Informatics

Question 1

CPOE

Answer 1

-this is what you use EHRs for besides documentation
-doctors/PAs orders
-not the same as electronic prescribing
-reduce errors- DDI
-point out tx or drug of choice

Question 2

healthcare information technology (HIT)

Answer 2

-design, development, creation, use and maintenance of information systems for healthcare
-automated and interoperable -> lower costs, improve efficiency, reduce error
-provide better consumer (Provider and pt) care
-serve
-most promising tool for improving overall quality, safety, and efficiency of health delivery system

Question 3

computer hx

Answer 3

-first general purpose computer (ENIAC) - 1946
-med informatics- 1960s
-MEDLINE reorganized medical literature searches (1960s)
-EHR- 1970s in VA and Massachusetts hospital
-Ai- 1970s
-internet- 1969
-WWW- 1990

Question 4

provider burnout due to EHR

Answer 4

6 main causes
-EHRs’ documentation and related tasks
* EHRs’ poor design
* Workload
* Overtime work (pajama time)
* Inbox alerts
* Alert fatigue

-50% more time than pt visit
-burnout costs money
-decline in safety and satisfaction if there is burnout
-insufficient compensation/reimbursement
-cognitive overload

Question 5

EHR

Answer 5

-conforms to nationally recognized interoperability standards
-can be created, managed, and consulted by clinicians and staff across more than 1 healthcare organization
-EHR=EMR
-less likely to be missing, legible, less difficult to retrieve, share and store data, 24/7
-clinical decision support
-productivity
-quality of care
-patient safety
-faster results, messaging, portals, education, e-prescription
-government supports EHR
-better coding = better money
-aggregated data = population studys
-data analytics- integrated data
-VA and Kaiser Permanente invested
-coordinated care

Question 6

integrated data

Answer 6

-integration with health information organizations, data analytics, public health reporting, AI, and genomic information

Question 7

five rights of CDS

Answer 7

-EXAM
The right information (what): should be based on the highest
level of evidence possible and adequately referenced.
∗ To the right person (who): the person who is making the
clinical decision, the physician, the patient or some other team
member
∗ In the right format (how): should the information appear as
part of an alert, reminder, infobutton or order set?
∗ Through the right channel (where): should the information be
available as an EHR alert, a text message, email alert, etc.?
∗ At the right time (when) : new information, particularly in the
format of an alert should appear early in the order entry
process so clinicians are aware of an issue before they
complete the task

Question 8

electronic health record key components

Answer 8

∗ Computerized provider order
entry!
∗ Clinical decision support
∗ Access via mobile technology
∗ Electronic prescribing
∗ Integration with images
-∗ Ability to create registries!!!!!!!!!!- risk factor data analysis

Question 9

electronic prescribing

Answer 9

-eRx
-part of EHR
-95% of pharmacies are connected
-associated with CDS*
-clinical decision support- allergies, DDI, insurance, prior auth, alerts, pregnancy, elderly, dosing
-ISSUES- alert fatigue, error (misclick), pharmacy issue

Question 10

EHR registries

Answer 10

-Chronic disease registries: able to track population cohorts
∗ Research registries: high volume allows research questions to be answered
∗ Safety registries: issues reported to FDA
∗ Public health registries: immunizations, cancer and biosurveillance
∗ Quality: data stored in registry and later forwarded to CMS or other public agencies

Question 11

HITECH ACT

Answer 11

-reimbursement for EHRs
-Ambulatory EHR adoption (2015): 86% have EHRs -> Larger practices MC for money reasons
-Inpatient (hospital) EHR adoption (2015): 96% -> many also in Meaningful Use program (reimbursement for meaningful use of EHR)
-Smaller urban and rural hospitals lag

Question 12

e-iatrogenesis

Answer 12

-medical errors due to technology

Question 13

EHR challenges

Answer 13

-financial- lack of reinbursement for some
-provider resistance- compliance
-loss of productivity- no change in workflow
-workflow changes- everyone must change
-reduced physician pt interaction
-usability issues- some are not user friendly
-integration with other systems- interfaces to communicate must be made
-lack of interoperability- data sharing between EHR
-privacy concern
-legal- unknown if will cause more or less malpractice
-inadequate proof of benefit- no proof that it will improve quality of care
-pt safety and unintended consequences- room for new errors

Question 14

open notes information: 21st century cures act

Answer 14

-organizations cannot block data
-millions of dollars fine from government
-you MUST share data with other organizations and the patient
-pt gets the notes and results

Question 15

high reliability organizations (HROs)

Answer 15

-dont allow for swiss cheese model

Question 16

clinical decision support systems (CDSSs)

Answer 16

-CPOE
-education
-Calculators: part of the EHR
-Flow charts and graphs: to look at lab or vital sign trends over time
-Weight based dosing (especially important in peds)
-Order sets
-Results checking (INR when ordering Coumadin, creatinine when ordering abx)
* Allergy checking
* Duplicate order checking (potassium overdose)
∗ Differential diagnosis
∗ Lab and Imaging decision support: what tests are indicated and at what costs?
∗ Public health alerts: primarily infectious disease alerts for new outbreaks

Question 17

picture archiving and communication systems (PACS)

Answer 17

medical imaging technology which provides economical storage of, and convenient access to, images from multiple modalities
-remote
-fast
-stack mode- view images back and forth
-computer aided detection (CAD) - AI

Question 18

digital imaging

Answer 18

Started in the 1970s
∗ First filmless hospital occurred in 1999
∗ Transitioning to PACS
∗ Similar to photography (film to digital)
∗ Introduction of computed tomography, ultrasound, and
magnetic resonance imaging that all became digital
∗ Eliminated need for film processing and storage rooms
∗ Images could be viewed at a remote location
∗ Advantages: cost savings, storage, retrieval

Question 19

telehealth vs telemedicine

Answer 19

Telehealth: The use of electronic information and
telecommunications technologies to support long-distance
clinical health care, patient and professional health-related
education, public health and health administration
∗ Telemedicine: “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status” or simply the remote delivery of healthcare

Question 20

basic models of telehealth

Answer 20

-synchronous- interaction of pt and provider live
-store and forward- results, imaging, portal to be viewed at later time
-remote monitoring- data collected from pt in remote location
-mobile health/wearables- promote healthy behavior, alerts, reminders, health trackers

Question 21

healthcare data

Answer 21

-Datasets are available in categories: health, state, national, Medicare, hospital, quality, community and inpatient
-Users can use filters: data type, subject, agency, date updated, coverage period, collection frequency, geographic area, release date and output format
-There are different levels of data
and data can be structured or
unstructured

Question 22

information hierarchy

Answer 22

-data
-information
-knowledge
-wisdom- understanding

Question 23

clinical informatics

Answer 23

-key to enabling technology assisted disruption in healthcare organizations
-technology by itself is not the real disruptor

Question 24

nurse informaticians *

Answer 24

There are about 3 million nurses in the US (2016 Bureau of Labor) so a
large labor pool for an informatics education
∗ Multiple nursing programs in the US offer a nursing informatics program
with certification
∗ There has been a certification program for nurse informaticians available
since 1995 and in 2016 there were 2040 certified nurse informaticians
(ANCC 2016 data)
∗ Nurses are extremely valuable given their clinical experience and exposure
to quality and project management as part of the nursing experience

Question 25

chief medical informatics officer

Answer 25

∗ Usually a physician – sometimes a PA or nurse who reports
to the CIO or CEO
∗ CMIOs are less technology oriented and more tasked to help
implement newer technologies and gain staff acceptance
∗ They are involved with training and adoption strategies, as
well as the development of a variety of policies to include
privacy/security
∗ Most have a Master’s degree in an information science and
often are Certified Professional in Health Information
Management Systems (CPHIMS) or have completed a
Clinical Informatics fellowship board certified by AMIA

Question 26

clinician information

Answer 26

∗ Smaller organizations may have a “go to” nurse, physician
or PA who is an early adopter and has much more IT
experience; a clinician informatician
∗ In 2013 physicians could become board certified in Clinical
Informatics for the first time. Details are on the AMIA web
site
∗ AMIA has recently created an Advanced Interprofessional
Informatics Certification that non-physicians can attain and
is similar to board certification in Clinical Informatics

Question 27

change framework

Answer 27

-20% supportive and positive towards change
-60% on the fence- need leadership in context to change
-20% negative