ELECTRONIC MEDICAL RECORDS (EMR)

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ELECTRONIC MEDICAL

RECORDS (EMR)

Osama Alswailem MD MA

SAUDI BOARD FOR COMMUNITY MEDICINE FIRST PART - FIRST SEMESTER (FALL 2010) COURSE

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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

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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

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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

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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;

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Paper

Record

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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

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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

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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

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Introduction to EMRs

 Why do we need EMRs?

 Clinical practice is a data intensive operation a

Inadequate data communication causes medical errorsHuman cognition is good at pattern recognition but not

at remembering lists or evaluating multiple business

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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,

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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

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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

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EMR active participation in pt care

 Computer supported prescription  Alerts and reminders

 Task specific view of data  Protocol guided care

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Raising the practice deviation and process gaps

 Patient discharge time improvement  Discharge medication order

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Creating knowledge from Information

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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

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How do Clinicians Interact with EMRs

LAB SYSTEM PHARMACY SYSTEM RADIOLOGY SYSTEM REGISTRATION SYSTEM BILLING SYSTEM Physicians Clerks Nursing Staff Coding Staff Patients Insurance Co.

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Figure

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References

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