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Electronic health record

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Electronic health record (EHR) with image and document links.

An electronic health record (EHR) is a distributed personal health record in digital format. The EHR provides secure, real-time, patient-centric information to aid clinical decision-making by providing access to a patient's health information at the point of care. An EHR is typically accessed on a computer or over a network. It may be made up of health information from many locations and/or sources, including electronic medical records (EMRs). An EHR almost always includes information relating to the current and historical health, medical conditions and medical tests of its subject. In addition, EHRs may contain data about medical referrals, medical treatments, medications and their application, demographic information and other non-clinical administrative information. The ideal EHR system, as of 2006, has not been implemented by any software or other vendor.

Types of records used

Multiple terms have been used to define electronic patient care records, with overlapping definitions.[1] Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use. The terms EHR and EMR are frequently used interchangeably, but there is a formal distinction in health informatics and medical records organizations.

Medical record

A medical record is both a general term for an individual's health documents and reports, or more specifically, a paper chart or folder containing this information. Because of the need for access at different care locations, a patient may have multiple medical record folders at each location at which care or testing was received. Each record may contain partial information, and the process of unifying and updating paper records is daunting. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to medical errors, according to the 1999 Institute of Medicine (IOM) report.[2] The follow-up IOM report advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions.[3]

Personal health record (PHR)

A personal health record is medical information in possession of an individual patient or patient's non-professional caregiver. The format may be either paper documents, electronic media, or a combination. The sources of the information include patient-generated lists, copies of reports from physicians, hospitals and labs, legal documents such as living wills and health care proxy forms, and insurance statements. Organizations such as the American Health Information Management Association (AHIMA) encourage individuals to keep their own complete PHR, including any information that a doctor may not have, such as exercise routines, dietary habits, herbal or nonprescription medications, or results of home testing, such as home blood pressure or sugar readings. Consumers can purchase PHRs from companies on the internet.[4] According to AHIMA, 42 percent of US adults surveyed said they keep some form of a personal health record. PHR is also available free of cost from several internet sites.[5][6][7]

Electronic medical record (EMR)

Main article: Electronic medical record

An electronic medical record (EMR) is a patient medical record that contains both documents in an electronic form and functions including:

  • Patient demographics.
  • Medical history, examination and progress reports of health and illnesses.
  • Medicine and allergy lists, and immunization status.
  • Scheduling, retrieval and archiving of laboratory and other tests.
  • Graphic image display of X-rays, MRIs and other medical imaging studies.
  • Medication ordering, including patient safety functions to minimize interactions or side-effects.
  • Evidence-based recommendations for specific medical conditions, termed clinical practice guidelines.
  • Appointment scheduling.
  • Claims and payment processing.
  • Patient reminders of follow up appointments, test completion, preventive health practices.

The EMR integrates these elements so that patient data is available to each component, for example, billing modules, appointment reminders and test ordering systems have access to patient account numbers, addresses, etc. The EMR software allows viewing of data by any other compatible system, and addition of new data in electronic format. Also, EMR must address security, confidentiality and compliance with legal requirements for a permanent document. An EMR is commonly generated and maintained by one care provider (physician) or institution (clinic or hospital), although it will contain some information from accessible sources, transmitted via CCR (below). Therefore, a patient may still have several EMRs, although access and updating is simplified by its electronic format and ability to communicate over a network.

Continuity of Care Record (CCR)

The Continuity of Care Record (CCR)[8] is a core data set of the most relevant and timely facts about a patient's healthcare. It is to be prepared by a practitioner at the conclusion of a healthcare encounter in order to enable the next practitioner to readily access such information. It includes a summary of the patient's health status (e.g., problems, medications, allergies) and basic information about insurance, advance directives, care documentation, and care plan recommendations. It also includes identifying information and the purpose of the CCR.

The CCR may be prepared, displayed, and transmitted on paper or electronically, provided the information required by this standard specification is included. However, for maximum utility, the CCR should be prepared in a structured electronic format that is interchangeable among electronic health record (EHR) systems. To ensure interchangeability of electronic CCRs, this standard specifies that XML coding is required when the CCR is created in a structured electronic format. XML coding provides flexibility that will allow users to prepare, transmit, and view the CCR in multiple ways, e.g., in a browser, as an element in an HL7 message or CDA compliant document , in a secure email, as a PDF file, as an HTML file, or as a word processing document. It will further permit users to display the fields of the CCR in multiple formats. . Equally important, it will allow the interchange of the CCR data between otherwise incompatible EHR systems.

Electronic health record (EHR)

The electronic health record (EHR) is all patient medical information from multiple sources, including all components of the EMR, accessible from any location by any provider caring for the patient. In this ideal, the information is continuously updated and current. Terms commonly used in describing the EHR include interactive, interoperability, secure, real-time and point-of-care. The EHR allows collection of data for uses other than for direct patient care, such as quality improvement, outcome reporting, resource management, and public health communicable disease surveillance.[9]

Standards

Although there are few standards for modern day electronic records systems as a whole, there are many standards relating to specific aspects of EHRs and EMRs. These include:

  • ASTM Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or Electronic Medical Record (EMR) systems, allowing easy interoperability between otherwise disparate enities.[10]
  • 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, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
  • CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
  • CEN - EHRcom (EN 13606), the European standard for the communication of information from EHR systems.
  • CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
  • DICOM - a heavily used standard for representing and communicating radiology images and reporting
  • 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.
  • IHE - Integrating the Healthcare Enterprise; while not a standard itself, IHE is a consortial effort to integrate existing standards into a comprehensive best-practice solution
  • ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
  • openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.

Various factors involving the timing, the right players, market history, utility, governance play a key role in the overall enrichment of the standard and certification development. The standardization and certification even though seem to bring uniformity in the EMR development, do not guarantee their acceptability and sustainability in the long run. [11]

Standards organizations

United States
Not-for-profit organizations such as the American Society for Testing and Materials (ASTM), Health Level 7 (HL7) and Healthcare Information and Management Systems Society (HIMSS) are involved in the standardization process for EHR in the United States. The Certification Commission for Healthcare Information Technology (CCHIT) is a private not-for-profit organization founded to develop and evaluate the certification for EHRs and interoperable health informatics networks.[12]
International
In Europe, CEN's TC/251 is responsible for EHR standards, while at a global level, ISO TC215 produces standards for EHR requirements as well as accepting certain standards from other standards organisations. CEN/TC 251 works on compatibility and interoperability between independent systems and to enable modularity in Electronic Health Record systems. The openEHR Foundation develops and publishes EHR specifications and open source EHR implementations, which are currently being used in Australia and parts of Europe. In Canada, Canada Health Infoway (a private not-for-profit organization started with federal government seed money) is mandated to accelerate the development and adoption of electronic health information systems.[13]

EHR issues

As of 2006, adoption of EHRs and other health information technology (HIT), such as computer physician order entry (CPOE), has been minimal in the United States. Less than 10% of American hospitals have implemented HIT,[14] while a mere 16% of primary care physicians use EHRs.[15] The vast majority of healthcare transactions in the United States still take place on paper, a system that has remain unchanged since the 1950s. The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.[16] The following issues are behind the slow rate of adoption:

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.[17]

In the United States, the development of standards for EHR interoperability is central to forming a National Health Information Network.[18] There are currently 25 major competing vendors of EHR systems, many selling software incompatible with competitors. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been estabilshed in many states in order to promote the sharing of health information. The US Congress is currently working on legislation to increase funding to these and similar programs.

The Center for Information Technology Leadership described four different categories (“levels”) of data structuring at which health care data exchange can take place. [19] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are[20]:

Level Data Type Example
1 Non-electronic data Paper, mail, and phone call.
2 Machine transportable data Fax, email, and unindexed documents.
3 Machine organizable data (structured messages, unstructured content) HL7 messages and indexed (labeled) documents, images, and objects.
4 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.


Adding older records to EHR

To attain the wide accessibility, efficiency, patient safety and cost savings promised by EHR, 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. Because many of these records involve extensive handwritten content, some of which may have been generated by different healthcare professionals over the life span of the patient, some of the content is illegible following conversion. The material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. In addition, the destruction of original healthcare records must be done in a way that ensures that they are completely and confidentially destroyed. Results of scanned records are not always usable; medical surveys found that 22-25% of physicians much less satisfied with the use of scanned document images than that of regular electronic data.[21]

Privacy

A major concern is adequate confidentiality of the individual records being managed electronically. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.[22] Multiple access points over an open network like the internet increases possible patient data interception. In the United States, this class of information is referred to as Personal Healthcare Information (PHI) and access is regulated by the Department of Health and Human Services (DHHS) under the Health Insurance Portability and Accountability Act (HIPAA) and local laws.[23] However, according to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client's knowledge or permission, according to the Journal.[24]

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[25] The organizations and individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. The growth of EHR creates new issues, since electronic data may be physically much more difficult to secure, as lapses in data security are increasingly being reported.[26] Information security practices have been established for computer networks, but technologies like wireless computer networks offer new challenges as well.

Social and organizational barriers

According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EHR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, dealing with physicians' resistance to change, and creating a collaborative environment that fosters communication between physicians and information technology project managers. Exemplifying this need are several highly publicized HIT implementation fiascos, including one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system.[27]

Preserving electronic records

Under data protection legislation and the law generally, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, owns the information contained within the record and has a right to view the originals, and to obtain copies under law.[28] Additionally, those responsible for the management of the EMR are responsible for ensuring that the hardware, software, and media used to manage the information remain usable and not degraded. This requires backup of the data and protection being provided to copies. It will also require the planned periodic migration of information to address concerns of media degradation from use.[29]

Medical records, such as physician orders, exam and test reports are legal documents, which must be kept in unaltered form and authenticated by the creator. The individually defined Legal Health Record (LHR) for each healthcare provider forms the basis for response to subpoenas and other legal processes that require evidentiary use of the patient's 'medical record'.

  • Digital signatures Most national and international standards accept electronic signatures.[30] According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer."[31] With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will continue to be prudent when using EMR.
  • Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006, national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM).[32]

Customization

Pricing for Electronic Health Record (EHR) systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EHR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit a medical specialty, environment or other specified needs.

There are also EHR systems available that do not use templates and therefore can be easily personalized by each individual user. Form-based EHRs, such as Practice Charts, provide physicians with exact electronic replicas of their current health record forms. Other customized EHR systems use Concept Processing technology to create entirely unique user-interfaces designed to maximize efficiency. [33]

Cost

In a 2006 survey by the Medical Records Institute,[34] lack of adequate funding was cited by the 729 health care providers responding as the most significant barrier to adopting electronic records. At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month.[35] Hidden costs may also include office workflow disruption during training or data re-entry required by a new system, with fewer patient visits and less income.

Public implementations

As of 2005, one of the largest projects for a national EHR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT (NPfIT), the NHS component of which is known as the "Connecting for Health Programme".[36]

The Canadian province of Alberta's Alberta Netcare project is a large-scale operational EHR system.

US medical groups' adoption of EHR (2005)

Adoption of electronic health records by US doctors is increasing slowly. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially electronic medical record systems (EMR) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey.[37] However, the survey also states that just 9.3% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.[38] Barriers to adopting an EMR system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options.[39]

Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. As of October 2006, CCHIT had certified 34 ambulatory EHR products.[40][41]

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests.

An unusual form of EHR may be the VeriChip system, a microchip that can be implanted under the skin to give instant access to a patient's records. The tiny electronic device, produced by Applied Digital Solutions Inc. of Delray Beach, Florida, transmits a unique code to a scanner that allows doctors to confirm a patient's identity and obtain detailed medical information from a database maintained by Applied Digital. Only the identification is provided by the implant, so the system remains limited to hospitals, doctors and patients having access to the scanner.[42]

See also

Reference

Notes

  1. ^ Waegemann, C. Peter (2002). "Status Report 2002: Electronic Health Records" (PDF). Medical Record Institute.
  2. ^ Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)". The National Academies Press. Retrieved 2006-06-20.
  3. ^ Institute of Medicine (2001). "Crossing the Quality Chasm: A New Health System for the 21st Century". The National Academies Press. Retrieved 2006-06-29.
  4. ^ American Health Information Management Association: Personal Health Record Retrieved 13 August 2006]
  5. ^ Bloodindex: Personal Health Record
  6. ^ American Health Information Management Association: My PHR
  7. ^ Medem, Inc.: iHealthRecord
  8. ^ ASTM International E2369-05 Standard Specification for Continuity of Care Record (CCR)
  9. ^ Healthcare Information and Management Systems Society (2003): Template:PDF Retrieved July 28, 2006
  10. ^ Nainil C. Chheda, MS (2005). "Electronic Medical Records and Continuity of Care Records - The Utility Theory" (PDF). Application of Information Technology and Economics. Retrieved 2006-07-25. {{cite journal}}: Unknown parameter |month= ignored (help)
  11. ^ Nainil C. Chheda, MS (2007). "Standardization & Certification: The truth just sounds different" (PDF). Application of Healthcare Governance. Retrieved 2007-01-16. {{cite journal}}: Unknown parameter |month= ignored (help)
  12. ^ Certification Commission for Healthcare Information Technology: website Retrieved July 29, 2006
  13. ^ Canada Health Infoway: Website Retrieved 21 August 2006
  14. ^ DJ Ringold, JP Santell, and PJ Schneider (2000). "ASHP national survey of pharmacy practice in acute care settings: dispensing and administration—1999". American Journal of Health-System Pharmacy. 57 (19): 1759–75. Retrieved 2006-08-04.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." WEllesley, MA: Center for Information Technology Leadership, 2003
  16. ^ Raymond, B. and C. Dold. "Clinical Information Systems: Achieving the Vision. Prepared for the Meeting "The Benefits of Clinical Information Systems" Sponsored by the Kaiser Permanent Institute for Health Policy, 2001.
  17. ^ Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601).
  18. ^ Centers for Medicare and Medicaid Services: Strategic Action Plan
  19. ^ Walker J, Pan E, Johnston D, Adler-Milstein J, Bates D, Middleton B. The Value Of Health Care Information Exchange And Interoperability. Health Affairs. Web Exclusive, January 19, 2005.
  20. ^ NAHIT Levels of EHR Interoperbility [1] Retrieved April 4, 2007
  21. ^ Hallvard Lærum, MD, Tom H. Karlsen, MD, and Arild Faxvaag, MD, PhD (2003). "Effects of Scanning and Eliminating Paper-based Medical Records on Hospital Physicians' Clinical Work Practice". Journal of the American Medical Informatics Association. 10: 588–595. Retrieved 2006-07-30.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Health & Medicine (2006-06-26). "At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded". Los Angeles Times. Retrieved 2006-08-08. {{cite news}}: Check date values in: |date= (help)
  23. ^ US Code of Federal Regulations, Title45, Volume 1 (Revised October 1, 2005): of Individually Identifiable Health Information (45CFR164.501) Retrieved July 30, 2006
  24. ^ Theo Francis, Spread of records stirs fears of privacy erosion, The Wall Street Journal, December 28, 2006 [2]
  25. ^ European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive Retrieved July 30, 2006
  26. ^ CNN.com (May 23, 2006): FBI seeks stolen personal data on 26 million vets Retrieved July 30, 2006
  27. ^ Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper". The Washington Post. Retrieved 2006-08-03. {{cite news}}: Check date values in: |date= (help)
  28. ^ Medical Board of California: Medical Records - Frequently Asked Questions Retrieved July 30, 2006
  29. ^ National Archives and Records Administration (NARA): Long-Term Usability of Optical Media Retrieved July 30, 2006
  30. ^ American Bar Association, Section of Science and Technology, Information Security Committee: Jurisdictions with legislation regarding electronic signatures Retrieved July 31, 2006
  31. ^ American Bar Association, Section of Science and Technology, Information Security Committee: Digital Signature Guidelines Retrieved July 31, 2006
  32. ^ The National Archives: Electronic Records Management Initiative retrieved July 31, 2006
  33. ^ Clayton L. Reynolds MD, FACP, FACPE (March 2006): Paper on Concept Processing Retrieved July 27, 2006
  34. ^ Medical Records Institute: [3], Retrieved December 6, 2006
  35. ^ Monegain (Ed.), Bernie (2006-10-11). "We've got to adopt health information technology, and get on with it". Healthcare IT News. Retrieved 2006-12-06. {{cite news}}: Check date values in: |date= (help)
  36. ^ NHS Connecting for Health: Delivering the National Programme for IT Retrieved August 4, 2006
  37. ^ National Center for Health Statistics: Electronic Medical Record Use by Office-Based Physicians:, United States, 2005 Retrieved July 24, 2006
  38. ^ CDC's National Center for Health Statistics: More Physicians Using Electrical Medical Records Retrieved July 27, 2006
  39. ^ Gans D, Kralewski J, Hammons T, Dowd B (2005). "Medical groups' adoption of electronic health records and information systems". Health affairs (Project Hope). 24 (5): 1323–1333. Retrieved 2006-07-04.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  40. ^ Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products Retrieved July 26, 2006
  41. ^ Certification Commission for Healthcare Information Technology (October 23, 2006): CCHIT Announces New Certified Electronic Health Record Products
  42. ^ Stein, Rob (2004-10-14). "Implantable Medical ID Approved By FDA". The Washington Post. pp. A01. Retrieved 2006-07-30. {{cite news}}: Check date values in: |date= (help)
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