Baptist University Introduction to Electronic Health Records EHR

1. Baptist UniversityIntroduction to Electronic Health Records (EHR) Michael Fung 21 October 2010

2. Agenda Definitions & Concepts Development History Potential Benefits Key Functions of EHR 10 Dimensions of EHR Worldwide Implementation Progress Levels of EHR Implementation Case Study of Hospital Authority

3. Electronic Health Records Objective To create an interoperable electronic health record for a safer, higher quality, more efficient continuous health service

4. Electronic Health Records (EHR) – Simple Definition Mostly used “generic term” Computer-stored collection of health information about one person linked by a person identifier

5. EHR Definition (Institution of Medicine 2003) Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or healthcare provided to an individual Immediate electronic access to person- and population-level information by authorized and only authorized users Provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care Support of efficient processes for healthcare delivery

6. EHR Implementation Not necessarily one single system Broad set of functionalities, depending on the organization, may be Provided by one or many systems From one of more vendors Not a single project Series of initiatives that represent more a Journey than a Destination

7. Computer-based Patient Record (CPR) Term used in the report of the Institute of Medicine Virtual computer-based medical record Includes all information (clinical and administrative) Covers all practitioners ever involved in a person’s health care Independent of medical specialties, Longitudinal, ideally include prenatal and postmortem information Integral part of decision support Issues on privacy, interoperability

8. Patient-carried Medical Record Health information on a device Smart card with a computer chip Card with optical stripes, magnetic high density stripes, 3-dimensional bar codes etc. Used in Veteran Administration Health Systems in mid 1980s but failed in late 1980s Card capacities Interoperability regarding content and terminology Lack of infrastructure for providers to record and read cards CD ROM with patient information at discharge

9. Computerized Medical Record (CMR) Document imaging of paper documents into a computer system Prepping, scanning/digitizing, indexing, performing quality control Benefits Shareable of medical records Higher level of document integrity Persistence in storage Passive computer recording

10. Electronic Patient Record (EPR) Grew out of the CPR concept, but differs in vision A collective vision of many systems and components which that are part of this overall concept Derived of all “relevant” patient information and driven by software, e.g. “normal” results may not be stored

11. EMR Definition A EMR Facilitates access of patient data by clinical staff at any given location an increase in liability coverage accurate and complete claims processing by insurance companies building automated checks for drug and allergy interactions standardization of care pathways and protocols clinical notes prescriptions scheduling sending to and viewing by laboratories

12. Electronic Medical Record (EMR) Interoperability issues on CPR & EPR An electronic healthcare information system regarding one patient within an enterprise Enterprise may be a clinic, hospital, health plan A natural stepping stone towards an EPR, DMR or EHR

13. Personal Health Record (PHR) Individual person should have an interest in one’s health, rather than leaving to medical profession Have a copy of health information ever created Generally understand content of health history Learn about health matters that affect her Be a partner, rather than parent/child relationship, to the care giver 5 types of PHR Off-line PHR Web-based commercial / organizational PHR Functional / purpose-based PHR Provider-based PHR Partial PHR

14. Electronic Health Record (EHR) Electronic version of medical record, or Particular concept which is different from the CPR – no pre-natal and post-mortem information. Includes wellness, alternative healthcare information & personal health records CMR – digital record that can be used in decision support applications and interactive recording EMR – not limited to a healthcare enterprise PHR – primarily created and managed by providers and practioners

15. Electronic Health Record (EHR) Roles Provider-based view of patient’s health history Clinical communication and care planning for patient’s healthcare practitioners Document services received by patient for reimbursement purposes Legal document describing healthcare services provided Source of data for clinical, health services, outcome research & public health Basis for decision support Encourage interactive recording at point-of-care

16. EHR (HKSAR Definition) EHR is the HKSAR wide electronic longitudinal (from "womb-to-tomb ") health record comprising of all important health data about a person.  It is contributed by various healthcare providers and the patient himself/herself, and the data can be accessed at anytime, anywhere by authorized personnel.

17. Development History Electronic Health Record systems started in 1960s Implementation progress had bee much slower than expected Institute of Medicine’s report on computer-based patient records in 1991 Technology advancement, Internet, wireless, mobile computing, RFID etc. Investments from CPR vendors, e.g. Siemens, Cerners, GE Medical, iSOFT, MedTrack, IBA …..

18. Potential Benefits of EHR Higher Efficiency Sharing of patient data Timely update and multiple access Speed up workflow More efficient clinical practice Access data and images at home or remote sites for expert consultations Better Quality of Care Make decisions with comprehensive clinical information Avoid errors associated with paper records Clinical decision support

19. Figure 1 Value of projects over time(from Gartner, 2007)

20. Figure 2 Cumulative value for multiple projects (from Gartner, 2007)

21. Speed Up Workflow

22. Speed Up Workflow

23. Speed Up Workflow

24. Speed Up Workflow

25. Speed Up Workflow

26. Speed Up Workflow

27. Improve Efficiency

28. More information in hand

33. Reduce Errors

34. Reduce Errors

35. Remote Access

36. Remote Access

37. Key Functions of EHR Recording Healthcare documentation Legal document Sharing of EHR information Healthcare became more complex with more practitioners involved Reduce medical errors & more efficient continuity of care Order Entry Laboratory test, Radiology Examination, drugs etc. Retrievability and Access Patient Information Pulls together relevant information and displays to practioners

38. Key Functions of EHR … Built-in Functionality for Key Elements of Health Documentation Unique identification of patients Accuracy Completeness Timeliness Clinical Decision Support Allergy checking Drug-drug interaction Dosage checking Disease-based checking

39. Key Functions of EHR … Security User authentication Information access control Audit control Digital signature Data encryption Interoperable with Other Systems LIS, RIS, Pharmacy system, ICU system … PACS Patient monitoring systems

40. 10 Dimensions of EHR

41. Data Content What is recorded ? Scope of specialties Scope of information available for exchange Each provider to record a minimum data set of a specific pathway of care Standardization of data structure

42. Information Capture Integrating voice, handwriting, direct input, document imaging etc. Compliance with Principles of Documentation Unique identification of patient Accuracy Completeness Timeliness Interoperability Authentication & accountability Auditability

43. Information Representation Terminology Code sets Language …. To ensure different practitioners have same meaning attached to vocabulary, code sets

44. Operational Dimension and Data Model Actors, actions, process states/state transitions, work flows, deployment, version control, audit levels, data models Standards are needed for interoperability purposes

45. Clinical Practice Standards of care/practice Protocols, e.g. care plans, critical paths Evidence Based Medicine Disease management Practice protocol & guidelines

46. Decision Support Standards for clinical decision making, algorithms, triggers, responses, logical support etc. Administrative decision support Clinical decision support

47. Security / Confidentiality Information flow pathway Accountability Authentication Access control Encryption Backup/recovery … International standards cover data integrity, authentication General system security and auditability HIPAA for US EHRs

48. Performance Performance standards Measure performance General user standards

49. Interoperability Inside system – convergence EHR domain Outside system – disparate domain, data & functional mapping Technical and system interoperability

50. QA and Testing System testing Operational quality assurance QA should be built into the EHR System testing procedures

51. Medical Informatics in North America 1950s, MYCIS & INTERNIST-1 1965, NLM started using MEDLINE & MEDLARS 1970 & 80s, MUMPS for clinical applications 2004, Veterans Health Information Systems and Technology Architecture (VistA) – CPRS for VA’s over 1000 hospitals 1996, HIPAA created impetus for physicians to use EMR for patient safety

52. European Health Informatics European eHealth Action Plan plays fundamental role in EU’s i2010 strategy UK NHS National Programme for IT (NPfIT) Contracts totaling £5.6B (HK$80B) over next 10 years have been awarded electronic appointment booking electronic care records service electronic transmission of prescriptions fast, reliable underlying IT infrastructure

53. Health Informatics in Oceania Health Informatics Society of Australia (HISA), member of IMIA Nurse informatician driven Branches in Queensland, New South Wales, Western Australia SIGs in nursing, pathology, aged and community care, industry and medical imaging

59. Levels of EHR Implementation

60. 5 levels of EHR computerisation (1) Level 1 Automated Medical Record (clinical information system) Level 2 Computerised Medical Record (document imaging) Level 3 Electronic Medical Record (active tool, organization level)

61. 5 levels of EHR computerisation (2) Level 4 Electronic Patient Record (spams across organization) Level 5 Electronic Health Record (longitudinal, comprehensive Source: Waegemann 1996

63. Gartner: 5 generations of EHR

64. Healthcare System in Hong Kong

65. 1990 –“Green fields” 1991 –Patient Administration 1992 –Pharmacy system 1993 –Lab results online 1994 –Radiology information system 1995 – Clinical Management System Clinician documentation and order entry 2000 – CMS Phase II Electronic Patient Record (ePR) 2003 – eSARS 2004 – ePR Image Distribution 2006 – ePR sharing with private sector The development of Clinical Systems and ePR in HA is a long journey since 1990s We start with patient administration, lab system and radiology systems first before we came to CMS in 1995. As CMS continued to develop, ePR was born in 2000 year. Later on, we have the eSARS in 2003 and since 2004, we put radiological images onto ePR and this year, we move our ePR outside the HA boundaries to the community to share the patient record with the private sectors. The development of Clinical Systems and ePR in HA is a long journey since 1990s We start with patient administration, lab system and radiology systems first before we came to CMS in 1995. As CMS continued to develop, ePR was born in 2000 year. Later on, we have the eSARS in 2003 and since 2004, we put radiological images onto ePR and this year, we move our ePR outside the HA boundaries to the community to share the patient record with the private sectors.

66. Clinical Management System - 2005

67. Corporate Clinical Systems Corporate Patient Master Index Clinical Management System Patient Appointment System Laboratory Information System Radiology Information System Pharmacy Management System

68. The HK Patient Master Index Using Hong Kong Identity Number (HKID #) HKPMI, Admissions/Discharges and Appointments Booking implemented across all HA hospitals and clinics HA HKPMI contains 8 million records

69. Clinical Management System CMS: Integrated clinical workstation for direct use by all clinicians in HA Phase I (1995-2001) – The Collector Phase II (2002-2004) – The Documenter Phase III (Planned) – The Helper Phase IV – The Colleague Phase V – The Mentor

70. Evolution of CMS Phase I - Functions Discharge summary Clinician coding of diagnosis & procedure codes Ordering of medications and laboratory tests Retrieving laboratory and radiology results Medication history Electronic booking of appointments Generate referral or reply letters and reports Cross hospital information enquiry Phase II - Modules Generic Clinical Requests (Order Entry) Generic Results Reporting (Forms) Clinical Data Framework Outcome Documentation Medication Decision Support Clinical Data Analysis and Reporting Electronic Patient Record (ePR)

71. CMS Phase III - Objectives Develop the content Standards-based, comprehensive, multimedia patient-based ePR Facilitate the process Support for operational care processes Workflow management and communication tools Improve the outcome Clinical decision support at point of care Support for QA activities

72. Electronic Patient Records (ePR)

73. ePR – Laboratory Results

74. Realising the Benefits of Investing in IT

75. Patient Benefits Scheduled appointments for convenience Having their whole record available at point of care for more accurate and timely clinical decisions No need for repeated tests Better quality care through clinical decision support at point of care Less repeated studies decreasing radiation exposure

76. Clinician Benefits More efficient clinical practice No need to search for information and forms Better decision-making with comprehensive information Avoid errors associated with paper records

77. Organization Benefits Better use of resources Enforcement of policies & best practice at point of care Data for planning, research and management

78. End