Curs EHR


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Course for the first year students on medical informatics

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  • The EHR contains information which is: 1. retrospective: an historical view of health status and interventions; 2. concurrent: a .now. view of health status and active interventions; and 3. prospective: a future view of planned activities and interventions
  • patients receive more health care the information is more complex a richer variety of examinations, investigations, treatments a greater use of multi-media technologies the information is more important in case of future litigation to justify the use of healthcare resources
  • Scale of the problem University Hospital of Heidelberg: 1700 beds creates about 400,000 new medical records per year containing 6.3 million pages requiring 1.7 km of storage (growing at the rate of 1500m per annum) Physicians create over 250,000 reports and 20,000 procedure reports each year service departments create around a million results {Reinhard, Ohr, et al} {Haux 1998}
  • Separation of EHR context and clinical knowledge: two-level approach Reference Model and Archetypes (approach also adopted by CEN TC/251)
  • FOLDER - The high-level organisation of Compositions within an EHR (or EHR Extract) • An optional hierarchy – Folders may contain other Composition Medico-legal unit of committal in the EHR – When committed, where, by whom Headed section Optional hierarchy • Informal containment for human navigation, filtering and readability • Corresponding to the clinical understanding of Headings ITEM Corresponds to a single clinical "statement" • Required to represent the structure of clinical observations, inferences and intended actions
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  • Key membership and leadership of EHR standards development: CEN 13606 EHR Communications CEN TS 14796 Data Types ISO TS 18308 (EHR Requirements) ISO DTR 20514 (EHR definition and scope) HL7 EHR Functional Specification HL7 Templates specification HL7 Clinical Document Architecture
  • Curs EHR

    1. 1. MEDICAL INFORMATION SYSTEMS Electronic Healthcare Record
    2. 2. 1. MEDICAL INFORMATION <ul><li>1.1. TYPES OF ACTIVITY </li></ul><ul><ul><li>a. MEDICAL ACTIVITIES (CONSULTATIONS, VISITS) </li></ul></ul><ul><ul><li>Different approaches: </li></ul></ul><ul><ul><ul><li>Time oriented </li></ul></ul></ul><ul><ul><ul><li>Patient oriented </li></ul></ul></ul><ul><ul><ul><li>Problems oriented ( S imptoms, O bjective, A ssesment, P lans - SOAP) </li></ul></ul></ul><ul><ul><li>Steps: </li></ul></ul><ul><ul><ul><li>DIAGNOSING </li></ul></ul></ul><ul><ul><ul><ul><li>DATA - MEDICAL OBSERVATION, INVESTIGATIONS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>KNOWLEDGE - EDUCATION, ETC </li></ul></ul></ul></ul><ul><ul><ul><li>THERAPY / FOLLOW-UP </li></ul></ul></ul><ul><ul><ul><li>NURSING </li></ul></ul></ul>
    3. 3. <ul><li>b. LOGISTIC SUPPORTT </li></ul><ul><ul><li>ADMINISTRATION </li></ul></ul><ul><ul><li>ACCOUNTING </li></ul></ul><ul><li>c. SOCIAL CONTEXT FRAME </li></ul><ul><ul><li>MEDICAL DATA CENTRALISATION </li></ul></ul><ul><li>d. MEDICAL EDUCATION (CME) </li></ul><ul><ul><li>STAFF </li></ul></ul><ul><ul><li>PATIENTS </li></ul></ul><ul><li>e. MEDICAL DOCUMENTATION </li></ul><ul><li>f. MEDICAL RESEARCH </li></ul>1. MEDICAL INFORMATION
    5. 5. “ Allied” Professionals in Healthcare
    6. 6. <ul><ul><ul><li>PRIMARY CARE </li></ul></ul></ul><ul><ul><ul><li>SECONDARY (SPECIALISED) CARE </li></ul></ul></ul><ul><ul><ul><li>HOSPITAL - HEALTHCARE UNITS </li></ul></ul></ul><ul><ul><ul><li>CENTRAL LEVELS : </li></ul></ul></ul><ul><ul><ul><ul><li>COUNTY HEALTH DEPARTMENTS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>NATIONAL LEVEL: HEALTH MINISTERY </li></ul></ul></ul></ul><ul><ul><ul><ul><li>INTERNATIONAL BODIES: WHO </li></ul></ul></ul></ul>1.3. Medical activities organisational levels
    7. 7. 1.4. DEFINITIONS <ul><ul><li>a. INFORMATIONAL SYSTEM = ensemble of structural units exchanging information between them </li></ul></ul><ul><ul><li>b. INFORMATION SYSTEM = that part of the informational system which comprises computer use </li></ul></ul>
    8. 8. Fluxul de informaţii în cadrul Sistemului Naţional Informaţional din Sănătate
    9. 9. Terminology <ul><li>CPR (computer-based patient record) </li></ul><ul><li>PCR (patient-carried record) </li></ul><ul><li>CMR (computerized medical record) </li></ul><ul><li>EMR (electronic medical record) </li></ul><ul><li>EPR (electronic patient record) </li></ul><ul><li>EHR (electronic healthcare record) </li></ul>
    10. 10. Integrated Care EHR <ul><li>ISO/DTR 20514 : </li></ul><ul><li>a repository of information regarding the health of a subject of care in computer processable form, stored and transmitted securely , and accessible by multiple authorised users . </li></ul><ul><li>It has a commonly agreed logical information model which is independent of EHR systems. </li></ul><ul><li>Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent and prospective. </li></ul>
    11. 11. Challenges facing today’s health record systems <ul><li>The need to record more data </li></ul><ul><li>The need to analyse more data </li></ul><ul><li>The need to share more data </li></ul>
    12. 12. <ul><li>University Hospital of Heidelberg: </li></ul><ul><li>400000 new medical records per year </li></ul><ul><li>6.3 million pages </li></ul><ul><li>1,7 km of storage </li></ul><ul><li>250000 reports generated </li></ul>
    13. 13. <ul><li>to observe trends and patterns within the historical record of one patient </li></ul><ul><li>to enable the use of clinical guidelines and decision support tools: evidence based health care </li></ul><ul><li>to perform clinical audit </li></ul><ul><li>to inform management and commissioning decisions </li></ul><ul><li>to support epidemiology, research and teaching </li></ul>The need to analyse more data
    14. 14. Share more healthcare data <ul><li>with other clinicians in the same team </li></ul><ul><ul><li>clinical firms, practice partnerships or nursing shifts </li></ul></ul><ul><li>with other healthcare professions </li></ul><ul><ul><li>doctors, nurses, physiotherapists, midwives, dieticians... </li></ul></ul><ul><li>with other disciplines </li></ul><ul><ul><li>a diabetic patient may also be under: ophthalmology, nephrology, orthopaedics, chiropody, wheelchair clinic.. </li></ul></ul><ul><li>with other institutions </li></ul><ul><li>with patients and their families </li></ul>
    15. 15. The mains advantages of EHR <ul><li>Reducing the storing space of the medical data </li></ul><ul><li>Facilitate researches activities </li></ul><ul><li>Standardized environment for medical data evidence, based on efficient Database Management Systems </li></ul><ul><li>Great level of data integration between different segments of information healthcare systems. </li></ul><ul><li>Increasing the quality of healthcare by the informational support provided to local and central administrative structures. </li></ul>
    16. 16. EHR adoption barriers <ul><li>Technical limitation for assuring the security, integrity and accesibility of stored data </li></ul><ul><li>Concerning about the records ownership </li></ul><ul><li>Big initial costs for implementation </li></ul><ul><li>The lack of operate abilities and trust in computerized systems from the medical stuff and the resistance to change </li></ul><ul><li>Low diversity of the quality EHR systems </li></ul><ul><li>Lack of universal recognized quality standards and adequate legal framework </li></ul>
    17. 17. Core Functionalities for an Electronic Health Record System <ul><li>Repository of health related data </li></ul><ul><li>Health information and data management </li></ul><ul><li>Results management </li></ul><ul><li>Order entry/management </li></ul><ul><li>Decision support management </li></ul><ul><li>Electronic communication and connectivity </li></ul><ul><li>Patient support </li></ul><ul><li>Reporting and Population Health Management </li></ul><ul><li>Administrative processes </li></ul>
    18. 18. EHR ARHITECTURE <ul><li>Object oriented, relational DBMS </li></ul><ul><li>Interoperability - transport of information over: </li></ul><ul><ul><li>Time </li></ul></ul><ul><ul><li>Space </li></ul></ul><ul><ul><li>Context, Communities, and Cultures </li></ul></ul>
    19. 20. <ul><li>Logical building blocks of the EHR: </li></ul><ul><li>FOLDER </li></ul><ul><li>COMPOSITION </li></ul><ul><ul><li>Tranzactional unit </li></ul></ul><ul><ul><li>Contribution – all compositions created/modified during a session </li></ul></ul><ul><li>HEADED SECTIONS - data segments for navigation purposes </li></ul><ul><li>ITEM – single clinical &quot;statement&quot; </li></ul>
    20. 22. The Record attributes <ul><li>Pacient identification </li></ul><ul><li>Medical stuff identification </li></ul><ul><li>Utilized standards identification </li></ul><ul><li>The Name of the parameter measured/observed </li></ul><ul><li>The value of the parameter </li></ul><ul><ul><li>[measure unit] </li></ul></ul><ul><ul><li>value [measured] </li></ul></ul><ul><ul><li>[normal value] </li></ul></ul><ul><li>data / time stamp </li></ul><ul><li>Observation circumstances </li></ul>
    21. 23. The “Core” EHR <ul><li>Key characteristics: </li></ul><ul><li>Concerns a single subject of care </li></ul><ul><li>Primary purpose is the support of present and future healthcare of the subject </li></ul><ul><li>Principally concerned with clinical information </li></ul><ul><li>Simplifies standardization of the EHR </li></ul><ul><ul><li>has a clear, limited scope enabling a manageable set of requirements to be specified and a manageable standardized model to be defined </li></ul></ul><ul><li>Fits more closely with the distributed systems or “system-of-systems” paradigm </li></ul><ul><ul><li>Allows more modular health information systems to be built </li></ul></ul>
    22. 24. The “Extended EHR” <ul><li>Includes not only clinical information but essentially the whole health information landscape . </li></ul><ul><li>It is a superset of the Core EHR </li></ul><ul><li>Extended EHR functions beyond the scope of the Core EHR include: </li></ul><ul><ul><li>Patient administration </li></ul></ul><ul><ul><li>Scheduling and resource allocation </li></ul></ul><ul><ul><li>Billing </li></ul></ul><ul><ul><li>Decision support </li></ul></ul><ul><ul><li>Access control and policy management </li></ul></ul><ul><ul><li>Demographics </li></ul></ul><ul><ul><li>Order management </li></ul></ul><ul><ul><li>Population health recording, querying, and analysis </li></ul></ul><ul><ul><li>Health professional recording, querying, and analysis </li></ul></ul><ul><ul><li>Business operations recording, querying, and analysis </li></ul></ul>
    23. 25. User view: functional grouping of data <ul><li>Demographic and general data </li></ul><ul><ul><li>Name, gender, date of birth, picture .. </li></ul></ul><ul><ul><li>Residence and contact data </li></ul></ul><ul><ul><li>Current job, education </li></ul></ul><ul><ul><li>Insurance condition </li></ul></ul><ul><li>Alerts – allergies, special conditions (pregnancies) </li></ul><ul><li>Current medication </li></ul><ul><li>Vaccines </li></ul><ul><li>Consultations </li></ul><ul><ul><li>SOAP </li></ul></ul><ul><ul><li>Schedule </li></ul></ul><ul><li>Surgical interventions </li></ul><ul><li>Reports </li></ul><ul><li>Healthcare costs </li></ul>
    24. 27. Standard definition <ul><ul><li>ISO/IEC defines a standard as a document, established by consensus and approved by a recognized body, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context </li></ul></ul>
    25. 28. STANDARDS <ul><ul><li>S tandard Attributes (SMART): </li></ul></ul><ul><ul><li>S = specific </li></ul></ul><ul><ul><li>M = measurable </li></ul></ul><ul><ul><li>A = acceptable </li></ul></ul><ul><ul><li>R = realistic </li></ul></ul><ul><ul><li>T = time related </li></ul></ul><ul><ul><li>Standard Organizations </li></ul></ul><ul><ul><li>ASRO – Romanian Association for Standardisation (TC 319) </li></ul></ul><ul><ul><li>CEN - Comité Européen de Normalisation </li></ul></ul><ul><ul><li>CEN/TC251 – Medical informatics Technical Committee </li></ul></ul><ul><ul><li>ANSI - American National Standards Institute </li></ul></ul><ul><ul><li>ISO - International Organization for Standardization . </li></ul></ul>
    26. 29. Standard Organizations ASRO
    27. 30. <ul><li>ISO DTR 20514 - EHR definition and scope </li></ul><ul><li>ISO TS 18308 - EHR Requirements </li></ul><ul><li>CEN TS 14796 - Data Types </li></ul><ul><li>CEN/TC 251 EN 13606 - EHR Communications </li></ul><ul><li>HL7 - EHR Functional Specification </li></ul><ul><li>HL7 - Templates specification </li></ul><ul><li>HL7 - Clinical Document Architecture </li></ul><ul><li>DICOM – Digital Imaging and Communications in Medicine </li></ul><ul><li>EDIFACT , XML – Messaging standards </li></ul>
    28. 31. <ul><li>DATA PROTECTION </li></ul><ul><ul><li>a) CONFIDENTIALITY - limited, leveled accessibility </li></ul></ul><ul><ul><li>b) PROTECTION - against accidental deterioration / access / loss </li></ul></ul><ul><ul><li>c) SECURITY - intended d/a </li></ul></ul>
    29. 32. EHR exemples <ul><li>OfficeMed ver 1.60 </li></ul><ul><ul><li>Integrated system for family physicians (GP) </li></ul></ul><ul><ul><ul><li>Conform to CoCa 2003 </li></ul></ul></ul><ul><ul><ul><li>FoxPro / MSDOS </li></ul></ul></ul><ul><ul><ul><li>“ Programul este agreat de Direcţia de  sănătate publică Bistriţa Năsăud” </li></ul></ul></ul><ul><li>Medins </li></ul><ul><ul><li>GP </li></ul></ul><ul><ul><li>MEDINET </li></ul></ul>
    30. 33. INFO WORLD <ul><li>“ ... soluţiile oferite au fost dezvoltate conform celor mai noi standarde în domeniu, precum HL7 şi DICOM ” </li></ul><ul><li>Hospital Manager Suite </li></ul><ul><li>CabiMed – GP </li></ul><ul><li>Cabinet Manager – ambulatory healthcare system . </li></ul><ul><li>ePractice – EPR system </li></ul>