Electronic Health Records for Quality Nursing and Health Care

• Provides foundational knowledge and understanding of the implementation and use of electronic health records (EHRs)
• Explains the system design life cycle of an electronic health record implementation
• Provides methods for evaluating patient and population health outcomes
• Numerous appendices provide supporting material and examples including a project timeline, workflow process map, and test script examples

This comprehensive reference provides foundational knowledge on electronic health records (EHRs) for the delivery of quality nursing care. Chapters cover descriptions of EHR components and functions, federal regulations within the HITECH Act, privacy and security considerations, interfaces and interoperability, design, building, testing, implementation, maintenance and evaluating outcomes. Key reference for nurse executives, nurse directors, nurse managers, advanced practice nurses, nurse researchers, nurse educators, and nurse informaticists.

Excerpts from the Foreword

As the importance of informatics spreads across all aspects of healthcare, the numbers of articles and books published on this topic have increased exponentially. Knowing what is available and what is important is a challenge.

The Electronic Health Record (EHR) is the centerpiece of the effective use of informatics in health and health care. As we create big data and increasingly depend on decision making with Computer Decision Support, quality becomes a major concern. We are not yet at the level of quality we need for the important use of data and extraction of knowledge. Electronic Health Records for Quality Nursing & Health Care provides an opportunity to view the changing roles of nurses to take full advantage of the opportunities offered by technology and the use of that technology for healthcare. The book is an easy read and is applicable for undergraduate or graduate work, or even just for someone interested in the field. The book addresses the right level of depth on a topic–deep enough for the reader to have a good understanding yet not get bogged down in too many details…

…Electronic Health Records for Quality Nursing & Health Care is a significant contribution to the field of literature in informatics. Some features that I like very much are the various scenarios included in each chapter that clearly help the readers increase their understanding of the material. The references at the end of each chapter are worth the price of the book. I am impressed with how Dr. Kelley weaves the reference material into her writings.

I strongly recommend this book for your book shelf. Whether you use this book for teaching or for class material, it is well suited for both. Dr. Kelley has grasped the flow and development of the field and shares that with the reader.

—W. Ed Hammond, PhD, FACMI, FAIMBE, FHL7, FIMIA

Foreword
Preface

Chapter 1. Introduction
1.1. The Nursing Profession and Electronic Health Records
1.2. Format of Electronic Health Records for Quality Nursing Care
1.3. Overview of Chapter 2–Chapter 12
1.4. References

Chapter 2. How it All Began: Electronic Health Records in the United States
2.1. Overview of the First Electronic Health Records and Initial Stages of EHR Development
(1960s-1990s)
2.2. Emergence of National Involvement and Advocacy for EHRs (1990s–2000s)
2.3. Continued National Advocacy (2000s–Present)
2.4. Chapter Summary
2.5. Discussion Questions
2.6. References

Chapter 3. Electronic Health Records
3.1. Defining CPR, EMR, EHR, and PHR
3.2. Components of Electronic Health Records
3.3. Electronic Medical Record Adoption Models
3.4. Electronic Health Record Adoption Models
3.5. Benefits of Adoption and Use of Electronic Health Records
3.6. Challenges of Adoption and Use of Electronic Health Records
3.7. Certification of Electronic Health Records
3.8. Chapter Summary
3.9. Discussion Questions
3.10. References

Chapter 4. Functions of Electronic Health Records
4.1. What is an Electronic Health Record Function?
4.2. Patient Searches
4.3. Patient Lists
4.4. Computerized Provider Order Entry Functions
4.5. Problem Lists
4.6. Structured Data Fields
4.7. Unstructured Data Fields and Notes
4.8. Copy and Paste
4.9. Device Integration
4.10. Electronic Medication Administration Record
4.11. Smart Infusion Pumps
4.12. Trending of Data
4.13. Scanning of Images and Documents
4.14. Calculations
4.15. Voice Recognition
4.16. Electronic Transmission of Data and Information
4.17. Security Settings in an Electronic Health Record
4.18. Chapter Summary
4.19. Discussion Questions
4.20. References

Chapter 5. HITECH Federal Regulations and Requirements from ARRA
5.1. Overview of HITECH Provisions within ARRA
5.2. Expansion of the Office of the National Coordinator for Health Information Technology
5.3. Funding Provisions to Expand the Health Information Technology Workforce
5.4. Privacy and Security Regulation Expansion
5.5. Regional Extension Centers to Support Providers with Electronic Health Records
5.6. Electronic Health Record Incentive Program
5.7. Chapter Summary
5.8. Discussion Questions
5.9. References

Chapter 6. Privacy and Security Concerns with Electronic Health Records
6.1. Relationship between Privacy and Security
6.2. Privacy
6.3. Security
6.4. Privacy and Security Federal Regulations and Requirements
6.5. Privacy and Security Steps for Health Care Organizations
6.6. Chapter Summary
6.7. Discussion Questions
6.8. References

Chapter 7. Standards, Interfaces, and Interoperability in Electronic Health Records
7.1. Relationship between Standards, Interfaces, and Interoperability
7.2. Standards
7.3. Interfaces
7.4. Interoperability
7.5. Chapter Summary
7.6. Discussion Questions
7.7. References

Chapter 8. Selecting and Planning for an Electronic Health Record
8.1. System Development Life Cycle for an Electronic Health Record
8.2. Selecting an Electronic Health Record
8.3. Planning for an Electronic Health Record
8.4. Chapter Summary
8.5. Discussion Questions
8.6. References

Chapter 9. Designing, Building, and Testing an Electronic Health Record
9.1. Designing an Electronic Health Record
9.2. Building an Electronic Health Record
9.3. Testing an Electronic Health Record
9.4. Chapter Summary
9.5. Discussion Questions
9.6. References

Chapter 10. Implementing and Maintaining an EHR
10.1. Implementing the Electronic Health Record
10.2. Maintaining an Electronic Health Record
10.3. Chapter Summary
10.4. Discussion Questions
10.5. References

Chapter 11. Outcomes Evaluation with Electronic Health Records
11.1. Importance of Evaluating Outcomes from the Use of Electronic Health Records in Health Care Organizations
11.2. Evaluating Outcomes from a Quality Perspective
11.3. Chapter Summary
11.4. Discussion Questions
11.5. References

Chapter 12. Future Directions of Electronic Health Records
12.1. Mobile Health Technologies
12.2. Big Data and Advanced Analytics
12.3. Enhanced Electronic Communication
12.4. Increased Patient Engagement
12.5. Expansive Efforts Toward Nationwide Electronic Health Record Interoperability
12.6. Increased Use of Cloud-based Electronic Health Records and Other Clinical Information System Solutions
12.7. Opportunities for Nurses in Informatics
12.8. Chapter Summary
12.9. Discussion Questions
12.10. References

Appendix A—Acronyms used in Electronic Health Records for Quality Nursing Care
Appendix B—List of Regional Extension Centers
Appendix C—Alternate Clinical Quality Measures for Eligible Providers in Stage I of the Electronic Health Record Incentive Program (2011-2013)
Appendix D—Clinical Quality Measures for Eligible Providers in 2014 for Stage I and Stage II of the Electronic Health Record Incentive Program
Appendix E—HIPAA Privacy Rule Protected Health Information Identifiers
Appendix F—Steering Committee Membership List
Appendix G—Electronic Health Record Project Sample Timeline
Appendix H—Workflow Process Map Example
Appendix I—Functional Test Script Examples
Appendix J—Integrated System Test Script Examples
Appendix K—Workflow Test Script Examples

Glossary
Index