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Electronic Medical and
Health records
Lections №5
Main Questions
 Medical
record Basics
 Electronic Medical Record and
Electronic Health Record
 EMR Implementation
 EMR systems in developing
countries
1. Medical record Basics
Medical record definition
 Purpose of the MR
 Format of the MR
 Contents of the MR
 Administrative issues of the MR usage
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1.1. Medical record definition
A medical record, health record, or
medical chart is a systematic
documentation of a patient's medical
history and care.
 The term 'Medical record' is used both
for the physical folder for each
individual patient and for the body of
information which comprises the total
of each patient's health history.
1.2. Purpose of the MR
The information in the MR allows health care providers to
provide continuity of care to individual patients.
The MR also serves as a basis for planning patient care,
documenting communication between the health care
provider and any other health professional contributing to
the patient's care, assisting in protecting the legal interest
of the patient and the health care providers responsible for
the patient's care, and documenting the care and services
provided to the patient.
The MR may serve as a document to educate medical
students/resident physicians, to provide data for internal
hospital auditing and quality assurance, and to provide
data for medical research.
1.3. Format of the MR
Traditionally, medicals records have been
written on paper and kept in folders.
These folders are typically divided into
useful sections, with new information
added to each section chronologically as
the patient experiences new medical
issues.
Active records are usually housed at the
clinical site, but older records are often
kept in separate facilities.
1.4. Contents of the MR
Content of the medical record may vary depending upon
specialty and location, it usually contains following
patients data:
 identification information;
 health history (what the patient tells the health care
providers about his or her past and present health
status);
 medical examination findings (what the health care
providers observe when the patient is examined).
 Other information may include lab test results;
medications prescribed; referrals ordered to health care
providers; educational materials provided; and what
plans there are for further care, including patient
instruction for self-care and return visits.
1.4.1. MR general sections
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Demographics include information regarding the patient
which is not medical in nature. It is often information to
locate the patient including identifying numbers, addresses,
and contact numbers. It may contain information about race
and religion as well as workplace and type of occupational
information. It may also contain information regarding the
patient's health insurance.
The medical history is a longitudinal record of what has
happened to the patient since birth. It chronicles diseases,
major and minor illnesses as well as growth landmarks. It
gives the clinician a feel for what has happened before to the
patient. As a result, it may often give clues to current disease
states.
1.4.1. MR general sections
Medical history section of the MR include:
 Surgical history - is a chronicle of surgery performed for the patient
(dates of operations, operative reports, etc.).
 Medications and medical allergies - a summary of the patient's
current and previous medications as well as any medical allergies.
 Family history - lists the health status of immediate family members
as well as their causes of death (if known). It may also list diseases
common in the family or found only in one sex or the other.
 Social history - is a chronicle of human interactions. It tells of the
relationships of the patient, his/her careers and trainings, schooling
and religious training. It may explain the behavior of the patient in
relation to illness or loss.
 Habits. Various habits which impact health, such as tobacco use,
alcohol intake, recreational drug use, exercise, and diet are
chronicled, often as part of the social history.
 Immunization history. The history of vaccination is included.
1.4.1. MR general sections
Medical encounters.
 Within the medical record, individual medical
encounters are marked by discrete summations of a
patient's medical history by a physician, nurse
practitioner, or physician assistant and can take several
forms.
 Hospital admission documentation (ie when a patient
requires hospitalization) or consultation by a specialist
often take an exhaustive form, detailing the entirety of
prior health and health care.
 Routine visits by a provider familiar to the patient,
however, may take a shorter form such as the problemoriented medical record (POMR).
1.4.1. MR general sections
Each medical encounter will generally contain the aspects:
 Chief complaint. This is the problem that has brought the
patient to see the doctor.
 History of the present illness. A detailed exploration of the
symptoms that the patient is experiencing which have
caused the patient to seek medical attention.
 Physical examination - is the recording of observations of
the patient. This includes the vital signs and examination of
the different organ systems, especially ones which might
directly be responsible for the symptoms that the patient is
experiencing.
 Assessment and plan - is a written summation of what are
the most likely causes of the patient's current set of
symptoms. The plan documents the expected course of
action to address the symptoms (diagnosis, treatment, etc.).
1.4.1. MR general sections
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Orders - written orders by medical providers are included in the
medical record. These detail the instructions given to other members
of the health care team by the primary providers.
Test results - the results of testing, such as blood tests (eg complete
blood count) radiology examinations (eg X-rays), pathology (eg
biopsy results), or specialized testing (eg pulmonary function testing)
are included.
Progress notes - when a patient is hospitalized, daily updates are
entered into the medical record documenting clinical changes, new
information, etc.
Other information - digital images of the patient, flowsheets from
operations/intensive care units, informed consent forms, EKG
tracings, outputs from medical devices (such as pacemakers),
chemotherapy protocols, and numerous other important pieces of
information form part of the record depending on the patient and his
or her set of illnesses/treatments.
1.5. MR Administrative issues
Medical records are legal documents and
are subject to the laws of the country/state
in which they are produced. As such, there
is great variability in rule governing:
 production,
 ownership,
 accessibility,
 destruction:
2. Electronic Medical Record
(EMR) and Electronic Health
Record (EHR)
Reasons
 EMR and EHR definitions
 Data types in the EMR (EHR)
 EMR Issues
 Standards used within EMR
 EMR categories

Go from Paper to Digital
Have patient information at your fingertips.
2.1. Top Reasons To Adopt an EMR
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Better access to data
Pull a patient chart within seconds rather than minutes.
Never waste valuable time looking for a chart.
Open and review your patient’s chart on any computer in the office with secure
HIPAA compliant software.
Have two or more people work with a chart at the same time.
Have clinical data at your fingertips when a consulting or referring physician
calls.
Open the patient’s chart on a wireless computer when you see him in the
hospital.
Access a patient’s chart online when he calls you with an emergency at 2 a.m.
Simplify Billing
More accurate insurance claims submissions.
Faster and easier Accounts Receivable management.
Customized and automated billing options.
Better charting
Never worry about illegible handwriting.
Update medication and problem lists with every visit.
Import lab results, diagnostic images, and hospital discharge summaries into the
patient’s record.
2.2. EMR and EHR Definitions

Electronic Medical Record (EMR)
– Electronic health-related information on an
individual within one healthcare organization

Electronic Health Record (HER)
– Electronic health-related information on an
individual across more than one health care
organization

Personal Health Record (PHR)
– Electronic health-related information on an
individual managed, shared and controlled by
the individual
2.2.1. Overlap in Terminology
An electronic medical record (EMR) is a
medical record in digital format.
 In health informatics an EMR is considered by
some to be one of several types of EHR
(electronic health record)s, but in general
usage EMR and EHR are synonymous.
 The term has sometimes included other (HIT,
or Health Information Technology) systems
which keep track of medical information, such
as the practice management system which
supports the electronic medical record.
2.3. Data types in the EMR
An electronic medical (health) record might include:
 Patient demographics.
 Medical history, examination and progress reports of health
and illnesses.
 Medicine and allergy lists, and immunization status.
 Laboratory test results.
 Radiology images (X-rays, CTs, MRIs, etc.)
 Photographs, from endoscopy or laparoscopy or clinical
photographs.
 Medication information, including side-effects and
interactions.
 Evidence-based recommendations for specific medical
conditions
 A record of appointments and other reminders.
 Billing records.
 Advanced directives, living wills, and health powers of
attorney.
2.4. EMR and EHR general notes
Ideal characteristics of an EHR:
 Information should be able to be continuously
updated.
 The data from an EHR system should be able to
be used anonymously for statistical reporting
for purposes of quality improvement, outcome
reporting, resource management, and public
health communicable disease surveillance.
 The ability to exchange records between different
electronic health records systems
("interoperability") would facilitate the coordination of healthcare delivery in non-affiliated
healthcare facilities
2.4.1. EMR Issues- Interoperability
In healthcare, interoperability is the ability of different
information technology systems and software
applications to communicate, to exchange data
accurately, effectively, and consistently, and to use
the information that has been exchanged.
 Health Information Exchange (HIE)
– The mobilization of healthcare information electronically
across organizations within a region of community
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For example, in 2004 in the USA the Office of the
National Coordinator for Health Information
Technology (ONC) was created, in order to address
interoperability issues and to establish a National
Health Information Network (NHIN).
2.4.2. Interoperability
The Center for Information Technology Leadership described
four different categories (levels) of data structuring at which
health care data exchange can take place. While it can be
achieved at any level, each has different technical requirements
and offers different potential for benefits realization:
N
Data Type
1 Non-electronic data
2
Machine transportable
data
Example
Paper, mail, and phone call.
Fax, email, and unindexed documents.
Machine organizable data
HL7 messages and indexed (labeled) documents,
3 (structured messages,
images, and objects.
unstructured content)
Machine interpretable
data (structured
4
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.
2.4.3. Older record incorporation
To attain the wide accessibility, efficiency, patient
safety and cost savings promised by EMR, older
paper medical records ideally should be
incorporated into the patient's record.
 The digital scanning process involved in conversion
of these physical records to EMR is an expensive,
time-consuming process, which must be done to
exacting standards to ensure exact capture of the
content.
 Results of scanned records are not always usable;
medical surveys found that 22-25% of physicians are
much less satisfied with the use of scanned document
images than that of regular electronic data.
2.4.4. Barriers and Limitations
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80% of the work of EMR implementation must be spent
on issues of change management, while only 20% is
spent on technical issues related to the technology itself.
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Organizational and social issues include restructuring
workflows, dealing with physicians' resistance to change,
as well as IT personnels' resistance to design and
implementation flexibility needed in the complex healthcare
environment, and creating a collaborative environment that
fosters communication between physicians and information
technology project managers.
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Limitations in software, hardware and networking
technologies has made EMR difficult to affordably
implement in small, budget conscious, multiple location
healthcare organizations too.
2.5. Standards used within EMR
There are many standards relating to specific aspects of EMRs.
These include:
 ASTM International Continuity of Care Record - a patient health
summary standard based upon XML, the CCR can be created,
read and interpreted by various EMR systems, allowing easy
interoperability between otherwise disparate enities.
 ANSI X12 (EDI) - A set of transaction protocols used for
transmitting virtually any aspect of patient data. Has become
popular in the United States for transmitting billing information.
 HL7 - HL7 messages are used for interchange between hospital
and physician record systems and between EMR systems and
practice management systems; HL7 Clinical Document
Architecture (CDA) documents are used to communicate
documents such as physician notes and other material.
 DICOM - a heavily used standard for representing and
communicating radiology images and reporting .
2.5.1. HL7 (Health Level 7)
– Most widely used standard. General clinical messaging standard.
Communicates structured data. Have a fields for:
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Diagnostic Results
Notes
Referrals
Scheduling Information
Nursing Notes
Problems
Clinical Trials data
– 2000 hospitals, the CDC and most referral labs.
– Also used in Canada, Australia, New Zealand, Japan and
extensively in Europe
– Bridges many systems, including laboratory, dictation, pharmacy,
electronic patient records, performance databases, data
repositories (cancer registries) etc.
– Web Site:
 http://www.mcis.duke.edu/standards/HL7/h17.htm
2.6. EMR categories
EHR components
Health Info & Data
Basic
Full
*
*
*
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Order Entry
Medication
Lab
Orders
Radiology
Rx
Orders
*
orders
*
sent electronically
Orders
*
sent electronically
*
Results Management
View
lab results
*
*
View
imaging results
*
*
Images
returned
Clinical Decision
support
Public Health
*
*
3. EMR Implementation
Status of EHR Adoption
 EHR development planing
 EHR examples
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3.1.Status of EHR Adoption
Only 4% of physicians use an
extensive, fully functional system for
electronic health records, and 13%
use some form of basic electronic
records
 Those who use electronic records are
generally satisfied with the systems
and believe that they improve the
quality of care that patients receive
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Source: Jha & DesRoches N ENGL J MED 359;1
3.1.Status of EHR Adoption
Setting
2006
(%)
2007
(%)
2008
(%)
PO (basic)
11
13
17
PO ( full)
3
4
4
Hospitals (basic)
NA
NA
8
Hospitals (full)
NA
NA
2
Source: CDC National Ambulatory Medical Survey (NAMC) of ~2700 physicians RR
62% AHA~3037 hospitals; RR 63%
2009
(%)
3.1.Status of EHR Adoption
3.1. Effect of Adoption of EHR
Systems
DesRoches CM et al. N Engl J Med 2008;359:50-60
3.2. EHR development planing
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System implementation projects, in general,
experience low success rates:
– 28% of projects meet full success
– 49% of projects are fully completed, but
over budget, over schedule and lack full
scope of planned functionality
– 23% of projects experience complete failure
or are cancelled
EMR/EHR system implementations have even
higher failure rates. Industry studies reveal
failure rates of 50%, others as high as 70%.
3.2.1. Planning for Success
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The key contributing factors to implementation failure
reported were:
– Lack of planning – unclear vision, goals and
approach, not aligned with vendor incentives,
schedules, other practice priorities and other
resource responsibilities.
– Incomplete, unclear and/or changing requirements.
– Lack of executive support and commitment.
– Lack of resources dedicated to the project (staff,
time, money, end-user involvement, project
management and IT support)
– Unrealistic expectations for what can be
accomplished and how quickly it can occur.
3.2.2. The EHR Adoption Process
3.2.3. Framework of EMR solutions
3.2.4. How do Clinicians Interact with
EMRs
3.3. EHR example
Electronic
health
record
(EHR) with
image and
document
links
EMR frontscreen – MediNotes
EMR – Veterans Affairs
VA – DoD
EMR – MS Office OneNote
EMR face sheet – AMBAS
EMR progress notes – AMBAS
Automated patient q’aire – ADS
Pediatric EMR – MDS Medical
PMS scheduler – AMBAS
4. EMR systems in developing
countries
• Developing country issues
• Critical issues
• Active EMR and reporting systems
By Philippe Boucher, World Health Organization, eHealth unit
London, UK, (2007)
4.1. Developing country issues
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Mobile populations
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limited means of patient identification
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Massive shortage of health care workers
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Physical access to health services
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Limited infrastructure
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Limited access to drugs
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High disease burden combined with poverty
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Donor and aid agency requirements
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Privacy, confidentiality, and security
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Delivery of specific health services by lay health workers (task
shifting)
4.2. Critical issues
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Approach
A shift in perspective from a reporting based model of
system design to a more learning based approach whose
main focus is on direct care.
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Localization
Systems need to be adaptable and relevant to local needs
and culture. This requires that they be usable in local
languages, properly understand data elements which vary by
culture such as personal names and addresses, and be able
to manage appropriate clinical terms and concepts which
describe local health care.
4.2. Critical issues
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Costing and ownership
Implementing organizations must consider innovative approaches to
managing the costs of development, licensing, deployment, and
support. Open source and open standards are viable options to use
alongside more traditional approaches. Local ownership of systems
must be encouraged and supported.
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Personal data protection
Patient data privacy and confidentiality is a key concern and must be
addressed by all systems both technologically and through policy and
legislation.
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Business case
Electronic Medical Record systems deployed in developing countries
are driven by programme management needs across districts, regions
and countries.
4.3. Active EMR and reporting
systems
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A very basic sampling of a few EMR and reporting systems
used in developing countries, developed using different
methodologies, sometimes locally, sometimes abroad
– CareWare (US & PEPFAR countries - Africa, Caribbean,
Asia)
– OpenMRS (Eastern Africa)
– SmartCare (Zambia)
– LabTracker (Zimbabwe)
– Fuschia (MSF)
– Esope (Esther)
– Baobab/Lighthouse system, Taiwanese Medical Mission
System (Malawi)
– DHIS (South Africa, India)
*Inclusion or exclusion of systems on this list does not imply WHO endorsement
WHO/Evelyn Hockstein
WHO/Evelyn Hockstein
Conclusion
In this lecture was considered next
questions:
 Medical record Basics
 Electronic Medical Record and Electronic
Health Record
 EMR Implementation
 EMR systems in developing countries
Literature

Electronic documentation on to the TDMU
server:
http://www.tdmu.edu.te.ua