Electronic%20Health%20Records

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Electronic Health Records
Dimitar Hristovski, Ph.D.E-mail
dimitar.hristovski_at_mf.uni-lj.si Institute of
Biomedical InformaticsMedical FacultyUniversity
of Ljubljana, Slovenia
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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, ...)

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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)

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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Minimal Basic Data Set

• Example 13 basic patient data elements from an
  acute care hospital
• 1. Hospital identification
• 2. Patient number
• 3. Sex
• 4. Age at admission
• 5. Marital status
• 6. Address
• 7. Date of admission

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(cont...)

• 8. Length of stay
• 9. Discharge status
• 10. Primary diagnosis
• 11. Secondary diagnosis
• 12. Surgical and obstetrics treatments
• 13. Other important treatments

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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)

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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)

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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

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Example problem list and therapy
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Example current problem left earache
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Example objective problem description
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Example diagnosis
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Example therapy
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Example list of laboratory tests
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Example laboratory tests order list