IMPLEMENTING THE EHR IN PHYSICIAN PRACTICE REQUIRES UNDERSTANDING OF CLINICAL WORK FLOWS

CHICAGO, February 23—Understanding the clinical work flows that drive data needs is the key to adopting a successful physician practice electronic health record (EHR), according to an American Health Information Management (AHIMA) e-HIM™ work group. The acceptance and value of the EHR within the physician practice setting is directly related to the EHR's usefulness for real-life application. Therefore, it is essential to provide a model that the clinician and others will understand and use to acquire, design, and implement EHRs.

“Caregivers require practical, related information during patient visit, assessment, treatment, and follow-up phases. The foundation of core data sets must be information that drives care giving activities,” stated Beth Hjort, RHIA, CHP, professional practice manager at AHIMA. “The aggregation of this data, in turn builds the EHR.”

The work group created model core data sets for eight sample clinical work flows. Four basic types of patient visits, for both new and established patients, were identified for pediatric and adult patients. The clinical work flow begins with the patient arriving at the reception desk and registering for the visit, as well as completing the necessary consents and authorizations. The clinical encounter begins with vital signs being taken, followed by chief complaint/reason for visit, then on to history of present illness. In each step, the core data needed to complete the documentation are identified. Each clinical work flow ends with the clinical encounter being completed and the patient being discharged, having received the necessary patient handouts and instructions.

The eight clinical work flows and their corresponding core data sets are intended for use by physician practices as a guideline and model for the development and implementation of an EHR in their practice. For a copy of the model core data sets, visit AHIMA’s Web site at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_022191.hcsp.
Susan Dowell Hanson, RHIA, member of the AHIMA e-HIM™ work group, will be presenting the group’s findings in “Workflows…Data Sets…Building the Core Workflow, Oh My!” at the annual Healthcare Information and Management Systems Society (HIMSS) Annual Conference & Exhibition. Her presentation will take place on Tuesday, February 24, at 1:00 p.m. in room S230E of the Orange County Convention Center.

The e-HIM™ work groups are supported in part by grants to AHIMA’s Foundation of Research and Education (FORE) from Dictaphone Corporation, McKesson Corporation, Meta Health Technologies, Inc., and Precyse Solutions. e-HIM™ is the term created by the AHIMA to represent the future reality of health information. For additional information on AHIMA’s e-HIM™ initiatives, visit the association’s Web site at http://www.ahima.org/infocenter/ehim/.

AHIMA is the national association of health information management (HIM) professionals. AHIMA's 52,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning. For information about the Association, go to www.ahima.org.