Lections ?5

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Lections ?5

• Electronic Medical and Health records

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Main Questions

• Medical record Basics
• Electronic Medical Record and Electronic Health
  Record
• EMR Implementation
• EMR systems in developing countries

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1. Medical record Basics

• Medical record definition
• Purpose of the MR
• Format of the MR
• Contents of the MR
• Administrative issues of the MR usage

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1.1. Medical record definition

• A medical record, health record, or medical chart
  is a systematic documentation of a patient's
  medical history and care.
• The term 'Medical record' is used both for the
  physical folder for each individual patient and
  for the body of information which comprises the
  total of each patient's health history.

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1.2. Purpose of the MR

• The information in the MR allows health care
  providers to provide continuity of care to
  individual patients.
• The MR also serves as a basis for planning
  patient care, documenting communication between
  the health care provider and any other health
  professional contributing to the patient's care,
  assisting in protecting the legal interest of the
  patient and the health care providers responsible
  for the patient's care, and documenting the care
  and services provided to the patient.
• The MR may serve as a document to educate medical
  students/resident physicians, to provide data for
  internal hospital auditing and quality assurance,
  and to provide data for medical research.
• Personal health records (PHR) combine many of the
  above features with portability, thus allowing a
  patient to share medical records across providers
  and health care systems.

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1.3. Format of the MR

• Traditionally, medicals records have been written
  on paper and kept in folders.
• These folders are typically divided into useful
  sections, with new information added to each
  section chronologically as the patient
  experiences new medical issues.
• Active records are usually housed at the clinical
  site, but older records are often kept in
  separate facilities.

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1.4. Contents of the MR

• Content of the medical record may vary depending
  upon specialty and location, it usually contains
  following patients data
• identification information
• health history (what the patient tells the health
  care providers about his or her past and present
  health status)
• medical examination findings (what the health
  care providers observe when the patient is
  examined).
• Other information may include lab test results
  medications prescribed referrals ordered to
  health care providers educational materials
  provided and what plans there are for further
  care, including patient instruction for self-care
  and return visits.

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1.4.1. MR general sections

• Demographics include information regarding the
  patient which is not medical in nature. It is
  often information to locate the patient including
  identifying numbers, addresses, and contact
  numbers. It may contain information about race
  and religion as well as workplace and type of
  occupational information. It may also contain
  information regarding the patient's health
  insurance.
• The medical history is a longitudinal record of
  what has happened to the patient since birth. It
  chronicles diseases, major and minor illnesses as
  well as growth landmarks. It gives the clinician
  a feel for what has happened before to the
  patient. As a result, it may often give clues to
  current disease states.

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1.4.1. MR general sections

• Medical history section of the MR include
• Surgical history - is a chronicle of surgery
  performed for the patient (dates of operations,
  operative reports, etc.).
• Medications and medical allergies - a summary of
  the patient's current and previous medications as
  well as any medical allergies.
• Family history - lists the health status of
  immediate family members as well as their causes
  of death (if known). It may also list diseases
  common in the family or found only in one sex or
  the other.
• Social history - is a chronicle of human
  interactions. It tells of the relationships of
  the patient, his/her careers and trainings,
  schooling and religious training. It may explain
  the behavior of the patient in relation to
  illness or loss.
• Habits. Various habits which impact health, such
  as tobacco use, alcohol intake, recreational drug
  use, exercise, and diet are chronicled, often as
  part of the social history.
• Immunization history. The history of vaccination
  is included.

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1.4.1. MR general sections

• Medical encounters.
• Within the medical record, individual medical
  encounters are marked by discrete summations of a
  patient's medical history by a physician, nurse
  practitioner, or physician assistant and can take
  several forms.
• Hospital admission documentation (ie when a
  patient requires hospitalization) or consultation
  by a specialist often take an exhaustive form,
  detailing the entirety of prior health and health
  care.
• Routine visits by a provider familiar to the
  patient, however, may take a shorter form such as
  the problem-oriented medical record (POMR).

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1.4.1. MR general sections

• Each medical encounter will generally contain the
  aspects
• Chief complaint. This is the problem that has
  brought the patient to see the doctor.
• History of the present illness. A detailed
  exploration of the symptoms that the patient is
  experiencing which have caused the patient to
  seek medical attention.
• Physical examination - is the recording of
  observations of the patient. This includes the
  vital signs and examination of the different
  organ systems, especially ones which might
  directly be responsible for the symptoms that the
  patient is experiencing.
• Assessment and plan - is a written summation of
  what are the most likely causes of the patient's
  current set of symptoms. The plan documents the
  expected course of action to address the symptoms
  (diagnosis, treatment, etc.).

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1.4.1. MR general sections

• Orders - written orders by medical providers are
  included in the medical record. These detail the
  instructions given to other members of the health
  care team by the primary providers.
• Test results - the results of testing, such as
  blood tests (eg complete blood count) radiology
  examinations (eg X-rays), pathology (eg biopsy
  results), or specialized testing (eg pulmonary
  function testing) are included.
• Progress notes - when a patient is hospitalized,
  daily updates are entered into the medical record
  documenting clinical changes, new information,
  etc.
• Other information - digital images of the
  patient, flowsheets from operations/intensive
  care units, informed consent forms, EKG tracings,
  outputs from medical devices (such as
  pacemakers), chemotherapy protocols, and numerous
  other important pieces of information form part
  of the record depending on the patient and his or
  her set of illnesses/treatments.

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1.5. MR Administrative issues

• Medical records are legal documents and are
  subject to the laws of the country/state in which
  they are produced. As such, there is great
  variability in rule governing
• production,
• ownership,
• accessibility,
• destruction

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2. Electronic Medical Record (EMR) and Electronic
Health Record (EHR)

• Reasons
• EMR and EHR definitions
• Data types in the EMR (EHR)
• EMR Issues
• Standards used within EMR
• EMR categories

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Go from Paper to Digital
Have patient information at your fingertips.
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2.1. Top Reasons To Adopt an EMR

• Better access to data
• Pull a patient chart within seconds rather than
  minutes.
• Never waste valuable time looking for a chart.
• Open and review your patients chart on any
  computer in the office with secure HIPAA
  compliant software.
• Have two or more people work with a chart at the
  same time.
• Have clinical data at your fingertips when a
  consulting or referring physician calls.
• Open the patients chart on a wireless computer
  when you see him in the hospital.
• Access a patients chart online when he calls you
  with an emergency at 2 a.m.
• Simplify Billing
• More accurate insurance claims submissions.
• Faster and easier Accounts Receivable management.
• Customized and automated billing options.
• Better charting
• Never worry about illegible handwriting.
• Update medication and problem lists with every
  visit.
• Import lab results, diagnostic images, and
  hospital discharge summaries into the
  patients record.

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2.2. EMR and EHR Definitions

• Electronic Medical Record (EMR)
• Electronic health-related information on an
  individual within one healthcare organization
• Electronic Health Record (HER)
• Electronic health-related information on an
  individual across more than one health care
  organization
• Personal Health Record (PHR)
• Electronic health-related information on an
  individual managed, shared and controlled by the
  individual

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2.2.1. Overlap in Terminology

• An electronic medical record (EMR) is a medical
  record in digital format.
• In health informatics an EMR is considered by
  some to be one of several types of EHR
  (electronic health record)s, but in general usage
  EMR and EHR are synonymous.
• The term has sometimes included other (HIT, or
  Health Information Technology) systems which keep
  track of medical information, such as the
  practice management system which supports the
  electronic medical record.

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2.3. Data types in the EMR

• An electronic medical (health) record might
  include
• Patient demographics.
• Medical history, examination and progress reports
  of health and illnesses.
• Medicine and allergy lists, and immunization
  status.
• Laboratory test results.
• Radiology images (X-rays, CTs, MRIs, etc.)
• Photographs, from endoscopy or laparoscopy or
  clinical photographs.
• Medication information, including side-effects
  and interactions.
• Evidence-based recommendations for specific
  medical conditions
• A record of appointments and other reminders.
• Billing records.
• Advanced directives, living wills, and health
  powers of attorney.

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2.4. EMR and EHR general notes

• Ideal characteristics of an EHR
• Information should be able to be continuously
  updated.
• The data from an EHR system should be able to be
  used anonymously for statistical reporting for
  purposes of quality improvement, outcome
  reporting, resource management, and public health
  communicable disease surveillance.
• The ability to exchange records between different
  electronic health records systems
  ("interoperability") would facilitate the
  co-ordination of healthcare delivery in
  non-affiliated healthcare facilities

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2.4.1. EMR Issues- Interoperability

• In healthcare, interoperability is the ability of
  different information technology systems and
  software applications to communicate, to exchange
  data accurately, effectively, and consistently,
  and to use the information that has been
  exchanged.
• Health Information Exchange (HIE)
• The mobilization of healthcare information
  electronically across organizations within a
  region of community
• For example, in 2004 in the USA the Office of the
  National Coordinator for Health Information
  Technology (ONC) was created, in order to address
  interoperability issues and to establish a
  National Health Information Network (NHIN).

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2.4.2. Interoperability

• The Center for Information Technology Leadership
  described four different categories (levels) of
  data structuring at which health care data
  exchange can take place. While it can be achieved
  at any level, each has different technical
  requirements and offers different potential for
  benefits realization

N Data Type Example
1 Non-electronic data Paper, mail, and phone call.
2 Machine transportable data Fax, email, and unindexed documents.
3 Machine organizable data (structured messages, unstructured content) HL7 messages and indexed (labeled) documents, images, and objects.
4 Machine interpretable data (structured messages, standardized content) Automated transfer from an external lab of coded results into a providers EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.
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2.4.3. Older record incorporation

• To attain the wide accessibility, efficiency,
  patient safety and cost savings promised by EMR,
  older paper medical records ideally should be
  incorporated into the patient's record.
• The digital scanning process involved in
  conversion of these physical records to EMR is an
  expensive, time-consuming process, which must be
  done to exacting standards to ensure exact
  capture of the content.
• Results of scanned records are not always usable
  medical surveys found that 22-25 of physicians
  are much less satisfied with the use of scanned
  document images than that of regular electronic
  data.

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2.4.4. Barriers and Limitations

• 80 of the work of EMR implementation must be
  spent on issues of change management, while only
  20 is spent on technical issues related to the
  technology itself.
• Organizational and social issues include
  restructuring workflows, dealing with physicians'
  resistance to change, as well as IT personnels'
  resistance to design and implementation
  flexibility needed in the complex healthcare
  environment, and creating a collaborative
  environment that fosters communication between
  physicians and information technology project
  managers.
• Limitations in software, hardware and networking
  technologies has made EMR difficult to affordably
  implement in small, budget conscious, multiple
  location healthcare organizations too.

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2.4.5. Preservation

• The physical medical records are the property of
  the medical provider that prepares them. This
  includes films and tracings from diagnostic
  imaging procedures such as x-ray, CT, PET, MRI,
  ultrasound, etc.
• In the USA, EMR is referred to as Protected
  Health Information (PHI) and its management is
  addressed under the Health Insurance Portability
  and Accountability Act (HIPAA) as well as many
  local laws.
• The patient, according to HIPAA, owns the
  information contained within the record and has a
  right to view the originals, and to obtain copies
  under law.
• Additionally, those responsible for the
  management of the EMR are responsible to see the
  hardware, software and media used to manage the
  information remain usable and not degraded. This
  requires backup of the data and protection being
  provided to copies.

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2.5. Standards used within EMR

• There are many standards relating to specific
  aspects of EMRs. These include
• ASTM International Continuity of Care Record - a
  patient health summary standard based upon XML,
  the CCR can be created, read and interpreted by
  various EMR systems, allowing easy
  interoperability between otherwise disparate
  enities.
• ANSI X12 (EDI) - A set of transaction protocols
  used for transmitting virtually any aspect of
  patient data. Has become popular in the United
  States for transmitting billing information.
• HL7 - HL7 messages are used for interchange
  between hospital and physician record systems and
  between EMR systems and practice management
  systems HL7 Clinical Document Architecture (CDA)
  documents are used to communicate documents such
  as physician notes and other material.
• DICOM - a heavily used standard for representing
  and communicating radiology images and reporting .

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2.5.1. HL7 (Health Level 7)

• Most widely used standard. General clinical
  messaging standard. Communicates structured data.
  Have a fields for
• Diagnostic Results
• Notes
• Referrals
• Scheduling Information
• Nursing Notes
• Problems
• Clinical Trials data
• 2000 hospitals, the CDC and most referral labs.
• Also used in Canada, Australia, New Zealand,
  Japan and extensively in Europe
• Bridges many systems, including laboratory,
  dictation, pharmacy, electronic patient records,
  performance databases, data repositories (cancer
  registries) etc.
• Web Site
• http//www.mcis.duke.edu/standards/HL7/h17.htm

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2.6. EMR categories

• The "born digital" record, which is information
  captured in a native electronic format originally
  is information that may be entered into a
  database, transcribed from an electronic tablet
  or notebook PC, or in some other manner captured
  from its inception electronically. The
  information is then transferred to a server or
  other host environment, where it is stored
  electronically.
• The records originally produced in a paper or
  other hardcopy form (x-ray film, photographs,
  etc.) that have been scanned or imaged and
  converted to a digital form. These records are
  best described as "digital format records", as
  their content is not able to be modified or
  altered (without a third party software using of
  to make "overlay notations") as electronic
  records are. Most medical records generated
  preceding the year 2000 are of this category.

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2.6.1. EMR categories
EHR components Basic Full
Health Info Data
Order Entry
Medication Orders
Lab Orders
Radiology orders
Rx sent electronically
Orders sent electronically
Results Management
View lab results
View imaging results
Images returned
Clinical Decision support
Public Health
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3. EMR Implementation

• Status of EHR Adoption
• EHR development planing
• EHR examples

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3.1.Status of EHR Adoption

• Only 4 of physicians use an extensive, fully
  functional system for electronic health records,
  and 13 use some form of basic electronic records
• Those who use electronic records are generally
  satisfied with the systems and believe that they
  improve the quality of care that patients receive

Source Jha DesRoches N ENGL J MED 3591
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3.1.Status of EHR Adoption
Setting 2006 () 2007 () 2008 () 2009 ()
PO (basic) 11 13 17
PO ( full) 3 4 4
Hospitals (basic) NA NA 8
Hospitals (full) NA NA 2
Source CDC National Ambulatory Medical Survey
(NAMC) of 2700 physicians RR 62 AHA3037
hospitals RR 63
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3.1.Status of EHR Adoption
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3.1. Effect of Adoption of EHR Systems
DesRoches CM et al. N Engl J Med 200835950-60
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3.2. EHR development planing

• System implementation projects, in general,
  experience low success rates
• 28 of projects meet full success
• 49 of projects are fully completed, but over
  budget, over schedule and lack full scope of
  planned functionality
• 23 of projects experience complete failure or
  are cancelled
• EMR/EHR system implementations have even higher
  failure rates. Industry studies reveal failure
  rates of 50, others as high as 70.

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3.2.1. Planning for Success

• The key contributing factors to implementation
  failure reported were
• Lack of planning unclear vision, goals and
  approach, not aligned with vendor incentives,
  schedules, other practice priorities and other
  resource responsibilities.
• Incomplete, unclear and/or changing requirements.
• Lack of executive support and commitment.
• Lack of resources dedicated to the project
  (staff, time, money, end-user involvement,
  project management and IT support)
• Unrealistic expectations for what can be
  accomplished and how quickly it can occur.

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3.2.2. The EHR Adoption Process
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3.2.3. Framework of EMR solutions
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3.2.4. How do Clinicians Interact with EMRs
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3.3. EHR example
Electronic health record (EHR) with image and
document links
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EMR frontscreen MediNotes
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EMR Veterans Affairs
VA DoD
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EMR MS Office OneNote
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EMR face sheet AMBAS
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EMR progress notes AMBAS
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Automated patient qaire ADS
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Pediatric EMR MDS Medical
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PMS scheduler AMBAS
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4. EMR systems in developing countries

• Developing country issues
• Critical issues
• Active EMR and reporting systems

• By Philippe Boucher, World Health Organization,
  eHealth unit
• London, UK, (2007)

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4.1. Developing country issues

• Mobile populations
• limited means of patient identification
• Massive shortage of health care workers
• Physical access to health services
• Limited infrastructure
• Limited access to drugs
• High disease burden combined with poverty
• Donor and aid agency requirements
• Privacy, confidentiality, and security
• Delivery of specific health services by lay
  health workers (task shifting)

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4.2. Critical issues

• ApproachA shift in perspective from a reporting
  based model of system design to a more learning
  based approach whose main focus is on direct
  care.
• LocalizationSystems need to be adaptable and
  relevant to local needs and culture. This
  requires that they be usable in local languages,
  properly understand data elements which vary by
  culture such as personal names and addresses, and
  be able to manage appropriate clinical terms and
  concepts which describe local health care.

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4.2. Critical issues

• Costing and ownershipImplementing organizations
  must consider innovative approaches to managing
  the costs of development, licensing, deployment,
  and support. Open source and open standards are
  viable options to use alongside more traditional
  approaches. Local ownership of systems must be
  encouraged and supported.
• Personal data protectionPatient data privacy and
  confidentiality is a key concern and must be
  addressed by all systems both technologically and
  through policy and legislation.
• Business caseElectronic Medical Record systems
  deployed in developing countries are driven by
  programme management needs across districts,
  regions and countries.

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4.3. Active EMR and reporting systems

• A very basic sampling of a few EMR and reporting
  systems used in developing countries, developed
  using different methodologies, sometimes locally,
  sometimes abroad
• CareWare (US PEPFAR countries - Africa,
  Caribbean, Asia)?
• OpenMRS (Eastern Africa)?
• SmartCare (Zambia)?
• LabTracker (Zimbabwe)?
• Fuschia (MSF)?
• Esope (Esther)?
• Baobab/Lighthouse system, Taiwanese Medical
  Mission System (Malawi)?
• DHIS (South Africa, India)?

Inclusion or exclusion of systems on this list
does not imply WHO endorsement
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WHO/Evelyn Hockstein
WHO/Evelyn Hockstein
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Conclusion

• In this lecture was considered next questions
• Medical record Basics
• Electronic Medical Record and Electronic Health
  Record
• EMR Implementation
• EMR systems in developing countries

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Literature

• Electronic documentation on to the TDMU server
• http//www.tdmu.edu.te.ua