Electronic Medical Records

1. Electronic Medical Records • Lakewood Resource and Referral Center • 212 2nd Street • Lakewood NJ, 08701

2. Introduction to EMRs • Why do we need Electronic Medical Records (EMRs)? • Many problems with the current healthcare system (underuse and overuse) • 30% of children receive excessive antibiotics for otitis • 20-50% of surgical procedures are not necessary • 50% of back pain x-rays not necessary • 50% of elderly patients don’t get a pneumovax

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

4. Why do we need EMRs? • Available 24 x 7 • Can be viewed by more than one user at a time • Is available from remote locations • To covering MDs • Others with appropriate needs • Data can nearly always be found • Is legible

5. Why do we need EMRs? • Enhances Communication: • Between providers--clinical messaging • Can tag EMR location with message • Referrals • Half of specialists didn’t know what the main question was • A third of the time no information came back to PCP

6. Why do we need EMRs? • Cost Savings: • Dictation cost savings • $170/FTE/month • Chart pull savings • $217/FTE/month • Savings accrue to practice, apply to all payers

7. Why do we need EMRs? • Assist with Decision Support: • Many domains—cost and selection of: • Drugs • 18% reduction found by Researchers • Lab tests • 10-15% reduction in cost for charges, last result, probability of abnormal • Radiological studies

8. Why do we need EMRs? • Decision Support: • In inpatients, computerizing ordering decreased • Serious medication errors by 55% • All medication errors by 81% • EMR can help by • Structuring medication orders • 34% error rate with paper vs. 6% with electronic • Alerting about • Allergies • Duplicate medications • Many other issues

9. Introduction to EMRs • Do EMRs make a difference? • UNEQUIVOCALLY YES, BUT AT A COST! • In multiple studies, EMRs have been shown to: • Shorten Length of Stay in a Hospital setting • Decrease Adverse Drug Events (ADEs) • Improve Readability, Consistency and Content of the medical record • Improve Continuity of Care • Reduce practice variation • Most benefits come from Decision Support.

10. EMR Use in the United States • Even though the US Health Care system is the costliest in the world, its performance ranks 37th in the world according to the World Health Organization • Only 5% of US primary care providers use EMRs (Bates et. Al., JAMIA 2003), 7% of all physicians (Wang, Bates, et. Al., American Journal of Medicine, April 2003)

11. EMR Use Around the World Use PCs Use EMR • Australia 90% 53% • Denmark 95% 62% • Netherlands 95% 88% • Sweden 95% 90% • United Kingdom 95% 58% (c) 2001 Harris Interactive

12. Breakdown by Function - 2002 Australia UK • Use EMR 90% 99% • Of Those: • Prescription 100% 80% • Notes Unknown 45% • Reminders Unknown 70% • Clinical Vocabulary 15% (ICPC) 100% (Read) • Paperless Unknown 45% • $2B initiative by UK to get all physicians online

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

14. What is an EMR? • So if an EMR is just a database, how is it different from other databases, and why is it so useful? • Value Added: • A Clinical Knowledge Heirarchy (term dictionary) • How do clinical concepts work together • Ex: Digoxin toxicity can occur with hypokalemia • A List of Current Clinical Recommendations • A List of Appropriate Medication Indications, Doses, Adverse Effects and Interactions and Cost Estimates • Costs, Indications and Utility of Tests

15. What is an EMR? • What are some typical EMR Components: • Lab System: Contains all lab tests ordered and their results and stored as coded results in many systems • Radiology System: Stores test reports • Pharmacy System:List of current medications, inactive meds and when they were last dispensed or ordered • Billing System : A list of diagnostic codes used for billing • Registration System: Names, Contact Info, Personal Info, etc. for patients

16. What is an EMR? • Additionally, many EMRs have: • An Order Entry System (where physicians enter orders, prescriptions, notes etc. online) • A Decision Support System • Often linked to the order entry system to provide guidance at the point of care • Contains databases for clinical knowledge, guidelines, list of medication indications, doses etc.

17. What is an EMR? • The spectrum of EMRs • EMRs target specific user bases, from solo office-based practices to large, multispecialty care centers • Many features are thus directed at managing workflows specifically to these user bases • For example, large commercial EMRs unbundle services such as clinical documentation, results display etc. while office systems typically integrate all of these under the same interface.

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

19. Different Types of EMRs • EMRs don’t necessarily need to be expensive and complicated or require that a computer be used to enter data • Can have hybrid computer/paper based approaches • Ex: In the CHICA™ System, paper is used to interact with an electronic data repository • Standardized paper forms are printed and then “scanned” • Characters are recognized and the electronic data so generated interacts with the data repository

20. Different Types of EMRs • At Indiana University, pediatric clinics use this system: • A data repository was developed using Microsoft SQL Server • A clinical guideline system was written in Arden Syntax • An optical character recognition system called Cardiff Teleforms is used to process handwritten numerical data on preprinted scanned forms • The data so generated is stored in the database and dynamic reminders are generated for the physician • These are printed on the clinic computer • The entire operation takes < 2-3 minutes!

21. Different Types of EMRs • The Mosoriot Medical Record System™ • Indiana University has an HIV Effort in Kenya • A Simple MS Access based database holds all patient records (3 years worth!) • Provides forms for data entry, standard term dictionary, medication listings, registration system, clinical documentation system etc. • Created by 1 programmer over 2-3 weeks! • Highly effective, easy to maintain, inexpensive!

22. Data Sources • So how can EMRs populate their databases? • Data can come from many many sources: • Admission/Discharge/Billing • Anesthesia Systems • Cytology Systems • Diagnostic Imaging Management Systems • EKG Carts • Endoscopy Systems • ER Systems

23. Data Sources • More Data Sources: • Home Care Systems • ICU Monitoring Systems • IV Fluid Infusion Control Systems • Laboratory Systems • Nurse Triage • Order Entry Systems • Pharmacy Systems (Inpatient/Outpatient) • Pulmonary Function Systems

24. Data Sources • More Data Sources • Radiology systems • Risk Management systems • Registration Systems • Scheduling and Clinic Charge Systems • Transcription Systems • Unit Dose Dispensing machines • Ventilator Management systems

25. Thank You Acknowledgments: William Tierney, MD Atif Zafar, MD AHRQ PBRN Resource Center Q&A