EHR / EMR Systems Analysis Book

September 1, 2011 § Leave a comment

Electronic Health Record: a Systems Analysis of the Medications Domain

with foreword by John Halamka, MD

  • Introduces clinicians to structured systems analysis
  • Clarifies the complexity of the medications domain to IT professionals
  • Covers the rules, regulations, standards, and terminologies in the Electronic Health Record (EHR) / Electronic Medical Record (EMR) domain in general, and those specifically related to medications
  • Summarizes a set of principles for an effective clinical / medical User Interface (UI)
  • Illustrates a minimal alert-fatigue approach to Clinical Decision Support (CDS)
  • Demonstrates meaningful use of EHR / EMR: reporting requirements and interoperability standards
  • Applies the methodology and tools of systems analysis to EHR / EMR – Medications domain

Starting with an accessible primer, this book introduces the reader to the tools and methodology of Structured Systems Analysis as well as the nuances of the Medications domain. The first part of the book proceeds with a top-down decomposition along two main paths:

  • Data in Motion – Workflows: Context and Data Flow Diagrams (DFD), Processes, Activities
  • Data at Rest – Databases: Conceptual / Logical models, Entity Relationship Diagrams (ERD)

Structured systems analysis methodology and tools are applied to:

  • Electronic Prescription (eRx)
  • Computerized Physician Order Entry (CPOE)
  • Drug dispensation (ePharmacy)
  • Medication Administration (eMAR)
  • Clinical Decision Support (CDS)

The book completes a comprehensive view of the EHR / EMR with dedicated chapters on:

  • User Interface considerations (Input)
  • Reporting requirements (Output)
  • Standards and Vocabularies for Meaningful Use (Interoperability)

Assuming the reader has no previous clinical and/or informatics knowledge, the author uses easily accessible language and clear explanations. With over 170 figures, 100 review questions and answers – the book is a great companion to Healthcare IT professionals as well as clinical informatics students.

Table of Contents

1. Short Primer on Structured Systems Analysis

What Is a System?
Why Systems Analysis?
Why Structured Systems Analysis?
Processes and Data
Dataflow Diagram
Entity Relationship Diagram
Data Dictionary
Functional Primitives Specification
Balancing the Models

2. The Medications Domain Workflows and Data Structures

Context Diagram
Workflow Responsibility
Data Model
Conceptual Model Step 1
One Brand—Many Packs
One Pack—Many Items
One Drug—Many Forms and Many Routes
One Drug Item—Many Ingredients and Strengths
National Drug Code
One Ingredient—Many Brands
One Ingredient—Many Classes
One Class—Many Ingredients
One Class—Many Parents and Many Children
Tall Man Letters
Conceptual Model Step 2
One Pack—Many Indications
One Ingredient—Many Contraindications
Dosing Types
Intermittent versus Continuous
Dose Units
Time Units
Not All Concepts Are Entities
Conceptual Model Step 3
The Patient Is Uniquely Identified
The Clinician Is Uniquely Identified
Medication Life Cycle
One Medication Life Cycle—Multiple Statuses
One Patient—Many Prescriptions, Orders, Dispensations, and Administrations
One Clinician—Many Prescriptions, Orders, Dispensations, and Administrations
One Prescription (Order, Dispensation, Administration)—Many Items
Not Indicated Is Not Equal to Contraindicated
The Actual Dose Has a Quantity
Dosing Regimens
Actual Dose May Be Different from the Recommended One
Drug Name and Other Parameters May Change during Medication Life Cycle
Half Tablets
Daily Dose versus Maximal Dose
Not All Drug Parameters Are Clinically Relevant            

3. Prescribe/eRx

DFD 1 Prescribe Workflow
DFD 1.1 Communicate Prescription
DFD 1.2 Review Patient Data
DFD 1.3 Select Drug
DFD 1.4 Select Dose
DFD 1.5 Consider Formulary
DFD 1.6 Sign Rx
Controlled Substances
Data Elements
Prescription-Related Communications
Patient Medications
Patient Non-Drug-Related Parameters
Patient’s Preferred Pharmacies

4. Order/CPOE

DFD 2 Order Workflow
DFD 2.1 Communicate Order
DFD 2.2 Review Patient Data
DFD 2.3 Select Drug
DFD 2.4 Select Dose
DFD 2.5 Consider Formulary
DFD 2.6 Sign Order
Reuse Considerations
DFD 2.7 Use Order Set
DFD 2.8 Reconcile Meds
Data Elements
Internal Data Store
External Actors
Multiple Destinations for One Drug Communication
Multiple Physical Measurements
Conditional and Sequential Complex Orders
Patient A/D/T Settings Location and Time Frames
Data Exchange with External Actors

5. Dispense/ePharmacy

Dispense Workflow
Automated Dispensing Cabinet
DFD 3 Dispense Workflow
DFD 3.1 Communicate Dispensation
DFD 3.2 Review Patient Data
DFD 3.3 Select Drug
DFD 3.4 Select Dose/Prepare
DFD 3.5 Consider Formulary
DFD 3.6 Dispense/Deliver
Data Elements

6. Administer/eMAR
5 Rights
DFD 4 Administer Workflow
Bar Code Medication Administration
Smart Pumps
Drug Storage
DFD 4.1 Communicate Administration
DFD 4.2 Review Patient Data
DFD 4.3 Select Drug
DFD 4.4 Select Dose/Prepare
DFD 4.5 Interact with Storage
DFD 4.6 Administer/Sign
Data Elements
Calculation of Dosing Parameters for a Continuous Drip

7. User Interface

Cognitive Load
Principles of Graphic Excellence
Characteristics of a Clinical Story
Cause and Effect
Titrate to Effect
Parallel Channels of Information
UI Main Elements
Time Axis
Caution: The Direction of Time Axis
Parameters Axis
Caution: Hidden Information
Tabular Versus Graphical Display of Data
Number of Clicks and Data Density
Trends Are Nice, but Where Are the Numbers?
Layers of Information
Review Patient Data: Ambulatory UI
Refill a Medication
Modify a Medication
Prescribe a New Medication
Order Set
Medication Administration
Medication Reconciliation

8. Clinical Decision Support

What Is CDS?
Types of CDS
Why Is CDS Needed?
Clinical Decision Characteristics
Trustworthy Medical Information
CDS Configuration
CDS Adaptability
CDS—A Binary Classification System
False-Positive versus False-Negative Alerts
Medication Errors
Medication CDS
Dialog Paradigm
Automated CDS Algorithm Outline
DFD 5 CDS Workflow
DFD 5.1 Filter Drug
DFD 5.2 Adjust Dose
DFD 5.3 Consider Demographics
5.3.1 Consider Age
5.3.2 Consider Gender
5.3.3 Consider Weight, Height
5.3.4 Consider Ethnicity
DFD 5.4 Consider Patient Condition
5.4.1 Consider Indication & EBM
5.4.2 Consider Allergy and C/I
5.4.3 Consider Adverse Reaction & Side Effect
5.4.4 Consider Pregnancy and Lactation
5.4.5 Consider Drug-Lifestyle
5.4.6 Consider Drug-Vital
5.4.7 Consider Drug-Procedure
DFD 5.5 Consider Patient Drugs
5.5.1 Consider Interaction
5.5.2 Consider Duplicate Therapy
5.5.3 Consider Alternative
5.5.4 Consider Setting
5.5.5 Consider IV Admixture
DFD 5.6 Consider Lab
5.6.1 Lab Affect Drug & Dose
5.6.2 Monitor Lab
5.6.3 Drug Interfere with Lab
DFD 5.7 Educate
Data Elements
Temp CDS Drug
Temp CDS Dose
Drug Interaction
IV Admixture
Dose Adjustment
Monitor Drug Lab
Drug Interfere Lab
Barriers to CDS Adoption
CDS and Genomics: Personalized Medicine

9. Report

Types of Reports
Measuring Healthcare Quality
Goals for the Healthcare System
Dimensions of Quality Measures
Evaluating Quality Measures
Organizations Involved in Quality Reports
PQRS and MU Measures
Anatomy of a Quality Measure
Reporting Methods
Medications Reports
Data Warehouse
Data Mining
CDS versus Reports
DFD 6 Report Workflow
DFD 6.1 Report on Single Patient
DFD 6.2 Report on Multiple Patients
Data Elements

10. Interoperability Standards and Vocabularies

Open Systems Interconnection Model
Language and Ontologies
Rocket Science Standards
U.S. Government and MU
Qualities of a Modern Clinical Terminology
Healthcare Standards Organizations
EHR Standards and Vocabularies
Medications Standards and Vocabularies
DFD 7 Update/Sync Workflow
HIE/Regional Health Information Organization/HUB
Data Elements
Discrete Data Elements
Semistructured Documents

Acronyms List
Answers to Review Questions


Each chapter includes a Summary, References, and Review Questions

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