Electronic Health Record Systems

Samuel Volchenboum!
July 5, 2011!
Week 3 - Medical Informatics 403DL!

Today

Background - Hardware, software, databases!

Electronic Health Systems!

Housekeeping

White papers due Monday, July 11!

Midterm - will be a mix of short-answer, multiple choice and T/F!

Available from 6/13 until 6/18!

Book Recommendation

Hardware
http://www.cdfreaks.com!

http://www.geeky-gadgets.com!

apple.com!

Server!
Share resources with other computers!
Support the activities of many users simultaneously!

Personal Computer!
vs.!
Workstation!
!

Computers use binary

http://www.thinkgeek.com!

Storage

Primary (memory)!

Secondary (hard drives, memory sticks)!

Tertiary (tape libraries, jukeboxes)!

Off-line (archival)!

What are some good methods for archival storage?!

What are some drawbacks?!

http://bit.ly/1yAHN David Pogue article about Data Rot!

A history of removable media

http://apple2.info/wiki/index.php?title=Floppy_Drives!

1987!
1440KB!

1970s!
79KB 1200KB!

CD!

1980s!
113KB 1200KB!

DVD!

http://www.raminc.com!

1990s!
1MB 1GB!

Flash drives

=!
16GB Flash Drive!

11,000 Floppies!

Other terms you should understand

Wide area network (WAN) vs. local area network (LAN)!

Bridges / routers / switches!
TCP/IP!
Domain name system (DNS) / IP addresses!
SQL / Access / Oracle!
FTP / Telnet / SSH / SMTP!
HTML vs. XML!
Firewall!
Virtual private network (VPN)!
Cryptography - public / private key!
Digitally signed certificates / SSL!

XKCD!

How does hardware help with accountability?

Surveillance!

Staff should know that there is a audit trail that will be scanned!

Technical controls!

Authentication - user/pass or RFID!

Authorization - user-specific limited access to data!

Electronic Health Record Systems

EHR vs. Computer-based record system!

EHR vs. Paper record!

How can the components of an EHR speak the same language?!

Clinical Decision Support!

Fundamental Issues for EHR development!

EHR vs. Computer-based patient-record system

EHR!

A repository of electronically maintained information about a

persons lifetime health data!
Wellness!

Illness!

Recovery!

Computer-based patient-record system!

Adds information management tools to provide clinical reminders

and alerts!

EHR vs. paper record

Accessibility!
Paper record = 1 user at a time!
Documentation legibility!
Data is reusable!
Important factors!
Comprehensiveness of data - what pieces are missing?!
Duration of use / data retention - again, whats missing?!
Data structure - free text vs. controlled defined vocabulary!
Ubiquity of access!
A big downside for an EHR is that failure of the system can be
catastrophic!

How can EHR speak the same language?

Different patient data sources use different vocabulary and different patient
identifiers!
Administrators of each EHR system have to revise message formats and map
the codes between systems!
Most clinical data sources can deliver content as health level 7 (HL7)
messages!

HL7 is a not-for-profit group developing international health care

standards!
Provides a framework for exchange, integration, sharing and retrieval of
electronic health data!

But many deviate from these standards, so data must be mapped / tweaked!

Multiple data source integration

Laboratory!

Order Entry!

Data entry!

Results review!

Event monitor!

Medical
logic
modules!

Pharmacy!
Database
interface!

Billing and
financial
systems!
Medical
entities
dictionary!

Radiology!
Patient
database!

Research
databases!

Clinical decision support

Most effective
when provided
at the point of
care!
Yet, the physician
needs to retain
control for the
ultimate decision.!

Decision
implementation
should be easy.
eg. mouse click or
return!

http://www.health.state.ny.us/nysdoh/antibiotic/brochure.htm!

Otitis media decision pathway!

Antibiotic decision support

Vitals / WBC!
Allergies!
Current meds!
Infection!
Suggestions!

Make it so!

Pediatric encounter form

Text is age-specific!

Reminders / alerts

Heparin decision support

Drug alerts

Access to knowledge resources

Laboratory alerts

Fundamental issues for computerized EHR

Data capture!
Electronic interfaces!
Data entry!
Physician-entered data!
Data validation!
Data display!
Flowsheets of patient data!
Summaries and abstracts!
Dynamic displays!
Query and surveillance systems!
Clinical care!
Clinical research!
Retrospective studies!
Administration!

Electronic interfaces

Preferred capture method is to implement an electronic interface

between the EHR and existing data sources!

Cons: Significant investment in time and money!

Pros: Fast, reduces errors, reduces labor costs!

Data entry - coding

Pros!

Data is classified & standardized!

Coding aids in decision-making!

Cons!

Slow, time consuming, labor intensive!

Potential for coding errors - difficult to detect!

Physician-entered data

This is the biggest challenge to EHR developers!

Dictation is preferred means of note writing!

Structured encounter form can speed up data

entry and improve accuracy!
Direct entry of data by caretaker!

Data validation

Range checks (eg. potassium 50 when range is 3.5 - 5.0)!

Pattern check (eg. XXX-XXX-XXXX or XXX-XX-XXXX)!

Computed checks (eg. sum of a cell differential)!

Consistency checks (eg. pregnant + female)!

Delta checks (large jumps in values - eg. weight)!

Spelling checks!

Flowsheets of patient data

Emphasizes changes over time!

Summaries & abstracts

Current systems can summarize important components - eg.

allergies, active medical issues, current medications, etc.!
EHRs have the potential to generate more sophisticated reports
- eg. detection of adverse events!

Dynamic displays

Much of the time, it is difficult to find relevant information within

an EHR!
Has a test been ordered? Has a med been given? Are the results
back yet?!
Special displays can bring together relevant data to help facilitate
clinical thought processes and decision making!

Clinical care

Identify patients who are due for tests or procedures (eg.

immunizations, mammograms, pap smears, etc.)!
Can help find a group of patients if needed (eg. those taking a
recalled medication)!

Clinical research

Identify patients who meet criteria for certain clinical trials!

Symptoms entered can help trigger alerts and reminders about a
patients eligibility for a particular study!

Retrospective studies

Prospective vs. retrospective!

EHR can provide much of the data for a retrospective study!

The system can identify the data and also perform the statistical
analyses!
EHRs facilitate research into physician practice patterns, efficacy of
treatments/test and drug toxicity!

Administration

Claims data are difficult to use when studying practice patterns!

An EHR can provide relationships between diseases, symptoms and
resource consumption!

Next week?

Finish White Papers!

Mid-Term available!