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1 Electronic patient record in primary care TDT4210 Health care informatics Professor Anders Grimsmo, DMF, NTNU 1935.

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Presentation on theme: "1 Electronic patient record in primary care TDT4210 Health care informatics Professor Anders Grimsmo, DMF, NTNU 1935."— Presentation transcript:

1 1 Electronic patient record in primary care TDT4210 Health care informatics Professor Anders Grimsmo, DMF, NTNU 1935

2 2 2005

3 3 1935

4 4 2005

5 5 Pasientjournal anno 1872

6 6 - a challenge to NTNU: Five millions NOK for five years Create a productive and viable competence community for research, development, implementation and knowledge sharing in conjunction with electronic patient record (EPR).

7 7 People per month Level of care 2 Regional hospital 13 Local hospital 150 Primary care 500 Self-care 85 Symptoms, no treatment 250 No symptoms 1000 Risk population Patients and Level of care

8 8 National Insurance Administration (RTV) Health center Nursing homes, physiotherapists, Care services Pharmacy Hospitals SSB, NPR, misc. central regisgistres Ministry of health and social affairs (SHD) Central Health company Local Specialists Internett Psychiatry Cooperation in the health care services The patient in center

9 9 Collaborating partners of the general practitioner SOSIALTJENESTER Bolig Barnevern 2. LINJETJENESTEN Poliklinikker, sykehus Privatpraktiserende spesialister TRYGDEKONTOR ANDRE STATLIGE INSTITUSJONER OG REGISTRE Folkehelsa Statens helseundersøkelser Fødselsregistre Statistisk sentralbyrå Kreftregistre med mer. POLITI LABORATORIER Klinisk-kjemiske Patologiske ALKOHOLISTOMSORG FRIVILLIGE ORGANISASJONER ADMINISTRASJON Helsesjef Helse- og sosialstyre PLEIE/OMSORG Hjemmesykepleie Syke- og aldershjem Psykiatri FOREBYGGENDE TJENESTER Helsestasjon/skolehelsetjeneste Miljørettet helsevern Skole/Barnehage/PP-tjeneste Bedriftshelsetjeneste The general practitioner Municipal services Specialist services Governmental entities REHABILITERING Fysioterapi Ergoterapi Vernepleie BEREDSKAP Legevakt, AMK, ambulanse HELSETILSYNET Fylkeslege APOTEK See glossary avaliable from the web pages

10 10 Information exchange in primary care 20 millons single bills to national assurance (contact bills). 1,9 millons referrals to hospital or specialist 3,8 millons epicrises from hospitals and out-patients’ clinics 1,0 millons physiotherapist requisitions 1,3 millons image requisitions 3,5 millons medical certificates and sickness benefit certificates 200.000 medical certificates on disablement 7 millons test requisitions to laboratories, each with 6-7 analyses 17 millons prescriptions per year Is written and sent:

11 11 Health service characteristics Primary care serviceSpecialist health service OrganisationDecentralized, autonomousGoverned, hierarchical EconomyPrice per unit, own risk,Framework, price per unit low costsHigh costs ServicesLarge volume, broad-spectrum,Segragated and specialized brief contacts Patient-doctor Continous, persona,Short-lived, limited relationship and binding

12 12 Work Technique Characterestics Primary care serviceSpecialist service No of health problemsUsually severalUsually one Clinical pictureEarly in the disease courseFully developed clin. picture Disease prevalenceLow and unselectedHigh and selected Diagnostic methodReductionisticSystematic complete Pattern recognition”Puzzle” Probability evaluation Tests and procedures Few and simpleNumerous and advanced TreatmentPatient oriented Organ- and disease-oriented Simple, searchinglyMore advanced, based on certain diagnosis

13 13 The diagnostic process Presented health problem Reason for contact Anamnesis, symptoms Pattern recogn. Hypotheses Searching for caracteristics (finds, results) Dignosis Treatment Revision of hypothesis Former knowledge about the patient Probability evaluation

14 14 Prediction value in medical diagnostics Prevalence, sensitivity, specificity 2 x 2 table: True positive False positive True negative False negative Ill Healthy Positive testNegative test

15 15 The meaning of sensitivity and specificity – an example: Prevalence: 1% (near-sighted at school start) Sensitivity: 95% Specificity: 95% No of children: 65.000 Ill 617 33 650 Healthy 3 218 61 132 64 350 65 000 Positive test Negative test Examination of school children

16 16 Prediction value of symptoms SymptomDiagnosis % av pasientene General practiceInternal medicinal dep. Pyrosis Gastric catarrh Gastric ulcer Gastric cancer 90 10 0,5 30 60 10 Spinelessness Depression Leukemia 37 0,05 General practiceHematologic pol 4 24

17 17 100 60 40 % 00 Share of true pos. False positives False positives True positives 1 %10 %100 % Prevalens of disease Example: Test sens. = 95 % Test spec. = 95 % Prevalence most important for the test result

18 18 Diagnosis - name of disease based on: Information from the patient The anamnesis Symptoms Clinical investigations Laboratory tests To diagnose is to classify

19 19 Migraine Criteria: Recurrent episodes of headache with three or more of the following finds: unilateral headache, nausea/vomiting, aura, other nevrological symptoms, migrain in the family Inclusion: vascular headache with/without aura Expulsion: cervikogen headache, cluster-headache, tension headache

20 20 Classification of Diagnoses Reason for contact/ hospitalization Symptoms, clinical finds, lab. results Code Diagnostic process Collect information Name disease/- problem Diagnosis criteria Classify Inclusion and expultion criteria Arrange classes Classification of diagnosis

21 21 Systems for diagnosis class. Hospitals and specialist services: ICD (International Classification of Diseases) Primary care services: ICPC (International Classification of Primary Health Care)

22 22 ICPC

23 23 Prevalence of chronic diseases in the practice population

24 24 Main objective of the patient record Medical, for the physician as a tool in diagnostics and treatment Juridical, for the patient according to rights. - is now documentation: - in the future also: Communication Decision support

25 25 Main functions in todays EPR: Pasient data/card file function Contacts and diagnosis Record notes (free text about symptoms, finds and considerations) Prescription module Laboratory module – requisitions and answers Correspondance – Referrals, certificates, word processing Schemes – archive, filling in Appointment book/waiting list Accounting module Simple statistics

26 26 Better overview and be adapted to the working methods of the general practitioner Support in diagnose and treatment Quality assurance of procedures Information sharing Information reuse ERP challenges A record which can give:

27 27 Mirror the contents and process of the consultation Subjective – symptoms (anamnesis) Objektive – Signs and finds (clinical examination/tests) Assessment – Considerations and conclusion (diagnosis) Plan – effectuation of action (prescr, report sick etc.) S O A P

28 28 "While the core of earlier patient records were schemes of book-keeping, the core of EPR ought to be the patient’s health problems represented by episodes of care" Problem oriented record

29 29 Episode of care Episode of disease Primary care Hospital Contacts:GP H Hospitalization Care services Nursing home GP=General pract. H=Home nursing GP ”Episode of care”

30 30 Diabetes Osteoarthritis Depression Appendix Tendinitis Pneumonia T Case history (episodes of care)

31 31 Problem list

32 32 Information needs in daily work Questions arise regularly while working with patients: attached to treatment, most often medication can be about much more than medical knowledge passes usually unanswered Preferably physicians ask their colleagues – oral/on the phone Information utility value = relevance x validity the effort needed to find the info

33 33 Use models and routines from ”best-practice” as foundation Convey models and systems from private sector and into the public health care sector Try to convey solutions developed in one county, to another Guaranteed to create problems Error ?

34 34 Mobile enheter Stemmegjenkjenning, Brukergrensesnitt, kurve Helseinformatikk laboratorium Brukbarhetstesting, Drama og prototyping Helhetlige forløp Problemorientert journal Representasjon av forløp Beslutningsstøtte Integrering av retningslinjer og behandlingsplaner Sikkerhet Rolle- og oppgavespesifikk tilgangskontroll, Automatisert anonymisering Meldingsutveksling Alle til alle kommunikasjon (ELIN-prosjektet) Pasientdeltagelse Tilgang til egen journal, rekvirere tjenester via nettet, Egenjournal Gjenbruk av data ”Datagruvedrift” Helse- og sykdomsregistre Deling av pasientinformasjon Legemidler, Individuell plan, Helsekort for gravide Research at NSEP Pasientjournalens rolle og funksjon Implementering og anvendelse Feltmetodikk

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