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EMR & EMR Modules . Lecture 9 Monday, February 4, 2013 Victoria Aceti Chlebus, MA. Agenda. EMR Lecture Leftovers Benefits of an EMR & Organization of an EMR EMR Modules Patient Care System (Data Entry) Computerized Physician Order Entry Electronic Medication Management & ePrescribing - PowerPoint PPT Presentation

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EMR & EMR Modules

EMR & EMR Modules Lecture 9Monday, February 4, 2013Victoria Aceti Chlebus, MAAgendaEMR Lecture LeftoversBenefits of an EMR & Organization of an EMR

EMR ModulesPatient Care System (Data Entry)Computerized Physician Order EntryElectronic Medication Management & ePrescribingPACSCADxClinical Decision Support Systems

Patient Care System (Data Entry)EMR is a view-only system where entered information is accessed by a patients care circle. Can be specialized to specialties (Critical Care, Ophthalmology, OB/GYN, Chronic Disease Management)A Patient Care System (called sometimes by different names) is where information is entered through:Progress Notes (free text or linked)Standard templatesAssessments (Tests)Interventions (Treatment Plans)Scanned reports3Clinical Decision Support SystemAn interactive computer software system which assists clinicians in making decisions about a patients current condition and treatment.There are many different modules which use CDSS:TriageComputerized Physician Order EntryElectronic Medication Management & ePrescribingCADx

4Clinical Decision Support SystemClinical Decision Support Systems (CDSS) work in the background and can create alerts for:Patient Acuity Drug interactionsAllergiesRoutine TestsDiagnosis assistance5Triage Support: ePod

6Orders are directives from physicians as to how to care for a patient and what medications they are prescribing. Order Entry is currently functional within many health organizationsComputerized Physician Order Entry has been shown to decrease the number of medication errors, prescribing errors, order-to-patient time, and increase patient safety. Some studies suggest a reduction in 18-32%Computerized Physician Order Entry7Computerized Physician Order Entry

8Cancer Care OntarioCanadas 1st cancer-specific CPOE SystemCurrently used in 11 cancer centres (ADCP not included)Largest ambulatory oncology CPOE implementation in Canada with 100% success rate & 90% physician adoption

9Electronic Medication Management & ePrescribingTuesday, April 3Lecture 1910Whats the Difference?Electronic Medication ManagementElectronic prescribing, administration and dispensing of medicationNo connection to pharmacy or pharmacistPrinted copy of prescription for patient to bring to pharmacyePrescribingElectronic prescribing within an electronic medical recordPharmacist has access to patient prescription historyPharmacist has electronic copy of pending prescriptionsPrinted copy of prescription for patient, or sent directly to pharmacist

11Electronic Medication ManagementPrescribingOrdering the drug, the dose, the frequency and route of administrationDetailed list of available medications (including generic products)Compiles all the medications that have been prescribed to that patientDoes not show which prescriptions have been filed or indicate current medications

12Electronic Medication ManagementMedication Decision SupportDrug interactionsDrug-to-drug warningsDrug-to-disease warningsAllergy reactionsDosing informationComplex dosing regimens (chemotherapy)Particularly important when treating neonates or children13Electronic Medication ManagementDispensing Legibility of prescriptionsLegibility of doctors ordersProvides an effective check and balance to capture errorsSecondary identification management (Bar coding)14Electronic Medication ManagementAdministrationIn hospital: RNHighly structuredUsually regulated by a form of technologyAt home: patient or RNOften not regulated by a medical professionalCan lead to complications15ePrescribingRequires:Common data languageAccess to secure VPN systemConsent from patients to share data with pharmacistUnderstanding between the provider and pharmacist as to responsibilities The ability to send error-free, accurate, and understandable prescriptions electronically from the provider to the pharmacy(ePrescribing Canada, 2012).16So whats the hold up?Data sharing and secure VPNsPatient privacy issues Pharmacists not wanting responsibility or liability Ammenwerth et al. (2008): The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic ReviewePrescribing can reduce the risk for medication errorsSearched literature from 1976-2006, n=27 met inclusion criteria23 of the 27 studies found medication error risk reductionSignificant error reduction from 13% to 98%Researchers found studies concluding 98% reduction grossly overestimatedPicture and Archiving Communication Systems (PACS)Picture and archiving information systemOriginal PACS system integrated in 1982 in the USAllows for sharing of diagnostic images through a centralized repository Different types of health information available in PACS:RadiologyCardiovascular

18DI19SAHIMAGINGGHC MAMMOGRAPHYARCHIVERADIOLOGIST RISDIREPORTRIS19Replacement of hard copy medical imagesRemote accessElectronic integration of information (EMR & RIS)Improvement of workflowAdditional tools to improve patient diagnosesImproved collaboration Improved communicationBenefits of PACS2020Technical issues impeding the delivery of imagesPotential loss of data or lack of data transmissionLegal issues of responsibility between organizationsHigh cost of integrating system and updating system

PACS Challenges2121Originally the Pan-Northern Ontario PACS ProjectNEODIN is one of four Diagnostic Imaging Repositories being implemented in OntarioNW-LHIN, NE-LHIN & Champlain LHINA total of 59 hospitals (including Group Health Centre) involvedOverall goal is to link up all 4 in Ontario for one repositoryPan-Northern Ontario PACS Project222223WSSAHIMAGINGGHC MAMMOGRAPHYARCHIVERADIOLOGIST RISWSREPORTRISDI-rSAHTOHHSN23Computer Assisted Diagnosis24Combines artificial intelligence and digital images to help diagnose irregularitiesUsed in the detection of cancers and heart disease at the screening stageIntroduced in 1960s who proposed the idea that computers could detect irregularities 24Reviewed evidence for the effectiveness of computer-assisted diagnosis in cancer imagingLooked at studies from 1990-2010N=48 from 9199 identified studiesLooked at sensitivity and specificity measures

25Eadie et al. Systematic Review25Binary classification used to measure the accuracy of a diagnosis:Sensitivity: measure of true positive and false negative diagnosesSpecificity: measure of true negative and false positive diagnoses

26Sensitivity & Specificity26ApplicationRadiologist AUC (SD)CADx AUC (SD)Mammogram (n=8)0.86 (0.07)0.95 (0.03)Breast US (n=7)0.88 (0.03)0.95 (0.01)Breast US+mammogram (n=3)0.81 (0.08)0.89 (0.04)Lung CT (n=3)0.84 (0.01)0.79 (0.01)27FindingsSystematic review conducted in 2011 found that CADx assist in the diagnosis of breast cancers, but no evidence of overall benefit from using CADx. Further there is no evidence that CADx are a detriment to diagnosis.27High rate of false-positives, thus still requires a Radiologist to differentiate between significant and insignificant resultsPotential loss of diagnosing ability without CADWhen should your clinical judgment override that of a computer?

28Issues with Computer-Assisted Diagnosis28Final ThoughtsEMRs have the potential to improve patient care and decrease medical risk.Clinicians need to be educated on the limitations of CDSSs as to understand when clinical judgment overrides system features.There is still much to be understood about how these systems are designed and flow into clinical practice.