Electronic Health Records Dimitar Hristovski, Ph.D. Institute of Biomedical Informatics Medical Faculty University of Ljubljana, Slovenia

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Types of (Paper) Medical Records  Time oriented  Data source oriented  Visits, laboratory results, X-ray images  Problem oriented (SOAP)  Subjective: patient description  Objective: physician or nurse description  Assessment: investigations results and diagnosis  Plan: treatment plan (therapy, surgery,...)

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Advantages of Paper Medical Records (compared to Electronic Med.Rec.)  Easy to move around  Freedom of expression  Easy browsing  Additional training not necessary  They always work (in contrast to computer based records)

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Disadvantages of Paper Medical Records (compared to Electronic Med.Rec.)  Not accessible from different locations  Do not allow different views of data  Fast search not possible  Lack structured data entry  Difficult usage for decision support  Not easily used for research  Do not support multidisciplinary healthcare  Time consuming data exchange

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records What is Electronic Health Record?  The electronic health record is a computer- stored collection of health information about one person linked by a person identifier.  It represents the basis for healthcare information systems development.

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Electronic Health Records in Relation to other Healthcare Info. sub-Systems They exchange data with these sub-systems:  Data entry and results browsing  Ordering tests and examinations  Event monitoring  Research databases  Laboratory information systems  Pharmacy information system  Radiology information system

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records The Five Levels of Healthcare Information Systems  Level 1: Automated medical records  Level 2: Document imaging  Level 3: Electronic medical records  Level 4: Electronic patient record systems (also called Computer-based patient record systems)  Level 5: Electronic health record

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Automated Medical Records  Most current systems fall into this category  Patient information mostly in paper form (although up to 50% is computer-generated)  Are the basis for some computer supported functions:  Admission/Discharge/Transfer (ADT) systems  Patient accounting and its linkage to clinical information  Department systems (radiology, laboratory, pharmacy, etc.)  Order entry / Results reporting

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Document Imaging  Why? To address the space shortage most providers experience in record storage  Documents are created on paper  Paper documents are indexed and scaned, and stored in computer form  Complete documents with their legal attributes such as data and signature are scanned  The human operator is not allowed to change or delete the scanned documents

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Electronic Medical Records  Is an upgraded version of previous record  Data is entered directly into the computer in structured form, suitable for various purposes  Successful use depends on:  User friendliness  User acceptance  System design and functionality

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Electronic Medical Record Essential Functions  Using enterprise-wide master-patient index  Making all enterprise-wide patient information available to all caregivers  Creating a security system:  Access control; Electronic signatures  Data integrity; Auditing; Availability  (Optional) Integration with expert programs:  Electronic handbooks and references  Clinical decision support programs  Drug selection and adverse drug reaction identification programs

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Electronic Patient Record Systems  Has a wider scope of information than the electronic medical record  Combines several enterprise-based electronic medical records concerning one patient and assembles a record that collects all professional health information on that one patient  If acceptable to the patient, may be a longitudinal record

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Prerequisites for Electronic Patient Record Development  Development of a national or international system of identifying all patient information available nationwide or worldwide.  Development of a system where either central databases or provider organizations collect, store, safeguard, and distribute patient information.  Developing an approach for common terminology, data sets, and structures.  Creating an international consensus on security systems that would allow electronic patient record systems to operate at a level of trust.

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records The Electronic Health Record  Contains additional data not being limited to information predominantly captured by caregivers regarding a patient.  Includes wellness information and other health- related information:  Behavioral  Dietary  Drug-related  Exercise related  Environmental  Sexual information

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Minimal Basic Data Set  Example: 13 basic patient data elements from an acute care hospital: 1. Hospital identification 2. Patient number 3. Sex 4. Age at admission 5. Marital status 6. Address 7. Date of admission

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records (cont...) 8. Length of stay 9. Discharge status 10. Primary diagnosis 11. Secondary diagnosis 12. Surgical and obstetrics treatments 13. Other important treatments

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Information Society (Internet) Influence on Healthcare  Patients will search for health related information on the Internet  Patients will like to have better access to their healthcare records  Internet has allowed (will allow) telemedical services:  Buying drugs  Medical consultations (including second opinion)

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Personal Health Record Types  Off-line (on paper, smart card, on a computer)  Web-based Commercial/Organizational  Functional/Purpose-based (e.g. emergency healthcare abroad)  Provider-based (appointments, medications, allergies,...)  Partial health record (user-profiles at various health-related websites)

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records “Smart” cards  Allow storing some of the patient information on a card of the size of a credit card.  Types of smart cards:  Magnetic  Laser (optical)  With a chip or without

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records

Example: problem list and therapy

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Example: current problem – left earache

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Example: objective problem description

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records

Example: diagnosis

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Example: therapy

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records Example: list of laboratory tests

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records

Example: laboratory tests order list