Electronic Health Record: A Systems Analysis of the Medications Domain, 1st Edition (Hardback) book cover

Electronic Health Record

A Systems Analysis of the Medications Domain, 1st Edition

By Alexander Scarlat, MD

Productivity Press

399 pages | 176 B/W Illus.

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pub: 2012-03-22
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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

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

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

About the Author

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.

Subject Categories

BISAC Subject Codes/Headings:
BUS041000
BUSINESS & ECONOMICS / Management
BUS070080
BUSINESS & ECONOMICS / Industries / Service Industries
COM032000
COMPUTERS / Information Technology
MED002000
MEDICAL / Administration