The Electronic Medical Record

By Dr.VISHAL SURYAWANSHI
[MBA-HCM]

This Presentation Discusses the Following :

Existing Hospital Records.......

Paper Charts of Patient Medical Records are the norm worldwide for recording patient information. All relevant patient information is documented in one file for reference - including Lab. results, test results and progress notes. These charts are easy to use. The same file is used on subsequent admission to the same institution. And as source of reference for medicolegal cases.

 By now most large health care institutions have a computer database of patients which matches : * Patients Hospital I.D. Number * Name * Date of Birth * Address .... This provides a rapid search to match a patient name with a chart no. when retrieving a record from storage. The source of the Electronic Medical Record is simply expanding on this database creating an online record for each Patient.

Against Paper Records:

Paper-based records are still by far the most common method of recording patient information for most hospitals and practices. The majority of doctors still find their ease of data entry and low cost hard to part with. However, as easy as they are for the doctor to record medical data at the point of care, they require a significant amount of storage space compared to digital records.

 When paper records are stored in different locations, collecting them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records.

 Because of these many "after entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records.

The Electronic Medical Record

The Electronic Medical Record (EMR) is the future of patient record documentation. There is very wide scope for applications and additions around a centralized record. The EMR can be accessed conveniently by appropriate health professionals to ensure ultimate maximum and optimal patient care.

Technical standards:
HL7 messages format for interchange between different record systems and practice management systems. ANSI X12 (EDI) A set of transaction protocols used in the US for transmitting virtually any aspect of patient data. CEN CONTSYS (EN 13940) - a system of concepts to support continuity of care. CEN EHRcom (EN 13606) - a standard for the communication of information from EHR systems. CEN HISA (EN 12967) - a services standard for intersystem communication in a clinical information environment. DICOM a standard for representing and communicating radiology images and reporting

Regulatory Compliance Compliance

International Regulations Healthcare privacy rules are
not limited to the United States. The European Union and many individual countries and provinces in other parts of the world have implemented patient confidentiality laws Proliferation of Healthcare Regulations.

HIPAA - The Health Insurance Portability and Accountability

Act (HIPAA) protects the privacy of an individuals health information and governs the way health care providers manage and disclose protected health information (PHI). Healthcare providers must introduce appropriate systems and practices to comply with HIPAA.

FTC Act The Federal Trade Commission Act ; Under this Act,
the Commission is empowered among other things to prevent unfair methods of competition and unfair or deceptive acts or practices in or affecting commerce.

HIPAA. HIPAA
The Health Insurance Portability and Accountability Act was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. There are two sections to the Act. Title I deals with protecting health insurance coverage for people who lose or change jobs. Title II includes an administrative simplification section which deals with the standardization of healthcare-related information systems. In the information technology industries, this section is what most people mean when they refer to HIPAA. HIPAA establishes mandatory regulations that require extensive changes to the way that health providers conduct business.

Goals of Using the EMR

Provide a single, uniform medical record. Ability to access medical records from any location . Improve documentation and coding . Improve research / clinical trials data / enhance quality. Reduce transcription and other rising costs.

Successful EMR. EMR

There are many aspects contributing to a typical EMR ....

I E

H A D

O M

I T I S S

AD L I A I O N

L S A I SB R E

O S

R U

A T DO E R C Y I S L T S

I O

G P R

E A

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E R T I T

A L I O N

T E R P N R O O

G R E T E S

At Hospital Admission...
Admission Details : Patient History Physical Exam. Observations - weight - b.p. - temp. - pulse are easily updated and reviewed at subsequent hospital admissions.

LABORATORY RESULTS GRAPH

Different variables at different dates can be seen at a glance. Variations from the normal values are also easily seen.
00 0 00 0 00 0 00 0 00 0 00 0 0 0 0 0 - 00 0 - 00 0 - 00 0 - 00 00 - 0 00 - 0 00 - 0 00 - 0
Glucose Normal

Glucose Cholesterol

# Lab. results can be received directly from the laboratory and are entered directly, available for the doctor to review.

A Centralized Record can be accessed easily by various hospital departments as illustrated below

a r e / T r e a t m e n t U H o s p i t a l W a r d P a t i e n t L o c a t i o n

it

L a b o r a t oR r ay d i o P a t h o l o g y B a c t e r i o l o g y

l oP g h y y s i o t h P r h a ap r y m e U n i t

PHARMACY ACCESS
A Medication Guide such as the one in the next slide gives a comprehensive overview of : Patient Drug History Drug Allergies Reasons for prescription Dose Through inclusion of an online guide such as MIMS, warning of impending drug interactions and contra-indications may be given.

MEDICATION MANAGER
Patient Name : I.D. No. : DIAGNOSIS : Urinary Tract Infection OTHER ACTIVE PROBLEMS ASTHMA Drugs Available for Diagnostic Profile : CODE: AMPICILLIN AMPICILLIN-SODIUM Drug Allergies : NONE KNOWN DRUG Becotide 250 DOSE 2/day Consultant : DRUG HISTPORT CURRENT CURRENT DRUG HISTORY Include : All current and expired drugs.

SELECT

CANCEL

PRESCRIBE RESULTS....

Processing results::
# CT Scan and X-ray results such as this can be processed, reviewed and entered directly into the patient file. # The results may be sent to other specialists by the Internet network for consultation.

Display Graphics... Graphics

The index of an Electronic Medical Record may look like.....

Applications of the E.M.R E.M.R

COMMUNICATION ...
One of the advantages of a central record is the ease of communication between ; - Hospital Departments e.g. for booking of diagnostic tests. -G.P. and hospital physician by email Standardized, structured messages may be sent from one person to another both of whom are familiar with the format, by the EDIFACT system (Electronic Data Interchange For Administration, Commerce and Transport).

Communication can be made easier via email services

H P a t i e

i t a

nS t p e c G i a e l in s e t S u r g e R o ne f e A n a e s t h e t t h e r h e a l t h

TELEMEDICINE ...
This is the practice of medicine using any data transfer linked with the process of care, in which some aspects of the care are assisted by remotely located professionals. Specialist communications may be made by Video-link. Components of Telemedicine

PATIENT SITE
PATIENT DATA

COMMUNICATION NETWORK

EXPERT SITE

TREATMENTS PHYSICIAN IN-CHARGE

SPECIALIST CONSULTATION EXPERT DATA

Telemedicine at Work...
The Eastern Health Board has introduced patient Smart Cards on a pilot basis, where a patients medical record may be carried by the patient as a plastic card and may be inserted into a special decoder, read and updated at hospitals and GP practices participating. Now a Days Airways are introducing a satellite communication with a doctor on the ground as a back-up to Flight Attendants with basic medical skills. Vital signs are communicated and doctors can manage patient care from the sky and decide whether an emergency landing is necessary.

Net To The Rescue.....

It was recently reported that two Chinese students at Peking University sent an appeal for help to find a diagnosis for their Chemistry student colleague who had developed a severe illness to which the doctors at Peking Union Medical College hospital had no cure. The medical information was sent to Sci.med newsgroups and within 24hrs was read by a doctor in Washington who recognized the girls serious condition could be due to thallium poisoning. Phoning the hospital in Beijing he advised to check for thallium poisoning. To the initial annoyance of the physicians over 600 email messages were received in reply to this appeal and the general consensus pointed to the same and correct diagnosis.

THE EMR AS AN INFORMATION SOURCE FOR STATISTICAL RESEARCH RESEARCH Specific information gathered from a
large number of patients for a certain disease with regard to - Severity - Duration of symptoms, can be represented graphically or scored.

This can be used as a reference for

aids to diagnosis . A Relational Database would be of this form and could be incorporated into the EMR.

QUESTIONNAIRE ON LIVER DISEASE

Conventions : Please mark all items P = Present O = Absent Lines ___= Enter Text s = Unknown/doubtful ...= Enter number

General Screen Yellow Sclera .....Age in years Male sex Weight loss Jaundice ....Duration (days) Deep Increasing since onset Decreasing Constant

Anorexia Nausea/vomiting Symptoms preceded jaundice Haemetamesis pale stool diarrhoea urine dark Abdomen palpable spleen palpable gallbladder tender gallbladder Ascites

liver definitely enlarged liver hard liver tender liver irregular obvious mass Other Fatigue Weight loss ......Doctors experience in yrs History taken from patient History taken from chart

 Charts such as the sample in In the I.C.U. this type of the previous slide are correlation, analysis of completed and the Laboratory results and information is coded into biochemical readings from computers. monitors may be incorporated to predict a From these standard form patients progress and findings, accumulated from forecast how long a patient thousands of patients, it is may have to stay in possible to set up a data base. intensive care. Through the use of Artificial This is important to Intelligence and applying hospital staff and statisitcal rules, the condition management as to how of a given patient - on which many places will be the same findings are available at a given time. available, can be predicted.

APPLICATIONS FOR HOSPITAL MANAGEMENT MANAGEMENT

1) CENTRAL RECORDING OF : # number of bed days # procedures and tests obtained by the patient, # units of treatment given 2) CODING OF DIAGNOSIS, PROCEDURES AND MEDICATIONS will make auditing of patient accounts easier and also more accurate. 3) TRANSMISSIBLE RESULTS MAY CUT DOWN ON THE NEED TO REPEAT TESTS.

Difficulties Associated..... Associated

It is clear from the previous slides that the technology is available to support far ranging possibilities for an Electronic Medical Record. However there are enormous problems to be overcome with regard to its use. Designers of EMRs must adhere to existing laws and legislation must be put in place to govern the appropriate use of data collected. Access - Patient confidentiality must be preserved at all times. Coded access e.g. by PIN would be a necessity. Different types of codes could be given to personnel who access the record for different purposes : ~ Doctors ~ Secretarial ~ Paramedical ~ Administrative

Standardization
Is a definite requirement for widespread use of electronic Records. This would include Lab. results units and precise medical terms. On-line dictionaries would help. Standardization of support software to link one system to another would also be necessary.

Cost Cost
The introduction of such a record would involve phenomenal financial expense ~ Hardware and Software equipment ~ Staff Training - would demand time and money which could be spent alleviating waiting lists. Although expensive test results available centrally would be a saving in health service costs.

Complexity Complexity
The EMR allows for increased processing of medical data. and enhances data analysis, which may ultimately complicate research with flawed data. The reasons why and the circumstances under which data is collected is not accounted for by simply coding observed facts into a structured computer Programme.

Conclusion Conclusion
The aim of the EMR is to encompass all underlying structures of paper record in a structured user-friendly format. Good history and physical exam. and clinical observation skills are the key to achieving information which is managed to support clinical decisions and actions taken in patient care. A Centralised record including lab. and procedure results and medication records will enhance patient record interpretation. Coding of Diagnoses, Procedures and Medications will benefit ~ Research ~ Auditing

 Many of the programmes concerning the EMR are still in the pilot stage. Legislation is needed to; Promote patient confidentiality Govern the use of data collected. Efficiency in the management of patient information, leading to more competent clinical action is the aim and should not be lost in megabytes of data input.