Transcript EPJ ved norske sykehus

What is an electronic medical record
and how should it be evaluated?
Hallvard Lærum, MD
Ph.D. fellow
The Norwegian University of
Technology and Science
What is an electronic medical record?
•
One institution,
periodic health
care
– ”the health personnel or instiution’s continous records
of information about each patient and elements of
importance for the needed health care”
•
Electronic Patient Record (NHS/ERDIP 2001)
– ”[The term] Electronic patient record describes the
record of the periodic care provided mainly by one
institution”
•
Multiple
institutions,
"cradle to grave"
Norwegian definition of a medical record (KITH 1996)
Electronic Health Record (NHS/ERDIP 2001)
– ”..concept of a longitudinal record of a patient’s health
and healthcare – from cradle to grave. It combines
both the information about patient contacts with
primary healthcare as well as subsets of information
associated with the outcomes of periodic care held in
the EPRs”
•
Computer-based patient record (IOM 1997)
– “electronically stored information about an
individual’s lifetime health status and health care… ”
– “...an electronic patient record that resides in a system
specifically designed to support users through
availability of complete and accurate data, practitioner
reminders and alerts, clinical decision support
systems, links to bodies of medical knowledge and
other aids.”
EPJ – The Norwegian Term
Hospital information system
Electronic
Medical
Records
•
•
•
Patient
Administration
data
As a legacy from the paper-based patient record, "EPJ" has been considered
containing clinical data and information only, not patient administration data
The "EPJ" is related to periodic care in single institutions, no personal health
record included.
”EMR” was the closest match for the ”Elektronisk pasientjournal” term in 1999
Integration of various sources of
clinical data and information
Clinical
biochemistry
Radiology
Pathology
X-ray, Ultrasound, CT, etc.
histopathological
examinations, autopsies
Blood, Urine, Spinal fluid, etc.
EMR
Medical narratives,
e.g. discharge
reports
daily notes, etc.
Paper-based
Mikrobiology
Microbe identification
Antibiotic resistance
Clinical
physiology
Clinical photos, old medical
records, letters
Other
NMR, Scintigraphy, etc.
ECG, EEG, Heart valve
ultrasound
Using the EMR to locate non-patient information
By exploiting the
information found here...
...we may quickly get the right
information here:
Medical knowledge
Clinical problem
Diagnosis
Treatment
Sex, age, weight,
etc.
Textbooks, clinical reminders, decision support
Population statistics
Logistic information
How to get the job done
Social influences/
Local Procedures
How others get the job done
Gorman PN. Information Needs of Physicians. Journal of the American Society for Information Science 1995;46:729-36.
Information to
patient
EMR
The difference between the EMR
and the EMR system
• In simplistic terms:
– An EMR is the electronic clinical data and
information
– An EMR system is the system handling
them
That means:
making them available to multiple legitimate users,
offering results management, order entry, decision
support, electronic communication and connectivity,
patient support, interdisciplinary work flow and
planning
Reality (year 1999)
• Continuous textual medical records
updated by and accessible to physicians
– admission reports, progress notes, surgery reports,
discharge reports and other documents
• Access to clinical biochemical lab data and
radiological results
• The paper-based medical record is still
being updated, thank you very much
EMR systems in Norwegian hospitals
• DocuLive EPR
– Integrates with third party PAS
• DIPS
– PAS included
• Infomedix
– PAS included
Norwegian EMR systems and the
IOM’s Core functionality of an Electronic Health Record System
Key Capabilities of an Electronic Health Record System: Letter Report (2003)
Core functionality
DocuLive/PAS
IMx
DIPS
I. Health information
and data
Key data (Diagnoses, Allergies,
Demographics, Diagnostic test results),
Narrative (Free text, Template-based,
Structured and coded diagnoses, Structured
and coded procedures, Treatment plan single
discipline), Capture of identifiers (People
and roles)
Key data (Diagnoses, Allergies, Demographics,
Diagnostic test results, Radiology results,
Disposition), Narrative (Free text, Template-based,
Structured and coded diagnoses, Structured and
coded procedures, Treatment plan, single discipline),
Capture of identifiers (People and roles)
Key data (Diagnoses, Medication list, Allergies,
Demographics, Diagnostic test results,
Radiology results, Disposition), Narrative (Free
text, Template-based, Structured and coded
signs and symptoms, Structured and coded
diagnoses, Structured and coded procedures,
Treatment plan, single discipline), Capture of
identifiers (People and roles)
II. Results
management
Results reporting (Laboratory, Consults),
Multimedia support (Images, Scanned
documents, incl. patient consensus)
Results reporting (Laboratory, Radiology reports,
Consults), Multiple views of data/presentation,
Multimedia support (Images, Waveforms, Scanned
documents, incl. patient consensus, Sounds)
Results reporting (Laboratory, Radiology
reports, Consults), Multiple views of
data/presentation, Multimedia support
(Images, Waveforms, Scanned documents, incl.
patient consensus, Sounds)
III. Order
entry/management
Computerized provider order entry
(Electronic prescribing, Laboratory, Consults)
Computerized provider order entry (Electronic
prescribing, Laboratory, XR, Consults)
Computerized provider order entry
(Electronic prescribing, Laboratory, XR,
Consults)
IV. Decision support
Access to knowledge sources (Drug alerts,
Allergy checking), Clinician work list,
Incorporation of patient and/or family
preferences
Access to knowledge sources (Domain knowledge),
Drug alerts (Allergy checking), Other rule-based
alerts, Clinician work list, Incorporation of patient
and/or family preferences
Access to knowledge sources (domain
knowledge), Drug alerts (Allergy checking),
Other rule-based alerts, Clinician work list,
Incorporation of patient and/or family
preferences
V. Electronic
Communication &
Connectivity
Provider-provider, Integrated medical
record (Within setting, Cross-setting
inpatient-outpatient, Cross-setting other)
Provider-provider, Medical devices, Trading
partners (external), Integrated medical record
(Within setting, Cross-setting inpatient-outpatient,
Cross-setting other)
Provider-provider, Medical devices, Trading
partners (external), Integrated medical record
(Within setting, Cross-setting inpatientoutpatient, Cross-setting other)
VI. Patient support
Patient support (Custom patient education,
Tracking)
Patient support (Custom patient education, Tracking)
Patient support (Custom patient education,
Tracking)
VII. Administrative
processes
Scheduling management (Appointments,
Admissions), Eligibility
determination(Insurance eligibility [EU
forms])
Scheduling management (Appointments,
Admissions, Surgery/procedure schedule), Eligibility
determination (Insurance eligibility [EU forms])
Scheduling management (Appointments,
Admissions, Surgery/procedure schedule),
Eligibility determination (Insurance eligibility
[EU forms])
VIII. Reporting and
population health
management
Patient safety and quality reporting(External
accountability reporting, Ad hoc reporting),
Public Health reporting (Reportable
diseases), Disease registries
Patient safety and quality reporting (External
accountability reporting, Ad hoc reporting), Public
Health reporting (Reportable diseases), Disease
registries
Patient safety and quality reporting (External
accountability reporting, Ad hoc reporting),
Public Health reporting (Reportable diseases),
Disease registries
(preliminary version, illustrative purposes)
IOM Functionality elements involved:
0 - 25%
25-49%
50-74%
75-100%
Hospitals with EMR systems
EMR systems in Norwegian somatic hospitals, September 2002
Hospitals
Hospital beds
Others
Others
6%
0%
None
4%
None
DIPS
6%
32 %
InfoMedix
DIPS
19 %
InfoMedix
29 %
32 %
DocuLive EPR
DocuLive EPR
29 %
43 %
Hospitals with an EMR software licence
67 of 70
96 %
Number of beds in these hospitals
12332 of 13097
94 %
Estimated number of beds in departments in
which EMR is implemented*
10500 of 13097
80 %
*In use by the physicians
EPR
DocuLive EPR
Desktop
Record explorer
Prescriptions
DIPS
Desktop
Record Explorer
Schedule
Critical
information
IMx
Desktop
Gastro module
Prescriptions
Properties of the three systems
EPR
DoucLive EPR
Infomedix
DIPS
Vendor
Siemens
TietoEnator Health Care
DIPS
Developed since
1992
1993
1986 (PAS)
PAS
Integrates with third
party PAS
Included in the system
Included in the system
User interface
Identical to all users
Separate modules for
physicians, nurses and clerical
staff
Identical to all users
Dominant structure of
clinical data
Document-based,
free text
Document-based,
free text
Document-based,
free text
Third party modules
available
Few
Many
Many
User-defined forms
Made by vendor
Made on site
Made on site
...but they are not complete
”The clinical gateway”
at Rikshospitalet
Demographic
information
Document-based
information
Radiology reports
Lab reports
Activity planning
How should the EMR
system be evaluated?
What is evaluation?
No single accepted definition of evaluation exist
Evaluation is an empirical process – data is collected
Evaluations may be performed to:
• judge merit and worth of an object
• reach consensus and lead to deeper understanding of the object
• make improvement of the object possible
A comparative element may be involved
• Pre-post studies
• Control and intervention studies
• Comparing to a predefined goal
Roles in evaluation of EMR systems
•
•
•
•
Evaluators
Development team
Users and patients
Stakeholders
–
–
–
–
–
Funders of development team
Funders of the evaluation project
Users of similar systems in other settings
Various public or political groups
Others
Why evaluate EMR systems?
Jayasuriya 97:
Friedman & Wyatt 96:
•
•
•
•
•
•
To establish the feasibility of a
new project
To make organizational
investment decisions
To review progress of
information system projects
To assess the impact of an
information system on the
organization
To assess value added by the
information system function as
a service providing department
•
•
•
To encourage the use of
information systems in
medicine
To uncover the principles of
medical informatics
To develop and test more
effective techniques and
development methods
To make sure it is safe, and to
make sure it is better than the
resource it replaces.
What to evaluate
Evaluation questions should cover a wide range of perspectives
When to evaluate – Phases
Before implementation
After implementation
Formative methods
Summative methods
Continous or at specific time points
How to evaluate – choice of data collection
methods and/or study design
• Methods and study design should be adapted to the chosen
evaluation questions and the phase it is to be performed in.
– Chose the wrong method, and you answer a different question than intended
• Quantitative and qualitative methods in combination
– The "what" by:
•
F.ex. questionnaires, system logs, work sampling, business case, etc.
– The "how and the "why" by:
•
F.ex. observations, focus groups, document studies, interviews, etc.
• Both formative and summative methods are needed
– Results from formative investigations (f.ex. usability studies) may guide the
development process directly in an phase ideal for modification of the system.
•
Modifying the EMR system after implementation is much more expensive
– Summative investigations of operational systems may provide the most
convincing descriptions of merit and worth.
However...
• The ideal evaluation involves multiple methods
used to answer multiple evaluation questions in
an accurate way in repeated investigations
• Will the ideal evaluation cost more than the
stakeholders are willing to pay?
• Are the hospitals who are buying the EMR
systems willing to pay the costs of even modest
evaluations?
• No evaluations of EMR systems published in
Norway as of 1999
– Stakeholders need a wake-up call