ELECTRONIC HEALTH RECORDS
Week 6
WHAT IS A PATIENT RECORD?

A historical record of patient care
Account of a patient’s health and disease following medical
consultation.
 Typically contains findings, considerations, test results and
treatment information related to an ailment / disease process.
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A communication tool among care providers
A research and knowledge-gaining tool
A teaching tool
An operational tool (e.g., order entry)
An administration record (e.g., to manage resources)
A legal record with considerable longevity
EVOLUTION OF PATIENT RECORDS (1)

In the late 19th century every clinician kept patient
medical details in a leather bound ledger.
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Contained a chronological account of all patient
consultations.
Known as a ‘Time-Oriented Medical Record’
Notes pertaining to a particular patient could be pages
apart depending on the dates of subsequent consultations.
This scattered nature made it difficult to assess disease
progression.
Furthermore, a patient could be treated by more than more
clinician, therefore some notes would be contained in other
clinicians ledgers.
In early 20th century a separate file for each patient
was adopted.
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Origin of patient-centered medical records
No fixed criteria for data entry therefore different
clinicians recorded differed pieces of data.
EVOLUTION OF PATIENT RECORDS (2)
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In 1920, a minimal set of data that all clinicians
should record was agreed upon.
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This early ‘standard’ became the foundation framework
from which current medical record data is recorded.
In 1960 the ‘Problem-Oriented Medical Record’ was
established.
Each patient assigned one or more problems.
 Notes recorded using the ‘SOAP’ structure
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S: subjective – complaints reported by the patient
O: objective – the findings of the clinical staff
A: assessment – test results, diagnosis
P: plan – the suggested treatment etc.
ISSUE: required a lot of effort to record information for a
patient reporting several problems in parallel.
EVOLUTION OF PATIENT RECORDS (3)

‘Source-Oriented Medical Records’ are the most
commonly used system today.
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Record ordered according to the method by which
they were obtained.
Notes of the visit
 X-ray reports
 Lab reports, blood tests etc.
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Within each section, records are stored in
chronological order.
 The SOAP method is still used for the clinical notes.
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How well is this paper based method suited for
its clinical purpose?
COMMON USES FOR PATIENT RECORDS

Support Patient Care
A source of evaluation and decision making
 A source for information that is shared among care
providers.
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A legal report of medical actions
 Supporting research
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Clinical research, epidemiological studies, assessing
quality of care, and post marketing surveillance of
drugs.
Educating clinicians
 Healthcare management and services
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SHORTCOMINGS OF PAPER BASED
PATIENT RECORD (1)

Increasing number of medical specialties
Likely that patient treated by a number of these specialists
for a single condition.
 One record /patient causes too many logistically issues
 Result: as many patient records for a single patient as
there are specialists managing their care.
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Patient data becomes scattered among different
specialists / centers.
Clinician must request this data from a number of
specialists to gain an overall picture
 Paper based records can only be in one place at a time –
often it become misplaced in transit.
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Handwriting Illegible, data missing, notes too
ambiguous.
Space requirements.
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Large warehouses exist to house patient records
PAPER BASED PATIENT RECORDS
SHORTCOMINGS OF PAPER BASED
PATIENT RECORD (2)
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Limited access to complementary medical information.
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X-ray, MRI results or other lab test feedback.
Data backup issues
http://www.youtube.com/watch?v=VzY12fTbNt8&feature=rela
ted
 http://www.youtube.com/watch?v=DV5jod3INHY&feature=rel
ated

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Perhaps the most fundamental limitation of paper-based
records is that they can only contribute ‘passively’ to the
decision making of the clinician.
Paper-based records cannot give rise to active reminders,
warnings or advice.
 Record cannot actively draw the attention of a clinician to:
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Abnormal lab results,
Errors in data / medication entry.
For scientific analysis, the contents need to be transcribed,
with the potential for errors.
PAPER FREE MEDICAL RECORDS

http://www.youtube.com/watch?v=9jAH9hdF0xk
&feature=related
WHAT IS AN ELECTRONIC HEALTH RECORDS
(EHR)?
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A repository of electronically maintained information about an
individuals lifetime health status and health care, stored such that
multiple persons can gain authorized access to it.
Also known as:
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Electronic Patient Records (EPR)
Electronic Medical Record (EMR)
Patient Health Record (PHR)
Computerised Patient Record (CPR)
Computer Based Patient Record (CBPR)
Electronic Clinical Information Systems (ECIS)
Centerpiece of Health Informatics

Potential to improve upon:
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Patient safety
Staff Productivity
Information Storage and Retrieval

http://www.youtube.com/watch?v=t-aiKlIc6uk
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EPR: 5 FUNCTIONAL COMPONENTS
Integrated
View of
Data
Integrated
Communic
ations
Support
Clinical
Decision
Support
Electronic
Health
Record
Access to
Knowledge
Resources
Clinical
Order
Entry
EHR COMPONENTS (1)

Clinical decision support
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Secure Messaging for communication support between
clinicians, patients and support staff.
Appointment scheduling and patient portal access.
Referral Management
Retrieval of lab and X-ray reports electronically
Access to previous consultation notes and medication history.
Support for paperless order entry services
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Provide alerts, reminders and clinical practice guidelines.
Electronic ordering for prescriptions, x-ray, consults and other
diagnostic tests.
Support for multimodal data input
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Text, image, voice, dictation.
EHR COMPONENTS (2)
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Interfacing with PDAs and portable computers
Remote access from home or office
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Ambulatory access
E-prescribing
Knowledge resources for both patients and clinical
staff
Ability to scan in text, images
Ability to create graphs, charts
Ability to generate patient lists or disease registries.
Data Warehouse –backup system
Public health tracking and reporting
Support for Client – Server or web based Application
Service Providers (ASPs)
RATIONALE FOR EHR SYSTEMS (1)
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EHR systems have the potential to bring huge benefits to
patients and are being implemented in health systems
across the developed world.
EHRs aim to provide easy navigation through the entire
medical history of a patient.
Storing and sharing health information electronically can:
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speed up clinical communication
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Records available 24/7
reduce the number of entry errors
 assist doctors in diagnosis and treatment
 patients can have more control of their own healthcare.
 electronic data also have vast potential to improve the quality
of healthcare audit and research.
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RATIONALE FOR EHR SYSTEMS (2)
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record can be used by multiple personnel at the same time
record is accessible from anywhere (even from home)
clear, well-organized, legible documentation
data can be reused for other purposes
data can be integrated from multiple sources transparently
data can be validated automatically
provide reminders that tests / examination are overdue.
enables multiple automated research and decision-support
functions (analysis, machine learning and data mining,
automated diagnosis, reminders, guideline-based care)
decision support can be integrated with use of the patient record
increasing access to data through EHR systems also brings new
risks to the privacy and security of health records.
RATIONALE FOR EHR SYSTEMS (3)
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EHR have the potential to provide many large
volumes of data!
Many of the major players are offering free services to
healthcare facilities in return for access to anonymous
patient data.
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http://www.youtube.com/watch?v=V35Kv6ZNGA&feature=related
POSITIVE EHR
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Patients Perspective
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http://www.youtube.com/watch?v=n1L4nKdYr6E&fea
ture=related
Doctors Perspective

http://www.youtube.com/watch?v=mtLi6vmJ4fo&feat
ure=fvw

http://www.youtube.com/watch?v=fjnyDNZE3RY&fea
ture=related
DIFFERENT USES OF EHRS (1)
Inpatient
Research
Department
Outpatient
Nursing
Home
Primary
Care
EHR
Disease
Specific
Hospital
Emergency
Department
Intensive
Care
DIFFERENT USES OF EHRS (2)
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General practitioners
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highest level of computerisation with the vast majority of surgeries using IT systems
both for administrative and clinical purposes.
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most practices store some patient information electronically
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dispensed with paper systems altogether after scanning old paper notes into new
electronic systems.
Hospitals
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Level of computerisation varied widely but consistently lower than in general practice.
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Most hospitals use basic Patient Administration Systems (PAS) for scheduling,
recording admissions and discharges, and storing patient demographic and basic
diagnosis information.
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In some clinical areas, such as theatres and pathology, more sophisticated systems
have often been used for both administrative and clinical purposes.
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The overwhelming majority of patient records are still stored in often voluminous
paper form.
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Lack of unifying standards means that IT systems in different departments within a
single hospital are often unable to communicate.
Community and mental health care providers
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Levels of IT use have been the lowest of all.
Disease Specific
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Complex systems have been developed across clinical networks with responsibility for
a particular patient group.
INTEGRATION OF EHR AND DECISION
SUPPORT MODULES
 Decision
support is most effective when
integrated with an EHR
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The most likely opportunity for providing decision
support is when the physician is assessing the
patient record or entering an order
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All or most relevant patient data can be accessible
to the DSS and do not require separate entry
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Physician should always be able to override the
recommendation and, if relevant, provide feedback
ORDER ENTRY
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A major function of an EHR system is allowing
care providers to enter clear, legible orders for
patient care anytime, anywhere
Supports validation of order, issuing of alerts,
suggestion of relevant information and
knowledge, and even actions
Quick effect on physician ordering behavior
EHR AND KNOWLEDGE SOURCES
 The
most effective time to provide access to
knowledge is when the care provider is
browsing the patient record
A
query can be formulated in a contextsensitive manner with respect to the patient
record, thus anticipating the physician’s
needs
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Note: Queries often have relatively expected
structure and content (e.g., which drug is useful for
condition X in context Y; What are side effects of
drug Z when used in manner W; What clinical
guidelines are most relevant for disease D in
patients of type P)
EHR ISSUES: COSTS
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Large initial set-up investments
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Hardware, software, training, support, maintenance
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Significant workflow changes
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Significant organisational changes
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Difficult data entry relative to handwriting
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Potential catastrophic failure – system crash,
hack, loss of data.
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Paper records also have “down” times
Notes unavailable 30% of the time, natural disasters
EHRS: MAJOR ISSUES
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Data Entry
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Data capture: the scope of the data that is or can be
represented in the EHR
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Data input: coded data are difficult to input by physicians;
text is less useful for processing
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Errors can be reduced by multiple validity checks
VALIDITY CHECKS DURING DATA ENTRY
IN AN EHR
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Range checks (Hemoglobin in [0..30] Gr/Dl)
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Pattern checks (a telephone number pattern)
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Numeric and other inter-data constraint checks (total of
WBC differential is 100%)
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Consistency checks (pregnant male??)
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Temporal-abstraction checks (weight cannot change by 50
Kgs in 2 days)
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Spelling checks
PHYSICIAN-ENTERED DATA
 The
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main challenge to EHR developers!
Patient histories, physical findings,
interpretations, diagnostic and treatment plans
 Several
very different entry methods
Transcription of dictated or written notes
 Structured encounter forms from which notes are
transcribed and even encoded
 Direct entry of data by physician via computer
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 Speech
recognition might alleviate some of
the difficulties
SECURITY ISSUES IN EHRS
 Authorization
 Is my dentist allowed
to see my gynecological
record?
 Which fields of my record can my or another GP
view?
 Who has asked to view my records last month?
 Authentication
 Is this user really
my physician?
 Encryption
 Can an eavesdropper
to my doctor?
 Eventually,
understand the message sent
security depends on people
SUMMARY OF ADVANTAGES AND
DISADVANTAGES
ADVANTAGES OF EHR (1)
 The
biggest advantage is that all data is
stored in one place, and, can effectively be
accessed anywhere.
This is as opposed to paper based records
where the records can only really be in one
place at any time.
 This means that a nurse in a hospital can view
the same records as a doctor in a remote
surgery is viewing.
 To move a paper based record to another
location requires faxing, posting etc. This is
costly and slow.
 With paper records one part of the medical
history may be stored in the hospital whilst
another part may be located in the doctors
surgery.
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ADVANTAGES OF EHR (2)
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The physical storage requirements of electronic
records are also by far superior to their paper
counterparts.
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Paper takes up much more physical space.
A particular issue with medical records is that they may
include different media, such as x-rays, notes, ECG
recordings, perhaps even vide or audio tapes. It is often
difficult to store different types of media in one place.
Electronic records get a round this problem as most
forms information can be stored and linked digitally on
the same media (i.e. on the same disk).
Information can also be archived and disk space can be
recycled much more efficiently.
ADVANTAGES OF EHR (3)
 Handwritten
and paper based records are
much more prone to error.
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Physicians are notorious for poor hand writing.
Forcing them to type up notes gets around this
problem.
Some forms of paper based or hard media
(such as micro films or images) may
deteriorate over time. Digital information will
not deteriorate.
This is particularly an issue in prescribing.
This potentially can reduce medical errors and
in turn reduce costs that may result from
incorrect diagnosis. These costs may arise
from more expenditure in patient treatment
and law suits.
DISADVANTAGES OF EHR (1)
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Cost
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Initial costs. It is costly to install all the infrastructure
necessary to effectively run such a system.
Think of the expenditure of kitting out all health centres in
NI with PCs and all hospitals.
 This would just represent a fraction of the start up cost.
 Other start up costs include training users, converting
existing records.
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Cost to maintain system. Healthcare providers must
provide all the support necessary to make sure the
system is extremely robust and versatile.
Cost of technical staff.
 Costs of training programmes to continually educate new
medical staff.
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Who should pay for each part?
DISADVANTAGES OF EHR (2)

How do we treat old records.
We already mentioned the cost of converting paper
based records to electronic records.
 But is there even a practical way to enter all these
records?
 Some systems opt for scanning the records in and
storing them as images, or use ocr.
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DISADVANTAGES OF EHR (3)
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Security.
Medical data is up there with bank details. Must be
treated with utmost respect!
 If data is being transmitted around a large system
there is much potential for loss of data or compromise
of data.
 How do we ensure that only the right people have
access to this data.
 People are very wary of this, both patients and
practitioners.
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
http://www.youtube.com/watch?v=JJjjLaw7PRM
DISADVANTAGES OF EHR (MISC)

Some more disadvantages:
It is difficult to get people to accept change.
 Many vendors are now producing healthcare
solutions and its hard to link all these systems
together.
 Methods of input may be difficult for older users.
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TRENDS IN EHR
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The biggest challenge that this technology faces is it’s
incorporation into current practices in healthcare delivery.
This problem is not easy to resolve.
There are other trends that advances in technology can address:
These include
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Facilitating better data entry.
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Making data entry as easy as possible is essential if we want clinicians to use
electronic means to enter and share accurate patient info on a national
network.
Typing may not be most suitable for all doctors.
Perhaps a way to proceed is to allow doctors to dictate information. Later
this information can be mined to store key words.
Facilitating easier data access and interpretation.
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It is quicker to retrieve and assimilate information by reading and scanning
than by listening to speech.
Reading print is quicker than reading from a screen.
Regardless the huge amounts of information stored in EHRs needs to be
presented carefully.
There is much more scope for effective presentation using computers. (i.e.
computers can generate the output in any way).
We need to think of the best ways to convey this information.
EHR SUMMARY
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EHR systems also bring new risks, particularly to the
privacy and safety of health information.
Electronic systems allow access to data from many
locations, increasing the likelihood of a security
breach;
they can also give individuals access to much more data
than was previously possible, increasing the damage
caused by system misuse.
 Personal health information is often highly sensitive, and
it is therefore difficult to repair the damage caused by a
breach of privacy.
 All these risks can be mitigated, but there is little doubt
that EHR systems will create, as the European Data
Protection Working Party acknowledged, “a new risk
scenario” for personal health information.

AMERICAN CASE STUDY
Veterans Health Information Systems and
Technology Architecture (VistA)
VETERANS HEALTH INFORMATION SYSTEMS
AND TECHNOLOGY ARCHITECTURE (VISTA)
Source:
http://upload.wikimedia.org/wikipedia/en/8/8f/VistA_
19 YEAR HISTORY


The Department of Veteran’s Affairs has had
automated information systems for medical
information since 1985.
Formerly known as the Decentralized Hospital
Computer Program (DHCP) it is now known as
the Veterans Health Information Systems and
Technology Architecture (VistA).
HISTORY (2)

In the late 1990’s the component of VistA known as the
Computerized Patient Record System (CPRS) was
introduced. This has been a highly successful venture that
integrated for the health care provider most of the tools for
patient centered healthcare.

Patient Centric Viewpoint allowing multiple users to view
information and work within the patient chart simultaneously
in a “tab-like” Graphical User Interface (GUI) environment.

Provided the order entry for Labs, Pharmacy, Imaging,
Nutrition and Consults and Procedures in one place.
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Reduced the chances of transcription error since orders flow
directly from the Clinician to ancillary service.
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Created tools for local modifications to create order sets, such
as standing or admission orders, and templates, providing
standard or required text in progress notes, consults and
procedures.
HISTORY (3)
o
o
o
Clinical Alerts for Critical Lab and Imaging results are sent
electronically to the ordering provider for viewing and action.
A backup system of alerts for clinical follow-up is also effective
in making sure there is some responsible clinician in case the
ordering provider does not act upon the alerts.
Order Checks are in place to prevent medication
contraindications based on previous patient orders, lab results
(ex. Creatinine Clearance) or other physical information.
Clinical Reminders provide information concerning needs for
the patient based diagnosis, age, or other highly
individualized factors.
o
o
Imaging results available online at any workstation for reference.
Remote Data allowing access to clinical information from any other
sites that the patient might have had a visit.
CPRS IS GOOD…. BUT DOES HAVE SOME
DISCREPANCIES
 Lacks
the ability to review across a
patient group
 Does not easily allow information that
would be tracked on a flow sheet
 Patient signatures are not available
electronically, meaning that there
continues to be some need of a paper
record
 Does not include the identified patient
with the ability to participate in their own
care
THE NEXT GENERATION

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CPRS-R (Computerized Patient Record
System-Repackaging) is the next phase in the
development of the clinical record.
HealtheVet Desktop is one of the first releases
of CPRS-R.
This will provide a framework that can be reengineered with a wide range of clinical
applications plus enabling seamless integration
between independently developed applications.
CPRS will only be one small part of CPRS-R, a
great deal more functionality and flexibility will
be available than currently exists.
CARE MANAGEMENT

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One of the first products in current use in the HealtheVet Desktop is Care
Management.
Care Management is unique since it finally allows the clinician the ability to
scan alerts, scan and sign multiple documents and create individual
personalized electronic messages across a group or team list of patients.
It also is one of the first tools that can provide by-role selection of information
via the use of Perspectives, currently as Clinician and Nursing.
Care Management has limitations to what activities, such as order entry,
progress notes or access to complete linear patient data. For this reason, the
HealtheVet Desktop provides the unique ability for linkage from Care
Management, connecting through to the same patient, to CPRS where these
tasks can be accomplished.
PERSONAL EMPOWERMENT: MY
HEALTHEVET
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My HealtheVet is a web-based application that creates a
new, online environment where veterans, family and
clinicians may come together to optimize veterans’ health care.
My HealtheVet empowers the veteran by providing powerful
heath education and assessment tools, online services, health
record access, and messaging between the veteran and
clinicians.
Provide online prescription refills and co-payment balance
review
Use online calendar to set and track their own appointments
Veterans will be able to view and maintain a copy of key
portions of their own health care record
The Veteran will be able to share all or part of the information
in their account with health care providers, inside and outside
the VA.
GLOBAL COLLABORATION:
HEALTHEPEOPLE (1)



HealthePeople is a collaborative strategy, including making
HealthePeople-VistA (the public version of VistA), that takes VistA
outside the VA to support high quality, accessible and affordable health
care that will substantially improve the health of veterans and,
potentially, all people in the U.S and perhaps other countries.
The title reflects the key thrust of the effort: a strong people focus, strong
health focus and a heavy reliance on “e” the electronic means as a key
enabler.
Public and private sectors organizations are encouraged to join this effort
to help adopt standards for architecture, data and communications to
develop model, high performance health information systems.
GLOBAL COLLABORATION:
HEALTHEPEOPLE (2)



Make high performance health information systems more
affordable, available and interoperable and make electronic
health information system information available to
organizations that serve the poor and near poor at close to
no cost as are possible.
Will enable easier and more secure sharing of health
information amongst people and their health care providers
VA is already working closely with DoD (Department of
Defense) and HHS (Human Health Services). Interest has
also been expressed by other public and private sector
health related organizations such as the Institute for
Medicine, foundations, commercial technology companies,
State and local agencies and other health care providers.