Electronic Health Record : A Systems Analysis of the Medications Domain book cover
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Electronic Health Record
A Systems Analysis of the Medications Domain




ISBN 9781439878521
Published March 22, 2012 by Productivity Press
426 Pages 176 B/W Illustrations

 
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Book Description

An accessible primer, Electronic Health Record: A Systems Analysis of the Medications Domain introduces the tools and methodology of Structured Systems Analysis as well as the nuances of the Medications domain. The first part of the book provides a top-down decomposition along two main paths: data in motion—workflows, processes, activities, and tasks in parallel to the analysis of data at rest—database structures, conceptual, logical models, and entities relationship diagrams.

Structured systems analysis methodology and tools are applied to: electronic prescription, computerized physician order entry, drug dispensation, medication administration, and clinical decision support. Assuming no previous clinical and/or informatics knowledge, the book supplies a comprehensive view of the EHR/EMR with dedicated chapters on: user interface considerations, reporting requirements, and standards and vocabularies for meaningful use.

Containing clear language and more than 170 figures and 100 review questions with answers—this book is a great companion for Healthcare IT professionals and an ideal resource for clinical informatics students.

Praise for the book:

… a common sense guide to this new world of informatics … should prove invaluable to the clinician making his/her way past the commercial hype into the realm of true understanding of the systems of medical informatics. … strongly recommended … .
—William F. Bria MD, CMIO Shriners Hospitals for Children, President of the Board, Association of Medical Directors of Information Systems

Finally, here’s a textbook that the market and the industry have been looking for. The author has captured the details of the information flows involved in the EHR while processing an order or prescription from inception to completion.
—Joseph T. Finn, RPh, MBA

… a thoughtful and well-constructed manual to understanding and incorporating the complex and many-sided aspects of medication concepts … a clear and accessible entry to this challenging topic.
—Don Martin, Managing Consultant

... encompasses high-value, high-volume therapeutic transactions of indescribable complexity that touch nearly every licensed professional in a hospital … I’m hoping the vendors of my own hospital’s systems take its recommendations to heart.
—Mr. HIStalk, Healthcare IT Blogger

…. a very useful guide … provides the necessary detail that is often missing in many books… very useful in health informatics education at universities and courses within community colleges.
—Jane M. Brokel, PhD, RN

… a welcome and valuable addition to the toolkit for IT professionals and clinicians participating in the design or implementation of EHR systems.
—Christine Greifzu, RN-BC, MBA, MSIS

Table of Contents

Short Primer on Structured Systems Analysis
What Is a System?
Why Systems Analysis?
Why Structured Systems Analysis?
Processes and Data
Dataflow Diagram
Entity Relationship Diagram
Normalization
Data Dictionary
Functional Primitives Specification
Balancing the Models

The Medications Domain Workflows and Data Structures
Context Diagram
DFD 0
Workflow Responsibility
Data Model
Conceptual Model Step 1
     One Brand—Many Packs
     One Pack—Many Items
     One Drug—Many Forms and Many Routes
     One Drug Item—Many Ingredients and Strengths
     National Drug Code
     One Ingredient—Many Brands
     One Ingredient—Many Classes
     One Class—Many Ingredients
     One Class—Many Parents and Many Children
     Tall Man Letters
Conceptual Model Step 2
     One Pack—Many Indications
     One Ingredient—Many Contraindications
     Dosing Types
     Intermittent versus Continuous
     Dose Units
     Time Units
     Frequency
     Duration
     SIG
     Precaution
     Not All Concepts Are Entities
Conceptual Model Step 3
     The Patient Is Uniquely Identified
     The Clinician Is Uniquely Identified
     Medication Life Cycle
     One Medication Life Cycle—Multiple Statuses
     One Patient—Many Prescriptions, Orders, Dispensations, and Administrations
     One Clinician—Many Prescriptions, Orders, Dispensations, and Administrations
     One Prescription (Order, Dispensation, Administration)—Many Items
     Not Indicated Is Not Equal to Contraindicated
     The Actual Dose Has a Quantity
     Dosing Regimens
     Actual Dose May Be Different from the Recommended One
     Drug Name and Other Parameters May Change during Medication Life Cycle
     Half Tablets
     Daily Dose versus Maximal Dose
Not All Drug Parameters Are Clinically Relevant            

Prescribe/eRx
Processes
     DFD 1 Prescribe Workflow
          DFD 1.1 Communicate Prescription
          DFD 1.2 Review Patient Data
          DFD 1.3 Select Drug
          DFD 1.4 Select Dose
          DFD 1.5 Consider Formulary
          DFD 1.6 Sign Rx
          Controlled Substances
     Data Elements
Prescription-Related Communications
Patient Medications
Patient Non-Drug-Related Parameters
CDS
PBM
Patient’s Preferred Pharmacies

Order/CPOE
Processes
     DFD 2 Order Workflow
          DFD 2.1 Communicate Order
          DFD 2.2 Review Patient Data
          DFD 2.3 Select Drug
          DFD 2.4 Select Dose
          DFD 2.5 Consider Formulary
          DFD 2.6 Sign Order
     Reuse Considerations
          DFD 2.7 Use Order Set
          DFD 2.8 Reconcile Meds
     Data Elements
          Internal Data Store
          External Actors
          Multiple Destinations for One Drug Communication
          Multiple Physical Measurements
          BMI and BSA
          Conditional and Sequential Complex Orders
          Patient A/D/T Settings Location and Time Frames
          Data Exchange with External Actors

Dispense/ePharmacy
Dispense Workflow
Automated Dispensing Cabinet
Processes
DFD 3 Dispense Workflow
     DFD 3.1 Communicate Dispensation
     DFD 3.2 Review Patient Data
     DFD 3.3 Select Drug
     DFD 3.4 Select Dose/Prepare
     DFD 3.5 Consider Formulary
     DFD 3.6 Dispense/Deliver
     Data Elements

Administer/eMAR
5 Rights
Processes
     DFD 4 Administer Workflow
          Bar Code Medication Administration
          Smart Pumps
          Drug Storage
     DFD 4.1 Communicate Administration
     DFD 4.2 Review Patient Data
     DFD 4.3 Select Drug
     DFD 4.4 Select Dose/Prepare
     DFD 4.5 Interact with Storage
     DFD 4.6 Administer/Sign
          Data Elements
          Calculation of Dosing Parameters for a Continuous Drip

User Interface
Usability
Cognitive Load
Principles of Graphic Excellence
Characteristics of a Clinical Story
Cause and Effect
Titrate to Effect
Parallel Channels of Information
UI Main Elements
Time Axis
Caution: The Direction of Time Axis
Parameters Axis
Caution: Hidden Information
Tabular Versus Graphical Display of Data
Number of Clicks and Data Density
Trends Are Nice, but Where Are the Numbers?
Layers of Information
Review Patient Data: Ambulatory UI
Refill a Medication
Modify a Medication
Prescribe a New Medication
Order Set
Medication Administration
Medication Reconciliation

Clinical Decision Support
What Is CDS?
Types of CDS
Why Is CDS Needed?
Clinical Decision Characteristics
Trustworthy Medical Information
CDS Configuration
CDS Adaptability
CDS—A Binary Classification System
False-Positive versus False-Negative Alerts
Medication Errors
Medication CDS
Dialog Paradigm
Automated CDS Algorithm Outline
Processes
     DFD 5 CDS Workflow
     DFD 5.1 Filter Drug
     DFD 5.2 Adjust Dose
     DFD 5.3 Consider Demographics
          5.3.1 Consider Age
          5.3.2 Consider Gender
          5.3.3 Consider Weight, Height
          5.3.4 Consider Ethnicity
DFD 5.4 Consider Patient Condition
          5.4.1 Consider Indication & EBM
          5.4.2 Consider Allergy and C/I
          5.4.3 Consider Adverse Reaction & Side Effect
          5.4.4 Consider Pregnancy and Lactation
          5.4.5 Consider Drug-Lifestyle
          5.4.6 Consider Drug-Vital
          5.4.7 Consider Drug-Procedure
DFD 5.5 Consider Patient Drugs
          5.5.1 Consider Interaction
          5.5.2 Consider Duplicate Therapy
          5.5.3 Consider Alternative
          5.5.4 Consider Setting
          5.5.5 Consider IV Admixture
DFD 5.6 Consider Lab
     5.6.1 Lab Affect Drug & Dose
     5.6.2 Monitor Lab
     5.6.3 Drug Interfere with Lab
DFD 5.7 Educate
Data Elements
     Temp CDS Drug
     Temp CDS Dose
     Precaution
     Drug Interaction
     IV Admixture
     Dose Adjustment
     Monitor Drug Lab
     Drug Interfere Lab
Barriers to CDS Adoption
Recommendations
CDS and Genomics: Personalized Medicine

Report
Motivation
Types of Reports
Measuring Healthcare Quality
Goals for the Healthcare System
Dimensions of Quality Measures
Evaluating Quality Measures
Organizations Involved in Quality Reports
PQRS and MU Measures
Anatomy of a Quality Measure
Reporting Methods
Medications Reports
Data Warehouse
Data Mining
CDS versus Reports
Processes
     DFD 6 Report Workflow
          DFD 6.1 Report on Single Patient
          DFD 6.2 Report on Multiple Patients
     Data Elements

Interoperability Standards and Vocabularies
Interoperability
Open Systems Interconnection Model
Language and Ontologies
Interfaces
Rocket Science Standards
U.S. Government and MU
Qualities of a Modern Clinical Terminology
Healthcare Standards Organizations
EHR Standards and Vocabularies
Medications Standards and Vocabularies
Processes
     DFD 7 Update/Sync Workflow
     HIE/Regional Health Information Organization/HUB
     Data Elements
          Discrete Data Elements
          Semistructured Documents

Appendix
Acronyms List
Answers to Review Questions

Index

Each chapter includes a Summary, References, and Review Questions

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Author(s)

Biography

Alexander Scarlat, MD is board certified in Anesthesiology. He has practiced medicine for 18 years and holds a degree in Computer Sciences. Dr. Scarlat has a strong background in healthcare informatics, working for more than two decades with vendors in electronic health records R&D and with hospitals implementing healthcare information technology. Fluent in both medical and IT languages, he is a knowledgeable and experienced liaison between clinicians and IT specialists.

Reviews

Finally, here’s a textbook that the market and the industry have been looking for. The author has captured the details of the information flows involved in the EHR while processing an order or prescription from inception to completion. The book should help any clinician or informatics professional understand what’s happening in the process of medication order, dispense, and administer.
Joseph T. Finn, RPh, MBA, Supervisor (WillowRx), Nemours Health Informatics 

... encompasses high-value, high-volume therapeutic transactions of indescribable complexity that touch nearly every licensed professional in a hospital, enrobing drug ordering, dispensing, and administration in sophisticated layers of clinical decision support, caregiver work lists, and back-end charging and continuum of care functions. I am pleased that the topic merits its own formal review and analysis in Dr. Scarlat’s book. I found the user interface chapter immediately useful – in fact, I’m hoping the vendors of my own hospital’s systems take its recommendations to heart.
Mr. HIStalk, Healthcare IT Blogger

The informatics transformation of American Healthcare as a result of the American Recovery and Reinvestment Act (ARRA) Meaningful Use (MU) program is now truly underway, creating an entirely new language and dimension to the practice of medicine. As physicians (and other clinicians) move through MU, past the stage of commercial technology acquisition and implementation, the need for a deeper understanding of the structure AND function of these new knowledge systems is not only necessary but essential. Dr. Scarlat’s comprehensive and logically structured handbook acts as a common sense guide to this new world of informatics that should prove invaluable to the clinician making his/her way past the commercial hype into the realm of true understanding of the systems of medical informatics. Well referenced and comprehensive, this work is strongly recommended to the new meaningful user as well as those that work with and support clinicians in this essential next generation of American Medicine.
William F. Bria MD, CMIO Shriners Hospitals for Children, President of the Board, Association of Medical Directors of Information Systems (AMDIS)

…a thoughtful and well-constructed manual to understanding and incorporating the complex and many-sided aspects of medication concepts into a coherent and logical informational framework. Drawing upon foundational data modeling and structured systems analysis techniques, the extensive use of graphical tools such as workflow, dataflow, and entity relationship diagrams to illustrate medication management processes  provides the IT professional with a clear and accessible entry to this challenging topic. The chapter on medication prescribing is particularly illustrative of the author’s facility for deconstructing complex, intricate medication processes into their granular tasks and activities to show the key interactions and communications among patient, clinician and technologist. I believe both the experienced and novice healthcare informatics practitioner will find Dr. Scarlat’s book to be a welcome and essential addition their toolkit.
—Don Martin, Managing Consultant, Novia Strategies

With the incredible expansion of medication management information technology, both in the hospital and ambulatory environments, the need for a comprehensive reference text was essential. Dr. Scarlat's book fulfills that role and creates a space where clinicians and programmers can share a common knowledge platform to improve and advance the use of medication safety and efficiency in complex EHR systems.
—Karl Matuszewski, MS, PharmD 

...a very useful guide to addressing not only the medication process but many service domains for practice, administration and patient-centered care in the community. The analysis and tools project a deeper understanding of how data are used by senders and receivers and how the capture and storage in appropriate data structures facilitate the data use for clinical decision support, health information exchange and future application with personal healthcare related to knowledge of genetic makeup to diagnose and treat. The critical process of structured system analysis (SSA) is necessary to inductively and deductively view the workflow processes from the point of view of many stakeholders. The SSA process guides open thinking and the data flow diagrams and entity relationship diagrams are types of tools to lead towards better application of data within events, thus better designs and better strategies to deliver care. Data workflow diagrams and the patient-centered process workflows require leveling from high level core practices to minute detail.

This book provides the necessary detail that is often missing in many textbooks. Dr. Scarlat takes the medication process and its interactions between stakeholders (e.g., patient, physician) to detail the interconnectedness necessary for better use of data that goes into and is used from our electronic health records and health information exchanges. Many clinicians and professionals may not appreciate the detail that is necessary to make a better EHR that works for physicians, nurses and pharmacists to more effectively access and use the patient’s information efficiently.

I particularly appreciate Dr. Scarlat’s message about the importance of data dictionaries for the clinician users within data workflow diagrams and entity relationship diagrams. I would agree this resource is to be used by both users and developers as a communication tool and knowledge database to clarify and define the context of terms during the system life cycle: analysis, design, code build, testing, implementation, training and maintenance. The figures and description to analyze the medication process generates thoughtful inclusion of detail such as indications, age bands, and ethnicity which are data components that will support better clinical decisions in the workflow. Genetic personalized healthcare will advance the clinical decisions related to best treatment plan, therefore our EHR systems should continuously evolve to support clinicians by handling the complexity of knowledge and patient information that must be present to make decisions related to age, gender, conditions and genetic makeup.

Dr. Scarlat’s Electronic Health Record: A Systems Analysis of Medications Domain is very useful in health informatics education at university and the HITECH courses within community colleges as well as for any programmers and managers responsible for system analysis and improvements in the design and application of data use.
Jane M. Brokel, PhD, RN, Iowa City, Iowa, September, 2011

Dr. Alexander Scarlat’s Electronic Health Record: a Systems Analysis of the Medications Domain is a welcome and valuable addition to the toolkit for IT professionals and clinicians participating in the design or implementation of EHR systems. As an RN in the healthcare IT field, I appreciate the importance of understanding clinician workflow and the desired future state, particularly in the medication process. Having taught a graduate level overview of information systems class as well, I also understand the challenges some students experience when learning to create entity-relationship diagrams and data flow diagrams. Dr. Scarlat’s easy-to-understand explanations are the most detailed I have seen. This book will be indispensable to students learning system analysis and a valuable adjunct to current professionals as they attempt to represent data and its flow through the EHR system. Since so many of the Stage 1 Meaningful Use objectives pertain to medications (use of CPOE for medication orders, drug-drug and drug-allergy checks, e-prescribing, active medication list, active medication allergy list, clinical decision support rule, drug formulary checks, and medication reconciliation), Dr. Scarlat’s book is especially timely.
Christine Greifzu, RN-BC, MBA, MSIS, Newtown Square, Pennsylvania, September, 2011

What is the ideal medication workflow? Simple – from doctor’s brain to patient’s vein without handwriting, handoffs, or hassle. Dr. Scarlat’s clear explanations empower healthcare professionals with tools that will enhance any IT project … it provides a framework that will enable clinicians to communicate with technologist. I plan to use this book in the BIDMC medication work, which seeks to achieve zero defects, cost reductions, and patient engagement. Both clinicians and IT professionals should find the book to be a valuable resource as they create the reformed healthcare delivery system of the future, beyond Meaningful Use.
From the foreword by John D. Halamka, MD