Electronic Health Record (EHR)
Electronic health record (HER) 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. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter--as well as supporting other care-related activities directly or indirectly via interface--including evidence-based decision support, quality management, and outcomes reporting.
Healthcare Information and Management Systems (HIIMSS). Retrieved from http://www.himss.org/
Electronic Medical Record (EMR)
The electronic medical record (EMR) is the term given to the collection of information on a patient-specific basis that is stored in an electronic format.
The EMR is a collection of patient-specific information that is captured in an electronic format. While we often associate this record with hospital patients, the EMR is a part of the outpatient setting as well. The concept of the EMR has existed for many years, and there has always been an assumption that it would mirror in many ways the information stored in paper records. However, this ideal has not reached fruition in most settings and now many organizations have adopted partial EMRs as a way of moving this process along.
For instance, it is quite easy to enter, store, and retrieve information about prescriptions and laboratory tests but difficult to do for patient signs and symptoms or medical histories. Some parts of the medical record are the sole purview of physicians and they are reluctant to believe their assessments can be codified, something that is required for moving into the electronic world. To date, we have seen some parts of a patient's medical record become electronic, but other parts still exist on paper and can be accessed only by hand.
ROLE OF THE EMR IN A POPULATION HEALTH MANAGEMENT PROGRAM
One view of population health management (see below) considers the EMR as a foundation upon which effective population health management programs are developed. In this conceptual model, the EMR is an integral component of enrollment, interventions, and monitoring (including outcomes evaluation).
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The EMR is seen by some as a critical part of predictive modeling because information housed in the medical record could be added to the mathematical and artificial intelligence tools that are used to develop predictive models. If the information is not available electronically, it is available neither for model development nor for patient identification. In addition, if EMRs were more available they could also serve as a means, using rules, for patient identification and enrollment in disease management programs.
The U.S. government made a commitment in 2004 to support development of a computerized nationwide system of patient records that links hospitals, pharmacies, and other medical providers. Multiple aims are driving this effort—to improve health care, reduce errors, and lower costs.
EMRs are likely to become an industry standard for hospitals and clinics throughout the United States. The Health Insurance Portability and Accountability Act (HIPPA) applies to EMRs, and provides an increased level of security not available with paper or hard-copy records. Smartcards are also available on which EMR information can be carried by the individual patient and read by a reader at the provider’s office.
POPULATION HEALTH MANAGEMENT-RELATED ISSUES
There is a fundamental conceptual difference between an EMR that is provider-centric in that it simply automates the chart room in a typical hospital or doctor’s office and an EMR that is patient-centric in the sense that the record is attached to the patient as she/he moves from medical provider to medical provider. The latter was essentially impossible to maintain in a paper-based system, but a variety of technologies are converging in ways that make it increasingly feasible today. When patients receive care from a variety of sources, including some that provide population health management services, a patient-centric EMR has important advantages over provider-centric information management.
Some online population health management services are provided directly to the consumer and the physician. Physicians can enroll their patients, who can then routinely enter their signs and symptoms into the proprietary, password-protected database. A personalized and customizable portfolio is created for the patient. It includes things such as coaching emails, health education, a health diary and reminders for important actions (such as getting a flu shot), a health data archive, and the member’s EMR.
Apcar, D. “LifeMasters debuts first Internet-based interactive medical-monitoring system.” LifeMasters. Press Release. 12 Oct. 1999. Retrieved from http://www.lifemasters.com/Corporate/abou/prInteractiveMonitoring.asp
Benedetto, R. “Bush advocates electronic medical record-keeping.” USA Today. 27 May 2004. Retrieved from http://www.usatoday.com/news/politicselections/nation/president/2004-05-27-bush-medical-records_x.htm
“Electronic medical records.” Business Ranks. Retrieved from http://www.businessranks.com/electronic-medical-records.htm
“HHS announces grant to help implement electronic health records in family practice medicine.” Centers for Medicare and Medicaid Services. US Department of Health and Human Services. Retrieved from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1075
Eligibility and Eligibility Criteria
Eligibility criteria are requirements for selection (or deselection) for benefit coverage in health plan or for employer sponsored wellness or care management programs, and measurement of the effect of a wellness or care management intervention.
See also population.
Population is a term used to refer to the aggregate or totality of all individuals who conform to a set of specifications. Organizations define eligibility criteria differently, depending on the specific population:
Health plan/group healthcare benefit eligible population: Eligible members (i.e., covered or insured members) for benefit coverage in the health plan or for an employer sponsored plan. Rules for eligibility coverage are typically well-defined in health plan and/or employer sponsored benefit plan contracts.
Program Eligible Population: Individuals meeting benefit coverage eligibility defined above and plan eligibility requirements for wellness or care management programs. Rules for program eligibility are typically well-defined in health plan and/or employer sponsored benefit plan coverage descriptions.
Identified Population for specific programs: Programeligible members who are identified as meeting wellness or care management program identification criteria.
Targeted Population: Subset of identified population who meet requirements for program qualifications and are targeted for wellness or care management program intervention.
Care Continuum Alliance. (2010). Outcomes guidelines report, vol. 5. Washington, DC: Care Continuum Alliance.
(Terms Associated with) Employee Productivity
Absenteeism is the act of physical absence from the workplace on the part of an employee. Absenteeism generally applies to the situation in which an employee is frequently or chronically absent (often as a result of a health condition) rather than infrequent or random absence. Absenteeism is often addressed through progressively stricter disciplinary measures that can result in termination of the individual's employment, as determined by the organization’s attendance policy.
Presenteeism is a term used to describe a situation in which an employee is physically at work but impaired by health problems and not performing to optimal productivity while at work.
The Bureau of Labor Statistics defines productivity as: “…the value of goods and services produced in a period of time, divided by the hours of labor used to produce them.”
Productivity is a measure of output from a production process.
Generally, disability refers to any long- or short-term reduction of a person’s capacity for activity as a result of an acute, chronic, physical, mental, or emotional condition. A strict definition of disability may be found in the Social Security law and is based on a combination of physical condition and inability to work.
The term disability (as defined in Section 223 of the Social Security Act) means –
- “Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months; or
- In the case of an individual who has attained the age of 55 and is blind (within the meaning of “blindness” as defined in section 216(i)(1)), inability by reason of such blindness to engage in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he has previously engaged with some regularity and over a substantial period of time.”
An individual is disabled under Social Security rules (and eligible for benefits) if the individual cannot do work that the individual did before and is unable to adjust to other work because of a medical condition(s). Disability must also last or be expected to last for at least 1 year or to result in death. Employers, workers’ compensation programs, and private insurers may apply different standards of incapacity in determining disability. For example, some programs may apply the concept of partial disability when an individual is impaired but able to perform some (but not all) duties, and a partial benefit may be payable.
Burton, W., et al. (2002). The economic burden of lost productivity due to migraine headache: A specific worksite analysis. Journal of Occupational Environmental Medicine, 44, 523-529.
“Disabilities/Limitations.” National Center for Health Statistics. U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/nchs/fastats/disable.htm
Duncan, I., and Crane, J. (1996). “Measuring the Total Cost of Lost Time.” Managing Workers’ Compensation.
Kraus, L., Stoddard, S. and, Gilmartin, D. (1996). Chartbook on disability in the U.S. access to disability data. U.S. National Institute on Disability and Rehabilitation Research. Retrieved from http://www.infouse.com/disabilitydata/disability/appendices_surveys.php#disability
Social Security Online. U.S. Social Security Administration. Retrieved from http://www.ssa.gov/
Passive engagement strategies do not require active member consent, or acknowledgement of program participation, and there are typically no defined action requirements on the part of the participant.
Active engagement strategies do require active member consent, or acknowledgement of program participation, and defined action on the part of the participant.
COACHING ENGAGED POPULATION
The Initially Engaged Population is a subset of enrolled members who are working or have worked directly with a nurse or health coach in a chronic care management or health improvement program within the reporting period.
- Members are interacting with the health professional in reference to their health improvement plan with “bidirectional interaction” meaning an exchange between the health professional and the member in both directions.
- A participant is considered initially engaged if she has completed a clinical and lifestyle behavioral risk assessment that includes a mutually agreed upon plan of care with goals and at least one follow-up coaching discussion within 90 days.
- Only real-time human interaction is included in this definition of initial engagement, regardless of the venue used for discussion.
See also population.
Outcomes Guidelines Report, vol. 5
Individuals enrolled in a wellness or care management program. Population is a term used to refer to the aggregate or totality of all individuals who conform to a set of specifications.
Types of enrollment processes include:
- Opt-in – Enrolled: members consenting to participate in the program.
- Opt-out – Enrolled: targeted population considered enrolled, unless individual takes action to disenroll.
See also population.
Electronic prescribing, or e-prescribing, is computer technology in which physicians use handheld or personal computer devices to review drug and formulary coverage and transmit prescriptions to a printer, EMR or pharmacy. E-prescribing software can be integrated with existing clinical information systems to allow access to patient-specific information to screen for drug interactions and allergies.
Health information technology. Agency for Healthcare Research and Quality (AHRQ) National Resource Center. Retrieved from http://healthit.ahrq.gov/portal/server.pt?open=512&objID=653&PageID=5583&cached=false&mode=2
Equivalence refers to the extent to which all factors (measured or unmeasured) might affect an outcome in addition to the population health management intervention. Equivalence indicates that all factors are the same in both the intervention and reference groups.
See actuarial adjustment.
Wilson, T., and MacDowell, M. (Fall 2003). A framework for assessing causality in disease management. Disease Management, 6(3), 143-158.
Evidence-based medicine refers to the application of the best available evidence to create medical, population health management, or other public health policies and practices. Evidence is drawn from many sources including epidemiologic, medical, economic, demographic, sociologic, and other research.
Evidence-based practices also focus on minimizing risks and maximizing benefits to patients.
Evidence-based practices and practice guidelines are integral to population health management programs. These are described as recommendations or guidelines that are based on valid scientifically proven outcomes.
The underlying research for evidence-based medicine is typically developed with input from the medical profession’s peer review and published in scientific journals. URAC notes that evidence-based information can be used to develop protocols, pathways, standards of care or clinical practice guidelines, and related educational materials.
Sackett, D., et al. (1996). Evidence-based medicine: What it is and what it isn’t. British Medical Journal, 312, 71-2.
URAC Home Page. URAC. Retrieved from http://www.urac.org
The intentional introduction of an intervention to a population (for example with a population health management or educational program) makes a study design experimental. Experimental studies (e.g., a randomized control study) are often the most rigorous, use matched reference or control groups, and meet scientific standards for accuracy and proof.
See study design.
In population health management, exposure has two meanings.
- A patient is exposed to an intervention by being a member of a group selected for intervention or a program.
- For measurement or actuarial calculations, exposure has a meaning synonymous with denominator and refers to the entire group eligible for an intervention or included in a study.
See also enrollment.
Benjamin, B., and Pollard, J. (1980). The analysis of mortality and other actuarial statistics (2nd ed.). Portsmouth, NH: Heinemann.