COMPUTER SYSTEMS FOR HEALTHCARE & WELLNESS ELECTRONIC PATIENT RECORDS

Transcription

1 COMPUTER SYSTEMS FOR HEALTHCARE & WELLNESS ELECTRONIC PATIENT RECORDS Daniela Fogli Department of Information Engineering University of Brescia

2 Pa#ent Record A repository for a variety of clinical data and informaeon that is produced by many different individuals involved in the care of the paeent 2

3 Purpose of pa#ent records All types of healthcare organiza#ons have paeent records in electronic or paper format Several key purposes for maintaining pa#ent records 1. Pa#ent care 2. Communica#on 3. Legal documenta#on 4. Billing and reimbursement 5. Research and quality management 3

4 Content of pa#ent records Iden#fica#on sheet Problem list Medica#on record History report Progress notes Consulta#on notes Physician s orders Imaging and X- ray reports Laboratory reports Consent and authoriza#on forms Opera#ve report Pathology report Discharge summary 4

5 Problems with paper- based records Records are oqen Illegible Incomplete Unavailable when needed Lack any type of ac#ve decision- support capability Make data collec#on and analysis cumbersome Passive role no longer sufficient today 5

6 Electronic record To be used in health informa#on systems the paeent record must become an electronic record Different kinds of electronic pa#ent records: Electronic Medical Record Electronic Health Record Personal Health Record 6

7 Electronic Medical Record An EMR is an electronic record of health- related informa#on on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organizaeon [National Alliance for Health Information Technology, cited in Wager et al. 2009] 7

8 Electronic Health Record An EHR is an electronic record of health- related informa#on on an individual that conforms to na#onally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organizaeon [National Alliance for Health Information Technology, cited in Wager et al. 2009] 8

9 Personal Health Record A PHR is an electronic record of health- related informa#on on an individual that conforms to na#onally recognized interoperability standards and that can be drawn from muleple sources while being managed, shared, and controlled by an individual [National Alliance for Health Information Technology, cited in Wager et al. 2009] 9

10 EMR It can be viewed as the hub of the organiza#on s clinical informa#on and as a tool for improving pa#ent care quality, safety, and efficiency It is not merely a digital version of the paper medical record Electronic Paper & Pencil: Six Easy Steps to a Low-Cos Electronic Medical Record 10 An encounter template created with Microsoft Word.

11 Core func#ons 1. Health informa0on and data: it includes medical and nursing diagnosis, a medica#on list, allergies, demographics, clinical narra#ves, and laboratory test results 2. Results management: it manages all types of results electronically 3. Order entry and support: it incorporates use of computerized provider order entry 4. Decision support: it employs computerized clinical decision- support capabili#es 11

12 Decision- support capabili#es FIGURE 5.1. Sample Drug Alert Screen The Electronic Medical Record 113 [Wager et al. 2009] The EMR reminds the clinician that the patient is allergic to certain medication Source: PartnersHealthCare FIGURE 5.2. Sample EMR Screen Clinician can keep the order, possibly indicating reasons for override (low risk cross sensitivity, no reasonable alternatives, ) 12

13 Decision- support capabili#es (2) Source: PartnersHealthCare [Wager et al. 2009] FIGURE 5.2. Sample EMR Screen Source: PartnersHealthCare Patient is 50 years old, or older, recommend influenza vaccination 13

14 Benefits for EMR adop#on 1. Improved quality, outcomes and safety 2. Improved efficiency, produc#vity and cost reduc#on 3. Improved service and sa#sfac#on 14

15 Improved quality, outcomes and safety Increased adherence to guideline- based care Enhanced surveillance and monitoring Decreased medica#on errors Examples from studies: computerized reminders and alerts can have effect on cancer preven#on appropriate use of an#bio#cs, reduc#on of adverse drug reac#ons, improved accuracy of drug dosing, reduc#on of omission errors communica#on improvement, assistance with calcula#ons, checks in real #me 15

16 Improved efficiency, produc#vity and cost reduc#on Making test results readily available Promp#ng physicians to use generic and formulary drugs Providing the infrastructure for measuring care processes Reducing costs related to the retrieval and storage of medical records (space savings means cost savings) Decreasing or elimina#ng transcrip#on services 16

17 Improved service and sa#sfac#on From both the pa#ent s and the user s perspec#ves PaEents Pa#ents response to physicians using an EMR is quite posi#ve Pa#ents like the fact that their health informa#on is readily available when and where it is needed Users (physicians, nurses, staff) Posi#ve impact on job sa#sfac#on and stress levels They are proud of the quality of their records and believe that their documenta#on is more complete, accurate, useful, Pa#ents view their physicians as being innova#ve and progressive Physician- pa#ent rela#onship may be improved by involving pa#ents more fully in their own care Nurses and support staff reported an enhancement in the ability to respond to pa#ents ques#ons No filing and pulling paper reports anymore for administra#on staff, easier bill processing 17

18 Limita#ons EMR might not save an individual physician #me in documen#ng pa#ent informa#on Yet that informa#on may be more complete and reduce unnecessary tests or improve coordina#on of care Anyway, much more work is needed for crea#ng EHR systems, to share pa#ent data across organiza#onal boundaries 18

19 Some tools Several open source EMR/EHR * projects Examples: GaiaEHR: hip://sourceforge.net/projects/ gaiaehr/?source=directory (Youtube video) OSCAR EMR hip://oscar- emr.com/? page_id=203 (Youtube video) OpenEMR: web demo OpenEHR: hip:// *note that the two terms are often used interchangeably 19

20 Each setting, such as intensive care, office practice, emergency room, and so forth, is described in a specific functional profile. Figure 9.2 shows the basic structure of the HL7 EHR Functional Model. Continuity of Care Record Standard Health The ASTM Continuity of Care Record (CCR) content standard is designed as a standards health care data summary. Its purpose is to aggregate essential health care data from multiple sources, such as patient records and other health care related documents in order to provide an overall clinical picture of a patient s current and past health status. The CCR was developed jointly by ASTM International, the Massachusetts Medical Society, the Healthcare Information and Management Systems Society, the American Academy of Family Physicians, the American Academy of Pediatrics, and other health HL7 EHR care organizations. Func#onal Model It provides a reference list of over 160 func#ons that may be present in an EHR system FIGURE 9.2. HL7 EHR Functional Model Outline Direct Care Supportive DC1.0 DC2.0 DC3.0 Care Management Clinical Decision Support Operations Management and Communication S1.0 Clinical Support S2.0 Measurement, Analysis, Research, Reporting S3.0 Administrative and Financial I 1.0 EHR Security Information Infrastructure I 2.0 I 3.0 I 4.0 I 5.0 I 6.0 I 7.0 EHR Information and Records Management Unique Identity, Registry, and Directory Services Support for Health Informatics & Terminology Standards Interoperability Manage Business Rules Workflow [Wager et al. 2009] 20 Source: Wise&Mon,2004,slide16.

21 Legal issues Medical record is a legal document Several issues Reten1on and destruc1on Authen1ca1on of informa#on with handwriien or electronic signature Privacy and confiden1ality of pa#ent informa#on Governments are modifying laws and regula#ons to reflect the change from paper to digital documenta#on 21

22 Legal issues for EHR EHR is a tool to achieve a good level of informaeon and parecipaeon among all actors involved in health processes Need for health standards for security and interoperability Need for privacy proteceon mechanisms (EU Commission proposal in 2012 for a General Data Protec#on Regula#on ) 22

23 What s happening in Italy? The Electronic Health Record Na0onal guidelines, Ministry of Health, March 2011 They provide indica#ons to promote the sharing of a reference model for the na#onal EHR The EHR is fed con#nuously by who takes care of the pa#ent under the Na#onal Health Service Purposes: preven#on, diagnosis, treatment and rehabilita#on 23

24 Areas of applica#on Support to the scenarios and to the processes of care Support for emergency / urgency Support for con#nuity of care Support ac#vi#es related to management and administra#ve processes of care 24

25 Content of the EHR Tax Code Surname (at birht) Name Sex Date of Birth Place of Birth Province of Birth Ministery of health Iden#fica#on data Address of legal residence Address of physical residence Identificative data - Description Date of death (date of closure of the record) 3.2 Administrative data concerning the health care The administrative data on health care consist of administrative information regarding the positioning 25 of patients in the National Health Service, with reference to the network of providers offered by the NHS and to other information, including the organization of health care assistance in the Region.

26 Province of Birth Address of legal residence Address of physical residence Date of death (date of closure of the record) Content of the EHR (2) 3.2 Administrative data concerning the health care The administrative data on health care consist of administrative information regarding the positioning of patients in the National Health Service, with reference to the network of providers offered by the NHS and to other information, including the organization of health care assistance in the Region. Administra#ve data Supplementary data - Description Local Health Authority of Residence (ASL) Start date of assistance c/o Local Health Authority (ASL) End date of assistance c/o Local Health Authority (ASL) (to indicate only if present) Tax code of the physician Surname of the physician Name of the physician Start date of assistance by the physician End date of assistance by the physician (to indicate only if present) Type of Assistance (general practitioners / pediatricians, etc) Contacts of physician (address, telephone number, etc.) Other information Exemptions and relative expiry date The Electronic Health Record National Guidelines Page 9 of 24 26

27 outpatient) stored electronically in dedicated repositories. The EHR will also contain informations and / or medical records relating to events prior to its constitution, but only if the patient gives specific consent. Documents In particular, the EHR is composed of a minimum core of essential documents that must be made available by the system and additional documents that allow to expand the scope of use of the EHR in support of the different pathways activated in order to ensure continuity of care. While the minimum core of data should be made available at regional level in order to guarantee freedom of choice of the patient to exercise the right to treatment even in case of change of residence from one Region to another, the other documents may become part of ad additional section of EHR based on the regional choices determined by the maturity level of digitalization processes and regional policies. EHR is composed of a minimum core of esseneal documents and addieonal documents that allow to expand the scope of use of the EHR Minimum data set Medical reports First Aid Reports Document of hospital discharge Synthetic Health Profile Minimum data set Other documents Other documents Prescriptions (ambulatory care, pharmaceutical care, etc..) Hospital care records (ordinary and day hospital) Health status 27

28 Minimum data set Medical reports First Aid Reports Documents of hospital discharge (2) Synthetic Health Profile Other documents Other documents Prescriptions (ambulatory care, pharmaceutical care, etc..) Hospital care records (ordinary and day hospital) Health status Home Care Therapeutical plans Residential and semi-residential care: multi-dimensional evaluation report Dispensing of drugs Certificates The Electronic Health Record National Guidelines Page 10 of 24 28

29 Pa#ent Summary (or Synthe#c Health Profile) It contains pa#ent s medical history and his/ her current health situaeon It is extracted from content available in the soqware applica#on used by general prac##oners and pediatricians Purpose: promote conenuity of care It is composed of three parts: 1. Header 2. Essen#al data 3. Other informa#on 29

30 Header Ministery of health The document is divided into the following components: Patient data Phisician data Any contact name Allergies, adverse reactions to drugs or contrast agents or other substances, allergies, and immune risks Significant health problems and diagnoses Therapies in progress State of health of the patient Treatments and therapeutic, surgical and diagnostic procedures Header Surname, name, tax code, sex, age (in years), date of birth, place of birth, home address, telephone (are important, if any, exemptions and belong to a pathology network Surname, name, tax code, , telephone The contact person (if the patient is under 18, or if it is not selfsufficient) Essential data (if available) Triggering substance, type of reaction. The absence of allergies or allergic reactions known must be communicated as if they were not detected because they do are not known. Current medical condition (chronic pathologies and / or relevant) of patient: past and present symptoms the patient; conditions, diagnostic suspicions and diagnosis, cancer screening; list of relevant previous illnesses, addictions, etc.. Drugs administered on an ongoing basis as well as those relating to prescriptions dispensed in the last month possibly integrated by other recognized as relevant by the doctor Useful indications, in particular, during the patient discharge from the facility in order to enable appropriate care pathways (e.g. mobility, mental state, self-sufficiency, etc..) Surgery and any references to relevant clinical, laboratory, 30 radiology, visits medical report, including any participation in clinical trials, reporting about the results of investigations made in the last year with the addition of information deemed relevant by the

31 Patient data Essen#al data Phisician data Any contact name Header Surname, name, tax code, sex, age (in years), date of birth, place of birth, home address, telephone (are important, if any, exemptions and belong to a pathology network Surname, name, tax code, , telephone The contact person (if the patient is under 18, or if it is not selfsufficient) Allergies, adverse reactions to drugs or contrast agents or other substances, allergies, and immune risks Significant health problems and diagnoses Therapies in progress State of health of the patient Treatments and therapeutic, surgical and diagnostic procedures Risk Factors Vaccinations Missing organs / transplants / explants Prosthesis, implants, assistive Essential data (if available) Triggering substance, type of reaction. The absence of allergies or allergic reactions known must be communicated as if they were not detected because they do are not known. Current medical condition (chronic pathologies and / or relevant) of patient: past and present symptoms the patient; conditions, diagnostic suspicions and diagnosis, cancer screening; list of relevant previous illnesses, addictions, etc.. Drugs administered on an ongoing basis as well as those relating to prescriptions dispensed in the last month possibly integrated by other recognized as relevant by the doctor Useful indications, in particular, during the patient discharge from the facility in order to enable appropriate care pathways (e.g. mobility, mental state, self-sufficiency, etc..) Surgery and any references to relevant clinical, laboratory, radiology, visits medical report, including any participation in clinical trials, reporting about the results of investigations made in the last year with the addition of information deemed relevant by the phisician. Hereditary risks, dependencies, exposure to toxic substances, etc Administration of which the physician is aware (type of vaccine, date and mode of administration). Presence of permanent and implantable devices 31 Monitoring parameters Other information about the patient Last recording of blood pressure, weight, height, lung functions

32 Treatments and therapeutic, surgical and diagnostic procedures Other informa#on phisician. Risk Factors Vaccinations Missing organs / transplants / explants Prosthesis, implants, assistive Monitoring parameters Active care plan Blood Group Other diseases of recent onset Pregnancy and childbirth Agreement / disagreement to the donation of organs the facility in order to enable appropriate care pathways (e.g. mobility, mental state, self-sufficiency, etc..) Surgery and any references to relevant clinical, laboratory, radiology, visits medical report, including any participation in clinical trials, reporting about the results of investigations made in the last year with the addition of information deemed relevant by the Hereditary risks, dependencies, exposure to toxic substances, etc Administration of which the physician is aware (type of vaccine, date and mode of administration). Presence of permanent and implantable devices Other information about the patient Last recording of blood pressure, weight, height, lung functions The set of information about prescriptions, interventions, bookings, procedures ongoing and not terminated Contains the declaration of the donor provided according to the art. 23 paragraph.3 of the Italian law 91/99 if declared to the GP The Electronic Health Record National Guidelines Page 12 of 24 32

33 Op#onal data Other data can op#onally be entered by the general prac##oner/pediatrician Findings Visits performed No chronic diseases CiEzen s personal notebook: a sec#on reserved to the pa#ent where he/she can enter data and personal informa#on 33

34 Methods of encoding informa#on Orienta#on towards HL7 standard, with progressive use of the CDA (Clinical Document Architecture) Release 2 The coding system is crucial for the proper sharing and interpreta#on of EHR content 34

35 Informed consent to data processing EHR gives rise to a way of further processing of personal data The ci#zen, with his/her consent, has the right to allow or not allow the establishment of his/her EHR Modular organizaeon of EHR and modular access through: A general consensus A specific consent on both the informa#on to make visible and the NHS operators providing care to the ci#zen The pa#ent has the right to impede the visibility of certain health informa#on ( obscura#on ) and some data type are confiden#al by default 35

36 Roles, profiles and access personal information - information regarding personal identification of the citizen; administrative data - regarding the exemptions and the practitioner; prescriptive data - regarding the prescriptions; Ministery of health clinical data - regarding all the clinical documents; personal data consent information - regarding - information the possibility regarding to process personal data identification within the EHR. of the citizen; administrative data - regarding the exemptions and the practitioner; The demographic prescriptive information data - regarding will the not prescriptions; be inserted directly into the EHR, but retrieved from the modes Ministery of health The registers modular clinical of the data citizens, - regarding organiza#on which guarantee all the clinical the correctness documents; of the and updating. EHR guarantees data consent - regarding the possibility to process data within the EHR. Role Enabled functions Data differen#ated profile ar#cula#on (data type/ac#vi#es) and Pharmacist Read Patient registry The demographic information will not be inserted directly into the EHR, Prescriptions but retrieved from the different levels of authoriza#on for operators (read/write) registers Health of the care citizens, professional which guarantee the correctness and updating. Consent of the pharmacy enabled to Write Consent the profession. Role Enabled functions Data type Administrative Pharmacist operator in health and social-health Health facilities care (e.g. professional Hospital, Read Patient registry Administrative Prescriptions Prescriptions Consent of Local the pharmacy Health Authority, enabled to Write Consent the profession. GP...). Write Consent Administrative Medical Director operator in health and social-health Read Patient registry Administrative facilities Doctor who (e.g. carries Hospital, out Prescriptions Clinics Local managerial Health activities Authority, Consent within GP...). a Health Write Consent Medical Director Read Patient registry Department in health and social-health facilities. Administrative Doctor General who Practitioner carries out managerial /Paediatrician activities Read Patient Clinics registry Administrative Consent Phisician within contracted a Health with a Prescriptions Local Department Health in Authority health and to Clinics social-health perform as a facilities. General Consent Practitioner General Practitioner /Paediatrician Write Read Patient Prescriptions registry /Paediatrician Clinics (only Administrative if envisaged as type of Phisician contracted with a Prescriptions documents) Local Health Authority to Consent Clinics Administrative perform as a General Director Read Patient Consent registry Practitioner /Paediatrician Write Administrative Prescriptions Person who carries out Clinics (only if envisaged as type of managerial activities documents) 36

37 Access and architecture Electronic IdenEty Card (CIE) and NaEonal Services Card (CNS): tools for accessing network services Access may also be allowed by smart cards issued by accredited cer#fiers or using userid and password The technological infrastructure should be based on a mule- level service- oriented architecture (SOA), including points of service delivery at first level ( regional nodes ) at second level ( local nodes ) 37

38 Personal Health Record (PHR) An electronic applica#on through which individuals can access, manage and share their health informa#on [Tang et al. 2006] 38

39 An interes#ng video hip:// families/video/health- it- you- giving- you- access- your- medical- records 39

40 Characteris#cs of PHRs Can include informa#on from a variety of sources Can help pa#ents securely and confiden#ally store and monitor health informaeon, as well as pa#ent contact informa#on, diagnosis lists, medica#on lists, allergy lists, Are separate from the legal record of any health care provider Are disenct from web portals that simply allow pa#ents to view provider informa#on or communicate with providers 40

41 Benefits of PHRs PHRs can help patients better manage their care Improve pa#ent engagement Help to ensure pa#ent informa#on is available Coordinate and combine informa#on from mul#ple providers Enhance provider pa#ent communica#on Encourage family health management 41

42 Ideal PHR Features Portable Interoperable Auto- populated with clinical and test results Controlled by the pa#ent Longitudinal record Private and secure Integrated into the clinician s workflow 42

43 From the technological point of view PHRs can be web- based or mobile (smart card, smartphone or USB drive) Moving towards PHRs integrated with EHRs and most likely residing in the cloud Some examples: MicrosoQ HealthVault Apple Health Indivo TM hip://indivohealth.org 43

44 MicrosoQ HealthVault A plauorm including a PHR and interfaces with other third party health applica#ons It is able to receive Con#nuity of Care Documents (CCDs) and Con#nuity of Care Records (CCRs) from physicians and hospitals DICOM images can also be stored 44

45 Health and Wellness ac#vi#es Keep track of all the details whether you're managing complex health issues or just want to stay on top of your family's wellness Medications Allergies Health history Fitness Blood pressure Lab results Conditions and illnesses X-rays, scans, and other images And many more kinds of health and wellness data 45

46 Health and Wellness ac#vi#es Get more out of doctor visits by bringing important data with you: Up-to-date medication and allergy lists Recent home health readings (such as blood pressure, blood glucose, and weight) Be prepared for an emergency by making your most important health info available for emergency responders. 46

47 Health and Wellness ac#vi#es Get your lab results, prescription history, and visit records from labs, pharmacies, hospitals, and clinics who send information to your HealthVault record on request Track your numbers to help monitor chronic conditions by using connected devices Save and share your medical images to easily show your images to your healthcare providers and keep them handy for later reference 47

48 Health and Wellness ac#vi#es Reach your weight and fitness goals with a weight management dashboard that helps you track your weight, activity, and diet, set goals, and see progress Celebrate your successes with personalized progress messages Get fit and stay fit by tracking your exercise or sports training with connected devices and using apps that help you stay motivated and improve your performance 48

49 How HealthVault works 119 applications 250 devices (December 2014) 49

50 Apple Health An ios app that gives the user an easy to read dashboard of his/her health and fitness data Back up data to icloud, where it is encrypted while in transit and at rest Developers can use a tool called HealthKit, to develop health and fitness apps to work together with Health and other apps 50

51 Dashboard and Health Data 51

52 Data control and Emergency Card 52

53 However, no consensus on some ques#ons What PHR func#onality is needed in the area of data collec#on, sharing, exchange and self- management? What is needed to improve adop#on of PHRs by pa#ents and clinicians? What is need to ensure privacy and security? What architecture and model is likely to be most effec#ve? 53

54 References Winter, A. et al. Health Informa#on Systems Architectures and Strategies, 2 nd edi#on, Springer, 2011 Hoyt, R. E. Health Informa#cs Prac#cal Guide for Healthcare and Informa#on Technology Professionals, 6 th edi#on, Informa#cs Educa#on, 2012 Wager et al. Health care informa#on systems A prac#ca approach for Health Care Management, 2 nd edi#on, John Wiley & Sons, 2009 The Electronic Health Record Na#onal guidelines, Ministry of Health, March