1 Electronic medical records Purposes Structures Related nomenclatures Implementations References
2 Purposes Collecting relevant data Reporting Management of medical data Administrative management Attestation and defending the patient Correspondence
3 Purposes EMR is a communication tool Between health workers Between GP's and hospitals Towards the patient
4 Purposes This means WORK! Who will do it? General Practitioner best placed (Patientcentric medicine!) Patient rights? Full access EXCEPT for personal notes of the physician Patients'own data input?? Health Vault, Google Health??
5 Structures 1. Journal (log-book) 1. SOAP registration 1. Segmented record 1. Pre-conditions/context of the patient 2. Mode of life/ habits 3. Pregnancy record 4. POMR (Problem Oriented Medical Registration) 5. Problem list 6. Diabetes record 1. Episode registration
7 Structures 1 patient + 1 physician + 1 contact: case: S Subjective element: patient's complaint O Objective measurement A Action taken P Planning: what next? Care plan? Clinical path?
8 Structures Problem Oriented Medical Registration (POMR) Patient (central element) Health agent Health care element Health approach Service(s) Contact/sub-contact
9 Structures Problem Oriented Medical Registration (POMR)
10 Structures Problem Oriented Medical Registration (POMR)
11 Structures Problem Oriented Medical Registration (POMR)
12 Structures Problem Oriented Medical Registration (POMR)
13 Structures Problem Oriented Medical Registration (POMR)
14 Structures Health Care Element : Can be defined by any item in the patient record describing the patient s state of health and for which something is (has been) done by a health professional. A Health Care Element is addressed by at least one service A Health Care Element is related to one defined patient and to one specific problem (item). Most of the time, this problem (item) can be identified by a diagnosis, by a patient s complaint, a risk factor, a life condition,...
15 Structures Health Care Element : attributes 1 p at ien t + 1 p r o b lem La b el(s ) d at e s t a r t d at e en d in d ex gr a vit y, cer t it u d e,... a ct ive / in a ct ive et c.
16 Structures Health Approach Comprises all that has been done by 1 health agent with a specific objective within one health care element Enables to differentiate the actions taken by different members of a health team: Physician (apporoach = follow-up ) Surgeon (approach = sugery ) Physiotherapist (approach = re-education ) Nurse (approach = pain control ) All in the context of a single health care element: broken leg
17 Structures Contact Any interaction between a professional and a patient with or without encounter includes at least 1 service related to a single health agent
18 Structures Subcontact Part of a contact dedicated to a single health approach including all services related to a health approch could be SOAP structured
19 Structures Service Recording (data entry) into the EPR of information related to any activity or process performed by the health professionals. Any data in the EPR is introduced through service. A service is related (directly or indirectly) to only one Health Agent. A service may be related to several sub-contacts (of the same contact), and thus to several Health Approaches (of a same Health Agent) and to several Health Care Elements (of a same patient).
20 Structures Problem Oriented Medical Registration (POMR)
21 Structures: POMR
22 Structures: POMR
23 Structures: POMR
24 Structures: POMR Routine: journal + link to health element(s)
25 Structures: POMR Routine: journal + link to health element(s)
26 Structures: POMR Plan service(s)
27 Structures: POMR Adjust planning
28 Structures: Problems versus HCE Problem = an issue specifically flagged as a problem active or inactive difference inactive previous problem Health care element = An issue for which the health care provider did/ does something What he does: is a service
29 Structures: Episode recording What is an health care episode? Simple cases: pregnancy, flue Chronic cases: beginning? End: death of the patient Difficult: end unknown: patient feels OK Un-noticed episodes: contaminations...
30 Structures: Episode recording What is a period? Examples: Phase: acute phase / remission Groupings of episodes of care for a specific problem linked to a specific health element and (1- n) approaches Event: hospitalization
31 Structures: Episode recording
32 Structures: Episode recording
33 Structures:View Presentation of data and different characteristics visualizing a care concept such as: Antecedents Problem list Episode list Laboratory data Hospital results
34 Active record management An electronic health record MUST BE MANAGED Medication interactions Therapy faithfullness of the patient Planning and active follow-up Risk assessment and behavior follow-up Overviews and summaries (SUMEHR) Audits Integration from external sources
35 Active record management An electronic health record MUST BE MANAGED Some useful register selections: Integration of vaccinations Generating listings: which patients need urgent attention? Age and gender register Smears register Call-back register Diabetes Mellitus register
36 Active record management An electronic health record MUST BE MANAGED Useful (sometimes obliged) reporting: Quality reporting (regional groups) Registration of urgent cases Reporting of infectuous diseases Participation in vaccination actions Surveillance
37 Active record management An electronic health record MUST BE MANAGED Moving /death of patients Family / living together links Lab and other reports archiving messages/letter exchange Problem list management (active/de-active) Quality audit
38 Active record management Exporting of SUMMARY RECORD (SUMEHR) Standard function in EHR Dataset standard Format: XML Non-addressed message? WHO generates this message? Belgium: GP with specific function
EHR Incentive Programs A program administered by the Centers for Medicare & Medicaid Services (CMS) An Introduction to the Medicaid EHR Incentive Program for Eligible Professionals cms.gov/ehrincentiveprograms
Electronic Health Record Usability Evaluation and Use Case Framework Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, Maryland
EHR Incentive Programs A program administered by the Centers for Medicare & Medicaid Services (CMS) An Introduction to the Medicare EHR Incentive Program for Eligible Professionals cms.gov/ehrincentiveprograms
ACCP WHITE P APER Clinical Pharmacy Should Adopt a Consistent Process of Direct Patient Care American College of Clinical Pharmacy Ila M. Harris,* Beth Phillips, Eric Boyce, Sara Griesbach, Charlene Hope,
Hamilton Niagara Haldimand Brant LHIN Rehabilitation/Complex Continuing PAG Service Delivery Model Review April, 2009 Service Delivery Model Review Introduction This document presents a summary of peer
Summary of Responses to an Industry RFI Regarding a Role for CMS with Personal Health Records Table of Contents EXECUTIVE SUMMARY... 4 1. INTRODUCTON... 7 2. CMS ROLE WITH PHRs... 9 What PHR functionalities
UPDATED MARCH 2015 Providing and Billing Medicare for Chronic Care Management Research studies have demonstrated time and again that care management reduces total costs of care for chronic disease patients
Providing Clinical Summaries to Patients after Each Office Visit: A Technical Guide July 2012 Prepared by: Jeff Hummel, MD, MPH Qualis Health Seattle, Washington Peggy Evans, PhD, CPHIT Qualis Health Seattle,
General Principles of Software Validation; Final Guidance for Industry and FDA Staff Document issued on: January 11, 2002 This document supersedes the draft document, "General Principles of Software Validation,
TRIM: 93267 National Consensus Statement: Essential Elements for Safe and High-Quality End-of-Life Care in Acute Hospitals Consultation draft January 2014 Commonwealth of Australia 2014 This work is copyright.
Follow-up information from the November 12 provider training call I. Admission Orders 1. Clarification regarding whether an admission order must be completed before any therapy evaluations are initiated.
National Safety and Quality Health Service Standards September 2012 National Safety and Quality Health Service Standards, September 2012 Endorsed by Australian Health Ministers September 2011 ISBN: 978-1-921983-04-7
Chapter 8. Selection of Data Sources Cynthia Kornegay, Ph.D.* U.S. Food and Drug Administration, Silver Spring, MD Jodi B. Segal, M.D., MPH Johns Hopkins University, Baltimore, MD Abstract The research
EUROPEAN COMMISSION DIRECTORATE GENERAL for HEALTH and CONSUMERS Consumer Affairs Health technology and Cosmetics MEDDEV 2.12/2 rev2 January 2012 GUIDELINES ON MEDICAL DEVICES POST MARKET CLINICAL FOLLOW-UP
Behavioral Health / Primary Care Integration and the Person-Centered Healthcare Home APRIL 2009 INTEGRATION AND THE HEALTHCARE HOME Table of Contents Executive Summary 1 Introduction 4 Section 1: The Patient-Centered
Multidisciplinary care for people with chronic heart failure Principles and recommendations for best practice 2010 National Heart Foundation of Australia. All rights reserved. This work is copyright. No
Report of the Mid-program evaluation of take the lead Centre for Clinical Governance Research Australian Institute of Health Innovation Produced in 2011 by the Centre for Clinical Governance Research in
GENERAL DISTRIBUTION OCDE/GD(95)115 OECD SERIES ON PRINCIPLES OF GOOD LABORATORY PRACTICE AND COMPLIANCE MONITORING NUMBER 10 GLP CONSENSUS DOCUMENT THE APPLICATION OF THE PRINCIPLES OF GLP TO COMPUTERISED
Key Measurement Issues in Screening, Referral, and Follow-Up Care for Young Children s Social and Emotional Development April 2005 Prepared by Colleen Peck Reuland and Christina Bethell of the Child and
Guide to Implementing Quality Improvement Principles Foreword Quality Improvement in health care continues to be a priority for the Centers for Medicare & Medicaid Services (CMS). In the Affordable Care
Good Practice Guidelines in the process of Organ Donation Good Practice Guidelines in the process of Organ Donation National Transplant Organization, 2011 That Spain is the leader in organ donations has
Core Principles & Values of Effective Team-Based Health Care Pamela Mitchell, Matthew Wynia, Robyn Golden, Bob McNellis, Sally Okun, C. Edwin Webb, Valerie Rohrbach, and Isabelle Von Kohorn* October 2012
DOCUMENTATION AND CODING GUIDELINES FOR PUBLIC HEALTH NURSES Version 2.0 October 2012 Office of Clinical and Preventive Services Indian Health Service U.S. Department of Health and Human Services ACKNOWLEDGMENTS