Electronic Health Record and

Clinical Informatics

Sheila Lyn U. Recidoro,RN

 Introduction
• January 2004
President George W. Bush raised
the profile of electronic health
records in his State of the Union
address by outlining a plan to ensure
that most Americans would have an
electronic health record by 2014.

Sheila Lyn U. Recidoro,RN

Electronic Health Record (EHR)
• A data warehouse or repository of
information regarding the health
status of a client, replacing the
former paper-based medical record.
• It is the systematic documentation of
a client’s health status and
healthcare in a secured digital format

Sheila Lyn U. Recidoro,RN

Electronic Health Record (EHR)
• also known as an Electronic Medical
Record 

• can be used to collect and look up

patient data by physicians or health
professionals at various locations such
as doctor’s offices or hospitals. 

Sheila Lyn U. Recidoro,RN

Information included in EHR :
• demographics
• patient problems
• medication
• allergies
• laboratory results, etc.

(Certification Commission for Healthcare Information

Technology [CCHIT], 2007).

Sheila Lyn U. Recidoro,RN

 Components
• The definition of an EHR is evolving.
• A survey of the literature reveals that
there are many different definitions, each
with its own terminology and developed
with a different audience in mind.
• The IOM definition is the most widely
referenced, however, and provides a
good starting point.
* IOM – Institute of Medicine

Sheila Lyn U. Recidoro,RN

 Components
• Health information and data is the
patient data required to make sound
clinical decisions
• Results management is the ability to
manage results of all types
electronically including laboratory and
radiology procedure reports, both
current and historical

Sheila Lyn U. Recidoro,RN

Components
Order Entry management
• is the ability for a clinician to enter
medication and other care orders
directly into a computer including
laboratory, microbiology, pathology,
radiology, nursing, supply orders,
ancillary services and consults.

Sheila Lyn U. Recidoro,RN

Components

Decision support
• is the computer reminders and
alerts to improve the diagnosis
and care of a patient.

Sheila Lyn U. Recidoro,RN

Components
Electronic communication
and connectivity
• is the online communication among
healthcare team members, their care
partners and patients including e-mail,
web messaging, and an integrated
health record within and across
settings, institutions and telemedicine

Sheila Lyn U. Recidoro,RN

Components

Patient support
• is the patient education and self-
monitoring tools including interactive
computer based patient education,
home telemonitoring and telehealth
systems

Sheila Lyn U. Recidoro,RN

Administrative Processes :
• electronic scheduling
- inpatient and outpatient visits
- procedures
• billing and claims management systems
- electronic insurance eligibility
validation
- claim authorization and prior approval
• identification of possible research study
participants
• drug recall support
Sheila Lyn U. Recidoro,RN
Reporting and population health
management
• is the data collection tools to
support public and private
reporting requirements including
data represented in a
standardized terminology and
machine-readable format

Sheila Lyn U. Recidoro,RN

Office of the National Coordinator for
Health Information Technology
(ONCHIT)
• was established after President Bush’s
state of the union address in 2004 the to
address these nuances and gaps in
defining an EHR.
• Primary Mission of ONCHIT :
- is to assure users of health information
technology systems that those systems
“provide needed capabilities, securely
manage information and protect
confidentiality and work with other systems
without reprogramming” (Department of Health and
Human Services, 2007).

Sheila Lyn U. Recidoro,RN

 Advantages :
• no longer having to interpret poor
penmanship and handwritten orders
• to reduce turn-around-time for lab results
in an emergency department
• For prompt administration of the first dose
of antibiotics in an inpatient nursing unit

Sheila Lyn U. Recidoro,RN

 Advantages :
In the ambulatory care setting :
• evidence of improved management of
cardiac related risk factors in patients
with diabetes
• effective patient notification of medication
recalls

Sheila Lyn U. Recidoro,RN

 Advantages

• Despite limited standards and published

studies, there is enough evidence to
warrant pursuing widespread
implementation of the EHR (Halamka, 2006)
• To further study of the EHR’s use and
benefit.

Sheila Lyn U. Recidoro,RN

 Ownership
• The process of becoming a successful
owner of an EHR has multiple steps
and requires integrating the EHR into
both the organization’s day to day
operations and long term vision, and
the clinician’s day to day practice.

Sheila Lyn U. Recidoro,RN

 Ownership
1. Vendor selection process.
• Pre-acquisition phase
- understanding the current state of
the health information technology
industry

Sheila Lyn U. Recidoro,RN

 Ownership
2. Select a system based on the
organization’s current and predicted needs.
• The criteria should include both subjective
and objective items :
common clinical workflows
decision support
reporting
usability
technical build
maintenance of the system.

Sheila Lyn U. Recidoro,RN

 Ownership
• Implementation planning should
occur concurrently with the
selection process, particularly the
assessment of the scope of the
work, initial sequencing of the EHR
components to be implemented
and resources required.
• The implementation plan should
also account for the long term
optimization of the EHR.

Sheila Lyn U. Recidoro,RN

Flexibility and Expandability
• At a very basic level, there is as yet no
electronic health record system
available that can provide all functions
for all specialties to a degree that all
clinicians would successfully adopt.
• Most healthcare organizations do not
yet have the capacity to implement and
maintain systems in all care areas.

Sheila Lyn U. Recidoro,RN

Flexibility and Expandability
• Financial and patient privacy hurdles
must also be overcome to achieve an
expansive EHR.
• The Department of Health and Human
Services recently loosened regulations so
that physicians may now be able to
receive healthcare IT software, hardware
and implementation services from
hospitals in an effort to alleviate the cost
burden on individual providers and foster
adoption of the EHR.

Sheila Lyn U. Recidoro,RN

 Flexibility
• Patient privacyand Expandability
is a pivotal issue to
determining how far and how easy it will be to
share data across healthcare organizations.
• For health exchanges such as these to reach
their full potential the public must be able to
trust that their privacy will be protected, or
else risk that patients may not share a full
medical history or worse yet may not seek
care, effectively making the exchange
useless.

Sheila Lyn U. Recidoro,RN

Incentives to Invest in EHRs
 “The value of electronic health records …
as tools to improve access, quality and
comprehensiveness of care should be
reinforced so that the public clearly
understands the benefits and demands of
their introduction.
 We recommend that providers,
governments and the public jointly commit
to the rapid adoption of these tools.”
(Health Council of Canada, Report to
Canadians, 2005)

Sheila Lyn U. Recidoro,RN

 Concerns with EHRs
 “issue of privacy, confidentiality and
protection of personal health information in
the context of an EHR system is perhaps the
most sensitive one raised”
 “Currently, there is significant variation in
privacy laws and data access policies across
the country that poses a challenge for EHR
systems that are dependent on inter-sectoral
and inter-jurisdictional flows of personal
health information. …”
Senator Kirby, Senate Report on the Health
of Canadians (2002)
Sheila Lyn U. Recidoro,RN
 Privacy, Confidentiality &
Security
• Privacy: one’s right to control who has
access to information about oneself

• Confidentiality: a duty owed by one to

preserve the secrets of another

• Security: mechanisms put in place to

safeguard privacy and ensure confidentiality
is maintained

Sheila Lyn U. Recidoro,RN

 Professional
• Hippocratic oath
Duties
– “Whatsoever I shall see or hear concerning
the life of men, in my attendance on the sick,
or even apart there from, which ought not to
be noised abroad, I will keep silence
thereon, counting such things to be as
sacred secrets.”

Sheila Lyn U. Recidoro,RN

 Health Info Privacy Code
• right of privacy fundamental in a free and
democratic society
• includes patient's right to determine with
whom he or she will share information and
to know of and exercise control over use,
disclosure and access concerning any
information collected about him or her
• right of privacy and consent are essential to
trust and integrity of the patient-physician
relationship.

Sheila Lyn U. Recidoro,RN

 Legislative
• public Developments
sector information and privacy
laws
• health information laws
– Manitoba (1997)
– Alberta (2001)
– Saskatchewan (2003)
– Ontario (2004)
• private sector privacy laws

Sheila Lyn U. Recidoro,RN

• EHRsNeed for legal
“potentially conflictframework
with privacy
principles unless patients control how the
record is shared and appropriate security
measures are in place.”

• “A coherent legal framework to appropriately

protect the privacy and confidentiality of
personal health records is therefore an
essential first step for successful EHRs”

Amanda Cornwall, “Connecting Health: A review of electronic

health record projects in Australia, Europe and Canada” (2003)

Sheila Lyn U. Recidoro,RN

 Consent
• Should individual consent be required
before information is included in EHR or
disclosed through EHR?
• To be legally valid, consent generally must
be informed:
– Who will have access to info?
– For what purposes?
– What security mechanisms are in place?
– What are risks of unauthorized access?

Sheila Lyn U. Recidoro,RN

 Saskatchewan HIPA
• comprehensive health records

• initially gave individuals right to refuse

consent

• removed in 2003

• retain right to restrict access to

comprehensive health record by giving
written instruction
Sheila Lyn U. Recidoro,RN
Section 59: Alberta HIA
required individual consent
before information could be disclosed
electronically
 authorization for custodian to disclose
 purpose for disclosure
 identity of recipient
 acknowledgement of reasons, risk, benefits
 date effective
 statement that consent may be revoked
Removed in 2003

Sheila Lyn U. Recidoro,RN

 Practical
• “in facilitating Experience
a province wide electronic
health record, practical experience made it
apparent that getting consent from Albertans
was going to be difficult and costly”
• not “possible to inform people in a meaningful
way of all the specific disclosures by
electronic means, which might ever be made of
their health information”
Frank Work, QC, Alberta Information & Privacy Commissioner

Sheila Lyn U. Recidoro,RN

• patient Australian
consent required Example
to include
information in EHR
• pilot project in Tasmania (2004):
– many patients were not asked for consent
– identified need for simple consent process
• discussion about moving to presumed
consent / opt-out model

Sheila Lyn U. Recidoro,RN

 United Kingdom example
 National Health Service “care record
guarantee” published May 2005

 consent for sharing patient information in

EHR is generally presumed

 but “You can choose not to have

information in your electronic care records
shared”

 consistent with 2006 BMA statement

Sheila Lyn U. Recidoro,RN

 Security
• maintain Obligations
administrative, technical and
physical safeguards to protect
confidentiality and privacy
• measures to guard against risks
associated with EHRs
• audit logs
• privacy impact assessments

Sheila Lyn U. Recidoro,RN

 Conclusions
Benefits and Risks of EHRs
1. professional obligations
– ethical and legal

2. patient rights
– consent and control

3. achieving an appropriate balance

Sheila Lyn U. Recidoro,RN

 Future
• Despite the challenges, the future
of EHRs is an exciting one for
patient and clinician alike.
• Benefits may be realized by stand-
alone EHRs as described here, but
the most significant transformation
will come as interoperability is
realized between systems.

Sheila Lyn U. Recidoro,RN

 Future
• There is a wealth of descriptive
data available pointing to the
benefits of an EHR.
• Nursing must stay engaged in
this evolution and help shape its
direction, as it has already
proven to have a significant
impact on our practice and our
patients.

Sheila Lyn U. Recidoro,RN

Thought Provoking Questions
1. What are the implications for nursing
education as the electronic health
record (EHR) becomes the standard for
caring for patients?

2. What are the ethical considerations

related to interoperability and a shared
electronic health record?

Sheila Lyn U. Recidoro,RN