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Lections № 5. Electronic Medical and Health records. Main Questions. Medical record Basics Electronic Medical Record and Electronic Health Record EMR Implementation EMR systems in developing countries. 1. Medical record Basics. Medical record definition Purpose of the MR
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Lections №5 Electronic Medical and Health records
Main Questions • Medical record Basics • Electronic Medical Record and Electronic Health Record • EMR Implementation • EMR systems in developing countries
1. Medical record Basics • Medical recorddefinition • Purpose of the MR • Formatof the MR • Contentsof the MR • Administrative issuesof the MR usage
1.1. Medical recorddefinition 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.
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.
1.3. Formatof 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.
1.4. Contentsof 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.
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.
1.4.1. MR general sections Medical historysection 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.
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).
1.4.1. MR general sections Eachmedical encounterwill 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.).
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.
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:
2. Electronic Medical Record (EMR) and Electronic Health Record (EHR) • Reasons • EMR and EHR definitions • Data types in the EMR (EHR) • EMR Issues • Standardsused within EMR • EMR categories
Go from Paper to Digital Have patient information at your fingertips.
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 patient’s 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 patient’s chart on a wireless computer when you see him in the hospital. • Access a patient’s 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 patient’s record.
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
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.
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.
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
2.4.1.EMR Issues- Interoperability In healthcare, interoperabilityis 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).
2.4.2.Interoperability The Center for Information Technology Leadership described four different categories (levels) of data structuringat 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:
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.
2.4.4.Barriersand 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.
2.5. Standardsused within EMR There are many standards relating to specific aspects of EMRs. These include: • ASTM InternationalContinuity 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.
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
3. EMR Implementation • Status of EHR Adoption • EHR development planing • EHR examples
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 359;1
3.1.Status of EHR Adoption Source: CDC National Ambulatory Medical Survey (NAMC) of ~2700 physicians RR 62% AHA~3037 hospitals; RR 63%
3.1. Effect of Adoption of EHR Systems DesRoches CM et al. N Engl J Med 2008;359:50-60
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%.
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.
3.3. EHR example Electronic health record (EHR) with image and document links
EMR – Veterans Affairs VA – DoD
4. EMR systems in developing countries By Philippe Boucher, World Health Organization, eHealth unit London, UK, (2007) • Developing country issues • Critical issues • Active EMR and reporting systems
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)
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.
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.
