What is a medical record? A medical record is a confidential record that is kept for each patient by a healthcare professional or organisation. It contains the patient's personal details (such as name, address, date of birth), a summary of the patient's medical history, and documentation of each event, including symptoms, diagnosis, treatment and outcome. Relevant documents and correspondence are also included. Traditionally, each healthcare provider involved in a patient's care has kept an independent record, usually paper based. The main purpose of the medical record is to provide a summary of a person's contact with a healthcare provider and treatment provided to ensure appropriate healthcare. Information from medical records also provides the essential data for monitoring patient care, clinical audits and assessing patterns of care and service delivery. In the current environment the medical record also forms the first link in the information chain producing the depersonalised aggregated coded data for statistical purposes. As every health professional, coder, manager and patient knows, considerable effort is invested in writing, filing, sorting, searching, retrieving, issuing and recovering the medical record, in whole or in part. There is no doubt that the ready availability of well organised, legible, accurate and comprehensive clinical notes can play a very significant role in the clinical decision making process and assisting in the provision of quality healthcare.
The Good European Health Record Document ID: Requirements for Clinical Comprehensiveness Version: 1.3 Document Date: 8.1.93 Workpackage: 1-4 2 The Historical Background of Clinical Records Some of the oldest surviving examples of medical recording are papyri from ancient Egypt which contain details of surgery and prescriptions. There has always been a recognised need for those involved in healing or treatment to pass on details of successful procedures or potions either by written methods or through an oral tradition. It is also likely that individual practitioners attempted to describe what they saw and what they did but this was not a widespread practice. The earliest surviving records that describe individual patients in the United Kingdom belong to St Bartholomew’s Hospital and date from its foundation in 1123 AD 1. This was in the reign of Henry I who established the first public records office in England. By the mid nineteenth century individual physicians often kept some notes about their patients but these were usually kept in books according to physician, one book for each year, with the patients filed in alphabetical order. This chronological method of recording meant episodes of illness were considered in isolation. As people became more interested in the cause of illness, the importance of reviewing past events was realised. In 1907 St Mary’s Hospital started a system of unit notes where the patient and not the disease episode became the unit for record compilation. The unit record received extensive development and evaluation at the Presbyterian Hospital in New York where it was implemented in 1916.
In 1969 Weed published a book &quot;Medical records, medical education and patient care“ which introduced a method of structuring a record, the Problem Orientated Medical Record (POMR) 10. This was a format for clinical recording consisting of a problem list, a data base (that is, the history, physical examination and laboratory findings), and then, written out separately for each problem, a plan (diagnostic, therapeutic and educational) and a daily SOAP (subjective, objective, assessment and plan) progress note. The problem list was kept at the front of the medical record and served as an index for the reader so that each problem could be followed through until it was resolved. This system widely influenced note keeping by recognising the four distinct phases of the clinical decision making process: data collection; formulation of problems (not necessarily diagnoses); devising a management plan; reviewing the situation and revising the plan if necessary. However the POMR was not widely adopted exactly as Weed proposed because it proved to be too time consuming. The individual note entries were classified according to problem but were still entered sequentially in date order, making it a time consuming process to acquire a retrospective picture of events within one problem 11 CLICK The electronic health record is a life to death record, containing summary information about key health and healthcare related events. CLICK It will contain some key personal clinical characteristics which don’t change much – if at all - over time. For example blood group, allergies etc CLICK We see the EHR getting populated from a variety of different sources. CLICK So over the life of an individual we can imagine various health, healthcare or life events happening – in early years there will be important information about vaccinations etc. Where there may be a more substantial event takes place – for example a case of appendicitis – then as well as basic information about the event a small block of more detailed information may be attached to the EHR record. CLICK Events continue over time, building up the life to death record.
Electronic health record
Dr PS Deb 18/06/10 ELECTRONIC HEALTH RECORD
What is Medical record? <ul><li>A medical record is a confidential record that is kept for each patient by a healthcare professional or organisation. </li></ul><ul><li>It contains the patient's personal details (such as name, address, date of birth), </li></ul><ul><li>A summary of the patient's medical history, and documentation of each event, including symptoms, diagnosis, treatment and outcome. </li></ul><ul><li>Relevant documents and correspondence are also included. </li></ul>18/06/10
Ideal Medical Record 18/06/10 Electronic Health Record Womb to tomb Health Record Acute EPR Social Care Direct Walk-In Centres Primary/Community EPR MMR Vaccination Meningitis Vaccination Alzheimer's Divorce Redundancy Depression Panic attacks Suspected cancer Fractured Femur Appendicitis Additional data associated with healthcare event, e.g. referral details, test results etc. Road Traffic Accident
Migrating from Paper to Electronic Data Starting Point “ the way I do it now” Paper “ feels like typing or dictating” Electronic free text “ feels like filling in a form” Partially structured “ feels like picking everything from a huge menu” Rigidly structured
Spectrum of National Health System 18/06/10 Community Visits Out Patients Visits GP/practice nurse Attends A&E Visits a walk-in centre Calls NHS Direct Uses NHS Direct.online Uses the Home Health Care Guide Calls OOH service Attends as in-patient Is visited at home by GP, nurse, care worker, midwife etc Goes to the pharmacy Visits the dentist
18/06/10 EHR EHR Architecture INVESTIGATION REPORTS Blood test Biochemistry Imaging CLINICAL DATA Histories Examination DEMOGRAPHICS NHS Number Name, Address Date of Birth, Sex Registered GP/Contact details HA/EHR identifier Potential ‘Patient URL’ DIAGNOSIS AND TREATMENT DATA
Primary Objective of EHR 18/06/10 Patient Care Legal Management Research Education Audit Decision Support
EHR Architecture 18/06/10 History Examination Investigation Diagnosis Treatment
Levels of EPR <ul><li>Clinical administrative data </li></ul><ul><li>Integrate clinical diagnosis and treatment </li></ul><ul><li>Clinical activity support </li></ul><ul><li>Clinical knowledge and decision support </li></ul><ul><li>Specialty specific support </li></ul><ul><li>Advanced multimedia and telemedicine </li></ul>18/06/10
Product Overview <ul><ul><li>Lifetime record of medical data </li></ul></ul><ul><ul><li>Semi-structured format for usability and usefulness </li></ul></ul><ul><ul><li>Secured data </li></ul></ul><ul><ul><li>Backups and archiving </li></ul></ul><ul><ul><li>Ad-hoc search, reports and Statistical analysis </li></ul></ul><ul><ul><li>Encompasses any specialty or services </li></ul></ul>18/06/10
18/06/10 The Encounter detail shows the past visit date time and type of visit The screen holds information about the personal details of the patient like Patient NI No, Name, NSH No, Age Sex Place , Referral Doctors name and Diagnosis with treatment details It has search feature, using which the user can access the desired patient’s NI No, NHS No or First name
Appointments 18/06/10 The appointments section opens up the appointments for the current day, for all the doctors registered into the software. The user can book appointments for the patient, with any particular doctor from here. The weekly and monthly appointments can also be viewed.
18/06/10 A new patient can be registered. His/her personal, home, job, and other details can be entered from here. The Encounter detail are entered here
18/06/10 Temporal History Electronic Health Record History 2 History 5 History 3 History 4 History 1
18/06/10 The history of the patient’s present illness are recorded & reflected here. History of present illness can be recorded
18/06/10 There is a dropdown list of the Systems in the body. Selecting a particular System brings up another exhaustive list of Symptoms pertaining only to the System selected.
18/06/10 Symptom details can be recorded in a more formal and structured way for analysis and Decision support
18/06/10 History of the patient’s past illness and family history of illnesses can be recorded here, in order to trace any hereditary illness.
18/06/10 Temporal Examination Electronic Health Record Examination 2 Examination 5 Examination 3 Examination 4 Examination 1
18/06/10 Clinical Examination details can be recorded here. A long exhaustive list of examinations is provided. This would open up another screen, in which questions for the selected examination are asked and the answers are fed into the system. This information is used to generate a calculated report for the same.
18/06/10 Pre-formatted medical examination can be changed with negative findings Body weight and vitals can be entered in structured text for follow up, analysis and trend
Temporal record of Investigation 18/06/10 Electronic Health Record Investigation 2 Investigation 5 Investigation 3 Investigation 4 Investigation 1
18/06/10 <ul><li>Lab tests are divided into Imaging, Biochemistry, Histopathology and hematology. </li></ul><ul><li>Selecting appropriate test details can be entered. Images of X-Ray, CT scan, and MRI also can be stored. Video clips of angiogram also can be stored. </li></ul><ul><li>Scanned images of test report also can be stored. </li></ul><ul><li>Summary of test report with date is shown in the front screen, which can bee arranged chronologically. </li></ul>The user can select from a list of lab tests to record details.
18/06/10 The relevant screen shows up when the lab test is selected from the list. Details pertaining strictly to the selected lab test are to be filled in by the user.
Temporal record of Life time Diseases 18/06/10 Electronic Health Record Disease 2 Disease 5 Disease 3 Disease 4 Disease 1
18/06/10 The diagnosis of the patient with date and ICD code is recorded in this screen The Details of Diagnosis con be entered by double clicking on Diagnosis The Functional Status Score of the system can be calculated. Assessment of case is recorded for each visit.
18/06/10 The Functional Status of the patient and different scales are used for follow-up Discussion of the case is entered in this screen with reason for diagnosis and plan for treatment t.
18/06/10 List of drug used for patient are recorded chronologically. Details of prescription is recorded clicking the drug, where start date, end date, dosage, unit, route, frequency, and duration are recorded Effect and side effect of the drug is recorded chronologically
18/06/10 Surgical notes and anesthesia details are also recorded by clicking the Procedure
18/06/10 <ul><li>Patient demographic and encounter summary is displayed on the header with patient picture. </li></ul><ul><li>This is most useful screen for filling information at one go. Only relevant medical information is displayed, detail is hidden behind. </li></ul><ul><li>This screen is useful for follow-up as well as for new patient medical recording. </li></ul><ul><li>Emergency Data Medical summary information including diagnosis, symptom, examination, lab test and treatment are displayed </li></ul><ul><li>Clicking any screen you can go to the detail screen. </li></ul>
Statistics 18/06/10 Statistics of the Diagnosis, Symptom, and Lab Test are depicted as graphs which enables the doctor to analyze his/her practice.
Mobile EPR 18/06/10 <ul><li>PDA is for mobile medical Record reviewing outside the place of practice. </li></ul><ul><li>Summary of medical information is stored here. </li></ul><ul><li>The user can synchronize PDA with PC medical record. </li></ul>
Trends <ul><li>Disease course </li></ul><ul><li>Symptom course </li></ul><ul><li>Examination parameter course (BP, Temp, RR, Wt, Ht) </li></ul><ul><li>Investigation result followup </li></ul><ul><li>Treatment result </li></ul>18/06/10
Search <ul><li>Data entered in structured yet conventional format </li></ul><ul><li>Any data can be retrieved based on search criteria </li></ul><ul><li>Ad-hoc search also possible </li></ul><ul><li>Data mining can be dome </li></ul>18/06/10
Archiving <ul><li>Old records can be removed form current system for improving performance </li></ul><ul><li>Summary data is stored for future reference </li></ul><ul><li>Archived data can be retrieved any time </li></ul>18/06/10
Web enabled <ul><li>Client server mode </li></ul><ul><li>Can be web enabled by changing front end design without changing backend architecture </li></ul>18/06/10
Portability <ul><li>Developed in Microsoft platform </li></ul><ul><li>Can be exported to any platform with minimal change in the architecture </li></ul>18/06/10
Standard <ul><li>Followed international standards </li></ul><ul><li>HL7 </li></ul><ul><li>AMA </li></ul><ul><li>ICD </li></ul><ul><li>CPT </li></ul><ul><li>Reeds code can be added </li></ul>18/06/10
Platform <ul><li>Models </li></ul><ul><ul><li>UML </li></ul></ul><ul><li>Database </li></ul><ul><ul><li>Oracle/SQL/Sybase/Cashe </li></ul></ul><ul><li>Front end </li></ul><ul><ul><li>VB, JAVA, EJB, Access, XML </li></ul></ul>18/06/10
Security <ul><li>User base authentication </li></ul><ul><li>Data filtering for viewing depends on user level </li></ul><ul><li>Data encryption for recording and transmitting </li></ul><ul><li>Archiving any modified data </li></ul><ul><li>Recorder and time stamp for audit trail </li></ul>18/06/10
Support <ul><li>Custom levels of support </li></ul>18/06/10 [email_address] www.magnaihealthcare.com Dedicated Technical Support Lines <ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul>
Paper Partially structured Rigidly structured Achieving an Optimum Balance is Key Electronic free text Starting Point Usefulness of Data Impact on Usability Optimum Value