The Electronic Medical Record Department of Medical Informatics

The Electronic Medical Record Department of Medical Informatics and Education by Lorna Duddy.

Existing Hospital Records. . . . H Paper Charts of Patient Medical Records are the norm worldwide for recording patient information. H All relevant patient information is documented in one file for reference - including Lab. results, test results and progress notes. These charts are easy to use. The same file is used on subsequent admission to the same institution. And as source of reference for medicolegal cases. H H H

By now most large health care institutions have a computer database of patients which matches : * Patient’s Hospital I. D. Number * Name * Date of Birth * Address. . This provides a rapid search to match a patient name with a chart no. when retrieving a record from storage. H H The source of the Electronic Medical Record is simply expanding on this database creating an “on -line” record for each Patient.

The Electronic Medical Record. H H H The Electronic Medical Record (EMR) is the future of patient record documentation. There is very wide scope for applications and additions around a centralized record. The EMR can be accessed conveniently by appropriate health professionals to ensure ultimate maximum and optimal patient care.

This tutorial discusses the following : Description of a typical EMR. H Potential applications. Problems associated with its use. H H

There are many aspects contributing to a typical EMR.

At Hospital Admission. . . Admission Details : H Patient History H Physical Exam. H Observations - weight - b. p. - temp. - pulse are easily updated and reviewed at subsequent hospital admissions.

LABORATORY RESULTS GRAPH Different variables at different dates can be seen at a glance. Variations from the normal values are also easily seen. Glucose Normal Lab. results can be received directly from the laboratory and are entered directly, available for the doctor to review.

A S. M. A. C. result may look like. .

A Centralised Record can be accessed easily by various hospital departments as illustrated below.

PHARMACY ACCESS A Medication Guide such as the one in the next slide gives a comprehensive overview of : H Patient Drug History H Drug Allergies H Reasons for prescription H Dose Through inclusion of an online guide such as BNF or MIMS, warning of impending drug interactions and contraindications may be given. H

MEDICATION MANAGER Patient Name : I. D. No. : Consultant CURRENT : DRUG HISTPORT CURRENT DRUG HISTORY DIAGNOSIS : Urinary Tract Infection Include : All current and expired drugs. OTHER ACTIVE PROBLEMS DRUG Becotide 250 ASTHMA Drugs Available for Diagnostic Profile : CODE AMPICILLIN-SODIUM SELECT CANCEL DOSE 2/day Drug Allergies : NONE KNOWN PRESCRIBE RESULTS. .

Processing results CT Scan and X-ray results such as this (see next slide) can be processed, reviewed and entered directly into the patient file. The results may be sent to other specialists by the Internet network for consultation.

Display Graphics. . . H The index of an Electronic Medical Record may look like. . .

Applications of the E. M. R.

COMMUNICATION. . . One of the advantages of a central record is the ease of communication between - Hospital Departments e. g. for booking of diagnostic tests. -G. P. and hospital physician by email. Standardised, structured messages may be sent from one person to another both of whom are familiar with the format, by the Edifact system (Electronic Data Interchange For Administration, Commerce and Transport).

Communication can be made easier via email services

TELEMEDICINE. . . This is the practice of medicine using any data transfer linked with the process of care, in which some aspects of the care assisted by remotely located professionals. Specialist communications may be made by Video-link. Components of Telemedicine PATIENT SITE PATIENT DATA COMMUNICATION NETWORK TREATMENTS PHYSICIAN IN-CHARGE EXPERT SITE SPECIALIST CONSULTATION EXPERT DATA

Telemedicine at Work. . . H The Eastern Health Board has introduced patient “Smart Cards” on a pilot basis, where a patients medical record may be carried by the patient as a plastic card and may be inserted into a special decoder, read and updated at hospitals and GP practices participating. H This Autumn British Airways are introducing a satellite communication with a doctor on the ground as a back-up to Flight Attendants with basic medical skills. Vital signs are communicated and doctors can manage patient care from the sky and decide whether an emergency landing is necessary. H

“Net To The Rescue”. . . H H H It was recently reported that two Chinese students at Peking University sent an appeal for help to find a diagnosis for their Chemistry student colleague who had developed a severe illness to which the doctors at Peking Union Medical College hospital had no cure. The medical information was sent to Sci. med newsgroups and within 24 hrs was read by a doctor in Washington who recognized the girls serious condition could be due to thallium poisoning. Phoning the hospital in Beijing he advised to check for thallium poisoning. To the initial annoyance of the physicians over 600 email messages were received in reply to this appeal and the general consensus pointed to the same and correct diagnosis. An Internet page is established to monitor the patient - Zhu Ling’s recovery. This can be accessed at http: //www. radsci. ucla. edu/telemed/zhuling.

THE EMR AS AN INFORMATION SOURCE FOR STATISTICAL RESEARCH. H Specific information gathered from a large number of patients for a certain disease with regard to Severity Duration of symptoms, can be represented graphically or scored. H This can be used as a reference for aids to diagnosis. A “Relational Database “ would be of this form and could be incorporated into the EMR.

QUESTIONNAIRE ON LIVER DISEASE Conventions : Please mark all items P = Present O = Absent s = Unknown/doubtful Lines ___= Enter Text General Screen Yellow Sclerae. . . Age in years Male sex Weight loss Jaundice. . Duration (days) Deep Increasing since onset Decreasing Constant . . . = Enter number Anorexia Nausea/vomiting Symptoms preceded jaundice Haemetamesis pale stool diarrhoea urine dark Abdomen palpable spleen palpable gallbladder tender gallbladder Ascites liver definitely enlarged liver hard liver tender liver irregular obvious mass Other Fatigue Weight loss. . . Doctors experience in yrs History taken from patient History taken from chart

H H H Charts such as the sample in the previous slide are completed and the information is coded into computers. From these standard form findings, accumulated from thousands of patients, it is possible to set up a data base. Through the use of Artificial Intelligence and applying statisitcal rules, the condition of a given patient - on which the same findings are available, can be predicted. H H In the I. C. U. this type of correlation, analysis of Laboratory results and biochemical readings from monitors may be incorporated to predict a patient’s progress and forecast how long a patient may have to stay in intensive care. This is important to hospital staff and management as to how many places will be available at a given time.

APPLICATIONS FOR HOSPITAL MANAGEMENT. CENTRAL RECORDING OF : • number of bed days • procedures and tests obtained by the patient, • units of treatment given in addition to CODING OF DIAGNOSIS, PROCEDURES AND MEDICATIONS will make auditing of patient accounts easier and also more accurate. TRANSMISSIBLE RESULTS MAY CUT DOWN ON THE NEED TO REPEAT TESTS.

Difficulties Associated. . . H H H It is clear from the previous slides that the technology is available to support far ranging possibilities for an Electronic Medical Record. However there are enormous problems to be overcome with regard to its use. Designers of EMR’s must adhere to existing laws and legislation must be put in place to govern the appropriate use of data collected. Access - Patient confidentiality must be preserved at all times. Coded access e. g. by PIN would be a necessity. Different types of codes could be given to personnel who access the record for different purposes : ~ Doctors ~ Secretarial ~ Paramedical ~ Administrative

Data The quality of data stored is also a problem of paper records. Data is a man-made artifact. Each individual has a method for recording relevant patient data within a framework. Marked discrepancies may occur between information reported during patient interview and that which is contained in the record. Not all patient facts reported may fit neatly into a structured record Such “misinformation” may be contained in the EMR due to misunderstanding of definitions and terms used. Standardization Is a definite requirement for widespread use of electronic records. This would include Lab. results units and precise medical terms. On-line dictionaries would help. Standardization of support software to link one system to another would also be necessary.

Cost The introduction of such a record would involve phenomenal financial expense ~ Hardware and Software equipment ~ Staff Training - would demand time and money which could be spent alleviating waiting lists. Although expensive test results available centrally would be a saving in health service costs. Complexity The EMR allows for increased processing of medical data. and enhances data analysis, which may ultimately complicate research with flawed data. The reasons why and the circumstances under which data is collected is not accounted for by simply coding observed facts into a structured computer programme.

Conclusion H H The aim of the EMR is to encompass all underlying structures of paper record in a structured user-friendly format. Good history and physical exam. and clinical observation skills are the key to achieving information which is managed to support clinical decisions and actions taken in patient care. A Centralised record including lab. and procedure results and medication records will enhance patient record interpretation. Coding of Diagnoses, Procedures and Medications will benefit ~ Research ~ Auditing

H Many of the programmes concerning the EMR are still in the pilot stage. Legislation is needed to H – Promote patient confidentiality – Govern the use of data collected. Efficiency in the management of patient information, leading to more competent clinical action is the aim and should not be lost in megabytes of data input.