The electronic patient record

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The electronic patient record
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The patient record

• Notes made by physician
• Long history

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Paper records

• Lloyd George envelope
• Can be very large
• Advantages
• Simplicity
• Availability
• Economy
• Durability

• Problems
• Availability
• Legibility
• Analysis

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Message types

• Data-oriented
• Different data types kept separate
• Task-oriented
• Different tasks kept separate
• Template-oriented
• Hybrid
• Cross-reference task lt-gt data

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Record structures

• Integrated or time oriented
• What happened at each episode
• Data-oriented
• Source oriented
• Examination notes
• X-ray reports
• Lab tests
• Also data-oriented

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The Problem-oriented medical record

• Lawrence Weed
• SOAP
• Subjective
• Objective
• Assessment
• Plan
• Separate section for each problem
• Template-driven (partially)

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Protocol-driven

• Standard procedure (e.g. diabetes)
• Template
• Always record same sequence of data
• Task-oriented

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The electronic patient record

• Definition the Patient Record held in
  electronic form whose Custodian(s) work within a
  single autonomous organisation
• Can be active support users by providing
  alerts, reminders, decision support medical
  knowledge etc.

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Issues

• Standards especially in terminology
• Narrative text vs coding
• Privacy and confidentiality
• Data entry by health professionals
• Integration
• Decision support
• (Shortliffe)

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EPR structure

• Source oriented
• Data from many sources are combined
• Time oriented
• Time is stamped on each piece of data
• Problem oriented
• Data should be linked to show physicians
  reasoning and progress of problem
• Protocol driven

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Predecessors of EPR

• HISS Hospital information support systems
• PAS Patient administration systems
• Demographic details
• Admission
• Discharge
• Departmental systems

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EPR in general practice

• Well-established (since 1970s)
• Widely-used (90 of practices)
• Useful
• Prescribing
• Registers
• Clinical information

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EPR in hospitals

• Plans since Information for Health 1998
• Few successful implementations (3)

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EPR level 1

• Clinical administrative data
• Patient administration
• Departmental systems (separate)

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EPR level 2

• Integrated clinical diagnosis and treatment
  support
• Level 1 plus
• Patient master index integrated with Departmental
  systems

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EPR level 3

• Clinical activity support
• Level 2 plus
• Clinical orders
• Results reporting
• Prescribing
• Multi-professional care pathways

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EPR level 4

• Level 3 plus
• Electronic access to knowledge bases
• Embedded guidelines
• Rules
• Electronic alerts
• Expert system support

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EPR level 5

• Level 4 plus
• Special clinical modules
• Document imaging

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EPR level 6

• Level 5 plus
• Telemedicine
• Multi-media applications
• Picture archiving and support systems

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Targets

• 2002 35 at EPR level 3
• 2005 all at EPR level 3

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The Electronic Health Record ISO/DTR 20514

• A repository of information regarding the health
  status of a subject of care in computer
  processable form,
• stored and transmitted securely, and accessible
  by multiple authorised users. It has a
  standardised or
• commonly agreed logical information model which
  is independent of EHR systems.

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EHR continued

• Its primary purpose is the
• support of continuing, efficient and quality
  integrated health care and it contains
  information which is
• retrospective, concurrent, and prospective

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Further reading

•  ISO/CEN TC 251 13606 http//www.prorecireland.ie/
  Gerard20Freriks.ppt
• http//www.prorecireland.ie/420Thomas20Beale.ppt
   
• HL7 Reference Information Model
• http//www.hl7.org.au/HL7-V3-Resrcs.htm
• OpenEHR
• http//www.openehr.org/getting_started/t_openehr_p
  rimer.htm