HIMSS EMRAM ChienYeh Hsu Ph D National Taipei

電子病歷推動與美國醫療資訊暨管理系 統協會之電子病歷採用模型 HIMSS EMRAM Chien-Yeh Hsu 徐建業 Ph. D 台北護理健康大學資訊管理系所 National Taipei University of Nursing and Health Sciences 台北醫學大學醫學資訊研究所 Taipei Medical University 台灣醫學資訊學會 Taiwan Association for Medical Informatics TAMI 1

二代醫療資訊網HIN 2. 0計畫 國家醫療資訊交換中心 Medical Information Exchange Center - MIEC

CA - Certificate Authority PRF - Patient Request Form HRF - Hospital Request Form HIS - Hospital Information System RS – Resource Server Patient Results (in XML) Secure e-mail, Fax, Voice, Mobile phone MIEC 2. 0 SSL CA Mail Server Web Server Internet or HIN 2. 0 PRF HRF Audit SSL Query (in HL 7) Secure e-mail HIN 2. 0 or Internet Hospital HL 7 Agent RS HL 7 Inter -face HIS

個人化健康資訊整合架構 TMT File Exchange Pathway Hospital Information System 1 TMT viewer Laboratory Information Systems 2 Data Mapping Gateway Laboratory Information Systems Data Mapping Gateway 3 Pre-Authorized TMT File TMT PHS File Personal Health Records Paperless server TMT mini-server TMT PHS File Personal Health 4 Records TMT mini-server Internet Health and Life Supporting Data Bank

HIT-Enabled Health Reform Achieving Meaningful Use of EMR 2009 2011 2012 -2013 2015 HIT-Enabled Health Reform Policies in Legislation (法案及規則建 立) National health insurance Stage 1 Meaningful Use Criteria (資料取得，決策支 援，品質測量) Capture/share data/decision support/quality measurement 需要完成的要求criteria Edward H. Shortliffe, MD, Ph. D Stage 2 Meaningful Use Criteria (持續醫療品質改善， 結構化的HER交換) Continuous quality improvement, structured exchange Stage 3 Meaningful Use Criteria (醫療品質，安全，效率， 自我健康管理) Quality, safety, efficiency, patient self-management to Improve Outcomes

EMR Exchange Center EMR providing Hospitals National EEC Center EMR Reading Hospitals Download, Querying, and Reading

Ministry of Health Image Exchange Center Health Insurance Center Index Server 134 hospitals, 2010 -2011 upload index 2, 168, 063 request: 6, 592 download: 81, 108 Hospital B Hospital A e. Signature Radiology Image Report Database CPOE Download image 8 Request for image Image Report Database Radiology CPOE Download image Dual Card system and inform consent Request for image inform consent

Surveys for Taiwan’s EHR project Government should establish software standards for EMR system Exchange of EMR should contain a serious and dangerous contagious diseases Department of Health should establish a secure trust information center for EMR storage and exchange control. Hospitals use EMR is the future trend. Government should set up education and training team to help hospitals to promote EMR Healthcare authorities should be more actively involved in funding and increasing manpower to accelerate the Smart Healthcare Project Government should be more actively educate the public and promote the EMR exchange policy. Regulations should be amended with the implementation of EMR Healthcare authorities should be more widely to promote the interpretation and exchange of medical image The Government should fully promote the implementation of Score from 1 to 7, all >5. 1 EMR in hospitals

Surveys for Taiwan’s EHR project Healthcare authorities should be more widely to promote security RFID systems used in health care facilities RFID chip technology can be used for hospital safety concern Use of EMR can promote personal health management The use of EMR can promote the development of domestic information industry Hospital may re-plan their service processes due to the implementation of EMR Implementation of EMR can reduce the medical expenses for national health insurance EMR should use the new version of ICD-10 (International Classification of Diseases coding) Use of EMR can enhance the national competitiveness In the future, patient’s data can be stored in cloud computing architecture Patients should be able to access their own EMR

HIMSS EMRAM 介紹 HIMSS Analytics Asia 簡介。 HIMSS EMRAM之介紹與探討。 HIMSS EMRAM之醫院評價流程。 HIMSS EMRAM作為國內電子病歷評價之可行性 探討。 12

HIMSS EMRAM 介紹 HIMSS Analytics Asia 簡介。 HIMSS EMRAM之介紹與探討。 HIMSS EMRAM之醫院評價流程。 使用HIMSS EMRAM作為國內電子病歷評價之可 行性探討。 15

HIMSS EMRAM 介紹 HIMSS Analytics Asia 簡介。 HIMSS EMRAM之介紹與探討。 HIMSS EMRAM之醫院評價流程。 HIMSS EMRAM作為國內電子病歷評價之可行性 探討。 20

HIMSS EMRAM之醫院評價流程 ◦ EMRAM 亞洲地區的評鑑項目： 將“Closed Loop Medication Administration”從第 5級移到第 6級，”Full Radiology PACS” 從第 6級移到第 5級。 Stage 6 Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS Stage 5 Closed loop medication administration Stage 4 CPOE, Clinical Decision Support (clinical protocols) Stage 3 Stage 2 Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable Stage 1 Ancillaries – Laboratory, Radiology, Pharmacy – All Installed Stage 0 All Three Ancillaries Not Installed Stage 7 24

United States EMR Adoption Model SM Stage Cumulative Capabilities 2013 Q 3 2013 Q 4 2. 2% 2. 9% 11. 1% 12. 5% 20. 9% 22. 0% 15. 1% 15. 5% 31. 9% 30. 3% 8. 4% 7. 6% Stage 1 Ancillaries - Lab, Rad, Pharmacy - All Installed 3. 5% 3. 3% Stage 0 All Three Ancillaries Not Installed 6. 9% 5. 8% Complete EMR; CCD transactions to share data; Stage 7 Data warehousing; Data continuity with ED, ambulatory, OP Physician documentation (structured templates), Stage 6 full CDSS (variance & compliance), full RPACS Stage 5 Closed loop medication administration CPOE, Clinical Decision Support (clinical protocols) Nursing/clinical documentation (flow sheets), Stage 3 CDSS (error checking), PACS available outside Radiology CDR, Controlled Medical Vocabulary, CDS, Stage 2 may have Document Imaging; HIE capable Stage 4 Data from HIMSS Analytics® Database © 2012 n=5437 n=5458 25

EMR Adoption Comparisons Across Regions EMRA United M Stage States Canada Germany Italy Spain Sweden UAE Singapore 7 1. 20% 0. 00% 0. 87% 0. 00% 6 5. 20% 0. 50% 0. 00% 1. 35% 4. 59% 2. 94% 0. 00% 66. 67% 5 8. 40% 0. 20% 11. 30% 2. 70% 32. 11% 26. 47% 16. 67% 0. 00% 4 13. 20% 2. 30% 6. 96% 5. 41% 14. 68% 2. 94% 2. 78% 0. 00% 3 44. 90% 36. 50% 7. 83% 8. 56% 0. 00% 2 12. 40% 20. 4% 12. 17% 15. 77% 12. 84% 35. 29% 33. 33% 1 5. 70% 14. 50% 1. 74% 6. 42% 11. 76% 2. 78% 30. 18% 9. 17% 0. 00% 30. 56% 0. 00% 0 9. 00% 25. 60% 59. 13% 36. 04% 20. 18% 20. 59% 13. 89% No. of Hospitals 5337 641 115 222 109 34 36 0. 00% 6

Description of Each Stage of the HIMSS Analytics Asia EMR Adoption Model EXPLANATION AND VALUE From HIMSS Analytics Asia 27

Stages 0 and 1 Stage 0 – Laboratory, Pharmacy, or Radiology are not installed. ◦ The patient record is paper based ◦ There may be some departmental systems, but they are not integrated ◦ Value: Departmental process improvement Stage 1 – The core ancillary systems are automated – Laboratory, Pharmacy, and Radiology ◦ ◦ ◦ The patient record is still primarily paper based Core clinical departmental systems are installed Systems not yet integrated Data is not yet being stored in a central database Value – Core clinical data related to results and medications are stored electronically 28

Stages 2 and 3 Stage 2 – A Clinical Data Repository is installed ◦ A central database containing core clinical data from the core ancillary departments ◦ The ancillary systems (laboratory, radiology, and pharmacy) are integrated through the clinical data repository ◦ Value: provides the platform for allowing access to key clinical data through one user interface. Creates the foundation for a patient centric electronic medical record Stage 3 – Order Entry, Nursing Documentation, and Electronic Medication Administration Record (EMAR) Installed ◦ Further capture of core clinical data ◦ Value: Allows for basic clinical decision support including duplicate order checking, order sequencing, microbiology and 29 pharmacy communication (e. g. antibiotic appropriateness)

Stages 4 and 5 Stage 4 – Computerized Practitioner Order Entry in at least one inpatient unit ◦ Physicians are entering their own orders ◦ Clinical Protocols available ◦ Value: Standardized and improved care delivery. Intermediate clinical decision support available to physicians thereby reducing the potential for medical errors. Stage 5 – Full Radiology Picture Archiving Computerized System ◦ All images are available for review in the Electronic Medical Record environment ◦ Value: Improved diagnostic efficiency and further elimination of paper 30

Stages 6 Stage 6 – Physician Documentation installed with structured templates in at least one inpatient unit, Full CDSS, and Closed Loop Medication Administration is being practiced ◦ Capture of structured data through the use of templates ◦ Physician Documentation with underlying clinical decision support (e. g. evidenced based clinical advice triggered from documentation) ◦ Use of bar coding at the point of care in the administration of medication – the patient and medication (unit dose) must be bar coded ◦ 5 Rights of closed loop medication administration – the right patient, right drug, the right dose, the right route, and the right time ◦ Value: Eliminates medication errors and improves patient safety and patient and family confidence. Structured data allows for data 31 sharing and sophisticated analytics

Closed Loop Medication Administration – Biggest Challenge to achieving Stage 6 e. MAR (Electronic Medication Administration Record) is updated and available for review and CDSS interactions Medication orders that pass CDSS flow to Pharmacy CPOE e. MAR Nurse scans patient and medication after logging onto scanner for five rights CDSS – “Passed” POC(Point of Care) medications are Administration administered Pharmacy Nurse retrieves medication from ADM and takes it to patient Pharmacy validates order and dispenses medication to ADM or floor ADM

Ward-based automated dispensing Nurse selecting stock medication from drawer in automated cabinet. The patient-specific drawers can be seen below the open drawer, and the screen to the right. -- in a 28 -bed general surgery ward of a London teaching hospital. Franklin, B. D. , O’Grady, K. , Donyai, P. , Jacklin, A. , & Barber, N. (2007). The impact of a closed-loop electronic prescribing and 33 administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care, 16, 279– 284.

Electronic drug trolleys One drawer is allocated to each patient for whom medication is due and their name shown on the liquid crystal display. The barcode scanner is on the top of the trolley. -- in a 28 -bed general surgery ward of a London teaching hospital. Franklin, B. D. , O’Grady, K. , Donyai, P. , Jacklin, A. , & Barber, N. (2007). The impact of a closed-loop electronic prescribing and 34 administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care, 16, 279– 284.

Stages 7 Stage 7 – Complete EMR, Continuum of Care Document (CCD) transactions for the sharing of data, Data Warehousing, Data Continuity, and Health Information Exchange ◦ No paper charts used for patient care throughout the hospital ◦ 90 percent of all medical orders entered by physicians in CPOE ◦ Use of discrete data in business intelligence and clinical data warehouses to analyze outcomes, protocols, and care delivery processes ◦ Use of CCD transactions to share data with other organizations ◦ Interoperability of data flows between inpatient, emergency department and outpatient ◦ No film in radiology ◦ Value: discrete data supports sharing with all stakeholders; market efficiency 35

HIMSS EMRAM 介紹 HIMSS Analytics Asia 簡介。 HIMSS EMRAM之介紹與探討。 HIMSS EMRAM之醫院評價流程。 HIMSS EMRAM作為國內電子病歷評價之可行性 探討。 38

Developmental goals of different EMRs evaluation systems [1]陳正美、徐建業(2012)：美、台、中電子病歷評價體系之比較研究，病歷資訊管理期刊，第 11 卷第 2 期。 [2] Chen CM, Hsu CY, J Andrew Worley. Evaluation Systems of the Electronic Medical Records: A Comparative Study. In: Proceedings of 4 th IEEE International Conference on Software Engineering and Service Sciences. 43 China: Beijing, 2013.

[1]陳正美、徐建業(2012)：美、台、中電子病歷評價體系之比較研究，病歷資訊管理期刊，第 11 卷第 2 期。 [2] Chen CM, Hsu CY, J Andrew Worley. Evaluation Systems of the Electronic Medical Records: A Comparative Study. In: Proceedings of 4 th IEEE International Conference on Software Engineering and Service 44 Sciences. China: Beijing, 2013.

[1]陳正美、徐建業(2012)：美、台、中電子病歷評價體系之比較研究，病歷資訊管理期刊，第 11 卷第 2 期。 [2] Chen CM, Hsu CY, J Andrew Worley. Evaluation Systems of the Electronic Medical Records: A Comparative Study. In: Proceedings of 4 th IEEE International Conference on Software Engineering and Service 45 Sciences. China: Beijing, 2013.

[1]陳正美、徐建業(2012)：美、台、中電子病歷評價體系之比較研究，病歷資訊管理期刊，第 11 卷第 2 期。 [2] Chen CM, Hsu CY, J Andrew Worley. Evaluation Systems of the Electronic Medical Records: A Comparative Study. In: Proceedings of 4 th IEEE International Conference on Software Engineering and Service 46 Sciences. China: Beijing, 2013.

近期 作事項 Ø 2012年 5月完成HIMSS EMRAM 教育訓練-種子教練。 Ø HIMSS 專人來台教育訓練 1小時專題演講+3小時演練操作 示範，包括： ◦ ◦ Method of filling in data+Things-to-note Essential and additional questions to answer Study Walkthrough Section-by-section walkthrough Ø 2012年 5月底完成HIMSS EMRAM 翻譯，包括問卷及說明 ，繁體中文版已經架設在HIMSS EMRAM網站上。 49

05/2012 HIMSS EMRAM教育訓練 HIMSS Analytic Asia主席 Dr. Steven 與學員進行討論 HIMSS Analytic Asia 程師說明HIMSS EMRAM調查內容 Day 2學員上機操作情形 學員聽講情形 50

Benchmarking Reports 與同為第 6級之其他醫院，在 operating revenue 上做比較 5億美元 54

Benchmarking Reports 與同為第 6級之其他醫院，在 operating expense上做比較 5億美元 55

Benchmarking Reports 42, 651, 000 NTD 56

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歡迎 各醫療機構參與認證 Ø 聯絡人姓名 徐建業 : cyhsu@tmu. edu. tw 陳正美 : d 610100003@tmu. edu. tw 饒孝先 : rauhh@gmail. com Ø 電話 02 -27361661 #3349 Ø 電話 02 -28227101 #2210, 3921, 3924 Ø 0939193212 59

謝謝聆聽 Chien-Yeh Hsu 徐建業教授 台北護理健康大學 臺北醫學大學 臺灣醫學資訊學會 National Taipei University of Nursing and Health Sciences Taipei Medical University Taiwan Association for Medical Informatics, TAMI http: //gimi. tmu. edu. tw/Prof. 0939193212 e-mail: cyhsu@tmu. edu. tw, cyhsu@ntunhs. edu. tw 60