detailed overview of the pan-Canadian EHR Standards Collaboration Process which was developed and validated through consultations with over 400 key stakeholders across Canada.

Objectives

Infoway has a mandate to deploy a pan-Canadian Electronic Health Record (EHR) within an aggressive timeframe and limited budget. To fulfill its mandate, Infoway must promote standardization across healthcare information systems. Not only will this facilitate interoperability, but standardization may also simplify deployment of solutions and increase the rate of adoption.

An important component of promoting standardization involves the Standards Collaboration Process, a process that will guide and govern the establishment of pan-Canadian EHR standards for Infoway investments.

The EHR Standards Collaboration Process includes those jurisdictions, standards-related organizations, healthcare professionals and vendors that will build, operate and use an interoperable EHR. The Canadian Institute for Health Information (CIHI) is a strategic partner in the Standards Collaboration Process.

The EHR Standards Collaboration Process will establish pan-Canadian standards for Infoway investments through collaboration and consensus.
The first focus of the EHR Standards Collaboration Process will be information standards as defined by the Federal/Provincial/Territorial Advisory Committee on Health Infostructure.
The diagram (opposite) provides a detailed overview of Advisory Committee on Health Infostructure Classification of Standards (ACHI).

Benefits

The launch and operationalization of the Standards Collaboration Process began in April of 2004. Standards Collaboration is expected to:

  • Support interoperability through the establishment of pan-Canadian standards
  • Promote the uptake of Infoway funded investments by:
  • Increasing confidence in the utility and stability of solutions
  • Reducing long term costs through convergence of standard solutions that support the EHR
  • Increasing end-user acceptance of Infoway solutions through this collaborative process
  • Support acceleration and implementation of EHR standards in Canada
  • Optimize the use of capacity and capability to support ongoing domestic and international standards work

REF :

Ladan Jalali 83233529