The emergence of the electronic health record (EHR) is now on the national agenda and on the minds of providers who are looking for solutions that could increase the effectiveness of care and greatly reduce errors and cost. EHRs allow care providers to gather, store, and use health information more efficiently. Today, I will provide an overview of EHR; In our second presentation, Ms Vicky Wangia will discuss the EHR standardization efforts; and in our third presentation, Dr. Saeed Hamdan will provide a demonstration of an existing EHR.
The concept of electronic records is not new, but technology and the will to change business practice in the healthcare industry have been slow to develop. My goal would be to improve the understanding of electronic health records through an overview of many of the current issues related to this subject.
Here’s the outline of my presentation. We would learn more about EHR details-- definition, core functionalities, uses, beneficial outcomes and potential applications, challenges and progress towards EHR implementation.
We begin by looking back at the changes in health care… transportation of patients and hospital infrastructure from way back then
Transporting patients from one institution to another… at present.
Looking back at hospital beds from the past.
A glimpse of a present day hospital bed
Operating Room (OR) during the olden days
Present day OR that integrate sophisticated computer capabilities with medical technology.
And of course, the paper-based medical record we are familiar with. Virtually every person in the United States who has received health care since 1918 has a patient record (MacEachern, 1937)
Today, most people have multiple patient records – one for each health care provider they have visited. But despite significant technological advances over the past few years, manual paper-intensive health record systems have remained basically unchanged.
Two phrases are now moving to the forefront to describe the automation of the traditional, paper-based medical record. The 2 popular phrases today are Electronic Health Record and Electronic Health Record System. These are complementary terms to represent applications that are used together to provide a longitudinal view of all electronic health information that is integrated across all care settings and time. The reason to use these applications is specifically to improve the health of the individual or population who is receiving care. For purposes of our presentation, we will use the term interchangeably but it means the same thing.
By whatever name to which it is referred, the concept of an automated health record has been the focus of an intense debate in the health care industry during the last few years. Commonly known as the Electronic Health Record (EHR). It is also referred to as Electronic Healthcare Record (EHCR), Electronic Patient Record (EPR), Electronic Medical Record (EMR), Computer-based patient record (CPR), or Computerized Patient Record (CPR). Source: Computer Applications in Health Care and Biomedicine, 2003 by E Shortliffe
We define the EHR as follows: “An electronic health record is any information relating to the past, present or future physical/ mental health, or condition of an individual which resides in electronic system (s) used to capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing health care and health-related services.” SOURCE: Electronic Health Records: Changing the Vision by Murphy, Hanken, and Waters, 1999
This definition is a synthesis of a number of definitions that have been proposed over the past decade. In particular, it focuses on the most inclusive terminology: - Individual health status and condition to encompass preventive medicine, illness, and patient-contributed information - System functions to reflect the broadest capability for using and linking information - Multimedia to identify the scope of possible electronic tools
In May 2003, the Department of Health and Human Services (DHHS) asked the Institute of Medicine (IOM) to provide guidance on the key care delivery-related capabilities of an EHR-S. A committee of the IOM has identified a set of 8 core care delivery functions that EHR systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery. Detailed in a new report, this list of key capabilities will be used by Health Level Seven (HL7), one of the world’s leading developers of healthcare standards, to devise a common industry standard for EHR functionality that will guide the efforts of software developers. The letter report was published on July 31 st and is one part of a public and private collaborative effort to advance the adoption of EHR systems.
The 1991 IOM’s Computerized Patient Record defined the EHR-S as: “ The set of components that form the mechanism by which patient records are created, used, stored, and retrieved. A patient record system is usually located within a health care provider setting. It includes people, data, rules and procedures, processing and storage devices (e.g., paper and pen, hardware and software), and communication and support facilities.” Today this definition remains as the benchmark definition used for Electronic Health Record System definitional activities.
The 2003 IOM Letter Report (Key Capabilities of an Electronic Health Record System)
defined the EHR system as including: “ (1) longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual;
(2) immediate electronic access to person- and population- level information by authorized, and only authorized, users;
(3) Provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and
(4) Support of efficient processes for health care delivery.”
The critical building blocks of an EHR-S are the electronic health records (EHR) maintained by providers (e.g., hospitals, nursing homes, ambulatory settings) and by individuals (also called personal health records).
The IOM Committee identified core functionalities falling into eight categories. I’ll run through the list quickly because my co-presenter will discuss the functional model later on.
The first category is the health information and data. Immediate access to key information that would improve the ability of clinicians to make sound decisions in a timely manner and ability to capture key data, including problem list, procedures, medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results, can therefore ensure improved access to at least some types of information needed by care providers when they need it.
Next category is Results Management. Quick access of new and past laboratory test results by all clinicians involved in treating a patient. Details from radiology, pathology plus results notification and multimedia support, such as images and sounds
The 3 rd category is Order Management/ Order Entry. Computerized entry and storage of data on all medications, tests and other services. Capability to do electronic prescribing and send electronic orders to the lab, imaging facility and so on.
Decision support: Computerized decision support system have demonstrated their effectiveness in enhancing clinical performance and access to clinical knowledge bases. Electronic alerts and reminders to improve compliance with best practices, ensure regular screenings and other preventive practices, identify possible drug interactions, facilitate diagnoses and treatments, detect adverse events and disease outbreaks
Electronic communication and connectivity: Secure and readily accessible communication using electronic communication tools, such as e-mail and web messaging, among clinicians, patients and physicians, and labs and physicians.
Patient support: Tools offering patients access to their medical records, interactive education and the ability to do home monitoring and self-testing.
Administrative processes: Tools, including scheduling systems for hospital admissions, inpatient and outpatient procedures, and visits, that improve administrative efficiencies and patient service.
Reporting and population health management: Electronic data storage that uses uniform data standards to enable physician offices and health organizations to comply with federal, state and private reporting requirements in a timely manner.
In considering the core functionalities of EHR-S, it is important to recognize their many potential uses. EHR-S must support the delivery of personal health care services, including care delivery, care management, care support processes, and administrative processes (e.g. billing and reimbursement). As individuals engage more actively in management of their own health, they too become important users of electronic health information.
There are also important secondary uses, including education, regulation (e.g. credentialing), clinical and health services research, public health and homeland security, and policy support.
Electronic records offer numerous benefits, only a few of which can be considered here.
The most compelling reason to utilize an EHR is for patient safety. Abundant evidence demonstrates that medication errors, the primary cause of iatrogenic injury, can be dramatically reduced by the use of computerized provider order entry (CPOE). Paul Tang, MD, Chair of American Medical Informatics Association (AMIA) EHR 2004 meeting was recently interviewed by the Wall Street Journal on the topic of electronic medical records &quot;Dr. Tang says electronic records help doctors take better care of patients -- and patients take better care of themselves. The average doctor spends 38% of the time retrieving and entering information in the paper-based medical record, he notes, and even then 81% of the time can't find the information needed to make patient care decisions&quot;. - Wall Street Journal, March 11, 2004
Accessibility offers enhanced quality of care through availability of the records to the clinician and minimized labor costs for producing, or reproducing a paper copy. Anyone who works in a facility with more than one clinic can appreciate the value of consistent access to the medical record. While a paper chart can only be in one place at a time, electronic records are accessible to all authorized users of a facility’s network, no matter where they are.
Timely data entry is another advantage of electronic records. Most of the data are entered directly by the user (nurse, provider, pharmacist, etc.) at the point of service which leads to an improved documentation which is immediately available to other users.
Legibility, a natural by-product of entering data into an automated system offers time savings for other clinicians and reviewers of the record and certainly offers a decreased risk of misinterpretation of handwritten entries. Thus, enhancing data quality.
Enhanced security and controlled access through the use of automation protects patient records from unauthorized access and undocumented alteration.
In a prior review of existing CDC guidelines, it was determined that approximately one-third of the guidelines contain recommendations that could be encoded and presented as reminders or alerts to clinicians. SOURCE: Garrett N and Yasnoff W. Disseminating Public Health Practice Guidelines in Electronic Medical Record Systems. J Public Health Management Practice, 2002, 8(3), 1-10.
There are some noteworthy examples of health care settings in both the private and public sectors in which EHRs have been deployed. A handful of communities and systems have established secure platforms for the exchange of data among providers; suppliers; patients; and other authorized users such as the federal government agencies: VA, DoD, and IHS. In the 1990s the Veterans Health Administration (VHA) made a decision to move all of its facilities to an electronic record. The VHA now has a robust and capable electronic record known as the Computerized Patient Record System, or CPRS. CPRS is constantly being upgraded and improved by a large team of clinical and technological experts within the VHA. Our last speaker today will thoroughly discuss the said system. The Department of Defense (DoD) also has its own version of an electronic record, the Composite Health Care System (CHCS) II, which is in the process of being deployed at military medical treatment facilities around the world. The Indian Health Service (IHS) has long been a pioneer in using computer technology to capture clinical and public health data. The Resource and Patient Management System (RPMS) was developed in the 1970s, and many IHS facilities have access to decades of personal health information and epidemiological data for local populations. The IHS is presently bringing RPMS to the next level of clinical technology, the IHS Electronic Health Record.
Before I raise your expectations top high, I shall warn you of real and potential pitfalls in implementing EHR. Since there are so many benefits to automating patient records, one must ask the question, “why has the healthcare industry been unable to accomplish with automation what other industries have been successful at for years?”
By far the biggest challenge the health care industry faces in achieving the EHR is convincing clinicians, to interact with the computer system bec. they traditionally document their orders, progress notes, and the like on paper systems. The main reason primary care providers are not adopting EHRs is that most of the financial benefits of their investment go to payers and purchasers, said Dr. David Bates, chair of the alliance and chief of the general internal medicine division at Brigham and Women’s Hospital. “Up front” costs for network can be substantial. Expect to spend between $8,000 and $20,000 per physician. That may sound cheap, but if we extrapolate results to a health care system with 500 physicians, it comes to big dollars . To Top it off, 1/6 of this cost is annual software and hardware maintenance cost. At the same time, there have been developments on open source software- such as CPRS used by VA hospitals nationwide. Since physicians are the ones entering the data most of the time in EHR, a good training would assure more standardized data and reduce variable practice behavior. Many of the EHRs are home grown systems and speak in different languages and hence, data cannot be exchanged. To overcome, that organizations like HL7 and SNOMED are coming up with standards that can allow interface and exchange of data. From the public health perspective, regulatory issues such as privacy requirements. Hence, federal regulations like HIPAA have made guidelines in this issue. Expertise in health informatics: This is more to increase demand for such a job. But in actuality, this can be accomplished a public health official who is expert in data management in consultation with health care provider. Most organizations planning for EHR should expect to add a fulltime Clinical Applications Coordinator position for support of training for the product.
The EHR is a patient-centered data source. Data generated via the EHR at the point of care delivery will be primarily used for clinical decision support and management of health services at that level, i.e. administrative perspectives as I mentioned from the potential lists of benefits. Public health will be a secondary user of the EHR, except when it is a direct provider of care. Health Care providers are the main data providers to public health. In addition, public health utilizes other non-patient-centered data sources e.g. environmental pollution data, ecological data, research data and survey data, to serve individuals and communities. Both Health Care Providers and Public Health workers are using non-patient data sources, e.g. inventory of medicines and vaccines. Health Care Providers can also be secondary users of public health data generated via EHR, e.g. public health registry data can be used for healthcare services planning.
This presentation affirms a vision articulated a decade ago, explains foundations and processes needed to achieve it, and shares individual progress to help chart the course. The vision today is to strengthen our collective view of the EHR/EHR-S and offer experienced-based models to help achieve it. Thus, EHR will provide the foundation for integration of healthcare and public health services.
Here are my references…
I’m grateful for the following persons….
Electronic Health Record (EHR) AJ Rosario, MD, MPH Victoria Wangia, MS Saeed Hamdan, MD, PHD Public Health Informatics Fellows April 15, 2004
Electronic Health Record: Where are we now? AJ Rosario, MD, MPH April 15, 2004 Centers for Disease Control and Prevention National Immunization Program Immunization Registry Support Branch