Theera-Ampornpunt N. Electronic health records. Presented at: Faculty of ICT, Mahidol University; 2012 Jan 18; Bangkok, Thailand.

1. Electronic Health Records
ITCS 404: IT for Healthcare Services
Nawanan Theera-Ampornpunt, MD, PhD
Faculty of Medicine Ramathibodi Hospital
Jan 18, 2012
http://www.slideshare.net/nawanan

2. 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 Analyst
Health Informatics Division
Faculty of Medicine Ramathibodi Hospital
Mahidol University
ranta@mahidol.ac.th
Research interests:
• Health IT applications in clinical settings (including
EHRs)
• Health IT “adoption”
• Health informatics education

3. EHRs: Fundamentals

4. What Is A Medical Record?

5. 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

6. Class Exercise 1
• Why do we need a health record?

7. 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?

8. 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”

9. 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?

10. 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

11. Class Exercise 2
• What do you think should be in the
medical records?

12. 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

13. 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.

14. 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

15. 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

16. “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)

17. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records Picture Archiving and
(EHRs) Communication System
(PACS)

18. Still Many Other Forms of Health IT
Health Information
Exchange (HIE)
m-Health
Biosurveillance
Personal Health Records
(PHRs)
Telemedicine &
Information Retrieval Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I

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

20. The Confusing Acronyms
Computer-Based
Patient Records
Electronic Medical
(CPRs)
Records (EMRs)
Electronic Patient
Electronic Health Records (EPRs)
Records (EHRs)
Personal Health
Records (PHRs)
Hospital
Information
Systems (HIS)

21. Benefits of EHRs and
EHR Adoption

22. 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)

23. Class Exercise 3
• Why do we need to “adopt” an
electronic version of medical
records?

24. Common “Goals” for
EHRs/Health IT Adoption
“Computerize”
“Go paperless”
“Get an electronic
copy
“Digital Hospital”
“Have EMRs”
“Modernize”
“Share data”

25. Is There A Role for Health IT?
(IOM, 2000)

26. Landmark IOM Reports
(IOM, 2000) (IOM, 2001)

27. 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

28. 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”

29. To Err Is Human
• Perception errors
Image Source: interaction-dynamics.com

30. To Err Is Human
• Lack of Attention
Image Source: aafp.org

31. Class Exercise 3
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125

32. Class Exercise 3
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125

33. To Err Is Human
• Cognitive Errors - Example: Decoy Pricing
# of
The Economist Purchase Options People
• Economist.com subscription $59 16
• Print subscription $125 0
• Print & web subscription $125 84
# of
The Economist Purchase Options People
• Economist.com subscription $59 68
• Print & web subscription $125 32
(Ariely, 2008)

34. What If This Happens in Healthcare?
• It already happens....
(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)
• What if health IT can help?

35. Fundamental Theorem of Informatics
(Friedman, 2009)
(Friedman, 2009)

36. Underlying Assumption
Adoption Use of Better
of EHRs EHRs Outcomes

37. Underlying Assumption
• Better clinical outcomes
• Improved patient satisfaction
Individual • More provider productivity/satisfaction
Adoption & use
• Improved operational efficiency
• Better data for research, quality improvements
• Reduced costs/increased revenues (e.g. better
Organizational
Adoption & Use claims & reimbursements)
• Better individual health/quality of life
• Better population health
Societal • Long-term cost savings
Adoption & Use

38. 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!!!!!

39. Electronic Health Record (EHR) Systems
• Are they just electronic documentation?
History Diag- Treat-
...
& PE nosis ments
• Or do they have some other values?

40. Literature Shows Benefits of Health IT
• 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

41. Functions That Should be Part of
EHR Systems
• 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

42. Adoption of Health IT: United States
U.S. Ambulatory Setting
100
90
% of Physicians
80
70
60
50
48.3 50.7
34.8 42.0
40
30
23.9 29.2 24.9
20
18.2 17.3 17.3 20.8 16.9 21.8
9.3 10.5 11.8
10
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Year of Study
Any EHR EHR with Basic Features
Basic Features: Demographics, problem lists, clinical notes, test results, imaging results, order entry for
medications
Source: National Ambulatory Medical Care Survey (NAMCS) 2001-2010

43. Adoption of Health IT: United States
U.S. Inpatient Setting
2008 2009
– Basic EHRs 7.2% 9.2%
– Comprehensive EHRs 1.5% 2.7%
– Computerized 17% 34%
Order Entry for Medications
Sources: Jha et al., 2009 & 2010

44. Definitions for Adoption Rates
Functions Jha et al.
Basic EHR Comprehensive EHR
Demographics  
Physicians’ notes  
Nursing assessments  
Problem lists  
Medication lists  
Discharge summaries  
Advanced directives 
Test and imaging results
Laboratory reports  
Radiologic reports  
Radiologic images 
Diagnostic-test results  
Diagnostic-test images 
Consultant reports 
Computerized provider-order entry
Laboratory tests 
Radiologic tests 
Medications  
Consultation requests 
Nursing orders 
Decision support
Clinical guidelines 
Clinical reminders 
Drug-allergy alerts 
Drug-drug-interaction alerts 
Drug-laboratory interaction alerts 
Drug-dose support 

45. EHR Adoption: Thailand (2011)
Estimate (Partial or Complete Nationwide
Adoption)
Basic EHR, combined inpatient & 49.8%
outpatient settings
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

46. EHR/HIS Adoption in Thailand (2004)
Pongpirul et al., 2004

47. EHR/HIS Adoption in Thailand (2011)
Abstract ePHIS
None 2% THIADES 1%
HoMC 2% HIMS
2% 1%
Other
7%
MedTrak/
TrakCare
2%
H.I.M. Professional
2%
MRecord
2%
Mit-Net HOSxP
2% SSB 50%
4%
Hospital OS
7%
Self-developed or outsourced
16%
Theera-Ampornpunt, 2011 [Dissertation]

48. EHRs: Implementation Issues

49. 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)

50. EHR Systems/HIS: Issues
• Reliability & contingency/business continuity
planning
• Roll-out strategies & change management
• Are they going to slow down patient care
process?
• System Interfaces

51. Class Exercise 4
• What do you think is better for
EHRs: structured or unstructured
data?

52. Increasing EHR Adoption

53. Facilitators of EHR Adoption
Jha et al. (2009)

54. Barriers to EHR Adoption
Jha et al. (2009)

55. EHR Adoption Barriers
(Why People Don’t Use EHRs?)
• “Workarounds”

56. 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

57. 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

58. 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”

59. Public Policy on EHR Adoption

60. 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.”
President George W. Bush
Sixth State of the Union Address
January 31, 2006
Source: Wikisource.org Image Source: Wikipedia.org

61. 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 Obama
Address to Joint Session of Congress
February 24, 2009
Source: WhiteHouse.gov

62. 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

63. National Leadership (U.S.)
 Office of the National Coordinator for Health Information
Technology (ONC -- formerly ONCHIT)
David Blumenthal, MD, MPP
National Coordinator for
Health Information Technology
(2009 - 2011)
Farzad Mostashari, MD, ScM
National Coordinator for
Health Information Technology
(2011 - Present)
Photos courtesy of U.S. Department of Health & Human Services

64. What is in HITECH Act?
Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.

65. “Meaningful Use”

66. “Meaningful Use”
“Meaningful Use”
Pumpkin
of a Pumpkin
Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009

67. “Meaningful Use” of Health IT
Stage 1
- Electronic capture of Better
health information
- Information sharing
Stage 3
Health
- Data reporting
Stage 2 Use of
EHRs to
Use of improve
EHRs to outcomes
improve
processes of
care
(Blumenthal D, 2010)

68. Meaningful Use Final Rule:
Core Objectives (Selected)
• 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

69. Meaningful Use Final Rule:
Menu Set (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)

70. Final Rule on Standards &
Certification Criteria (Selected)
• Content Exchange Standards
– HL7 CDA Release 2 & CCD
– NCPDP SCRIPT
• Vocabularies
– SNOMED CT
– LOINC®
– RxNorm ®
• Security
– NIST-certified encryption algorithms
• Etc.

71. Personal Health Records
(PHRs)

72. 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.” (Markle
Foundation, 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)

73. 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

74. 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)

75. 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

76. EHRs and the Bigger Picture

77. Health Information Exchange (HIE)
Government
Hospital A Hospital B
Clinic C
Lab Patient at Home

78. Google Flu Trends
(Biosurveillance)
Source: Google.org/FluTrends

79. Implications
• 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

80. Summary
• 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)

81. 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

82. Questions?