1. Electronic Health Records Dimitar Hristovski, Ph.D. E-mail: dimitar.hristovski@mf.uni-lj.sidimitar.hristovski@mf.uni-lj.si Institute of Biomedical Informatics Medical Faculty University of Ljubljana, Slovenia

2. 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,...)

3. 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)

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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)

18. 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)

19. 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

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

21. Example: problem list and therapy

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

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

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

25. Example: diagnosis

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

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

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

29. Example: laboratory tests order list