Assignment on hospital records, stores and inventory.

Submitted by:
Rohini Pradhan
Roll no. 06
MHA SEM 3

Questions:
1) What is ICD, explain?
2) Explain EMR..what are the challenges in its implementation?

Ans 1) . ICD
Introduction
A classification of diseases may be defined as a system of categories to
which morbid entities are assigned according to established criteria.
There are many possible axes of classification and the one selected will
depend upon the use to be made of the statistics to be compiled. A
statistical classification of diseases must encompass the entire range of
morbid conditions within a manageable number of categories.

The volumes of the Tenth Revision of the International Statistical

Classification of Diseases and Related Health Problems (ICD-10) contains
guidelines for recording and coding, together with much new material
on practical aspects of the classifications use, as well as an outline of the
historical background to the classification. The material is presented as a
separate volume for ease of handling when reference needs to be made
at the same time to the classification (Volume 1) and the instructions for
its use. Detailed instructions on the use of the Alphabetical Index are
contained in the introduction to Volume 3.
 The manual provides a basic description of the ICD, together with
practical instructions for mortality and morbidity coders, and guidelines
for the presentation and interpretation of data. It is not intended to
provide detailed training in the use of the ICD. The material included
here needs to be augmented by formal courses of instruction allowing
extensive practice on sample records and discussion of problems. If
problems arising from the use of the ICD cannot be resolved either
locally or with the help of national statistical offices, advice is available
from the WHO Collaborating Centres for the Family of International
Classifications

ICD purpose and uses

Purpose and applicability: A classification of diseases can be defined
as a system of categories to which morbid entities are assigned
according to established criteria. The purpose of the ICD is to permit
the systematic recording analysis, interpretation and comparison of
mortality and morbidity data collected in different countries or areas
and at different times. The ICD is used to translate diagnoses of
diseases and other health problems from words into an alphanumeric
code, which permits easy storage, retrieval and analysis of the data.

ICD is the foundation for the identification of health trends and

statistics globally, and the international standard for reporting
diseases and health conditions. It is the diagnostic classification
standard for all clinical and research purposes. ICD defines the
universe of diseases, disorders, injuries and other related health
conditions, listed in a comprehensive, hierarchical fashion that allows
for:
- easy storage, retrieval and analysis of health information for
evidenced-based decision-making;
- sharing and comparing health information between hospitals,
regions, settings and countries; and
- data comparisons in the same location across different time periods.

Uses include monitoring of the incidence and prevalence of diseases,

observing reimbursements and resource allocation trends, and
keeping track of safety and quality guidelines. They also include the
counting of deaths as well as diseases, injuries, symptoms, reasons for
encounter, factors that influence health status, and external causes of
disease.

Volumes ICD-10 comprises three volumes:

Volume 1 contains the main classifications; Volume 2 provides

guidance to users of the ICD; and Volume 3 is the Alphabetical Index
to the classification. Most of Volume 1 is taken up with the main
classification, composed of the list of three-character categories and
the tabular list of inclusions and four-character subcategories.

The ‘core’ classification – the list of three-character categories

(Volume 1) – is the mandatory level for reporting to the WHO
mortality database and for general international comparisons. This
core classification also lists chapter and block titles. The tabular list,
giving the full detail of the four-character level, is divided into 21
chapters. Volume 1 also contains the following:

Morphology of neoplasms. The classification of morphology of

neoplasms may be used, if desired, as an additional code to classify
the morphological type for neoplasms which, with a few exceptions,
are classified in Chapter II only according to behaviour and site
(topography). The morphology codes are the same as those used in
the special adaptation of the ICD for oncology (ICD-O). Special
tabulation lists. Because the full four-character list of the ICD, and
even the three-character list, are too long to be presented in every
statistical table, most routine statistics use a tabulation list that
emphasizes certain single conditions and groups others. The four
special lists for the tabulation of mortality are an integral part of the
ICD. Lists 1 and 2 are for general mortality and lists 3 and 4 are for
infant and child mortality (ages 0–4 years). There is also a special
tabulation list for morbidity. These are set out in Volume 1. Guidance
on the appropriate use of the various levels of the classification and
the tabulation lists is given in Section 5 of this volume.

• Definitions. The definitions in Volume 1 have been adopted by the

World Health Assembly and are included to facilitate the international
comparability of data.
• Nomenclature regulations. The regulations adopted by the World
Health Assembly set out the formal responsibilities of WHO Member
States regarding the classification of diseases and causes of death,
and the compilation and publication of statistics. They are found in
Volume 1. 2.4.2 Chapters The classification is divided into 21 chapters.
The first character of the ICD code is a letter, and each letter is
associated with a particular chapter, except for the letter D, which is
used in both Chapter II, Neoplasms, and Chapter III, Diseases of the
blood and blood-forming organs and certain disorders involving the
immune mechanism, and the letter H, which is used in both Chapter
VII, Diseases of the eye and adnexa and Chapter VIII, Diseases of the
ear and mastoid process.

Four INTERNATIONAL CLASSIFICATION OF DISEASES 16 chapters

(Chapters I, II, XIX and XX) use more than one letter in the first
position of their codes. Each chapter contains sufficient
three-character categories to cover its content; not all available codes
are used, allowing space for future revision and expansion.

Chapters I–XVII relate to diseases and other morbid conditions, and

Chapter XIX to injuries, poisoning and certain other consequences of
external causes. The remaining chapters complete the range of
subject matter nowadays included in diagnostic data. Chapter XVIII
covers Symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified. Chapter XX, External causes of morbidity and
mortality, was traditionally used to classify causes of injury and
poisoning, but, since the Ninth Revision, has also provided for any
recorded external cause of diseases and other morbid conditions.

Finally, Chapter XXI, Factors influencing health status and contact with
health services, is intended for the classification of data explaining the
reason for contact with health-care services of a person not currently
sick, or the circumstances in which the patient is receiving care at that
particular time or otherwise having some bearing on that person’s
care.

International Statistical Classification of Diseases and Related Health

Problems 10th Revision

Chapter Blocks Title

I A00–B99 Certain infectious and parasitic diseases

II C00–D48 Neoplasms

III D50–D89 Diseases of the blood and blood-forming organs and

certain disorders involving the immune mechanism

IV E00–E90 Endocrine, nutritional and metabolic diseases

V F00–F99 Mental and behavioural disorders

VI G00–G99 Diseases of the nervous system

VII H00–H59 Diseases of the eye and adnexa

VIII H60–H95 Diseases of the ear and mastoid process

IX I00–I99 Diseases of the circulatory system

X J00–J99 Diseases of the respiratory system

XI K00–K93 Diseases of the digestive system

XII L00–L99 Diseases of the skin and subcutaneous tissue

XIII M00–M99 Diseases of the musculoskeletal system and

connective tissue

XIV N00–N99 Diseases of the genitourinary system

XV O00–O99 Pregnancy, childbirth and the puerperium

XVI P00–P96 Certain conditions originating in the perinatal period

XVII Q00–Q99 Congenital malformations, deformations and

chromosomal abnormalities

XVIII R00–R99 Symptoms, signs and abnormal clinical and

laboratory findings, not elsewhere classified

XIX S00–T98 Injury, poisoning and certain other consequences of

external causes
XX V01–Y98 External causes of morbidity and mortality

XXI Z00–Z99 Factors influencing health status and contact with

health services

XXII U00–U99 Codes for special purposes.

Ans 2). EMR

Introduction :
An electronic health record (EHR), or electronic medical record (EMR),
is the systematized collection of patient and population
electronically-stored health information in a digital format.[1] These
records can be shared across different health caresettings. Records are
shared through network-connected, enterprise-wide information
systems or other information networks and exchanges. EHRs may
include a range of data, including demographics, medical history,
medication and allergies, immunization status, laboratory test results,
radiology images, vital signs, personal statistics like age and weight, and
billing information.
EHR systems are designed to store data accurately and to capture the
state of a patient across time. It eliminates the need to track down a
patient's previous paper medical records and assists in ensuring data is
accurate and legible. It can reduce risk of data replication as there is only
one modifiable file, which means the file is more likely up to date, and
decreases risk of lost paperwork. Due to the digital information being
searchable and in a single file, EMR's are more effective when extracting
medical data for the examination of possible trends and long term
changes in a patient. Population-based studies of medical records may
also be facilitated by the widespread adoption of EHR's and EMR's.
Comparison with paper records:
The increased portability and accessibility of electronic medical records
may increase the ease with which they can be accessed and stolen by
unauthorized persons or unscrupulous users versus paper medical
records, as acknowledged by the increased security requirements for
electronic medical records included in the Health Information and
Accessibility Act and by large-scale breaches in confidential records
reported by EMR users.Concerns about security contribute to the
resistance shown to their widespread adoption.
Handwritten paper medical records may be poorly legible, which can
contribute to medical errors. Pre-printed forms, standardization of
abbreviations and standards for penmanship were encouraged to
improve reliability of paper medical records. Electronic records may help
with the standardization of forms, terminology and data
input.[14]Digitization of forms facilitates the collection of data for
epidemiology and clinical studies.
Technical features:

 Digital formatting enables information to be used and shared over

secure networks
 Track care (e.g. prescriptions) and outcomes (e.g. blood pressure)
 Trigger warnings and reminders
 Send and receive orders, reports, and results
 Decrease billing processing time and create more accurate billing
system
Health Information Exchange
Implementation and patient considerations:
Quality
Several studies call into question whether EHRs improve the quality of
care.One 2011 study in diabetes care, published in the New England
Journal of Medicine, found evidence that practices with EHR provided
better quality care.
EMR's may eventually help improve care coordination. An article in a
trade journal suggests that since anyone using an EMR can view the
patient's full chart, it cuts down on guessing histories, seeing multiple
specialists, smooths transitions between care settings, and may allow
better care in emergency situations.EHRs may also improve prevention
by providing doctors and patients better access to test results,
identifying missing patient information, and offering evidence-based
recommendations for preventive services.
Costs
The steep price of EHR and provider uncertainty regarding the value they
will derive from adoption in the form of return on investment has a
significant influence on EHR adoption.In a project initiated by the Office
of the National Coordinator for Health Information (ONC), surveyors
found that hospital administrators and physicians who had adopted EHR
noted that any gains in efficiency were offset by reduced productivity as
the technology was implemented, as well as the need to increase
information technology staff to maintain the system.
Time
The implementation of EMR can potentially decrease identification time
of patients upon hospital admission. A research from the Annals of
Internal Medicine showed that since the adoption of EMR a relative
decrease in time by 65% has been recorded (from 130 to 46 hours).
Software quality and usability deficiencies
Physicians are embracing mobile technologies such as smartphones and
tablets at a rapid pace. According to a 2012 survey by Physicians Practice,
62.6 percent of respondents (1,369 physicians, practice managers, and
other health care providers) say they use mobile devices in the
performance of their job. Mobile devices are increasingly able to sync up
with electronic health record systems thus allowing physicians to access
patient records from remote locations. Most devices are extensions of
desk-top EHR systems, using a variety of software to communicate and
access files remotely. The advantages of instant access to patient
records at any time and any place are clear, but bring a host of security
concerns. As mobile systems become more prevalent, practices will
need comprehensive policies that govern security measures and patient
privacy regulations.
Hardware and workflow considerations
When a health facility has documented their workflow and chosen their
software solution they must then consider the hardware and supporting
device infrastructure for the end users. Staff and patients will need to
engage with various devices throughout a patient's stay and charting
workflow. Computers, laptops, all-in-one computers, tablets, mouse,
keyboards and monitors are all hardware devices that may be utilized.
Other considerations will include supporting work surfaces and
equipment such as mobile computer carts, wall desks or articulating
arms for end users to work on. Another important factor is how all these
devices will be physically secured and how they will be charged.
Unintended consequences
Per empirical research in social informatics, information and
communications technology (ICT) use can lead to both intended and
unintended consequences.
Privacy and confidentiality
In the United States in 2011 there were 380 major data breaches
involving 500 or more patients' records listed on the website kept by
the United States Department of Health and Human Services (HHS)
Office for Civil Rights.[60] So far, from the first wall postings in
September 2009 through the latest on 8 December 2012, there have
been 18,059,831 "individuals affected," and even that massive number is
an undercount of the breach problem. The civil rights office has not
released the records of tens of thousands of breaches it has received
under a federal reporting mandate on breaches affecting fewer than 500
patients per incident.

Challenges in its implementation:

Here are a few potential challenges and barriers you may face in EHR
use. Learning common barriers can help your practice manage around
them and set realistic goals that can be accomplished.

1. The technical ability

According to the Morsani College of Medicine of USF Health, a

computer's ability to retrieve and send data throughout healthcare is
effected by its age and other factors, such as the area in which the
practice is located. Connecting to the system and internet can be
more difficult for a system that is located in a rural setting over an
urban region. Make certain the location of your practice will make
EHR implementation and usage a non-stressful task .

2. The cost of use

Advances in health information technology, such as EHRs, can be

expensive in both implementation and usage. Finding the expenses to
invest in training, support, and the physical infrastructure itself can be
a common barrier, especially for smaller practices. Before making the
decision to implement EHRs, it's important to lay out the funding
beforehand.

3. The people

Unfortunately, not everyone is on board with the idea of

implementing and using EHRs. There will be patients and providers
along the way that may reject EHRs or easily give up on them if there
are initial technical malfunctions. Before bringing EHRs into your
practice, consider the barrier you may face with patients and
coworkers – it's important to be ready to face each and every
opinion.

4. The workflow break up

One of the main purposes of implementing EHRs is to create a steady

workflow in the practice. Unfortunately, Getting Paid said sometimes
EHR implementation can mess up the workflow in a practice entirely if
it is not customized to fit its purpose properly. To avoid this problem,
make certain your vendor gives you a proper demonstration of how
the implementation will work in your practice.

5. The training

During EHR implementation, practices are suggested to train their

employees throughout the new and improved workflow process.
Unfortunately, this takes extra time, effort and resources some
practices may not be able to afford. Before agreeing to implement
EHRs, find out exactly how much training should go into the process
and only go through with it if your practice is ready to complete it.
Training is one of the most important parts for successful EHR
implementation.
6. The concerns with privacy

According to USF Health, some healthcare providers and patients may

be concerned about medical privacies when using EHRs. Common
concerns include lost information due to a natural disaster and cyber
hacks. Before implementing EHRs, ask questions in regard to how
strict privacy will be in your new system.

Some of the major challenges (opportunities too!) which these EHR

systems continue to face are:

Industry Consolidation:

Although the year 2013 was dubbed as the “Year of the EHR
replacement” by a Black Book survey, the trend is expected to
continue well into this year. With this demand backdrop, it was
difficult for many small to medium sized EHR vendors to keep up with
the pace of change and several others saw this as an opportunity to
gain market share. This industry continues to see high levels of
consolidation activity in order to support these market dynamics. So
much so, that one of the most important factors for EHR vendor
selection is the long time viability of the EHR vendor.

Certification Challenges:

Eligible Professionals (EP) and hospitals must adopt certified EHR

technology. Over a period of five years starting from 2011, the
meaningful use criteria, measures and objectives are scheduled to
evolve in three stages. Each EHR system needs to be certified for
every stage.

The validation of EHR compliance with Meaningful Use is done

through certification by the Office of the National Coordinator for
Health Information Technology (ONC) Certification Program, based on
objectives and measures set by CMS.

The number of EHR systems which are Stage 2 certified is far less than
the number of EHR systems which were Stage 1 certified, indicating
the difficulty that the EHR vendors are faced with when developing
features to satisfy the Clinical Quality Measures (CQM). It can also
point to the fact that significant effort is required to track and
follow-up with certification requirements from an EHR vendor’s
perspective.

Features to support Meaningful Use Stage 1, Stage 2 and Beyond:

One of the overall objectives of Meaningful Use is to have common

inter-operable data. Healthcare, by its very nature, relies on common
terminology and standards (drug, disease, procedures and other
concepts) like SNOMED, LOINC, RxNORM, NDC and others to achieve
this. The vast array of standards to support the various stages of
Meaningful Use Stage is mind-boggling. Starting with the
implementation of HL7 v2, HL7 Clinical Document Architecture (CDA)
and following coding standards like SNOMED-CT for findings and
disease coding, LOINC for lab and ICD 9 CM for disease content has
produced a sea change for the EHR systems from the days when they
were just transcription systems.

The features which require support from an EHR System to support

Meaningful Use is quite extensive. Some of the challenging ones are:
Computerized Physician Order Entry, e-Prescribing and integration to
Formulary/Pharmacy systems, Order/Reminder Alerts, Audit Logs,
Encryption for local storage, sessions, handling information for
patients < 18 years of age, Secured Messaging, Patient Education,
Medication reconciliation, Immunization Registries.

Compliance despite making information sharing easier:

Health Insurance Portability and Accountability Act (HIPAA) sets clear

guidelines on who can access medical records of a patient.

The entire EHR has to be designed so that it does not violate the
information sharing principles set by HIPAA, but on the other hand it
also needs to make information sharing easier.

For example, one of the core measures for MUF Stage 2 is “Provide
patients the ability to view online, download and transmit their health
information within four business days of the information being
available to the Eligible Professional.” But this has to be
implemented and designed to meet HIPAA guidelines. This means EHR
systems having the ability to verify users of the EHR systems, using
encryption/hashing algorithms and safe transmission / storage
mechanisms which involve quite a bit of development overhead and
may compromise ease of use.

Clinical Decision Support Implementation:

One of the core rules, the CDS implementation can be particularly

tricky. The CDS certification is predicated on the ability to support
interventions for the following: Problem List, Medication List,
Medication Allergy List, Demographics, Laboratory tests and
values/results and Vital Signs.

To implement the above along with the required drug-drug,

drug-allergy contraindications frequently means development in
conjunction with other Clinical evidence based content providers
through HL7 Infobutton standard or other means. This can be a
difficult process as this may require development and testing
co-ordination.

Support for International Classification of Diseases revision 10

(ICD-10) :

The U.S. Department of Health and Human Services (HHS) mandated

the use of ICD-10 starting Oct 1. 2013. Although delayed for at least a
year, the move to mandate support for ICD-10 codes means that the
EHR systems would need to be ready for that. This is apart from the
process and workflow redesign and training requirements. One
particular feature that would also be dependent on content vendors is
the HL7v3 Infobutton integration and support for ICD-10 based
context rich information retrieval.

Customizing for specialties:

With the arrival of highly customized EHR systems that are targeted
specifically for a practice, the generic EHR system vendors face the
question of whether to cater to this market and if yes, how so
(customized templates, versioning, add-on components are some
methods used to customize).

Overall IT changes :

The overall technology surrounding the healthcare in terms of

hardware and software has undergone lots of changes over the last
few years. With the change in the usage and acceptance levels of
mobile devices/tablets in a hospital setting, conversion to 64 bit
OS/hardware and the use of cloud technologies, there are several
considerations for the EHR vendors to think about.

Despite these challenges, there also numerous opportunities for EHR

system vendors who are able to adapt and adapt quickly.