Download Electronic Health Record File

Topic 3: Introduction to
Electronic Health Record

Learning Objectives




Introducing the fundamental concepts related to HER
 Define the term electronic health record (EHR)
 Describe the types of EHR Data
 Explain the core functions of Electronic health record
Discuss the rationale (i.e., significance and benefits) of HER
Identify the users of the EHR
Illustrate the barriers of adopting EHR

Learning Objectives







Background
What is electronic health record (EHR)
Types of EHR Data
Explain the functions of Electronic health record
Discuss the significance and benefits of HER
Identify the users of the EHR
Illustrate the barriers of adopting HER
 The potential solutions of EHR’s barriers

Health care providers use records (called medical or
patient records) to capture their clinical findings
and conclusions
 Medical record documenting who, what, when, where,
why, and how the healthcare services are provided

Traditionally, medical records have been captured
on paper and are accessed by recording providers
only

Electronic Medical Record (EMR)
 A digital version of a paper medical record
 Electronic Health Record (EHR)
 A generic term that is commonly used and adopted by
different countries with variation in definitions and the
extent of coverage
 Over the past decade, EHR have become widely adopted
 Professional organizations, governments, and social
forces have contributed to EHR adoption
 EHR’s Adoption will massively reduce healthcare cost
and reduce various medical errors


EHR is a longitudinal electronic record of
patient health information that is generated
by one or more encounters in any care
delivery setting.
Data included in EHR:





Patient demographics and progress notes
Problems, medications, and vital signs
Past medical history and immunizations
laboratory data and radiology reports.
Other data


[HIMSS]
Health Information and Management Systems Society

A repository of healthcare information that is stored in
computer process-able form

EHR primary purpose
 Support of continuing, efficient, quality healthcare

EHR contains information, which is retrospective,
concurrent, and prospective

[ISO/TR 20514]

Sharable EHR
 Transmitted and accessed securely by multiple authorized
users
 Sharing of EHR data across different healthcare organizations
via distributed processing environment

Integrated EHR
 Used in integrated healthcare setting

[ISO/TR 20514]

Based on the above definitions
 EHR is shared across multiple healthcare providers
 EHR aims at providing care to a patient across healthcare
organizations
 EHR Contains complete records of encounters of a
patient throughout the visited healthcare organizations for
that particular encounter





Different terminologies have evolved with EHR
 These terms are either a subset of EHR or used by different
groups to refer to the same as EHR
Computer-Based Patient Record (CPR)
 First version of HER (mid 1990)
Electronic Patient Record (EPR)
 Relevant information to Inpatient care
Personal Health Record (PHR)
 Managed and controlled by a patient (2004)
Electronic Medical record (EMR)
 Records of a patient related to a single encounter (2000)
 Resident
 Health information related to long-term care
CPR
ComputerBased
Patient
Record
EMR
Electronic
Medical
Record
PHR
Personal
Health
Record
EHR
Electronic
Health
Record
PMI &
Demographic
Data
Clinical Note
Summary
Summary of
encounter
With
Healthcare
Providers
Diagnosis,
Procedures &
Medication
EHR Data
Laboratory &
Radiology
Results
Referral
Between
Providers
Adverse
Reactions &
Allergies
Birth &
Immunization
Records

Only EHR information necessary for continuity of
quality healthcare will be shared.
 Data access is restricted to pre-defined scope of EHR
sharable data


All information that falls outside EHR sharable
scope will not be shared.
Principle related to the scope of EHR sharable data
 EHR sharable scope should consider the clinical need of
healthcare professionals to provide healthcare services
 EHR data should be complete and integral to maintain the
quality of healthcare.
 Sharable EHR data should comply with technical
systems’ capabilities of healthcare providers
1.
Clinical Note Summary

A summary for a particular clinical encounter or
episode that include:
 Episode origination, related diagnostic findings and
treatment
 Adverse drug reactions, allergies and clinical alert found
 Problems identified
 Follow-up arrangement
 Education delivered to patients and their families
2.
Personal Identification & Demographic Data

Person Master Index (PMI)
 A set of identity and demographic data used for
identification of patients

The key patient’s identifiers include:




Name
Identity Document Type and Number
Date of Birth
Sex
3.
Referral Between Providers

Healthcare providers (referring provider) refers a
patient to other healthcare providers (referred
provider) to facilitate team-oriented healthcare
delivery
Referral data should be shared to facilitate referral
of a patient between healthcare providers

4.
Adverse Reactions and Allergies

Healthcare providers should be alerted if the
medication they prescribe may trigger an adverse
reaction and/or allergies:
 Any medication that may trigger an adverse reaction
to the patient.
 Any type of biological, physical or chemical agents
that would give rise to adverse health effects
 Details of the occurred adverse reactions or allergies
 Adverse reaction and allergy information is essential to vital
clinical decision support
5.
Birth and Immunization Records

The basic information about the patients’ birth and
immunization
 Birth related data includes birth place, birth date,
birth weight, birth institution, etc.
 Immunization data includes details of all the
vaccines given to patients
6.
Laboratory and Radiology Results

Results of laboratory tests which are classified
according to the nature of the test
 Results from other diagnostic tests, either discrete data
element or a full report of the test.

Radiology results which include radiology report in
different modalities.
 Images, such as clinical photos or tracing, could be
included.
7.
Diagnosis, Procedures & Medication

Any significant procedures done for diagnosis,
exploratory or treatment purposes
Medication ordered and dispensed during healthcare
process

8.
Summary of Episodes and Encounters
With Healthcare Providers

Data that represents the health status of patients:
 Booked appointments
 Dates of attendance when patients consult healthcare
providers
 Major diagnostic findings related to the episode
 Significant procedures performed and other related
treatment
 Patients’ condition, therapeutic orders or treatment plan
Health
information
and data
Replicate the
Workflow
Patient
Support
Administrative
processes &
reporting
Electronic
communication
& connectivity
Efficient
Interaction
Clinical
decision
support

1.
The institute of Medicine (IOM) defines seven core
functions of EHR
Health information and data
 Store health information of patients such as patient’s
history, allergies, laboratory, reports, diagnosis, current
medications, etc.
 Provide access to healthcare providers for taking
appropriate clinical decisions for better patient care.
 Integrate data from various sources and make it available
to the people involved in the care of a patient
2.
Replicate the Workflow
 EHR should work in-synchronous with the original
workflow of the healthcare organization
3.
Efficient Interaction
 It should work effectively, saving time of care providers
by keeping things concise
4. Clinical decision support
 Support provision of reminders, prompts, alerts, ...
 Help clinician to diagnose patients illness
 Such features help in improving clinical and preventive
practices and reduce frequency of adverse events
5.
Electronic communication and connectivity
 EHR should enable exchange of data in known/ standard
formats for supporting interoperability of healthcare
applications
 It should also enable processing of incoming data in
known/standard formats.
6.
Patient support
 EHR should allow patients to access their health
information, enabling them to be involved in their own
healthcare
7.
Administrative processes and reporting
 EHR should provide administrative tools, such as
 scheduling systems, for improving efficiency of clinical
practices and timely service to patients
Patients
Benefits
Clinician
Benefits
Benefits
of HER
Community
Benefits

Ease of Maintaining Health Information of Patients
 EHR provides clinicians a timely access to
comprehensive health information
 Efficient healthcare interventions and quality clinical
practice.
 Improved availability and transparency of information
shared between healthcare providers
 Efficiency gains by avoiding the need to store, collate
and transfer paper records
 Facilitate improvements in practice of professions
through knowledge management support

EHR improves efficiency and quality of care
provided to patients





Continuous and accurate information for care
Reduce medication errors
More efficient and effective use of diagnostic tests
Timely treatment
Improved efficiency and accuracy of diagnosis and
disease management
 Reducing costs associated with duplicate tests,
treatments, medications, and procedures

EHR facilitates better collaboration & interface
between different healthcare providers
 Enhance efficiency and quality of care
 Better disease surveillance and monitoring of public
health
 Ability to gather and analyze the data at a population
level
 This would enhance the detection of factors that influence
patients’ health, disease causes, etc.
 Gather more comprehensive statistics to support policy
formulation and public health research
 Better collaboration and seamless interfacing between
public and private healthcare sector

The Institute Of Medicine (IOM) defines the users of
EHR as:
“Individuals who enter, verify, correct, analyze, or
obtain information from the record, either directly or
indirectly”

Primary users patient care providers
Patient care providers such as Physicians, nurses, and other
health professionals
 Documenting patient care
Patient care managers and support staff
 Evaluate performance of staff
 Use aggregate data to improve future patient care

Primary users
 Coding and billing staff
 Assign diagnostic and procedure codes
 Submit bill to third-party payer
 Patients
 Access own health records
 Request amendments to health record
 Obtain copies of health record
 Employers
 Occupational risks
 Manage insurance for employees
 Disability claims

Primary users
Lawyers
 Protect legal interests of facility and care providers
 Used in medical malpractice cases
 Mental competence of individuals
Law enforcement officials
 Investigate gunshot injuries, and other crimes
 Identify and locate suspects, fugitives and others
 In support of national (homeland) security
Healthcare researchers and clinical investigators
 Evaluate effectiveness of treatment
 Make decisions about disease processes and treatment

Primary users
Health science publishers and journalists
 Aggregate information used to generate articles on alternative
medicine, preventative medicine and more
Government policy makers
 Evaluate health of populations
 Reporting communicable diseases
 Reporting of gunshot wounds
Healthcare delivery organizations




Provide services
Evaluate and monitor use of resources
Seek reimbursement
Planning and Marketing

Other secondary users
Accreditation and Licensing organizations
Educational organizations
Third-party payers
Research institutes and centers
Government and policy-making agencies

EHR deals with
 Multiple healthcare applications
 Various types of healthcare providers
 Various types of health data/information
 Therefore, the adoption of the EHR is complex and requires extra
efforts and time
 Moreover, several factors affects on the adoption of the HER
 Financial barriers
 Technical barriers
 Organizational barriers
 Legislative barriers

Financial Barriers
The adoption of an EHR by a health care organization
requires significant capital funds
 Purchasing/development cost
 Healthcare professions training cost
 Operating and maintenance cost

Technical Barriers
Technical requirements related to patients information’s
privacy, security, and safety
Data/information standardization
Semantic and technical interoperability of EHR
Data/information among different providers

Organizational Barriers
Organizational barriers lies into the resistance to change
(i.e., EHRs adoption) by most healthcare professions
Healthcare professions usually have concerns of adopting
EHRs will increase the time spend with patients and the
overall productivity

Legislative barriers
Legislative requirements related to patients information’s
privacy, security, and safety
Legislative acts related to EHRs adoption, information
exchange policy, etc.
1.
2.
3.
4.
5.
Paraded Sinha, Gaur Sunder, Prashant Bendale,
Manisha Mantri, Atreya Dande. Electronic Health
Record Standards, Coding Systems, Frameworks, and
Infrastructures, 2013
Richard Gartee. Essentials of Electronic Health
Records 1st Edition, 2010
MARCO EICHELBERG, THOMAS ADEN and JORG
RIESMEIERA. Survey and Analysis of Electronic
Healthcare, ACM Computing Survey, 2005
ISO Technical Report (20514): Health informatics:
Electronic health record, Definition, scope and
context, 2005
http://www.ehealth.gov.hk/, last access 01/02/2017