Electronic Health Records - An Overview - Martin C. Were, MD MS March 24, 2010

Transcription

1 Electronic Health Records - An Overview - Martin C. Were, MD MS March 24, 2010

2 Why Electronic Health Records (EHRs) EHRs vs. Paper Components of EHRs Characteristics of a good EHRs A Kenyan EHRs implementation Overview

3

4 Problems with Paper Records

5 EMR HIV Clinic DISCORDANT COUPLES 5% 12% 4% 1% 3% 3% 2% 0% MTRH Mosoriot Turbo Burnt Forest Amukura Chulaimbo Webuye 70% Naitiri Teso

6

7 Patient arrives at Health Centre Registry: visit #, name, visit reason Check-in Window Registry, Blue book Antenatal Clinic Log: Drugs Dispensed Log: Test Results Registry, Blue book Pharmacy Laboratory Well Child Clinic Log: Charges, Payments Financial Office Patient leaves Clinic

8 "The (paper) medical record is an abomination... it is a disgrace to the profession that created it. More often than not the chart is thick, tattered, disorganized and illegible; progress notes, consultant's notes, radiology reports and nurses notes are all co-mingled in accession sequence. The charts confuse rather than enlighten; they provide a forbidding challenge to anyone who tries to understand what is happening to the patient. - Bleich, H., MD, Computing Vol 10 no 2, p70, 1993.

9 Paper Record Shortcomings Difficult to find and re-use items Difficult to share can only be in one place at one time Difficult to move Difficult to use for decision support Difficult to aggregate for reporting e.t.c.

10

11 Definition - HIMSS The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. - Health Information Management Systems Society (HIMSS)

12 Definitions Electronic Health Record (EHR) Generic term for all electronic patient care systems Computer-based Patient Record (CPR) Lifetime patient record that includes all information from all specialties (even dentists, psychiatrists) and requires full interoperability (potentially internationally) Electronic Medical Record (EMR) Electronic record with full interoperability within an enterprise (hospital, clinic, practice) - EHR vs. CPR vs. EMR article in the May 2003 issue of Healthcare Informatics

13 EHRs Components - Administrative Registration-Admission-Discharge-Transfer Used to accurately identify a patient Patient Identifier Number Patient names Demographics (e.g. age, gender, marital status) Contact information (phone & address info) Next of kin Employer information Insurance

14

15 Components Clinical Documentation Physician, nurse, and other clinician notes Flow sheets (vital signs, input and output, problem lists, meds given) Peri-operative notes Discharge summaries Transcription document management Medical records abstracts Advance directives or living wills

16 Components Clinical Documentation Durable powers of attorney for healthcare decisions Consents (procedural) Medical record/chart tracking Releases of information (including authorizations) Staff credentialing/staff qualification and appointments documentation Chart deficiency tracking Utilization management

17

18 Components Laboratory Components Typically standalone systems interfaced to EHRs Known as Laboratory Information Systems (LIS) Laboratory results can be entered directly into an EHRS LIS integrate orders, results, schedules and billing for laboratory tests

19

20 Components Radiology Components Typically standalone systems interfaced to EHRs Known as Radiology Information Systems (RIS). RIS integrated radiology data: orders, interpretations, Images (Picture Archiving Communication System (PACS))

21

22 Components Pharmacy Components Typically standalone systems interfaced to EHRs Manage: - prescriptions - dispensing history - formulary - inventory

23 Computerized Provider Order Entry Allows for electronic ordering of laboratory, pharmacy, and radiology services. Can be linked to clinical decision support to provide alerts or care suggestions Can be used for order sets CPOE not very broadly used, even in developing countries Terms: CPOE Computerized Provider Order Entry CDS Clinical Decision Support

24 Computerized Provider Order Entry

25 Computerized Provider Order Entry

26 Computerized Provider Order Entry

27 - NIH/NCRR EHR Overview. MITRE Corp. 2006

28 Billing System Personnel Management Inventory & Stock Control System Not Core Part of EHRs

29 Good EHRs Characteristics - Security Security Physical & Electronic Secure Sockets Layer (SSL) authentication Data encryption Password-controlled access Audit trail and logs

30 EHRs Characteristics Coded Data Data Stored as Coded Observations Example - Clinic Note Patient is currently on a primary anti-retroviral regimen of Triomune-30. He denies being on PCP prophylaxis, and is taking INH for TB prophylaxis. He is not on regular TB treatment or crypto-coccus treatment

31 EHRs Characteristics - Vocabulary Standards-Based Clinical Vocabulary Diseases - SNOMED CT (Systematized Nomenclature of Medicine - - Clinical Terms) e.g means myocardial infarction (MI). - International Classification of Diseases (ICD) e.g for acute myocardial infarction Labs & Clinical Results Logical Observation Identifiers Names and Codes (LOINC)

32 EHRs Characteristics - Interoperability Support Interoperability through accepted messaging standards HL7 is the most widely used messaging standard Sends structured encoded data from one application to another The messaging standard has to be appropriately implemented to allow for easy interfacing with other applications

33 Good identification System Good EHRs Characteristics

34 Good EHRs Characteristics Must conform and support the workflow Must be implemented well

35 Good EHRs Characteristics Scalable Configurable Not restricted to one disease entity Easy to maintain Affordable

36 Academic Model for Prevention & Treatment of HIV-AIDS Over 100,000 HIVpositive patients under treatment Catchment area of over 2 million people Nobel peace price nomination

37 AMPATH Patient Enrollment Catchment area for AMPATH: 2 million individuals

38

39

40

41

42

43

44

45 Clinical Summaries Getting data back to clinicians Information Is care Don Berwick President, Institute of Health Improvement

46

47 Studies

48 Universal IDs for all patients in the program Connectivity between sites Some Challenges Integrating with other systems e.g. LIS, Pharmacy system, DHIS Extending beyond HIV Care (Primary care, Inpatient Care, Specialty clinics) Clinical Decision Support (e.g. alerts for drug interactions) Multiple modalities to enter and access data Sustainability ($, expertise)

49

50 Asanteni.