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Informatics in Health and

Research: the Electronic

Health Record (EHR)
Romulo de Castro, Ph.D.
Balik Scientist
UP Manila/Mapua/PGC-ELSI

Topics covered
Impetus for EHR Adoption
Doctor and patient opinions
CDS, HIE, disasters
Nursing informatics

What is your view of EHRs?
18 favorable, 2 neutral

What is the top barrier for EHR adoption?

11 cost, 9 lack of infrastructure/manpower, 2 not needed,
1 backward-thinking politicians, 1 lack of government
support, 1 lack of clear intended use

Electronic health record (EHR) - a longitudinal collection of the health
information of an individual.
EHRs focus on total health going beyond standard clinical data collected
in the providers office and inclusive of a broader view on a patients care.
EHRs are designed to reach out beyond the health organization.

Electronic medical record (EMR) - a patient record created by

providers for specific encounters in hospitals and ambulatory
environments, and which can serve as a data source for an EHR.
EMRs are a digital version of the paper charts in the clinicians office.
An EMR contains the medical and treatment history of the patients in a

Personal health record (PHR) - an electronic application for personal

medical data that the individual patient controls

Other Terms
Patient registry a collection of standardized information about
a group of patients who share a condition (disease)
Chronic disease management system (CDMS) a system used to
capture, manage and provide information on specific conditions
to support organized care management for patients

Why talk about EHRs?

EHRs not the only topic of informatics, but one of the
hottest right now
Attracting attention from the various ps: patients,
providers, purchasers, payors, public health, policy
EHR and PHR are profoundly impacting practice of
medicine (Siegler, 2010; Kirst, 2011)
Big data

Limitations of the paper record

Single user one person at a time
Disorganized especially for complex patients
Incomplete reports missing or lost, some providers are not
sharing their reports with the rest
Nawawala yung record ehhindi mahanap.
Sana dala ng kamag-anak yung folder.
Ini-interview na lang namin ulit.

Requires a lot of manpower to file/re-file, transport, copy

Insecure no audit trail, easily copied or stolen, not disasterproof

What does the EHR do?

Stores patient data; standardizes data input (forms) and
Facilitates search for patient information.
Tracks down a patients many medical records; facilitates
coordinated care
Provides up to date information with only one modifiable file
(reduces data replication)
Captures patient health across time; examine trends and long term
changes in a patient.
Facilitates population-based studies on health (e.g. disease

Even more
Provides ubiquitous access to patient data (anywhere,
Allows multiple views of data
Lists, tables, flow charts, graphs (trends)
Codifies clinical guidelines (CDS)
Facilitates communication with other providers, including
allied health providers, and with patients

What can be found in the EHR?

Medical history
Medication and allergies
Immunizations and status
Vital signs, personal statistics (age, height, weight, etc)
Laboratory and imaging test results
Procedures, orders, diagnoses, treatment plans, clinical notes
Billing and other administrative information

Capabilities of an Electronic Health Record

System (2003, IOM)
Health information and data management
Order management
Result management
Communication and connectivity
Patient support
Decision support
Reporting and population health management
Administrative processes

All functions should address five

healthcare quality criteria
Improve patient safety
Support delivery of effective patient care
Facilitate management of chronic conditions
Improve efficiency
Have feasibility of implementation

Benefits of EHRs
Quality of care assessments
Clinical decision support or CDS (MU) facilitates diagnosis
and treatment
Health information exchange or HIE (MU) facilitate
coordinated care
PHRs allow more patient participation in their healthcare
Data for clinical research and public health (MU)

Improved care by physicians, nurses and other members of

the healthcare continuum
MU=meaningful use

Clinical decision support - CDS (MU)

Decision support uses EHR data to provide contextspecific advice, such as
Assisting with choices in diagnosis and therapy
Detecting problematic situations: medication errors or drugdrug interactions

Delivered at point of care, when clinical decisions are

being made
Types of CDS: information display, reminder systems,
alerts, clinical practice guidelines

There are challenges

Data quality
Data usability
Standards and interoperability
Privacy, confidentiality, security

The importance of standards

Promote consistent naming and understanding of
events, diagnoses, treatments, etc.
Allow better use of data for patient care as well as
secondary uses such as quality assurance, research, etc.
Enhance ability to transfer data among applications,
allowing better system integration
Integral part of transforming and improving healthcare

ICD-10 codes, funny

W55.41XA: Bitten by pig, initial encounter.
V97.33XD: Sucked into jet engine, subsequent
Z63.1: Problems in relationship with in-laws.
V95.43XS: Spacecraft collision injuring occupant,
W56.22xA: Struck by orca, initial encounter
R46.1: Bizarre personal appearance.

Benefits of the ICD-10 transition?

Privacy, confidentiality, security

Privacy right to keep personal things to yourself
Confidentiality right to keep personal things about you
from being disclosed to others
Security protection of your personal information
Think about
Who owns medical data?
Personal privacy vs. the common good; de-identify data
Data breaches seems to occur everyday; more technology,
more access
Paper records are also insecure

EHR implementation:
what will it cost?

EHR implementation cost

Hardware: database servers, desktop computers, tablets/laptops,
printers, and scanners.
Software: EHR application, modules, and upgrades.
Implementation assistance: IT contractor, attorney, electrician,
and/or consultant support; chart conversion; hardware/network
installation; and workflow redesign support.
Training: train physicians, nurses, and office staff to understand how
to use the EHR and how the EHR will create new workflows
Maintenance: ongoing costs for hardware and software license, staff
education, telecom fees, and IT support fees. Hire new staff, such as
IT operations staff, clinical data analysts, or application analysts.

Implementation strategies
Parallel keep new and old systems running
Phased add modules sequentially across organization
Pilot install full system in one unit at a time; may
Big bang all at once; has risks but has been used
successfully with proper planning

Implementation reports
It is well-known that physician productivity (patient volume) dips upon
adoption on an EHR, but it is recovered once users get used to the
Small-practice: four-physician practice encountered many challenges.
Needed to re-design office workflow;costs higher than budgeted; would
not return to paper (Baron 2005, 2010)
Big hospital: transition from standalone to institutional EHR in OHSU
Emergency Department (ED) found workflow issues most essential
(Handel, 2009)
Of 58% of physicians who either dislike their EHRs or are lukewarm about
them, 85% said they are spending more time documenting patient visits,
and 66% said they are seeing fewer patients. More than half called their
software difficult to use.
Among satisfied EHR users, the thing they like the most are charts that
never get lost (82%), the ability to access charts remotely (75%), and
meaningful-use bonuses (56%). (International Data Group, 2013)

"I am a fan of the EHR edict, but I believe the EHR is

mainly a repository for clinical, regulatory and financial
data. One doctor in JAMA commented that the EHR is
destroying his ability to listen to the patient's story and
to do an examination in the way he wants to do it. I
don't mean to slam EHRs; we do need them. But there
are ways we can work smarter with them to take some
burden off doctors and nurses so that their time is spent
in patient encounters instead of typing into computers.
Bridget Duffy, MD, Chief Medical Officer, Vocera
Communications, San Jose, Ca.

"While not yet perfect in terms of physician workflow, EHR

vendors are making strides to design systems that are
more intuitive and clinically driven. EHR technology
supports the patient-centered medical home, a
foundation of primary care. EHRs also enable robust
population and chronic disease management, optimal
care coordination, continuity and patient-centeredness.
This enables physicians to deliver safe, high-quality care
for the optimal health of patients, families and
Michael Munger, MD, Overland Park, Ks.

What patients are saying

A survey of more than 2,100 patients found that only 26% want their
medical records to be digital. Only 40% believe EHRs will result in
better, more efficient care. And 85% expressed concern about digital
records. Their main worries: privacy and security of their information.
(Xerox, 2012)
When asked what, specifically, worries them about EHRs, respondents
said they were concerned that their information could be:
stolen by a hacker (63%),
the files could be lost, damaged or corrupted (50%),
their personal information could be misused (51%),
or a power outage or computer problem could prevent doctors from
accessing their information (50%)
15%, had no worries.

Health Information Exchange/HIE (MU)

Data following the patient Anytime, anywhere access
to clinical information for the care of patients
Patients travel, are referred, change doctors, loose
insurance, etc (care continuity)
Electronic sharing of data among hospitals, physicians,
clinical laboratories, radiology centers, pharmacies,
health plans (insurers), and public health departments.
(And also patients.) (GAO, 2010)
Requires that information be interoperable and flow
seamlessly (Kuperman, 2011)

Indiana Network for Patient Care

Participants: hospitals, labs and imaging facilities, homeless care
systems, public health departments, and physician offices (large
number of participants illustrates buy-in from the community)
Central (community) clinical repository; secure network for delivering
clinical data messages to/from repository
Tools and processes for standardizing the data and using it for different
Formal agreements among all participants spelling out processes,
allowable uses, and HIPAA compliance
Provides clinical messaging and public health surveillance, clinical data
repository and quality improvement services for central Indiana (1.7
million patients)
DOCS4DOCS delivers data from hospitals and labs to providers by
HL7 messaging or fax
Quality Health First provides disease management and preventive
health summaries
Public Health Electronic Syndromic Surveillance (PHESS)

HIE Successes and failures:

challenges remain
Failures: didnt focus on value, didnt involve
stakeholders, no one was willing to pay for services,
lack of sustainable business models (Glaser, 2006; Vest,
Lack of progress in standards and interoperability
(Brailer, 2005)
Differing models, public utility model vs. point-to-point

EHR utility in disasters

Hurricane Katrina (New Orleans, 2005)
Paper records were lost; only available source of medical information was
SureScripts database of medication histories

California Wildfires (San Diego, 2007)

Sharp Healthcare transitioned to EHR in 2005, two years after 2003 wildfires
Closed 5 hospital/clinics in October 2007 due to wildfires 100,000 people
Established communications/call center staffed by physicians who had
access to EHR; delivered healthcare by phone.

Hurricane Sandy (New York City and New Jersey, 2012)

Through HIE, health information was available before, during and after the
storm and the flooding that ensued
Questions remain about privacy of records during a disaster
Long Beach Medical Center used its EHR through microwave ethernet data

Typhoon Haiyan
Large numbers of medical groups post-disaster
Very few were willing to share data afterwards for analysis
of the disaster medical response.
Could EHRs be useful for the next typhoon?

Typhoon Lando

Priority of healthcare information

in a disaster (Kimura et al., 2011)
In reference to earthquake/tsunami experiences, where a
shared hospital information system played an important
role in 2011:
High: Severity of injury/disease, Prescription history,
Type of injury/disease
Middle: Images of the patient (visible or X-ray), Past
disease history (incl. examination results), Past progress
Low: Past health checkup record.

Nursing informatics (Staggers, 2002)

-integrates nursing science, computer science, and information
science to manage and communicate data, information, and
knowledge in nursing practice.
-facilitates the integration of data, information, and knowledge to
support patients, nurses, and other providers in their decision
making in all roles and settings.
-accomplished through the use of information structures, information
processes, and information technology.

Nursing workflow includes:

Patient care responsibilities
Patient scheduling
Medication and treatments
Admission, transfer, discharge

Agenda for nursing informatics

Technology Informatics Guiding Education Reform (TIGER, 2007)
laid out ten-year vision and three-year action plan for technology
leadership and education
TIGER vision
Allow informatics tools, principles, theories and practices to be used
by nurses to make healthcare safer, effective, efficient, patientcentered, timely, and equitable
Interweave enabling technologies transparently into nursing practice
and education, making information technology the stethoscope for the
21st century

Position statement from National League for Nursing advocates

preparing next generation of nurses to practice in a technologyrich environment (2008)

60% believe that informatics nurses have a high degree of impact on the quality of care
provided to patients.
Informatics nurses bring value to the implementation phase (85%) and optimization phase
(83%) of clinical systems processes.
Informatics nurses are beginning to play a critical role in ensuring user acceptance (75%)
and the appropriate adoption of emerging technologies; 70% agreed that nurses play an
important role in medical device integration.

Thank You!
UP Manila, Mapua, PCG-ELSI (Drs. Badong Caoili, Lemuel
Tayo and Peter Sy)
Dr. Bill Hersh, OHSU
Colleagues at Charles Drew Center for Biomedical
Informatics (Drs. Lola Ogunyemi, Robert Jenders, Sheba
George, Paul Robinson)
MSU hosts Dr. Arnold Lubguban and Dean Clowe