MEDICAL INFORMATION SYSTEMS Electronic Healthcare Record 1 MEDICAL

MEDICAL INFORMATION SYSTEMS Electronic Healthcare Record

1. MEDICAL INFORMATION 1. 1. TYPES OF ACTIVITY a. MEDICAL ACTIVITIES (CONSULTATIONS, VISITS) Different approaches: • • • Time oriented Patient oriented Problems oriented (Simptoms, Objective, Assesment, Plans - SOAP) Steps: • DIAGNOSING – DATA - MEDICAL OBSERVATION, INVESTIGATIONS – KNOWLEDGE - EDUCATION, ETC • THERAPY / FOLLOW-UP • NURSING

1. MEDICAL INFORMATION b. LOGISTIC SUPPORTT ADMINISTRATION ACCOUNTING c. SOCIAL CONTEXT FRAME MEDICAL DATA CENTRALISATION d. MEDICAL EDUCATION (CME) STAFF PATIENTS e. MEDICAL DOCUMENTATION f. MEDICAL RESEARCH

1. 2. CYCLES OF MEDICAL INFORMATION FLOW

1. 3. Medical activities organisational levels • PRIMARY CARE • SECONDARY (SPECIALISED) CARE • HOSPITAL HEALTHCARE UNITS • CENTRAL LEVELS : – COUNTY HEALTH DEPARTMENTS – NATIONAL LEVEL: HEALTH MINISTERY – INTERNATIONAL BODIES: WHO

1. 4. DEFINITIONS a. INFORMATIONAL SYSTEM = ensemble of structural units exchanging information between them b. INFORMATION SYSTEM = that part of the informational system which comprises computer use

Fluxul de informaţii în cadrul Sistemului Naţional Informaţional din Sănătate

Terminology • CPR (computer-based patient record) • PCR (patient-carried record) • CMR (computerized medical record) • EMR (electronic medical record) • EPR (electronic patient record) • EHR (electronic healthcare record)

Integrated Care EHR ISO/DTR 20514 : • a repository of information regarding the health of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users. • It has a commonly agreed logical information model which is independent of EHR systems. • Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent and prospective.

Challenges facing today’s health record systems Ø The need to record more data Ø The need to analyse more data Ø The need to share more data

University Hospital of Heidelberg: • 400000 new medical records per year • 6. 3 million pages • 1, 7 km of storage • 250000 reports generated

The need to analyse more data • to observe trends and patterns within the historical record of one patient • to enable the use of clinical guidelines and decision support tools: evidence based health care • to perform clinical audit • to inform management and commissioning decisions • to support epidemiology, research and teaching

Share more healthcare data • with other clinicians in the same team – clinical firms, practice partnerships or nursing shifts • with other healthcare professions – doctors, nurses, physiotherapists, midwives, dieticians. . . • with other disciplines – a diabetic patient may also be under: ophthalmology, nephrology, orthopaedics, chiropody, wheelchair clinic. . • with other institutions • with patients and their families

The mains advantages of EHR • Reducing the storing space of the medical data • Facilitate researches activities • Standardized environment for medical data evidence, based on efficient Database Management Systems • Great level of data integration between different segments of information healthcare systems. • Increasing the quality of healthcare by the informational support provided to local and central administrative structures.

EHR adoption barriers • Technical limitation for assuring the security, integrity and accesibility of stored data • Concerning about the records ownership • Big initial costs for implementation • The lack of operate abilities and trust in computerized systems from the medical stuff and the changing resistance • Low diversity of the quality EHR systems • Lack of universal recognized quality standards and adequate legal framework

Core Functionalities for an Electronic Health Record System • • Health information and data management Results management Order entry/management Decision support management Electronic communication and connectivity Patient support Reporting and Population Health Management Administrative processes

EHR ARHITECTURE • Object oriented, relational DBMS • Interoperability - transport of information over: – Time – Space – Context, Communities, and Cultures

Modelul dual - CEN/TC 251

Reference Model Logical building blocks of the EHR: • FOLDER • COMPOSITION – Tranzactional unit – Contribution –all compositions created/modified during a session • HEADED SECTIONS - data segments for navigation purposes • ITEM – single clinical "statement"

The Record attributes • • • Pacient identification Medical stuff identification Utilized standards identification The Name of the parameter measured/observed The value of the parameter – [measure unit] – value [measured] – [normal value] • data / time stamp • Observation circumstances

The “Core” EHR • Key characteristics: • Concerns a single subject of care • Primary purpose is the support of present and future healthcare of the subject • Principally concerned with clinical information • Simplifies standardization of the EHR has a clear, limited scope enabling a manageable set of requirements to be specified and a manageable standardized model to be defined • Fits more closely with the distributed systems or “system-of-systems” paradigm Allows more modular health information systems to be built

The “Extended EHR” • Includes not only clinical information but essentially the whole health information landscape. • It is a superset of the Core EHR • Extended EHR functions beyond the scope of the Core EHR include: – – – – – Patient administration Scheduling and resource allocation Billing Decision support Access control and policy management Demographics Order management Population health recording, querying, and analysis Health professional recording, querying, and analysis Business operations recording, querying, and analysis

User view: functional grouping of data • Demographic and general data – Name, gender, date of birth, picture. . – Residence and contact data – Current job, education – Insurance condition • Alerts – allergies, special conditions (pregnancies) • Current medication • Vaccines • Consultations – SOAP – Schedule • Surgical interventions • Reports • Healthcare costs

OMS 1623/2004 Setul minim de date la nivel de pacient (SMDP)

Standard definition ISO/IEC defines a standard as a document, established by consensus and approved by a recognized body, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context

STANDARDS Standard Attributes (SMART): S = specific M = measurable A = acceptable R = realistic T = time related Standard Organizations – ASRO – Romanian Association for Standardisation (TC 319) – CEN - Comité Européen de Normalisation – CEN/TC 251 – Medical informatics Technical Committee – ANSI - American National Standards Institute – ISO - International Organization for Standardization.

Standard Organizations ASRO

EHR Relevant Standards • ISO DTR 20514 - EHR definition and scope • ISO TS 18308 - EHR Requirements • CEN TS 14796 - Data Types • CEN/TC 251 EN 13606 - EHR Communications • HL 7 - EHR Functional Specification • HL 7 - Templates specification • HL 7 - Clinical Document Architecture • • DICOM – Digital Imaging and Communications in Medicine EDIFACT , XML – Messaging standards

DATA PROTECTION a) CONFIDENTIALITY - limited, leveled accessibility b) PROTECTION - against accidental deterioration / access / loss c) SECURITY - intended d/a

EHR exemples • Office. Med ver 1. 60 – Integrated system for family physicians (GP) • Conform to Co. Ca 2003 • Fox. Pro / MSDOS • “Programul este agreat de Direcţia de sănătate publică Bistriţa Năsăud” • Medins – GP – MEDINET

INFO WORLD “. . . soluţiile oferite au fost dezvoltate conform celor mai noi standarde în domeniu, precum HL 7 şi DICOM” DICOM • Hospital Manager Suite • Cabi. Med – GP • Cabinet Manager – ambulatory healthcare system • e. Practice – EPR system