Digital Health Records

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Contents

Introduction

Electronic Health Records and Electronic Medical Records allow for digital recording of health information for use by patients or medical professionals. Electronic health records present an opportunity for cost savings and streamlining of administration, particularly in a telehealth scenario. Electronic Health records may be generated and stored by medical or healthcare professionals, or by the user/patient (referred to as 'Personal Health Records').

As EHRs are not yet in universal or even general use there are two 'classes' of existing data: EHR information that has been scanned in or generated at a later date than from the original hard-copy or paper record and EHR information that has existed in digital form from the start. Paper records may suffer from illegibility, degradation, incompatibility with current formats.

Electronic Medical Records (EMRs) and Electronic Health Records (EHRs)

The two terms Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are often used interchangeably. In fact they are not quiet the same thing and it is important to establish the differences.

Electronic Medical Record - EMR: Definition according to Himmsanalytics: An application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry (CPOE), pharmacy, and clinical documentation applications. This environment supports the patient s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO) i.e. hospital, clinic or other care facility. The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO.

Electronic Health Record - Is owned by the patient and has patient input and access that spans episodes of care across multiple CDOs within a community, region, or state or countries. The EHR can be established only if the electronic medical records of the various CDOs have evolved to a level that can create and support a robust exchange of information between stakeholders within a community or region.

So an electronic health record (EHR) is the super set of all Electronic medical records (EMRs). Where as the EMR may report only part of the overall health picture and will be concerned with treatment and care visit details, the EHR will be the overall view on all the EMR entries. For example a person receiving care in different CDOs, each with their own EMR and that do not share data with each other. The EHR will span these systems and collate the data in to an overall record that the patient owns and can add details (for example personal health data, fitness data, weight, etc). A good example of a recent EHR is Google Health (2).

There is a nice illustration here of the structure of EMRs and EHRs and the boundaries of each.


The Center for Information Technology Leadership has described four different categories or levels at which information exchange may take place:

  • Non-electronic data - Paper, mail, and phone call.
  • Machine transportable data - Fax, email, and un-indexed documents.
  • Machine organized data (structured messages, unstructured content) - HL7 messages and indexed (labeled) documents, images, and objects.
  • Machine interpretable data (structured messages, standardized content) - Automated transfer from an external lab of coded results into a provider's EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.

(TABLE taken from Wikipedia)

Components of an Electronic Medical Record

  • Administrative System Components - Registration, admissions, discharge, and transfer (RADT) data are key components of EHRs. These data include vital information for accurate patient identification and assessment, including, but not necessarily limited to, name, demographics, next of kin, employer information, chief complaint, patient disposition, etc
  • Laboratory Systems - Laboratory systems generally are standalone systems that are interfaced to EMRs. Typically, there are laboratory information systems (LIS) that are used as hubs to integrate orders, results from laboratory instruments, schedules, billing, and other administrative information.
  • Radiology Systems - Radiology information systems (RIS) are used by radiology departments to tie together patient radiology data (e.g., orders, interpretations, patient identification information) and images. The typical RIS will include patient tracking, scheduling, results reporting, and image tracking functions. RIS systems are usually used in conjunction with picture archiving communications. The market for PACs systems is quite mature in fact however very few systems still tie in with an EMR.
  • Pharmacy System - Pharmacies in healtcare settings can range from totally manual paper based systems requiring much human involvement, to highly automated and electronic systems with sophisticated put away, picking, packing and verification processes. One aspect though is common generally - they pharmacies operate in a silo mode i.e. standalone systems that do not communicate with other systems.
  • Computerized Physician Order Entry (CPOE) - CPOE systems enable physicians to order prescriptions, laboratory and radiology services electronically i.e. by using a PC, Tablet PC, PDA or other input device. CPOE systems offer a range of functionality, from pharmacy ordering capabilities alone to more sophisticated systems such as complete ancillary service ordering, alerting, customized order sets, and result reporting. CPOE systems offer the potential of reducing medical errors (wrong medications, wrong procedures etc). The dissemination rate of CPOE though has been slow. CPOE systems are often viewed by doctors with some suspicion and it is often charged that these systems actually slow down work (they can be seen as an unnecessary layer of extra bureaucracy).
  • Clinical Documentation - Clinical notes; patient assessments; and clinical reports, such as medication administration records. Examples include; Physician, nurse, and other clinician notes, Flow sheets (vital signs, input and output, problem lists), Peri-operative notes, Discharge summaries, Advance directives or living wills, Consents (procedural), Medical record/chart tracking, Staff credentialing/staff qualification and appointments documentation


Ideal Characteristics of an EHR

  • Data should be continuously updatable
  • Data should be able to be anonymously used for quality assurance, epidemic monitoring/prediction, resource management
  • Data should be able to be exchanged between different EHR systems (interoperability)

Issues

Implementation

Interoperability

US: Office of the National Coordinator for Health Information Technology (ONC) -->Regional Health Information Organizations RHIOs

Certification Commission for Healthcare Information Technology (CCHIT) - developing standards and certification (US)

While there are yet no universally adopted standards for EHRs there are many existing standards in specific areas e.g. HL7, ISO TC 215

Enterprise Master Patient Index (EMPI) technologies are designed to help transfer of patient medical records between facilities. On admission to a medical facility a patient may be assigned a Medical Record Number, which may not correspond to the same patient's record number from another facility.

Older Record Digitisation - older paper records should ideally be added into a users current EHR. This digitisation/scanning process is time consuming and must be done to high standards to ensure all relevant data is captured.

Security/Privacy

Systems must be in place to ensure no unauthorised access to an individual's EHR is possible. This includes access by outside parties (e.g. hackers, identity thieves) as well as limiting access to sensitive information by authorised users (e.g. carers, billing departments, insurance companies). US: EHR information is referred to as Protected Health Information (PHI) and security and management are covered under the Health Insurance Portability and Accountability Act (HIPAA). EU: several directives of the European Parliament and Council protect transfer and use of personal data, including that contained in EHRs.

Technology Limitations

Portable, straight forward input devices (e.g. Tablet PCs, PDAs) only now becoming viable, systems capable of dealing with a huge amount of data with many complex and potentially interacting variables.

Preservation

Storage of data and maintenance of equipment for reading specialised data (e.g. X-Rays, MRI, Ultrasound) or migration of that data into a currently readable format.

Cost of implementation

Benefits may not be seen by small or local physicians yet they may bear costs of training/adjustment.

Social and Organisational Resistance

Fear of big brother scenarios, resistance to standardisation from corporate sector (proprietary technologies)

Justification

Studies have shown cost savings and revenue gains from implementation of EHRs (CITE). Gains are also to be had in terms of easy and efficient supply of patient relevant information to healthcare providers at appropriate times (e.g. on admission for emergency treatment, data mining for early indicators of potential health problems). More studies needed to confirm this and indicate gaps.

Benefits

Improved Billing Accuracy, reduction of effort duplication, facilitation of clinical trials, improved access,

Commercial Products

Personal Health Records

Electronic Medical Records

Patient/User ID

Players (links to VCs/Angels/Agencies/MNCs/SME)

Business Models

Most current business models based around DHRs are either in the supply of systems to organisations or individuals and the provision of health record data collection and records maintenance e.g. MediConnect Global-for a fee, they will gather a user's medical records from around the world and add them to his or her GoogleHealth profile or Passport MD who provide a similar service.

Standards

HL7

Navigation

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