electronic health records: manual for developing countries

Acknowledgements

WHO Regional Office for the Western Pacific acknowledges the contributions made by Professor Phyllis J. Watson to this publication.

WHO Library Cataloguing in Publication Data

ElectronicHealthRecords:ManualforDevelopingCountries

1.Medicalrecordssystems,Computerized.2.Manuals. 3.Developingcountries.

ISBN 92 9061 2177 (NLM Classification: WX 173)

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The named author/s alone is/are responsible for the views expressed in this publication.

ElectronicHealth RecordsA Manual for Developing Countries

ElEctronic HEaltH rEcordsManual For developing countries v

CONTENTS

Chapter 1: General Overview ...................................................... 9

- DefininganElectronicHealth Record(EHR).......................................................... 10 - ExamplesofEHRPractices....................................... 13

Chapter 2: Preliminary Steps .................................................... 17

- ReviewofCurrentHealthRecordSystem.................... 17 - ReviewofPoliciesRelatingto MedicalRecordPractice........................................... 24

Chapter 3: Issues and Challenges ............................................. 27

Chapter 4: Planning for the Introduction of an EHR .................... 35

Chapter 5: Factors to be Considered when Developing an EHR Implementation Plan ......................................... 51

Chapter 6: Implementation Plan ................................................ 59

Annotated Bibliography ............................................................... 65

Glossary of Terms ....................................................................... 73

ElEctronic HEaltH rEcordsManual For developing countries vii

Electronic Health Records: INTRODUCTION

Basic Concepts

This manual has been designed as a basic reference for use whenexploringthedevelopmentandimplementationofElectronicHealthRecord(EHR)systems.Itprovidesageneraloverview,somebasicdefinitionsandexamplesofEHRpractices.AlsocoveredarepointsforconsiderationwhenmovingtowardstheintroductionofanEHR,someissuesandchallengeswhichmayneedtobeaddressedandsomepossiblestrategies,alongwithstepsandactivitiestoimplementation.Thereisaparticularfocusonsettinggoals,revising policies, developing an action plan and outlining implementationprocedures.

Electronichealthrecordsareacomplexissueandthefollowinginformationispresentedinasimple,conciseandstraight-to-the-pointfashion,intendedasanintroductoryreferenceforthetopic.Forthosewhowantmoredetailedinformationthereisawealthofliteratureavailableiftheywishtoreadmoredeeplyonthesubject.AMedlinesearchwasconductedandashortannotatedbibliographyhasbeenincluded.

Target Users of the Manual

Thismanualhasbeendesignedwiththefollowingpersonsinmind:

• MinistryofHealthstaffatnationalandprovincialordistricthealthcentre levels actively involved in exploring the development ofelectronichealthrecords.

• Peoplewhodonothavean in-depthknowledgeofEHRandwhoneedageneraloverview,particularlyiftheyaremembersofamulti-disciplinarycommitteetaskedwithinvestigatingtheintroductionofanEHR.

• Healthrecordmanagers/administratorswhoareresponsible for themedical/healthrecordandrecordservicesatprimaryandsecondarylevelsofcareindevelopingcountries.

Using the Manual

Itisimportantthatthereadertreatsthismanualnotasasetofdefinitiverulesapplicableineverysituation,aseachinstitution/countryhavedifferentneedsandrequirements,butasaguidetohelpensurethatsomeimportant

ElEctronic HEaltH rEcordsManual For developing countriesviii

activitiesandissueshavebeenconsideredandaddressedbeforeproceedingwiththetaskofdevelopingandimplementinganEHR.

The Structure

The text has been divided into six chapters. The first chapter dealswith a general overview, basic EHR definitions and some examples ofEHRpractices.Chapter2coverssomepreliminarysteps requiredprior todevelopingaplanforimplementation.Chapter3coversissuesandchallengeswhichneedtobeidentifiedandaddressed.Chapter4dealswithplanningfortheintroductionofanEHRandincludesperceivedbenefits,settinggoals,developing strategies and preparing policies and procedures. Chapter 5covers factors tobe consideredwhendevelopingan implementationplanandChapter6dealswithimplementation.Theabovechaptersarefollowedbyanannotatedbibliographyandaglossaryofterms.

ElEctronic HEaltH rEcordsManual For developing countries �

CHAPTER 1 General Overview

Withthemanyadvancesininformationtechnologyoverthepast20years, particularly inhealthcare, anumber of different formsofelectronichealthrecords(EHR)havebeendiscussed,developed,

and implemented. Some institutions/countries are currently planning theintroduction of a nationwide electronic health record while others haveactuallyimplementedsomeformofEHR.However,thetypeandextentofelectronichealthrecordsvaryandwhatonecountrycallsanEHRmaynotbethesameasthatdevelopedinanothercountry.Althoughworkhasbeenundertakenbyinstitutions/countriesonsomeformofacomputerisedpatienthealthcareinformationsystem,asyetnotmanyhospitalshavesuccessfullyintroducedanelectronichealthrecordwithclinicaldataentryatthepointofcare.

Although interest in automating the health record is generally high inbothdevelopedanddevelopingcountriesunfortunately, insomecases, theintroductionofanEHRsystemseemsoverwhelmingandalmostoutofreachtomanyhealthcareprovidersandadministratorsaswellasmedicalrecord/health information managers. Why is this so? The obstacles may not beavailable technology but technical support and the cost of changing to anelectronic system coupled with insufficient healthcare funding. In manydevelopingcountriescosts,available technology, lackof technicalexpertiseandcomputerskillsofstaff,andlackofdataprocessingfacilitiesareinfactmajor issueswhichwould need to be addressed before implementation ispossible.

Inadditiontotheabove,resistancebysomemedicalpractitionersandhealthprofessionalsgenerallytoachangefrommanualtoelectronicdocumentationmaybeaprobleminbothdevelopedanddevelopingcountries.Mosthealthadministratorsandinformationmanagersareawarethatitmaytaketimetochangeoratleastmodifyhealthpractitionerbehaviourandattitudes.

Thereasonforwantingtochangetoanelectronicsystemisimportant.Manypersonsinvolvedinhealthcaretodayexpecttomovefromapapertoapaperlessenvironment.Thisisamajorstepandhasonlybeensuccessfullyachievedinafewhealthcareinstitutionstodate.Institutionsshouldnotfocusonjustgoingpaperless.Theyshouldfocusonencouragingdepartmentsandhealthcarepractitionerstomovetoanelectronicsystemto:

• Improve the accuracy and quality of data recorded in a healthrecord

• Enhance healthcare practitioners’ access to a patient’s healthcareinformation enabling it to be shared by all for the present andcontinuingcareofthatpatient

ElEctronic HEaltH rEcordsManual For developing countries10

• Improvethequalityofcareasaresultofhavinghealthinformationimmediatelyavailableatalltimesforpatientcare

• Improvetheefficiencyofthehealthrecordservice

• Containhealthcarecosts

Apaperlessenvironmentwillcome.

Also in some instances there is a tendency to expect that with theintroduction of an electronic health recordmany of the problems currentlyexperiencedinmaintainingpaperhealthrecordswillbeeliminated.Thisisnotthecase.

An electronic health record is not a simple replacement of the paper record.

IfidentifiedproblemsarenotaddressedandremediedpriortointroducinganEHR systemmerely automatinghealth record content andproceduresmayperpetuatedeficienciesandnotmeettheEHRgoalsoftheinstitution/country.

Current problems identified in healthcare documentation, as well as privacy and confidentiality issues must be addressed and quality control measures introduced before a successful change can be implemented.

Although the introduction of a fully electronic health record systemmayseem faroff inmanyhealthcare institutions/countries theyarebeingintroducedrapidlyinothersandthereisnodoubtthatthefutureofhealthinformationmanagementlieswithautomationandtheautomatictransmissionofinformationrequiredforpatientmanagementatalllevelsofhealthcare.

Defining an Electronic Health Record

Asmentionedabovewhenpeoplerefer towhat theyhavebeenusingasanelectronichealthrecord, itmaynotbethesameasotherelectronichealth records developed in different institutions/countries. This may beconfusing.Insomecasesitmaybealongitudinalrecordwidelyavailableacrossanumberofinstitutionsbutinothersinmaybealimitedautomatedsystemonlyavailablewithinaconfinedcommunityorwithinaspecificunitordepartment.Itisimportant,therefore,toknowwhatdefinitionsarebeingusedanddeterminethetypeandextentofelectronichealthrecordsystemyourinstitution/countrywishestoimplement.

Overtheyearsanumberoftermshavebeenusedtodescribethemovefromamanualorpaperrecordtoonegeneratedelectronicallyinoneformor another. Some of the better known terms include: Automated Health

ElEctronic HEaltH rEcordsManual For developing countries 11

Records(AHR),ElectronicMedicalRecord(EMR),Computer-basedPatientRecord(CPR),andElectronicHealthRecord(EHR).

• Automated Health Records (AHR)

ThetermAutomatedHealthRecordshasbeenusedtodescribeacollectionofcomputer-storedimagesoftraditionalhealthrecorddocuments.Typically,thesedocumentsarescannedintoacomputerandtheimagesarestoredonopticaldisks.

Mostofthefocusintheearly1990’swasondocumentscanningontoopticaldisks.Thisaddressedaccess,space,andcontrolproblemsrelatedtopaperbasedrecordsbutdidnotaddressdata input/outputatpatientcarelevel.

• Electronic Medical Record (EMR)

ThetermElectronicMedicalRecordorEMR,aswithAutomatedHealthRecords,hasbeenusedtodescribeautomatedsystemsbasedondocumentimagingorsystemswhichhavebeendevelopedwithinamedicalpracticeorcommunityhealthcentre.Thesehavebeenusedextensivelybygeneralpractitionersinmanydevelopedcountriesandincludepatientidentificationdetails,medicationsandprescriptiongeneration, laboratory resultsand insomecasesallhealthcare informationrecordedby thedoctorduringeachvisitbythepatient.Insomecountries,suchasKorea,thetermEMRisusedtodefineanelectronicrecordsystemwithinahospitalwhichaswellastheaboveincludesclinicalinformationenteredbythehealthcareprofessionalatthepointofcare.

• Computer-based Patient Record (CPR)

IntheUSAthetermComputer-basedPatientRecord(CPR)wasintroducedin the1990’s. Thiswasdefinedasacollectionofhealth information foronepatient linkedbyapatient identifier. TheCPRcould includeas littleasasingleepisodeofcareforapatientorhealthcareinformationoveranextendedperiodoftime(Amatayakul,2004).

Early CPR’s focused on functions such as medical alerts, medicationorders, providing integrated data on a patient’s registration, admission,and financial details, and recording information from nurses, laboratory,radiology,andpharmacy.Althoughthisformofacomputer-basedpatientrecordwas implemented in a variety of settings the focus on exchanginghealthinformationwaslimitedtoinpatientfacilities.

• Electronic Health Record (EHR)

ThetermElectronicHealthRecordiswidelyusedinmanycountrieswithvariationindefinitionsandtheextentofcoverage.Intoday’senvironmentitisgenerallyacceptedasalongitudinalhealthrecordwithentriesbyhealthcare


practitionersinmultiplesiteswherecareisprovided.IntheUSAthecurrentdefinitionofanEHRis:

The electronic health record includes all information contained in atraditionalhealthrecordincludingapatient’shealthprofile,behaviouralandenvironmentalinformation.AswellascontenttheEHRalsoincludesthe dimension of time, which allows for the inclusion of informationacrossmultipleepisodesandproviders,whichwillultimatelyevolveintoalifetimerecord(Mon,2004,Amatayakul,2004).

Moresimplystated, this typeofa longitudinalelectronichealthrecordcouldbedefinedas:

The Electronic Health Record:• Contains all personal health information belonging to an

individual;

• Is entered and accessed electronically by healthcare providers over the person’s lifetime; and

• Extends beyond acute inpatient situations including all ambulatory care settings at which the patient receives care.

TheWorldHealthOrganization’sdeclarationofHealthforAllbytheYear2000highlighted the need for better healthcare services, not only at thehospital(secondary)level,butalsoforprimaryhealthcareandcommunityhealthservices.Thishasrequiredachangeoffocusinhealthcareinmanyareastoensure,ifpossible,thattheimplementationofanelectronichealthrecord covers healthcare delivery services across a broad spectrum ofhealthcare.

TheUSA,UK,AustraliaandsomeEuropeancountrieshaveadoptedthisconceptpromotingthedevelopmentofalongitudinalelectronichealthrecordaimedatimprovingthedeliveryofhealthcareandensuringthatcaregiventoanindividualbyvarioushealthcarepractitionersfrommanydifferentsettingsintheirlifetimeismaintainedinasinglerecordandreadilyavailable.Thisisconsideredbymanytobetheidealsituation.

Thistypeofsystemwouldrequireacomputerprogramthatcapturesdataatthetimeandplacewherehealthcareisprovided,whetheratahospitalor primary care level over an extended period of time. It would enablehealthcare information, suchasaperson’sallergies, recent test results orprescribinghistorytobereadilyavailableatalltimestoassistwithdecisionsondiagnoses,treatmentandmedicationatalllevelsofhealthcare.

Ideally it should reflect the entire health history of an individual across his or her lifetime including data from multiple providers from a variety of healthcare settings.


Suchanextensivesystem,however,hasnotbeenintroducedbymanyinstitutions/countriestodate,althoughmanyareplanned,butmaystillnotbepossibleinsomedevelopingcountriesorinfactsomedevelopedcountries.

Theidealsituationisnotalwayspossibleandhealthcareadministratorsneedtoidentifyhowtheycanproceedtoautomationwithavailableresourcesbothtechnicalandhuman.

Given the situation in your institution/country would a longitudinalelectronichealthrecordbefeasible?Orwouldtheinstitutionbelookingatasimplerapproach?Forexample:

The proposed electronic health record will:

• Contain all personal health information of an individual patient, from the patient’s first admission or attendance at the hospital;

• Be entered electronically by healthcare providers at the point of care over the patient’s lifetime;

• Have information readily available and accessed by all healthcare providers attending to the patient.

Whatever the type of electronic health record decided upon thehealth informationcontained in itmustbeorganizedprimarily to supportcontinuing,efficient,andqualityhealthcare.Itmustalsocontinuetomeetlegal,confidentiality,andretentionrequirementsofthepatient,theattendinghealthprofessionalandthehealthcareinstitution/country.

Forthepurposeofthismanual,thetitleelectronichealthrecord(EHR),asdefinedimmediatelyabove,willbeusedasthepreferreddefinition.

Examples of EHR Practices

Implementationofsomeformofelectronichealthrecordhasbeenachievedinanumberofcountriesoverrecentyears.ExamplesofafewEHRpracticesareasfollows:

• InMalaysiatwohospitalshavealreadygonepaperless.A960-bedhospital was the first and a 270-bed hospital, the second. Oneprimary healthcare facility also has an electronic health recordand does not maintain a paper record. In addition, in 1985aTeachingHospitalinKualaLumpurdevelopedaHealthInformationManagementAdministrationSystem(HIMAS)usinganIBMmainframecomputercoveringpatientadmission,transfer,andseparation(ATS),appointmentschedulingandamedicalrecordstracingsystem.

The present INFOMEDsystem being used now at the hospital is


an upgraded version of HIMAS whichincludes the ATS, patientscheduling, and medical records tracking applications,pharmacyordering, laboratory ordering/reporting, radiological ordering andreporting,patientaccountingandasmallsystemoncase-mix.Allthesystemsarenotfullyintegrated,butthehospitalstartedanewHealthInformationSystem(HIS)in2004aimedatupgradingINFOMEDtointegratethepresentsystemsandaddmoresystemscompletewithe-records.ThehospitaladministrationstartedtheimplementationofHISinphasesin2004andplanforcompletionwithinsevenyears.

• InKorea11hospitalshave implementeda fullyElectronicMedicalRecord(EMR).Theyincludeallinpatientandoutpatienthealthcareinformation.Brokendownbybedsize,onewiththebedcapacityof300-399,twowiththebedcapacityof500-599,twowiththebedcapacityof600-699,andsixwithabedcapacityofover700. Inaddition,therearethreehospitalswithover500bedswithanEMRimplemented for inpatients only, and two hospitals with over 700bedswithanEMRforoutpatientsonly.AnotherthreehospitalshavepartiallyimplementedanEMRsystem.

In one of themajor hospitals theEMRwas introduced inOctober2004forbothinpatientsandoutpatients.Mostoftheoldmedicalrecordshavebeenscannedandveryrecentonesarecurrentlybeingscannedwith thehospitalhoping to complete themby theendof2005.

Forinpatients,dataisenteredatthebedsideusinganotebookcomputer.Foroutpatients,doctorsinputdataatthepointofcareviacomputerterminals,butiftheyaretoobusy,physician’sassistantsenterdataforthem.ThelanguagebeingusedfortheEMRisSNOMEDCT.SignedconsentformsfortreatmentarescannedimmediatelyafterdischargeandconnectedtotheEMRasarelettersfromreferringpractitionersandhospitals.Sometestreportswhichareproducedfromequipmentnot yet interfaced to the EMR are also scanned immediately afterdischargeenablinguserstoviewthemviaamonitor.Thisequipmentistobeinterfacedassoonaspossible.

A goal of thehospital is to share informationwith all thenationalhospitalsandpublichealthcarefacilitiesbutatpresenttheycanonlysharedatawithonebranchofthehospital.


• An EHR standard is being developed in Indonesia and is mainlyconcernedwith thehospital-basedenvironmenteven thoughsomedatamayalsocomefromcommunityhealthcaresectors.InanareainthemiddleofJava,thereisadistrictthathasalreadylinkedthereporting and recording of several primary healthcare centers intotheircomputersystem(usingaLocalAreaNetwork,approachingtoWAN). Thehealthworkersarenowable todeterminehowmanyTBpatientsarebeingtreatedaswellasanumberofotherdiseasestreatedintheirarea.Thisareahasbeenchosentobethecentreoftrainingforprimaryhealthcarefacilities.Mosthospitals,howeverstilluse traditionalnon-EHrecordsalthoughprogress isbeingmade indevelopinganEHRpolicyandstandards.

• InChina,anumberofhospitalshavesuccessfullyintroducedsomeformofelectronichealthrecordbutasyet,asfarascanbeascertained,nonehavebeenabletogopaperless.TheconceptofalongitudinalelectronichealthrecordisenvisagedbytheChineseHealthMinistrybut problemshavearisenbecause some institutions areunable tosharedatadue to the incompatibility of their systems. This is anextremelyimportantissueandcompatibilitywithothersystemswithwhichtheproposedsystemneedstointerfacewithisanimportantconsiderationbeforetheintroductionofanEHR.

Nationwideelectronichealthrecordsarestilllimitedbutprogressisbeingmadeinanumberofinstancessuchas:

• The Australian Government is funding the implementation of anational health information network, called HealthConnect – aproposednetworkaimedatimprovingtheflowofinformationacrosstheAustralianhealthsector (HealthConnect2000). It isasysteminvolving theelectroniccollection, storageandexchangeofpatienthealthinformationviaasecurenetworkandwithinprivacysafeguards.TheHealthConnectobjectiveaimsat improvingtheoveralldeliveryandefficiencyofhealthcare,achievebetterqualitycareandpatientsatisfaction. Under this system health related information aboutapersonwouldbedocumented in a standard electronic format atthe point-of-care, such as at a hospital or a general practitioner’soffice. The informationcould thenbe retrievedonlinewhenever itwas needed and exchanged, with the patient’s consent, betweenauthorizedhealthcareprofessionals. AcrossAustralia anumber ofinitiativesbasedonHealthConnect are already inplacewithmorebeingdevelopedandimplemented.

Other countries such as Singapore, Taiwan,HongKong andThailandarealsodevelopingelectronichealth records inone formoranotherwithsuccessfulimplementation.

Thereisnoquestionthatelectronichealthrecordsareheretostay.Theextent and type of automation, however, will differ considerably not onlybetweencountriesbutbetweeninstitutionswithinacountry.


The introduction of an EHR can be a mammoth undertaking.Someadministratorsandmedicalpractitionersmaystillbehesitantaboutsuchamajorstepbutwithclearlydeterminedgoalsastothetypeandextentofthesystemrequiredandwellpreparedplansforimplementation, the introduction of an EHR should go smoothly.Theremay be some teething problems and some peoplemay notbe supportive at first but as the benefits become visible its valuewillbecomeapparent. Once fullyupand running it shouldbeasacceptedasmobilephones ande-mail facilities are in the currentenvironment.

Itisimportanttorememberthattheintroductionofanyformofelectronichealthrecordmusthavecompletebackingandsupportoftheadministration,medicalandnursingstaff,andclericalpersonnel.Itisalsoimportanttorememberthat:

Whether a manual or electronic health record is maintained there is still the need to ensure that the information generated by healthcare providers is accurate, timely, and available when needed.

References:

Amatayakul, M.K. (2004). Electronic Health Records: A Practical Guide for Professionals and Organizations.AHIMA,Chicago.

HealthConnect(2000).A Health Information Network for Australia: Report to Health Ministers by the National Electronic Health Records Taskforce.CommonwealthofAustralia,Canberra.

Merrell,RC.MerriamN.DoarnC.(2004).Informationsupportfortheambulanthealthworker.Telemed J E Health 2004Winter;10(4):432-6.

Mon, DT. Defining the Differences between the CPR, EMR, and EHR. Journal of AHIMA. October2004;75/9,74.


CHAPTER 2 Preliminary Steps

Whenconsideringamovefromamanualmedicalrecordsystemtosomeformofelectronichealthrecordthemajorquestionis:Wheretobegin?

TheExecutiveCommitteechargedwithinvestigatingtheintroductionofanelectronichealthrecordsystemshouldtakesomepreliminarysteps.

Firstly,iftheyfeeltheydonothaveanadequatetechnicalbackgroundtomaketherightdecisionsonanEHRsystemtheyshouldconsideremployingaconsultant. Ifpossibletheconsultantshouldhaveastrongbackgroundin health information management, health informatics and electronichealthrecordimplementation.Justhavinganinformationtechnology(IT)background is not sufficient. Theyneed tounderstand thehealth recordenvironment and how manual health records are maintained as well aselectronichealthrecordsystems.TheyalsoneedtohavesomeknowledgeofsystemsoperatingindevelopingcountriesandanyrestrictionsthatmayaffectEHRimplementation,suchaslackoffunds,lackoftechnicalsupport,unreliable supply of electricity, and lack of trained staff. Thismay seemdifficultbuttherearepersonscurrentlyworkinginhealthrecordmanagementin a number of countries, both developed and developing who could berecruited.

Thenextstepwouldbetoreviewtheexistingmedicalrecordsystemtoassess thequalityofcurrent recordsandmedical recordservices, identifyproblemsandpreparea formal reportsummarizingresults.Suchareviewwouldbeextremelyusefulwhenassessingthetypeofsystemtobeselectedandthepossiblebenefitsofmovingtoanelectronichealthrecord.

Review of Current Health Record System

Whenreviewingcurrentmedicalrecordservicesthefirstquestionstobeaskedare:

• Are medical records currently kept on all patients - inpatients, outpatients and accident and emergency (A & E) patients?

Theanswertothisquestionshouldbe“yes”andisthecaseinmostinstitutions. SomemaynotkeepA&E recordsanddonotwishto include them. However, it should be remembered that A & Erecordsareoftenusedinmedico-legalcasesandmaycontainthefirstinformationavailableaboutapatient’shealthoraninjuryandareveryimportant.

• What type of medical record is kept? Is the medical record system centralised using a unit numbering system? That is, are


all admissions, outpatient notes and accident and emergency records filed under one number in the one medical record?

Ifthisisthecasethetransitionfromamanualsystemtoanelectronicsystemwillbeeasier.If,infact,apatienthasmorethanonerecord–thatis,numerousmedicalrecordsscatteredthroughoutthefile,thisisNOTgoodmedicalrecordpracticeandshouldbechanged.

Thismaybethesituationinsomedevelopingcountrieswhereaserialnumberisusedwithpatientsreceivinganewnumberandnewrecordeachtimetheyattendthehospital.Insomecountriesitisusedtoenablethecollectionofstatisticswhich is not necessary and bad practice.Someinstitutionsissueanewnumberforeachadmissionbutfilealladmissionsintheonefolder.

It is not good practice to issue a new hospital number each timethepatientattends.Inamanualrecordsystemoranelectroniconepatientsshouldbeissuedwithanumberonthefirstattendanceandretainthatnumberforallfutureadmissionsandattendances.

Ifinpatientandoutpatient,includingA&E,medicalrecordsarekeptseparately,itmaymeanthattheinstitutionwilleitherneedtostartwithautomatingtheinpatientmedicalrecordfirstandwhenrunningsmoothly incorporate the outpatient attendances or alternativelyconsidercombiningbothatthetimeofimplementation.Thelatter,however, could be amajor undertaking andwould require carefulplanning.

Thenextimportantquestionsrelatetopatient identification.Thisisakeyissueinhealthinformationmanagementasitisvitalthateachpatientisuniquelyidentified,notonlywhenconsideringautomationbutalsoinallmanualsystems:

• How are patients identified? Do all persons have a national identification number? Is this used to uniquely identify the patient? If a national identification number is not issued what information is used to identify each patient?

Ideally,toidentifyapersonwhenanationalidentificationnumberisnotusedinstitutionsneedtodeterminewhatpieceofinformationisnotlikelytobechanged.Namesandaddressesshouldnotbeusedastheycanbereadilychanged.DateofBirthcouldbeusedbutithasbeenfoundthatmanypeopleastheyagecannotremembertheirbirthdateaccurately.Somecountriesuse:

o Thepatient’smother’smaidenname–thishasproventhemostusefulasitdoesnotchangebuttheremaybeexceptionsassomepatient’smaynotknowtheirmother’smaidenname;

ElEctronic HEaltH rEcordsManual For developing countries 1�

o Father’sfirstname–againsomepatient’smaynotknowtheirfather’sfirstname;

o Biometriccharacteristicssuchasafingerprintorfootprinthavebeenusedforidentification;

o Apersonalnationalinsurancenumberorsocialsecuritynumber–theremayalsobeproblemsassociatedwithboththeseasallpersonsmaynothaveapersonalnationalinsurancenumberorasocialsecuritynumber.

Thereforesomeformofnationalidentificationnumberisconsideredthebestwayofuniquelyidentifyingindividualpatients.

Itisimportanttonotethatauniquepatientidentificationnumberisnotthesameasahospital/medicalrecordnumber.Itisthemeansofuniquelyidentifyinganindividual–onceidentified,ahospitalormedical record number is usually issued to enable all informationonan individualpatient tobe filedandmaintainedwithin theonemedicalrecord.

• Does the institution have a Patient Master Index (PMI)? Is it computerised?

ThePMIisanindexofallpatientswhohaveattendedthehospitalasan inpatient,outpatientoraccidentoremergencypatient. It isessential tobeable to identifyan individualmedical recordand iftheinstitutiondoesnothaveonestepsneedtobetakenassoonaspossibletointroduceaPMI.

ThePMIshouldonlycontainidentifyinganddemographicinformationto be able to identify a patient’s medical/health record. It wouldinclude the patient’s full name, hospital medical record number,address,dateofbirthandage,nationalIDnumber(ifany)orotherpieceofinformationthatwillhelptouniquelyidentifythatpatient.

Aproblemwhichmayneedtobeaddressedprior to implementinganEHRisthelackoftrainingofclericalstaffontheneedtocarefullyquestion each patient or relative to ensure that they can uniquelyidentifythepatient.Incorrectspellingofnamescanbeaproblemifclericalstaffisnotproperlytrained.

A well designed electronic health record is dependent on the patient being correctly identified and all information for that patient maintained in the one record within the system.


• Are medical records well documented? What is the quality of the medical record?

o Has all essential information been recorded, are all entries signed and dated?

o Are quality checks performed on current paper records? If so, have any documentation problems been identified?

Oneofthemajorproblemsovertheyearsinmanyinstitutions/countrieshas been inadequate medical record documentation. Problemsincludeincomplete,insufficientorpoordocumentationandnon-useofstandardterminology.

A move to an electronic health record will not be successful ifdocumentation deficiencies are not addressed and healthcarepractitionerseducated ingoodhealthcaredocumentation. Healthpractitionersshouldalsobeencouragedtoenterallrelevantdataatthepointofcareatthetimethatcareisgiven.

• Are daily admissions and discharge lists produced?

ThisisamajorconcerninamanualsystembecauseiftheMRDdoesnotreceivealistofdischargesanddeathseachday,itisimpossibletoknowwhethertheyhavereceivedallthemedicalrecordsofdischargedpatients.

The lackofadischarge list couldhaveadetrimentaleffecton themonthlymorbiditystatisticsasstaffmaynotbeabletoaccountforalldischargedordeceasedpatients.

Anadvantageofanelectronicsystemwouldbethatbothanadmissionandadischargelistshouldbeautomaticallygeneratedaswouldthedailybedcensus.

• Does the MRD receive loose forms after patients have been discharged?

Thisisamajorissueparticularlyifitisanimportantx-rayorlaboratoryreport.LooseformsareoftenreturnedtotheMRDfromwardsandclinicsdaysorweeksafterthepatienthasbeendischargedordiedandneedtobeplacedinthecorrectmedicalrecord.ThisisoftenextremelydifficultasinmanycasesloosesheetsdonotcontaintheMRNand/orthepatient’sname.

If thishasbeenand still is aproblem the introductionof anEHRshould ensure that identifying information is automatically entered


inallsectionsofthepatient’shealthrecordandtheproblemofloosesheetsormissingdatashouldbeeliminated.

Otherquestionsandissuesinclude:

• Are inpatient morbidity statistics collected and compiled by medical record staff?

Are they responsible for the submission of monthly returns and the annual report of hospital activity? What about Outpatient statistics? Are there any problems with the collection and are they produced within the anticipated time frame?

Computerisation has had a marked effect on the production ofmorbidity statisticsbut if theoriginal information isnotcorrect thestatisticswillnotbeaccurateevenwithautomation.

• Are medical records returned to the medical record department on discharge of the patient?

If they are returned promptly have they been completed or are they usually incomplete and without a discharge summary?

How should staff handle incomplete medical records?

Amajorprobleminmanyinstitutionsisincompletemedicalrecords.This iscompoundedwhenmedical recordsarenot returned to theMRDpromptly.

The introduction of an EHR system is seen bymany as away ofimproving this situation butmay not always be the case if healthpractitionersarenottrainedorre-trainedtocompletemedical/healthrecordsonthewardatthetimeofdischarge.WiththeintroductionofanEHRsystemthedoctorshouldbeabletocompletethehealthrecordviaacomputerterminalintheward.

• How are medical records filed?

Are medical records filed by the medical record/hospital number? What system of filing is used?

Medicalrecordfilingisoftenamajorproblem.Ifthereisinsufficientspacetoaccurately filemedicalrecords it isdifficult forstaff to fileand retrievemedical records efficiently and often leads tomisfiledormissingrecords.Overcrowdedshelvescompoundtheproblemofmisfilingormisplacingmedicalrecords.

Manyinstitutionsseefilingspaceasamajorproblemandlookforwardtocomputerisationasasolution.


• Is there a problem with duplicate medical records?

If the patient’s medical record cannot be found, although he or she has attended the hospital previously, should staff prepare a new or duplicate medical record?

In this instance, a duplicate medical record needs to be preparedbutmustbeclearlylabelled“duplicate”andcombinedwiththeoldrecordswhentheyare located.Withcomputerisationthisproblemshouldbeeliminatedaslongaseachpatientisaccuratelyidentifiedatalltimes.

• How is information released for medico-legal purposes?

The reviewer should determine how staff should handle requestsfor information for workers compensation cases, and medico-legalrequestsfrominsurancecompaniesandlawyers.

Is the information readily accessible and available?

Is there a delay experienced in the completion of the reports by medical staff?

Ifmedico-legalinsuranceandworkerscompensationreportsarenotcompletedaccuratelyandpromptly,thepatientcouldbeaffectedascouldthehospitalinlitigationcases.

Withanelectronichealthrecord,suchreportsshouldbeabletobegeneratedautomaticallybymedicalstaffas longasmedical recorddocumentation is completed accurately and at the time care isgiven.

• When the medical record has been completed by the doctor do medical record staff code the main condition using a classification system such as ICD 10?

Do they code procedures? Are coders trained in coding using ICD 10?

Are the codes indexed to enable the retrieval of medical records for research, health statistics and epidemiological studies?

The accurate classification of diseases treated and proceduresperformedisamajorpartoftheworkofthehealthrecordservices.Inmanycases,itisnotperformedaccuratelyorinatimelyfashion.

Some of the problems are caused by poorly documented and incomplete medical records, lack of standard terminology,


and untrained or poorly trained coding staff.

Computer-assistedcodinghasbeenintroducedbymanyinstitutionsbut staff still need tobewell trained in codingandhealth recordsneedtobeaccurateandcomplete.

Withanelectronicsystemproblemswithdocumentationandstandardterminologyshouldbeeliminatedaslongasstandardterminologyisimbeddedinthesystem.

• Do outpatient staff complete Outpatient Morbidity statistics?

Are outpatient’s clinical conditions coded using the ICD-10 or the International Classification of Primary Care (ICPC-2)?

This does now occur in many hospitals and returns are sent tothe Medical Records Department for the completion of monthlystatistics.Someinstitutionshoweverdocodeoutpatientattendanceselectronicallywhichisseenasapossiblebenefit.

ThereviewersalsoneedtoidentifyITsystemscurrentlyinplacethatcouldconstitutetheearlystagesoftheplannedEHR.Doestheinstitutionalreadyhaveanyofthefollowing?•

o AComputerisedPatientMasterIndex(PMI)

o A Computerised Patient Administration System (PAS) – thiswouldcoveradmissions,transfersanddischarges/separations

o Automatedpathologyandradiologyreportingsystem

o Electronicallygenerateddischargesummaries

o Computer-assistedcodingandindexing

o Computergeneratedhealthcarestatistics–bothmorbidityandmortality

o Acomputerisedmedicalrecordtrackingsystem

At thecompletionof the review theExecutive shouldnowbeabletodetermineanyproblemsrequiringattentionbefore theycanprogress toautomation.Itshouldalsogivethemanideaastowhatbenefitstheycouldanticipateif theyprogresstowardEHRimplementation.Thefinalquestionthereforeshouldbe:

• What are the areas that need immediate attention before a successful EHR system could be introduced? Important items include:

o Allpatientsshouldhaveonemedicalrecord:Isthisthecase?


o Allpatientsshouldbeuniquely identified: Is this thecase?Anyproblemsassociatedwithpatientidentificationshouldbesolvedassoonaspossible.

o APMIismaintained:Isthisthecase?Ifnot,itshouldalsobeintroducedassoonaspossible.

o Health practitioners complete the medical records bydocumentingpatientcareinformationatthepointandtimeofcareusingstandardterminology:Isthisthecase?

Asmentionedpreviously,inadequatemedicalrecorddocumentationhasbeen,andstillisinmanyinstitutions,amajorprobleminhealthcare.Ifthereviewteamfoundproblemsinmedicalrecorddocumentation,theyneedtolookatwaysandmeansofencouraginghealthpractitionerstoimprovetheirdocumentationpracticesbeforeintroducinganEHR.ComputerisationwillNOTchangepoordocumentationunlesshealthpractitionersareeducatedorre-educatedwithregardtobestpracticeinhealthrecorddocumentation.

Review of Policies Relating to Medical Records Practice

TheExecutiveshouldalsoreviewtheexistingpoliciesrelatingtomedicalrecordpracticetoidentifyareaswhichwillrequireupdatingtocoverelectronichealthrecords.

For examplequestions relating to somepolicies currently inplacemayinclude:

• Does the facility have a record retention policy? If so, is it beingapplied?Willitrequirerevision?

• Does the facility have a policy on the release of information frompersonalhealthrecords?Doesitneedrevision?

• Whatisthepolicyonpatientaccesstotheirhealthcareinformation?Ifthereisnopolicyisitenvisagedthatpatientswillhaveaccesstotheirhealthinformationinthefuture?

Followinga full reviewof theexistingmedical recordsystem theExecutiveshouldbeabletoconsiderthetypeofelectronichealthrecordtheinstitution/countrycouldbelookingat,thatis:

• Whattheproposedsystemwouldcoverandwhatrestrictionsneedtobeaddressedbeforemovingforward?

Dotheyseethepossibilityofafullyelectronicrecordthatwill:


• Automaticallycollectclinical,administrativeandfinancialdataatthepointofcontactwithapatient;

• Readily exchange data between health professionals to facilitatecontinuingcare;

• Measureimprovementinthehealthofindividualsaswellasmeasurehealthcareoutcomeswithinthecommunity/country;

• Maintainprivacy,confidentialityandsecurityofhealthinformation;

• Facilitateresearchandassistwithteachinghealthcareprofessionals;

• Providetimelystatisticaldata,inanefficientmanner,topublichealthandgovernmentministries(suchreportingofhealthdataisimportantin the detection and monitoring of disease outbreaks, as well asprovidingmeaningfulandaccuratestatistics tomeasure thehealthstatusofthepopulation);and

• Supportmanagement inadministrativeand financial reportingandotherprocesses(Mon,2004).

If the Executive has decided that the institution/country should moveforwardonthepossibleintroductionofanelectronichealthrecordtheyshould,ifpossible,trytoobtainanestimateastothepossiblecostofconversionfromamanualsystem.Theycancontinuetomoveforwardbutbeforemakingafinaldecisiontheywillneedtohaveanideaastowhatispossiblegivenavailablefunds,technology,andtechnicalsupport.Atthisstageimportantquestionswouldinclude:

• What do they see as possible and achievable given availablefunding?

• Whattypeandsizeofcomputersarerequiredtomeettheneedswithinavailablefunds?

• Whattechnicalsupportisneeded?Whatiscurrentlyavailable?

• Will the current telecommunication system available meet theidentifiedneeds?

• Would expert information technology and health informationmanagementadvicebereadilyavailable?


Manual Medical Record Information Flow

Inanelectronichealthrecordinformationflowforinpatientsshouldbethesameasformanualmedicalrecordsasoutlinedinthediagramabove.Therecordcommencesontheadmissionofthepatientwithregistrationandidentification data verified. In theward, all healthcare datawould thenbeenteredelectronicallyatthebedsideornursesstationviaaterminalorother electronic device by attending healthcare practitioners. Other datawouldbeaddedtothepatient’srecordelectronicallyfromotherdepartmentssuchaspathology,biochemistry,radiology,etc.Ondischargeordeaththehealthrecordwouldbecheckedelectronicallyforcompletion,diseasesandprocedurescoded,andstatisticscompiled.TheintroductionofanEHRshouldbeaimedatincreasingtheefficiencyofhealthcaredeliverybytheinstitutionand/orcountry,andcontainingcostsbyeliminatingtheunnecessaryduplicationofservices.Inaddition,asforcurrentpaperrecords,itmustensuretheconfidentialityofdata,improvethequalityofcareandhelptopromotethehealthandwellbeingofthepopulation.

References:

Mon DT. Defining the Differences between the CPR, EMR, and EHR. Journal of AHIMA.October2004;75/9,74.

Patient identified - admittedMedical record begins

Pathology, x-rayBiochemistry etc.

Patient in wardClinical data added

ConsultationsSurgical procedure. PT etc.

Patient dischargedMedical record completed

Medical record coded -Coded clinical data recorded

Morbidity/mortalityStatistics collected

File medical record


CHAPTER 3 Issues and Challenges

Ifadecision to introduceanelectronichealthrecordsystemhasbeenmade,thenextstepistoidentifyandaddressissuesandchallengesthatmayaffectsuccessfulimplementation.

The benefits of an electronic health record system are many. If theplannedbenefitsarenotachievedordonotseemtohavebeenachieved,thevalueofthesystemorfuturesystemsmaybequestioned.

Issues and challenges therefore must be identified and addressed before proceeding.

Accuratepatientidentificationisthebackboneofaneffectiveandefficienthealthrecordsystem,whethermanualorelectronic.Asdiscussedpreviouslyuniquepatientidentificationisamajorissuethatshouldbeaddressedbeforemovingforwardtoautomation.Otherpossibleissuesmayinclude:

1. Clinicaldataentryissuesandlackofstandardterminology

2. Resistancetocomputertechnologyandlackofcomputerliteracy

3. Strongresistancetochangebymanyhealthcareproviders

4. High cost of computers and computer systems and fundinglimitations

5. Concernbyprovidersastowhetherinformationwillbeavailableonrequest

6. Concernsraisedbyhealthcareprofessionals,patientsandthegeneralcommunityaboutprivacy,confidentialityandthequalityandaccuracyofelectronicallygeneratedinformation

7. Quality of electronic healthcare information and accuracy of dataentries

8. Lack of staff with adequate knowledge of disease classificationsystems

9. Manpowerissues–lackofstaffwithadequateskills

10. Environmental issues – electrical wiring and supply of electricity,amountandqualityofspaceneededforcomputers,etc.

11.Involvementofcliniciansandhospitaladministrators


1. Clinical Data Entry Issues

Thechosencomputersystemmustbeabletoidentifystatementssuchas‘thepatientpresentedwithredweepyeyes’andassociatethemwithotherdata for futureprocessing. Useof local terminologycouldbeaproblemwhen trying to implement a systemacross awide variety ofhealthcaresettingsorevenwithinaninstitution.Mostinstitutionsarecurrentlylookingatadoptingastandard,comprehensivevocabularytohelpfacilitateabroaderuseofavailableclinicaldecisionsupportsystemstoensurethatdataenterediscomparabletootherdataentered.Thereareseveralsuchcommercialvocabulariesavailable,suchasSNOMEDCT,developedby theAmericanCollegeofPathologists. Havingbeendevelopedinaparticularcountry,itmayormaynotbesuitableforyourenvironment.

The other possibility is to use or develop a data dictionary. A datadictionaryisasetofcommonstandardsfordatacollectionandisusedtopromoteuniformityindocumentation,dataprocessingandmaintenance.Clinicaldatastandardsaredevelopedtoensurethatdatacollectedinonehospitaldepartmentorfacilitymeansthesameinanotherdepartmentorfacility.IfpurchasinganEHRsystem,mostcomputerfirmshaveadata dictionary incorporatedwithin the system that is unique to theirsystem.However,theinstitutionmaycompileasimpledatadictionarytomeettheneedsof their institution.Eachentry inadatadictionarywouldcontainthedataelementsuchas‘personal identification’withadefinitionordescriptor suchas“the unique number assigned to each patient within a hospital that distinguishes the patient and his or her health record from all others” (Johns, 2002)

TheSteeringCommitteeneedstoreviewwhatisavailableanddetermineifanywouldmeettheirspecificneeds.

The lack of standard terminology could be a major stumbling block to the successful introduction of an electronic health record system.

Providersalsoneedtobeeducatedon:• Thebenefits of using standard terminology for clinical decision

makingsupport;and

• Needtoeducateandtrainusersinhealthrecorddocumentation,topreparethemfortheimplementationofanEHRsystemandalsoformanagingworkflowchanges.

2. Resistance to Computer Technology and Lack of Computer Literacy

Even in today’s environmentmany healthcare professionals still resisttheuseofcomputertechnologywhenattendingtoapatient.Theypreferto write by hand, finding it difficult or uncomfortable using electronicmedia. Newer technology, however, such as small wireless devices,


notebookcomputers,andmobilephoneswithdatacapturecapability,aswellasimprovementsinvoiceandhandwritingrecognitiondevicesarebeginningtoaddresssuchissues.

Inmanycases,however,theissueisnotresistancetocomputertechnologyassuchbutalackofcomputerliteracy.Thiscanbeamajorissue,notonlyformedicalandnursingstaffbutalsoforclericalandotherstaff.Ifautomationisplanned,attentionneedstobepaidtothisissue.Someinstitutionshavefoundthat the introductionofabasiccomputerskillscourse forpersonnelhashelpedalleviate the situation. Resistance toattending suchcourses couldbeaproblemand the staff needs tobeencouragedandsupportedtoovercometheirreluctance.

SuccessfulimplementationofanEHRwillbedependentonthecomputerskillsofallhealthcareprofessionalsandotherstaff.Althoughintoday’sworldmanyusecomputers,particularlytheInternet,somearestillnotproficientinthisareaastheydonotroutinelyusecomputersatworkorathome.

3. Strong Resistance to Change by Many Healthcare Providers

Overcominguncertaintyandresistancetochangewillalsochallengetheimplementation team. Aswith resistance tocomputer technology thishasbeenoneofthemostdiscussedissuesaffectingtheintroductionofelectronichealthcaresystemsoverrecentyearsandonethatneedstobeaddressedbeforeproceedingtoEHRimplementation.

Formany health professionals the change to entering patients’ healthrecorddataviaacomputerorotherelectronicdevicemaybedaunting.This issue will require intensive training of healthcare practitioners tohelp thembecomemorecomfortablewith,andensureacceptanceof,thenewtechnology.

Overcoming resistance tochangebyhealthcareprofessionals,whetherinamanualsystemoranelectroniconecouldbeachallengebutwiththerightstrategycouldbeovercome.Asmentionedpreviously,themainstrategy tohave inplace tohelpovercomesuch resistance is tohavethem involved fromtheoutset indiscussionson thedevelopmentandimplementationofanEHR.Aswellasbeingtrainedinthetechnology,theyneedtobeinvolvedinsystemselectionanddesign.

4. High Cost of Computers and Computer Systems and Funding Issues

Perceivedhigh costs of computers and computer systemsand lackoffundsforhealthcarehasbeenseenasamajorissueinthedevelopmentandimplementationofanEHR.Healthadministratorsandgovernmentofficials see suchanundertakingasan investment thatmustbe self-supporting in a time when available funding for healthcare is limited


andoverallhealthcarecostsareescalating.TheinitialoutlayassociatedwiththeintroductionofanEHRwouldundoubtedlybesignificant,bothintimeandfinance,totailorittotheindividualneedsoftheinstitution/countryandtodealwiththebroaderaspectsofthechangetothenewsystem. It is therefore important to identify specific requirements, aswellasclinicalpracticeguidelines. Inaddition,administratorsshouldundertakeacomparisonofcurrentsystemcostsplusperceivedcostsforthenewsystemagainsttheproposedbenefitsforthechangetodeterminethelong-termvalueoftheanticipatedEHRsystem.

5. Concern by providers as to whether the information they generate will be available on request

Providersneedtobeassuredthatwhiletheinformationwillnotonlybereadilyavailableatalltimes,theywillbeabletoaccessitmoreefficiently.Thisassuranceshouldalso includetheavailabilityof information fromothersourcessuchaspathology,radiology,pharmacy,etc.Infact,theinformationwillbemorereadilyavailablethaninamanualsystemwheremedicalrecordsarefiledinanMRDwhichisnotopen24-hoursaday.

6. Concerns raised by providers, patients and the general community

about the privacy, confidentiality and quality of information generated

Everyone involved, including the patient, healthcare professional andthe general population, needs reassurance that all data generated ismaintainedinasecureenvironment.Aswithpaper-basedhealthrecords,locallawstocoverelectronichealthrecordswhichaddresssuchconcernsmustbeup-to-dateandinplace.Therelevantlegalissuesshouldincluderetentionschedulesandhowinformationistoberetrievedfromelectronicmediaonwhichitisstored.Thedurabilityoftheelectronicmediamustalsobetestedanddocumented.

7. Quality of electronic healthcare information and accuracy of data

entries

Aswithmanualsystems,theaccuracyofelectronicallyrecordeddataisalsoaconcern forhealthcareadministratorsandprofessionals. ManyadvocatesofEHRs,however,believethatelectronichealthrecordsareinfactmorelikelytobeaccurateandreadilyavailablethanmanualrecords.Inaddition,itissuggestedthatthequalityofelectronicallyrecordeddataisbetterastherearemeasuresinplace,suchaseditchecking,aimedatensuringaccuracy.

Rememberthecharacteristicsofdataqualityinclude:

• Accuracyandvalidityoftheoriginalsourcedata;


• Reliability – data is consistent and information generated isunderstandable;

• Completeness–allrequireddataispresent;

• Legibility–dataisreadable;

• Currencyandtimeliness–dataisrecordedatthepointofcare;and

• Accessibility–dataisavailabletoauthorizedpersonswhenandwhereneeded.

All these characteristics are important in both manual and electronicrecordsystemsandwhenchanging toanelectronicsystemtheymustbekept inmindandaddressed. Whatever the system, thequality ofhealthcaredataiscrucial,notonlyforpatientcarebutalsoformonitoringthehealthcareservicesandtheperformanceoftheinstitution.

8. Lack of staff with adequate knowledge of disease classification systems

Currently,thereismorecomputer-assistedcodingthancodingentirelybycomputer.Workiscontinuingonthedevelopmentofonlinecodingbutitwillbesometimebeforecomputerscantakeovercodingcompletelyinmostcountries.Thetrainingandeducationofcompetentcodersisstillamajorprobleminmanycountries,particularlydevelopingcountrieswheretheavailabilityof,andaccessto,codingtrainingprogramsisextremelylimited. If this is thecase in your institutionconsideration shouldbegiventothepossibilityofrecruitinganexpertinthisareatooffercodingprograms. Thestaff tobe trainedshouldbecarefully selected. Theyshouldhavegoodclericalskillsandattentiontodetail.Trainingshouldincludesessionsinmedicalterminologyifthepeopleselecteddonothaveamedicalornursingbackground.Thetrainingalsoneedstoincludetheuseofcomputer-assistedcodingsystems.

9. Manpower issues – lack of staff with adequate skills

Theavailabilityofawell-trainedworkforceisanotherissueforconsiderationwhen preparing to introduce an EHR system. In many developingcountries, staffmaybeavailablebut their skillsmaynotbeadequateforthetasksexpectedofthem.Again,thiswouldrequiresomeformofin-servicetrainingprogramtodeveloptheskillsrequired.Personstobetrainedagainshouldbecarefullyselectedandbemotivatedtolearntoimprovetheirskills.Incentivesmayneedtobeofferedsuchasabetterpositionwithintheinstitution.

10. Environmental issues

Amajorconcerninmanydevelopingcountriesisanavailableandreliablesupplyofelectricitywithinthehealthcarefacility.Ifelectricitysupplyisa


problem,itwillneedtobeaddressedbeforemovingforward.

Another important environmental issue is the amount and quality ofavailablespaceneededforcomputersandotherequipment.Areviewofexistingspaceshouldbeundertakentodetermineifit issufficientandappropriatetohousetherequiredequipment.

11. Involvement of clinicians and hospital administrators

Whenplanningasystemtobeusedinthehealthcareenvironment, itis important for those involved in itsdevelopment tohavea thoroughunderstanding of clinical data and how health professionals use thatdata in clinical decision making. In addition, the involvement ofcliniciansandhospitaladministratorsintheidentificationofinformation/dataisessential.Theirspecificationsandinputareimportantfortheiracceptanceofthesystemespeciallyissuesrelatingtoownershipoftheinformation.

Willingnessbyhealthcareproviderstocollaborateandsharedatawithotherprovidersandalsowiththepatientcouldbethemostdifficultofthenon-technicalissuestobeaddressed.Thisisanexampleofoneofthemanychallengesandissuesthatneedtobeovercome.

If the system does not meet expectations and users have a bad experience, overcoming that experience could be a greater challenge than overcoming other issues.

Safeguards which may also need to be addressed:

Aswithmanualsystems,safeguardsmustbeinplacetoensureagainstloss, destruction, tampering and unauthorized use of electronic records.Somesafeguardsmayincludeplansfor:

• Databack-upasinanycomputersystem,theremustbeanefficientback-upsystemavailable

• Contingencyplansfordisasterrecoveryalsoneedtobeinplaceinthecaseofanelectricalbreakdownorotheremergency

• Securingworkstations and requirement of passwords for all users.Thepasswordsshouldbechangedregularlytomaintainsecurity

• Accesscontroltoensurehealthrecordsareavailablewhenneededforpatientcareandotherofficialpurposesbutmaynotbeaccessedbyunauthorized persons

• Audit controls where access may be monitored to ensure onlyauthorizedpersonsusethesystemandtoidentifywhenchangesaremadeintherecord


Administrativesecurityrequirementsforriskanalysisprocessesandformanagementmustalsobeinplace.Thereshouldbeaninformationsecurityofficerdesignatedtoperformclearancechecksonmembersoftheworkforcewhowillhaveregularaccesstothesystem.Inaddition,incidentreportingandresponsemechanismsmustbeavailable,asshouldbethemeansforongoingmonitoring and evaluation of the system to ensure that all usersadhere to the stated standards. Policies and procedures and workforcetrainingneedtobeinplacetoensurethatusesanddisclosuresaremadeonlyaspermittedorrequiredbylaw.

Remember that itmaybepossible to implementawelldesignedEHRbutifpotentialissuesandchallengeshavenotbeenaddressed,andifusershavenotbeeninvolvedinthedesignorintheselectionofthesystem,arenotproperlytrained,and/orarenotsupportedbythehealthcareauthorities,thesystemmaynotbeusedeffectivelyandmaythereforefailtoproducetheanticipatedoutcome.

References:

Amatayakul,M.K.(2004).Electronic Health Records: A Practical Guide for Professionals and Organizations.AHIMA,Chicago.

Johns,M.L.(2002).Health Information Management Technology: An Applied Approach. Chicago,AmericanHealthInformationManagementAssociation.

SNOMED International. 2004 SNOMED Clinical Terms Core Content as of Jan 2004. Available at http://www.snomed.org.


CHAPTER 4 Planning for the Introduction of an EHR

OncethedecisionhasbeenmadetogoaheadwiththeintroductionofanEHR,andallissuesandchallengesareidentified,thenextstepwouldbe to formaSteeringCommittee toundertake theplanning

anddevelopmentoftheproposedsystem.ThisCommitteeshouldconsistofmembers of the administration, health information management, potentialusers from themedical andnursing services, representatives from financialandITservices,andanyotherindividualidentifiedasimportanttoinclude.

The Steering Committee should seek to ensure that there be earlyinputfrommembersofmedical,nursingandotherkeypersonnelwithintheinstitution.Remember:

It is extremely important that there is support from the anticipated users of the system who need to be involved from the onset of discussions.

ThefirstjoboftheSteeringCommitteewouldbetofollow-uptheExecutiveCommittee’sreviewoftheexistinghealthrecordsystemanddetermineifthereisanysectionneeding further reviewsuchascurrentpatient identificationandhealthcaredocumentation.ItisimportantthatmembersoftheSteeringCommitteeunderstand:

• Thecurrentsituation;

• Thepresenceofanyproblemsthatmayneedtobeaddressedbeforeachangecanbeplanned;and

• Theassessmentoftheattitudeofbothclericalandmedical/nursingstafftotheproposedchange.

Once theSteeringCommitteehasbeenable to investigate thecurrentsituation,undertakeproblemsolving,andrecommendstepsforimprovement,ifnecessary,theyneedtocommenceplanningforthedevelopmentof theproposedsystem.Somestepstheyneedtotakeincludethe:

• Preparation a report outlining the perceived benefits of a systemchange;

• Outlininghowexistingdataandsecuritystandardswillbeadopted;

• Preparationofastatementonprivacy,consentandothermedico-legalissues,emphasizinghowtheprivacyandsecurityofpatienthealthcareinformationwillbemaintained;


• Identificationofwhoshouldbeinvolvedintermsofbothcliniciansandconsumers;

• Introduction,ifnotalreadyavailable,auniquemeansofidentifyingindividualpatients;

• Developmentofatimeframeforimplementationandfunding.

Withtheinformationcollectedandaddressed,theExecutiveandSteeringCommitteeshouldbereadyto:

1. DeterminethetypeofEHRenvisagedbytheinstitution/country

2. IdentifyperceivedbenefitsofanEHRsystem(addedfromChapter1)

3. Setachievableoutcomegoalsthatwillmeettheneedsofbothusersandconsumers

4. DevisestrategiesinpreparationforanEHR

5. Developpoliciesforuseinanelectronichealthrecordsystem

1. Determine the type of EHR envisaged by the institution/country and it’s respective government

ThetypeofEHRsystemtheinstitution/governmentwantsgivenavailableresourcesshouldbedetermined.Criticalquestionswhichshouldhavebeenaddressedbythisstageinclude:

• Is it possible for the institution/government to move from a paperhealthrecordtoafullyelectronichealthinformationsystem?

• Wouldtheinstitution/countrybeabletomanageallhealthinformationelectronically?Thatis,implementafullyintegratedevidence-basedhealthcaresystemwiththedistributionofanindividual’shealthcareinformation beyond acute inpatient situations to ambulatory careincludingnursinghomes,ruraloroutlyingclinics,homehealthcare,etc

Giventhesituationinyourinstitution/country,whatwouldbefeasible?Wouldtheinstitutionbelookingatasimpleapproachasdiscussedpreviouslysuchas:

• The proposed electronic health record will be limited to hospitalswithintheregion/country?

• Theproposedelectronichealthrecordwillbeimplementedatasinglehospital?


Whatever the extent determined, the expectation should be that theintroductionofanEHRwillprovide immediateaccess todataandenableprocessingthatdatainavarietyofwaystosupportboththedecision-makingprocess by health professionals for patient care and clinical and healthservicesresearch.

Ifasimpleelectronichealthrecordisenvisageditcouldbedefinedasfollows:

The proposed electronic health record will cover the following:

• All personal health information about an individual, entered electronically by healthcare providers at the point of care over a person’s lifetime;

• Accessibility by healthcare providers and departments within the hospital from which the patient has received care;

• Organization of information primarily to support continuing, efficient and quality healthcare within the healthcare facility.

Adiagrammaticexampleofasimpleelectronichealthrecordisshownbelowindicatingsomeareasfeedingintotherecordfromunits/departmentswithintheinstitution.Therecouldbeothersdependingontheextentandscopeofthesystem.

A Simple Electronic Health Record System

EHR

Patient IDRegistration

ATS

Clinical data treatment orders/results

OPD visits

Lab/haem/Path/Bio-chem/etc.Radiology

DiseaseClassification

andindexing

Scanneddocuments/ previousmedicalrecords


2. Identify perceived benefits of an EHR system

TheExecutiveandSteeringCommittee,withtheassistanceoftheconsultant,ifonehasbeenappointed,shouldbeabletoidentifywhatbenefitstheyseeaspossiblewiththeintroductionofanelectronichealthrecord.Forexample,benefitscouldinclude,butnotbelimitedto,thefollowing:

• Patientswillbeuniquelyidentifiedatalltimes

• All healthcare information generated within the institution will bedocumentedatthepointofcare

• Standardterminologywillbeusedtoensureinformationisuniversallyunderstood

• Allhealthrecordswillbeaccurate,reliable,andcompletedpromptly

• Datawillbeprocessedtosupportbetterdecision-makingbyhealthcarepractitioners

• Informationaboutanindividualpatientwillbeimmediatelyavailableatalltimesforpresentandfuturecare

• Quality of healthcare will be enhanced by the provision of betterinformation for clinicians to make decisions about treatment andhealthcareplanning

• Patientconfidentialityandprivacywillbemaintained

• With improvedclinicaldocumentationat thepointofcare,problemsassociatedwithcodingofdiseasesandprocedureswillbeeliminated

• Morbidity and mortality statistics will be completed promptly andaccurately

• Problemsrelatingtofiling,loosesheets,etcwillbeeliminated

• Spaceproblemsassociatedwiththestorageofpapermedicalrecordswillbeeliminated

• Increasedefficiencyoftheinstitutionwithdecreasedcostsinthelong-term

3. Set achievable outcome goals

Once the extent to which automation may be achieved has beendetermined,theExecutiveandSteeringCommitteeneedtosetoutcomegoalsthatwillencompasstheperceivedbenefitsandmeettheneedsofbothusersandconsumers.Theyshouldbeclearlystatedmakingsurethattheyareboth


realisticandachievable. Bychanging toa simpleelectronichealth recordsystemwithinaninstitutionthegoalscouldbeto:

• Ensure that all healthcare data is comprehensive, timely, accurateandreadilyavailableatalltimesforpatientcare

• Improvecommunicationbetweenhealthcareprovidersatbothdataentrylevelanddataretrievallevel

• Providebetteraccess toan individual’shealthcare informationandimprovehealthcaredeliverybysharingtheirdatabetweenattendingpractitioners

• Enableindividualstoaccesstheirpersonalhealthinformation

• Providetimelyandaccurateinformationformedico-legalpurposes

• Providetimelyandaccurateinformationforthecollectionofmorbidityandmortalitystatistics,forclinicalresearch,andteaching

• Supporttheadministrationintheirpolicydecision-makingandpublichealthreporting

If a longitudinal electronic health record is planned, the goals couldincludetheprovisionofabetterlinkbetweenprimarycarecenters,betweenprimarycareandsecondarycare(hospitals),andbetweenhospitals.

The goals should not simply be to change processes for the sake ofchangebuttoimprovetheoutcomeofhealthcare.

4. Devise strategies in preparation for an EHR

When determining strategies in preparation for the introduction of anEHRsystem, itmustbekept inmindthat theinstitution/country is intheprocessofintroducingamajorchangewithinthehealthcaredeliverysystemand managing that change effectively and efficiently will be crucial to asuccessfuloutcome.

Strategiesshouldincludetheidentificationofcriticalfactorstosuccess.Theycouldinclude,butmaynotbelimitedto,astrategyfor:

a) Patientidentification

b) Documentationstandards–fortheexchangeofinformation

c) Incorporationofprovidersignatures

d) Educationandtrainingofallstaff–medical,nursing, administration,andclerical

e) Storingelectronichealthrecords


f) Riskmanagement

g) Qualityassurance

h) PersonalHealthRecords–withthecurrenttrendforpatients tobemoreinvolvedintheirownhealthcarepersonalhealth recordsareplayingagreaterroleinhealthcareinmany countries

The Steering Committee will also need to determine how they willcommunicate the planned changes and market them to providers andconsumers.Inaddition,workpracticeissuesneedtobeaddressedaswellaspossible issuesandchallenges thatmaycauseproblemsanddelay inimplementationsuchaslackofavailablepersonnelwithtechnicalexpertiseto operate the system; lackof dataprocessing facilities; and staff lackingcomputerskills.

a) Patient Identification

As mentioned many times, an essential step to be taken when preparing for the introduction of an EHR is to ensure that all patients are uniquely identified at all times.

Some formofUniquePatient Identifier is essential to provide thelinkingmechanismthatunderpinstheEHR.

Inmanycountries,nationalpatientidentificationnumbersarealreadybeingused.Ifthisisthecaseinyourcountry,youarealreadyonthefirstrungoftheladdertoimplementinganEHR.Ifitisnotpossibletohaveanationalidentificationnumber,thecurrentsystemusedforpatientidentificationshouldbeusedandadaptedifrequiredbutifthereareproblemswithpatientidentificationthatneedtobesolvedbeforemovingforward.

Aspreviouslymentioned,identifyinginformationshouldbestoredinaPatients’ Master Index (PMI)andwouldincludedemographicinformationsuchasauniquepatientidentificationnumber,medicalrecord/hospitalnumber,dateofbirth,sex,address,andotherspecificdemographicinformation.Currently,manyinstitutionshavealreadyautomatedtheirPMI.Ifthisisnotthecase,anelectronicpatients’masterindexsystemisessentialwhenconsideringimplementinganelectronichealthrecord.

Automationwouldrequireagroupofprograms,accessedbyusersviadisplayterminals,and/orprintingterminals.Theprogramswouldbedesigned toenableaccess to the informationheldon thePMIfile,and tobuildormodify the file informationas requiredby theinstitution.


b) Documentation Standards for Information Exchange

Justasthereareasetofstandardsformanualmedicalrecordsandmedicalrecordservices,therealsoneedtobestandardsinelectronichealthrecordssystems.TheSteeringCommitteeneedstoensurethatstandardsareinplacetoaddressdefinitionsofdatatobeexchanged,thetimingoftheexchange,themanagementandintegrationofdatatosupportpatientcare,andtheevaluationofhealthcareservices.

There are several accredited standard-developing organizationsoperating in the international healthcare industry, the most well-knownbeingHealthLevel7.Thisorganizationand thestandardstheydevelopareknownasHL7.Thesestandardsaredevelopedtoprovideastructurethatdefinesdataanddataelementsandspecifieshowdataiscoded.

SpecificationsdevelopedbyHL7includethewidelyusedmessagingstandardthatenablesdisparatehealthcareapplicationstoexchangekey sets of clinical and administrative data. Such standardshave been developed specifically to create flexible, cost-effectiveapproaches, standards, guidelines, methodologies and relatedservicesforinteroperabilitybetweenhealthcareinformationsystems(HL72005).

Theuseofinternationallyacceptedstandardsinindividualapplicationswillimprovetheintegrationoftheapplicationwithotherapplicationsin thesystem. Adecisionneeds tobemadeas towhich, ifany,standardsorganizationtheinstitution/governmentwilluse.InmanycommercialEHRsystemsstandardsarealreadyimbeddedwithintheprogram.

c) Incorporating Provider Signatures

Inanelectronichealthrecord,asinmanualrecords,treatmentandmedicationordersmustbesigned.Theauthenticityofanelectronicsignatureisextremelyimportantparticularlywhentherecordisusedfordocumentaryevidenceinlegalcases.

Inanelectronicsystem,authenticityisofteneasierwithdocumentsautomatically stamped with date, time, and user identification.Somesystemsuse theprovider’spasswordas verificationof theirsignature.Thisisaccomplishedbyrequestingthatthepasswordbeenteredasecondtimeforverification.

Somecountriesdonotseethisassufficientandplantouseadigitalsignaturecreatedcryptographically.Cryptographykeepsdatasecretthroughmathematicalorlogicalfunctionsthattransformintelligibledata into seemingly unintelligible data and back again so as toauthenticate the user and provide non-repudiation (Amatayakul,


2004).Thatis,itisaprocessthatenablespositiveidentificationofthesenderofacomputermessagesothatthesendercannotdenysendingthemessage

d) Education and Training

Oneofthemostcrucialissueswhenpreparingtointroduceamajorchangeinanyorganisationisthetrainingandeducationofusersofthesystem.Thechangefromamanualmedicalrecordsystemtoanelectronichealthrecordsystemisamajorchangeandmanypeople–healthcareprofessionals,administrative,clericalstaff–needtobethoroughlytrainedifthechangeistobesuccessful.

Resistancetochangeorhesitancyinelectronicdocumentationneedstobeaddressedandalthoughsomestaffmaystillbehesitant, theymaybe willing to become involved. It is extremely important to gain theconfidenceofallstaffparticularlymedicalandnursingstaff.Asthemajorusers of the system, doctors andnurses need to understandhow thesystemwillfunctionandbeconfidentthatalllegalandethicalissueswillbesafeguarded.

e) Storing Electronic Health Records

Astrategyneedstobeinplacetoaddressthestorageofelectronichealth records. As for manual medical records, the electronichealth record needs to be maintained in an accessible media forfutureretrievalforpatientcareandotherusessuchasresearchandteaching.TheSteeringCommitteeshouldidentifywhetherprevioushealthrecordswillbescannedandincludedaspartofthesystem,howtheywillbestored,andif thesystemwill includeemergencyattendances.

The strategy should include what type of media will be used to store the EHR

Primarystorageisusuallymaintainedinthecentralprocessingunit(CPU)withinformationreadilyavailableonline.Whendevelopingastrategyforstorage,itisimportanttorememberthatspeedandbackupareimportantconsiderationsasitmustfullysupportcontinuousandinstantaneousaccesstodata.

Secondary storage also needs to be considered. AnEHR systemstores huge amounts of data and decisions need to be made onthe type of storagedevice to beused. Thebetter-knowndevicesaremagnetictape,harddisksystems,andopticaldisks.Thelatterarewellsuitedforstoringmultiplemediaincludingimagessuchasx-rays.Itmaybeon-linetotheCPUforrealtimeaccessoroff-linerequiringon-lineloading.


Otherquestionsand issuesonstorage tobeaddressedwouldinclude:

• What are the environmental conditions? Are there anyphysicalhazards?

• Whatcontrolwilltherebeforequipmentandmedia?Whomayhaveaccess?

• Whatcontingencyplansareinplaceifthesystemisdown–secondaryorback-upcopy?

• Whatwill the storageperiod for each record typebe?–locallawsneedtobetakenintoconsideration;and

• A plan is in place for the transfer of electronic healthrecordstonewmediabeforedegradationoccurs.

f) Risk Management

A risk management strategy should be in place to address anyforeseeablebarrierstotheimplementationofanEHR.Elementsofthisstrategyshouldincludeplansto:

• Ensureadequatefundingisavailabletoprovidethesourceapplications,hardwareinfrastructureandimplementationresourceswitha funding/financialmanagementplan inplacetoincorporateongoingneeds

• Ensure sufficient skilled resources, both human andtechnical,areavailabletoprovideprogrammanagementduringimplementationandtogiveon-goingsupport

• Developandimplementamarketingstrategytopromotethe benefits of the proposed EHR to consumers andhealthcareproviderssuchasbrochuresoranewslettertokeeppersonnelup-to-datewithdevelopments

g) Quality Assurance

ThisstrategyshouldsetouttheaimsofanEHR,whichshouldincludeimprovinghealthoutcomes,populationhealth,andthemanagementofhealthresourcesandservicesby:

• Providing better information for clinicians to makedecisionsabouttreatmentandcareplanning

• Supporting a best practice, evidence-based healthsystem

• Increasing access to information for medical auditpurposes

• Providing decision-support to allow clinicians to makethebesttreatmentdecisionsfortheirpatients


• Ensuringtheavailabilityofmedicalalertandprescriptiondecision-supporttoreduceadverseevents

• Providing information to support an understanding ofserviceutilizationpatternsandbetterserviceplanning

h) Personal Health Records

A decision as to whether a personal health record (PHR) will bean integral part of the EHR plus the form it will take should bedeterminedduringtheplanningstage.

Insomecountriesapersonalhealthrecordisprovidedviaasmartcard,likeaplasticcreditcard.Itisusedtostorepatientinformationincludingidentificationanddemographicdetails,allergies,andbloodtype,aswellascurrenthealthproblemsandmedications,includingrecent findings (Hebda et al, 2001). Theymay also include thepatient’sphotographforpositiveidentification.Patientscarrytheirsmart card with them when they attend a healthcare facility andpresent it to the provider who processes it via an electronic cardreader.Thecardisnotpartofanelectronicnetworkandprovidesdetailedaccurateinformationthatisreadilyavailable.Suchpersonalhealth recordsarepopular in somecountriesandcontain varyinglevelsofinformation.

5. Develop policies for use in an electronic health record system.

Policydevelopmentisessentialtoensurethatexistingpolicieshavebeenrevised and redeveloped to address the implementation of an electronichealth record system. Apolicy is abasic guideof action thatprescribestheboundarieswithinwhichactivitiesaretotakeplace.Itisimportanttoidentifyhowtheproposedautomationofhealthrecordswillaffectexistingpoliciesandproceduresandrevisethemaccordingly.Somepoliciesrequiredmayinclude:

a.) Information Flow

InasimpleEHRsystemtheinformationflowforinpatientsshouldbethesameasforamanualsystemexceptthatdatawillbeenteredatthenurses’ordoctors’stationinthewardviaanelectronicdevicewithotherdatatransmittedelectronicallyfromotherdepartmentswherethe patient has received tests, treatment, etc. An existing policyoninformationflowshouldbereviewedandrevisedtoincorporateelectronicdataentry.

The actual entering of clinical data at the time theprovider visitsa patient has been an important factor that has restricted theimplementationofafullyelectronichealthrecordinmanyinstitutions.Toovercomethisproblem,dataentryhasbeenimprovedbyusingastructuredformatthatpromptstheprovider.


b.) Work Flow

Currentwork-flowpolicyneedstobereviewedandrevisedtomeetthedemandsoftheelectronicsystemastherewillbemanychangesparticularlyintheMRD.Work-flowvariesfromonehealthcaresettingto another and needs to be clearly understood and documentedbeforeimplementation.

c.) Content and Format of the Health Record

Thecurrentpaperrecordcontentandformatshouldbeassessedtoseeiftheyaresuitableforadaptationtotheelectronicsystem.Formsmayneedtoberedesignedtoenhancedataentry.Therecordformatneeds tobeofakind thatwillensureefficient retrievalofneededdata.

In a manual system, procedures should be in place to enablecorrectionandamendmentstodataentryinhealthrecordswithstrictguidelines for correctingdataand reports.Thesamewill apply toelectronicdataentry.Inpaperrecords,correctionsinarecordentryare easily identified. This may not occur in an electronic recordandthecomputerprogramshouldprovideanaudittrailthatshowswhen changes were made and by whom. Policies on how dataistobevalidatedalsoneedtobeinplaceaswellasrulesforthecompletionprocessfollowingthedischargeofaninpatient(thatis,howclinicianscompletetheirrecords).

Completion of a health record by the attending physician should be done at the time of discharge.

Astandardformofpatientconsentfortreatmentneedstobedesignedwithdetailedpoliciesandguidelinesforitsuse,includinghowthepatient’ssignaturewillbeincorporated.InmanycasesthesignedConsentFormisscannedandincludedintheEHR.

d.) Downtime Policy

Apolicyandprocedureneedstobeinplacetoaddressissuesrelatingtodowntimeandbackup.Howthesystemistobebackedupisanimportantissueandimplementationcannottakeplaceuntilthishasbeendetermined.

e.) Printing Policy

There needs to be a policy on printing documents. It must bedetermined for what purposes a record will be printed. Ideally,for patient care, all entries and retrieval of datawouldbe via the


computer.Copieswillbeprintedandwillbetracedbyanaudittrailtoidentifyuserswhohaveprintedreportsfromthesystem.Thisistoensurethatthepatient’sprivacyhasbeenmaintained.

f.) Retention Policy

Itiscriticaltodeterminethelengthoftimedocumentsanddataistoberetained.Informationwillneedtobeculledandapolicyneedstobedevelopedtocoverwhatdatawillberetainedandforhowlong.

Otherpoliciesandproceduresthatmaybeuniquetoyourinstitutionandshouldbeinplacebeforeproceedingtoimplementationshouldbeidentifiedandaddressed.

Next Steps in the Planning Process

ThenextstepsinplanningfortheintroductionofanEHRwouldbetoappointateamtooverseeimplementationandestablishanumberofworkinggroupstoassistwiththedevelopmentofpoliciesrelatingtospecifictasks.

1. Appointment of an implementation coordinator and an implementation team

Skilledinformationmanagementpersonnelandawell-trainedtechnologyworkforce are essential for successful implementation of an EHR. Anappropriateorganisationalstructurealsoneedstobeinplaceandkeyusersmadeready.

Theinstitution/countryshoulddeterminewhethertheSteeringCommitteewillbegiventhetaskofimplementationorateamofdedicatedstaffdelegatedfor thepurpose. Somemembersof theSteeringCommitteemaybe readytomoveonas their specific taskhasbeencompleted, somemaynot feelabletobepartoftheimplementationteam,whileothersmaybebothwillingandcompetenttoparticipateintheimplementation.Giventhecriticalnatureof the implementationphase,however, twogroupsmaybe required– theSteeringCommitteetoseetotheoverallimplementationandadedicatedteamtoundertakespecifictasksasoutlinedintheplan.

An implementationcoordinatorwill lead the implementation teamandmay have a title such as Program Coordinator or Project Manager. Thisperson may be a member of the Steering Committee, someone alreadyon staff, or someone specifically employed for the task. Alternatively, theinstitution/countrymaywishtoemployaconsultantoroutsideadvisorwithabroadrangeofexperienceinhealthinformationmanagementandelectronichealthrecordimplementationtoassisttheSteeringCommittee.

Theimplementationteamleaderwillberesponsibleforcoordinatingtheimplementation of the new system. The person appointed or contractedforthisrolemustberespectedandvaluedbyhisorherpeers,beagood


communicator,astrong leaderwithgoodnegotiationandproblem-solvingskills.

The implementation team (whatever its form) should include askilled workforce with the expertise to support the Steering Committee,implementation coordinator, and potential users. Remember that it isextremelyimportantthatallpotentialusersareinvolvedintheformulationofpoliciesandguidelinestofosterparticipativedecision-making–vitaltothesuccessfulintroductionofthenewsystem.

Organization Structure

2. Establishing a number of working groups for specific tasks

Anumberofworkinggroupsneedtobeidentifiedandappointedforeachspecificresponsibilitysuchasa/an:

a.)InformationSecurityGroup–todealwithmedico-legal aspectsincludingprivacyandconfidentialityissuesb.)EducationandTrainingGroupc.)QualityAssuranceGroup

MoregroupsmayberequiredandtheSteeringCommittee,inconjunctionwiththeimplementationcoordinatorandteam,needtoidentifyareasneedingspecialattention.

a.) Information Security Group – medico-legal aspects including privacy and confidentiality

The Steering Committee should appoint a team to develop andmaintain a medico-legal checklist, incorporating governmentregulations, to guide the implementation and on-goinguse of theEHR. Remember that measures need to be directed at ensuringappropriatesecurityandstorageofinformationtopreventimproperdisclosure.

Withinthe institution/countryanInformationSecurityPolicyshould

Executive

Steering Committee Providers and users

ImplementationCoordinator Working groups

Implementation team


beinplace,withstandards,implementationguidelines,andanactionplan.Compliancewithsuchapolicywillsafeguardtheaccuracyandcompletenessofinformationandensurethat:

• Only authorized persons have access to healthcareinformation

• Dependantprivacypolicyandrelatedlegislationareupheld• Informationisstoredandhandledinasecuremanner

Implementation of an Information Security Policy will ensure thatinformation related to health encounters will be protected fromunauthorizedaccesswhen theEHR isoperational. It is importanttorememberthatforamanualhealthrecordsystemtheprivacyandconfidentiality of patient information in an electronic health recordmustbeprotectedatalltimes.

b.) Education and Training Group

Atrainingteamneedstobeinplacetodevelopeducationandtrainingprograms. Aspreviouslydiscussed,on-site training is required toaddress work practice issues and develop a group of competentusers,confidentintheirknowledgeoftheproposedsystemandreadytoacceptthechange.TheSteeringCommitteemayidentifytheneedtohavemoretrainersthanstaffon-siteduringearlypreparationfortheintroductionofanEHRsystem.

Systemshavebeenknowntofailbecauseindividualsrequiredtousethesystemhavenotbeenadequatelytrainedanddonotunderstandthesystem.Theyalsomaynothavebeeninvolvedfromthebeginningofdiscussionsandnegotiations.Training,however,shouldcommencewith the more interested users with keyboard skills and a betterknowledgeofcomputerswhowillsubsequentlybeusedtopromotetothelessinterested,motivatedorskilledpersons.

Remember, a key ingredient for successful implementation is user-involvement from the beginning. It is critical to success. So too is training.

Thefirststepwouldbetoconductaneedsassessmenttodeterminethe levelof trainingrequiredforalldataprovidersanddatausers.Fromthisassessment,theEducationandTrainingGroupwillbeabletoidentifythetrainingneedsofusers,determinecontentofthetrainingprogramandmethodsofteachingandsetupascheduleforclasses.Whentheabovehasbeencompletedthegroupneedstodeterminethelocationwheretrainingwilltakeplaceandwhathardwareandsoftwarewillbeneeded.Itisalsoimportanttoestimatethecostsoftrainingandhowtheprogramsaretobeevaluated.

Fromtheneedsassessmentitmaybefoundthatnotallusersneedtrainingat the same level and thatdifferent levelsof classesmay


needtobeconducted.Thefirstgrouptobetrainedshouldbethetrainers and a program (specifically to “train the trainers”) needsto be designed and implemented. This group will then take ontheresponsibilitytotraintherestoftheprovidersandotherusers.Trainingwill be an on-going function andwill not stopwhen thesystemisupandrunning.Therewillalwaysbenewprovidersandusersrequiringtrainingbeforeusingthesystem.

It may be wise to consider some one-on-one training sessionsfor clinicians who may be reluctant or too busy to attend groupsessions.

Thetraininggroupwouldneedto:

•Prepareatrainingprogramwithclearlystatedlearningobjectives.The program should aim at not only educating staff but alsoensuring that the value of the EHR in healthcare delivery isunderstood.

•Starttrainingsessionswitha“trainthetrainers”programtoenablethedevelopmentofatrainingworkforce.

•Presenttheprogramsclearlyandenthusiasticallyenablinghands-onexperience.

•EncouragemembersofthehealthservicestocommittoreviewingworkpracticesandendorsethechangesrequiredtoimplementtheEHRformaximumefficiencygains.

•Preparestafftoparticipateindefiningthenewworkpracticesanddeveloping policies and guidelines to promote user-ownershipandincreasecompliance.

c.) Quality assurance group

A quality assurance coordinator and team should be establishedtooverseethatdatacollectedandprocessedareaccurate,reliable,andorganizedinsuchawaythattheyarebothreadilyunderstoodandavailablewhenneededbyhealthcareproviders.Toensurethatdocumentationmeets the required standards,qualityassessmentsmustbeundertakenbeforehandandcontinuedonanon-goingbasis.Poor quality data is a major hindrance to planning and decision-making and data quality is an important concern for healthcareinstitutionsandgovernments,regardlessastohowdataisrecordedandprocessed.

As shown in the following diagram the working groups will beresponsibletotheSteeringCommitteeandshouldreportbacktotheCommitteeonaregularbasis.


Working Groups

SteeringCommittee

Education andTraining

Quality AssuranceInformation Securityand Privacy

Specific trainers

Remember that an essential requirement for the successfulimplementation of an electronic health record system is thecooperation and commitment of all staff to the new system,includingadministration,medicalandnursingstaff,otherhealthcareprofessionals, and computer and clerical staff. It also must beremembered that just selecting an electronic health record systemthathasbeenimplementedelsewhereandexpectingittoworkforyour institution /countrycouldcausedisappointment if itdoesnotmeetyourperceivedneedsoravailableresources

References:

HealthConnect (2000). A Health Information Network for Australia: Report to Health Ministers by the National Electronic Health Records Taskforce. Commonwealth ofAustralia,Canberra.

Hebda T. Czar P. and Mascara C. (2001). Handbook of Informatics for Nurses and Healthcare Professionals (2nd ed). Upper Saddle River, NJ: Prentice Hall.

Health Seven Eleven (HL7). http://www.hl7.org//about/hl7about.htm

Mon DT. Defining the Differences between the CPR, EMR, and EHR. Journal of AHIMA. October2004;75/9,74.

WHO(2004).Developing Health Management Information Systems: A Practical Guide for Developing Countries. WHO,Manila


CHAPTER 5 Factors to be Considered when Developing an EHR Implementation Plan

WhenthetypeofEHRsystemhasbeendetermined,goalsidentified,issuesandchallengesrecognizedandaddressed,somestrategiesdevisedanddocumentsrelatingtopoliciesandprocedurescovering

theproposedEHRSystempreparedthenextstepisthedevelopmentofanimplementationplan.Somefactorsforconsiderationwhendevelopingaplanforimplementationareoutlinedinthischapter.

The implementationplanshouldshowall steps required tomove fromamanualmedicalrecordsystemtoanelectronichealthrecordsystem.AsuccessfullyimplementedEHRsystemshouldpromoteandmeetthespecific,stated EHR goals of the institution/country. Most importantly, it shouldalso improve theoverallperformanceof the institutionand theservices itprovides.

A sound implementation plan can mean the difference between success and failure.

Factors to be Considered

ItisextremelyimportantwhenplanningforachangetoanEHRtoanticipatetheimpactoftheintroductionofanEHRonwork-flow,productivity,users,andpatients.Therearemanyfactorstobeconsideredwhendevelopingaplanforimplementationforexample:

1. Whatcomputersystemsdoestheinstitutioncurrentlyhave?

2. Whatformwilltheimplementationtake?Willitbephasedin?How?

3. Howwillpastdatabeintegratedandolddataretained?

1.) What computer systems does the institution currently have?

Determineiftheproposedsystemwouldbecompatiblewithelectronicdatasystems(ifany)alreadyinusebytheinstitution/country.Theymayinclude:

• Electronic Patients' Master Index (PMI)–Asoutlinedpreviously,an electronic patients’ master index system is essential and, ifnot already in place, should be the first stepundertakenwhenchangingtoanelectronichealthrecordsystem.


• An Automated Patient Administration System (PAS)–Thiswouldalsobecriticalfortheeffectiveoperationoftheproposedsystem.Anadmission,discharge,andtransfersystemenablesstafftomaintainafileonallpatientsawaitingadmission,currentlyinhospital,transferredwithinthehospital,recentlydischargedordiseased. It enables authorized users to have direct access tothepatient’sinformation.Italsoautomaticallygeneratesthebedcensusandotherdailystatisticsrequiredbytheadministration.

• Clinical Systems–Inmanyinstitutions/countries,systemsarealreadyinplacethatarecapableofreportingresults–laboratory,pathology,radiology,treatmentordersandmedications,surgicalreports, discharge summaries, etc. Some specialized unitsoffer forms of clinical documentation may have already beenimplemented.

• Automated clinical coding and disease and procedure indexing – in many institutions/countries computer-assistedcodingofdiseasesandproceduresisconductedon-line.Ifthisisnotthecaseinyourinstitution/countrythisisanotherimportantarea to be developed and implemented. With such a systemtheuseofastandardmedicalvocabularyisessential.Withtheuseofautomatedclinicalcoding,dataqualitywillbemonitoredautomatically.

2.) What form should the implementation take?

The Steering Committee needs to determinewhether theywant tomove into full implementation, have phased implementation, orstartwithimplementationatapilotsite.Thereadinessofthesite,readinessofalluserstoacceptchange,andtheavailabilityoffundsfor implementation are a few of the issues thatmay influence theCommitteeinitsdecisionontheformimplementationshouldtake.

• Full Implementation-Inanenvironmentwithastrongtechnicalinfrastructure,thetendencymaybeforfullimplementation.Thiswouldrequiredetailedpreparationwithalltechnicalrequirementsin place and working telecommunication infrastructure fullyoperational,thesystemtestedthoroughly,andallstaffreadyandfullytrained.Ifthisisthedesiredimplementation,dataforallactivepatientsmustbeuploadedimmediatelybeforethecut-off–thatis,identificationanddemographicdetailsofallpatientscurrentlyinhospitaluploadedintothenewsystem.Decisionsneedtobemadeastowhethertheelectronicsystemwillrunparalleltothemanualsystemforatrialperiodortakeovercompletelyfromthemanualone.Runningparallelsystemswouldensurebackup,butsometimeswhensystemsruninparallelitisoftendifficulttocut-offlater.Iftheaboveissueshavebeenaddressedandtheinstitution/governmentseesapossibilityofsuccessfulimplementation,itmay


bebesttohaveacompletecut-offfromthemanualsystemuponfullimplementationoftheEHR.

• Phased Implementation - The second option is to phase-inimplementationunit-by-unit.Thisappearstobepreferredbymanyinstitutions/countriesthatrealisetheintroductionofanEHRsystemisanenormoustaskwithsignificantchangerequired.Itmayalsobethemostappropriateplanfordevelopingcountries.Withlimitedresources, both technical and human, phased implementationcouldhelptomanagetheimpactofthechange.

Initially, some institutions/governments may prefer limited implementationwithapilotprogram.Apilotprogramcouldenabletheinstitution/governmentto determine the project’s potential, assess its value, and determine theinstitution’s readiness for thesystem,orbuy time togainuseracceptance.Otherreasonsforconductingapilotprogrammayincludedifficultyinmanagingamajorchangeduetoinexperienceoftheworkforceandusers,limitedstaffandtechnicalsupport,insufficientfundsforsuchachange,oruncertaintyastowhetherthenewsystemwillactuallywork.

TheSteeringCommittee’sdecisionontheformofimplementationneeds tobebasedonall the relevant factsandconsiderations,includingcosts,thereadinessofthesite,usersandthesystem.Ifthedecisionistophase-inimplementationthefirstsiteshouldbecarefullyselected.Thefirstsiteshouldbeonethatisself-contained with fully trained staff to test the system. The unitshouldnotbetoobigortoosmall.

Interest of users is another factor to consider when selectingeachsiteandtheorder theEHRwillbe implemented. Whenthefirstunithascompleted implementationthecommitteeandimplementationcoordinatorshouldbeabletoassesstheimpactonusersandpatients,work-flow,andproductivitybeforethenextphaseisimplemented.Onceitisdeterminedthatthesystemisworkingwell,thenextunitorunitsshouldbephasedinone-by-oneuntilalldepartments/unitsareonline.

3.) How will past data be integrated and old data retained?

Bythisstage,theSteeringCommitteeneedstohavedecidedhowpastdatawillbeintegratedandolddataretained.Questionsandsuggestionstoconsiderinclude:

• Will all old records be scanned and made part of the electronic

recordwhenthepatientfirstpresentsforcareafterthenewsystemisintroduced?

• Willoldrecordsbescannedandkeptinasecondarystoragedeviceandbroughtintothenewsystemifandwhenneeded?


• Oldrecordswillnotbescannedbutsummaryinformationofapatientwill be entered into the electronic health record when the patientattendsforthefirstwiththenewsysteminplace.

• Old records will be scanned and remain in manual storage for aprescribedtimebeforebeingdestroyed.

Itisimportanttonotethatscanningpastrecordscouldbeverycostlyandthatthereareotheroptionsstatedabove.Ifalloldrecordsarescanned,apercentageofthemwillberecordsofpatientswhowillneverreturntothefacility.

Development of a Comprehensive Implementation Plan

When the formof implementationhas beendetermined, theSteeringCommittee and implementation team need to ensure that the institution/governmentisreadytomoveforward.Thenextstepswouldbeto:

a) Select the best system to meet the needs of the institutiongovernment

b) Determinethattherequiredtechnological infrastructureisinplace

c) Determinewhatclinical data capture and data retrieval isrequiredandwhatcurrentdatacollectionisredundant

d) Ensure that important policies and procedures are clearlydocumented

a.) Select the Best System

Knowwhat youwant. There aremany commercial systems availablebutindividualinstitution/countryrequirementsaredifferentandthesystemMUSTbeabletomeetlocalneedsorbeabletobeadjustedtodoso.Thatis:

• Select the EHR system that is right for your institution/country

What system will best meet the needs of the institution/government? The institution/government, through the SteeringCommittee,needstodeterminewhethertheywanttobuildtheirownEHRsystem,orbuyorleaseonefromareputablecomputersystemsvendor. Allhaveasignificantcostattached. Buildingone’sownsystemcouldbe time-consumingandexpensivebutshouldenabletheorganisationtodesignonetomeettheirspecificneeds.This,however,wouldrequireahighlevelofexpertisethatmaynotbeavailableintheinstitution/country.


Purchasing a system already developed and implementedelsewhere would have an initially high financial outlay. Asthere aremany EHR systems on themarket selecting the onemostsuitablewouldrequiredetailedinvestigationtoensurethatitwillmeet theanticipateddefinition,needs,andgoalsofyourinstitution/country.

Leasing the EHR system would enable access to softwareapplications managed off-site. The initial costs would be lessthanfortheothertwooptionsbutmayprovemorecostlyoveralongperiodoftime.

Whateversystemisdeterminedmustbecompatiblewithsystemsalreadyinstalledandalsowithotherinstitutionswithwhomtheinstitution wishes to share information and needs to interfacewith.

Athoroughcost-benefitanalysisshouldbeconductedtocomparetheoptionsagainst eachotherand thecostsof anyproposedsystemagainst theperceivedbenefits, so as to determine thevalueofthesystemtoyourinstitution/government.

• Look at the total picture before committing to a specific system

Whatyoualsoneedtoknowinselectingasystemaretheclinicalinformationneedsofyourinstitution/country.Thatis,determinewhatistobecaptured,stored,andviewedtosupporttheEHRobjectives.Developingaframeworkdefininghowclinicalinformationistobecapturedandrepresentedsuchaslists,views,orreportsintheproposedEHRisessential.Thepurposeoftheframeworkistohelppeopledevelopingorselectingthesystemtodecide:

• Whatinformationshouldberecorded;

• Howthisinformationistobedescribedandclassified;and

• What are the collection and retention priorities forinformation.

b) Technological Infrastructure

Thetechnologicalinfrastructureishowhardwareandsoftwareworktogether.TherearemanytypesofcomputersysteminfrastructureandtheSteering Committee should review the current (if any) infrastructure anddeterminewhatisneededtoensurethattherighttechnicalinfrastructureisavailablefortheproposedEHRsystem.Briefly,itshouldinclude:

• ACentral Processing Unitoroperatingsystem–Thecentralcomputerperformsallprocessingandstoragefunctionsandsendsandreceivesdatatoandfromterminalsandprinters.


• Input/Output devices – Current devices, if any, need to beassessedtoseeiftheywillmeettheneedsofandarecompatiblewiththeproposedsystem.Therearenumerousdevicesavailableandthetypetobeusedmustbecompatiblewiththeproposedsystem

• Network–Iftheinstitutionalreadyhasasetofcomputers,ensurethattheyarelinkedtoenablethesharingofsoftwareanddata.It may be a Local-area Network (LAN), a Wide-area Network(WAN),oraWirelessLocal-areaNetwork(WLAN).AnefficientEHRsystemdependsonlinkinginformationfrommanysources.With an EHR system, two other network configurations usinginternettechnologyareused,intranetsandextranets:

o An intranetusesInternettechnologythatenablesuserstofind,use,andsharedocuments.

o Extranets are used to connect a given institution toits users and business associates outside the physicallocationoftheinstitution–thesewouldbenecessaryifalongitudinalhealthrecordwasplanned.

• Supporting software–Theseareprogramsor instructionsthatdirecttheprocessingofdataincomputers.

o Operating system softwareidentifiesinputfromexternaldevices, sending output to terminal screens, keepingtrackof files,andcontrollingperipheraldevicessuchasprinters.

o Application softwaremakes applicationsperform theirfunctions.

o Application integration/interfaceissoftwaredesignedtoworktogetherwithoutanyexternalintervention.Interfacefacilitates the exchange of information across differentsystems.

o Messaging standards are also called interoperabilitystandardsordataexchangestandards.

c) Clinical Data Capture and Data Retrieval

Whatisrequiredandwhatcurrentdatacollectionisredundant.

• Clinical Data CaptureThisiswherefindingsandactionsaredocumentedbyprovidersof


healthcareanddataobtainedaboutapatientinreal-time.Howthedataistobecapturedisimportantandmustnotbecomplicatedortime-consuming.Decisionsneedtobemadeastohowdatawillbeenteredandcouldincludefree-textentryorstructureddataentryfrompull-downmenus.Mostclinicianswouldprefer‘freetext’bykeyboard,dictation,voicerecognition,orhandwritingrecognition.Technologyisavailableforall thesemethodsbutthereareanumberof issuesinvolvedwiththeiruseandtheSteeringCommittee/implementationteamwillneedtoinvestigateallpossibilitiesandmakeadecisionthatwillbestsuittheneedsoftheinstitution/government.

• Clinical Data Retrieval When obtaining healthcare data in real-time, access menus andnavigationaldevicesareused,suchasamouse,keypad,scrollkeysandsoon,usedtomovedatathroughpartsofacomputerscreen.Theyareimportantastheyenableahealthcareprovidertoretrievedatadirectlyfromthesystem.Thisisanotherareathatneedstobefullyinvestigatedsoastoensurethatthesystemselectedordevelopedwillenabledatatobereadilyretrievedforpatientcare.

d) Policies and Procedures

As mentioned previously, policies and procedures may need tobe revised toencompass thechange toanelectronicsystem.Thereadiness of the institution/country for the change is extremelyimportant and a change management strategy must be in placeto ensure a smooth transition. Change management techniquesshouldbeusedtohelphealthprofessionalsadoptadifferentformofdocumentingandusinghealthinformation.

• Confidentiality and Security setup Asmentionedpreviously,securitymustbeinplacetoensurethatallmedico-legal issues including privacy, confidentiality, and securityareaddressed.Securityarrangementsshouldbeclearlydocumentedandcommunicatedtoallpotentialusers.

• Education material prepared and training programs for users commenced Educationprogramsshould start as soonaspossible,butnot tooearlythatinformationisforgottenbeforeitcanbeapplied,toensurethatallusersareadequatelytrainedbythetimethesystemisreadyto‘go-live’.

Itisimportanttoremember:

The administration needs to plan, advise, and educate staff, and work with providers and patients to ensure a smooth transition.

All theabove factorsneed tobeconsideredalongwithothers thatmaybe


identifiedanduniquetoyour institution/country.Thedecisiontogoaheadcannotberushed.Theinstitution/countryneedstoensurethatallissuesandchallengesareaddressed,policiesrevised,andstafftrained.Theyalsoneedtobeclearastowheretheyareheadingandconfidentthattheyarereadytomoveforward.

References:Amatayakul,M.K.(2004).Electronic Health Records: A Practical Guide for Professionals and Organizations. AHIMA,Chicago.


WHO(2004).Developing Health Management Information Systems: A Practical Guide for Developing Countries. WHO,Manila.


CHAPTER 6 Implementation Plan

TheSteeringCommittee,implementationcoordinator,andteamshouldnowhaveathoroughunderstandingoftheenvironmentinwhichthesystemwillbe functioning, the informationneedsof the institution,

functionalrequirementstoensurethesystemwillwork,andmostimportantlybeconfident in their ability to effect change. They shouldunderstand theoverallscopeoftheproposedsystemandhavedecidedwhatinformationwillbeloadedintothesystembeforegoinglive.

ThedecisiontoconverttoanEHRallatonceorinstageswillalsohavebeenmade. Assuming thedecisionwasmade tophase-in the systembyunit or department a timeframe for implementation for each unit shouldbeprepared.Thefirstunitmaytakelongertoimplementthesystemthansubsequentunits.Asthefirst implementationwillbeatrial,theplanmayneedtobemodifiedbeforeproceedingtootherunits.Itisimportantfortheimplementationteamtoensureeachphaseisfunctioningwellbeforemovingtothenextunitordepartment.

Theremaybesomeunitmanagerswhoarereadyandverykeentostartwhile others may not be fully confident and wish to see how it works inotherplacesbeforeimplementing.Thisshouldbetakenintoaccountwhendeterminingthesequenceofunitsforimplementation.Whenoverallphasinghasbeendeterminedand timeframesestablished,detailed tasksshouldbeplottedonaplan.Rememberthattheplancouldcoverhundredsoftasks.

It is a huge undertaking so successful implementation is particularly important. Thoroughly addressing all the relevant issues beforehand will help guarantee success.

Timeline for Implementation

Thetimelineforimplementationwillvaryfrominstitutiontoinstitutionandwillbedependentonwhethertheinstitution/countryhasdecidedtoimplementtheEHRsystemallatoncewitha“bigbang”orphaseitinbyunit/departmentoveralongerperiodoftime.

Each stepof the implementationplan shouldhave its own timeline tocoincidewiththeoverallprojectplanforimplementation.

Thetimelineorprojectplanshouldbemappedoutonalargeboard.Quiteoftenwhiteboardsareusedtoenablechangestobemadeiforwhenrequired.Itemswould includeadetail listofEHRproject taskswitha timeframeforeach task. Implementationmay takedays,weeks,monthsorevenyears.A realistic timeline should be prepared if possible but everyone should bepreparedforchangesifproblemsorunidentifiedissuesarisewhichmaycauseadelayinimplementation.


Theplanshouldcontainthestepspreviouslydiscussedsuchasthe:

1. Reviewofcurrentmedicalrecordsystem

2. Identificationandaddressingofissuesandchallengestobeaddressedpriortimplementation

3. EstablishmentofaSteeringCommittee

4. PreparationofaclearlydefinedstatementofthetypeofEHRtobeimplemented

5. IdentificationofperceivedbenefitstotheinstitutionwiththeintroductionofanEHRsystem

6. Preparationofalistofclearlystatedgoalsandstrategiesforimplementation

7. Reviewofcurrentmedicalrecordpoliciesandproceduresanddevelopthemtocoverproposedchanges

8. Appointingofanimplementationco-ordinatorandteam

9. Establishmentofworkinggroups

• SecurityandConfidentialityGroup

o Prepareaconfidentiality,securityandprivacypolicy

• EducationandTrainingGroup

o Prepareeducationprograms

o Preparetheeducationsite

o Identifyparticipants

o Commencetraining

• QualityAssuranceGroup

o Preparequalityassuranceguidelinesandpolicies

10.Determinerecordstructureandcontent

• Ensureapatientidentificationsystemisinplace

• Determineaneffectivemeansofobtainingthepatient’sinformedconsent


• Introducedatastandardsandtheuseofacommonterminology

• Other

11.Determinetechnologyinfrastructurerequired

• Cabling

• Terminals

• Other

12.Determinetelecommunicationsinfrastructurerequired

13.Determinehowsystemwillbephasedin

In addition the plan should also include:

1. Sitepreparation;and

2. Systemtesting.

1. Preparing the Site

Thesitesforimplementationneedtobeprepared.Theextentofthesystemwilldeterminethenumberofareasneedingpreparation.Forexample,willtherebeterminalsfordataentryandretrievalinallwardsinthehospital,alloutpatientrooms,andotherpatientserviceareas?

Beforethesystemcan“golive”,thetechnologicalinfrastructureneedstobeinplacewithdataentryfacilitiesinallpoint-of-careareas.Forinpatients,theywouldincludetheadmissionoffice,wards,andotherareasatthepoint-of-care.Foroutpatients,theywouldrequirethereceptionareaandallconsultingandtreatmentrooms.Allrequiredcablingforalldevicesneedtobeinplaceandoperable.

Ifalongitudinalhealthrecordisplanned,dataentryfacilitiesneedtobeinplaceinallcommunitycarecentresandoutlyingclinics.Adetailedplanshowingtheinfrastructureneedstobepreparedanddisplayed.

2. Pre-test the System

Whenthesitehasbeenpreparedwiththeappropriateinfrastructure,thesoftwareinplace,allissuesrelatingtoconfidentialityandsecurityaddressed,and all users trained (including healthcare professionals, technicians andclericalstaff),itistimetoinstallandpre-testthesystematapoint-of-careareainconditionsthatcloselyreflectactualsituations.


Thedecisionastowherethesystemwillbepre-testedshouldhavebeenmadeusingasetofselectioncriteriawhichincludetechnicalfactorssuchasthelevelofexpertiseofthestaff,infrastructuresupport,andstaffsupport(WHO,2004).Inaddition,differentlevelsofstaffneedtoparticipateinthepre-testing,especiallyhealthprofessionalswhowillbebothprovidersandusersofdata.Thelengthoftimethesystemwillbepre-testedneedstobedetermined.

Finally,thesystemneedstobemonitoredduringpre-testingtoidentifyanyproblemsandtoenableinformeddecisionstobemadewithregardtofurtherimplementation.

Determine Readiness

Questions which should have been asked to determine readinessinclude:

• Arethereanybarriersstilltobeovercome?

• Haseveryonewhowillbeinvolvedbeentrainedandaretheyready?

• Haveanyproblemsidentifiedinthepre-testofthesystembeenreportedandcorrected?

• Areweready?

Ifallthesequestionsareansweredpositivelythesystemisnowreadytoimplement.

System StartupTheday selected to “go live” shouldbeonaweekendoradaywhen

thereare fewpatientsexpected.The institutionmaybeable to re-organiseadmissionsandclosesomeoutpatientareas.Thiswouldneedtohavebeendecidedmuchearlier.Inaddition,itisimportantthatonthedayallstaffareavailable and readywith supportpersonnel available toprovideassistanceasneeded. If thesystemwaspurchased fromacomputercompany,keymembersoftheirstaffalsoneedtobeonsite.

Whenallpre-requisiteshavebeenaddressed,adetailedimplementationplaninplace,thesiteready,allusersandsupportstafftrainedandready,andthesystempre-tested,thenextstepisimplementation.

It is now time to ‘go live’!


Correct course if needed, and enhance the system

Asmentionedmanytimes,amajorchangesuchastheimplementationofanelectronichealthrecordsystemisanenormoustaskandthestaffneedstobeon thealert for anyproblemswhichmayarise. That is, expect theunexpected.Whenthefirstunit/departmenthasgoneliveit isimportanttoreviewandcorrectany identifiedproblemsor issuesassoonaspossible. If it isnotwhatwasexpected,itisasignalforcoursecorrection.Whenproblemsareaddressedandexpectationsmet,theresultscanjustifyfurtherenhancementstothesystem.

Conclusion

Theprincipalbenefitsidentifiedfortheintroductionofanelectronichealthrecordsystemaresupportingpatientcareandimprovingthequalityofthatcare.Accurateandtimelyhealthinformation,whichisaccessiblewhenneededbybothproviders/usersandconsumershasgreatadvantagesforthehealthcareofallindividualsandwouldenhancethehealthandwelfareofthecommunity.Itwillalsoenhancetheproductivityofhealthcareprovidersinthedeliveryofcare,andbeastrongsupporttoclinicalandhealthserviceresearch.

Implementation of EHRs has been said to revolutionise how we collect,store, and use health information. Patients are expected to become moreinvolvedinhealthcaredecisionswhenelectronicsystemsprovidethemwitheasilyaccessibleandaccurate informationabout theirhealthproblemsandcare.Itisoftenadvocatedthathealthcarepractitionerstendtodeliverbetterhealthcarebybeingable tomore efficientlyprovideup-to-datedetails of apatient’shealthcaretoothersinvolvedintreatingthepatientandbyhavingbetteraccesstobestpracticeandthelatestresearchfindings.

References:


WHO(2004).Developing Health Management Information Systems: A Practical Guide for Developing Countries. WHO,Manila.


Annotated Bibliography

Following a Medline search relating to design, definitions, goals, andimplementationofelectronichealthrecordsovertheperiod2000to2005,84citationswererecovered.Somereferenceshavebeenincludedtoassistreadersobtainfurtherinformationifrequired.

General Aspects of EHRs

Amatayakul, M.K.(2004).ElectronicHealthRecords:APracticalGuideforProfessionalsandOrganizations.AHIMA,Chicago.

A practical Guide for persons interested and/or involved in EHRplanningandimplementation.ThebookcoverselementsoftheEHRfrom developing a migration path to implementation and on-goingmanagementofthesystem.Itoffersthereaderanimportantinsightinto the history of EHR development, current trends and possiblepitfalls.

Audet AM. Doty MM. Peugh J. Shamasdin J. Zapert K. Schoenbaum S.(2004).InformationTechnologies:WhenWillTheyMakeItIntoPhysicians’BlackBags?MedGenMed.2004Dec6;6(4):2.

Theauthorsdiscusstheslownessofphysiciansinadoptinginformationtechnology tools in patient care and present their findings of astudy designed to investigate physicians’ current use of informationtechnology,futureplansandperceivedbarrierstoadoptingelectronicmedical records, computerised prescribing, order entry, clinicaldecisionsupportsystems,andelectroniccommunication(e-mail)withotherphysiciansandpatients. Aself-administeredmailsurveywasusedbyarandomsampleofphysiciansinvolvedindirectpatientcare.Conclusionsshowedthattherewasanunevenadoptionandthatcostsremainthemostimportantbarriertoadoption.

Giere W. (2004).ElectronicPatientInformation–PioneersandMuchMore:Avision,lessonslearnedandchallenges.MethodsInfMed.2004;43(5):537-42.

Professor Giere from the Centre of Medical Informatics, UniversityHospitalFrankfurt,Germany,introducesthetopicofelectronicpatientrecordsandhow,withallitsdifferentkindsofpatientinformation,itcanbestructuredinmanyways.Theprimaryfocusisonthedevelopmentofan informationsystemforboth inandoutpatients inGermany incomparisonwithsystemsintheUSA.Hegivesanhistoricaloverviewofwhathereferstoasthe‘ironage’and‘goldenage’yieldeduntilthemid-1970’sandthenfollowingthedarkyearsinthe1980’s.Inhis


conclusion,hesuggeststhatinthefuture,theuseofmedicallinguisticsforsuccessfulEMRsshouldbebettersupported.

Gillies J. Holt A.(2003).Anxiousaboutelectronichealthrecords?Noneedtobe.NewZealandMedicalJournal.116(1182):U604,2003Sep26.

The authors discuss aspects of both manual and electronic healthrecordsidentifyingsomeweaknessesandstrengthsofbothnotingthattheeverydaytakeoverofpaperrecordsbyelectronicversionsseemsinevitable.ThepaperaimstoreassurecliniciansthattheEHRislikelytoenhancethequalityoftheirprofessionalpractice.

Hanauer D.(2004).Disasterrecoveryforelectronicdata:Areyouprepared?JournalofMedicalPracticeManagement.2004Sept-Oct;20(2):82-7.

Inthisarticletheauthoraddressesdisastersthataffectmedicaldataandtheproblemsthatcanariseifdataislost.Howtorecoverlostdataisdiscussedplushowtopreventorguardagainstdisasterinthefutureandadescriptionofhowcertainpracticesinadvancecouldeasetheprocessofrecovery.

Hebda T. Czar P. and Mascara C.(2001).Handbookof InformaticsforNursesandHealthcareProfessionals(2nded).UpperSaddleRiver,NJ:PrenticeHall.

Thisisanexpandedguidetocomputertechnologyfornursesandotherhealthcareprofessionals.Itcontainsexpandedcoverageofintranets,search tools, outsourcing, strategies, planning, security, and patientinformation.Italsocontainsdiscussionsonelectroniccommunication,strategicplanningforinformationmanagement,disasterplanningandrecovery,aswellassamplesandcasestudiesillustratingthepracticaluseofinformationtechnology.

James B.(2005).E-Health:StepsOntheRoadToInteroperability.HealthAff(Millwood).2005Jan19;(E-pubaheadofprint–www.healthhaff.org).

The author approaches the topic of how interoperable electronicmedicalrecordshavethepotentialtoproducebetterhealthoutcomeswhile improving the efficiency of healthcare delivery at the sametimereducingcosts.Aseriesofidentifiedstepstoassistasuccessfultransitionstrategyarediscussedaswellashowlargegroupswillplayacriticalrole.

Laerum H. Karlsen TH. Faxvaag A. (2004).Use of and attitudes to ahospital information system by medical secretaries, nurses and physiciansdeprivedofthepaper-basedmedicalrecord:Acasereport.BMCMedInformDecisMak.2004Oct16;4(1):18.

This report covers the outcome of a case study to determine thefrequency of use of a hospital information system (HIS) where thepaper-basedmedicalrecordsarescannedandeliminated.Thestudy


involvedquestionnairesandinterviewsdesignedtoassessandcomparethefrequencyofuseoftheHISforessentialtasks,taskperformanceandusersatisfactionamongmedicalsecretaries,nursesandphysicians.Conclusionsshowthatreplacingthepaperrecordprimarilybenefitedthemedicalsecretarieswhereasthebenefittonursesandphysiciansappearedless.

Likourezos A. Chalfin DB. Murphy DG. Sommer B. Darey K. Davidson SJ. (2004).PhysicianandnursesatisfactionwithanElectronicMedicalRecordSystem.JournalofEmergencyMedicine.2004Nov;27(4):419-24.

This paper covers an assessment of physician and nursesatisfaction after the implementation of an EmergencyDepartmentEMRinalargeurbanteachinghospital.Asurveyofphysiciansandnursesincludedcomputerbackgroundandexperience,perceptionsregardingEMRuse,andconcernsabouttheimpactuponqualityofpatientcare.AlthoughthephysiciansfoundtheEMReasytouseandweregenerallysatisfiedtheyreportedthattheythoughttheEMRhadnopositiveimpactonpatient care. Someconfusionwas reported in following thesequence of screens, concern about the time it took to usetheEMRand the confidentiality of patient information. Theresearchersreportedsimilarresultsbetweenthephysiciansandnurses.

Lunney M. Delaney C. Duffy M. Moorhead S. Welton J.(2005).AdvocatingforStandardisedNursingLanguagesinElectronicHealthrecords.JournalofNursingAdministration.2005Jan;35(1):1-3.

AuthorsdiscusstheimportanceofnursingcontributionstotheestablishmentofanEHR,outliningtheadvantagestonursesusing standardised nursing language. They advocate thatnursesmust rise to thechallengeandacquiresoftware fromvendorsthatincludetheANA-recognisednursinglanguageorcanaccommodateoneormoreoftheselanguages.ConcludingthattotakeadvantageofthecapabilitiesofanEHRhealthcarefacilities need to include recognised nursing languages inclinicaldocumentationsoftware.

Mantas J. (2002). Electronic health record. Studies in HealthTechnology&Informatics.65:250-7,2002.

The EHR is compared with traditional handwritten healthrecords. A definition of electronic health records andassociatedterminology,classificationandcodingispresented.EHR architecture and strategic approaches to designingsupportingsystemsarealsodiscussedalongwiththecurrentstate of implementation including obstacles for furtherimplementation.


McConnell H.(2004).Internationaleffortsinimplementingnationalhealthinformation infrastructureandelectronichealthrecords. WorldHospitals&HealthServices.40(1):33-7,39-40,50-2,2004.

Theauthoraddressestheissueofhowmanycountriesaredevelopingnationalstrategiesusinginformationandcommunicationtechnologiesto implementhealth information infrastructureandelectronichealthrecords. This paper looks at some national initiatives as well aschallengespresentedbydifferentapproachesaround theworldandreviews the many organizations looking at international standardsrelatingtoeHealthandtheimplementationofEHRs.

McLane S. (2005). Designing an EMR Planning Process Based on StaffAttitudes Toward and Opinions About Computers in Healthcare. ComputInformNurs.2005Mar-Apr;23(2):85-92.

ThispaperdiscusseselectronicmedicalrecordsystemsnotingstudiesdocumentingnursingsatisfactionwiththeEMR,benefitsofanEMR,implementation barriers, user acceptance, the importance of staffbuy-in,andtheimportanceofattitudestowardandexpectationsfromuserby-in. Theauthoralsonotes thatdatacollected fromanEMRcontaining rich, accurate documentation of nursing interventionsandpatientresponsessupportevidence-basedpracticechangesanddocumentscareprovidedbynurses.

Munir S. Boaden R.(2001).Patientempowermentandtheelectronichealthrecord.Medinfo.10(Pt1):663-5,2001.

This article reports on a random sample of patients viewing andcontrollingtheirelectronichealthrecordattheHatfieldMedicalCentre,Derbyshire,UK.Theresearchers investigatedthenatureandscopeofdemandfrompatientsempoweredintermsoftheirownhealthandviewing their electronic health record. Researchers found that themajorityofpatientswantedtoviewtheirhealthrecordsbutpreferredthepaperrecordtotheEHRandasignificantnumberofpatientsdidnotwanttocontroltheirownhealthrecord.Demographicvariablessuchasageand levelofeducationhadasignificant impacton thepatientcontrollingandviewingtheirownhealthrecords.

Powell J. (2005). Electronic Health Records Should Support ClinicalResearch.JournalofMedicalInternetResearch.2005;7(1):e4)doi:10.2196/jmir.7.1.e4.

TheauthoraddressestheissueoftheuseofelectronichealthrecordsinresearchandhowthisaspectoftheEHRhasreceivedlittleattention.Benefitsareenumeratedwhich range fromsystematicallygeneratedhypothesestoundertakingentirestudiesusingelectronichealthrecorddata.Healsohighlightsthefactthatbothcliniciansandpatientsmusthaveconfidence in theconfidentialityandsecurityarrangements fortheusesofsecondarydata.


Sprague L. (2004).Electronichealth records:Howclose?Howfar togo?NHPFIssueBrief.(800):1-17,2004Sep29.

TheauthorexaminesthecentralroleinhealthinformationtechnologyoftheelectronichealthrecordandtheextentEHRsareusedandtheinitiativesdesigned to increase thatuse.Barriers to implementationandwidespreadadoptionarealsoexploredwithparticularattentiontocost,physicianresistance,standardsandlegalissues.

Trpisovsky T.(2004).Electronichealthrecordsoncards.StudiesinHealthTechnology&Informatics.2004;103:459-62.

In this article the author presents a brief evaluation of smart cardtechnology with regard to implementing EHRs. Activities currentlyunderway in Europe are covered along with basic standards andrecommendationswithstronglyperceivedinternationalharmonisationandinteroperability.

Walsh SH. (2004).Theclinician’sperspectiveonelectronichealthrecordsandhowtheycanaffectpatientcare.BritishMedicalJournal.328:1184-1187.doi:10.1136/bmj.328.7449.1184.

In this article the author examines important lessons learned fromattempts to get clinicians to use computers in healthcare and howcliniciansactuallywork. Discussioncovers theuseofnarratives inclinicalreasoning,theimpactoftheconstructionofthepatientrecordonclinicalinsightandhowconstructingtheelectronicrecordaffectsclinicalinsight.Problemsinenteringdataarealsocoveredalongwiththeneedforeasyaccessandfuturechallengesdiscussed.

Wood Jt 3rd. Aceves R.(2005).Fivestepstoelectronichealthrecordsuccess.HealthFinancialManagement.2005Jan;59(1):56-61.

This article covers five important steps to implementing an EHR –includingdefiningtheEHR,settingappropriateexpectations,carefullychoosing the technology, and carefully planning the transition frompaperrecordstoelectronicones.

General Practice, Primary and Ambulatory Care Aspects of EHRs

Kay JD. Nurse D. Bountis C. Paddon K. (2004). The Oxford ClinicalIntranet: providing clinicians with access to patient records and multipleknowledgebaseswith Internet technology.Studies inHealthTechnology&Informatics.2004;100:130-8.

This paper describes the Oxford Clinical Intranet which providesclinicians in primary and secondary care across Oxfordshire withaccess to information about their patients held on multiple remote


disparate computer systems, including admissions and episodes,laboratorymedical reports, radiology reports and hospital dischargeletter.Theauthorsnotethattheintranetwasdevelopedatlowcostand the approach appears to be transferable across systems andorganisations.

Merrell RC. Merriam N. Doarn C. (2004). Information support for theambulanthealthworker.TelemedJEHealth2004Winter;10(4):432-6.

Thispaperdescribeshow19medicalstudentsevaluated2700patientsinfourvillagesinKenyawheretherewasnopowerortelephone.Amodel of information support including personal digital assistants(PDA),electronicmedicalrecords(EMR),satellitetelecommunications,medicalsoftwareandsolarpowerwasused.ThestudentsfoundtheadvantageofPDAoverpaperandbyusingsoftwarefordecisionsupportandinteractingwiththeEMRdataformedicalexpertiseonlyafewlivetelemedicineconsultationswereneeded.Theauthorsconcludedthatthe cost of this information supportwas low (US0.28dollars) perpatientandthatresourcescanbeprovidedinremoteenvironmentsatreasonablecost.

Pyper C. Amery J. Watson M. Crook C. (2004). Access to electronichealthrecordsinprimarycare–asurveyofpatients’views.MedicalScienceMonitor.10(11):SR17-22,2004Nov.

With plans to move to electronic access for health records by theNationalHealthService(NHS)intheUKtherewasanidentifiedneedtoinvolvepatientsinthedevelopmentprocess.Thisstudyaimedatexploringtheviewsofalargesampleofpatientsaboutonlineaccesstoelectronicpatientrecords(EPR)andhealthinformationinprimarycare.Areascoveredinthestudyincludedaccuracyrightstoaccess,security,confidentialityandsmartcards.Theresultsofthestudyarepresentedandtheauthorsconcludedthatitisessentialthatpatientsareinvolved,andtheirviewstakenintoconsideration,ateverystageofthedevelopmentofEPRs.

Legal – Access, Privacy and Confidentiality Aspects of EHRs

Barber B. (2002).TheprotectionofindividualsbyprotectingmedicaldatainEHRs.StudiesinHealthTechnology&Informatics.87:38-43,2002.

Theauthordiscusseschangesinthedeliveryofhealthcareandhowindividualsneedtobeprotectedbyprotectingtheirelectronichealthrecords.Securityissuesanddataprotectionneedtobetakenseriouslyandhealthinformationprofessionalsneedacodeofethicstoensuresecurityismaintained.


France FH. Beguin C. van Breugel R. Piret C. (2000). Long termpreservationofelectronichealthrecords.RecommendationsinalargeteachinghospitalinBelgium.StudiesinHealthTechnology&Informatics.77:632-6,2000.

Thisarticlediscusseshowhealthrecordsshouldbereadilyaccessedbyauthorisedpersonsforpatientcareandlegalsecurityduringapatient’slifetimeandafterwardsforresearchandteaching.Thepreservationof health information in a large teaching hospital in Belgium isdiscussedwithtworecommendations:thefirst,thatafterthepatientisdischargedallhisorherhealthinformationshouldbemanagedbyauniqueorganisationthathasthefacilitytoupdateregularaccessestoalldatabasesaboutthepatient.HealtharchivesshouldbeformattedusingXML(ExtensibleMarkupLanguage)softwareonsupportssuchasDVD-ROMtobeupgradedandupdatedwhenneeded.Thesecondrecommendation suggests the use of Computer Output Microfilm(COM)andscannersfornonelectronicdatatobepreserved.

Gritzalis S. (2004). Enhancing privacy and data protection in electronicmedicalenvironments.JournalofMedicalSystems2004Dec:28(6):535-47.

The need to raise awareness and provide guidance to on-line dataprotection is discussed togetherwith the equally important issue ofapplying privacy-related legislation in a coherent and coordinatedway.Theissueofpatientprofilesthatrevealsensitiveinformationishighlightedandfocusesoncountermeasuresthatcanbeemployedtoprotect theprivacyofpersonalandmedicaldata transmittedduringelectronicmedicaltransactions.

Pharow P. Blobel B.(2005).Electronicsignaturesfor long-lastingstoragepurposesinelectronicarchives.InternationalJournalofMedicalInformatics.2005Mar:74(2-4):279-87.

This paper highlights the importance of electronic signatures basedonasymmetriccryptographyasameansofsecuring the integrityofamessageorfileaswellasforaccountabilitypurposes.Theauthorsalsoexplainhowelectronicsignaturesalongwithcertifiedtimestampsor time signatures are especially important for long-life storage notonlyforelectronichealthrecordsbutalsoforelectronicarchives.Inaddition,theyidentifymechanismsofre-signingandre-stampingdataitems,filemessages,setsofarchivalitemsordocuments,andwholearchives.

Ruotsalainen P.(2004).SecurityrequirementsinEHRsystemsandarchives.StudiesinHealthTechnology&Informatics.2004;103:453-8).

ThispaperaddressessecurityissuesrelatingtoEHRsandelectronicarchivesandproposesthatinsideasecuritydomainboththearchiveandtheelectronichealthrecordsystemmusthaveacommonsecuritypolicy.Inaddition,theauthorcommentsthatthearchivingorganisation


should have a documented policy for information preservation andalsoapolicyforaccessanddistributionofinformationbetweenotherarchives.

Ueckert FK. Prokosch HU. (2002). Implementing security and accesscontrolmechanismsforanelectronichealthcarerecord.Proceeding/AMIA.AnnualSymposium:825-9,2002.

Thisarticlecoverstheuseofpersonalelectronichealthrecords,patientempowerment and the patient’s control over their personal healthinformation.Criticalrequirementsandaccessmanagementinrelationto data security and mechanisms to provide secure data storage,communicationandflexibleaccessmanagementarealsodiscussed.

Some useful web sites:

AmericanHealthInformationManagementAssociation(AHIMA):http://www.ahima.org

AmericanHospitalAssociation:http://www.aha.org

AmericanMedicalAssociation:http://www.ama-assn.org

AustralianDepartmentofHealthandAging:http://www.health.gov.au/healthconnectAustralianNationalTelehealthPlan:http://www.health.gov.au/healthonline/telehealth.htm

JournaloftheAmericanMedicalAssociationJAMA):http://www.ama.assn.org.public/journal/jama/jamahome.htm

JournaloftheAmericanMedicalInformaticsAssociation:http://www.WorldHealthAssociation:http://www.who.ch/


Glossary of terms:

AuditTrail: Aprogrammethatrecordsaccessand/oractionthatoccursinacomputerrecordbyloggingtheuser identification, recording date and time ofaccessandactioncarriedout.

Backup: The creation of a second copy of recordsor information in case the original is lost ordamaged.

Clinician: Allhealthprofessionalswhoprovidecaredirectlytoapatient–doctors,nurses,physicaltherapists,occupationaltherapists,etc.

Confidentiality: The act of limiting disclosure of privateinformation.

Consumer: Arecipientofhealthcaresuchasthepatient.

Cost-benefitAnalysis: A comparison of costs against benefits todetermine the long-termvalueof theproposedsystem.

Cryptography: Mathematicalfunctionsthattransformintelligibledataintoseeminglyunintelligibledataandbackagain.

Data: Acollectionofnumbers,charactersorfactsthataregatheredaccordingtosomeperceivedneedforanalysis.

Database: Afilestructurethatsupportsthestorageofdatainanorganisedfashionandallowsdataretrievedasmeaningfulinformation.

DataIntegrity: Theabilitytocollect,storeandretrievecorrect,completeandcurrentdatasothatitisavailabletoauthoriseduserswhenneeded.

DataSet: Agroupofdataelementsrelevantforaparticularuse.

DataStructure: Howdata isstored,as ina file,adatabase,adatarepository,etc.


Decision–supportSystems:Programs that organise information to aiddecision-making related to patient care oradministrativeissues.

DigitalSignature: Ascannedimageofawrittensignature.

DocumentImaging: Involves scanning paper records to computerdisks or other media to facilitate storage andhandling.

ElectronicSignature: Ameanstoauthenticateacomputer-generateddocument through a code or digital signaturethatisuniquetoeachauthorisedsystemuser.

Encryption: The use of mathematical formulas to codemessages.

Evidence-basedmedicine: Clinicaldecisionsupportbasedonevidenceofbestpractice.

Extranet: AnetworkthatsitsoutsidetheprotectedinternalnetworkofaninstitutionbyoutsidersandusesInternetsoftwareandcommunicationprotocolsforusebysuppliersorcustomers.

GanttChart: A graphic tool used to plot tasks inManagement.

Goal: Anopen-endedstatementdescribingwhatisto

beaccomplished

Go-live: The process of starting to use the informationsystem.

HealthInformation: Healthcaredatathathasbeenorganisedintoameaningfulformat.

HealthInformationSystem: A system that integrates data collection,processing, reporting, and the use of theinformation necessary for improving healthservice effectiveness and efficiency throughbettermanagementatalllevelsofhealthservices(WHO2004).

HealthLevel7(HL7): A standards organisation which developsstandards for the exchange of clinical databetween information systems by means of anextensivesetofrulesthatapplytoalldatasent.ThestandardsarealsoreferredtoasHL7.

HealthPractitioner: See‘Clinician’


Infrastructure: Theunderlyingframeworkofacomputersystemthatprocessesdataandinformation.

Integration: The process by which different informationsystemsareabletoexchangedatainafashionthatisseamlesstotheenduser.

Interface: A computer system that tells two differentsystemshowtoexchangedata.

Interoperability: Theabilityforsystemstoworktogether.

Intranet: A computer network using Internet protocolsandtechnologies to facilitatecollaborativedatasharing.

Longitudinal: Toreflecttheentirehistoryofanindividualacrosshisorherlifetime,includingdatafrommultipleusers.

Mapping: Theprocesswheretermsdefinedinonesystemareassociatedwithcomparabletermsinanothersystem.

MessagingStandards: Standardprotocolsthatassistintheexchangeofdatabetweentwoseparatesystems.

Multimedia: Presentationsthatcombinetext,voiceorsound,still or video images as well as supportinghardwareandsoftware.

Network: A combination of hardware and software thatallowscommunicationandelectronictransferofinformationbetweencomputers.

OpticalCharacterRecognition(OCR): The technology of reading text by electronic

meansandconvertingittodata.

Password: Analpha-numericcoderequiredforaccessanduseofsomecomputersorinformationsystemsas a security measure against unauthoriseduse.

PersonalHealthRecord: A record maintained by or for direct patientaccess.

Point-of-CareSystem: A computer system that captures data at thelocationwherehealthcareisprovided.


Practitioner: Healthcareprofessional such as doctor, nurse,physicaltherapistetc.

Providers: Caregivers–atermusedtorefertocliniciansorthehealthcareinstitutionprovidinghealthcare.

RealTime: Theprocessingofdata that takesplaceat thetimeaneventoccurs.

Retention: The maintenance and preservation ofinformation.

SmartCard: Astoragedeviceresemblingaplasticcreditcardcontainingpatientinformation.

SNOMED: Systematized Nomenclature of Human andVeterinaryMedicine–acomprehensiveclinicalvocabulary.

Standard: Aspecimenorspecificationbywhichsomethingmaybetestedormeasured.

StrategicPlanning: Thedevelopmentofacomprehensivelong-rangeplanforguidingactivitiesandoperationsofanorganisation.

Structureddata: Datathatfollowsaprescribedformat.

UniquePatientIdentifier: A single, universal identifier for patient healthinformation thatensuresavailabilityofalldataassociatedwithaparticularperson.

UnstructuredData: Data that does not follow a prescribed formatsuchasmaybeseeninnarrativerecording.

Validity: The extent to which data measures what itpurportstomeasure.

VoiceRecognition: Technology using voice patterns to allowcomputers to record voice and automaticallytranslateitintowrittenlanguageinrealtime

Work-flow: Thesequenceofactionsappliedtoaprocesstoachievearesult;typicallycrossesorganisationalunitsordifferentstepstakenbythesameuser.

ISBN 92 9061 2177

electronic health records: manual for developing countries

Documents