Information Technology in RHAs: From HIS to HERS

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Information Technology in RHAs From HIS to HERS

• Calgary Regional Health Authority
• July 19, 1999

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From HIS to HERS (The EPR journey)

• HIS Hospital Information System
• HERS HEalth Record System
• Electronic Patient Record (EPR)
• Computer-based Patient Record System (CPR)
• Electronic Medical Record (EMR)
• Electronic Health Record (HER)

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Characteristics of the Current Environment
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What is?

• fat
• clumsy
• bursting out at the seams
• illogical
• unfit for the job
• confused

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The existing paper medical record!
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HINF 351 (1998) Student Views

• archaic, redundant, one dimensional
• confusing, illegible, inconsistent
• data limited, data logging
• illegible, private, informative
• large, unweildy, problematic
• redundant, costly, tedious
• redundant, dispersed, subjective
• redundant, large and expensive
• redundant, large storage needed
• redundant, large storage space needed, not
  concise (or too descriptive)
• repetition and duplication of information
• repetitious
• slow, space hog, inaccurate
• unsecure(?) i.e. vulnerable, inconsistent,
  confusing
• vast, unorganized, immense
• volume, storage, transcription

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HINF 351 (1999) Student Views

• Illegible (sometimes), manual,
• Illegible, repetitive, inflexible
• Inefficient, inaccessible
• Inflexible, voluminous, 3 dimensional (asset)
• Redundant, awkward
• Redundant, illegible, repetitive
• Redundant, inconvenient
• Slow, archaic, errors
• Standardized, repetitious, medical codes
• No consistency, no consolidation, difficult
  analysis
• Cant do single words - probably docs think it is
  inflexible because they cant write text, and
  diagrams as appropriate but not great for
  research purposes or sharing

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Alleged advantages of paper medical records

• familiar to users - no new skills required
• continuously available (to key user)
• portable - available at point of care
• flexible and easy recording
• easy to browse and scan
• secure
• contemporaneous and attributable

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Alleged disadvantages of paper medical records

• poor content
• incomplete and inaccurate data
• duplicate, illegible
• format
• partial picture
• unstructured and unsystematic
• fragmented
• idiosyncratic

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Alleged disadvantages of paper medical records

• inaccessible, unavailable
• one location only, misfiling
• separate parts
• discontinuity of care records
• separation of records
• cost
• completing, handling, storage

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History of IT in hospitals

• 1950 to 1959 pre-computer era
• 1960 to 1969 hardware development, financial
  data
  
  
  
  processing
• 1970 to 1979 software development, departmental
  
  
  
  
  systems
• 1980 to 1989 microprocessors, distributed
  
  
  
  
  processing, some HIS
• 1990 to 1999 open systems, client servers,
  networks
• YR2000, integrate
  and "regionate"

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What do current HISs do?

• transmit, receive, store and process patient data
  for medical, nursing and hospital personnel in
  time to affect patient care
• automate parts of the communications system
• automate existing processes
• passive, at best reactive system(s)

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What impact have these systems had on health
care?

• Limited some efficiency gains
• Marginal impact on productivity
• Fundamental care delivery paradigm unchanged

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Hence the journey to the EPR
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• The EPR is a journey, not a destination.
• Protti D, Peel V
• Critical Success Factors for Evolving a Hospital
  Electronic Patient Record System A Case Study of
  Two Different Sites
• J of Healthcare Information Management
• Vol. 12, No. 4, PP. 29-38, Winter 1998

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CPR Definition

• 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
• Institute of Medicine (IOM), 1991

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IOM gold standards (12) for a CPR system

• offers a problem list
• is able to measure health status and functional
  levels
• can document clinical reasoning and rationale
• provides a longitudinal CPR and has timely
  linkages with other patient records

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IOM gold standards for an CPR system

• guarantees confidentiality, privacy and audit
  trails
• offers continuous access for authorized users
• supports simultaneous multiple user views into
  the CPR
• supports timely access to local and remote
  information resources

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IOM gold standards for an CPR system

• facilitates clinical problem solving
• supports direct entry by physicians
• supports practitioners in measuring or managing
  costs and improving quality
• has flexibility to support existing or evolving
  needs of clinical specialties

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Data Types in The EPR

• text
• images (pictures)
• document images
• diagnostic images and signals
• sound
• diagnostic sounds
• voice dictation
• speech recognition
• full-motion video

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• The goal of these gold standards is to describe
  a path toward a completely electronic patient
  record.
• Nussbaum GM
• The Best Little Data Warehouse
• J of Healthcare Information Management
• Vol. 12, No. 4, PP. 79-93, Winter 1998

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The EPR is a journey not a destination

• Consider this group of people taking a trip
  somewhere to consult and advise
• Think about
• what you would need to get there?
• what expectations you have about the environment
  you are going to?
• What if the trip was to Toronto?
• What if it was to Paris, France?
• What if it was to Sierra Leone?

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The EPR is very much about the expectations (and
unknowns) of what it will be like when we to a
distant destination
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EPR Conceptual Framework

• One repository of clinical information (no
  professional separation)
• Different professional view of the data
• Strong focus on care plan
• Data organized according to clinical protocols
• Standardized nomenclatures related to protocol
  administration
• Available everywhere instantly

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United Kingdom National Health Service

• 1998 - 2005 Information Strategy
• Electronic Patient Record Systems

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Electronic Patient Record

• The record about the periodic care provided
  mainly by one institution.
• Typically will relate to the healthcare provided
  to a patient by an acute hospital.
• EPRs may also be held by other healthcare
  providers, for example - specialist units or
  mental health NHS Trusts.
• Section 2.10

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Electronic Health Record

• Describes the concept of a longitudinal record of
  patients 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.

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EPR Paradigm Shifts
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EPR Paradigm Shifts
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EPR Paradigm Shifts
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• The CPR-type system and the pursuit of such a
  project should be seen as journey that will
  involve many iterations over several years until
  goals are achieved.
• Nussbaum GM
• The Best Little Data Warehouse
• J of Healthcare Information Management
• Vol. 12, No. 4, PP. 79-93, Winter 1998

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Finite
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Additional Materials
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Computer-Based Patient Record Institute (CPRI)

• a non-profit membership organization committed to
  advancing improvements in health care quality,
  cost, and access through routine use of
  information technology.
• unique because it is the only organization that
  represents all stakeholders in health care
  focusing on clinical applications of information
  technology.
• serves as a neutral forum for bringing diverse
  interests together to raise issues, exchange
  ideas, and develop common solutions for
  management of health information.
• incorporated in 1992 following the
  recommendations of the National Academy of
  Sciences, Institute of Medicine report on
  Computer-based Patient Records An Essential
  Technology for Health Care.

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CPRI definition

• A computer-based patient record is electronically
  maintained information about an individual's
  lifetime health status and health care.
• The computer-based patient record replaces the
  paper medical record as the primary source of
  information for health care, meeting all
  clinical, legal, and administrative requirements.
  
• The computer-based patient record is much more
  than today's medical record.
• Health data stored in multiple, dispersed systems
  can be captured, processed, communicated,
  secured, and presented, thereby providing
  meaningful information and contributing to the
  knowledge of authorized users for legitimate
  health care purposes.

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CPRI definition (contd)

• The computer-based patient record focuses on the
  individual recipient of health care.
• It integrates all aspects of an individual's
  health, encompassing management of illnesses and
  injuries, health maintenance, and disease and
  accident prevention.
• The computer-based patient record is a
  value-added source of information for all users.
• It provides information to improve quality of
  health care while realizing improvements in
  access to care and moderation in cost of care.
• Computer-based Patient Record Description of
  Content
• CPRI Work Group on CPR Description, May 1996