Electronic Health RecordsITCS 404: IT for Healthcare Services

Nawanan Theera-Ampornpunt, MD, PhDFaculty of Medicine Ramathibodi Hospital

Jan 18, 2012

http://www.slideshare.net/nawanan

A Bit About Myself

2003 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 Universityranta@mahidol.ac.th

Research interests:• Health IT applications in clinical settings (including

EHRs)• Health IT “adoption”• Health informatics education

EHRs: Fundamentals

What Is A Medical Record?

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

Class Exercise 1

• Why do we need a health record?

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?

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”

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?

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

Class Exercise 2

• What do you think should be in the medical records?

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

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.

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

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

“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)

Various Forms of Health IT

Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)

Electronic Health

Records (EHRs)

Picture Archiving and Communication System

(PACS)

Still Many Other Forms of Health IT

m-Health

Health Information Exchange (HIE)

Biosurveillance

Information RetrievalTelemedicine &

Telehealth

Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I

Personal Health Records (PHRs)

Longitudinal Records

• Records documented over time (multiple encounters)• Ideally, “life-long” is a complete record of the patient’s health

Electronic Medical Records (EMRs)

Computer-Based Patient Records

(CPRs)

Electronic Patient Records (EPRs)Electronic Health

Records (EHRs)Personal Health Records (PHRs)

The Confusing Acronyms

Hospital Information

Systems (HIS)

Benefits of EHRs and EHR Adoption

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)

Class Exercise 3

• Why do we need to “adopt” an electronic version of medical records?

“Computerize”“Go paperless”

“Digital Hospital”

“Modernize”

“Get an electronic copy

“Have EMRs”

“Share data”

Common “Goals” for EHRs/Health IT Adoption

Is There A Role for Health IT?

(IOM, 2000)

Landmark IOM Reports

(IOM, 2001)(IOM, 2000)

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

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”

To Err Is Human

• Perception errors

Image Source: interaction-dynamics.com

Image Source: aafp.org

To Err Is Human

• Lack of Attention

The Economist Purchase Options

• Economist.com subscription $59• Print subscription $125• Print & web subscription $125

Class Exercise 3

The Economist Purchase Options

• Economist.com subscription $59• Print & web subscription $125

Class Exercise 3

• Cognitive Errors - Example: Decoy Pricing

The Economist Purchase Options

• Economist.com subscription $59• Print subscription $125• Print & web subscription $125

(Ariely, 2008)

16084

The Economist Purchase Options

• Economist.com subscription $59• Print & web subscription $125

6832

# of People

# of People

To Err Is Human

What If This Happens in Healthcare?

• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)

• What if health IT can help?

Fundamental Theorem of Informatics

(Friedman, 2009)(Friedman, 2009)

Underlying Assumption

Adoption of EHRs

Use of EHRs

Better Outcomes

Underlying Assumption

Individual Adoption & use

• Better clinical outcomes• Improved patient satisfaction• More provider productivity/satisfaction

Organizational Adoption & Use

• Improved operational efficiency• Better data for research, quality improvements• Reduced costs/increased revenues (e.g. better

claims & reimbursements)

Societal Adoption & Use

• Better individual health/quality of life• Better population health• Long-term cost savings

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!!!!!

• Are they just electronic documentation?

• Or do they have some other values?

Diag-nosis

History & PE

Treat-ments ...

Electronic Health Record (EHR) Systems

• 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

Literature Shows Benefits of Health IT

• 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

Functions That Should be Part of EHR Systems

Adoption of Health IT: United States

18.2 17.3 17.3 20.823.9 29.2 34.8 42.0

48.3 50.7

9.3 10.5 11.816.9 21.8

24.9

0

10

20

30

40

50

60

70

80

90

100

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

% o

f Phy

sici

ans

Year of Study

Any EHR EHR with Basic Features

Source: National Ambulatory Medical Care Survey (NAMCS) 2001-2010

U.S. Ambulatory Setting

Basic Features: Demographics, problem lists, clinical notes, test results, imaging results, order entry for medications

2008 2009– Basic EHRs 7.2% 9.2%

– Comprehensive EHRs 1.5% 2.7%

– Computerized 17% 34%Order Entry for Medications

Adoption of Health IT: United States

U.S. Inpatient Setting

Sources: Jha et al., 2009 & 2010

Definitions for Adoption RatesFunctions 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

EHR Adoption: Thailand (2011)

Estimate (Partial or Complete Adoption)

Nationwide

Basic EHR, combined inpatient & outpatient settings

49.8%

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 medications

Comprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, order entry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts

EHR/HIS Adoption in Thailand (2004)

Pongpirul et al., 2004

EHR/HIS Adoption in Thailand (2011)

HOSxP50%

Self-developed or outsourced16%

Hospital OS7%

SSB4%

Mit-Net2%

MRecord2%

H.I.M. Professional2%

MedTrak/TrakCare

2%

HoMC2%

None 2% THIADES2% HIMS

1%

Abstract ePHIS1%

Other7%

Theera-Ampornpunt, 2011 [Dissertation]

EHRs: Implementation Issues

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)

• Reliability & contingency/business continuity planning

• Roll-out strategies & change management• Are they going to slow down patient care

process?• System Interfaces

EHR Systems/HIS: Issues

Class Exercise 4

• What do you think is better for EHRs: structured or unstructured data?

Increasing EHR Adoption

Facilitators of EHR Adoption

Jha et al. (2009)

Barriers to EHR Adoption

Jha et al. (2009)

• “Workarounds”

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

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

EHR Adoption Barriers(Why People Don’t Use EHRs?)

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”

Public Policy on EHR Adoption

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.”

Source: Wikisource.org Image Source: Wikipedia.org

President George W. BushSixth State of the Union Address

January 31, 2006

?

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 ObamaAddress to Joint Session of Congress

February 24, 2009

Source: WhiteHouse.gov

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

National Leadership (U.S.)

Office of the National Coordinator for Health Information Technology (ONC -- formerly ONCHIT)

David Blumenthal, MD, MPPNational Coordinator for Health Information Technology (2009 - 2011)

Photos courtesy of U.S. Department of Health & Human Services

Farzad Mostashari, MD, ScMNational Coordinator for Health Information Technology (2011 - Present)

What is in HITECH Act?

Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

“Meaningful Use”

“Meaningful Use”

“Meaningful Use” of a PumpkinPumpkin

Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

“Meaningful Use” of Health IT

Stage 1- Electronic capture of health information- Information sharing- Data reporting

Stage 2

Use of EHRs to improve processes of care

Stage 3

Use of EHRs to improve outcomes

Better Health

(Blumenthal D, 2010)

• 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

Meaningful Use Final Rule: Core Objectives (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)

Meaningful Use Final Rule: Menu Set (Selected)

• Content Exchange Standards– HL7 CDA Release 2 & CCD– NCPDP SCRIPT

• Vocabularies– SNOMED CT– LOINC®

– RxNorm ®

• Security– NIST-certified encryption algorithms

• Etc.

Final Rule on Standards & Certification Criteria (Selected)

Personal Health Records (PHRs)

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.” (MarkleFoundation, 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)

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

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)

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

EHRs and the Bigger Picture

Health Information Exchange (HIE)

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Google Flu Trends (Biosurveillance)

Source: Google.org/FluTrends

• 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

Implications

• 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)

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

Summary

Questions?