This document provides an overview of electronic medical records and health IT standards presented by Thomas Petry at an AITP meeting on September 10th, 2015. It defines key health IT terms and concepts, describes the differences between EMRs and EHRs, lists the components of an EMR, and discusses the benefits of electronic health records. It also covers topics like structured versus unstructured data, data analysis skills, health IT standards, ICD-10 implementation, and preparing organizations for the ICD-10 transition.

1. Structure versus Non-Structure
Order versus Chaos
September 10th, 2015
Thomas J. Petry
DC Chapter - AITP
YOUR ELECTRONIC MEDICAL RECORD

2. WHO IS THIS GUY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 2

3. • Electronic Medical Record (EMR)
• Electronic Health Record (EHR)
• Clinical Health Repository (CHR)
• Virtual Health Record (VHR)
• Personal Health Record (PHR)
• Patient Portal
• Regional Health Information
Organization (RHIO)
• Continuity of Care Document (CCD)
• CDA, CDR, Green CDA
• Enterprise Data Warehouse (EDW)
• Certified EHR Technology (CEHRT)
• Meaningful Use (MU)
• Regional
• Health Information Exchange (HIE)
• Health Information Service Provider
(HISP)
• Nationwide Health Information
Network (NHIN/NwHIN)
• eHealth Exchange
• Fast Healthcare Interoperability
Resources (FHIR)
DEFINITIONS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 3

4. EMR/EHR WHAT’S THE DIFFERENCE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 4
• Electronic Medical Record:
• Digital version of the paper charts in the clinician’s office.
• Contains Medical and treatment history of the patients in a single practice
• Tracks patients progress over time
• Doesn’t travel easily outside the practice
• Electronic Health Record:
• Goes beyond standard clinical/medical information
• Moves with patient to specialists, hospitals, nursing homes, across state/country
boundaries
• Built to share information across the entire care continuum

5. COMPONENTS OF AN EMR
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 5

6. • Registration/Pre-Registration/Quick
Registration
• CPOE/CDSS/Alerts
• Billing ICD-9/ICD-10
• Interfaces
• Registries
• Patient Chart (Progress Note)
• Demographics
• Medical Summaries/Discharge
Instructions/problem lists/differential
diagnosis
• Scheduling/Administrative
• Patient Communications and
Engagement
• Referrals
• Patient Documentation/Education
• Rx/eRx
• Circle/Plan of Care
• Consultations and Referrals (Care
Transition)
• Patient Histories (Family, Medical,
GYN/OB, Sexual/Behavior, Surgical,
Social
• Clinical Document (CD)
PARTIAL LIST OF EHR COMPONENTS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 6

7. BENEFITS OF ELECTRONIC HEALTH RECORDS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 7
• The information gathered by the PCP informs ED clinician about patient’s life-threatening
allergy so that care can be adjusted appropriately even if patient is unconscious.
• A patient can log on to his own PHR to see the trend of lab results over the past year which can
help motivate medication compliance and appropriate life-style changes.
• Lab results run last week are already in the record to tell the specialist what she needs to know
without running duplicate tests.
• The Clinician’s notes from the patient’s hospital stay can help inform the discharge instructions
and follow-up care and enable the patient to move from one care setting to another more
smoothly.
***Just one word “medical” vs “health” – Subtle distinction – World of difference***

8. STRUCTURED DATA
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 8
• Data that resides in a fixed field within a record or file
• Includes data contained in relational databases and spreadsheets
• Depends on creating a data model
• Data type (Numeric, currency, alphabetic, name, date, address, etc.)
• Data restrictions/Validation (Mr., Ms., or Dr.; M or F; etc.)
• Can be easily entered, stored, queried, and analyzed
• Structured data is often managed using Structured Query Language (SQL)

9. UNSTRUCTURED DATA
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 9
• Doesn’t fit into a neat box (photos, graphics, images, videos, streaming instrument data,
webpages, PDF files, PowerPoint Presentations, emails, blog entries, wikis and word
processing documents)

10. SEMI-STRUCTURED DATA
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 10
• Cross between structured and unstructured data
• Type of structure but lacks the strict data model structure
• Tags or other types of markers are used to identify certain elements within the data but
the date does not have a rigid structure.
• Examples: word processing software can now include metadata showing the author’s
name and date created with the bulk of the document just being unstructured text.
• Emails have a sender, recipient, date, time and other fixed fields added to the
unstructured data of the email message content and any attachments.
• Photos or other graphics can be tagged with keywords such as the creator, date, location
and keywords,
• XML and other markup languages are often used to manage semi-structured data

11. THE SQUARE PEG IN THE ROUND HOLE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 11

12. BIG DATA
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 12
• Volume – Velocity – Variety (3Vs)
• EMR’s collect huge volumes of data
• Large Patient Populations generate large volumes of data with great velocity
• Diverse Healthcare Organizations generate great volume and velocity with great variety
• Most healthcare organizations don’t need big data to meet most of their analytics and reporting
needs
• We’ve not come close to stretching the limits of what healthcare analytics can accomplish
• Regulatory reporting and operational dashboards
• More suited to regional/national/statewide population health management and policy
• Most healthcare organizations not prepared to use big data
• Requires Technical Expertise
• May involve complex machine learning and data mining
• Requires more robust and integrated security surrounding it

13. MIGRATING SKILL SETS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 13
• Analysts
• Reporting Analysts
• Configuration Specialists
• Support Specialists
• Medical Informaticists
• Nursing/Physician Informatics
• IT People with clinical backgrounds/Clinicians with IT skills
• Data Scientists
• Hard to come by
• Expensive
• Ph.D level thinkers
• Significant Expertise

14. ESSENTIAL DATA ANALYST SKILLS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 14
• Structured Query Language (SQL)
• Export – Transform – Load (ETL)
• Data modeling
• Data analysis
• Business Intelligence (BI) Reporting
• Story Telling

15. EHR/EMR INTEROPERABILITY PROBLEMS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 15
• Interoperability not specifically incentivized through Meaningful Use
• EHR vendors not satisfying interoperability gap
• Privacy and Security Issues
• All lack free and easy sharing in some aspect
• Impacts to industry workflows
• Errors in Documentation
• Structured/Unstructured Data Representation and Quality
• Stepwise, Rushed and Incremental Lifecycle Development
• Interruption of the doctor-patient relationship

16. TRIPLE AIM OF HEALTHCARE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 16
• Better outcomes
• Improved quality of experience
• Lower cost

17. POPULATION HEALTH
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 17
• Children’s Health & Obesity Prevention
• Family income/education/neighborhood safety
• Disease Management
• Health coaching
• Wave or reduce cost(s) associated with preventative medicine and routine office
visits
• Incentivizing care coordination/improvement on patient outcomes
• Prevention and Wellness
• 80% of healthcare costs consumed by 5 top chronic conditions
• Interagency Collaboration
• 60% of your health impacts occur outside physician offices and hospitals

18. PERSONALIZED MEDICINE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 18
• Mutation of the MET gene and MET inhibitors
• We now have the ability to manufacture antibodies/vaccines using genomics

19. HEALTH POLICY ISSUES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 19
• Entitlement Programs
• Health Insurance Exchanges
• Integration of Mental, Dental, Vision Care
• Health Workforce Adequacy
• US Aging Population
• Framework for Multiple Chronic Conditions (MCC)

20. • Healthcare-Associated Infections
• Human Immunodeficiency Virus
• CDC Vital Signs
• Public Health Grand Rounds
• Million Hearts ™
• Helping Smokers Quit
• Newborn Screenings
• Heads-Up Program
• Food Safety
• Children’s Mental Health
• Clinical Preventive Services for
Children/Adolescents
• Preventing Parasitic Diseases
• Global Efforts to Prevent Violence
Against Children
CDC 13 PUBLIC HEALTH ISSUES OF 2013
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 20

21. HEALTH DISPARITIES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 21

22. • Race
• Ethnicity
• Preferred Language vs Language
Competencies
• Sexual Orientation
• Sexual Identity
• Sexual History
• Social-Economical Status
• Geographic Location
• Trans Status (MTF/FTM related health
issues
• Culture
• Religion
• Age
• Disability Status
• Citizenship
• Immigration Status
• Length of time in Country
• Primary Language (ESL)
• Not mutually exclusive.
• Often interacting in important ways
• Impacts sub-groups differentially
HEALTHCARE DISPARITIES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 22

23. RISK FACTORS FOR TYPE 2 DIABETES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 23
• Non-modifiable
• Family History of type 2 diabetes
• Genetic Factors
• Age
• Ethnicity (African-American, Hispanic, Native-Americans, Asian-Americans, Pacific Islanders/Micronesia)
• Modifiable
• Obesity/Weight
• Physical Activity/Inactivity
• Diet/Nutrition
• Co-morbidity
• Previously identified IFG or IGT
• History of gestational diabetes
• Delivering a baby weighing > 9 pounds
• Polycystic ovary syndrome
• Alzheimer’s

24. Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 24

25. • Level of Exercise
• Diet
• Language Proficience
• Health Literacy
• Blood Glucose Level
• Glasgow Coma Scale
• Pulse Oximetry
• End-tidal CO2
• Functional Status
• Shortness of Breath
• Gate Speed
• Temperature
• Pulse
• Respiratory Rate
• Blood Pressure
• I/O
• Pain Level (AKA: Sixth VS)
VITAL SIGNS EVOLUTION
Existing Vital Signs New or Proposed
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 25

26. SECURITY AND PRIVACY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 26
• Health Exchange
• Referrals
• Continuity of Care
• Care Transitions
• Circle of Care
• BYOD
• FIDO-compliant authentication
• Federated Identification Management
• Trusted Relationships

27. BYOD
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 27
• Bring your own device (BYOD)
• Unrestricted Supported
• Restricted Supported
• Unrestricted Unsupported
• Strategy:
• Corporate-Owned Personally Enabled (COPE)
• Choose Your Own Device (CYOD)
• Corporate-Owned Business Only (COBO)
• Mobility-as-a-service (MAAS)
• For the first time, a large amount of iOS malware has made it past Apple's App Store security
controls, potentially affecting hundreds of millions of users
• Mobile Malware: The Hackers’ New Playground!

28. STANDARDS AND CODE SETS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 28
• Systematized Nomenclature of Medicine – Clinical Terms (SNOWMED-CT)
• International Classification of Diseases (ICD-9, ICD-10, etc.)
• NATIONAL COUNCIL FOR PRESCRIPTION DRUG PROGRAMS (NCPDP) SCRIPTS
• Logical Observation Identifiers Names and Codes) LOINC
• ANSI X12.N Healthcare Transactions and Code Sets
• ASTM E31 – HEALTHCARE INFORMATICS COMMITTEE OF ASTM INTERNATIONAL –
CONTIUITY OF CARE DOCUMENT (CCD)
• Current Procedural Terminology (CPT)
• Healthcare Common Procedure Coding System (HCPCS) Level II coding
• Evaluation and Management (E&M) Codes and calculatons (CPT: 99201 through 99499)
• Health Level 7 (HL7)
• Digital Imaging and Communications In Medicine (DICOM)
• UMLS, IEEE,

29. • HIT/Messaging
• HL7
• IEEE
• NCPDP
• ANSI X12
• CCOW
• Imaging
• DICOM
• Billing
• ICD
• CPT
• HCPCS
• Clinical Terminology
• SNOMED
• LOINC
• UMLS
CATEGORIES OF STANDARDS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 29

30. Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 30

31. INTERNATIONAL CLASSIFICATION OF DISEASES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 31
• Currently the most widely used statistical classification system for diseases in the world.
• Dates back to an 1860 proposal submitted by Florence Nightingale
• ICD-6 published in 1949
• ICD-9 – Proposals adopted by WHO in Geneva in 1978.
• Coded for approximately 17,000 codes.
• Work on ICD-10 began in 1983 (ICD-11 is planned for 2017)
• The United States of America is the last industrialized country to adopt ICD-10
• New ICD-10 allows for more than 155,000 different codes and codes greater
specificity
WARNING: The US HHS ICD-10 compliance date is: October 1st, 2014

32. ICD-9 VERSUS ICD-10
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 32
• ICD-9 (Compare to VCR technology – old school)
• 5,000 diagnostic categories (Numeric only)
• 14,000 diagnosis codes
• 4,000 procedure codes
• Causes confusion requiring additional authorizations and certificates of medical necessity
• ICD-10 (Compare to DVR technology – new kid on the block)
• 8,000 diagnostic categories (Alpha-numeric coding)
• 68,000 diagnosis codes (clinical modifications)
• 72,000 procedure codes
• Much more detailed with sub-classifications and sub-categories
• Codes for greater specificity, laterality, chronic versus acute, etc.

33. PREPARING FOR ICD-10
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 33
• Three areas lacking in provider preparedness for Oct 1 deadline
• Internal Testing
• External Compatibility Testing
• Health Exchabges
• Registries
• Labs, Imaging, Pharmacy
• Employee Education
• Huge drop in revenue anticipated during the transition
• Four State Medicare Programs implementing backward crosswalks to ICD-9 adjudication rules
• HHS CMS (Medicare/Medicaid) implementing 1-year grace period on misuse of ICD-10
specificity

34. • Templates
• Order Sets
• ICD Groups
• Superbills
• Diagnostic alerts
• Claims
• Adjudication
• Rejection
• Follow up
• Appeals
• ICD-CPT Combinations
• Reporting
• Compliance Reporting
• Forecasting
• Trend Analysis (US Cause of
Death Statistics)
• ICD Manifestation Codes (Specialists)
• ICD Categories
• Future Lab Orders
• Revenue Cycle
• Charge Bills
SCOPE OF ICD-10 IMPLEMENTATION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 34

35. HEALTHCARE FINANCE REFORM
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 35
• Employer-based Healthcare System
• Kaiser Permanente
• Blue-Cross/Blue-Shield
• Bottom-Line versus Patients First
• Emergency Medical Treatment & Labor Act (EMTALA)
• Fee-for-Service
• Single Payer, tax payer subsidized, free healthcare for all???
• Value-based reimbursements
• Improved Patient Outcomes
• Increased Patient Safety
• Lower Cost
• Better Population Management

36. RACE – ETHNICITY – LANGUAGE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 36
• Language Preference
• First Language
• Language Competency
• Constructed Languages (CONLANG) – ARTIFICIAL OR INVENTED ALANGUAGE
• Braille
• Sign Language (not necessarily ASL)

37. TYPING SPANISH ACCENTS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 37
• More than just a “Spanish” version of the software
• Impacts who the clinician is communicating too, not who is doing the documentation
• Two Options
• Type in cryptic codes – Cumbersome and frustrating!
• Re-map your computer keyboard
• Workstation Specific
• Sounds too ominous for the average user
• Use the U.S. International Keyboard
• Impacts apostrophe and quotes (i.e.: Impacts more than just Spanish Accent Characters)
• Impacts patient communications in multiple ways
• Email
• Patient Portal
• SMS/Text Messaging

38. IMPACT OF SPANISH ACCENTS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 38
• Multiple Modalities
• Patient Education Pamphlets
• Drug Information Sheets
• Email, Snail Mail and related communications
• Impacted by Technology
• Not consistently supported between MAC, PC, Linux/Unix and/or Mobile Devices
• May require a Windows CD or other product activation
• Not consistently supported by vendors (even within their own applications)
• http: Accept-Charset Accept-Language
• Minority Languages of Spain
• Basque/Euskara (EU)
• Aragonese (AN)
• Asturian/Leon (AU)
• Catalan (CA)
• Valencian (CA-Valencia)
• Galician (GL)
• Ladino/Judeo-Spanish (LY)
• Leísmo

39. SEX – ORIENTATION – IDENTIFICATION –
HISTORY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 39
• Sexual Orientation (SO), Sexual Identification (SI) and Past Sexual Behavior (Sexual
History - SrX) all have significant clinical implications:
• Access to healthcare
• Healthcare Disparities
• Variable Risk Factors
• HHS is only beginning to standardize structured collection and reporting regulatory
requirements
• Similar to Race, Ethnicity and Language
• Meanwhile individual healthcare providers and the vendors that support them are adding
in these requirements in a stepwise pattern

40. RACE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 40

41. ETHNICITY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 41

42. HOW ARE THEY EVOLVING
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 42
• Medical care is getting more and more complex …
• New information is already overwhelming physician’s
• Physicians need new technologies to help them cope
• Continued growth in digital record generation and dissemination (But: Who has time to read it)?
• From sole-source provider to multiple provider care team(s) …
• From clinical data repositories to sharing and coordination of data across the entire care continuum …
• From fee-for-service to value based payment models …
• Shift from individual care to population health …
• From transactional health records to relational health records …
• From recent clinical significance to significance of the entire longitudinal health record …
• Personalized medicine, genomics and epi-genomics driving this need across generations …
• Shift from targeting individual major disease categories to Multiple Chronic Disease Conditions (MCC)
• Greater emphasis on evidence based medicine and CDDS …

43. MULTIPLE CHRONIC CONDITIONS (MCC)
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 43
• A strategic framework proposed by HHS to improve health status for individuals with MCC
• Enhanced focus on prevention and public health
• Shifts emphasis from individual chronic disease (ICD/CPT) to using a relational MCC approach
• One in 4 Americans have multiple (two or more) concurrent chronic conditions
• Condtions that last a year or more and require ongoing medical attention and/or limit
activities of daily living
• Also includes: substance abuse, addiction disorders, mental illness, dementia, other
cognitive imparement disorders, developmental disabilities
• Increases with age (substantial in older adults)
• Direct correlation (number of MCCs – Elevation of Risk and Poor Outcomes)
• Mortality, functional status, unessisary hospitalization, adverse drug events, duplicative
tests, conflicting medical advise, non-meds compliance
• Substantial out-of-pocket expenses under current delivery of care

44. MCC FRAMEWORK GOALS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 44
• Foster healthcare and public health system changes to improve the health of individuals with
MCC
• Heightened coordination of complex medical and longitudinal psychosocial care (including
coordination across acute- and long-term care systems
• Maximize the use of proven self-care management and other services by individuals with MCC
• Home based physical activity training, family caregiving, evidence-based care models
• Provide better tools and information to healthcare, public health and social services workers
who deliver care to individuals with MCC
• Most management of MCC happens outside of a health care setting
• Facilitate research to fill knowledge gaps about, and interventions and systems to benefit,
individuals with MCC
• Individuals with MCC typically excluded from clinical trials

45. DRIVERS OF INNOVATION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 45
• Evidence based medicine
• Complexity of Data Dictionary
• Regulatory Environment
• Interoperability
• Usability
• Longitudinally
• Volume, data retention and clinical significance
• Reporting

46. HEALTHCARE REGULATORY ENVIRONMENT
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 46
• Health Insurance Portability and Accountability Act (HIPAA)
• The American Recover and Reinvestment Act of 2009 (ARRA)
• HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT
(HITECH)
• EHR certification programs
• Entitlement Programs (Medicare, Medicaid and CHIPS)
• Indian Health Services
• Veteran’s Health

47. MEANINGFUL USE (MU)
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 47
• Highly successful in some regards
• Miserable failure in other regards
• Successes
• Incentivized the adoption of EMR systems
• Resulted in widespread investment in electronic health records (EHR) endeavors.
• Greatly accelerated e-Prescribing in America
• Failures
• Caused costly upgrades
• Slowed down the evolution and maturity of EMRs
• Made EMR vendors “reactive” rather than “proactive”

48. IMPACT OF EMR ADOPTION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 48
• Improved outcomes
• Decreased cost
• Improved Care Coordination
• Increased Quality of Data
• Increased Integrity of Data

49. RISKS OF EMR ADOPTION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 49
• System design flaws
• Poor Usability
• Improper Use
• Inappropriate documentation
• CDSS introduced errors

50. • Healthcare-Associated
Infections
• Antibiotic Resistance
• Personal Protective
Equipment Protocols
• Hand Hygiene
• Health IT Issues
• Medical Errors
• Workforce Safety
• Transitions of Care
• Diagnostic Errors
• Patient Engagement
TOP TEN PATIENT SAFETY ISSUES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 50

51. • Healthcare-Associated
Infections
• Antibiotic Resistance
• Personal Protective
Equipment Protocols
• Hand Hygiene
• Health IT Issues
• Medical Errors
• Workforce Safety
• Transitions of Care
• Diagnostic Errors
• Patient Engagement
TOP TEN PATIENT SAFETY ISSUES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 51

52. • Meaningful Use
• Health Information Exchange
• Healthcare Reform
• HIPAA Compliance
• Mobile health and BYOD
• Wireless Networking
• Telemedicine
• Patient Engagement
• Clinical Data Analysis
• Storage Infrastructure
• The Healthcare Cloud
• ICD-10 implementation
TOP 12 HEALTH IT ISSUES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 52

53. POLITICS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 53
• Congress trying to squelsh ICD-10 implementation.
• Senator Lamar Alexander (R Tennessee) and chairman of the Senate Health, Education,
Labor and Pensions Committee calls for delaying implementation of Meaningful Use
Stage 3.
• Republicans always looking for ways to defund and/or overturn “Obamacare”

54. UNINTENDED CONSEQUENCES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 54
• Poor EMR design and improper use
• Increased Fraud and Abuse
• Forced or Rushed Adoption driven by Regulatory Compliance
• HIT-induced medical errors significantly increased
• Patient Identification Errors
• Patient Merging, Matching and Segregation
• Lack of case studies leading to successful implementations working one place that fail or
don’t work well in others
• Impacts workflow of clinicians adding excessive steps to treating patients

55. SCOPE OF IMPACT
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 55
• Sheer volume of Data Dictionary
• Additional layers of complexity to an already complex delivery system
• Potential unintended consequences of EMR adoption growing
• Lack of proper training and use
• Delays in treatment
• No way to systematically measure HIT induced errors
• Dosing errors
• Failure to detect specific conditions

56. INTEROPERABILITY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 56
• Electronic Health Exchange (eHx)
• RHIO/HiE
• Registries
• ePrescribing
• Peer to peer referral networks
• Billing
• LIS, RIS/PACS, Radiological/Referral reports/readings
• Telemedicine

57. MATCHING PAIRS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 57

58. PATIENT MATCHING
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 58
• Unmatched Patient Records
• Mismatched Patient Records
• Overlaid Patient Records
• Internal Patient Matching
• Matching Across the Continuum
• Merging Patient Records
• Unmerging Patient Records

59. E-PRESCRIPTIONS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 59
• NEW Rx
• Refill Requests
• Refill Response
• CanRx Requests
• CanRx Response
• Denials
• Medication History
• Currently no way to discontinue medcations electronically
• Most doctors use comments field in new prescrption asking pharmacist to
discontinue prior meds.

60. MEDICAL DATA BREACHES
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 60
• Data Breaches and Cyber Security Attacks at an all-time high
• Health plans are top targets for cyber attacks
• Criminal attacks cited as the number one cause of data breaches in healthcare
• More than 90% of healthcare organizations and almost 60% of their business associates have
experienced a data breach.
• Virtually 80% of healthcare organizations have experienced multiple breaches since 2010.
• Theft accounts for almost ½ of all cybercrime in healthcare.
• Credit card records are worth $1 on the black market
• Healthcare records command 10 times as much, because the rich data provides fertile ground
for fraud.
• US Healthcare is a $3 trillion/year industry
• 2014 Chinese hackers compromised 4.5 million patients
• Large payer breaches can yield millions of records and data points instantaneously.

61. MEDICAL RECORDS RETENTION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 61
• Full time job!
• Policy Issues
• HIPAA privacy and security regulations
• EHR system upgrades
• Release of Information Request
• Who manages the record when Physician is out dies or retires?
• ½ of all current active doctors will reach traditional retirement age by 2020
• Deloitte’s 2013 survey of over 20,000 physicians notes 62% say “it’s likely that many physicians
will retire earlier than planned in the next one to three years.
• Higher operating costs and lower reimbursements are driving many physicians out of private
practice.
• Only one-in-three doctors will remain independent by the end of 2016.
• Patients, payers, employees and lawyers may still have a vested interest

62. • Financial
• Insurance
• Medical
• Criminal
• Driver’s License
• Social Security
• Synthetic
• Child
TYPES OF IDENTITY THEFT
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 62

63. WHAT IS MEDICAL IDENTITY THEFT
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 63
• Use’s a person’s identity without the person’s knowledge or consent to obtain goods or
services
• Uses a person’s identity to make false claims
• Not a victimless crime
• This type of identity theft can actually kill you

64. MEDICAL IDENTITY THEFT
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 64
• Frequently results in erroneous entries being put into existing medical records
• Can involve the creation of fictitious medical records in the victim’s name
• Not a victimless crime and in fact can KILL YOU!
• Despite the profound risk it carries, is the least studied and most poorly documented
identity theft crime.
• Most difficult to fix after the fact.
• Victims have limited rights are recourses.
• Leaves a trail of falsified information in medical records that can plague victim’ medical
and financial lives for years

65. • Names
• All geographical subdivisions smaller
than a state (including street address,
city, county, precinct and zip code)
• All elements of dates (except year)
directly related to an individual (including
birth, admission, discharge and death)
• Phone Numbers
• Fax Numbers
• Email Addresses
• Social Security Numbers
• Medical Record Numbers
• Health Plan Beneficiary Numbers
• Account Numbers
• Certificates and License Numbers
• Vehicle Identifiers and Serial Numbers
• Device Identifiers and Serial Numbers
• Web URLs
• IP Address Numbers
• Biometric identifiers including
fingerprints and voice prints
• Full face photographic images and any
comparable image
• Any other unique ID number,
characteristic or code
HIPAA LIST OF 18 IDENTIFIERS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 65

66. • Account Numbers
• Certificates and License Numbers
• Vehicle Identifiers and Serial Numbers
• Device Identifiers and Serial Numbers
• Web URLs
• IP Address Numbers
• Biometric identifiers including fingerprints and
voice prints
• Full face photographic images and any
comparable image
• Any other unique ID number, characteristic or
code
• Names
• All geographical subdivisions smaller than a
state (including street address, city, county,
precinct and zip code)
• All elements of dates (except year) directly
related to an individual (including birth,
admission, discharge and death)
• Phone Numbers
• Fax Numbers
• Email Addresses
• Social Security Numbers
• Medical Record Numbers
• Health Plan Beneficiary Numbers
PROTECTED HEALTH INFORMATION
“Any information about health status, provision of health care, or payment for health care
that can be linked to a specific individual.”
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 66

67. CERTIFICATION VS USABILITY
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 67
• CERT program includes rigorous functionality standards
• Does not address usability testing standards
• HHS Office of the National Coordinator for Health Information Technology (ONC) now
addressing this via UCD requirements:
• User-Centered Design (UCD)
• A process that places the needs of the frontline user at the forefront of development
• EHR vendors now required to provide written statements naming the UCD process they
used and the results of their usability tests
• Needs to include at least 15 representative end-user participants
• Reports must be made public once the produce is certified

68. WHAT’S IN THE FUTURE
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 68
• Fee-for-service business models being changed to value based models
• Technology shifts from transactional based to relational based
• Clinical significance expands from recent encounters/assessments to the longitudinal
history of the population throughout the life of generations.
• Framework for treating Multiple Disease Conditions (MCC)
• More rushing forward blindly running to implement flawed systems in order to meet
arbitrary government deadlines.
• Wearable Devices
• Personalized Medicine, Genomics, Robotics and Nano-Technology
• The Internet of Things (IoT)
• Time to step back and evaluate the good, the bad and the ugly.

69. GLOBAL HEALTH
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 69
• Ebola
• HIV/AIDS
• Global Warming
• Immunizations

70. CONCLUSIONS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 70
• “Meaningful Use” cannot be achieved using a carrot and stick approach
• Technology is only as valuable as its ability to server and support our collective well being
and most importantly the patients we serve.
• Solving complex business problems through the use of technology can often cause
technologically-induced opportunities for more problems.
• Disintegrated healthcare delivery system.

71. DIRECT TRUSTED AGENT ACCREDITATION
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 71
• The Direct Trusted Agent Accreditation Program (DTAAP)
• Collaborative Program Initiative co-sponsored by EHNAC and Direct Trust
• Validates the technical, security, trust and business practice conformance of Trust Agents
involved in Direct.
• Assures HISP-to-HISP interoperability among accredited Trust Agents and other Direct
participants.
• Facilitates security, interoperability and trust among Direct exchange participants and fosters
public confidence.
• Reduces risk to PHI and operations through the demonstration of a risk management program
with effective controls that appropriately minimize threats.
• Prepares your organization for implementing secure communications in support of Meaningful
Use requirements by the ONC.

72. CAN YOU REALLY AUTOMATE EVERYTHING
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 72

73. QUESTIONS
Thomas J. Petry - DC
Chapter Association of
IT Professionals
ALFIO'S - SEPTEMBER 10TH 2015 73
“Knowing is not enough; we must apply.
Willing is not enough; we must do.” – Goethe