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Electronic Medical and Health records

Main QuestionsMain Questions

Medical record BasicsElectronic Medical Record and

Electronic Health RecordEMR ImplementationEMR systems in developing

countries

1.1. Medical record Basics Medical record Basics

Medical record definitionPurpose of the MRFormat of the MRContents of the MRAdministrative issues of the MR usage

1.1.11. . Medical recordMedical record definitiondefinitionA medical record, health recordmedical record, health record, or

medical chartmedical chart is a systematic documentation of a patient's medical medical history and carehistory and care.

The term 'Medical record' is used both for the physical folderphysical folder for each individual patient and for the body of body of informationinformation which comprises the total of each patient's health history.

1.1.22. . Purpose of the MRPurpose of the MRThe information in the MR allows health care providers to

provide continuity of care to individual patientsprovide continuity of care to individual patients.The MR also serves as a basis for planning patient carebasis 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 educate medical students/resident physiciansstudents/resident physicians, to provide data for internal internal hospital auditing and quality assurancehospital auditing and quality assurance, and to provide data for medical research.

1.1.33.. Format Format of the MRof the MRTraditionally, medicals records have been

written on paperwritten on paper and kept in folders.These folders are typically divided into divided into

useful sectionsuseful sections, with new information added to each section chronologically as the patient experiences new medical issues.

Active records are usually housed at the Active records are usually housed at the clinical siteclinical site, but older records are often kept in separate facilities.

1.1.44.. Contents Contents of the MRof the MRContentContent of the medical record may vary depending upon depending upon

specialty and locationspecialty and location, it usually contains following patients data:

identification informationidentification information; health historyhealth history (what the patient tells the health care

providers about his or her past and present health status); medical examination findingsmedical 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.

1.1.44..1. 1. MR general sectionsMR general sections DemographicsDemographics 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 historymedical 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.

1.1.44..1. 1. MR general sectionsMR general sectionsMedical history section of the MR includeinclude: Surgical historySurgical history - is a chronicle of surgery performed for the patient

(dates of operations, operative reports, etc.). Medications and medical allergiesMedications and medical allergies - a summary of the patient's

current and previous medications as well as any medical allergies. Family historyFamily 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 historySocial 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.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 historyImmunization history. The history of vaccination is included.

1.1.44..1. 1. MR general sectionsMR general sectionsMedical encounters.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).problem-oriented medical record (POMR).

1.1.44..1. 1. MR general sectionsMR general sectionsEach medical encountermedical encounter will generally contain the aspects: Chief complaintChief complaint. This is the problem that has brought the

patient to see the doctor. History of the present illnessHistory 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 examinationPhysical 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 planAssessment 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.).

1.1.44..1. 1. MR general sectionsMR general sections Orders -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 -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 notesProgress notes - when a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc.

Other informationOther 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.

1.1.55.. MR Administrative issues 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,production,ownership,ownership,accessibility,accessibility,destructiondestruction:

2. 2. Electronic Medical Record Electronic Medical Record (EMR) and Electronic Health (EMR) and Electronic Health Record (EHR)Record (EHR)ReasonsEMR and EHR definitionsData types in the EMR (EHR)EMR IssuesStandards used within EMREMR categories

Go from Paper to DigitalGo from Paper to Digital

Have patient information at your fingertips.Have patient information at your fingertips.

2.1. Top Reasons To Adopt an EMR2.1. Top Reasons To Adopt an EMR Better access to dataBetter 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 BillingSimplify Billing More accurate insurance claims submissions. Faster and easier Accounts Receivable management. Customized and automated billing options. Better chartingBetter 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 Definitions2.2. EMR and EHR Definitions Electronic Medical Record (EMR)Electronic Medical Record (EMR)

– Electronic health-related information on an individual within one healthcare organization

Electronic Health Record (HER)Electronic Health Record (HER)– Electronic health-related information on an individual

across more than one health care organization Personal Health Record (PHR)Personal Health Record (PHR)

– Electronic health-related information on an individual managed, shared and controlled by the individual

22.2..2.1. 1. Overlap in TerminologyOverlap in TerminologyAn electronic medical record (EMR)electronic medical record (EMR) is a

medical record in digital formatmedical record in digital format. In health informatics an EMREMR is considered by

some to be one of several types of EHR EHR (electronic health record)s(electronic health record)s, but in general usage EMR EMR and EHR EHR are synonymous.

The term has sometimes included other (HITHIT, or Health Information TechnologyHealth Information Technology) systems which keep track of medical information, such as the practice management systempractice management system which supports the electronic medical record.

2.3. Data types in the EMR2.3. Data types in the EMRAn electronic medical (health)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.

2.42.4.. EMR and EHR general notes EMR and EHR general notesIdeal characteristics of an EHRIdeal characteristics of an EHR: Information should be able to be continuously continuously

updatedupdated. The data from an EHR system should be able to

be used anonymouslyanonymously for statistical reportingstatistical 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 ("interoperabilityinteroperability") would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities

22.4.4..1.1. EMR Issues- InteroperabilityEMR Issues- InteroperabilityIn healthcare, interoperabilityinteroperability is the ability of different

information technology systems and software applications to communicate, to exchange data to communicate, to exchange data accurately, effectively, and consistentlyaccurately, effectively, and consistently, and to use the information that has been exchanged.

Health Information Exchange (HIE)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 Office of the

National Coordinator for Health Information National Coordinator for Health Information Technology (ONC)Technology (ONC) was created, in order to address interoperability issues and to establish a National National Health Information Network (NHIN).Health Information Network (NHIN).

22.4.4..2.2. InteroperabilityInteroperabilityThe Center for Information Technology LeadershipCenter for Information Technology Leadership described

four different categories (levels) of data structuringfour 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.

3Machine 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 provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.

22.4.3.4.3. . Older record incorporationOlder record incorporationTo attain the wide accessibility, efficiency, patient accessibility, efficiency, patient

safetysafety and cost savingscost savings promised by EMR, older older paper medical recordspaper medical records ideally should be incorporated into the patient's recordincorporated into the patient's record.

The digital scanningdigital 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.

22.4.4..4.4. BarriersBarriers and Limitationsand Limitations 80%80% of the work of EMR implementationEMR implementation must be spent on

issues of change managementchange management, while only 20%20% is spent on technical issues related to the technology technology itself.

Organizational and social issuesOrganizational 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 Limitations in software, hardware and networking technologiestechnologies has made EMR difficultdifficult to affordably implement in small, budget conscious, multiple location healthcare organizations too.

22.5.5. . StandardsStandards used within EMRused within EMRThere are many standardsstandards relating to specific aspects of EMRs.

These include: ASTM InternationalASTM 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)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.

HL7HL7 - 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 DICOM - a heavily used standard for representing and communicating radiology images and reporting .

2.5.1. HL7 (Health Level 7)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

EHR components Basic FullHealth Info & Data * *Order EntryMedication Orders * *Lab Orders *Radiology orders *Rx sent electronically *Orders sent electronically *Results ManagementView lab results * *View imaging results * *Images returned *Clinical Decision support

*

Public Health

2.6. 2.6. EMREMR categoriescategories

33. . EMR ImplementationEMR Implementation

Status of EHR AdoptionEHR development planingEHR examples

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 3.1.Status of EHR AdoptionAdoption

3.1.Status of EHR Adoption3.1.Status of EHR Adoption

Setting 2006(%)

2007(%)

2008(%)

2009(%)

PO (basic) 11 13 17

PO ( full) 3 4 4

Hospitals (basic) NA NA 8Hospitals (full) NA NA 2

Source: CDC National Ambulatory Medical Survey (NAMC) of ~2700 physicians RR 62% AHA~3037 hospitals; RR 63%

3.1.Status of EHR Adoption3.1.Status of EHR Adoption

3.1. Effect of Adoption of EHR 3.1. Effect of Adoption of EHR SystemsSystems

DesRoches CM et al. N Engl J Med 2008;359:50-60

3.2. EHR development planing3.2. EHR development planing System implementation projects, in general,

experience low success rates:– 28% of projects meet full success28% of projects meet full success – 49% of projects are fully completed, but 49% of projects are fully completed, but

over budget, over schedule and lack full over budget, over schedule and lack full scope of planned functionalityscope of planned functionality

– 23% of projects experience complete failure 23% of projects experience complete failure or are cancelledor 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 Success3.2.1. Planning for Success The key contributing factors to implementation failure

reported were:– Lack of planningplanning – unclear vision, goals and

approach, not aligned with vendor incentives, schedules, other practice priorities and other resource responsibilities.

– Incomplete, unclear and/or changing requirementsrequirements.– Lack of executive support and commitmentexecutive support and commitment.– Lack of resourcesresources dedicated to the project (staff,

time, money, end-user involvement, project management and IT support)

– Unrealistic expectationsexpectations for what can be accomplished and how quickly it can occur.

3.2.2. 3.2.2. The EHR Adoption ProcessThe EHR Adoption Process

3.2.3. Framework of EMR solutions3.2.3. Framework of EMR solutions

3.2.4. How do Clinicians Interact with 3.2.4. How do Clinicians Interact with EMRsEMRs

3.3. EHR example3.3. EHR example

Electronic Electronic health health record record

(EHR) with (EHR) with image and image and document document

linkslinks

EMR frontscreen – MediNotesEMR frontscreen – MediNotes

EMR – Veterans AffairsEMR – Veterans Affairs

VA – DoD

EMR – MS Office OneNoteEMR – MS Office OneNote

EMR face sheet – AMBASEMR face sheet – AMBAS

EMR progress notes – AMBASEMR progress notes – AMBAS

Automated patient q’aire – ADSAutomated patient q’aire – ADS

Pediatric EMR – MDS MedicalPediatric EMR – MDS Medical

PMS scheduler – AMBASPMS scheduler – AMBAS

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

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)

4.1. Developing country issues

ApproachApproachA shift in perspective from a reporting based model of system

design to a more learning based approach whose main focus is on

direct care.

LocalizationLocalizationSystems 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 ownershipCosting 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 protectionPersonal 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 caseBusiness caseElectronic Medical Record systems deployed in developing countries are driven by programme management needs across districts, regions and countries.

4.2. Critical issues

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

4.3. Active EMR and reporting systems

WHO/Evelyn Hockstein

WHO/Evelyn Hockstein

ConclusionConclusion

In this lecture was considered next questions:

Medical record BasicsElectronic Medical Record and Electronic

Health RecordEMR ImplementationEMR systems in developing countries

LiteratureLiterature

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