EMR systems in Norway Hallvard L

1
EMR systems in NorwayHallvard Lærum MD PhD,
Manager of Clinical Information Systemsleder,
seksjon for klinisk virksomhetRikshospitalet
2
Overview

• What is an electronic medical record?
• EMRs in Norway
• Do the Norwegian doctors really use them?
• The burning records in Arendal
• The Master of Integration at Rikshospitalet

3
Electronic medical record vs Electronic Health
record

• Electronic Patient record
• The term Electronic patient record describes
  the record of the periodic care provided mainly
  by one institution (NHS/ERDIP 2001)
• A computer based clinical data system designed
  to replace paper patient records. (Wyatt JC, Liu
  JL. Basic concepts in medical informatics J
  Epidemiol Community Health. 2002
  Nov56(11)808-12.)
• Electronic Health Record
• ..a concept of a longitudinal record of a
  patients health and healthcare from cradle to
  grave. It combines both the information about
  patient contacts with primary healthcare as well
  as subsets of information associated with the
  outcomes of periodic care held in the EPRs
  (NHS/ERDIP 2001)

4
The Electronic medical record as a system of
systems
EMRMedical narratives, e.g. discharge reports,
progress notes, etc.
5
EMR vs PAS
Hospital information system
Patient ID
Electronic Medical Records
Patient Administration system

• EMR contains clinical information, e.g. admission
  reports, progress notes, heart rate, blood
  pressure.
• PAS contains business related information, e.g.
  regarding reimbursement, patient tracking,
  booking.
• Some information overlap exist, e.g.diagnose codes

6
Using the EMR to locate non-patient information
By exploiting the information found here...
...we may quickly get the right information here
Medical knowledgeTextbooks, clinical reminders,
decision support
EMRClinical problemDiagnosisTreatmentSex,
age, weight,etc.
Population statistics
Information to patient
Logistic informationHow to get the job done
Social influences/Local ProceduresHow others
get the job done
Gorman PN. Information Needs of Physicians.
Journal of the American Society for Information
Science 199546729-36.
7
Reality (year 2004)

• Continuous textual medical records updated by and
  accessible to physicians, nurses and other health
  personnel
• admission reports, progress notes, surgery
  reports, discharge reports and other documents,
• some include scanned documents
• Access to clinical biochemical lab data and
  radiological results
• The paper-based medical record is still being
  updated
• Except Sykehuset Telemark HF, Sørlandet Sykehus
  HF and Helse Bergen hF

8
Hospitals with EMR systems in Norway
9
Use and implementation of EMR systems

• A lot of implemented functionality appears not
  to be used

DIPS
Infomedix
DocuLive
1. Review the patient's problems2. Seek out
specific information from patient records3.
Follow the results of a test or investigation
over time4. Obtain the results from new tests or
investigations5. Enter daily notes 6. Obtain
info on investigation or treatment procedures7.
Answer questions concerning general medical
knowledge 8. Produce data reviews for specific
patient groups 9. Order clinical biochemical
laboratory analyses10. Obtain the results from
clin. biochemical lab. analyses 11. Order X-ray,
ultrasound or CT investigations 12. Obtain the
results from X-ray, ultrasound or CT inv. 13.
Order other supplementary investigations 14.
Obtain the results from other supplementary inv.
15. Refer the patient to other departments or
specialists16. Order treatment directly
(medical, surgery. or other)17. Write
prescriptions 18. Complete sick-leave forms 19.
Collect patient info for various medical
declarations 20. Give written specific
information to patients21. Give written general
information to patients 22. Collect patient
information for discharge reports23. Check and
sign typed dictations
General Medical knowledge Aggregated
data Supplementary investigations Actions
Patient info Communication and flow of
information
Percent of respondents offered functionality/
using it
Cut-off Respondents answering half of the time
or better are users
10
Use and implementation of EMR systems

• Some physicians enter daily notes themselves

DIPS
Infomedix
DocuLive
1. Review the patient's problems2. Seek out
specific information from patient records3.
Follow the results of a test or investigation
over time4. Obtain the results from new tests or
investigations5. Enter daily notes (i.e.
progress notes) 6. Obtain info on investigation
or treatment procedures7. Answer questions
concerning general medical knowledge 8. Produce
data reviews for specific patient groups 9.
Order clinical biochemical laboratory
analyses10. Obtain the results from clin.
biochemical lab. analyses 11. Order X-ray,
ultrasound or CT investigations 12. Obtain the
results from X-ray, ultrasound or CT inv. 13.
Order other supplementary investigations 14.
Obtain the results from other supplementary inv.
15. Refer the patient to other departments or
specialists16. Order treatment directly
(medical, surgery. or other)17. Write
prescriptions 18. Complete sick-leave forms 19.
Collect patient info for various medical
declarations 20. Give written specific
information to patients21. Give written general
information to patients 22. Collect patient
information for discharge reports23. Check and
sign typed dictations
General Medical knowledge Aggregated
data Supplementary investigations Actions
Patient info Communication and flow of
information
Percent of respondents offered functionality/
using it
11
Use and implementation of EMR systems

• Obtaining lab data (and other results) is
  popular, order entry is not

DIPS
Infomedix
DocuLive
1. Review the patient's problems2. Seek out
specific information from patient records3.
Follow the results of a test or investigation
over time4. Obtain the results from new tests or
investigations5. Enter daily notes 6. Obtain
info on investigation or treatment procedures7.
Answer questions concerning general medical
knowledge 8. Produce data reviews for specific
patient groups 9. Order clinical biochemical
laboratory analyses10. Obtain the results from
clin. biochemical lab. analyses 11. Order X-ray,
ultrasound or CT investigations 12. Obtain the
results from X-ray, ultrasound or CT inv. 13.
Order other supplementary investigations 14.
Obtain the results from other supplementary inv.
15. Refer the patient to other departments or
specialists16. Order treatment directly
(medical, surgery. or other)17. Write
prescriptions 18. Complete sick-leave forms 19.
Collect patient info for various medical
declarations 20. Give written specific
information to patients21. Give written general
information to patients 22. Collect patient
information for discharge reports23. Check and
sign typed dictations
General Medical knowledge Aggregated
data Supplementary investigations Actions
Patient info Communication and flow of
information
Percent of respondents offered functionality/
using it
12
Use and implementation of EMR systems

• Big surprise Nobody is using the EMR system to
  write prescriptions or complete sick-leave forms

DIPS
Infomedix
DocuLive
1. Review the patient's problems2. Seek out
specific information from patient records3.
Follow the results of a test or investigation
over time4. Obtain the results from new tests or
investigations5. Enter daily notes 6. Obtain
info on investigation or treatment procedures7.
Answer questions concerning general medical
knowledge 8. Produce data reviews for specific
patient groups 9. Order clinical biochemical
laboratory analyses10. Obtain the results from
clin. biochemical lab. analyses 11. Order X-ray,
ultrasound or CT investigations 12. Obtain the
results from X-ray, ultrasound or CT inv. 13.
Order other supplementary investigations 14.
Obtain the results from other supplementary inv.
15. Refer the patient to other departments or
specialists16. Order treatment directly
(medical, surgery. or other)17. Write
prescriptions 18. Complete sick-leave forms 19.
Collect patient info for various medical
declarations 20. Give written specific
information to patients21. Give written general
information to patients 22. Collect patient
information for discharge reports23. Check and
sign typed dictations
General Medical knowledge Aggregated
data Supplementary investigations Actions
Patient info Communication and flow of
information
Percent of respondents offered functionality/
using it
13
The burning records of Arendal

• Sykehuset Sørlandet HF ArendalThe paper-based
  medical record is scanned and obliterated!
• Questionnaire survey and interviews

14
The EMR in Aust-Agder Hospital
15
Physicians use of the regular EMR at Aust-Agder
Hospital
Much higher frequency of EMR use than in other
hospitals having the same system
16
The physicians reported a less frequent use of
the scanned document images
17
Physicians Change in ease of performing the
clinical tasks
Most tasks related to information retrieval are
reportedly easier using the system, but 33 of
internists found task 1 and 2 more difficult
18
User satisfaction of physicians
The physicians are relatively satisfied with the
regular EMR, but not with the use of the scanned
document images
19
User satisfaction of physicians, nurses and
medical secretaries
The medical secretaries are most satisfied, the
physicians least satisfied with the system
20
The Master of Integration at Rikshospitalet
21
The challenge

• 160 clinically relevant subsystems and counting
• Lack of functionality nonetheless
• No medication
• No booking or POE
• Numerous extremely specific systems wanted
  (Gender Identity Disorder clinic, craniofacial
  reconstructive team, organ and tissue
  transplantation, etc.)

22
DocuLive at Rikshospitalet 2002
EMRMedical narratives, e.g. discharge
reportsprogress notes, etc.
23
Other EMR systems
RadiologyX-ray, Ultrasound, CT, etc.
EMRMedical narratives, e.g. discharge
reportsprogress notes, etc.
24
Rikshospitalet 2004
EMRMedical narratives, e.g. discharge
reportsdaily notes, etc.
25
CSAM / Klinisk Portal

• Clinical Systems All Merged
• Single sign-on
• Oct 04 Six independent subsystems integrated,
  delivering information within eight areas
• Patient administrative data (PIMS)
• Documents of the medical record (DocuLive)
• Clinical biochemistry (NetLab)
• Immunology (NetLab)
• Pharmacology (NetLab)
• Pathology (Sympathy)
• Microbiology (Miclis)
• Radiology (RISWeb)

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CSAM principal architecture
Pasient
Sykepleier
Primærlege
Lege
Helsepersonell
Autentisering - rollebasert tilgangskontroll
Mitt skrivebord
Klinisk skrivebord
Pasientjournal
HF/RHF intranett
Min journal
Autorisasjon
Røntgen
Epost
Inneliggende
Kalender
Labsvar
Epikrise
Metakatalog
Venteliste
Henvisning
Dagsprogram
Felleskatalog
Forordning
PAS
EPJ
SPES1
LAB
ADM
RIS
SPES..n
PACS
Maskin / infrastruktur
27
CSAM Technical architecture
28
(No Transcript)
29
DocuLive
30
NetLab
31
RisWeb
32
Miclis
33
Sympathy
34
Implementation and first feedback

• Made available to all clinical users (3000)
  june-oct 2004.
• 1400-1600 hits per day and climbing
• This version of Klinisk Portal was aimed at
  physicians
• Popular, high expectations of further development

35
Not out of the woods yet

• Influence by vendors
• Six independent vendors and counting
• Will they risk losing market shares?
• Technical quality of subsystems
• Enterprise level capacity and management
• User management and change logs
• Long term perspective (nonproprietary formats)
• Control of redundancy
• Redundancy of functionality
• Redundancy of information
• Reference Information Model needed
• Choice of modular subsystems
• Few vendors offer modules or tri-tier
  architecture
• Cost
• Integration is cheap, development is expensive

36
Thank you!
37
Why this lack of EMR use? 1Answers provided by
the questionnaire is limited
Low computer literacy? Con The physicians had at
least a basic knowledge of computers (average
score 72.2 1.6, 92 owned a computer) Pro
Specific EMR system training may be needed
I wish the EMR could be more like WordStar
Wheres the PC when I need it?
Lack of available computers? Con Some PCs were
available 93 a computer in their office, 97
had a computer available in other rooms used for
clinical work. Pro Clinicians work is not
stationary. No hospitals have yet implemented
mobile computing, and no hospitals can afford a
PC in every room (personal communications)
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Why the lack of EMR use? 2
Low usability of the EMR system as a
whole? Prescriptions Navigating to the
prescription module, finding the correct
medication, typing dosage, administration route
and package size and printing on the correct type
of paper may represent more work than doing it by
hand. Sick-leave forms Slow system response
times (12-15 sec)
I know my pre- scriptions by heart!
Id like to find all the information in one place
Order entry is a nurses job!
The EMR is not complete Pro Until all relevant
clinical information is found in the EMR, it will
serve a secondary role. Pro The functionality of
current EMR systems is limited
Typing is a secretarys job!
Resistance to new work roles? Pro The usage
patterns found in the national study are conform
to traditional work roles. Pro Work role issues
were the most prevalent theme in the answers to
the open-ended questions in the validity study
(Paper 4).
Follow-up studies in each hospital are necessary