The Electronic Medical The Electronic Medical RecordRecord

Department of Medical Informatics and Education

by

Lorna Duddy.

Existing Hospital Records .......Existing Hospital Records .......

Paper Charts of Patient Medical Records are the norm worldwide for recording patient information.

All relevant patient information is documented in one file for reference - including Lab. results, test results and progress notes.

These charts are easy to use. The same file is used on subsequent admission to the

same institution. And as source of reference for medicolegal cases.

By now most large health care institutions have a computer database of patients which matches :

* Patient’s Hospital I.D. Number

* Name

* Date of Birth

* Address ....

This provides a rapid search

to match a patient name

with a chart no. when

retrieving a record from storage.

The source of the Electronic Medical Record is simply expanding on this database creating an “on-line” record for each Patient.

The Electronic Medical Record.The Electronic Medical Record. The Electronic Medical Record (EMR) is the

future of patient record documentation. There is very wide scope for applications and

additions around a centralized record. The EMR can be accessed conveniently by

appropriate health professionals to ensure ultimate maximum and optimal patient care.

This tutorial discusses the following :

Description of a typical EMR.Potential applications.

Problems associated with its use.

There are many aspects contributing to a typical There are many aspects contributing to a typical EMR.EMR.

G E N E R A LPRACTITIONER

H O S P ITA LA D M IS S IO N

D IA G N O S IS LA B O R A TO R YR E S U LTS

PROG RESSN O TE S

TR E A TM E N TS

D E C IS IO N S

P A T IE N T

Admission Details : Patient History Physical Exam. Observations - weight

- b.p. - temp. - pulse

are easily updated and reviewed at subsequent hospital admissions.

At Hospital Admission...

LABORATORY RESULTS GRAPHLABORATORY RESULTS GRAPHDifferent variables at different dates can be seen at a glance.Different variables at different dates can be seen at a glance.

08/01/95 15/02/95 31/05/95 28/09/950

50

100

150

200

250

300

350

08/01/95 15/02/95 31/05/95 28/09/95

GlucoseCholesterol

Lab. results can be received directly from the laboratory andare entered directly, available for the doctor to review.

Variations from the normal values are also easily seen.

Glucose Normal

A S.M.A.C. result may look A S.M.A.C. result may look like....like....

0

50

100

150

200

250

300Creatinine

Uric Acidumol/l

Alk phosu/l

LDH u/l

AST u/l

ALT u/l

GGT u/l

0

1

2

3

4

5

6

7

8 Glucose

urea

Calcium

Phosphate

Cholesterol

A Centralised Record can be accessed easily by various A Centralised Record can be accessed easily by various hospital departments as illustrated below.hospital departments as illustrated below.

LaboratoryP athology

B ac terio logy

R adio logy P hys iotherapyU nit

P harm acy

C are/Treatm ent UnitH ospita l W ard

P atient Location

A Medication Guide such as the one in the next slide gives a comprehensive overview of :

Patient Drug History Drug Allergies Reasons for prescription Dose

Through inclusion of an on-line guide such as BNF or MIMS, warning of impending drug interactions and contra-indications may be given.

PHARMACY ACCESSPHARMACY ACCESS

MEDICATION MANAGER

Patient Name : CURRENT DRUG HISTPORTI.D. No. :

DIAGNOSIS : Urinary Tract Infection

OTHER ACTIVE PROBLEMS

ASTHMA

Drugs Available for Diagnostic Profile : CODEAMPICILLINAMPICILLIN-SODIUM

SELECT CANCEL

Consultant :

CURRENT DRUG HISTORY

Include : All current and expired drugs.

DRUG DOSEBecotide 250 2/day

Drug Allergies : NONE KNOWN

PRESCRIBE RESULTS....

CT Scan and X-ray results such as this (see next slide)can be processed, reviewed and entered directly into the patient file.

The results may be sent to other specialists by the Internet network for consultation.

Processing resultsProcessing results

Display Graphics...Display Graphics...

The index of an Electronic Medical Record

may look like.....

Applications of the E.M.R.Applications of the E.M.R.

COMMUNICATION ...

One of the advantages of a central record is the ease of communication between - Hospital Departments -

e.g. for booking of diagnostic tests. -G.P. and hospital physician by email.

Standardised, structured messages may be sent from one person to another both of whom are familiar with the format, by the Edifact system (Electronic Data Interchange For Administration, Commerce and Transport).

Communication can be made easier via email Communication can be made easier via email services services

P atient S pec ia lis tS urgeon

A naes thetis tO ther health care personnel

G enera l P rac titionerR eferee

H ospita l P hys ic ian

TELEMEDICINE...This is the practice of medicine using any data transfer linkedwith the process of care, in which some aspects of the care are assisted by remotely located professionals.Specialist communications may be made by Video-link.

Components of Telemedicine

PATIENT SITE EXPERT SITE

COMMUNICATION NETWORK

PATIENT SPECIALIST DATA TREATMENTS CONSULTATION

PHYSICIAN EXPERT IN-CHARGE DATA

Telemedicine at Work...Telemedicine at Work... The Eastern Health Board has introduced patient “Smart Cards” on a

pilot basis, where a patients medical record may be carried by the patient as a plastic card and may be inserted into a special decoder, read and updated at hospitals and GP practices participating.

This Autumn British Airways are introducing a satellite communication with a doctor on the ground as a back-up to Flight Attendants with basic medical skills.

Vital signs are communicated and doctors can manage patient care from the sky and decide whether an emergency landing is necessary.

“Net To The Rescue”..... It was recently reported that two Chinese students at Peking

University sent an appeal for help to find a diagnosis for their Chemistry student colleague who had developed a severe illness to which the doctors at Peking Union Medical College hospital had no cure.

The medical information was sent to Sci.med newsgroups and within 24hrs was read by a doctor in Washington who recognized the girls serious condition could be due to thallium poisoning.

Phoning the hospital in Beijing he advised to check for thallium poisoning.

To the initial annoyance of the physicians over 600 email messages were received in reply to this appeal and the general consensus pointed to the same and correct diagnosis.

An Internet page is established to monitor the patient - Zhu Ling’s recovery. This can be accessed at http://www.radsci.ucla.edu/telemed/zhuling.

THE EMR AS AN INFORMATION SOURCE THE EMR AS AN INFORMATION SOURCE FOR STATISTICAL RESEARCH.FOR STATISTICAL RESEARCH.

Specific information gathered from a large number of patients for a

certain disease with regard to

Severity

Duration of symptoms,

can be represented graphically or scored.

This can be used as a reference for aids to diagnosis .

A “Relational Database “ would be of this form and could be incorporated into the EMR.

QUESTIONNAIRE ON LIVER DISEASE

General ScreenYellow Sclerae.....Age in yearsMale sexWeight loss

Jaundice....Duration (days)DeepIncreasing since onsetDecreasingConstant

AnorexiaNausea/vomitingSymptoms precededjaundiceHaemetamesispale stooldiarrhoeaurine darkAbdomenpalpable spleenpalpable gallbladdertender gallbladderAscites

liver definitely enlargedliver hardliver tenderliver irregularobvious massOther FatigueWeight loss......Doctors experience in yrsHistory taken from patientHistory taken from chart

Conventions : Please mark all items P = Present O = Absent s = Unknown/doubtful

Lines ___= Enter Text ...= Enter number

Charts such as the sample in the previous slide are completed and the information is coded into computers.

From these standard form findings, accumulated from thousands of patients, it is possible to set up a data base.

Through the use of Artificial Intelligence and applying statisitcal rules, the condition of a given patient - on which the same findings are available, can be predicted.

In the I.C.U. this type of correlation, analysis of Laboratory results and biochemical readings from monitors may be incorporated to predict a patient’s progress and forecast how long a patient may have to stay in intensive care.

This is important to hospital staff and management as to how many places will be available at a given time.

APPLICATIONS FOR HOSPITAL MANAGEMENT.

CENTRAL RECORDING OF :•number of bed days•procedures and tests obtained by the patient,•units of treatment givenin addition to CODING OF DIAGNOSIS, PROCEDURES AND MEDICATIONS will make auditing of patient accounts easier and also more accurate.

TRANSMISSIBLE RESULTS MAY CUT DOWN ON THE NEED TO REPEAT TESTS.

Difficulties Associated.....Difficulties Associated..... It is clear from the previous slides that the technology is

available to support far ranging possibilities for an Electronic Medical Record.

However there are enormous problems to be overcome with regard to its use.

Designers of EMR’s must adhere to existing laws and legislation must be put in place to govern the appropriate use of data collected.

Access - Patient confidentiality must be preserved at all times. Coded access e.g. by PIN would be a necessity.

Different types of codes could be given to personnel who access the record for different purposes :

~ Doctors ~ Secretarial

~ Paramedical ~ Administrative

The quality of data stored is also a problem of paper records. Data is a man-made artifact. Each individual has a method for recording relevant patient data within a framework. Marked discrepancies may occur between information reported during patient interview and that which is contained in the record.Not all patient facts reported may fit neatly into a structured record

Such “misinformation” may be contained in the EMR due to misunderstanding of definitions and terms used. Standardization Is a definite requirement for widespread use of electronic records.This would include Lab. results units and precise medical terms.On-line dictionaries would help.Standardization of support software to link one system to another would also be necessary.

Data

CostThe introduction of such a record would involve phenomenalfinancial expense~ Hardware and Software equipment~ Staff Training - would demand time and money which could be spent alleviating waiting lists.Although expensive test results available centrally would be a saving in health service costs.

ComplexityThe EMR allows for increased processing of medical data.and enhances data analysis, which may ultimately complicate research with flawed data.The reasons why and the circumstances under which data is collected is not accounted for by simply coding observed facts into a structured computer programme.

ConclusionConclusion The aim of the EMR is to encompass all underlying structures

of paper record in a structured user-friendly format. Good history and physical exam. and clinical observation skills

are the key to achieving information which is managed to support clinical decisions and actions taken in patient care.

A Centralised record including lab. and procedure results and medication records will enhance patient record interpretation.

Coding of Diagnoses, Procedures and Medications will benefit ~ Research

~ Auditing

Many of the programmes concerning the EMR are still in the pilot stage.

Legislation is needed to

– Promote patient confidentiality

– Govern the use of data collected. Efficiency in the management of patient information,

leading to more competent clinical action is the aim and should not be lost in megabytes of data input.