Electronic Health Records (EHR)

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Electronic Health Records (EHR)
Electronic health record (EHR) with image and
document links.

• Basic Definitions
• Electronic Health Records (EHR)
• Medical Records
• Personal Health Records (PHR)
• Continuity of Care Record (CCR)
• Standards
• HL7
• Adoption Issues
• Interoperability
• Adding Older Records
• Privacy
• Social and Organizational Issues
• Legal Status
• Customization and Cost

Electronic patient chart of a health information
system
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Electronic Health Records (EHR)

• An electronic health record (EHR) is a
  distributed personal health record in digital
  format.
• The EHR provides secure, real-time,
  patient-centric information to aid clinical
  decision-making by providing access to a
  patient's health information at the point of
  care.
• An EHR is typically accessed on a computer or
  over a network.
• It may be made up of health information from
  many locations and/or sources, including
  electronic medical records (EMRs).
• An EHR almost always includes information
  relating to the current and historical health,
  medical conditions and medical tests of its
  subject.
• In addition, EHRs may contain data about medical
  referrals, medical treatments, medications and
  their application, demographic information and
  other non-clinical administrative information.
• The ideal EHR system, as of 2006, has not been
  implemented by any software or other vendor.

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Electronic Health Records (EHR)

• An electronic medical record (EMR) is a patient
  medical record that contains both documents in an
  electronic form and functions including
• Patient demographics.
• Medical history, examination and progress reports
  of health and illnesses.
• Medicine and allergy lists, and immunization
  status.
• Scheduling, retrieval and archiving of laboratory
  and other tests.
• Graphic image display of X-rays, MRIs and other
  medical imaging studies.
• Medication ordering, including patient safety
  functions to minimize interactions or
  side-effects.
• Evidence-based recommendations for specific
  medical conditions, termed clinical practice
  guidelines.
• Appointment scheduling.
• Claims and payment processing.
• Patient reminders of follow up appointments, test
  completion, preventive health practices.

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Electronic Health Records (EHR)

• The electronic health record (EHR) is all patient
  medical information from multiple sources,
  including all components of the EMR, accessible
  from any location by any provider caring for the
  patient.
• In this ideal, the information is continuously
  updated and current. Terms commonly used in
  describing the EHR include interactive,
  interoperability, secure, real-time and
  point-of-care.
• The EHR allows collection of data for uses other
  than for direct patient care, such as quality
  improvement, outcome reporting, resource
  management, and public health communicable
  disease surveillance.

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Medical Records

• A medical record is both a general term for an
  individual's health documents and reports, or
  more specifically, and often a paper chart or
  folder containing this information.
• Because of the need for access at different care
  locations, a patient may have multiple medical
  record folders at each location at which care or
  testing was received.
• Each record may contain partial information, and
  the process of unifying and updating paper
  records is daunting.
• Handwritten reports or notes, manual order
  entry, non-standard abbreviations and poor
  legibility lead to medical errors, according to
  the 1999 Institute of Medicine (IOM) report.
  (Institute of Medicine (1999). To Err Is Human
  Building a Safer Health System (1999). The
  National Academies Press. Retrieved on
  2006-06-20. )
• The follow-up IOM report advised rapid adoption
  of electronic patient records, electronic
  medication ordering, with computer- and
  internet-based information systems to support
  clinical decisions.

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Medical Records (IOM report) http//books.nap.edu/
catalog.php?record_id9728

• Examples of Mistakes
• The knowledgeable health reporter for the Boston
  Globe, Betsy Lehman, died from an overdose during
  chemotherapy. Willie King had the wrong leg
  amputated. Ben Kolb was eight years old when he
  died during ''minor" surgery due to a drug
  mix-up.
• These horrific cases that make the headlines are
  just the tip of the iceberg.
• Two large studies, one conducted in Colorado and
  Utah and the other in New York, found that
  adverse events occurred in 2.9 and 3.7 percent of
  hospitalizations, respectively. In Colorado and
  Utah hospitals, 6.6 percent of adverse events led
  to death, as compared with 13.6 percent in New
  York hospitals. In both of these studies, over
  half of these adverse events resulted from
  medical errors and could have been prevented.
• When extrapolated to the over 33.6 million
  admissions to U.S. hospitals in 1997, the results
  of the study in Colorado and Utah imply that at
  least 44,000 Americans die each year as a result
  of medical errors.
• . More people die in a given year as a result of
  medical errors than from motor vehicle accidents
  (43,458), breast cancer (42,297), or AIDS
  (16,516).

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Personal Health Records (PHR)

• A personal health record is medical information
  in possession of an individual patient or
  patient's non-professional caregiver.
• The format may be either paper documents,
  electronic media, or a combination. The sources
  of the information include patient-generated
  lists, copies of reports from physicians,
  hospitals and labs, legal documents such as
  living wills and health care proxy forms, and
  insurance statements.
• Organizations such as the American Health
  Information Management Association (AHIMA)
  encourage individuals to keep their own complete
  PHR, including any information that a doctor may
  not have, such as exercise routines, dietary
  habits, herbal or nonprescription medications, or
  results of home testing, such as home blood
  pressure or sugar readings.
• Consumers can purchase PHRs from companies on the
  internet.
• According to AHIMA, 42 percent of US adults
  surveyed said they keep some form of a personal
  health record. PHR is also available free of cost
  from several internet sites.

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Personal Health Records (PHR) (cont)
http//www.myphr.com/

• Sample list of information gathered for patient
  care
• History and Physicaldescriptions of any major
  illness and surgeries you have had, any
  significant family history of disease, your
  health habits, current medications, as well as
  what your provider found when examining you.
• Progress Notesnotes made by your healthcare
  provider that reflect your response to treatment,
  their observations, and plans for continued
  treatment
• Consultationopinion about your condition made by
  a physician other than your primary care
  physician
• Physician's Ordersdirections to other members of
  the healthcare team regarding your medications,
  tests, diets, and treatments
• Imaging and X-ray Reportsdescription of the
  findings of x-rays, mammograms, ultrasounds, and
  scans.
• Lab Reportsdescription of the results of tests
  conducted on body fluids. Common examples include
  throat culture, urinalysis, cholesterol level,
  and complete blood count
• Operative Report--documentation that describes
  surgery performed Pathology Reportdescription of
  tissue removed during an operation and the
  diagnosis based on examination of that tissue
• Discharge Summarysummary of a hospital stay,
  including the reason for admission, significant
  findings from tests, procedures performed,
  therapies provided, response to treatment,
  condition at discharge, and instructions for
  medications, activity, diet, and follow-up care

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Continuity of Care Record (CCR)

• The Continuity of Care Record (CCR is a core data
  set of the most relevant and timely facts about a
  patient's healthcare.
• It is to be prepared by a practitioner at the
  conclusion of a healthcare encounter in order to
  enable the next practitioner to readily access
  such information.
• It includes a summary of the patient's health
  status (e.g., problems, medications, allergies)
  and basic information about insurance, advance
  directives, care documentation, and care plan
  recommendations. It also includes identifying
  information and the purpose of the CCR.
• The CCR may be prepared, displayed, and
  transmitted on paper or electronically, provided
  the information required by this standard
  specification is included.
• However, for maximum utility, the CCR should be
  prepared in a structured electronic format that
  is interchangeable among electronic health record
  (EHR) systems
• .
• To ensure interchangeability of electronic CCRs,
  this standard specifies that XML coding is
  required when the CCR is created in a structured
  electronic format. XML coding provides
  flexibility that will allow users to prepare,
  transmit, and view the CCR in multiple ways,
  e.g., in a browser, as an element in an HL7
  message or CDA compliant document , in a secure
  email, as a PDF file, as an HTML file, or as a
  word processing document. It will further permit
  users to display the fields of the CCR in
  multiple formats. . Equally important, it will
  allow the interchange of the CCR data between
  otherwise incompatible EHR systems.

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Standards

• Although there are few standards for modern day
  electronic records systems as a whole, there are
  many standards relating to specific aspects of
  EHRs and EMRs.
• These include
• ASTM Continuity of Care Record - a patient health
  summary standard based upon XML, the CCR can be
  created, read and interpreted by various EHR or
  Electronic Medical Record (EMR) systems, allowing
  easy interoperability between otherwise disparate
  enities.10
• ANSI X12 (EDI) - A set of transaction protocols
  used for transmitting virtually any aspect of
  patient data. Has become popular in the United
  States for transmitting billing information,
  because several of the transactions became
  required by the Health Insurance Portability and
  Accountability Act (HIPAA) for transmitting data
  to Medicare.
• CEN - CONTSYS (EN 13940), a system of concepts to
  support continuity of care.
• CEN - EHRcom (EN 13606), the European standard
  for the communication of information from EHR
  systems.
• CEN - HISA (EN 12967), a services standard for
  inter-system communication in a clinical
  information environment.
• DICOM - a heavily used standard for representing
  and communicating radiology images and reporting
• HL7 - HL7 messages are used for interchange
  between hospital and physician record systems and
  between EMR systems and practice management
  systems HL7 Clinical Document

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HL7 Standards

• Health Level Seven, Inc. (HL7), is an
  all-volunteer, not-for-profit organization
  involved in development of international
  healthcare standards.
• Headquartered in Ann Arbor, Michigan, U.S.,
  Health Level Seven is a Standards Developing
  Organization (SDO) that is accredited by the
  American National Standards Institute (ANSI).
• Founded in 1987 to produce a standard for
  hospital information systems, HL7 is currently
  the selected standard for the interfacing of
  clinical data in most institutions .
• HL7 and its members provide a comprehensive
  framework (and related standards) for the
  exchange, integration, sharing and retrieval of
  electronic health information.
• The standards, which support clinical practice
  and the management, delivery, and evaluation of
  health services, are the most commonly used in
  the world

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HL7 Standards (cont)

• The HL7 organization has grown from a 14 members
  in 1987 to over 2200 members worldwide, including
  500 corporate members today and international
  affiliates in thirty three countries.
• Collectively, they develop standards designed to
  increase the effectiveness, efficiency and
  quality of healthcare delivery
• In fact, HL7s primary mission is to create
  flexible, low-cost standards, guidelines, and
  methodologies to enable the exchange and
  interoperability of electronic health records.
• Such guidelines or data standards are an
  agreed-upon set of rules that allow information
  to be shared and processed in a uniform and
  consistent manner.
• Without data standards, healthcare organizations
  could not readily share clinical information.
• Theoretically, this ability to exchange
  information should help to minimize the tendency
  for medical care to be so geographically isolated
  and highly variable.

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HL7 Standards (cont)

• Today HL7 standards development initiatives
  include the following
• standardization of knowledge representation
  (Arden syntax)
• specification of components for context
  management (known as CCOW)
• support for healthcare data interchange using
  object request brokers
• In distributed computing, an object request
  broker (ORB) is a piece of middleware software
  that allows programmers to make program calls
  from one computer to another, via a network.
• extend interoperability for the development of
  Health Information Exchange
• standardization of XML document structures
• The Extensible Markup Language (XML) is a
  general-purpose markup language.1 Its primary
  purpose is to facilitate the sharing of data
  across different information systems. XML is a
  generic framework for storing any amount of text
  or any data whose structure can be represented as
  a tree structure. This means that the text must
  be enclosed between a root opening tag and a
  corresponding closing tag. The following is a
  well-formed XML document
• ltbookgtGallia omnia divisa est in partes tres
  .... lt/bookgt
• specification of robust vocabulary definitions
  for use in clinical messages and documents (cf.
  SNOMED CT, LOINC)
• SNOMED (Systematized Nomenclature of Medicine),
  is a systematically organised computer
  processable collection of medical terminology
• functional specifications for an electronic
  health record
• work in the area of security, privacy,
  confidentiality, and accountability.

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Standards (cont)

• Architecture (CDA) documents are used to
  communicate documents such as physician notes and
  other material.
• The HL7 Clinical Document Architecture (CDA) is
  an XML-based markup standard intended to specify
  the encoding, structure and semantics clinical
  documents for exchange.
• IHE - Integrating the Healthcare Enterprise
  while not a standard itself, IHE is a consortial
  effort to integrate existing standards into a
  comprehensive best-practice solution
• ISO - ISO TC 215 has defined the EHR, and also
  produced a technical specification ISO 18308
  describing the requirements for EHR
  Architectures.
• openEHR - next generation public specifications
  and implementations for EHR systems and
  communication, based on a complete separation of
  software and clinical models.

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Standards Organizations

• United States 
• Not-for-profit organizations such as
• -the American Society for Testing and Materials
  (ASTM)
• -Health Level 7 (HL7) and Healthcare Information
  and Management - -Systems Society (HIMSS) are
  involved in the standardization process for
  EHR in the United States.
• -The Certification Commission for Healthcare
  Information Technology (CCHIT) is a private
  not-for-profit organization founded to develop
  and evaluate the certification for EHRs and
  interoperable health informatics networks.
• International 
• In Europe, CEN's TC/251 is responsible for EHR
  standards
• -while at a global level, ISO TC215 produces
  standards for EHR requirements as well as
  accepting certain standards from other standards
  organizations.
• -CEN/TC 251 works on compatibility and
  interoperability between independent systems and
  to enable modularity in Electronic Health Record
  systems.
• -The openEHR Foundation develops and publishes
  EHR specifications and open source EHR
  implementations, which are currently being used
  in Australia and parts of Europe.
• In Canada
• Canada Health Infoway (a private not-for-profit
  organization started with federal government
  seed money) is mandated to accelerate the
  development and adoption of electronic health
  information systems.

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Adoption

• EHR issues
• As of 2006, adoption of EHRs and other health
  information technology (HIT), such as computer
  physician order entry (CPOE), has been minimal in
  the United States.
• Less than 10 of American hospitals have
  implemented HIT
• while a mere 16 of primary care physicians use
  EHRs.
• The vast majority of healthcare transactions in
  the United States still take place on paper, a
  system that has remain unchanged since the 1950s.
  
• The healthcare industry spends only 2 of gross
  revenues on HIT, which is meager compared to
  other information intensive industries such as
  finance, which spend upwards of 10.
• The following issues are behind the slow rate of
  adoption
• 1)Interoperability
• In healthcare, interoperability is the ability of
  different information technology systems and
  software applications to communicate, to exchange
  data accurately, effectively, and consistently,
  and to use the information that has been
  exchanged.

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Adoption (cont) Interoperability
The Center for Information Technology Leadership
described four different categories (levels) of
data structuring at which health care data
exchange can take place.
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Adoption (cont) Adding of Older Records

• To attain the wide accessibility, efficiency,
  patient safety and cost savings promised by EHR,
  older paper medical records ideally should be
  incorporated into the patient's record.
• The digital scanning process involved in
  conversion of these physical records to EMR is an
  expensive, time-consuming process, which must be
  done to exacting standards to ensure exact
  capture of the content.
• Because many of these records involve extensive
  handwritten content, some of which may have been
  generated by different healthcare professionals
  over the life span of the patient, some of the
  content is illegible following conversion.
• The material may exist in any number of formats,
  sizes, media types and qualities, which further
  complicates accurate conversion.
• In addition, the destruction of original
  healthcare records must be done in a way that
  ensures that they are completely and
  confidentially destroyed.
• Results of scanned records are not always usable
  medical surveys found that 22-25 of physicians
  much less satisfied with the use of scanned
  document images than that of regular electronic
  data.

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Adoption (cont) Privacy

• A major concern is adequate confidentiality of
  the individual records being managed
  electronically.
• According to the Los Angeles Times, roughly 150
  people (from doctors and nurses to technicians
  and billing clerks) have access to at least part
  of a patient's records during a hospitalization,
  and 600,000 payers, providers and other entities
  that handle providers' billing data have some
  access also.
• Multiple access points over an open network like
  the internet increases possible patient data
  interception. In the United States, this class of
  information is referred to as Personal Healthcare
  Information (PHI) and access is regulated by the
  Department of Health and Human Services (DHHS)
  under the Health Insurance Portability and
  Accountability Act (HIPAA) and local laws.
• However, according to the Wall Street Journal,
  the DHHS takes no action on complaints under
  HIPAA, and medical records are disclosed under
  court orders in legal actions such as claims
  arising from automobile accidents.
• HIPAA has special restrictions on psychotherapy
  records, but psychotherapy records can also be
  disclosed without the client's knowledge or
  permission, according to the Journal.

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Adoption (cont) Social and Organizational
Barriers

• According to the Agency for Healthcare Research
  and Qualitys National Resource Center for Health
  Information Technology, EHR implementations
  follow the 80/20 rule
• that is, 80 of the work of implementation must
  be spent on issues of change management,
• while only 20 is spent on technical issues
  related to the technology itself.
• Such organizational and social issues include
• restructuring workflows
• dealing with physicians' resistance to change
• creating a collaborative environment that fosters
  communication between physicians and information
  technology project managers.
• Exemplifying this need are several highly
  publicized HIT implementation fiascos, including
  one at Cedars Sinai Medical Center in Los
  Angeles, in which physicians revolted and forced
  the administration to scrap a 34 million system.

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Legal Status of EHRs

• Medical records, such as physician orders, exam
  and test reports are legal documents, which must
  be kept in unaltered form and authenticated by
  the creator.
• The individually defined Legal Health Record
  (LHR) for each healthcare provider forms the
  basis for response to subpoenas and other legal
  processes that require evidentiary use of the
  patient's 'medical record'.
• Digital signatures Most national and
  international standards accept electronic
  signatures.
• According to the American Bar Association. "A
  signature authenticates a writing by identifying
  the signer with the signed document. When the
  signer makes a mark in a distinctive manner, the
  writing becomes attributable to the signer.
• With proper security software, electronic
  authentication is more difficult to falsify than
  the handwritten doctor's signature.
• However, as the recent rise in identity theft
  demonstrates, no security method can totally
  prevent fraud, so auditing information security
  will continue to be prudent when using EMR.

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Customization and Cost

• Customization
• Pricing for Electronic Health Record (EHR)
  systems is highly dependent on each practice's
  unique needs.
• Because every medical practice has distinct
  requirements, systems usually need to be custom
  tailored.
• This is due to the majority of EHR systems being
  based on templates that are initially general in
  scope.
• In many cases, these templates can then be
  customized in co-operation with the
  vendor/developer to better fit a medical
  specialty, environment or other specified needs.
• Cost
• In a 2006 survey by the Medical Records
  Institute, lack of adequate funding was cited by
  the 729 health care providers responding as the
  most significant barrier to adopting electronic
  records.
• At the American Health Information Management
  Association conference in October 2006, panelists
  estimated that purchasing and installing EHR will
  cost over 32,000 per physician, and maintenance
  about 1,200 per month.
• Hidden costs may also include office workflow
  disruption during training or data re-entry
  required by a new system, with fewer patient
  visits and less income.

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US medical groups' adoption of EHR (2005)
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