Electronic Health Records
Dimitar Hristovski, Ph.D.E-mail: [email protected]
Institute of Biomedical InformaticsMedical Faculty
University of Ljubljana, Slovenia
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Types of (Paper) Medical Records
Time oriented Data source oriented
Visits, laboratory results, X-ray images Problem oriented (SOAP)
Subjective: patient description Objective: physician or nurse description Assessment: investigations results and
diagnosis Plan: treatment plan (therapy, surgery, ...)
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Advantages of Paper Medical Records(compared to Electronic Med.Rec.)
Easy to move around Freedom of expression Easy browsing Additional training not necessary They always work (in contrast to computer
based records)
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Disadvantages of Paper Medical Records(compared to Electronic Med.Rec.)
Not accessible from different locations Do not allow different views of data Fast search not possible Lack structured data entry Difficult usage for decision support Not easily used for research Do not support multidisciplinary healthcare Time consuming data exchange
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
What is Electronic Health Record?
The electronic health record is a computer-stored collection of health information about one person linked by a person identifier.
It represents the basis for healthcare information systems development.
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Electronic Health Records in Relation to other Healthcare Info. sub-Systems
They exchange data with these sub-systems: Data entry and results browsing Ordering tests and examinations Event monitoring Research databases Laboratory information systems Pharmacy information system Radiology information system
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
The Five Levels of Healthcare Information Systems
Level 1: Automated medical records Level 2: Document imaging Level 3: Electronic medical records Level 4: Electronic patient record systems
(also called Computer-based patient record systems)
Level 5: Electronic health record
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Automated Medical Records
Most current systems fall into this category Patient information mostly in paper form (although
up to 50% is computer-generated) Are the basis for some computer supported
functions: Admission/Discharge/Transfer (ADT) systems Patient accounting and its linkage to clinical
information Department systems (radiology, laboratory, pharmacy,
etc.) Order entry / Results reporting
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Document Imaging
Why? To address the space shortage most providers experience in record storage
Documents are created on paper Paper documents are indexed and scaned,
and stored in computer form Complete documents with their legal
attributes such as data and signature are scanned
The human operator is not allowed to change or delete the scanned documents
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Electronic Medical Records
Is an upgraded version of previous record Data is entered directly into the computer in
structured form, suitable for various purposes
Successful use depends on: User friendliness User acceptance System design and functionality
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Electronic Medical Record Essential Functions
Using enterprise-wide master-patient index Making all enterprise-wide patient information
available to all caregivers Creating a security system:
Access control; Electronic signatures Data integrity; Auditing; Availability
(Optional) Integration with expert programs: Electronic handbooks and references Clinical decision support programs Drug selection and adverse drug reaction identification
programs
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Electronic Patient Record Systems
Has a wider scope of information than the electronic medical record
Combines several enterprise-based electronic medical records concerning one patient and assembles a record that collects all professional health information on that one patient
If acceptable to the patient, may be a longitudinal record
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Prerequisites for Electronic Patient Record Development
Development of a national or international system of identifying all patient information available nationwide or worldwide.
Development of a system where either central databases or provider organizations collect, store, safeguard, and distribute patient information.
Developing an approach for common terminology, data sets, and structures.
Creating an international consensus on security systems that would allow electronic patient record systems to operate at a level of trust.
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
The Electronic Health Record
Contains additional data not being limited to information predominantly captured by caregivers regarding a patient.
Includes wellness information and other health-related information:
Behavioral Dietary Drug-related Exercise related Environmental Sexual information
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Minimal Basic Data Set
Example: 13 basic patient data elements from an acute care hospital:
1. Hospital identification2. Patient number3. Sex4. Age at admission5. Marital status6. Address7. Date of admission
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
(cont...)
8. Length of stay
9. Discharge status
10. Primary diagnosis
11. Secondary diagnosis
12. Surgical and obstetrics treatments
13. Other important treatments
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Information Society (Internet) Influence on Healthcare
Patients will search for health related information on the Internet
Patients will like to have better access to their healthcare records
Internet has allowed (will allow) telemedical services: Buying drugs Medical consultations (including second
opinion)
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Personal Health Record Types
Off-line (on paper, smart card, on a computer)
Web-based Commercial/Organizational Functional/Purpose-based (e.g. emergency
healthcare abroad) Provider-based (appointments, medications,
allergies, ...) Partial health record (user-profiles at various
health-related websites)
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
“Smart” cards
Allow storing some of the patient information on a card of the size of a credit card.
Types of smart cards: Magnetic Laser (optical) With a chip or without
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: problem list and therapy
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: current problem – left earache
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: objective problem description
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: diagnosis
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: therapy
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: list of laboratory tests
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records
Example: laboratory tests order list