Electronic Health Records Dimitar Hristovski, Ph.D. E-mail: [email protected]@mf.uni-lj.si Institute of Biomedical Informatics.

Electronic Health Records

Dimitar Hristovski, Ph.D.E-mail: [email protected]

Institute of Biomedical InformaticsMedical Faculty

University of Ljubljana, Slovenia

mailto:[email protected]

Alpe Adria Master Course :: Medical Informatics :: Dr. D. Hristovski: Electronic Health Records

Types of (Paper) Medical Records

Time oriented Data source oriented

Visits, laboratory results, X-ray images Problem oriented (SOAP)

Subjective: patient description Objective: physician or nurse description Assessment: investigations results and

diagnosis Plan: treatment plan (therapy, surgery, ...)


Advantages of Paper Medical Records(compared to Electronic Med.Rec.)

Easy to move around Freedom of expression Easy browsing Additional training not necessary They always work (in contrast to computer

based records)


Disadvantages of Paper Medical Records(compared to Electronic Med.Rec.)

Not accessible from different locations Do not allow different views of data Fast search not possible Lack structured data entry Difficult usage for decision support Not easily used for research Do not support multidisciplinary healthcare Time consuming data exchange


What is Electronic Health Record?

The electronic health record is a computer-stored collection of health information about one person linked by a person identifier.

It represents the basis for healthcare information systems development.


Electronic Health Records in Relation to other Healthcare Info. sub-Systems

They exchange data with these sub-systems: Data entry and results browsing Ordering tests and examinations Event monitoring Research databases Laboratory information systems Pharmacy information system Radiology information system


The Five Levels of Healthcare Information Systems

Level 1: Automated medical records Level 2: Document imaging Level 3: Electronic medical records Level 4: Electronic patient record systems

(also called Computer-based patient record systems)

Level 5: Electronic health record


Automated Medical Records

Most current systems fall into this category Patient information mostly in paper form (although

up to 50% is computer-generated) Are the basis for some computer supported

functions: Admission/Discharge/Transfer (ADT) systems Patient accounting and its linkage to clinical

information Department systems (radiology, laboratory, pharmacy,

etc.) Order entry / Results reporting


Document Imaging

Why? To address the space shortage most providers experience in record storage

Documents are created on paper Paper documents are indexed and scaned,

and stored in computer form Complete documents with their legal

attributes such as data and signature are scanned

The human operator is not allowed to change or delete the scanned documents


Electronic Medical Records

Is an upgraded version of previous record Data is entered directly into the computer in

structured form, suitable for various purposes

Successful use depends on: User friendliness User acceptance System design and functionality


Electronic Medical Record Essential Functions

Using enterprise-wide master-patient index Making all enterprise-wide patient information

available to all caregivers Creating a security system:

Access control; Electronic signatures Data integrity; Auditing; Availability

(Optional) Integration with expert programs: Electronic handbooks and references Clinical decision support programs Drug selection and adverse drug reaction identification

programs


Electronic Patient Record Systems

Has a wider scope of information than the electronic medical record

Combines several enterprise-based electronic medical records concerning one patient and assembles a record that collects all professional health information on that one patient

If acceptable to the patient, may be a longitudinal record


Prerequisites for Electronic Patient Record Development

Development of a national or international system of identifying all patient information available nationwide or worldwide.

Development of a system where either central databases or provider organizations collect, store, safeguard, and distribute patient information.

Developing an approach for common terminology, data sets, and structures.

Creating an international consensus on security systems that would allow electronic patient record systems to operate at a level of trust.


The Electronic Health Record

Contains additional data not being limited to information predominantly captured by caregivers regarding a patient.

Includes wellness information and other health-related information:

Behavioral Dietary Drug-related Exercise related Environmental Sexual information


Minimal Basic Data Set

Example: 13 basic patient data elements from an acute care hospital:

1. Hospital identification2. Patient number3. Sex4. Age at admission5. Marital status6. Address7. Date of admission


(cont...)

8. Length of stay

9. Discharge status

10. Primary diagnosis

11. Secondary diagnosis

12. Surgical and obstetrics treatments

13. Other important treatments


Information Society (Internet) Influence on Healthcare

Patients will search for health related information on the Internet

Patients will like to have better access to their healthcare records

Internet has allowed (will allow) telemedical services: Buying drugs Medical consultations (including second

opinion)


Personal Health Record Types

Off-line (on paper, smart card, on a computer)

Web-based Commercial/Organizational Functional/Purpose-based (e.g. emergency

healthcare abroad) Provider-based (appointments, medications,

allergies, ...) Partial health record (user-profiles at various

health-related websites)


“Smart” cards

Allow storing some of the patient information on a card of the size of a credit card.

Types of smart cards: Magnetic Laser (optical) With a chip or without



Example: problem list and therapy


Example: current problem – left earache


Example: objective problem description



Example: diagnosis


Example: therapy


Example: list of laboratory tests



Example: laboratory tests order list

Electronic Health Records Dimitar Hristovski, Ph.D. E-mail: [email protected]@mf.uni-lj.si Institute of Biomedical Informatics.

Documents

electronic medical recordsis

automated medical recordslevel

categorypatient information

laboratory results

record storagedocuments

paper form

investigations results

subsystemsthey exchange