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![EHR/HIS Adoption in Thailand (2011)
Abstract ePHIS
None 2% THIADES 1%
HoMC 2% HIMS
2% 1%
Other
7%
MedTrak/
TrakCare
2%
H.I.M. Professional
2%
MRecord
2%
Mit-Net HOSxP
2% SSB 50%
4%
Hospital OS
7%
Self-developed or outsourced
16%
Theera-Ampornpunt, 2011 [Dissertation]](https://image.slidesharecdn.com/ehrs-itcs404-120128000818-phpapp02/75/Electronic-Health-Records-ITCS404-IT-for-Healthcare-Services-47-2048.jpg)
![Personal Health Records (PHRs)
• “An electronic application through which individuals can access, manage
and share their health information, and that of others for whom they are
authorized, in a private, secure, and confidential environment.” (Markle
Foundation, 2003)
• “A PHR includes health information managed by the individual... This
can be contrasted with the clinician’s record of patient encounter–related
information [a paperchart or EHR], which is managed by the clinician
and/or health care institution.” (Tang et al., 2006)](https://image.slidesharecdn.com/ehrs-itcs404-120128000818-phpapp02/75/Electronic-Health-Records-ITCS404-IT-for-Healthcare-Services-72-2048.jpg)
Uploaded byNawanan Theera-Ampornpunt
Electronic Health Records (ITCS404: IT for Healthcare Services)
The document provides an overview of electronic health records (EHRs) and their significance in healthcare, detailing their functionalities, uses, and the barriers to their adoption. It discusses the importance of medical records for patient continuity, safety, and communication among healthcare providers, along with the benefits of EHRs in improving clinical outcomes and operational efficiency. Additionally, it highlights the challenges faced in implementing EHR systems and the necessary support from political entities to enhance health information technology.
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Electronic Health Records (ITCS404: IT for Healthcare Services)
- 1. Electronic Health Records ITCS 404: IT for Healthcare Services Nawanan Theera-Ampornpunt, MD, PhD Faculty of Medicine Ramathibodi Hospital Jan 18, 2012 http://www.slideshare.net/nawanan
- 2. A Bit AboutMyself 2003 M.D. (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) Health Informatician/Systems Analyst Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University [email protected] Research interests: • Health IT applications in clinical settings (including EHRs) • Health IT “adoption” • Health informatics education
- 3.
- 4. What Is AMedical Record?
- 5. What Is AMedical Record? • A record or documentation of a patient’s medical history, examination, and treatments. • Medical Record vs. Health Record – Essentially the same
- 6. Class Exercise 1 •Why do we need a health record?
- 7. Class Exercise 1 •Why do we need a health record? • In other words, why do we need a documentation of a patient’s medical care?
- 8. Potential Uses ofMedical Records • Continuity of providing care – Note important information for later use – Especially important in chronic diseases (e.g. hypertension, diabetes) or in follow-up (e.g. after surgery) • Patient safety – Preventing something bad because of lack of information – Such as drug allergies, list of current medications, “problem list”
- 9. Potential Uses ofMedical Records • Communications between providers – Referral to specialists or other physicians – Consulting among physicians – Communications between physicians and nurses, pharmacists, physical therapists, etc. – Transfer from a hospital to another • Medico-legal purposes – e.g. Court evidence against malpractice – What was done or provided to the patient? Why? By whom? When? – Was the care provided up to the professional standard?
- 10. Potential Uses ofMedical Records • Claims and reimbursements – What services were provided to the patient – How (and how much) will the hospitals/doctors be paid? – Audit of medical records by “payers” • Patient’s uses – Health insurance claims – Self-education & self-care • Clinical research – Find ways to improve health care through new knowledge
- 11. Class Exercise 2 •What do you think should be in the medical records?
- 12. Data Elements inMedical Records • Patient demographics • General information about each visit (visit = encounter) – Type (outpatient, inpatient, emergency) – Date/Time – Location (clinic or ward) “Clinical Notes” • Patient’s problems (“Patient history”) – Chief complaint – Present illness – Past history – Family and social history
- 13. Data Elements inMedical Records • Clinical findings by physicians (“Physical examination”) – Any important positive (usually abnormal) findings – Also important negative (usually normal) findings • “Investigations” – Laboratory tests (blood tests, urine, etc.) – Radiological examinations (X-rays, CT, MRI, ultrasound) – Other diagnostic procedures • Electrocardiography (EKG/ECG) -- heart’s function • Electroencephalography (EEG) -- brain wave scans • Etc.
- 14. Data Elements inMedical Records • “Problems” or “Diagnoses” – Summary of problems relevant to this visit • Treatments – Medications – Surgical procedures – Advice to patients – Admission (hospitalization) • Plans – Surgeries – More investigations to be done later – Follow-up appointments
- 15. Data Elements inMedical Records • Inpatient clinical notes – Admission notes – Orders (medications, procedures, investigations, nursing care, etc.) – Medication administration records – Vital signs and other measurements – Results of lab tests and radiological examinations – Progress notes – Discharge summary
- 16. “Electronic” Medical Records •Electronic Medical Records (EMRs) vs. Electronic Health Records (EHRs) • Debate about similarities & differences • Summary – Definitions subjective, depending on how people think – EMRs mostly refer to electronic documentation of medical care at one visit – EHRs mostly refer to electronic documentation that is longitudinal in nature (may be several visits) – EMRs commonly used in Thailand (but means the same as EHRs)
- 17. Various Forms ofHealth IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records Picture Archiving and (EHRs) Communication System (PACS)
- 18. Still Many OtherForms of Health IT Health Information Exchange (HIE) m-Health Biosurveillance Personal Health Records (PHRs) Telemedicine & Information Retrieval Telehealth Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
- 19. Longitudinal Records • Recordsdocumented over time (multiple encounters) • Ideally, “life-long” is a complete record of the patient’s health
- 20. The Confusing Acronyms Computer-Based Patient Records Electronic Medical (CPRs) Records (EMRs) Electronic Patient Electronic Health Records (EPRs) Records (EHRs) Personal Health Records (PHRs) Hospital Information Systems (HIS)
- 21. Benefits of EHRsand EHR Adoption
- 22. Innovation Adoption • Innovation:“an idea, practice, or object that is perceived as new by an individual or other unit of adoption” – EHRs and health IT are innovation • Adoption: “a decision to make full use of an innovation as the best course of action available” • Diffusion of innovations theory (Rogers, 2003)
- 23. Class Exercise 3 •Why do we need to “adopt” an electronic version of medical records?
- 24. Common “Goals” for EHRs/Health IT Adoption “Computerize” “Go paperless” “Get an electronic copy “Digital Hospital” “Have EMRs” “Modernize” “Share data”
- 25. Is There ARole for Health IT? (IOM, 2000)
- 26. Landmark IOM Reports (IOM,2000) (IOM, 2001)
- 27. Landmark IOM Reports:Summary • Humans are not perfect and are bound to make errors • Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality • Recommends reform that would change how health care works and how technology innovations can help improve quality/safety
- 28. Why We NeedHealth IT • Health care is very complex (and inefficient) • Health care is information-rich • Quality of care depends on timely availability & quality of information • Clinical knowledge body is too large • Short time during a visit • Practice guidelines are put “on-the-shelf” • “To err is human”
- 29. To Err IsHuman • Perception errors Image Source: interaction-dynamics.com
- 30. To Err IsHuman • Lack of Attention Image Source: aafp.org
- 31. Class Exercise 3 The Economist Purchase Options • Economist.com subscription $59 • Print subscription $125 • Print & web subscription $125
- 32. Class Exercise 3 The Economist Purchase Options • Economist.com subscription $59 • Print & web subscription $125
- 33. To Err IsHuman • Cognitive Errors - Example: Decoy Pricing # of The Economist Purchase Options People • Economist.com subscription $59 16 • Print subscription $125 0 • Print & web subscription $125 84 # of The Economist Purchase Options People • Economist.com subscription $59 68 • Print & web subscription $125 32 (Ariely, 2008)
- 34. What If ThisHappens in Healthcare? • It already happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005) • What if health IT can help?
- 35. Fundamental Theorem ofInformatics (Friedman, 2009) (Friedman, 2009)
- 36. Underlying Assumption Adoption Use of Better of EHRs EHRs Outcomes
- 37. Underlying Assumption • Better clinical outcomes • Improved patient satisfaction Individual • More provider productivity/satisfaction Adoption & use • Improved operational efficiency • Better data for research, quality improvements • Reduced costs/increased revenues (e.g. better Organizational Adoption & Use claims & reimbursements) • Better individual health/quality of life • Better population health Societal • Long-term cost savings Adoption & Use
- 38. Benefits of GoingElectronic (EHRs) • Ubiquitous availability (anytime, anywhere, everyone who is authorized) • Multiple concurrent uses • The end of “Where the heck is the patient’s record?!?” • Ability to control & enforce access security • Structured data entry possible • Data presentation that is easier to understand (e.g. graphs) • Efficiency in data entry? (but sometimes it slows users down!) • Process improvement (business process reengineering/redesign, quality improvement) • No doctor’s handwriting!!!!!
- 39. Electronic Health Record(EHR) Systems • Are they just electronic documentation? History Diag- Treat- ... & PE nosis ments • Or do they have some other values?
- 40. Literature Shows Benefitsof Health IT • Literature suggests improvement in health care through – Guideline adherence – Better documentation – Practitioner decision making or process of care – Medication safety – Patient surveillance & monitoring – Patient education/reminder – Cost savings and better financial performance
- 41. Functions That Shouldbe Part of EHR Systems • Patient Demographics • Physician Notes • Computerized Medication Order Entry • Computerized Laboratory Order Entry • Computerized Laboratory Results • Problem Lists • Medication Lists • Discharge Summaries • Diagnostic Test Results • Radiologic Reports
- 42. Adoption of HealthIT: United States U.S. Ambulatory Setting 100 90 % of Physicians 80 70 60 50 48.3 50.7 34.8 42.0 40 30 23.9 29.2 24.9 20 18.2 17.3 17.3 20.8 16.9 21.8 9.3 10.5 11.8 10 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year of Study Any EHR EHR with Basic Features Basic Features: Demographics, problem lists, clinical notes, test results, imaging results, order entry for medications Source: National Ambulatory Medical Care Survey (NAMCS) 2001-2010
- 43. Adoption of HealthIT: United States U.S. Inpatient Setting 2008 2009 – Basic EHRs 7.2% 9.2% – Comprehensive EHRs 1.5% 2.7% – Computerized 17% 34% Order Entry for Medications Sources: Jha et al., 2009 & 2010
- 44. Definitions for AdoptionRates Functions Jha et al. Basic EHR Comprehensive EHR Demographics Physicians’ notes Nursing assessments Problem lists Medication lists Discharge summaries Advanced directives Test and imaging results Laboratory reports Radiologic reports Radiologic images Diagnostic-test results Diagnostic-test images Consultant reports Computerized provider-order entry Laboratory tests Radiologic tests Medications Consultation requests Nursing orders Decision support Clinical guidelines Clinical reminders Drug-allergy alerts Drug-drug-interaction alerts Drug-laboratory interaction alerts Drug-dose support
- 45. EHR Adoption: Thailand(2011) Estimate (Partial or Complete Nationwide Adoption) Basic EHR, combined inpatient & 49.8% outpatient settings Comprehensive EHR, combined 5.3% order entry of medications, combined 90.2% order entry of all orders, combined 79.4% Basic EHR: a score > 1 in a 5-point scale for IT support for demographics, MD notes, nursing assessments (inpatient only), discharge summaries (inpatient only), test results, order entry for medications Comprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, order entry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts
- 46. EHR/HIS Adoption inThailand (2004) Pongpirul et al., 2004
- 47. EHR/HIS Adoption inThailand (2011) Abstract ePHIS None 2% THIADES 1% HoMC 2% HIMS 2% 1% Other 7% MedTrak/ TrakCare 2% H.I.M. Professional 2% MRecord 2% Mit-Net HOSxP 2% SSB 50% 4% Hospital OS 7% Self-developed or outsourced 16% Theera-Ampornpunt, 2011 [Dissertation]
- 48.
- 49. EHR Systems/HIS: Issues •Functionality & workflow considerations • Structure & format of data entry – Free text vs structured data forms – Usability – Use of standards & vocabularies (e.g. ICD-10, SNOMED CT) – Templates (e.g. standard narratives, order sets) – Level of customization per hospital, specialty, location, group, clinician – Reduced clinical value due to over-documentation (e.g. medico-legal, quality accreditation) – “Copy & Paste” garbage – Special documents (e.g. operative notes, anesthetic notes) – Integration with paper systems (e.g. scanned records, legal documents)
- 50. EHR Systems/HIS: Issues •Reliability & contingency/business continuity planning • Roll-out strategies & change management • Are they going to slow down patient care process? • System Interfaces
- 51. Class Exercise 4 •What do you think is better for EHRs: structured or unstructured data?
- 52.
- 53. Facilitators of EHRAdoption Jha et al. (2009)
- 54. Barriers to EHRAdoption Jha et al. (2009)
- 55. EHR Adoption Barriers (Why People Don’t Use EHRs?) • “Workarounds”
- 56. EHR Adoption Barriers (Why People Don’t Use EHRs?) • Technical & design issues – Poor software implementation • Does not meet requirements • Buggy – Poor usability and user experience • Complex/clunky UI • Easy to make error or miss something – Poor system performance • Slow • Unreliable
- 57. EHR Adoption Barriers (Why People Don’t Use EHRs?) • Management issues – Does not seem to improve their work process – Too much work entering data – Unclear values to users (or even negative outcomes!) • “Unintended consequences” of using health IT – Executives not fully supporting the project – “Power shift” among users – Communications and engagement (involvement) of users early and repeatedly during various phases of the project – Poor training and technical support – Users perceived they are treated poorly or their voices are not heard
- 58. The Importance of“Change Management” “One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated” Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”
- 59. Public Policy onEHR Adoption
- 60. Political Support BehindHealth IT ? “...We will make wider use of electronic records and other health information technology, to help control costs and reduce dangerous medical errors.” President George W. Bush Sixth State of the Union Address January 31, 2006 Source: Wikisource.org Image Source: Wikipedia.org
- 61. President Obama BacksHealth IT “...Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives.” President Barack Obama Address to Joint Session of Congress February 24, 2009 Source: WhiteHouse.gov
- 62. American Recovery &Reinvestment Act • Contains HITECH Act (Health Information Technology for Economic and Clinical Health Act) • ~ 20 billion dollars for Health IT investments • Incentives & penalties for providers
- 63. National Leadership (U.S.) Office of the National Coordinator for Health Information Technology (ONC -- formerly ONCHIT) David Blumenthal, MD, MPP National Coordinator for Health Information Technology (2009 - 2011) Farzad Mostashari, MD, ScM National Coordinator for Health Information Technology (2011 - Present) Photos courtesy of U.S. Department of Health & Human Services
- 64. What is inHITECH Act? Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
- 65.
- 66. “Meaningful Use” “Meaningful Use” Pumpkin of a Pumpkin Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
- 67. “Meaningful Use” ofHealth IT Stage 1 - Electronic capture of Better health information - Information sharing Stage 3 Health - Data reporting Stage 2 Use of EHRs to Use of improve EHRs to outcomes improve processes of care (Blumenthal D, 2010)
- 68. Meaningful Use FinalRule: Core Objectives (Selected) • Electronic capture of information – Demographics – Vital signs – Medication list – Allergies – Problem list – Smoking • Medication order entry • Drug-allergy & drug-drug interaction checks • Patient access to/copy of health information
- 69. Meaningful Use FinalRule: Menu Set (Selected) • Drug formulary checks • Lab results incorporation into EHRs • Generate lists of patients by specific conditions • Medication reconciliation • Electronic reporting to governmental agencies • Advanced directives for elderly patients • Patient reminders for certain services (for clinics) • Patient access to health information (for clinics)
- 70. Final Rule onStandards & Certification Criteria (Selected) • Content Exchange Standards – HL7 CDA Release 2 & CCD – NCPDP SCRIPT • Vocabularies – SNOMED CT – LOINC® – RxNorm ® • Security – NIST-certified encryption algorithms • Etc.
- 71. Personal Health Records (PHRs)
- 72. Personal Health Records(PHRs) • “An electronic application through which individuals can access, manage and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.” (Markle Foundation, 2003) • “A PHR includes health information managed by the individual... This can be contrasted with the clinician’s record of patient encounter–related information [a paperchart or EHR], which is managed by the clinician and/or health care institution.” (Tang et al., 2006)
- 73. Types of PHRs •Patient portal from a provider’s EHRs (“tethered” PHRs) • Online PHRs – Stand-alone – Can be integrated with EHRs from multiple providers (unidirectional/bidirectional data sharing) • Stand-alone PHRs – PC-based applications – USB Drive – CD-ROM or other data storage devices – Paper
- 74. Ideal PHRs • Integrated •Accessible • Secure • Comprehensive • Accurate & current • Patient able to manage sharing & update information • Engaging & educational • User-friendly, culturally & literacy appropriate The “Hub and Spoke” Model (Kaelber et al., 2008)
- 75. Use Cases ofPHRs • Data entry/update by patients • Data retrieval by providers – With patient’s consent – “Break-the-glass” emergency access • Data update from EHRs • Privacy settings • Personalized patient education • Communications with providers
- 76. EHRs and theBigger Picture
- 77. Health Information Exchange(HIE) Government Hospital A Hospital B Clinic C Lab Patient at Home
- 78. Google Flu Trends (Biosurveillance) Source: Google.org/FluTrends
- 79. Implications • This iswhy we need standards!!! – Information exchange from one EHR system to another needs standards – Seamless exchange of information would improve quality, continuity, and efficiency of care
- 80. Summary • EHRs (orEMRs) are both – Electronic documentation of patient care and – a broad term for an information system used to improve the process of patient care through better documentation and other care processes such as ordering medications, lab tests, or x-rays and viewing lab results and x- ray reports (among others)
- 81. Summary • It isimportant to focus both on the technical aspect of EHR implementation as well as the management aspect (such as change management) • Otherwise, a well-designed system may not be used, and patient care is not improved • Many countries are trying to improve the EHR “adoption rate” • EHRs are just one piece of the big puzzle for the whole healthcare system • PHRs are a separate, but related concept of EHRs
- 82.