EHR+Specialties

LIS 4785 Final Report Matt Farrell, Yi Fang, Mackenzie Lee, Jan Van Konijnenburg


 * Problem statement**

The problem that we have chosen to address in regard to electronic health and medical record systems and their implementation is that they are not fully interoperable with the many departments in healthcare. The inefficiency of these systems is due not only to the system’s infancy, but also due to a lack of catering to each hospital department’s special needs. Few clinicians based in a specialized registry use EHR applications due to the lack of EHR specialization and interoperability. Many EHR systems are made for primary care, which leads to an excess of information not always needed by the specialist doctor and specialists receive information that is irrelevant to their practice. EHR information doesn’t always transfer properly among physicians, resulting in a decrease in the quality of patient-doctor experience.

Healthcare Information Technology (HIT) aims to implement electronic health and medical systems through the meaningful use program, which includes improving patient care, keeping privacy and security of information, engaging patients and families in the care they are getting, and improving care coordination and overall societal health. There are three stages of meaningful use: data capture and sharing, advancing clinical processes, and improving outcomes. Data capturing and sharing is where our concerns with EHRs lie, particularly with the capturing of data. If physicians in a specialty can’t meet the first stage of MU with simple data capturing, this could lead to many not wanting to or being able to implement an EHR system.

All in all, there are not many EHR databases that allow specific practice management or that involve an all integrative platform for primary care, special registries care, and billing so this is the type of software we aim to develop.


 * Evidence to support the problem**

According to a study entitled //Health Information Technology in the United States, 2015: Transition to a Post-HITECH World//, conducted by The Robert Wood Johnson Foundation in conjunction with students at Harvard school of Public Health and University of Michigan, only 15% of efforts in the meaningful use program have been observed for submitting electronic records for cases related to a specialized registry, excluding cancer. Additionally, the study states that the transfer of data takes the majority of use of EHRs and other electronic records systems to other hospitals (77.4%), submitting/recording lab results (63.2%), and registering/recording immunizations (59.4%) among others. The database and structure for EHRs is somewhat universal, which is a good thing for timely adoption, acceptance by hospitals, and primary care clinicians, but it is not a good thing for those in a specialty and needs more effort put into raising the aforementioned 15% data figure. According to the article titled //Medical Malpractice Liability in the Age of Electronic Health Records//, only 6% of hospitals had a comprehensive EHR system, while 56% had implemented electronic systems for inputting physicians’ notes, and 52% started implementation for clinical decision support systems (Sandeep S. 2010).

The barrier between primary care EHR data input and specialty data input not only puts a damper on efficiency and ease of use, but also decreases quality of patient care. According to David B. Troxel in The Doctors Company, a computer could create a barrier between the doctor and the patient (Troxel, 2012). The lack of fluidity and interoperability of an EHR would further degrade the patient doctor experience, and therefore requires much more development to providing the best healthcare possible.

Despite the major growth of EHR systems with more useful ways to operate within specialty registries and increased support by the government incentives, there still seems to be EHR vendors that continue to keep the barrier up to hinder clinicians use. What is stopping these vendors from making changes to keep up with advances? Well, we know technology isn’t the problem because our technology is advanced enough to do many operations. We can hope that one day it is required by standards that systems be able to exchange data with special registries, but until then we need to establish integrative systems to create optimal interoperability and data capturing/sharing (Rich, 2015).


 * Potential solutions**

In order to address these issues, and to achieve the goal of the best possible health care while utilizing health information technology, we have developed some solutions for specializing EHRs, for improving interoperability, and for improving overall patient care.

Our potential solutions ideally adhere to EHR standards while improving EHRs and their information exchange because current EHR standards are reasonable, yet tentative.

First, specialized templates are suggested for doctors who require more complex forms, or simply just require specific additions in the EHR system for their specialty. These templates are viewed as an enhancer for current EHR systems in order to increase interoperability. Doctors can utilize this feature to make electronic data management easier. Having a specific drop down option or icon selection (can be seen in our prototypes) would make an easy option for a specialist to avoid redundant primary care-type prompts and they can get straight to data as it pertains to the patient's needs. For example, a cardiologist may need EKG graphs for data input or syncing.

Another potential solution part of our DoctorWorks EHR system is to maintain ‘special notes’ section which is an easy-to-use patient health information (PHI) section where physicians can input information with important notes included that clinicians can use to improve patient care. Our team also added a quick patient search engine to find a patient's EHR by their name, date of birth, or social security number.

A new creative addition that DoctorWorks has for another solution to the problem at hand is a doctor user profile and an integrative clinician community. This pertains to interoperability and allows for doctors to exchange patient information in an organized manner.

Technical support is offered for our EHR to aid clinicians using the system that connects to a technician online or by telephone. Also any problems that arise while using the application mobile version of DoctorWorks will be handled by our technical support team that works for our company. Ultimately our solution is to successfully integrate these new additions to an EHR platform to allow for specialty practice management and improvement in patient care, doctor usability, and system interoperability.


 * Research on existing/alternate solutions tried by others**

Other researchers have had access to current EHR systems spread across America, and have pinpointed some crucial aspects of EHRs that need to be addressed in order to maximize interoperability. Archetypes (formal model that can be re-used) and harmonised standards play a key role in increasing interoperability: “The definition of archetypes is an important step for the realisation of EHRs and achieving semantic interoperability”(Garde, Knaup, Hovenga, & Heard, 2007).

“In order to achieve technical and semantic interoperability, existing standards (e.g. CDISC) have to be harmonized and bridged” (ohmann, C, & Kuchinke, W. 2009).

These statements above emphasize the importance of what our team has tried to do, creating a “harmonized” or integrative system that is all inclusive for clinician use. Other companies have learned that this is the key to future EHR/EMR software as well, but we need to get everyone on board.

According to Rich, various organizations have searched for a solution that will develop a well-integrated EHR. In 2009, the American College of Cardiology launched its EHR-based “PINNACLE Registry” which helps physicians (primarily cardiologists in this case) have specifics for practice management for things like hypertension, coronary artery disease, and heart failure which are things you wouldn’t see in a basic primary care EHR. This registry also calculates and delivers fast feedback without disruption and it has lead to other medical groups to invest in similar registries (Rich, 2015).

Overall, efforts can be found of new systems to create an all-in-one EHR platform with specialty registries and billing information integration. An example of a company joining our efforts is called CureMd and they stand by a “Practice without boundaries”. This company shows a true example of what our team wants to accomplish, only DoctorWorks aims to be even better and broad for the use of any health organization.


 * Feasibility of each solution**

1.Improvement of EHR Standards: By increasing information exchange standards, we can eliminate discrepancies between different EHR systems. Also, by making additional requirements pertaining to specialty registries, we can make sure that all data input and data exchange must conform to understanding specialty practice management and forces vendors to all get on board with these changes.

2. Specialized EHR templates: Instead of creating separate EHR processes, our templates would be integrated into current EHR systems and allow for physicians to exchange information with practice management. The easy to use template will allow for icons or a drop down mean for doctor to select their specialty and follow with prompts that pertain to their feild of work.

3. ‘Special Notes’ section: Simple and easy to use while allowing pertinent information display regarding patients, no matter the health department. Things that a doctor feels is important to know when caring for a certain patient can be made note of for clinician community to have for better evidence-based care.

4. Doctor user profile: An easy sign on, secure page allows for primary care doctors to have the items needed for exchange of information with specialists and vise versa. Allow keeps information organized and confidential. 5. Patient search: Allows for a quick find of a PHI that sees that particular doctor so the doctor can easy give medical advice based off last appointment, blood work, prescription information, and patient individual differences. Our software allows search by name, social security number, and/or date of birth.

6. Technical Support: Proper training can merge this aspect with the IT department of health organizations. Our IT team will be there 24 hours a day in order to support the users of our EHR database.


 * Our approach and reasons for what we did**

Our team wanted to adhere to EHR standards, while improving the system and exchange. We decided to create specialized, pre-made, templates for doctors who require more complex forms, or simply just require specific additions for their specialty and they can utilize this tool to make electronic data management easier. The reason DoctorWorks puts such an emphasis on adjusting EHR systems to be more inclusive for specialists is because these adjustments will improve EHR interoperability and compatibility within an entire healthcare organization. By having an EHR with a separate primary care section, and a separate special care section, we can bridge these together to have an improved system and to help fix the problem with data capturing/input, while catering to a larger number of clinicians. The selection options for specialty registries is feasible and can be intuitively used by most clinicians even if they aren’t computer savvy. This system is made to be the easiest program to use while being all encompassing for health professionals.

The doctor user profile and sign in allows for basically security and HIPAA regulations. This is for clinician use only and for the management of PHI. This is a personalized doctor profile where clinicians can manage their patient information and other EHR documentations. Connecting these profiles with the clinician community establishes an efficient network that is key to a well-functioning EHR system.

We included a ‘special notes’ section at the bottom of our primary care EHR. This simple add on could make a huge impact on a patient's experience at the doctors or in the hospital by avoiding simple mistakes by just reading up on the PHI. On our website and mobile application we included a technical support section to aid clinicians using the system and that connects to a technician online or by telephone to improve usability and speed up the integration process. Even though a technical support addition may seem redundant, we feel it is an important component to our system and we invested a lot money to educate our IT crew to be properly trained on how to make the most of the database.


 * Your timeline for completion**

August 2015: Group members put together by professor September 2015: Topic Selection and Two Page Proposal for HIT problem October 2015: Research on topic and start of software development November 2015: Application Template Demo and Final Presentation fixing probelms from before December 2015- Final Report on development


 * Team workload and roles**

Throughout the semester we divided the workload evenly between the four group members. We each contributed on the two page proposal, the slideshow for the initial proposal presentation, the slideshow for the final presentation, and putting together the prototypes/pictures for the project. Each member did each have a focus point when developing DoctorWorks.

__This included:__ -Matt Farrell’s focus and creation of the user secure log-in page, the doctor user profile, and web page design. -Mackenzie Lee’s focus and creation of the special practice EHR templates and patient search engine. -Jan van Konijnenburg’s focus and creation of the primary care EHR template and patient information entries. -Yi Fang’s focus and creation of the technical support and mobile app version wireframes.


 * Meeting minutes**

During the semester we met on multiple occasions. Most meetings took place before each new development or presentation of our system and they lasted between an hour to two hours. Remaining work that needed to be done as a group was done via online using google documents and through a group chat. By using Google Docs and a group chat, all member of the team were able to communicate effectively and we were able to work around everyone's busy schedule.


 * Solution prototypes**

User log-in page:

Doctor user profile:

Primary care EHR template:

Special care template:

Tech support:

Mobile/tablet application version:


 * Final Solution**

Our solution simply updates the current EHR system to include all aspects required for improvement and to make advances in the healthcare environment. We have made information easy to exchange by improving interoperability within the system and promote clinician connectedness that will lead to improved patient outcomes and better patient-doctor relations. The solution to our problem was to bring down the barrier that exists between specialty registries and primary care. By creating an integrative platform where doctors can be involved in practice management, we can revolutionize HIT and meaningful use.


 * Next Steps**

With our solution having been achieved, EHR interoperability can be further developed through the integration of electronic health records and personal health records to encourage patient health and well-being. Also, standardization of EHR systems could be regulated to require a minimum amount of EHR system support and involvement among a broad spectrum of health departments, and not just primary care. Our ‘clinician community’ could be further developed to including secure video conferencing and other telecommunications to create a more secure and a more efficient health environment and organization.


 * Citations**

Blumenthal, D. (2011). Implementation of the federal health information technology initiative. New England Journal of Medicine, 365(25), 2426-2431.

Garde, S., Knaup, P., Hovenga, E. J., & Heard, S. (2007). Towards Semantic Interoperability for Electronic Health Records--Domain Knowledge Governance for open EHR Archetypes. Methods of information in medicine, 46(3), 332-343.

Health Information Technology in the United States, 2015: Transition to a Post-HITECH World. (2015, September 18). Retrieved from http://www.rwjf.org/content/dam/farm/reports/reports/2015/rwjf423440

Mangalmurti, Sandeep S. et al (2010). Medical Malpractice Liability in the Age of Electronic Health Records. New England Journal of Medicine. Retrieved from []

Rich, William L. How Much Longer Will We Allow Data Blocking To Slow Us Down? (2015, August 3). Retrieved December 7, 2015, from http://www.ihealthbeat.org/perspectives/2015/how-much-longer-will-we-allow-data-blocking-to-slow-us-down?view=print

Ohmann, C., & Kuchinke, W. (2009). Future developments of medical informatics from the viewpoint of networked clinical research. Methods Inf Med, 48(1), 45-54.