ELECTRONIC MEDICAL RECORDS (EMR)

Transcription

1 ELECTRONIC MEDICAL RECORDS (EMR) SAUDI BOARD FOR COMMUNITY MEDICINE FIRST PART - FIRST SEMESTER (FALL 2010) COURSE SBCM 002: MEDICAL INFORMATICS Osama Alswailem MD MA

2 Medical Record function 1. It s a mean of communication between staff who are actively managing a patient 2. The record is the single data access point for HCP during active management of patient illness 3. Work space to record ideas and impression 4. Single point of a long term archive of patient information

3 Paper Record

4 Serious reportable events 1999 Institute of Medicine Report, 44k-98k people die annually due to errors in inpt hospital treatment, More than MVA, Breast cancer and HIV Yet received less attention To Err Is Human: Building a safe health system. is IOM 2000 report CDC report in 2000 said hospital acquired infection added $5Billion to medical cost

5 Paper Record, physical aspects Used for one task at a time Record are available 80% of time in large institutes! Time of request, effort of process and tracking Space consumption,.5m active and 5M Chronic patients with large records Paper is fragile and susceptible to damage The paper production has environmental consequences

6 Paper Record, Content The models that interpret the data captured on paper are contained with the head of the reader There is increased opportunity for errors to occur; missing or inaccurate data

7 Paper Record, Information Retrieval Searchability within a record of across a body of records for specific data. HCP search routinely to find pieces of information they need during a patient consultation 168 outpt consultation found that data were searched for but not found in 81% of cases, when 95% of the cases the record was available during the consultation. (36% lab & procedure, 31% history, and 23% meds & treatment) Indexing Dewey system, Medical record system.

8 EMR, physical aspects Advancements of Physical Data storage The ability to duplicate the record, to share and more importantly to back-up More formal data models Vs informalities with paper charts Portability Multiple access, availability, No missed charts Protected by different security measures

9 EMR, Content Standardized model of interpretation The speed of searchable content with complex cases and across thousands of recodes for specific item Unified codes Readable and legible Pt care process mandate availabilities of long list of information and wider range of communication beyond EMR, all can be included Pt list, schedule list, LOS, formulary, Researches can do retrospective studies of epidemiology of sp disease. Is available from remote locations To covering MDs Others with appropriate needs Data is legible

10 Introduction to EMRs Why do we need EMRs? Clinical practice is a data intensive operation a Inadequate data communication causes medical errors Human cognition is good at pattern recognition but not at remembering lists or evaluating multiple business rules.

11 Why do we need EMRs? Enhances Communication: Between providers--clinical messaging Trace paper MR location Referrals Half of specialists didn t know what main question was A third of the time no information came back to PCP Encourage patients to participate in their healthcare, the pt portal

12 Integrated Clinical Information System ICIS ICIS from Cerner co. Phase one 2002 Registration Scheduling Orders (CPOE) and Documentation Lab Radiology Phase two Medication process, Inpt and Outpt pharmacy OR Management System Health Information Management ER Management System Clinical Pathway and Physician Documentations

13 Introduction to EMRs Do EMRs make a difference? UNEQUIVOCALLY YES, BUT AT A COST! In multiple studies, EMRs have been shown to: Shorten Length of Stay in a Hospital setting Decrease Adverse Drug Events (ADEs) Improve Readability, Consistency and Content of the medical record Improve Continuity of Care Reduce practice variation Most benefits come from Decision Support. EMR may suggest what pt info needs to be collected, or alert physicians to better management action

14 EMR active participation in pt care Computer supported prescription Alerts and reminders Task specific view of data Protocol guided care Clinical audit and outcome assessment

15 Raising the practice deviation and process gaps Patient discharge time improvement Discharge medication order

16 Creating knowledge from Information Reward providers for innovation

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18 What are the data sources of EMR? At their heart, EMRs are just a database This database hold many kinds of information (coded and not coded) This database is organized by date, time, pat ID and contains: Patient registration data (name, contact info, DOB, etc.) Test results (laboratory, radiology, nuc med etc.) Medications (active, inactive) and Allergies Current list of diagnoses and problems Appointment Data Clinical Notes Billing Information Eligibility information

19 How do Clinicians Interact with EMRs Patients Clerks Nursing Staff REGISTRATION SYSTEM LAB SYSTEM PHARMACY SYSTEM Physicians Coding Staff RADIOLOGY SYSTEM BILLING SYSTEM Insurance Co. Order Entry/Results Reporting

20 QUESTIONS