Baptist University Introduction to Electronic Health Records EHR

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Baptist UniversityIntroduction to Electronic
Health Records (EHR)

• Michael Fung
• 16 October 2009

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Agenda

• Definitions Concepts
• Development History
• Potential Benefits
• Key Functions of EHR
• 10 Dimensions of EHR
• Worldwide Implementation Progress
• Levels of EHR Implementation
• Case Study of Hospital Authority

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Electronic Health Records Objective

• To create an interoperable electronic health
  record for a safer, higher quality, more
  efficient continuous health service

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Electronic Health Records (EHR) Simple
Definition

• Mostly used generic term
• Computer-stored collection of health information
  about one person linked by a person identifier

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EHR Definition (Institution of Medicine 2003)

• Longitudinal collection of electronic health
  information for and about persons, where health
  information is defined as information pertaining
  to the health of an individual or healthcare
  provided to an individual
• Immediate electronic access to person- and
  population-level information by authorized and
  only authorized users
• Provision of knowledge and decision-support that
  enhance the quality, safety, and efficiency of
  patient care
• Support of efficient processes for healthcare
  delivery

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EHR Implementation

• Not necessarily one single system
• Broad set of functionalities, depending on the
  organization, may be
• Provided by one or many systems
• From one of more vendors
• Not a single project
• Series of initiatives that represent more a
  Journey than a Destination

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Computer-based Patient Record (CPR)

• Term used in the report of the Institute of
  Medicine
• Virtual computer-based medical record
• Includes all information (clinical and
  administrative)
• Covers all practitioners ever involved in a
  persons health care
• Independent of medical specialties,
• Longitudinal, ideally include prenatal and
  postmortem information
• Integral part of decision support
• Issues on privacy, interoperability

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Patient-carried Medical Record

• Health information on a device
• Smart card with a computer chip
• Card with optical stripes, magnetic high density
  stripes, 3-dimensional bar codes etc.
• Used in Veteran Administration Health Systems in
  mid 1980s but failed in late 1980s
• Card capacities
• Interoperability regarding content and
  terminology
• Lack of infrastructure for providers to record
  and read cards
• CD ROM with patient information at discharge

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Computerized Medical Record (CMR)

• Document imaging of paper documents into a
  computer system
• Prepping, scanning/digitizing, indexing,
  performing quality control
• Benefits
• Shareable of medical records
• Higher level of document integrity
• Persistence in storage
• Passive computer recording

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Electronic Patient Record (EPR)

• Grew out of the CPR concept, but differs in
  vision
• A collective vision of many systems and
  components which that are part of this overall
  concept
• Derived of all relevant patient information and
  driven by software, e.g. normal results may not
  be stored

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EMR Definition

• A EMR Facilitates
• access of patient data by clinical staff at any
  given location
• an increase in liability coverage
• accurate and complete claims processing by
  insurance companies
• building automated checks for drug and allergy
  interactions
• standardization of care pathways and protocols
• clinical notes
• prescriptions
• scheduling
• sending to and viewing by laboratories

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Electronic Medical Record (EMR)

• Interoperability issues on CPR EPR
• An electronic healthcare information system
  regarding one patient within an enterprise
• Enterprise may be a clinic, hospital, health plan
• A natural stepping stone towards an EPR, DMR or
  EHR

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Personal Health Record (PHR)

• Individual person should have an interest in
  ones health, rather than leaving to medical
  profession
• Have a copy of health information ever created
• Generally understand content of health history
• Learn about health matters that affect her
• Be a partner, rather than parent/child
  relationship, to the care giver
• 5 types of PHR
• Off-line PHR
• Web-based commercial / organizational PHR
• Functional / purpose-based PHR
• Provider-based PHR
• Partial PHR

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Electronic Health Record (EHR)

• Electronic version of medical record, or
• Particular concept which is different from the
• CPR no pre-natal and post-mortem information.
  Includes wellness, alternative healthcare
  information personal health records
• CMR digital record that can be used in decision
  support applications and interactive recording
• EMR not limited to a healthcare enterprise
• PHR primarily created and managed by providers
  and practioners

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Electronic Health Record (EHR) Roles

• Provider-based view of patients health history
• Clinical communication and care planning for
  patients healthcare practitioners
• Document services received by patient for
  reimbursement purposes
• Legal document describing healthcare services
  provided
• Source of data for clinical, health services,
  outcome research public health
• Basis for decision support
• Encourage interactive recording at point-of-care

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EHR (HKSAR Definition)

• EHR is the HKSAR wide electronic longitudinal
  (from "womb-to-tomb ") health record comprising
  of all important health data about a person. 
• It is contributed by various healthcare providers
  and the patient himself/herself, and the data can
  be accessed at anytime, anywhere by authorized
  personnel.

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Development History

• Electronic Health Record systems started in 1960s
• Implementation progress had bee much slower than
  expected
• Institute of Medicines report on computer-based
  patient records in 1991
• Technology advancement, Internet, wireless,
  mobile computing, RFID etc.
• Investments from CPR vendors, e.g. Siemens,
  Cerners, GE Medical, iSOFT, MedTrack, IBA ..

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Potential Benefits of EHR

• Higher Efficiency
• Sharing of patient data
• Timely update and multiple access
• Speed up workflow
• More efficient clinical practice
• Access data and images at home or remote sites
  for expert consultations
• Better Quality of Care
• Make decisions with comprehensive clinical
  information
• Avoid errors associated with paper records
• Clinical decision support

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Figure 1 Value of projects over time(from
Gartner, 2007)
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Figure 2 Cumulative value for multiple projects
(from Gartner, 2007)
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Speed Up Workflow
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Speed Up Workflow
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Speed Up Workflow
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Speed Up Workflow
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Speed Up Workflow
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Speed Up Workflow
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Improve Efficiency
Critical Results Alert System
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More information in hand
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Reduce Errors
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Reduce Errors
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Remote Access
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Remote Access
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Key Functions of EHR

• Recording
• Healthcare documentation
• Legal document
• Sharing of EHR information
• Healthcare became more complex with more
  practitioners involved
• Reduce medical errors more efficient continuity
  of care
• Order Entry
• Laboratory test, Radiology Examination, drugs
  etc.
• Retrievability and Access Patient Information
• Pulls together relevant information and displays
  to practioners

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Key Functions of EHR

• Built-in Functionality for Key Elements of Health
  Documentation
• Unique identification of patients
• Accuracy
• Completeness
• Timeliness
• Clinical Decision Support
• Allergy checking
• Drug-drug interaction
• Dosage checking
• Disease-based checking

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Key Functions of EHR

• Security
• User authentication
• Information access control
• Audit control
• Digital signature
• Data encryption
• Interoperable with Other Systems
• LIS, RIS, Pharmacy system, ICU system
• PACS
• Patient monitoring systems

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10 Dimensions of EHR
Information Capture
Information Representation
Content
Operational Dimension Data Model
QA Testing
EHR
Clinical Practice
Interoperability
Decision Support
Performance
Security/Confidentiality
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Data Content

• What is recorded ?
• Scope of specialties
• Scope of information available for exchange

• Each provider to record a minimum data set of a
  specific pathway of care
• Standardization of data structure

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Information Capture

• Integrating voice, handwriting, direct input,
  document imaging etc.

• Compliance with Principles of Documentation
• Unique identification of patient
• Accuracy
• Completeness
• Timeliness
• Interoperability
• Authentication accountability
• Auditability

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Information Representation

• Terminology
• Code sets
• Language .

• To ensure different practitioners have same
  meaning attached to vocabulary, code sets

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Operational Dimension and Data Model

• Actors, actions, process states/state
  transitions, work flows, deployment, version
  control, audit levels, data models

• Standards are needed for interoperability purposes

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Clinical Practice

• Standards of care/practice
• Protocols, e.g. care plans, critical paths

• Evidence Based Medicine
• Disease management
• Practice protocol guidelines

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Decision Support

• Standards for clinical decision making,
  algorithms, triggers, responses, logical support
  etc.

• Administrative decision support
• Clinical decision support

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Security / Confidentiality

• Information flow pathway
• Accountability
• Authentication
• Access control
• Encryption
• Backup/recovery

• International standards cover data integrity,
  authentication
• General system security and auditability
• HIPAA for US EHRs

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Performance

• Performance standards
• Measure performance

• General user standards

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Interoperability

• Inside system convergence EHR domain
• Outside system disparate domain, data
  functional mapping

• Technical and system interoperability

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QA and Testing

• System testing
• Operational quality assurance

• QA should be built into the EHR
• System testing procedures

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Medical Informatics in North America

• 1950s, MYCIS INTERNIST-1
• 1965, NLM started using MEDLINE MEDLARS
• 1970 80s, MUMPS for clinical applications
• 2004, Veterans Health Information Systems and
  Technology Architecture (VistA) CPRS for VAs
  over 1000 hospitals
• 1996, HIPAA created impetus for physicians to use
  EMR for patient safety

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European Health Informatics

• European eHealth Action Plan plays fundamental
  role in EUs i2010 strategy
• UK NHS National Programme for IT (NPfIT)
• Contracts totaling 5.6B (HK80B) over next 10
  years have been awarded
• electronic appointment booking
• electronic care records service
• electronic transmission of prescriptions
• fast, reliable underlying IT infrastructure

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Health Informatics in Oceania

• Health Informatics Society of Australia (HISA),
  member of IMIA
• Nurse informatician driven
• Branches in Queensland, New South Wales, Western
  Australia
• SIGs in nursing, pathology, aged and community
  care, industry and medical imaging

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Australia Health Online

• A Health Information Action Plan for Australia
• National Health Information Management Advisory
  Council

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Australia Health Connect

• Online health events at 3 years
• National framework at 5 years
• EHR centres at 6 years
• National EHR at 10 years
• GEHR
• General practice as leader

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The Asia Pacific is catching up

• Well developed systems in
• Korea
• Japan
• Australia
• Taiwan
• Hong Kong
• Singapore
• Malaysia
• New Zealand

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The Asia Pacific is catching up

• Keen interests in developing health informatics
• China
• India
• Vietnam
• Pakistan
• Sri Lanka
• Thailand
• Indonesia

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Levels of EHR Implementation
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5 levels of EHR computerisation (1)

• Level 1
• Automated Medical Record (clinical information
  system)
• Level 2
• Computerised Medical Record (document imaging)
• Level 3
• Electronic Medical Record (active tool,
  organization level)

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5 levels of EHR computerisation (2)

• Level 4
• Electronic Patient Record (spams across
  organization)
• Level 5
• Electronic Health Record (longitudinal,
  comprehensive
• Source Waegemann 1996

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Gartner 5 generations of EHR
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Healthcare System in Hong Kong
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CMS Development In HA

• 1990 Green fields
• 1991 Patient Administration
• 1992 Pharmacy system
• 1993 Lab results online
• 1994 Radiology information system
• 1995 Clinical Management System
• Clinician documentation and order entry
• 2000 CMS Phase II
• Electronic Patient Record (ePR)
• 2003 eSARS
• 2004 ePR Image Distribution
• 2006 ePR sharing with private sector

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Clinical Management System - 2005
6.5 million patient records
12000 workstations
29000 clinical users
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Corporate Clinical Systems

• Corporate Patient Master Index
• Clinical Management System
• Patient Appointment System
• Laboratory Information System
• Radiology Information System
• Pharmacy Management System

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The HK Patient Master Index

• Using Hong Kong Identity Number (HKID )
• HKPMI, Admissions/Discharges and Appointments
  Booking implemented across all HA hospitals and
  clinics
• HA HKPMI contains 8 million records

Uniquely identify all patients and can
facilitate linking together episodes of care
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Clinical Management System

• CMS Integrated clinical workstation for direct
  use by all clinicians in HA
• Phase I (1995-2001) The Collector
• Phase II (2002-2004) The Documenter
• Phase III (Planned) The Helper
• Phase IV The Colleague
• Phase V The Mentor

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Evolution of CMS

• Phase I - Functions
• Discharge summary
• Clinician coding of diagnosis procedure codes
• Ordering of medications and laboratory tests
• Retrieving laboratory and radiology results
• Medication history
• Electronic booking of appointments
• Generate referral or reply letters and reports
• Cross hospital information enquiry

• Phase II - Modules
• Generic Clinical Requests (Order Entry)
• Generic Results Reporting (Forms)
• Clinical Data Framework
• Outcome Documentation
• Medication Decision Support
• Clinical Data Analysis and Reporting
• Electronic Patient Record (ePR)

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CMS Phase III - Objectives

• Develop the content
• Standards-based, comprehensive, multimedia
  patient-based ePR
• Facilitate the process
• Support for operational care processes
• Workflow management and communication tools
• Improve the outcome
• Clinical decision support at point of care
• Support for QA activities

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Electronic Patient Records (ePR)
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ePR Laboratory Results
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Realising the Benefits of Investing in IT
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Patient Benefits

• Scheduled appointments for convenience
• Having their whole record available at point of
  care for more accurate and timely clinical
  decisions
• No need for repeated tests
• Better quality care through clinical decision
  support at point of care
• Less repeated studies decreasing radiation
  exposure

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Clinician Benefits

• More efficient clinical practice
• No need to search for information and forms
• Better decision-making with comprehensive
  information
• Avoid errors associated with paper records

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Organization Benefits

• Better use of resources
• Enforcement of policies best practice at point
  of care
• Data for planning, research and management

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End