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Electronic Health Records

This paper discusses about the concept EHR, associated standards and types of data stored in these records. The article also discusses about implementation barriers and merits of these records in comparison with paper records.

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TABLE OF CONTENTS
Introduction ............................................................................................................3 Healthcare Challenges ..............................................................................................3 Patient safety and Medical Errors ............................................................................3 Quality ................................................................................................................4 Disease Management ............................................................................................5 Electronic Health records help in reducing few Healthcare challenges through .................6 Improve quality of care .........................................................................................6 Reduce healthcare costs ........................................................................................6 Promote evidence-based medicine ..........................................................................7 Users of EHR and EMR..............................................................................................7 Concept of EHR .......................................................................................................9 History of EHRs .................................................................................................. 11 Standards of EHRs ................................................................................................ 12 Three main organizations create standards related to EHRs: .................................... 12 Clinical standards................................................................................................ 13 Advantages of Electronic health records over paper records ........................................ 14 Ideal characteristics of an electronic health record (EHR) ......................................... 15 Types of data stored in an electronic health record ................................................. 15 Barriers to implementing an EHR & EMR systems....................................................... 17 Difficulty in adding older records to an EHR system ................................................. 17 Synchronization of records ................................................................................... 17 Privacy .............................................................................................................. 18 Summary ............................................................................................................. 19 References............................................................................................................ 19

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Introduction
Of each dollar spent on Healthcare in the United States, 31% of the money goes to hospital care, 21% goes to physician services, 10% goes to pharmaceuticals, 8% to nursing homes, 7% to administrative costs, and the remaining 23% to all other categories. (I.e. diagnostic laboratory services, pharmacies, medical device manufacturers etc.) It is common knowledge that healthcare IT lags far behind the technological capabilities of other global businesses like banking, telecommunications and media. Nearly 31 cents of every US Healthcare dollar goes towards administrative and other similar costs. Therefore, the big question is how to create a system that both reduces costs and improves patient care quality. The answer is arrived at by equipping each of the stakeholders in patient care with the right information, in the right structure, at the right time to affect the course of care and optimize healthcare outcomes. One of the crucial steps is in the adoption of Electronic Health Records (EHR) and a comprehensive Health Information exchange (HIE) systems. The benefit of such a program is not simply reducing paper, but creating an accessible information portal that enables physicians to coordinate care, use clinical research to devise the best treatments, encourage prevention and better management of chronic conditions. Its a system that works by changing the behavior of payers, physicians and the patients themselves.

Healthcare Challenges
Patient safety and Medical Errors
Patient safety is a new healthcare discipline that emphasizes reporting, analysis, and prevention of medical errors that often leads to adverse healthcare episodes. Recognizing that healthcare errors impact one in every 10 patients around the world, the World Health Organization calls patient safety, an endemic concern. Factors such as variations in healthcare provider training and experience, fatigue, different patients, unfamiliar settings, time pressures etc. could contribute to human error. Medical complexities such as, complicated technologies, powerful drugs, Intensive care, prolonged hospital stay also adds to healthcare errors. The number of deaths related to medical mistakes was estimated to be about 44,00098,000 annually according to the Institute of Medicine (IOM 2000). Although other studies have questioned these numbers, few dispute the importance of the problem. Medical mistakes also exist in rare situations

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like amputation of the wrong limb, or much more common but potentially more lethal situations of prescribing contraindicated drugs or a drug overdose. Many other factors affecting patients safety include inadequate patient assessment, incorrect diagnoses, testing failures and referral problems.

Common root causes for these errors would be:


Human Factors Fatigue/stress/ task overload. Incomplete procedures and Poor documentation - Unavailable medical history, missing diagnostic test results, discharge summaries. Incorrect patient identification. Common breakdown in communications - Verbal orders, hand offs and Transitions.

Quality
Today, there is a growing awareness of the need to improve quality. People legitimately have widely different perceptions of what they consider to be the critical dimensions of quality of care. A physician is likely to view quality in a technical sense, such as whether an accurate diagnosis is made, whether a surgical procedure is performed proficiently and whether the patients health status has improved. The patient is likely to judge his or her encounter with the healthcare system both by its outcome and more on a personal level, like whether the physician paid attention, communicated clearly, clarified all questions effectively, was compassionate as well as skilled in delivering care. The healthcare manager, payer, or purchaser (health plan, employer, or government program such as Medicare or Medicaid) would want to know if the services are cost-effective, i.e. a desired health outcome is achieved in the most efficient and effective manner. The public health official would also wish to know whether healthcare resources are being used appropriately to optimize population health, as well as being provided equitably within the population.

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Disease Management
In the U.S., studies published in leading medical journals consistently report findings that people with acute and chronic medical conditions receive only about two-thirds of the healthcare that they need while 20% to 30% of the tests and procedures provided to patients are not needed or beneficial during usual disease management programs.

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As per HIMSS (Healthcare EMR would be defined as

Information and Management Systems Society) EHR and

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface including evidence-based decision support, quality management, and outcomes reporting. It is important to note that an EHR is generated and maintained within an institution, like a hospital, integrated delivery network, clinic, or physicians office. An Electronic Medical Record (EMR) is usually a computerized medical record created in an organization that delivers care, like a hospital. Electronic Medical Records tend to be a part of a local stand-alone health information system that allows storage, retrieval and manipulation of records. In other words, the Electronic Record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individuals health and care. An EMR is the record of a single diagnosis or treatment maintained in the office, most likely used by a specialist or a CDO (Care Delivery Organization).

Electronic Health records help in reducing few Healthcare challenges through


Improved care quality
An EHR system can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine enable proliferation of ongoing improvements in healthcare efficacy.

Reduce healthcare costs


One of the major sources of rapid growth in healthcare costs stems from medical imaging. Medicare Part B spending on Imaging rose from $6.8 billion in the year 2000 to $14.11 billion in the year 2006. Access to a patient's images through EHR is an effective way to avoid duplicating expensive imaging procedures. Another high cost to healthcare is the printing and mailing of checks. America could save $11 billion annually, if all medical

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payment transactions in the U.S. were handled electronically via direct deposit. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.

Promote evidence-based medicine


EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices. In general, medical records may be "physical" media like film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage. Furthermore, when paper records are stored in different locations, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance. It is estimated that one in seven hospitalizations occurred when medical records were not available. Additionally, one in five lab tests were repeated, because results were not available at the point of care. Electronic Medical Records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.

Users of EHR and EMR


An EHR will provide a more comprehensive view into a patient's health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives. Meanwhile, an EMR is the record of a single diagnosis or treatment maintained in silos, most likely used by a specialist. In case of one unique problem, like an orthopedist consultation, then a stand-alone EMR may suffice. Certain specialists may not need information about patient history as much as they need speciality-specific workflows and templates.

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Electronic Medical Records Electronic Health Records 1. The legal record of the CDO. (Care 1. Subsets of information from various Delivery organization) CDOs where patient have had encounters. 2. Owned by CDO. 2. Owned by patients or stakeholders. 3. May have patient access to some 3. Provides interactive patient access as results effected through a portal but it well as the ability for the patient to is not interactive. append the information. An EHR system increase physician efficiency and reduces costs, as well as promotes standardization of care. Hence even though EMR systems with a Computerized Provider Order Entry (CPOE) have existed for more than 30 years, it is established that fewer than 10% of hospitals as of the year 2006, have a fully integrated system.

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Concept of EHR

An Electronic Record may be created for each service, a patient receives from an ancillary department like radiology, laboratory, or pharmacy, or as a result of an administrative action. For e.g., creating a claim. Very often, these Electronic Records are not integrated and are captured and remain in silo systems. The above figure depicts the same scenario. Different vendors (Hospitals, physicians office, Long Term Care facilities etc.) may use different standards in this stand alone data records and a clinical user may have to open a series of applications, login and then find the patient record within each application before viewing the complete patient record. In practice, what often happens is that the electronic data gets faxed or printed and inserted into a paper record at the inpatient setting. If new results are available

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electronically, old results can be corrected, or new alerts (for e.g., allergies) can be added, but the clinician may not be notified unless they logged into the ancillary system. Furthermore, the disparate data cannot be aggregated into integrated displays, such as flow sheets for clinical analysis.

In a different scenario, if the clinician has access to integrated set of data where all the cases of patient are available as a single set of record/s. An integrated architecture is often created to allow sharing of data across systems. Each system in the above figure stores its own data locally. To share patient information, a system (or system user) must allow another system to access its files, or it must transmit a copy of the file to the other systems. Once the file is identified for sharing, it can be integrated with other files, depending upon the level of interoperability between the integrating systems.

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Most commercial EHRs are designed to combine data from the large ancillary services, such as pharmacy, laboratory, and radiology, with various clinical care components (like nursing plans, medication administration records [MAR], and physician orders). The EHR, therefore, may import data from the ancillary systems via a custom interface or may provide interfaces that allow clinicians to access the silo systems through a portal.

History of EHRs
The first known medical record was developed by Hippocrates, in the fifth century B.C. He had prescribed two goals: A medical record should accurately reflect the course of disease. A medical record should indicate the probable cause of disease. These goals are still appropriate, but Electronic Health Records systems can also provide additional functionalities like interactive alerts to clinicians, interactive flow sheets, and tailored order sets, all of which cannot be achieved through paper-based systems. EHR activities first began in the 1960s. By 1965, Summerfield and Empey reported that at least 73 hospitals and clinical information projects and 28 projects for storage and retrieval of medical documents and other clinically-relevant information were underway. Many of todays EHRs are based on the pioneering work done by Academic Medical centers (AMCs) and for major government clinical care organizations. Notable early projects include: COSTAR (the Computer Stored Ambulatory Record) developed by Barnett, Harvard, placed in the public domain in 1975 and implemented in hundreds of sites worldwide. HELP (Health Evaluation through Logical Processing), Warner developed at LatterDay Saints Hospital at the University of Utah (brought to the market by the 3M Corporation). HELP is notable for its pioneering decision support features. TMR (The Medical Record), Stead and Hammond, Duke University Medical Center. THERESA, Walker, at Grady Memorial Hospital, Emory University, notable for its success in encouraging direct physician data entry.

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CHCS (Composite Health Care System), the Department of Defenses (DoD) clinical care patient record system used worldwide. DHCP (De-Centralized Hospital Computer Program), developed by the Veterans Administration and used nationwide. TDS, developed by Lockheed in the 1960s and 1970s.

Standards of EHRs
Although EHRs are used by many different vendors, because there is a great deal of variation in their implementation methods, these systems are not interoperable and it is difficult to exchange data amongst themselves. In order to, make the implementation of Electronic Health Records more useful, so that data can be easily exchanged among different entities, different technical and clinical standards were proposed to be used.

Three main organizations create standards related to EHRs:


Health Level Seven (HL7), Comite European de Normalization Technical Committee (CEN TC) 215, and the American Society for Testing and Materials (ASTM) E31.

Technical standards used for exchanging the healthcare information through messaging would be:

ANSI X12 (EDI)- Transaction protocols used for transmitting patient data. It is popular in the United States for transmission of billing data. Examples Eligibility transactions (270-71), Claims transactions 837, Remittance advices - 835. CEN's TC/251- Provides EHR standards in Europe including: o EN 13606- Communication standards for EHR information. o CONTSYS (EN 13940)- Supports continuity of care record standardization. o HISA (EN 12967)- Is a services standard for inter-system communication in a clinical information environment. DICOM - An international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA. (National Electrical Manufacturers Association) HL7 Is a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems. ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures.

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Clinical standards
During Member encounter with the healthcare services, provider or clinician will document the findings in a free text unstructured format e.g. member medical history or current disease and the procedure used for treating the associated disease. This data is usually transferred into a more structured format and subsequently linked to payment processing and reimbursement activities. These data sets used in the medical encounters include standards wrt clinical definition of medical diseases or procedure performed and are classified as CPT codes (Current Procedure Terminology), ICD (International classification of disease) and DRG codes (Diagnosis related grouping). These terminologies (ICD9 - CM, CPT codes and DRG codes) will be used as clinical standards during creation of medical records for patient encounters and in billing and claims processing for these records.

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Advantages of Electronic health records over paper records


Health records may be on "physical" media like film (x-rays), paper (notes), or photographs, often of different sizes and shapes. The physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. Also physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time

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consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant. Handwritten paper health records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption.

Ideal characteristics of an Electronic Health Record (EHR)


1. Information can be continuously updated. 2. The data from an Electronic Health Records system can be used anonymously for statistical reporting for purposes of quality improvement, outcome reporting, resource management, and public health communicable disease surveillance. The ability to exchange records between different Electronic Health Records systems ("interoperability") would facilitate the co-ordination of healthcare delivery in nonaffiliated healthcare facilities.

Types of data stored in an Electronic Health Record


1. Patient demographics. (For e.g.: Age, Sex / Gender, Race/ Ethnicity, Location of residence, socioeconomic status (SES), Religion, Marital status, Ownership (home, car, pet, etc.), Language etc.) 2. Medical history, examination and progress reports of health and illnesses. 3. Medicine and allergy lists, and immunization status. 4. Laboratory test results. 5. Radiology images (X-rays, CT scans, MRIs, etc.) 6. Photographs from endoscopy or laparoscopy or clinical photographs. 7. Medication information, including side-effects and interactions.

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8. Evidence-based recommendations for specific medical conditions. 9. A record of appointments and other reminders. 10.Billing records.

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Barriers to implementing an EHR and EMR systems


Difficulty in adding older records to an EHR system
Older paper medical records ought to be incorporated into a patient's Electronic Health Record. One method is to merely scan the documents and retain them as images. Surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone, however, rather than fully electronic data-based systems. EHR systems with image archival capability (such as Vista Imaging) are able to integrate these scanned records (along with other types of image-based records) into fully Electronic Health Records systems. Another method to convert written records (such as notes) into electronic format is to scan the documents then perform optical character recognition. For typed documents, accurate recognition may only achieve 90-95%, and may require extensive corrections. Furthermore, illegible handwriting is poorly recognized by optical character readers. Some states have proposed making existing statewide database data (such as immunization records) available for download into individual Electronic Medical Records (EMRs).

Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both locations in a proper manner. This is a problem that develops in distributed computer records. Two models have been used to satisfy this problem: A centralized data server solution and a peer-to-peer file synchronization program. In the United States, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of great concern. Synchronization programs can be adapted, once record standardization occurs. Merging of already existing public healthcare databases is a common software challenge. The ability of Electronic Health Record systems to provide this function is a key benefit and can improve healthcare delivery.

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Privacy
Privacy concerns in healthcare apply to both paper and According to the Los Angeles Times, roughly 150 people (from technicians and billing clerks) have access to at least part of during a hospitalization, and 600,000 payers, providers and handle providers' billing data have some access also. electronic records. doctors, nurses, to a patient's records other entities that

Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet. Electronic Healthcare Data ("Personal Healthcare Information (PHI)") access is regulated by the Department of Health and Human Services (DHHS) under the Health Insurance Portability and Accountability Act (HIPAA), and also comes under the jurisdiction of some local bodies as well. Publicity of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing Electronic Medical Records in a central location. However, this concern is no different than the concern for breach of security at central storage warehouses of papers, charts etc. In fact, it is possible that, with proper security, electronic records may be more secure than physical records. In the European Union (EU), several Directives of the European Parliament and Council protect the processing and free movement of personal data, which includes health care purposes too.

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Summary
EHR plays a big role in providing a single composite longitudal view of patient record. Electronic Health Records will be the key to the transformation of Healthcare. EHRs will be able to: Improve the quality of care through enhanced evidence-based clinical decision support, the timely communication of clinical information, and better documentation. Increase operational efficiency and contain costs by automating routine tasks, streamlining clinical workflow, and avoiding duplication of procedures. Help collect data for uses other than clinical care, such as billing, quality reporting, disease surveillance, public health reporting, and fraud detection and deterrence Protect the privacy of health information through secure mechanisms and authorized access and control procedures.

Thus widespread use of EHRs has the potential to improve the quality of care, increase patient safety, reduces medical errors, and control healthcare costs.

References
1. Electronic Health Records Overview - NIH National Center for Research Resources.
2. Electronic Health Records - A Global perspective by HIIMSS. 3. Healthcare IT Challanges - Vignette corporation 4. Electronic Medical Records - HIMSS Analytics. 5. Research Triangle Institute.

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