ProRec QREC Workshop 2011 Nicosia, 24 March 2011

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1 ProRec QREC Workshop 2011 Nicosia, 24 March 2011 Electronic Health Records in Europe- What is its value? What does it require? What can Medical Informatics contribute? Rolf Engelbrecht 1, Claudia Hildebrand 2, Hans Demski 2, Siegfried Jedamzik 3 1 ProRec Germany, Ismaning, Germany 2 IBMI -Institute for Biological and Medical Imaging, MEDIS - Medical Information Systems, Helmholtz Zentrum München, M German Research Center for Environmental Health, Munich, Germany 3 GO-IN Physicians Network Ingolstadt

2 Information and Communication Technology in Health Care The History, the Past The Future???? Why use it?

3 Vision We have multi-contact health systems even cross border and expect: Better and secure communication between the different levels of health care Primary care, Hospitals, Specialized (university) clinics, Nursing homes, Rehabilitation, Home care, Patients BetterBetter Integration of data and knowledge Optimised delivery and higher quality of healthcare service for patients Ease Ease of work for health professionals Reduced time for decision process through the provision of data and knowledge Cost Cost savings

4 Key Problems in Information Systems for Health Care access to actual and relevant patient data and clinical knowledge (evidence, guidelines, reference data and cases) user-friendly data entry and retrieval systems for clinicians and other health professionals which improve efficiency, reduce risks and a return on investments quality of information systems terminology and data items which are unique to each system and cannot be shared communication -internally between subsystems- and -externally between different institutions and persons including security and privacy

5

6

7 Management Chronic Conditions: Integrating care Dr. Rafael Bengoa, 2008

8

9 The Five Purposes of EHRs (Peter Waegemann, MRI Boston) 1. Documentation of Health History 2. Continuity of Care Sharing Information Interoperability 3. Outcomes Comparative Data 4. Clinical Research 5. Interactive Guidance (Decision Support Systems) Interactive Medical Knowledge

10 An electronic medical record (EMR) facilitates access of patient data by clinical staff at any given location accurate and complete claims processing prescriptions building automated checks for drug and allergy interactions clinical notes scheduling sending to and viewing by labs and experts

11 Support of Decision Support Decisions in health care are based on Patient data (EHR, EPR, reports,,,, ) Knowledge (Education, experience, evidence, guidelines,,,, ) Information (generated from data using knowledge)

12 DIABCARD Model of Communication Hospital Care Primary Care Patient DIABCARD - Smart Card - Data Set Self- treatment Pharmacy

13 DIABCARD Data Set DIABCARD Groups Nervous System Kidneys General DIABCARD Core EU / G7 Administration Monitoring Measurements Feet Eyes Heart Emergency Diabetes Passport BIS Medication Diet Pregnancy

14 DIABCARD Workflow

15 DIABCARD HaB (Health across Borders)

16

17 Intent of CCR (Continuity of Care Record) Improve efficiency of health information exchange between providers: fill gap of patient information flow between providers

18 Intent of CCR Improve efficiency of health information exchange between providers: fill gap of patient information flow between providers Assure at least a minimum standard of health information transportability when a patient is seen in a new or different environment

19 Intent of CCR Improve efficiency of health information exchange between providers: fill gap of patient information flow between providers Assure at least a minimum standard of health information transportability when a patient is seen in a new or different environment Support clinical practice and accelerate EHR adoption

20 Introduction CCR (Continuity of Care Record) CCR was developed as standard by ASTM international Developed by 12 organisations representing physicians and informaticians CCR describes a comprehen- sive data set which is able to substitute the classical doctor s s report, e.g. as letter Data are stored in XML Format for easy use in different applications.

21 USES OF THE CCR For referrals, inpatient or outpatient For transfers between institutions, e.g. from GPs setting to acute care For discharges without a referral or transfers For personal health records For other uses, including Moving to a new community Disease management Home health monitoring Public health reporting Access while traveling Disasters

22 Status of Implemention in USA More than 100 Implementations in EHR-systems, in physicians nets und telemedicine applications In 2008, more than a million medical records will travel from one pharmacy chain s s clinics (MinuteClinic( MinuteClinic) ) to patients primary caregivers, or medical homes, using ASTM International E2369, Specification for Continuity of Care Record. Personal health record running in other developments HL7 has extended the CDA to CCD by CCR Microsoft Health Vault and Google Health are using it CCR standard is established in USA

23 Copyright 2008 ASTM International and American Academy of Family Physicians Screen Shot

24

25 Communication Standard ISO EN OpenEHR and EHRcom All clinical information created in the openehr EHR is ultimately expressed in Entries. An Entry is logically a single clinical statement, and may be a single short narrative phrase, but may also contain a significant amount of data. In terms of actual content, the Entry classes are the most important in the openehr EHR Information Model, since they define the semantics of all the hard information in the record. They are intended to be archetyped, and in fact, archetypes for Entries and sub-parts of Entries make up the vast majority of archetypes defined for the EHR.

26 Archetype Intuitive model of clinical content

27 Clinicians define domain knowledge Empowerment of domain experts: The domain experts create & change the knowledge on their own Standardisation of archetypes helps to maximise the use of data and information Document data once use multiple times! Data aggregation when reporting Semantic interoperability between systems Enable lifelong electronic records

28 Archetype example

29

30 Clinical Work Information and Communication technologies Organisation of m edicine and health care (system) Three Domains Needing an Effective Fit

31 EuroRec Repositories and Tools Archetypes repository Certification Criteria Other ProRec-Centres and EuroRec partners (27 in EHR-Q Q TN project)

32 EU Projekt Semantic Health

33 EU Project Semantic Health

34 EU-Vision Interoperability

35 Communication in ByMedConnect

36 Demands electronic communication ByMedConnect Study (May 2010)

37 Conclusion on EHR Systems Standards and its application Medical documenting Storing Communicating Medical knowledge HL7 (CDA, CCD) CCR EHRcom (ISO EN 13606) ISO requirements for EHR architectures. IHE DICOM QREC Quality Criteria for Electronic Health Record Systems EHR systems relate standards Security and privacy standards

38 More Information: Standard Specification for Continuity of Care Record XML Schema of CCR ://sourceforge.net/projects/ccr-resourcesresources Actual Information Videos on ASTM CCR Standard DE.org muenchen.de

39 Thank you for your attention! Questions and answers

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