ELECTRONIC MEDICAL
RECORDS (EMR)
Osama Alswailem MD MA
SAUDI BOARD FOR COMMUNITY MEDICINE FIRST PART - FIRST SEMESTER (FALL 2010) COURSE
Medical Record function
1. It’s a mean of communication between staff who are
actively managing a patient
2. The record is the single data access point for HCP
during active management of patient illness
3. Work space to record ideas and impression 4. Single point of a long term archive of patient
Serious reportable events
1999 Institute of Medicine Report, 44k-98k people
die annually due to errors in inpt hospital treatment,
More than MVA, Breast cancer and HIV Yet received less attention
To Err Is Human: Building a safe health system. is IOM
2000 report
CDC report in 2000 said hospital acquired infection
Paper Record ,
physical aspects
Used for one task at a time
Record are available 80% of time in large institutes ! Time of request, effort of process and tracking
Space consumption, .5M active and 5M inactive @KFSH Chronic patients with large records
Paper is fragile and susceptible to damage
Paper Record ,
Content
The models that interpret the data captured on paper
are contained with the head of the reader
There is increased opportunity for errors to occur;
Paper
Record
,
Information Retrieval
Searchability within a record of across a body of
records for specific data.
HCP search routinely to find pieces of information they
need during a patient consultation
168 outpt consultation found that data were searched for but not
found in 81% of cases, when 95% of the cases the record was available during the consultation. (36% lab & procedure, 31% history, and 23% meds & treatment)
Indexing
EMR,
physical aspects
Advancements of Physical Data storage
The ability to duplicate the record, to share and
more importantly to back-up
More formal data models Vs informalities with
paper charts
Portability
Multiple access, availability, No missed charts Protected by different security measures
EMR,
Content
Standardized model of interpretation
The speed of searchable content with complex cases and across thousands
of recodes for specific item
Unified codes
Readable and legible
Pt care process mandate availabilities of long list of information and wider
range of communication beyond EMR, all can be included
Pt list, schedule list, LOS, formulary,
Researches can do retrospective studies of epidemiology of sp disease. Is available from remote locations
To covering MDs
Others with appropriate needs
Introduction to EMRs
Why do we need EMRs?
Clinical practice is a data intensive operation a
Inadequate data communication causes medical errors Human cognition is good at pattern recognition but not
at remembering lists or evaluating multiple business
Why do we need EMRs?
Enhances Communication:
Between providers--clinical messaging Trace paper MR location
Referrals
Half of specialists didn’t know what main question was A third of the time no information came back to PCP
Encourage patients to participate in their healthcare,
Integrated Clinical Information System ICIS
ICIS from Cerner co. Phase one 2002
Registration Scheduling
Orders (CPOE) and Documentation Lab
Radiology
Phase two
Medication process, Inpt and Outpt pharmacy OR Management System
Health Information Management ER Management System
Introduction to EMRs
Do EMRs make a difference? UNEQUIVOCALLY YES, BUT AT A COST! In multiple studies, EMRs have been shown to:
Shorten Length of Stay in a Hospital setting Decrease Adverse Drug Events (ADEs)
Improve Readability, Consistency and Content of the medical
record
Improve Continuity of Care Reduce practice variation
Most benefits come from Decision Support. EMR may
suggest what pt info needs to be collected, or alert physicians to better management action
EMR active participation in pt care
Computer supported prescription Alerts and reminders
Task specific view of data Protocol guided care
Raising the practice deviation and process gaps
Patient discharge time improvement Discharge medication order
Creating knowledge from Information
What are the data sources of EMR?
At their heart, EMRs are just a database
This database hold many kinds of information (coded and not
coded)
This database is organized by date, time, pat ID and
contains:
Patient registration data (name, contact info, DOB, etc.) Test results (laboratory, radiology, nuc med etc.)
Medications (active, inactive) and Allergies Current list of diagnoses and problems Appointment Data
Clinical Notes
Billing Information Eligibility information
