What is an electronic medical record and how should it be evaluated?

What is an electronic medical recordand how should it be evaluated?

The Norwegian University of Technology and ScienceHallvard Lærum, MD

Ph.D. fellow

What is an electronic medical record?

• Norwegian definition of a medical record (KITH 1996)

– ”the health personnel or instiution’s continous records of information about each patient and elements of importance for the needed health care”

• Electronic Patient Record (NHS/ERDIP 2001)

– ”[The term] Electronic patient record describes the record of the periodic care provided mainly by one institution”

• Electronic Health Record (NHS/ERDIP 2001)

– ”..concept of a longitudinal record of a patient’s health and healthcare – from cradle to grave. It combines both the information about patient contacts with primary healthcare as well as subsets of information associated with the outcomes of periodic care held in the EPRs”

• Computer-based patient record (IOM 1997)

– “electronically stored information about an individual’s lifetime health status and health care… ”

– “...an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids.”

One institution,periodic health

care

Multiple institutions,

"cradle to grave"

EPJ – The Norwegian Term

Hospital information system

ElectronicMedicalRecords

• As a legacy from the paper-based patient record, "EPJ" has been considered containing clinical data and information only, not patient administration data

• The "EPJ" is related to periodic care in single institutions, no personal health record included.

• ”EMR” was the closest match for the ”Elektronisk pasientjournal” term in 1999

PatientAdministration

data

Integration of various sources of clinical data and information

RadiologyRadiologyX-ray, Ultrasound, CT, etc.X-ray, Ultrasound, CT, etc.

PathologyPathologyhistopathological histopathological

examinations, autopsiesexaminations, autopsies

Clinical Clinical biochemistrybiochemistry

Blood, Urine, Spinal fluid, etc.Blood, Urine, Spinal fluid, etc.

Paper-basedPaper-basedClinical photos, old medical Clinical photos, old medical

records, lettersrecords, letters

Clinical Clinical physiologyphysiology

ECG, EEG, Heart valve ECG, EEG, Heart valve ultrasoundultrasoundOtherOther

NMR, Scintigraphy, etc.NMR, Scintigraphy, etc.

MikrobiologyMikrobiologyMicrobe identification Microbe identification Antibiotic resistanceAntibiotic resistance

EMREMRMedical narratives, Medical narratives,

e.g. discharge e.g. discharge reportsreports

daily notes, etc.daily notes, etc.

Using the EMR to locate non-patient information

EMREMRClinical problemClinical problem

DiagnosisDiagnosisTreatmentTreatment

Sex, age, weight,Sex, age, weight,etc.etc.

Medical knowledgeMedical knowledgeTextbooks, clinical reminders, decision supportTextbooks, clinical reminders, decision support

By exploiting the information found here...

...we may quickly get the right information here:

Population statisticsPopulation statistics

Social influences/Social influences/Local ProceduresLocal ProceduresHow others get the job doneHow others get the job done

Logistic informationLogistic informationHow to get the job doneHow to get the job done

Information to

Information to

patientpatient

Gorman PN. Information Needs of Physicians. Journal of the American Society for Information Science 1995;46:729-36.

The difference between the EMR and the EMR system

• In simplistic terms:– An EMR is the electronic clinical data and

information

– An EMR system is the system handling them

That means:

making them available to multiple legitimate users, offering results management, order entry, decision support, electronic communication and connectivity, patient support, interdisciplinary work flow and planning

• Continuous textual medical records updated by and accessible to physicians– admission reports, progress notes, surgery reports,

discharge reports and other documents

• Access to clinical biochemical lab data and radiological results

• The paper-based medical record is still being updated, thank you very much

Reality (year 1999)

EMR systems in Norwegian hospitals

• DocuLive EPR– Integrates with third party PAS

• DIPS– PAS included

• Infomedix– PAS included

Norwegian EMR systems and the IOM’s Core functionality of an Electronic Health Record System

Core functionality DocuLive/PAS IMx DIPS

I. Health information and data

Key data (Diagnoses, Allergies, Demographics, Diagnostic test results), Narrative (Free text, Template-based, Structured and coded diagnoses, Structured and coded procedures, Treatment plan single discipline), Capture of identifiers (People and roles)

Key data (Diagnoses, Allergies, Demographics, Diagnostic test results, Radiology results, Disposition), Narrative (Free text, Template-based, Structured and coded diagnoses, Structured and coded procedures, Treatment plan, single discipline), Capture of identifiers (People and roles)

Key data (Diagnoses, Medication list, Allergies, Demographics, Diagnostic test results, Radiology results, Disposition), Narrative (Free text, Template-based, Structured and coded signs and symptoms, Structured and coded diagnoses, Structured and coded procedures, Treatment plan, single discipline), Capture of identifiers (People and roles)

II. Results management

Results reporting (Laboratory, Consults), Multimedia support (Images, Scanned documents, incl. patient consensus)

Results reporting (Laboratory, Radiology reports, Consults), Multiple views of data/presentation, Multimedia support (Images, Waveforms, Scanned documents, incl. patient consensus, Sounds)

Results reporting (Laboratory, Radiology reports, Consults), Multiple views of data/presentation, Multimedia support (Images, Waveforms, Scanned documents, incl. patient consensus, Sounds)

III. Order entry/management

Computerized provider order entry (Electronic prescribing, Laboratory, Consults)

Computerized provider order entry (Electronic prescribing, Laboratory, XR, Consults)

Computerized provider order entry (Electronic prescribing, Laboratory, XR, Consults)

IV. Decision support Access to knowledge sources (Drug alerts, Allergy checking), Clinician work list, Incorporation of patient and/or family preferences

Access to knowledge sources (Domain knowledge), Drug alerts (Allergy checking), Other rule-based alerts, Clinician work list, Incorporation of patient and/or family preferences

Access to knowledge sources (domain knowledge), Drug alerts (Allergy checking), Other rule-based alerts, Clinician work list, Incorporation of patient and/or family preferences

V. Electronic Communication & Connectivity

Provider-provider, Integrated medical record (Within setting, Cross-setting inpatient-outpatient, Cross-setting other)

Provider-provider, Medical devices, Trading partners (external), Integrated medical record (Within setting, Cross-setting inpatient-outpatient, Cross-setting other)

Provider-provider, Medical devices, Trading partners (external), Integrated medical record (Within setting, Cross-setting inpatient-outpatient, Cross-setting other)

VI. Patient support Patient support (Custom patient education, Tracking)

Patient support (Custom patient education, Tracking) Patient support (Custom patient education, Tracking)

VII. Administrative processes

Scheduling management (Appointments, Admissions), Eligibility determination(Insurance eligibility [EU forms])

Scheduling management (Appointments, Admissions, Surgery/procedure schedule), Eligibility determination (Insurance eligibility [EU forms])

Scheduling management (Appointments, Admissions, Surgery/procedure schedule), Eligibility determination (Insurance eligibility [EU forms])

VIII. Reporting and population health management

Patient safety and quality reporting(External accountability reporting, Ad hoc reporting), Public Health reporting (Reportable diseases), Disease registries

Patient safety and quality reporting (External accountability reporting, Ad hoc reporting), Public Health reporting (Reportable diseases), Disease registries

Patient safety and quality reporting (External accountability reporting, Ad hoc reporting), Public Health reporting (Reportable diseases), Disease registries

(preliminary version, illustrative purposes)

Key Capabilities of an Electronic Health Record System: Letter Report (2003)

0 - 25%IOM Functionality elements involved: 25-49% 50-74% 75-100%

Hospitals with EMR systemsHospitals with EMR systems

EMR systems in Norwegian somatic hospitals, September 2002

Hospitals with an EMR software licence 67 of 70 96 %

Number of beds in these hospitals 12332 of 13097 94 %

Estimated number of beds in departments in which EMR is implemented*

10500 of 13097 80 %

*In use by the physicians

Hospitals

DIPS32 %

DocuLive EPR29 %

InfoMedix29 %

None4 %

Others6 %

Hospital beds

DIPS19 %

DocuLive EPR43 %

InfoMedix32 %

None6 %

Others0 %

Desktop

Record explorer Prescriptions

DocuLive EPREPR

DIPS

Desktop

Record Explorer

Schedule

Criticalinformation

IMx

Desktop

Prescriptions

Gastro module

Properties of the three systems

DoucLive EPR Infomedix DIPS

Vendor Siemens TietoEnator Health Care DIPS

Developed since 1992 1993 1986 (PAS)

PAS Integrates with third party PAS

Included in the system Included in the system

User interface Identical to all users Separate modules for physicians, nurses and clerical staff

Identical to all users

Dominant structure of clinical data

Document-based, free text

Document-based, free text

Document-based, free text

Third party modules available

Few Many Many

User-defined forms Made by vendor Made on site Made on site

EPR

...but they are not complete

”The clinical gateway” at Rikshospitalet

Demographicinformation

Document-basedinformation

Lab reports

Radiology reports

Activity planning

How should the EMRsystem be evaluated?

What is evaluation?

No single accepted definition of evaluation exist

Evaluation is an empirical process – data is collected

Evaluations may be performed to:• judge merit and worth of an object• reach consensus and lead to deeper understanding of the object• make improvement of the object possible

A comparative element may be involved• Pre-post studies• Control and intervention studies• Comparing to a predefined goal

Roles in evaluation of EMR systems

• Evaluators• Development team• Users and patients• Stakeholders

– Funders of development team

– Funders of the evaluation project

– Users of similar systems in other settings

– Various public or political groups

– Others

Why evaluate EMR systems?

• To establish the feasibility of a new project

• To make organizational investment decisions

• To review progress of information system projects

• To assess the impact of an information system on the organization

• To assess value added by the information system function as a service providing department

Jayasuriya 97:

• To encourage the use of information systems in medicine

• To uncover the principles of medical informatics

• To develop and test more effective techniques and development methods

• To make sure it is safe, and to make sure it is better than the resource it replaces.

Friedman & Wyatt 96:

What to evaluateWhat to evaluate

Evaluation questions should cover a wide range of perspectives

When to evaluate – PhasesWhen to evaluate – Phases

Before implementation After implementation

Continous or at specific time points

Formative methods Summative methods

How to evaluate – choice of data collection methods and/or study design

• Methods and study design should be adapted to the chosen evaluation questions and the phase it is to be performed in.– Chose the wrong method, and you answer a different question than intended

• Quantitative and qualitative methods in combination– The "what" by:

• F.ex. questionnaires, system logs, work sampling, business case, etc.

– The "how and the "why" by:• F.ex. observations, focus groups, document studies, interviews, etc.

• Both formative and summative methods are needed– Results from formative investigations (f.ex. usability studies) may guide the

development process directly in an phase ideal for modification of the system.• Modifying the EMR system after implementation is much more expensive

– Summative investigations of operational systems may provide the most convincing descriptions of merit and worth.

However...

• The ideal evaluation involves multiple methods used to answer multiple evaluation questions in an accurate way in repeated investigations

• Will the ideal evaluation cost more than the stakeholders are willing to pay?

• Are the hospitals who are buying the EMR systems willing to pay the costs of even modest evaluations?

• No evaluations of EMR systems published in Norway as of 1999– Stakeholders need a wake-up call