Santa Clara County Grand Jury
• 2006-2007
2006-2007 Santa Clara County Civil Grand Jury Report Electronic Medical Records:
⚠️ Translation Notice: This content has been automatically translated. The original English text is the official version. Translation may contain errors.
⚠️ Este contenido ha sido traducido automáticamente. El texto original en inglés es la versión oficial. La traducción puede contener errores.
Findings and Recommendations 6 findings
F1
HHS has not published a formal definition that defines EMR components, deliverables, and costs.
Related Recommendations (1)
R1
Prepare a formal definition of EMR, including its purpose, its components, and specific deliverables. The definition needs to contain a definitive list of all of the components to be included in EMR.
F2
A member of the BOS was unable to convey to the Grand Jury that they understand what the functional components of EMR are that HHS is going to deliver.
Related Recommendations (1)
R2
See Recommendation 1.
F3
Custody Health, which is expected to be a primary user of EMR, has had minimal input and involvement in the definition and planning of this project.
Related Recommendations (1)
R3
Involve Custody Health as an equal partner in the planning and implementation of EMR.
F4
The total cost of EMR has not been determined. The $8 million A-EMR project currently being implemented may represent only a small part of the true cost of a countywide EMR system.
Related Recommendations (1)
R4
Prepare a financial projection of the total implementation and ongoing maintenance cost of EMR broken down by its components.
F5
There is a lack of communication of HHS goals and strategies for EMR to those who will implement and be affected by the system. System features are being developed without consulting with those who will use them.
Related Recommendations (1)
R5
Develop a communication plan that updates project goals and status monthly to all entities and levels of HHS. Plan meetings with staff to discuss plans and status, and to prepare and deliver appropriate training.
F6
Implementation of this system is expected to draw resistance from some potential users. 8
Related Recommendations (1)
R6
Page 9
Mandate use of EMR. Appendix A: Verbatim email exchange (names excised) between a Grand Juror and a senior management official at HHS. An example of HHS unable to provide a specific, clear definition of an EMR system. Grand Juror: When we first met, [name] asked us for our definition of EMR but we have never gotten a definition from you what HHS uses as a working definition of EMR. I see a lot of projects, applications and diagrams in the Strategic Plan that seem to relate to an EMR system, but can't find a vision statement or goal -- "EMR serves this purpose and consists of these functions and data. When all of that is in place, we will have an EMR system." If there is a definition of EMR in the Strategic Plan, please reference it for me. If you have a definition in another document or taped to the wall somewhere, let me know and I can come pick it up. If you do not have a definition of EMR, let me know that too. HHS response: To clarify, a good starting point may be generally accepted definitions in the industry. The Health Information Management Systems Society (HIMSS) defines EMR and EHR as follows: HIMSS EHR = "The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports." HIMSS EMR = "EMR definition — An EMR is electronically originated and maintained clinical health information, derived from multiple sources, about an individual’s lifetime health status and health care. An EMR is supported by clinical decision systems and replaces the paper medical record as the primary source of patient information." As is evident, there is overlap and the A-EMR emphasizes only the Ambulatory Electronic Medical Record based on the patients [sic] encounter in the ambulatory care setting at this time. This means that the focus of this electronic record differs from a more global perspective. The HER [sic], on the other hand, emphasizes the more “longitudinal” aspects of the patient record and is more broad in its scope of gathering clinical data from multiple systems and contributing to a repository of this data, the Lifetime Clinical Record, which has been discussed and has been demonstrated to the Civil Grand Jury. Appendix B: Function Lists SCVHHS Presentation The Electronic Medical Record: SCVMC’s Road to the Electronic Health Record (May 2006) – (1) Major Systems Investments VMC and Departments: “The missing piece of the puzzle is the A-EMR” • Core Health Information System (Siemens) • Cardiology (Heartlab) • Enterprise Wide Scheduling (GE) • Diagnostic Imaging and PACS (Siemens and Agfa) • Emergency Department (Wellsoft) • Clinical Laboratory and Pathology (Misys and CoPath) • Medical Records (SoftMed) • Nutrition and Food System (CBORD) • Perioperative Services (SIS) • Renal Care (CyberRen) • Physical Medicine & Rehabilitation (MediServe) • Respiratory Care System (MediServe) • Managed Care (Siement/Perot) (2) What Does the Future Hold? • Rules-based Computerized Provider Order Entry (CPOE) • Medication Administration Checking • Automated Vital Signs • Computerized Patient Assessments • Patient Safety Bar Code • Inpatient EMR • Expansion of Wireless, Mobile Computing and Secure Communications 11 Appendix B: Function Lists - continued Kurt Salmon Associates Santa Clara Valley Health & Hospital System Information Technology Strategic Plan (February 2006) – (3) Diagram “The CDR/EMR/EHR Database Continuum” (p II-36) (cid:131) Electronic Health Record • Computerized Patient Record (CPR/EMR) • Clinical Data Repository (CDR) • CPOE • Order Communication • Results Retrieval • Clinical Documentation • Vital Signs & I&Os • MAR • Clinical Decision Support • Critical Care • Ambulatory Electronic Medical Record • Emergency Department • Home Health • Acute Care • Patient’s Personal Data (4) Diagram “The EMR Ambulatory Environment” (p II-37) (cid:131) Clinical Care Processes (EMR) • Workflow Management • Patient Summary • Chart/Results Review • Encounter Documentation • Order Entry • Clinical Decision Support • Medication Management • Health Maintenance • Disease Management • Immunization Record • Digital Imaging • Patient Education • Phone Notes • Clinical Messaging • Remote Access • Personal Health Record • Dictation/Transcription • Document Imaging • Tools for Reporting 12 Appendix B: Function Lists - continued (5) NextGen Functions & Module List – Base functions in NextGen A-EMR system for limited release in Spring 2008 • Patient Registry • Electronic Chart (EMR) • Workflow Management • Electronic Superbill • Image Management • Coding Optimization • Follow Up / Recall Tracking • Lab Module • Fax Capability • Prescription Generation • Graphing • Advance Security • Enterprise Data Sharing • Template Editor • Knowledge Base • Medication Module • Interface Engine • Provider Approval Queue • Allergy Module • Family Unit Module • First Data Drug Database • NextGen EMR RTF Monitor • NextGen OPTIK User License • NextGen Patient Education • NextGen Edits • InfoScan Formulary Database • ACP PIER Content • Diagnosis & Procedure Code Tables • Crystal Reports 13 Appendix C: The EMR Environment Santa Clara Valley Health & Hospital System Information Technology Strategic Plan (February 2006) Kurt Salmon Associates 14 Bibliography Barry, Maryann. Letter to Joyce Wing, Business IP Strategic Planner, Information Services, “Technology Request” (for consultant to perform Business Process Re- Engineering study), January 22, 2001. CTG HealthCare Solutions. Prepared for: Santa Clara Valley Medical Center, Current State Descriptions & Current State Workflows, September 25, 2006 through October 10, 2006. Cutland, Laura. County dismisses indictment of its health record system, June 10, 2005. http://www.bizjournals.com/sanjose/stories/2005/06/13/newscolumn1.html (accessed June 14, 2007) Health Level Seven, Inc. Electronic Health Record-System Functional Model, Release 1, February 2007. Johnson, Sherry. Memorandum to Wendy Mena, Santa Clara County Information Services Department, “Request for access to the warrant information in CJIC”, February 17, 2006. Kurt Salmon Associates. Santa Clara Valley Health & Hospital System Information Technology Strategic Plan, February 2006. Lopez, Kaci R. Memorandum to George W. Kennedy, District Attorney, “Custody Health Services Requests for Expanded CJIC Access and Electronic Interface with CJIC”, December 6, 2006. Lopez, Kaci R. Memorandum to Chair, CJIC Steering Committee, “Custody Health Services(CHS), a Department of the Health and Hospital System (HHS) 1) Request for Authorizaiton for Existing CJIC Access; 2) CHS PALS Program Request for Access to CJIC Warrant Screen”, February 9, 2007. Medical Records Institute. Medical Records Institute’s Eighth Annual Survey of Electronic Health Record Trends and Usage for 2006, June 2006. National Institutes of Health, National Center for Research Resources. Electronic Health Records Overview, April 2006. Santa Clara County 2004-2005 Civil Grand Jury Final Report. Santa Clara County Electronic Healthcare Records – The Time is Now, May 25, 2005. Santa Clara County Information Technology Executive Committee. Executive Summary Cover Sheet for Children’s Shelter Custody Health Services Correctional Medical Management System, March 2002. Bibliography - continued Santa Clara County, Procurement Department, Request for Proposal #206 for Jail Medical Information Management System (JMIMS), January 31, 2005. Santa Clara Valley Health & Hospital System. CSCHS Medical Information Systems Upgrade Project, September 30, 2006. Santa Clara Valley Health & Hospital System. Memorandum to Wendy Mena, Santa Clara County Information Services Department, “Request for approval to utilize CJIC Inmate/patient demographic data in the PCSI Pharmacy System,” September 11, 2006. Santa Clara Valley Health & Hospital System. Memorandum to Wendy Mena, Santa Clara County Information Services Department, “Request for approval to utilize CJIC Inmate/patient demographic data in the Ambulatory Electronic Medical Record (AEMR) System,” September 11, 2006. Santa Clara Valley Health & Hospital System, Acting Executive Director. Presentation to BOS titled “Various Actions Related to Siemens Contract Term, Component Termination Amendments and Salary Ordinance Additions,” September 26, 2006. Santa Clara Valley Health & Hospital System, Acting Executive Director. Presentation to BOS titled “Virtual Clinical Technology Tour,” September 2006. Santa Clara Valley Health & Hospital System, Acting Executive Director. Presentation to Health & Hospital Committee titled “Presentation on Information Technology and Health Care,” May 5, 2006. Santa Clara Valley Health & Hospital System, Executive Director. Response to SCC Civil Grand Jury Report “Santa Clara County Electronic Healthcare Records – The Time is Now,” July 25, 2005. Santa Clara Valley Health & Hospital System, Children’s Shelter & Adult Custody Health Services. JMIMS Systems Requirements, March 5, 2004. Santa Clara Valley Health & Hospital System, Children’s Shelter & Adult Custody Health Services. JMIMS Project Charter, March 5, 2004. Santa Clara Valley Health & Hospital System, Information Services Department. A-EMR Project Organization—Teams, Rev April 11, 2007. Santa Clara Valley Health & Hospital System, Information Services Department. A-EMR Project Roles & Responsibilities, October 2, 2006. Bibliography - continued Santa Clara Valley Health & Hospital System, Information Services Department. Information Services Annual Report, June 2006. Santa Clara Valley Health & Hospital System, Information Services Department. NextGen Functions & Module List, September 2006. Santa Clara Valley Health & Hospital System, Information Services Department. Santa Clara Valley Medical Center A-EMR Ambulatory Electronic Medical Record, April 2007. Santa Clara Valley Health & Hospital System, Information Services Department. SCVHHS NextGen A-EMR Workplan, March 19, 2007 (Revision Date: May 2, 2007). Interviews September 18, 2006 Santa Clara Valley Health & Hospital System official. November 15, 2006 Santa Clara Valley Health & Hospital System officials. January 19, 2007 Santa Clara Valley Health & Hospital System officials. March 7, 2007 Santa Clara Valley Health & Hospital System officials. March 12, 2007 Santa Clara Valley Health & Hospital System officials. March 26, 2007 Santa Clara Valley Health & Hospital System officials. April 1, 2007 Santa Clara Valley Health & Hospital System Valley Health Clinic staff. April 2, 2007 Santa Clara Valley Health & Hospital System Custody Health officials. April 9, 2007 Santa Clara Valley Health & Hospital System Valley Health Clinic staff. April 11, 2007 Santa Clara Valley Health & Hospital System Custody Health official. April 16, 2007 Santa Clara Valley Health & Hospital System Valley Health Clinic staff. April 24, 2007 Santa Clara Valley Health & Hospital System Custody Health official. April 25, 2007 Santa Clara Valley Health & Hospital System Custody Health official. May 4, 2007 Santa Clara Valley Health & Hospital System official. May 7, 2007 Santa Clara County District Attorney’s Office official. May 23, 2007 Santa Clara Valley Health & Hospital System Custody Health official. Santa Clara Valley Health & Hospital System official. May 31, 2007 Member of Santa Clara County Board of Supervisors. PASSED and ADOPTED by the Santa Clara County Civil Grand Jury on this 19th day of June 2007. Ronald R. Layman Foreperson David M. Burnham Foreperson Pro tem Kathryn C. Philp Secretary 19
Conclusions 1
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CL1 Page 7HHS clearly has a very complex task to manage. There is no single vendor or application that addresses all aspects of healthcare delivery related to the EMR. Healthcare delivery applications include patient scheduling and billing, patient-physician encounters, prescription ordering, medical tests and test results, managing the care giving environment, and numerous other activities. All of these functions overlap and interact, which adds another layer of complexity of data integration. However, EMR is a concept that creates expectations in decision-makers and planners as well as healthcare workers who use computer systems in their work. It is incumbent on HHS to define EMR in order to address those expectations. The absence of written deliverables and the lack of education of potential users and decision-makers create an image of EMR lacking substance. The Grand Jury recommends that, after input from various user groups, HHS prepare and publish a definition of EMR so that everyone can understand its mission. The Grand Jury also recommends that HHS develop a method of communicating regularly and consistently with all decision-makers and users about goals and progress on its path to an EMR. 7