ELECTRONIC HEALTH RECORDS 1980 90 HELP system at

전자의무기록 ELECTRONIC HEALTH RECORDS

• 1980 -90년대 임상진료 지원 기능이 추가 된 시스템 개발 – HELP system at LSD hospital (Pryor, 1988), Columbia University system (Johnson et al. , 1991), CCC system at Beth Israel Deaconess Medical Center (Slack and Bleich, 1999), Regenstrief System at Wishard Memorial Hospital (Tierney ea al. , 1993; Mc. Donald et al. , 1999)

• Ambulatory care medical record systems – COSTAR* (Barnett et al. , 1978; Barnett, 1984) – Regenstrief Medical Record System (RMRS)* (Mc. Donald et al. , 1975) *현재까지 사용됨 – STOR (Whiting-O’Keefe et al. , 1985) – TMR (Stead and Hammond, 1988)

초기 전자의무기록시스템 연도 시스템 시설 1968 COSTAR Harvard Community (HMO) 1969 CPR Kaiser Permanante (HMO) 1970 TMR (The Medical Record) Duke University Medical Center 1971 PROMIS (Problem Oriented Medical Record) Vermont Medical Center 1972 RMRS (Regenstrief Medical Record System) Indiana University Medical Center 1973 HELP LDS Hospital, Salt Lake City, Utah 1978 STOR (Summary Time Oriented Record) California University, San Francisco Medical Center

l What’s EMR l Needs for an EMR l Functionalities of an EMR l Implementation l Dissemination What’s EMR OCS Lab (LIS) ADT Nursing PACS Scheduling EMR Pharmacy Billing OCS Lab (LIS) ADT Nursing PACS Scheduling Clinical Pharmacy Billing Documentation

What’s EMR MRI (Medical Record Institute) 전자의무기록의 발 전 5단계 Level 1: AMR (Automated Medical Record) Level 2: CMR (Computerized Medical Record) Level 3: EMR (Electronic Medical Record) Levle 4: EPR (Electronic Patient Record), CPR (Computer-based Patient Record) Level 5: EHR (Electronic Health Record) Electronic Medical Record (EMR) Electronic Patient Record (EPR) Electronic Health Record (EHR) Computer-based Patient Record (CPR) Computerized Medical Record (CMR)

EMR/EHR Industry

Key Capabilities of an EHR System[1] 1. 2. 3. 4. 5. Health information and data 건강정보(저장) Results management 결과관리 Order entry/management 처방관리 Decision support 의사결정지원 Electronic communication and connectivity 전자의사소통 6. Patient support 환자지원 7. Administrative process 행정관리 8. Reporting and population health management 보고 및 인구집단건강관리 Institute of Medicine. Key Capabilities of an Electronic Health Record System: Letter Report. 2003 (available at http: //www. nap. edu/catalog. php? record_id=10781)

DATA CAPTURE: 저장기능

1. Health information and data 건강정보(저장) – central repository for patient’s data from a variety of sources 환자데이터 중앙저장소 – Procedures, Diagnoses/ Coded or free text – 코드 표준(LOINC, Rx. Norm, SNOMED CT 등) 적용 Meaningful Use (MU 2) (Chaps. 7 & 27) [5] 2. Results management 결과관리 – From diagnostic test – Result reporting, notification, multiple views of data 3. Order entry/management 처방관리 – Order test and prescribe medication and treatment – CPOE for medication, nursing, consults

4. Decision support 의사결정지원 – Help clinicians manage care through evidence-based guidelines – 임상 의사결정을 도와주는 ‘reminders’ 기능이 임상절차를 향상시킴(Haynes 2011; Damiani et al. 2010; Schedlbauer et al. 2009) [5] – 지식원 접근: Pub. Med & Medline. Plus (NLM), CDC, AHRQ’s National Guideline Clearinghouse, Up. To. Date, Micromedex 5. Electronic communication and connectivity 전자의 사소통 – Communicate among providers and resources to coordinate care – Integrated medical records – Health Information Exchange (HIE): community-based EHRs 6. Patient support 환자지원 – Offer education for the patients – Connectivity to patient’s home: 환자 알림, home health monitoring (혈압, 혈당 등), PHR

7. Administrative process 행정관리 – Better scheduling and billing – Scheduling, eligibility determination 8. Reporting and population health management 보고 및 인구집단건강관리 – – – Patient safety and quality reporting Report infectious disease Public health reporting Disease registry Support epidemiology research

Health information and data system Narrative Natural process language n Signs & Sx: Structured, coded n Tx plan: Interdisciplinary Key Data -Level of service Narrative -Templatebased Severity of illness -Severity adjustment Key Data(Coded) Narrative - Problem list - Free text - Procedures - Structured & coded - Diagnoses *diagnoses - Medication list *procedures - Allergies - Demographics - Diagnostic test -Treatment plan *single results discipline - Radiology results - Disposition Severity of illness - nursing workload Results Management Multimedia support v. Images v. Waveforms v. Pictures v. Sounds Order Entry & Decision Support v. Diagnostic decision support v. Use of epidemiologic data Results reporting v Consults v Multimedia support v Scanned documents -Patient consents Drug alerts v. Drug dose v. Drug–lab v. Drug-condition v. Drug-diet Results reporting v Laboratory v Microbiology v Pathology v Radiology reports Computerized provider order entry v E-prescribing v Laboratory v Microbiology v Pathology v XR v Ancillary v Nursing v Supplies v Consults v Results Notification v Multiple views of data / presentation Incorporation of patient/family preferences Automated surveillance v Adverse events Clinical guidelines & and near misses pathways v v. Context-sensitive Disease outbreaks v Integrated Access to knowledge sources v Domain knowledge v Patient education Drug alerts v Drug dose defaults v Allergy checking v Drug interaction checking Reminders v Preventive services Clinical guidelines and pathways (Passive) Clinician work list

HL 7 전자의무기록 시스템의 기능모델 ANSI/HL 7 EHR System Functional Model, R 1 -2007 Direct Care DC. 1 Care Management DC. 2 Clinical Decision Support DC. 3 Operation Management & Communication Suppor S. 1 tive Clinical Support 진료 의사결정지원 임상지원 S. 2 Measurement, Analysis, Research & Reports S. 3 Administrative & Financial Inform IN. 1 ation IN. 2 Infrastr ucture IN. 3 Security 관리/의사소통 측정/분석/연구/보고 행정/재정 보안 Health Record Information & Management Registry & Directory Services 기록정보관리 등록 IN. 4 Standard Terminologies & Terminology Services IN. 5 Standards-based Interoperability IN. 6 Business Rules Management IN. 7 Workflow Management 상호운용성 비지니스규칙관리 업무흐름관리 표준용어관리

HL 7 EHR-System Functional Model, Release 2 ANSI/HL 7 EHR, R 2 -2014 (revision of ANSI/HL 7 EHR, R 1 -2007) 개요 진료 진료지원 건강지원 행정지원 기록 인프라 트러스트 인프라

HL 7 EHR-S FM Introductory Tutorial - HL 7. org

ONC Health IT Certification Criteria 출처: 유수영(2018). 대한의무기록협회 춘계학술대회

“Gathering data and interpreting their meaning are central to the health care process. (Shortliffe & Cimino, 2014)” H&P vs. SOAP History Subject C. C P. I. PHx. SHx. FHx. ROS Physical Examination Object V/S G/A HEENT C-P G-I G-U Back & Ext. Neurological Musculoskeletal Impression Assessment Plan 43

국내 의무기록서식 (예시) 한글 영문 입퇴원기록 Face sheet, Admission and Discharge record 퇴원요약 Discharge summary 병력기록 History notes 신체검진기록 (이화학검사기록) Physical examination 응급실 기록 Emergency record 경과기록 Progress notes (Admission note, Brief op, Transfer in/out note) 협의진료기록 Consultation record 수술기록 Operation record (수술동의서, 마취기록지, 수술기 록지, 조직검사기록지) 의사지시기록 Doctor’s order, Physician’s order 검사결과 (진단검사, 영상의학, 기능검사) 간호기록 Nursing record (TPR기록지, 투약기록지 포함) 44

종이기반 의무기록 VS. 전자의무기록 CDS • • • Medical Record HL 7 EHR-S FM R 2 (Universal Chart Order)1 (Care Provision) (Care Provision Support) 입퇴원기록 병력/신체검진기록 의사지시기록 경과기록 협진기록 간호경과기록 활력징후기록 투약/처치기록 검사결과 STATIC • • CP. 9. 1 Summary Record CP. 1 Clinical History CP. 4 Order CP. 3 Clinical Documentation ← OCS/CPOE CP. 3 Clinical Documentation CP. 3. 2 Clinical Measurements CP. 6 Medication, Immunization, Treatment Administration • CP. 5 Results VS. • CPS. 4 Support Order • CPS. 3 Support Clinical Documentation ← CDS • CPS. 6 Support Treatment Administration • CPS. 5 Support Results DYNAMIC 1. https: //www. nj. gov/military/vmh-policies/35 -02 -004. pdf State of New Jersey – Medical Records: Chart assembly of active medical records

인간은 누구나 실수하게 마련이다! To Err is Human: Building a safer health system (IOM, 1999) • Preventable Death: 투약사고, 수 술사고, 진단 부정확, 시스템 오류 및 장비의 문제, 감염, 수혈사고, 처 방오류 등을 포함 – 의료오류(MEDICAL ERRORS)로 사망하는 환자가 연간 48, 000 to 98, 000명 – 이 숫자는 교통사고, 유방암, AIDS 환자 사 망보다 많음 • 이로 인한 비용은 90 -150억 달러 • 정보기술을 이용하여 시스템을 개 선해야 함 Kohn LT, Corrigan JM, Donaldson MS, editors. A report of the Committee on Quality of Health Care in America, Institute 50 of Medicine. Washington, DC: National Academy Press; 2000. To err is human: building a safer health system.

의료오류의 대표적 문제: 수술오류, 약물오류 등 Sentinel events vs. Never events Source: Sentinel Event Statistics. September 30, 2009. The Joint Commission Web site Source: Adverse Health Events in Minnesota. Fifth Annual Public Report. St. Paul, MN: Minnesota Department of Health; January 2009. Available at: http: //www. health. state. mn. us/patientsafety/publica tions/ 51 consumerguide. pdf. Accessed December 30, 2009.

EMR/EHR 기술인프라 • 데이터베이스: DBMS(MUMPS, RDB), Data warehouse • 데이터교환표준 Data Exchange Standards – HL 7, DICOM, NCPDP, ANSI, ASTM International E 31 • 데이터비교표준(용어) Data Comparability Standards – Controlled vocabulary, standard vocabulary – SNOMED-CT, UMLS, ICD – LOINC, Rx. Norm, UMDNS – NDC, CPT

• 전자문서관리 Electronic Document/Content Management – Document imaging, Enterprise report management • 결과조회관리기술 Results Retrieval and Management Technology • 데이터입력기술 Data Capture Technology – 음성인식, 무선통신(PDA 등), 자연어처리 등 • Clinical Decision Support • System Communication and Networks – 아키텍쳐: Client/server architecture, web server – 네트웍: LAN, WAN • 저장기술 Storage Technology

EHR 표준개발 기구 • HL 7 Health Level 7 • HIMSS Healthcare Information and Management Systems Society • AHIMA American Health Information Management Association • ASTM American Society for Testing and Materials 미국의 산업계 표준개발 기구 • HITSP HIS Standard Panel • CCHIT Certification Commission for HIT

ASTM E 1384 -07: EHR 내용/구조표준 Standard Practice for Content and Structure of the Electronic Health Record (EHR) No Category/Segments Entity Administrative Data 1 Demographics 인적사항 Patient 2 Legal agreement 동의서 Patient 3 Financial information 진료비 Patient 4 Provider/practitioner 의사 Provider Clinical Data: Problems/Diagnoses 5 Problem list 문제목록 Problem Clinical Data: History 6 Immunization 예방접종 7 Hazardous stressor exposure 위험인자노출 Observation 8 Health history 병력 Observation Service instance

No Category/Segments Entity Clinical Data: Assessments/Examinations 9 Assessments 평가 Observation Patient-reported data 환자진술정보 Observation Clinical Data: Care/Treatment Plans 10 Clinical orders 의사처방 Orders Clinical Data: Services 11 Diagnostic tests 진단검사 12 Medications 약제 13 Scheduled appointments/events 예약 Observation Service Instance Encounter

No Category/Segments Entity Encounters: Administrative 14 Health history 병력 Encounter disposition 상태 Patient Encounters: Clinical Chief complaint/diagnosis 주호소/진단 Observation Clinical course 임상경과 Observation Therapy procedures 치료/처치 Service instance

• CDR, Central Data Repository 중앙데이터저장소 • CDS, Clinical Decision Support/rules engine 의사 결정지원 • HIE, Health Information Exchange 진료정보교류 • CPOE, Computerized Practitioner Order Entry 컴 퓨터의사처방입력 • PACS, Picture Archiving Communication System 영상정보전송시스템 • CCD, Continuity of care document 지속환자기록 • e. MAR, Electronic Medication Administration Record application 전자투약기록 2017

Percent of non-Federal acute care hospitals with adoption of at least a Basic EHR with notes system and possession of a certified EHR: 2008 -2015 출처: Henry, J. , Pylypchuk, Y. , Searcy T. & Patel V. (May 2016). Adoption of Electronic Health Record Systems among U. S. Non-Federal Acute Care Hospitals: 2008 -2015. ONC Data Brief, no. 35. Office of the National Coordinator for Health Information Technology: Washington DC. 68

MU의 3단계 • MU timeline stage 1 -3: Focus areas for each stage – Stage 1 (2011 -3): [저장] Data capture and sharing/(2016)Data capture and patient access – Stage 2 (2014 -5): [공유] Advanced clinical processes/(2016)Information exchange and care coordination – Stage 3 (2016 -7): [결과향상] Improved outcomes 2017

인증 전자의무기록과 MU • Certified EMR vs. Meaningful Use – 국가에서 인증하는 EMR은 어떤 기능? • Certification IS what the EHR can do – responsibility of ONC (how the EHR must work), CCHIT – 인증 EMR을 병원에서 어떻게 사용하는가? • Meaningful Use IS how the EHR is used – responsibility of providers and facilities (how the EHR must be used) 2017

진료정보교류(HIE)와 EMR/EHR • National Health Information Infrastructure (United States) – – – Architecture Standards and vocabularies Privacy and confidentiality Financial incentive “Meaningful Use” Consumer support Research and population • EHR system – U. K. – Canada

모바일 POC Point of Care

References [1] 김윤. 의료정보학 세미나. 서울대학교 의과대학 의료 관리학교실(대학원 강의록). 2004. [2] 강성홍 등. 병원경영정보관리(제 4판). 고려의학; 2012 대한의료정보학회. 보건의료정보학 제 3판. 현문사; 2014. [3] Abdelhak M, Grostick S, Hanken MA, Jacobs E. Health Information: Management of a strategic resource. fourth edition. Philadelphia: Saunders; 2011. [4] Shortliffe E. H. , Cimino J. J. , Forth Edition(2014), Biomedical Informatics. Springer Science+Business Media. [5] Roberto A. Rocha (2010). Personal Health Records. Biomedical Informatics Course. Marine Biological Laboratory in Woods Hole, MA