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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Challenges & Prospects for Electronic Health Records
Lorraine NicholsonImmediate Past President
IFHIMA
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Challenges & Prospects for Electronic Health Records
HIMSS http://www.himss.org/asp/topics_ehr.asp
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
The Electronic Health Record
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. (HIMSS http://www.himss.org/asp/topics_ehr.asp)
EHRs can be made up of different types of records held on a variety of media e.g. text, images, audio, video, machine outputs etc.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Examples of EHRs Around the World (i)
Australia is dedicated to the development of a lifetime electronic health record for all citizens.
Canada Health Infoway (Infoway) is an independent, not-for-profit organization funded by the federal government which jointly invests with every province and territory to accelerate the development and adoption of electronic health information systems in Canada.
The European Commission wants to boost the digital economy by enabling all Europeans to have access to online medical records anywhere in Europe by 2020.
UK - The NHS in the England began deployment of EHR systems in 2005 - the goal was to have 60 million patients with a centralized electronic health record by 2010. The plan was greatly delayed and frequently criticised and as an overarching program it was stopped in 2011. There are other EHR initiatives in Wales, Scotland and Northern Ireland.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Examples of EHRs Around the World (ii)
USA - In a 2008 survey by DesRoches et al. of 4484 physicians (62% response rate), 83% of all physicians, 80% of primary care physicians, and 86% of non-primary care physicians had no EHRs. The American Medical Association (AMA) provides fundamental rules in embracing the electronic medical record system
Estonia is the first country in the world that has implemented a nationwide EHR system, registering virtually all residents' medical history from birth to death.
In November 2011 a planned national electronic patient record for The Netherlands was shelved due to privacy concerns and budget cuts. The Netherlands are now developing regional solutions.
Abu Dhabi is using national EHR data as a live longitudinal cohort in the assessment of risk of cardiovascular disease.
Arab Health Awards 2010 recognizes Saudi Arabia National Guard Health Affairs for advancement in EHR development
There are more!
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
The Challenges
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Implementation Issues & Challenges
There are a number of issues and challenges surrounding the implementation of EHRs including:
Managing & Supporting Users Usability & User Acceptance Capital & Revenue Costs Fear of Failure & the Costs of Failure Interoperability of Systems is crucial
Lets look at these challenges in a bit more detail
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Managing & Supporting Users
Historic practice in record-keeping has been largely paper-based - in the Daily Times NG on 25th April 2012 in his article HIMAN calls for e-health record keeping, Mr. Wole Ajayi stated that the paper-based record keeping system was the most common method of recording patient information in most hospitals
Top-down approach to system selection & implementation does not engage users
Peoples resistance to change Effectiveness of user training is crucial Support for users is important Data sharing issues can cause privacy concerns
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Usability & User Acceptance
There must be engagement with all users, particularly clinical users, from the very beginning
All users need effective training and good systems support
Systems need to be intuitive and user friendly
Systems also need to be easy to navigate Systems need to be tailored to meet the specific
needs of different organizations and users
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Capital & Revenue CostsThe procurement, implementation and use of EHR systems is expensive both in terms of capital costs and revenue consequences. These include
Training & administration costs Licensing costs Connectivity costs Interoperability costs Costs of effective back-up systems Systems support costs Ongoing maintenance, upgrade & replacement costs Governance costs to ensure systems and data security Costs of tailoring systems to meet the specific needs of
different organizations and users
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Fear of Failure and the Costs of Failure
To build confidence and protect against failure users need effective training in necessary computer skills in addition to systems-specific training backed-up by good systems support when they experience problems
Infrastructure Issues e.g. unreliable power supply or poor systems maintenance & support this can mean down-time in commerce and industry but in the healthcare sector it can mean the difference between life and death!
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Interoperability of Systems
Interoperability between multiple heterogeneous systems and compatibility between various platforms and software packages is crucial for a fully functional fit for purpose EHR to facilitate the electronic exchange of health information between disparate systems to enable the delivery of safe and effective patient care
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Another challenge! How do we move from paper to EHRs
?
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
The Transition from Paper to Electronic Health Records
The transition from a paper-based health record to an electronic health record (EHR) must be addressed and managed on many different and complex levels: administratively, financially, culturally, technologically, and institutionally.
The EHR consists of many components that work together to create the foundation of the legal health record (US terminology) including software applications such as computerized physician order entry; integration with laboratory, radiology, and cardiology systems; an electronic document management system; or other solutions.
The transition may take many years and require many change-management dynamics that will challenge each of those involved with the transition process.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Making the Transition
A challenge for the organization! Learn lessons from other organizations which
have made the transition and avoid making the same mistakes
A focus on patient safety, best practices, and return on investment and ease of end-user adoption has driven healthcare organizations to adopt solutions that support workflow performance improvement rather than those that simply automate existing processes or system dysfunctions.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Managing the transition from paper-based records to EHRs
This is a complex process due to the multitude of systems, functionality, and rapid technological advances.
No single standard approach exists for solving the transitional process issues.
Each healthcare organization must determine the steps and policies that are needed as it evolves into using a fully functioning EHR.
Many healthcare organizations have some degree of hybridizationthat coincides with the implementation plan.
There are many decisions to consider when determining steps and guidelines for managing the transition process from paper to hybrid records and then hybrid to electronic records PLAN CAREFULLY!
Healthcare organizations must ensure that the quality and integrity of the health record remains intact during the transition process.AHIMA. "Managing the Transition from Paper to EHRs." (Updated November 2010). http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048418.hcsp?dDocName=bok1_048418
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Transition via Hybrid Heath Records
Because of the slowness of adoption of EHRs, funding barriers, competing technical priorities, strained human resources, and the lack of industry education, many healthcare providers are finding themselves maintaining a combination of paper and electronic records i.e. the hybrid health record
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Examples of Hybrid Health Record Scenarios
Dictation, laboratory & X-ray results available electronically BUT progress notes, ancillary care, provider information, graphic sheets, and doctors orders are on paper.
Patient health information is stored on various other media types such as film, video or an imaging system.
Patient information may be stored as scanned images in a separate part of the system rather than integrated in a chronological health record.
Hospital records are electronic but out-patient clinic records are on paper which is processed & stored in the clinic & never become part of the core EHR.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Hybrid Health Records (i)A hybrid health record is a system with functional components that include any of the following: Where there are both paper and electronic
documents without a central electronic document management system where all patient information is maintained
Where there are manual and electronic processes to compile components of the medical record
Where there are multiple repositories of information (paper or electronic) that need to be accessed by the end user to compile the health record for a single episode of care
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Hybrid Heath Records (ii) Having a hybrid health record is not ideal for any
facility for any extended length of time. Avoiding hybridization, or minimizing the effect
of hybrid components, will decrease the risk to patient safety and it will be more cost-effective and efficient.
Therefore, it is imperative for organizations to identify and address the challenges related to the hybrid record and implement solutions to mitigate potential risks.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Managing the Change: Top 10 Paper/Hybrid/EHR Principles (i)
1. The EHR must be part of an organizations vision and strategic plan & there should be a standard definition for the legal health record.
2. There must be adequate leadership, consultation, staff training, equipment, policies & procedures, & funding or other resources are in place to support EHR development.
3. Establish a legal health record steering committee to guide the organization from a paper to an electronic environment which is empowered to make proactive and constructive changes.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Managing the Change: Top 10 Paper/Hybrid/EHR Principles (ii)
4. The steering committee must develop and publish policies and procedures for operating in the paper state, hybrid state, & electronic state & include long-term archive, purge, retention, & destruction guidelines.
5. HIM professionals must participate actively in the development and implementation of the EHR.
6. Establish a formal process for approving EHR software and hardware to ensure that it can adequately support the organization's operational needs for paper, hybrid, and electronic health records.
7. Establish a formal process for managing forms, paper, electronic, hybrid, and system-generated records.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Managing the Change: Top 10 Paper/Hybrid/EHR Principles (iii)
8. Establish a formal process and written guidelines addressing access, confidentiality, security, print control, disclosure, & e-discovery.
9. Complete and maintain a full inventory of all existing storage & management of paper, hybrid, shadow (duplicate), and electronic record.
10. Develop a policy for retention & destruction of all health records (paper, hybrid, or electronic health records).
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Evolving Roles for HIM Professionals in the Electronic Environment
A professional challenge for HIMs!The 2010 AHIMA practice brief e-HIM Practice Transformation identified several additional roles for the HIM professional. HIM roles should be reviewed & updated when planning the transition from a paper-based environment to a hybrid or completely electronic environment.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
The Future.
What are the prospectslikely to be for HIMs & EHRs in the future?
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
eHealth eHealth promotes, empowers & facilitates health
& wellbeing for citizens, families & communities It supports & enhances professional practice
through the use of ICT & eHealth information management (eHIM)
eHealth is not just technology - it is about finding, using, recording, managing, and transmitting information to support health care, in particular to make decisions about patient care
Computers (and other ICT devices) are merely the technology that enables this to happen
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
eHealth also encompasses:
Virtual healthcare teams M-Health use of mobile devices to
support treatment & care Tele-Health e.g., tele-dermatology,
remote patient monitoring etc. Medical research Health knowledge management Health Information Systems
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Health information Management (HIM)
is the practice of maintenance & care of health records by traditional (paper-based) and electronic means in hospitals, clinics, primary healthcare facilities, and other organizations that provide health care or maintenance of health records.
Effective sharing of patient information using only paper-based systems is ineffective
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
I want to share with you.
. An e-Health integrated care model for a Patient-Centred Approach
Apologies that my diagram is a very European one!!
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
GP
CommunityNurse
HospitalCare/NursingHome
Physiotherapy
Pharmacy
Laboratory
DentistOpticianSpecialist Clinics
HealthCare
Personal Support
Housing
Community ServicesHome Safety
SocialCare
LearningNeeds
Leisure
Voluntary Services
Private sector support
Diagram after P. Hill
Chiropody
eHealth integrated care modelHofdijk, Jacob, Casemix Advisor, Ministry of Health, Introduction to the Silo Crossing Integrated Care Approach, Presentation at eHealth Week 2012, Copenhagen, Denmark, 8th May 2012 - Session MR18, OC4 Continuity of Care
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
In order to support the Patient-Centred Approach
HIM must become e-HIM
The e-Health integrated care model requires the sharing of data from multiple sources keeping an electronic record for the patient
These records must come together (THE BLUE LINE in the diagram) to facilitate the delivery of high quality safe and effective care in the patients own environment
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Data Integrity & e-HIM In this model ownership of the data
belongs to the patient Patients will have full access to their data
engagement & empowerment They can choose who the data is shared
with BUT With ownership comes responsibility! The Patient-Managed Health Record
may become a reality!
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Benefits of Using Health IT Effectively to Improve Care Delivery
Supports citizens to manage their own health and well-being
Supports citizens to become more active participants in their own care & the services provided
Supports citizens with long-term conditions Improves availability of information for health & social
care workers to improve the safety & quality of care Improves safety for citizens taking medication
(eliminates errors) Supports the integration of care for patients like Mary
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Interoperability & Use of a Common Language between Care Providers
There is a need to link electronic systems from multiple health and social care providers (using interoperable systems) to support the integrated care approach.
Interoperability requires the use of common data standards and definitions and a common terminology such as SNOMED
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Data Sharing & Information ExchangeIssues for eHealth & eHIM
Privacy concerns regarding patient records, mainly confidentiality of data, with data sharing amongst multiple providers of care
Standards & definitions must be standardised to ensure that information is shared effectively
Standardisation of terminology is crucial to facilitate effective communication, information exchange & data sharing SNOMED will help
There must be a sound infrastructure for data sharinge.g. data sharing protocols, codes of practice etc.
Risk assessment (liability issues) for tele-health is under development
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
What does all this mean for HIMs?The challenges for our Profession!
The transition from HIM to e-HIM is a big professional issue for Health Information Managers around the world
AHIMA has been undertaking work in this area since 2003 when an e-HIM Task Force was established (Bloomrosen, Meryl. "e-HIM: From Vision to Reality." Journal of AHIMA 76, no.9 (October 2005): 36-41)
IFHIMA & AHIMA will work collaboratively on the management of health information in the age of eHealth
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Challenges for HIM Professionals in the Transition from HIM to eHIM
AHIMAs e-HIM Task Force established in 2003 identified 7 major issues affecting healthcare (rising costs, ageing & mobile population, lack of data standards, growth of technology, shrinking HIM work force, the need for consumer (citizen) education, & changing public imperatives
All 7 still remain central but former taskforce members identified 3 that are still in the forefront today i.e. The HIM Workforce, Technology & Data Standards
The transition from HIM to e-HIM is a big professional issue (a challenge) for Health Information Managers around the world, which IFHIMA will be taking forward globally.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Challenges for the Future Top 10 Trends Impacting HIM in 2016
(Linda Kloss, HIM in 2016, Precyse Solutions)1. Clinical and business process leaders must own the EHR and other
technologies in order for them to be successful.2. Some level of Information Management is a basic competence for most
who work in healthcare.3. HIM functions are distributed and embedded throughout healthcare
organizations.4. Greater recognition of the importance of managing the Records
Management/Information Management aspects of digital information through its life cycle
5. Health systems need to be overall cost effective6. Health systems are working to reducing overall costs by 20%7. The link between data quality and financial performance is well
documented8. Many people rely on technology and information to assist in self-
management e-Health, m-Health etc9. Clinicians need tools and information to anticipate the outcomes and cost
consequences of clinical decisions at the point of care.10. The design of ICD-11 is being evaluated, and planning for
implementation is projected for 2020.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Education & Support for HIM ProfessionalsTo Make the Transition
Identification of core e-HIM competencies Development of applied and interactive ways of
learning Ensure that HIM educators can access
advanced education focused on e-HIM Attract the right calibre of students through
targeted recruitment strategies Develop & deliver e-HIM conferences & other
educational opportunities to assist existing HIM professionals make the transition from traditional practice to new ways of working
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
What is IFHIMA doing??!!!! IFHIMA is working around the world to support
HIMs I am leading out-reach work in Africa to help
take HIM forward in the region My visit to Nigeria is a VERY important step for
IFHIMA to help HIMAN to raise the profile of HIM in your country
The congress in Montreal in May 2013 is a unique opportunity for us all to work together to play our part in dealing with the challenges for HIM. Between now and then let us work on the challenges together and then meet to discuss and share our experiences in Canada
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
IFHIMAs 4 Strategic Initiatives1. HIM EDUCATION IFHIMA Education Modules are on the website (free of charge),
International Educators Day in Montreal on Saturday 11th May 2013 (free of charge)2. NEEDS OF DEVELOPING COUNTRIES - IFHIMA Education Modules on the
website (free of charge), Needs of Developing Countries project and a White Paper to be published on the website before the congress in Montreal
3. DATA QUALITY/DATA MANAGEMENT - Joint working with WHO on the International Training & Certification Program for mortality & morbidity coders, free coding information sheets on the website, IFHIMA contributed to the FREE WHO ICD-10 training tool, IFHIMA is providing input to the development of ICD-11, working with WHO on a 3-year project to provide training in ICD 10 to all countries in Africa
4. THE ELECTRONIC HEALTH RECORD (EHR) White Paper to be published on the website before the congress in MontrealThe IFHIMA Executive Board is currently preparing a strategic plan for presentation at the IFHIMA General Assembly on Sunday 12th May 2013 in Montreal. Join the discussion groups at the IFHIMA General Assembly and contribute to IFHIMAs Strategic Planning Process. Its free of charge to attend and your input will be greatly valued.
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
What can YOU do?Your professional challenges!
Contribute to IFHIMAs Global News Reach out across country, regional and
international borders Communicate & share best practices Be professional in your working practices
at all times
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Other things for you to doYour personal challenges!
Embrace & be proud of your profession Embrace change, dont resist it Be focused Take responsibility and initiative Commit to continuous learning Communicate effectively Be the best that you can be!
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Thank you all very much
for inviting me to Nigeria, for your very warm welcome and for asking me to contribute to your meetings!
Being here means a great deal to me! Lorraine
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
Contact DetailsLorraine Nicholson FHRIM
Immediate Past President of IFHIMA141 Leander Drive,
Castleton,Rochdale OL11 2XE,
Lancs., UKTel: +44 1706 355957
E-mail:[email protected]: http://www.ifhima.org
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HIMAN National Meeting 6 - 7 Nov 2012Yaba, Lagos, Nigeria
References HIMSS http://www.himss.org/asp/topics_ehr.asp Daily Times NG, 25th April 2012, HIMAN calls for e-health record keeping,
Mr. Wole Ajayi http://dailytimes.com.ng/article/himan-calls-e-health-record-keeping
American Health Information Management Association (AHIMA) "Managing the Transition from Paper to EHRs." (Updated November 2010). http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048418.hcsp?dDocName=bok1_048418
Hofdijk, Jacob, Casemix Advisor, Ministry of Health, Introduction to the Silo Crossing Integrated Care Approach, Presentation at eHealth Week 2012, Copenhagen, Denmark, 8th May 2012 - Session MR18, OC4 Continuity of Care
Bloomrosen, Meryl. "e-HIM: From Vision to Reality." Journal of AHIMA 76, no.9 (October 2005): 36-41
Linda Kloss, Health Information Management in 2016, Precyse Solutions http://www.precyse.com/resources/HIM%20in%202016%20White%20Paper
_042412.pdf