Section 1.1 Adopt – Assess
Visioning and Strategic Planning—
Including Health Care Homes
(See accompanying Webinar and PowerPoint handouts)
Health information technology (HIT) refers to the broad class of information technology that aids
health care organizations in achieving efficient and effective care delivery. Electronic health record
(EHR) system refers to the specific application of HIT to capture data at the point of care and use it
in making clinical decisions. All HIT encompasses software applications and hardware, as well as
requisite people, policies, and processes.
Many clinics already have a practice management system (PMS). Some are able to connect with
laboratories, imaging centers, hospitals, and other sources of clinical data. An increasing number of
providers have started using standalone e-prescribing. In some cases, the sources of clinical data may
be merely fax, email, or print files that can be downloaded from a provider portal. Practice guidelines
and other evidence-based medical research data frequently are in paper form or images retrieved
from the Web. Data from all of these sources—including data you generate about patients—needs to
be available in a manner that allows computer software to process it into useful information.
Minnesota Health Care Homes
Providers can use the functions and capabilities of their EHR system to help deliver care as a health
care home. A health care home (HCH), also known as a medical home, is an approach to health care
in which primary care providers, families, and patients work in partnership to improve health
outcomes and quality of life. To be certified as a health care home in Minnesota, the Minnesota
Department of Health requires clinics to meet criteria related to the five following standards:
 Access and communication: Facilitate consistent communication among the HCH, the
patient and family (“participant”), and other providers to provide the participant with
continuous access to their HCH.
 Participant registry and tracking participant care activity: Use an electronic, searchable
registry that enables the HCH to identify gaps in patient care and manage health care
services.
 Care coordination: Include care coordination that focuses on patient and family-centered
care.
 Care plan: Include a care plan for selected patients with a chronic or complex condition that
involves the patient and the patient’s family in care planning.
 Performance reporting and quality improvement: Reflect continuous improvement in the
quality of the patient’s experience, health outcomes, and cost-effectiveness of services.
As you plan your EHR selection, consider the capabilities and functions that support the health care
home standards, including:
 Storing and retrieving patient information, both clinical and other pertinent information (i.e.,
cultural background, racial heritage, primary language, values, beliefs, and preferred method
of communication).
 Leveraging communication and interoperability capabilities to facilitate care coordination
between the patient, the patient’s family, other providers involved in the patient’s care and
other organizations (pharmacies, testing labs, etc.).
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 1
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Using data to develop individualized care plans that guide and educate patients and their
families about the risks, benefits, and likely outcomes of available health care options.
Demonstrating data reporting and analysis capabilities that enable performance reporting and
tracking of key quality metrics.
Computing Components that Comprise an EHR
When acquiring an EHR, what you are actually getting is a special kind of database, called a clinical
data repository, and software to enable you to capture, retrieve, and have the data processed with
evidence-based guidance. Depending on what other information systems or sources of data you may
have, you may need interfaces or other tools to help you retrieve the data and put it into the
repository. Some of the data that go into the repository will be discrete, or structured, data, meaning
each data variable is selected by the clinician to represent clinical findings. These data are encoded
by the computer and able to be processed using clinical decision support software. Other data may
come to you as digital images of documents, print files, voice files, email, fax, Web pages, and
clinical pictures from picture archiving and communication systems (PACS). These images or parts
of images can be retrieved for viewing (or listening) and can have electronic signatures appended to
them, but individual data recorded in them generally are not able to be processed. The computer
cannot create a graph of lab results directly from print files or perform drug-lab checking or other
clinical decision support processing on images of documents. The goal of most EHRs is to capture as
much discrete data as possible. Entering data via templates at the point of care directly supplies the
reminders and alerts that create the value in using EHRs.
Data Processing in an EHR
Data must also be archived, so storage functionality is part of what is acquired through an EHR. As
the EHR becomes a mission critical system with no backup dictation files or printed copies of
documents that are filed, you not only need to have back up storage, but redundant processing as
well. Some clinics invest in dual processing or mirrored servers to reduce the risk of downtime.
Various input devices, network hardware and software, and other equipment are also part of an EHR.
Finally, some means to generate special reports is needed. Many EHRs come with report writer
software, but this software is generally used to process relatively small amounts of data into a report,
such as how many patients need to be called this month for follow-up visits, or which patients
received a specific medication that is now being recalled. For more sophisticated analysis of large
amounts of data in your EHR, you may need a different kind of database, called a clinical data
warehouse. Data from the clinical data repository are extracted and placed into the warehouse for
analysis. This type of database has been optimized for performing data mining and special other
kinds of analysis. Because it is separate from the clinical data repository used for day-to-day clinical
transactions, organizations experience no degradation of performance on the daily functioning of the
EHR when a warehouse is used.
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 2
Conceptual Model of EHR
The following diagram illustrates the components of an EHR system:
Software Applications
The term HIT covers many types of information system applications. In general, these include:
1. Financial and administrative systems include at a minimum, patient registration-admission,
discharge, transfer (R-ADT) and billing systems. R-ADT includes the ability to maintain an
index to all patients you have treated; document their demographic, contact, and insurance
information; and manage the census of current patients, and other associated functions.
Billing systems will support charge capture, accounts receivable, collections, general ledger,
accounts payable, etc.
2. Clinical information systems support health care professionals in direct care delivery. When
these clinical systems work together, they are often described as an electronic health record
system. Clinical information systems in clinics may be all inclusive in a single suite of
functions or may be several distinct modules, which may not necessarily be implemented in a
specific sequence. A suite of applications for documentation may include assessments,
clinical pathways, vital signs documentation, and workflow support. More sophisticated
clinical systems typically include computerized provider order entry (CPOE) Although
clinical decision support (CDS) is generally included in CPOE applications as relating to
medication management, more sophisticated CDS and point-of-care (POC) charting are
applications that frequently are implemented after most others. Many of the more
sophisticated systems depend on connectivity with administrative systems and with external
sources of information. For example, scheduling and other alerts may impact CPOE; lab
results and other information may need to come from a lab, hospital, another provider office,
durable medical equipment supplier, etc.
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 3
3. Clinical data repository (CDR) is the means by which data from the various applications
come together for processing into clinical decision support. A CDR is essentially a database
that is optimized to manage transactions for a given patient. For example, a CDR may enable
developing a graph showing a patient’s vital signs in comparison to the administration of a
new medication.
4. Clinical decision support is greatly enabled by a CDR. For example, when a nurse goes to
administer a drug for a given patient, the ordered drug is compared with drug knowledge
information and the patient’s lab results. (The patient’s lab results have been entered into the
CDR by the laboratory information system.) If the drug being ordered is contraindicated for
poor liver function and if the lab results for the specific patient for whom the drug is ordered
indicate poor liver function, an alert will display stating a potential contraindication. The
nurse would then need to take appropriate action to have the drug order changed.
Some EHR vendors fully integrate their clinical components with a data repository. Some
clinics acquire all their applications from a single vendor that provides a well-integrated
solution. If you have to buy different applications from different vendors, you will lack such
strong integration. In this case, you may find you will need to manage multiple interfaces
between the applications. You can buy a separate clinical data repository into which all data
from the disparate applications can be directed. Although a clinical data repository is
primarily designed to integrate discrete data, repositories can also include pointers to
documents and images.
5. Electronic document management system (EDMS) is often used where a bridging strategy
is needed to achieve a paperless environment during the time clinical systems are being
implemented. EDMS allows document scanning and indexing to archive documents until all
data collection aspects of the health record are automated. Later EDMS supplements the EHR
when external documents are received in paper or digital form (e.g., email, e-fax, or digital
dictation).
6. Portals are another important application to connect different providers to one another, such
as physicians to an area hospital or your clinic to various community resources, contractors,
etc. In general, a portal is a Web interface that serves as a secure door to related sets of data
and services. For example, a physician from another office location may gain access to the
clinic’s EHR and obtain patient vital signs and sign orders. Patient portals allow a patient or
family member to complete intake forms and perform other functions, including potentially
managing a personal health record (PHR). Most recently, point-to-point portals are beginning
to be replaced by health information exchange (HIE) services.
7. Data warehouse is also a database, but one that has been optimized to collect and manage
data on which complex queries and analysis, such as data mining, can be performed. Such
databases may also be called translational or analytical databases. While you can do some
analysis and reporting from any database, including the databases in individual applications
or the CDR, very complex analyses on large quantities of data will significantly slow down
the system in performing its operations. Most health care organizations contribute data to
external data warehouses, such those as held by the Centers for Medicare & Medicaid
Services (CMS), their corporation, or various other payers, quality registries, etc.
8. Telehealth, personal health records, and health information exchange services are yet
other forms of HIT which are rapidly evolving and being adopted by large and small health
care delivery organizations. Clinics can use such services for remote reading of x-rays. Many
small and rural communities have extensive telehealth implementations, connecting to their
closest tertiary care facility or to reach out to very remote areas for patient monitoring and to
supplement care delivery. Some clinics may already be using a form of telehealth to connect
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 4
personnel in the field with a base station. Home health agencies will certainly find using a
referral management system that reaches out to a variety of other organizations to be
advantageous. PHRs are just starting to be recognized as important adjuncts to health care
delivery. CMS is developing a PHR system for Medicare beneficiaries to keep track of their
medications. Several health plans (including a number of Blue Cross Blue Shield plans) also
are doing this. The US Department of Veterans Affairs has created myHealtheVet, a PHR
system for veterans. Some vendors are supplying various forms of PHRs, from client-friendly
summaries of care to access to lab results and even self-administered medical history systems
that reduce the documentation burden for providers. Many families of chronically ill clients
or elderly clients in nursing homes find that PHR is the only way they can keep track of all
the medications, physician visits, etc.
9. Middleware is a final type of software that is important to include in HIT. While often not a
concern to end users, various report writing applications, presentation layer utilities,
interfaces, database management systems, and other software is required to make all of the
end-user applications work.
Hardware
Information system applications require computer hardware. Hardware includes the various
processing devices and servers to run the applications. If you are using a hosted application,
application service provider (ASP), software as a service (SaaS), or an on-demand application, you
will not need to acquire servers in house. In these cases the vendor maintains these and you pay a
monthly fee for their use. Data entry requires various input devices (e.g., desktop computers, tablets,
personal data assistants [PDAs], speech microphones, etc.) and output devices (monitors, display
screens, printers, fax machines, speakers, etc.). They are all hardware elements you will need to
purchase. Data also must be archived, so storage functionality is needed. This may be part of your
remote hosting or something you need in-house. This may include various forms of storage devices,
each with their associated media (such as magnetic disks, optical disks, flash drives, etc.). Various
storage area networks and storage management systems are used to manage large volumes of
archived data. As the HIT becomes more mission critical, backup storage and redundant processing
devices are necessary, often with middleware applications to provide automatic failover. All of these
devices must connect to one another in a network, so various network devices and their associated
media (including various forms of cable for wired networks and wireless network capability) must be
acquired and maintained. A clinic’s network capabilities are critical in order to connect with all staff
working remotely. You must have sufficient speed and bandwidth, and have some form of
redundancy and backup capability, in the event your primary network connection fails.
Conceptual Model of HIT and EHR Technology
The diagram below illustrates the many HIT components described. While this diagram may seem
overwhelming, recognize that as clinical computing requirements are addressed, the complexity of
applications, technology, and operational elements to support them increase in complexity, as do the
capabilities for use of the resultant information and knowledge.
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 5
More information on health care homes is available at
http://www.health.state.mn.us/healthreform/homes/index.html.
This tool was adapted from the Health Information Technology Toolkit for Physician Offices by
Stratis Health through a contract with the Minnesota Academy of Pediatric Foundation, for the
Minnesota Department of Health (MDH) Health Care Home Resources and Education Project.
The full Health Information Technology Toolkit for Physician Offices is available at
http://www.stratishealth.org/HIT_Toolkit_clinics.
Copyright © 2010, Margret\A Consulting, LLC. Used with permission of author.
For support using the toolkit
Stratis Health  Health Information Technology Services
952-854-3306  info@stratishealth.org
www.stratishealth.org
Section 1.1 Adopt – Assess – Visioning and Strategic Planning, Including Health Care Homes - 6