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Betania Calderon
Millennia Atlantic University
Author Note
Betania Calderon Valenzuela, Health Information Management, Millennia Atlantic University
This research is a report assignment of Implementation of Electronic Health Records class.
Contact: Betania.calderon@gmail.com
Running head: CUSTOMIZATION OF AN EHR 2
Abstract
the process and the healthcare provider must be first, assess their process, needs and what
technology it has. Based on that do the vendor and system analysis and selection and according
what the supplier can provide, define what updates the new application will require. Changes
related to data migration and/or upload, security measures, the ones dictated by HIPAA,
integration with internal administrative or clinical programs and external entities, such as
support the interoperability required to maintain the quality in customer services; other code
updates or new developments to handle the setting particularity processes and functionalities are
just part of the most common modification that an out-of-the-box technological solution needs to
response the healthcare provider. But customization has pros and cons that must be consider
before to take a decision, cost if it true that at least a minimum of modification will be need it,
the must changes the more costs, complexity during the escalation after the application is in
Introduction
There is a misconception about EHR or any type software or hardware solution, that only
No matter the type of application or software solution acquired by any type of setting, at
least some customization is required. This is because in first place that the almost all application
are developed, as out-of-the-box”, to cover and support the best practice and the most common
processes, there is always the need to handle some data, data entry or migration from another
system, some interfaces are probably required, especially in the healthcare industry, where
hospitals need to exchange information with third party such as, insurance companies,
But what is customization? It is an adaptation put into place because the “vanilla
software” solution does not fulfill completely the “desired” business needs.
When the decision of go ahead and the acquisition begin, the workflow process analysis,
a snapshot of the setting present situation and goal is defined and the vendor selection starts.
The customization needed will depend of different factors of the healthcare facility, such
as the size, the system that the setting has or not, the regulations under which the institution is
Meaningful use
Authorized Testing and Certification Bodies (ONC-ATCB s) test and certify that
certain types
HIPAA compliant.
There also are some features that are consider “Nice to have” such as:
Handwriting recognition
Voice recognition
physician-patient encounters are translated into five digit CPT codes to facilitate
billing.
Patient portal
Data Entry
Generally speaking, the most common customizations that are done in any type of system
Interfaces: Changing vendor-supplied system and/or writing new ones to send or receive
functions in another manner, i.e. to use different business rules than those provided by the
HIPAA pursues to set standards for the security of electronic protected health information
(e-PHI), electronic exchange, and the privacy and security of health information and its newly
revised HIPAA Security Rule requires providers to assess the security of their databases,
applications, and systems that contain patient data against a list of 75 specific security controls.
Running head: CUSTOMIZATION OF AN EHR 6
These controls include specific safeguards to be in place for the purpose of protecting
PHP.(HIPAA, 2012)
Even many EHR vendors claim they have covered the security features required, not
always are fully configured or enabled properly. Plus, medical devices and new adjustment to the
Such measures leverage an integrated use of data loss prevention tools, intrusion
authentication programs, role-based access and data security solutions. (Ferran, 2015)
authorized users.
Audit trails to track every activity made within the system that affect patient
information.
safeguard the proper use and integrity of e-PHI, by the utilization of electronic initiatives.
must be avoided, using technical security measures over the network. (HHS, 2006)
The integration capabilities that the next-generation of EHRs should have (McNickle,
2012).
Single sign-on (SSO). This a tendency that pursue to help with the usability of set of
applications or a particular one. Where the authorization and authentication foo the user is
centralized.
Launch in context. No matter the amount of applications running in the setting, patient
and other transactional or administrative data should be integrated in order to simplify the work
of the staff and the managers in order to have the full information when you need it. So the
portable code, that can be insert in any other application and that que be use in an easier and
lighter manner. By publishing and consuming widget EHR will be able to get part of a system
with all of its rules without the need to touch the code or do any integration. An example of this
use is Personal Health Record and the utilization of another internal application embedded within
the EHR.
Dashboards and templates customization. Some applications provide a simple way to set
dashboards and templates that can be tailored by user according different concepts, like user role,
organization or other
Interactive Voice Response (IVR). IVR allows EHRs to interact with users through
phones and other voice systems, such as Skype, through keypads or basic voice commands in
Voice recognition and/or handwriting recognition. There are different types of Voice
recognition systems, like Nuance, that help to perform data collection and other tasks in EHRs
should be basic functions. Also and less use, handwriting recognition apps, let the user or data
input via hand-written notes, input either directly or via a scanned or photographed page of
information.
Customizable import and export of data. Even data exchange can be perceived as a basic
function, many EHRs don't allow the easy import or export of data. The ideal system must
permit importing and exporting lists in different formats, such as Excel, CSV and XML. This is
both internal, to get patient information from or to another internal application or file, and
external to share patient data with Human and Health Department, CMS and private insurance
HL7 info button. This is context link embedded in HER, when it is certified in
Meaningful use stage 2 which has the purpose of patient and health facility information in
context.
HL7 messages and data types. HL7 is the standard to exchange health information,
clinical or administrative.
Data insertion and comparison should start at the beginning of the project
implementation, due data is one of the biggest issues that requires planning, time and execution.
Running head: CUSTOMIZATION OF AN EHR 9
The process to handle data varies depending on if the data is paper based or system.
Besides, some hospital or healthcare providers have the combination of both cases.
The first question regarding the data conversion process is whether the vendor provides
this service. If not, the setting should consider the use of in-house staff by using temporary
workers or assigning this tasks to any employee already part of the setting or hire an outside
company. you may consider utilizing in-house staff or hiring an outside firm.
Then, data must be evaluated identifying which information requires to “clean”, which is
going to be upload in the system and what not, how far back in a patient's history does the
electronic version need to go, how long will the conversion process take, how far and what will
happen with the all records, meaning after the information will be loaded in the system, if the
files will be shredded or if they are digital, the system will be deleted or saved as a backup
When the data assessment and planning is done, the data mapping is the next step, where
each data in the old system or paper is related with the new field in the system.
Not all data is collected because is not cost and time effective. Just the recurring patients
or most relevant information for those patients, such as demographic, history and physical, etc.,
On the other hand, during the data collection in some cases the use of an external tool or
software is used.
Additionally, there are other type of data that need to be upload in the system in case the
supplier does not support it, some examples of this are: ICD and CPT coding, medication and
Patient unique identification is still today in United States a not completely defined
standards. AHIMA has been limited the use of Social Security number as a Patient Identifier, but
still there is a lot of hospital that continue requesting and storing SS number. (AHIMA, 2011)
Besides, the social security number, other types of ID are being used to identify the
Part of the data collects a long list of demographics that are separated into fields: first
name, middle name, last name, date of birth, gender, whole social security number, street
address, city, state, ZIP, and phone. And part of the customization could be created the identifier
validation, insurance policy and name validation, address and others, that could be through an
interface or a data uploaded in the application. Plus, the setting could request the inclusion of
Changes related to Billing will be required depending if the healthcare provider has or not
a preexisting Billing system, in this case the setting could substitute or not this system by the
EHR; if the billing process will be impacted with the implementation and need to be modified,
how many integrations among internal or external system need to be done, e.g. inventory or other
The billing process in healthcare varies slightly the institution, but in high level is
During each step of the process some fields to capture important data should be required,
online and batches interfaces will be needed to handle the reimbursement process and process
credit/debit card payment and co-payment, new validation rules should be inserted in order to
ensure the workflow quality, by avoiding the error in coding or data, and finally and not less
Other changes
parameters, properties etc. e. g. Server settings, logging parameters etc. It usually is benign, and
affects the application and sometimes the database layer. Such updates are vendor supported too.
Running head: CUSTOMIZATION OF AN EHR 12
Let’s say the healthcare setting is a specialty or has some task additional or in different
order than the out-of-the box system. For example, you need to automate an order in the CPOE
that the system doesn’t have or the order has to run under some rules.
3. Technical Customization
Most of the EHR has basic reporting, but not necessarily bring a tailor or ad hoc reporting
module. Or even worse, the system does not have a way to export the information.
3.2. Server monitoring, backups, and data recovery. The data and an infrastructure that
sustain the technical platform must be ensure. IT experts or the vendor can recommend
measures and features to prevent data loss, backup and monitory actions to avoid risks.
implementing a customized EHR system, both in terms of time and financial investment. The
more the changes the biggest the time and cost resources.
Some providers underestimate the need of a technical representative during the project
assuming the vendor will just install and train the staff and nothing else need to be done. EHR
implementation requires the involvement the staff and vendor, and a careful leadership to ensure
Best practices deviation. Even changes are important to facilitate the usability in the
facility, mainly in specialty, huge changes can lead to a complete change of direction of the best
Running head: CUSTOMIZATION OF AN EHR 13
practices and standards. This not only affects the interoperability but the scalability of the system
in the future.
Other points of consideration are the complex and long-term system changes such as
updates, that could create bugs in the system, provoking highest costs and time to solve them.
Conclusions
critical to guarantee that both the practice and the health of the patients’ satisfaction.
Changes in the vendor application will depend on if the implementation will be to replace
a previous system or a paper base HER. The existing process analysis. The supplier application
that requires less customization due support better meaningful use and best practice. And how
the supplier can help with data entry and migration in the system.
Even those and other benefits, costs and time factors must be considered in the decision
making. To determine how much to customize and how appropriate it will be the updates in the
system, technical, human and time availability must be weighted. For example, when you have
an active "problem list" for a patient (e.g., diabetes, hypertension, high cholesterol, etc.) someone
has to be responsible for updating his or EHR medication and keep the problem list accurate.
Running head: CUSTOMIZATION OF AN EHR 15
References
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Ferran, T. (2015). Don't confuse EHR HIPAA compliance with total HIPAA compliance.
http://www.healthcareitnews.com/blog/don%E2%80%99t-confuse-ehr-hipaa-
compliance-total-hipaa-compliance
Human and Health Department, HHS. (2006). Summary of the HIPAA Security Rule. Retrieve
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ZH Healthcare. (2016). The Pros and Cons of Customizing Your HER, Retrieve on November
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