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Electronic Health Records (ITCS404: IT for Healthcare Services)


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Theera-Ampornpunt N. Electronic health records. Presented at: Faculty of ICT, Mahidol University; 2012 Jan 18; Bangkok, Thailand.

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Electronic Health Records (ITCS404: IT for Healthcare Services)

  1. 1. Electronic Health Records ITCS 404: IT for Healthcare ServicesNawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital Jan 18, 2012
  2. 2. A Bit About Myself2003 M.D. (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)Health Informatician/Systems AnalystHealth Informatics DivisionFaculty of Medicine Ramathibodi HospitalMahidol interests:• Health IT applications in clinical settings (including EHRs)• Health IT “adoption”• Health informatics education
  3. 3. EHRs: Fundamentals
  4. 4. What Is A Medical Record?
  5. 5. What Is A Medical Record?• A record or documentation of a patient’s medical history, examination, and treatments.• Medical Record vs. Health Record – Essentially the same
  6. 6. Class Exercise 1• Why do we need a health record?
  7. 7. Class Exercise 1• Why do we need a health record?• In other words, why do we need a documentation of a patient’s medical care?
  8. 8. Potential Uses of Medical Records• Continuity of providing care – Note important information for later use – Especially important in chronic diseases (e.g. hypertension, diabetes) or in follow-up (e.g. after surgery)• Patient safety – Preventing something bad because of lack of information – Such as drug allergies, list of current medications, “problem list”
  9. 9. Potential Uses of Medical Records• Communications between providers – Referral to specialists or other physicians – Consulting among physicians – Communications between physicians and nurses, pharmacists, physical therapists, etc. – Transfer from a hospital to another• Medico-legal purposes – e.g. Court evidence against malpractice – What was done or provided to the patient? Why? By whom? When? – Was the care provided up to the professional standard?
  10. 10. Potential Uses of Medical Records• Claims and reimbursements – What services were provided to the patient – How (and how much) will the hospitals/doctors be paid? – Audit of medical records by “payers”• Patient’s uses – Health insurance claims – Self-education & self-care• Clinical research – Find ways to improve health care through new knowledge
  11. 11. Class Exercise 2• What do you think should be in the medical records?
  12. 12. Data Elements in Medical Records• Patient demographics• General information about each visit (visit = encounter) – Type (outpatient, inpatient, emergency) – Date/Time – Location (clinic or ward)“Clinical Notes”• Patient’s problems (“Patient history”) – Chief complaint – Present illness – Past history – Family and social history
  13. 13. Data Elements in Medical Records• Clinical findings by physicians (“Physical examination”) – Any important positive (usually abnormal) findings – Also important negative (usually normal) findings• “Investigations” – Laboratory tests (blood tests, urine, etc.) – Radiological examinations (X-rays, CT, MRI, ultrasound) – Other diagnostic procedures • Electrocardiography (EKG/ECG) -- heart’s function • Electroencephalography (EEG) -- brain wave scans • Etc.
  14. 14. Data Elements in Medical Records• “Problems” or “Diagnoses” – Summary of problems relevant to this visit• Treatments – Medications – Surgical procedures – Advice to patients – Admission (hospitalization)• Plans – Surgeries – More investigations to be done later – Follow-up appointments
  15. 15. Data Elements in Medical Records• Inpatient clinical notes – Admission notes – Orders (medications, procedures, investigations, nursing care, etc.) – Medication administration records – Vital signs and other measurements – Results of lab tests and radiological examinations – Progress notes – Discharge summary
  16. 16. “Electronic” Medical Records• Electronic Medical Records (EMRs) vs. Electronic Health Records (EHRs)• Debate about similarities & differences• Summary – Definitions subjective, depending on how people think – EMRs mostly refer to electronic documentation of medical care at one visit – EHRs mostly refer to electronic documentation that is longitudinal in nature (may be several visits) – EMRs commonly used in Thailand (but means the same as EHRs)
  17. 17. Various Forms of Health ITHospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records Picture Archiving and (EHRs) Communication System (PACS)
  18. 18. Still Many Other Forms of Health IT Health Information Exchange (HIE) m-Health BiosurveillancePersonal Health Records (PHRs) Telemedicine &Information Retrieval Telehealth Images from Apple Inc.,, Google,, and American Telecare, I
  19. 19. Longitudinal Records• Records documented over time (multiple encounters)• Ideally, “life-long” is a complete record of the patient’s health
  20. 20. The Confusing Acronyms Computer-Based Patient RecordsElectronic Medical (CPRs) Records (EMRs) Electronic Patient Electronic Health Records (EPRs) Records (EHRs) Personal Health Records (PHRs) Hospital Information Systems (HIS)
  21. 21. Benefits of EHRs and EHR Adoption
  22. 22. Innovation Adoption• Innovation: “an idea, practice, or object that is perceived as new by an individual or other unit of adoption” – EHRs and health IT are innovation• Adoption: “a decision to make full use of an innovation as the best course of action available”• Diffusion of innovations theory (Rogers, 2003)
  23. 23. Class Exercise 3• Why do we need to “adopt” an electronic version of medical records?
  24. 24. Common “Goals” for EHRs/Health IT Adoption “Computerize”“Go paperless” “Get an electronic copy “Digital Hospital” “Have EMRs” “Modernize” “Share data”
  25. 25. Is There A Role for Health IT? (IOM, 2000)
  26. 26. Landmark IOM Reports(IOM, 2000) (IOM, 2001)
  27. 27. Landmark IOM Reports: Summary• Humans are not perfect and are bound to make errors• Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality• Recommends reform that would change how health care works and how technology innovations can help improve quality/safety
  28. 28. Why We Need Health IT• Health care is very complex (and inefficient)• Health care is information-rich• Quality of care depends on timely availability & quality of information• Clinical knowledge body is too large• Short time during a visit• Practice guidelines are put “on-the-shelf”• “To err is human”
  29. 29. To Err Is Human• Perception errors Image Source:
  30. 30. To Err Is Human• Lack of Attention Image Source:
  31. 31. Class Exercise 3 The Economist Purchase Options• subscription $59• Print subscription $125• Print & web subscription $125
  32. 32. Class Exercise 3 The Economist Purchase Options• subscription $59• Print & web subscription $125
  33. 33. To Err Is Human• Cognitive Errors - Example: Decoy Pricing # of The Economist Purchase Options People• subscription $59 16• Print subscription $125 0• Print & web subscription $125 84 # of The Economist Purchase Options People• subscription $59 68• Print & web subscription $125 32 (Ariely, 2008)
  34. 34. What If This Happens in Healthcare?• It already happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005)• What if health IT can help?
  35. 35. Fundamental Theorem of Informatics (Friedman, 2009) (Friedman, 2009)
  36. 36. Underlying AssumptionAdoption Use of Betterof EHRs EHRs Outcomes
  37. 37. Underlying Assumption • Better clinical outcomes • Improved patient satisfaction Individual • More provider productivity/satisfactionAdoption & use • Improved operational efficiency • Better data for research, quality improvements • Reduced costs/increased revenues (e.g. betterOrganizationalAdoption & Use claims & reimbursements) • Better individual health/quality of life • Better population health Societal • Long-term cost savingsAdoption & Use
  38. 38. Benefits of Going Electronic (EHRs)• Ubiquitous availability (anytime, anywhere, everyone who is authorized)• Multiple concurrent uses• The end of “Where the heck is the patient’s record?!?”• Ability to control & enforce access security• Structured data entry possible• Data presentation that is easier to understand (e.g. graphs)• Efficiency in data entry? (but sometimes it slows users down!)• Process improvement (business process reengineering/redesign, quality improvement)• No doctor’s handwriting!!!!!
  39. 39. Electronic Health Record (EHR) Systems• Are they just electronic documentation? History Diag- Treat- ... & PE nosis ments• Or do they have some other values?
  40. 40. Literature Shows Benefits of Health IT• Literature suggests improvement in health care through – Guideline adherence – Better documentation – Practitioner decision making or process of care – Medication safety – Patient surveillance & monitoring – Patient education/reminder – Cost savings and better financial performance
  41. 41. Functions That Should be Part of EHR Systems• Patient Demographics• Physician Notes• Computerized Medication Order Entry• Computerized Laboratory Order Entry• Computerized Laboratory Results• Problem Lists• Medication Lists• Discharge Summaries• Diagnostic Test Results• Radiologic Reports
  42. 42. Adoption of Health IT: United States U.S. Ambulatory Setting 100 90 % of Physicians 80 70 60 50 48.3 50.7 34.8 42.0 40 30 23.9 29.2 24.9 20 18.2 17.3 17.3 20.8 16.9 21.8 9.3 10.5 11.8 10 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year of Study Any EHR EHR with Basic FeaturesBasic Features: Demographics, problem lists, clinical notes, test results, imaging results, order entry formedications Source: National Ambulatory Medical Care Survey (NAMCS) 2001-2010
  43. 43. Adoption of Health IT: United StatesU.S. Inpatient Setting 2008 2009 – Basic EHRs 7.2% 9.2% – Comprehensive EHRs 1.5% 2.7% – Computerized 17% 34% Order Entry for Medications Sources: Jha et al., 2009 & 2010
  44. 44. Definitions for Adoption Rates Functions Jha et al. Basic EHR Comprehensive EHRDemographics  Physicians’ notes  Nursing assessments  Problem lists  Medication lists  Discharge summaries  Advanced directives Test and imaging resultsLaboratory reports  Radiologic reports  Radiologic images Diagnostic-test results  Diagnostic-test images Consultant reports Computerized provider-order entryLaboratory tests Radiologic tests Medications  Consultation requests Nursing orders Decision supportClinical guidelines Clinical reminders Drug-allergy alerts Drug-drug-interaction alerts Drug-laboratory interaction alerts Drug-dose support 
  45. 45. EHR Adoption: Thailand (2011) Estimate (Partial or Complete Nationwide Adoption) Basic EHR, combined inpatient & 49.8% outpatient settings Comprehensive EHR, combined 5.3% order entry of medications, combined 90.2% order entry of all orders, combined 79.4%Basic EHR: a score > 1 in a 5-point scale for IT support for demographics, MD notes, nursing assessments(inpatient only), discharge summaries (inpatient only), test results, order entry for medicationsComprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, orderentry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts
  46. 46. EHR/HIS Adoption in Thailand (2004) Pongpirul et al., 2004
  47. 47. EHR/HIS Adoption in Thailand (2011) Abstract ePHIS None 2% THIADES 1% HoMC 2% HIMS 2% 1% Other 7% MedTrak/ TrakCare 2%H.I.M. Professional 2% MRecord 2% Mit-Net HOSxP 2% SSB 50% 4% Hospital OS 7% Self-developed or outsourced 16% Theera-Ampornpunt, 2011 [Dissertation]
  48. 48. EHRs: Implementation Issues
  49. 49. EHR Systems/HIS: Issues• Functionality & workflow considerations• Structure & format of data entry – Free text vs structured data forms – Usability – Use of standards & vocabularies (e.g. ICD-10, SNOMED CT) – Templates (e.g. standard narratives, order sets) – Level of customization per hospital, specialty, location, group, clinician – Reduced clinical value due to over-documentation (e.g. medico-legal, quality accreditation) – “Copy & Paste” garbage – Special documents (e.g. operative notes, anesthetic notes) – Integration with paper systems (e.g. scanned records, legal documents)
  50. 50. EHR Systems/HIS: Issues• Reliability & contingency/business continuity planning• Roll-out strategies & change management• Are they going to slow down patient care process?• System Interfaces
  51. 51. Class Exercise 4• What do you think is better for EHRs: structured or unstructured data?
  52. 52. Increasing EHR Adoption
  53. 53. Facilitators of EHR Adoption Jha et al. (2009)
  54. 54. Barriers to EHR Adoption Jha et al. (2009)
  55. 55. EHR Adoption Barriers (Why People Don’t Use EHRs?)• “Workarounds”
  56. 56. EHR Adoption Barriers (Why People Don’t Use EHRs?)• Technical & design issues – Poor software implementation • Does not meet requirements • Buggy – Poor usability and user experience • Complex/clunky UI • Easy to make error or miss something – Poor system performance • Slow • Unreliable
  57. 57. EHR Adoption Barriers (Why People Don’t Use EHRs?)• Management issues – Does not seem to improve their work process – Too much work entering data – Unclear values to users (or even negative outcomes!) • “Unintended consequences” of using health IT – Executives not fully supporting the project – “Power shift” among users – Communications and engagement (involvement) of users early and repeatedly during various phases of the project – Poor training and technical support – Users perceived they are treated poorly or their voices are not heard
  58. 58. The Importance of “Change Management” “One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated”Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”
  59. 59. Public Policy on EHR Adoption
  60. 60. Political Support Behind Health IT ? “...We will make wider use of electronic records and other health information technology, to help control costs and reduce dangerous medical errors.” President George W. Bush Sixth State of the Union Address January 31, 2006Source: Image Source:
  61. 61. President Obama Backs Health IT “...Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.” President Barack Obama Address to Joint Session of Congress February 24, 2009Source:
  62. 62. American Recovery & Reinvestment Act• Contains HITECH Act (Health Information Technology for Economic and Clinical Health Act)• ~ 20 billion dollars for Health IT investments• Incentives & penalties for providers
  63. 63. National Leadership (U.S.) Office of the National Coordinator for Health Information Technology (ONC -- formerly ONCHIT) David Blumenthal, MD, MPP National Coordinator for Health Information Technology (2009 - 2011) Farzad Mostashari, MD, ScM National Coordinator for Health Information Technology (2011 - Present) Photos courtesy of U.S. Department of Health & Human Services
  64. 64. What is in HITECH Act?Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
  65. 65. “Meaningful Use”
  66. 66. “Meaningful Use” “Meaningful Use”Pumpkin of a Pumpkin Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
  67. 67. “Meaningful Use” of Health ITStage 1- Electronic capture of Betterhealth information- Information sharing Stage 3 Health- Data reporting Stage 2 Use of EHRs to Use of improve EHRs to outcomes improve processes of care (Blumenthal D, 2010)
  68. 68. Meaningful Use Final Rule: Core Objectives (Selected)• Electronic capture of information – Demographics – Vital signs – Medication list – Allergies – Problem list – Smoking• Medication order entry• Drug-allergy & drug-drug interaction checks• Patient access to/copy of health information
  69. 69. Meaningful Use Final Rule: Menu Set (Selected)• Drug formulary checks• Lab results incorporation into EHRs• Generate lists of patients by specific conditions• Medication reconciliation• Electronic reporting to governmental agencies• Advanced directives for elderly patients• Patient reminders for certain services (for clinics)• Patient access to health information (for clinics)
  70. 70. Final Rule on Standards & Certification Criteria (Selected)• Content Exchange Standards – HL7 CDA Release 2 & CCD – NCPDP SCRIPT• Vocabularies – SNOMED CT – LOINC® – RxNorm ®• Security – NIST-certified encryption algorithms• Etc.
  71. 71. Personal Health Records (PHRs)
  72. 72. Personal Health Records (PHRs)• “An electronic application through which individuals can access, manage and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.” (Markle Foundation, 2003)• “A PHR includes health information managed by the individual... This can be contrasted with the clinician’s record of patient encounter–related information [a paperchart or EHR], which is managed by the clinician and/or health care institution.” (Tang et al., 2006)
  73. 73. Types of PHRs• Patient portal from a provider’s EHRs (“tethered” PHRs)• Online PHRs – Stand-alone – Can be integrated with EHRs from multiple providers (unidirectional/bidirectional data sharing)• Stand-alone PHRs – PC-based applications – USB Drive – CD-ROM or other data storage devices – Paper
  74. 74. Ideal PHRs• Integrated• Accessible• Secure• Comprehensive• Accurate & current• Patient able to manage sharing & update information• Engaging & educational• User-friendly, culturally & literacy appropriate The “Hub and Spoke” Model (Kaelber et al., 2008)
  75. 75. Use Cases of PHRs• Data entry/update by patients• Data retrieval by providers – With patient’s consent – “Break-the-glass” emergency access• Data update from EHRs• Privacy settings• Personalized patient education• Communications with providers
  76. 76. EHRs and the Bigger Picture
  77. 77. Health Information Exchange (HIE) GovernmentHospital A Hospital B Clinic C Lab Patient at Home
  78. 78. Google Flu Trends (Biosurveillance)Source:
  79. 79. Implications• This is why we need standards!!! – Information exchange from one EHR system to another needs standards – Seamless exchange of information would improve quality, continuity, and efficiency of care
  80. 80. Summary• EHRs (or EMRs) are both – Electronic documentation of patient care and – a broad term for an information system used to improve the process of patient care through better documentation and other care processes such as ordering medications, lab tests, or x-rays and viewing lab results and x- ray reports (among others)
  81. 81. Summary• It is important to focus both on the technical aspect of EHR implementation as well as the management aspect (such as change management)• Otherwise, a well-designed system may not be used, and patient care is not improved• Many countries are trying to improve the EHR “adoption rate”• EHRs are just one piece of the big puzzle for the whole healthcare system• PHRs are a separate, but related concept of EHRs
  82. 82. Questions?