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EMR

ELECTRONIC MEDICAL RECORDS
Paper-based records have been in existence for centuries and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems and for past few years in India. Though India is amongst lead nations in Information Technology, computerized information systems have not achieved the same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail industries. Further, deployment has varied greatly from hospital to hospital and from specialty to specialty and in many cases has revolved around local systems designed for local use. Whatever EMR systems are there those have been implemented however have been used mainly for administrative rather than clinical purposes. Electronic medical record systems lie at the center of any computerized health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerized medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20 years, is however yet to become reality even in the western countries. Over the past decade, the political impetus for change in almost all western countries has become stronger and stronger. Incontrovertible evidence has increasingly shown that current systems are not delivering sufficiently safe, high quality, efficient and cost effective healthcare, and that computerization, with the EMR at the centre, is effectively the only way forward. Better use of IT is no panacea, but there's scarcely a problem in the health system it can't improve. For the first time, the responses have been national and coordinated. Governments in Australia, Canada, Denmark, Finland, France, New Zealand, the UK, the USA and other countries have announced - and are implementing - plans to build integrated computer-based national healthcare infrastructures based around the deployment of interoperable electronic medical record systems. And many of these countries aim to have EMR systems deployed for their populations within the next 10 years.

TERMINOLOGY

Terms used in the field include electronic medical record (EMR), electronic patient record (EPR), electronic health record (EHR), computer-based patient record (CPR) etc. These terms can be used interchangeably or generically but some specific differences have been identified. For example, an Electronic Patient Record has been defined as encapsulating a record of care provided by a single site, in contrast to an Electronic Health Record which provides a longitudinal record of a patient’s care carried out across different institutions and sectors. But such differentiations are not consistently observed.

DEFINITIONS

The 2003 IOM Patient Safety Report describes an EMR as encompassing:

1. "a longitudinal collection of electronic health information for and about persons
2. [immediate] electronic access to person- and population-level information by authorized users;
3. provision of knowledge and decision-support systems [that enhance the quality, safety, and efficiency of patient care] and
4. support for efficient processes for health care delivery." [IOM, 2003, P4 (footnote)]

The 1997 Institute of Medicine report: The Computer-Based Patient Record: An Essential Technology for Health Care provides the following more extensive definition:

"A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems)." [IOM, 1997]

The HIMSS EHR definitional model document [HIMSS, 2003] includes "a working definition of an EHR, attributes, key requirements to meet attributes, and measures or "evidence" to assess the degree to which essential requirements have been met once EHR is implemented".

KEY CAPABILITIES OF AN ELECTRONIC HEALTH RECORD SYSTEM
There are three essential capabilities of an electronic health record as follows:

1. To capture data at the point of care 2. To integrate data from multiple internal and external sources 3. To support caregiver decision making.

The US IOM report, Key Capabilities of an Electronic Health Record System, identified a set of 8 core care delivery functions that electronic health records systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery:

The eight core capabilities that EHRs should possess are:
1. Health information and data. Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner.
2. Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.
3. Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.
4. Decision support. Using reminders prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
5. Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
6. Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes.
7. Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.
8. Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance.

BENEFITS OF EMRS

1. Replace paper-based medical records which can be incomplete, fragmented (different partsin different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up to date, accurate, rapidly retrievable source of information, potentially available anywhere at any time. Require less space and administrative resources. Potential for automating, structuring and streamlining clinical workflow.
2. Provide integrated support for a wide range of discrete care activities including decision support, monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering and results display.
3. Maintain a data and information trail that can be readily analyzed for medical audit, research and quality assurance, epidemiological monitoring, disease surveillance ....
4. Support for continuing medical education.

BARRIERS

Widespread implementation of EMRs has been hampered by many perceived barriers including:

1. Technical matters (uncertain quality, functionality, ease of use, lack of integration with other applications,
2. Financial matters - particularly applicable to non-publicly funded health service systems (initial costs for hardware and software, maintenance, upgrades, replacement, ROI ...)
3. Resources issues, training and re-training; resistance by potential users; implied changes in working practices.
4. Certification, security, ethical matters; privacy and confidentiality issues
5. Doubts on clinical usefulness
6. Incompatibility between systems (user interface, system architecture and functionality can vary significantly between suppliers' products).

ISSUES

1. Integrated systems require consistent use of standards in e.g. medical terminologies and high quality data to support information sharing across wide networks
2. Ethical, legal and technical issues linked to accuracy, security confidentiality and access rights are set to increase as national EMR systems come online. These issues become more pressing with the current movement to promoting consumer empowerment and information ownership, championed by the European Commission for example, which is leading towards patient records accessible by patients (Personal Health Records).
3. Common record architectures, structures
4. Clinical information standards and communications protocols
5. Security and confidentiality of information
6. Patient data quality; data sets, data dictionaries.

INTEROPERABILITY

Interoperability aims to support:

1. Data transfer and sharing on much more than a local or enterprise-wide scale
2. Knowledge transfer and integration
3. Medical terminology transfer, mapping and integration
4. Image transfer
5. Integration with clinical and non-clinical applications

There are four levels for interoperability between health information systems:

1. Level 1: Non-electronic data (e.g. mail, telephone)
2. Level 2: Machine-transportable data (e.g. faxed or scanned documents)
3. Level 3: Machine-organisable data (e.g. e-mail, proprietary file formats)
4. Level 4: Machine-interpretable data (e.g. structured data within standardized messages).

The US National Committee on Vital and Health Statistics describes three levels of interoperability:

1. Basic interoperability. Allowing a message from one computer to be received by another, but not requiring the receiving computer to be able to interpret the data.
2. Functional interoperability. An intermediate level defining the format of messages. This ensures messages between computers can be interpreted at the level of data fields, so that data can pass from a structured field in one system to a comparably structured field in another. Neither system, however, has understanding of the meaning of the data within the field(s).
3. Semantic interoperability. Provides common interpretability, that is, information within the data fields can be used intelligently.