health records...
TRANSCRIPT
Dr Dipak Kalra
Health Records
The clinician in the information age
Dr Dipak Kalra
Clinical Senior LecturerCentre for Health Informatics and Multiprofessional Education (CHIME)
University College [email protected]
EPJEPJ--Observatoriet Observatoriet Arskonference Arskonference 2002, 2002, NyborgNyborg
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Dr Dipak Kalra
Health Records
Realising the EHR:what are we concerned about?
Realising the EHR:Realising the EHR:what are we concerned about?what are we concerned about?
• What is the definition of an EPJ?– or EHR, EPR, CPR, EMR…
• How many enterprises have “got one” ?– in 2002, planned for 2003, 2004, target for 2005, 2006.. ?
• What resources are available ?• What vendors have one to sell ?• … STOP !!
Dr Dipak Kalra
Health Records
If realising the EHR is a journey…If realising the EHR is a journey…If realising the EHR is a journey…
…then
• Where are we heading ?
• Why are we going there ?
• Why is the journey so difficult ?
Dr Dipak Kalra
Health Records
Information needs in health care Information needs in health care Information needs in health care
Challenges and changes– Increasing complexity of health care provision – Requirement to deliver evidence-based care– Shift of care from specialist centres to community settings– Increasingly distributed and mobile clinical workforce– Critical reliance upon comprehensive patient records– Overwhelming growth of medical knowledge– Growth of consumerism and patient participation in health
care– Increasing concerns about the confidentiality of patient
records
{ Jennings,Miller,Materna1997}
Dr Dipak Kalra
Health Records
Challenges facing today’s health record
Challenges facing today’s Challenges facing today’s health recordhealth record
Ø The need to record more data
Ø The need to analyse more data
Ø The need to share more data
Dr Dipak Kalra
Health Records
The need to record more health care dataThe need to The need to recordrecord more health care datamore health care data
• patients receive more health care• the information is more complex
– a richer variety of examinations, investigations, treatments– a greater use of multi-media technologies
• the information is more important– clinical care is more information-dependent– professions are increasingly accountable– litigation is increasing– the use of healthcare resources needs to be justified
Dr Dipak Kalra
Health Records
1999 US Dept. of Commerce study1999 US Dept. of Commerce study1999 US Dept. of Commerce study
• health care is the fourth most information reliant industry sector after:– telephone & telegraph– radio & television– security brokerage
Dr Dipak Kalra
Health Records
UK Audit Commission Survey (1995)UK Audit Commission Survey (1995)UK Audit Commission Survey (1995)
• ~15% of hospital resources are spent gathering information
• Up to 25% of doctors’ and nurses’ time is spent collecting and using information
Dr Dipak Kalra
Health Records
Scale of the problemScale of the problemScale of the problem
• University Hospital of Heidelberg: 1700 beds– creates about 400,000 new medical records per year– containing 6.3 million pages– requiring 1.7 km of storage – (growing at the rate of 1500m per annum)– Physicians create over 250,000 reports and 20,000 procedure
reports each year– service departments create around a million results
{Reinhard, Ohr, et al} {Haux 1998}
Dr Dipak Kalra
Health Records
Dr Dipak Kalra
Health Records
Dr Dipak Kalra
Health Records
Dr Dipak Kalra
Health Records
The need to analyse more health care dataThe need to The need to analyseanalyse more health care datamore health care data
• to observe trends and patterns within the historical record of one patient
• to enable the use of clinical guidelines and decision support tools, supporting evidence-based care
• to perform clinical audit– including the evaluation of clinical outcomes
• to inform management and commissioning decisions– including public health and needs assessment
• to support epidemiology, research and teaching
Dr Dipak Kalra
Health Records
Exploiting good clinical dataExploiting good clinical dataExploiting good clinical data
• Alerting systems have been shown to save lives “to a remarkable degree” {Teich and Wrinn 2000}
• Alerting system examples– drug prescription interactions and adverse effects {Miller, Reichley
et al. 1999}, {Rogers, Jain et al. 1999}
– alert algorithms for laboratory values, drug interactions and contraindications {Warner, Miller et al. 1998}
– a pager-based alerting system for physicians looking after intensive care patients in a tertiary care hospital {Shabot, LoBue et al. 2000}
– image processing and interpretation of mammograms {Alberdi, Taylor et al. 2000}
Dr Dipak Kalra
Health Records
1995 Audit Commission Report on Patient Health Records
1995 Audit Commission Report on 1995 Audit Commission Report on Patient Health RecordsPatient Health Records
• 36% of case-notes not immediately available• Multiple records for same patient in 75% of hospitals• 30% of history sheets inadequate• 20% of prescriptions illegible• 40% of handwritten discharge medication sheets
illegible
Dr Dipak Kalra
Health Records
Importance of data quality and its availabilityImportance of data quality and its availabilityImportance of data quality and its availability
• The US Institute of Medicine report "To Err is Human" has estimated that 100,000 US citizens die each year through medical errors
• Medical errors may rank as the eighth leading cause of death in the US, and contribute 4% ($37.6 billion) to the cost of US healthcare {Anderson 2000 }
Dr Dipak Kalra
Health Records
Requirements of evidence based medicineRequirements of evidence based medicineRequirements of evidence based medicine
• the learned literature has doubled every 10-15 years over the past 300 years;
• in the field of biomedicine 20,000 journals and 17,000 books are produced every year
Dr Dipak Kalra
Health Records
Growing numbers of conceptsGrowing numbers of conceptsGrowing numbers of concepts
• Around half of the concepts believed to exist in the world (500,000) are in the medical domain {Baud, Lovis, et al. 1998}
Dr Dipak Kalra
Health Records
Growing numbers of conceptsGrowing numbers of conceptsGrowing numbers of concepts
• Growth of the Columbia Presbyterian MED– 1994: 32,000 terms {Cimino 1994}
– 2000: 60,000 concepts, 208,000 synonyms, 84,000 hierarchic relations, 114,000 other semantic relations {Cimino et al 2000}
• Size of SNOMED: – 1979: 45,000 terms– 2000: 157,000 terms– 2002: SNOMED CT est. 350,000 concepts, 450,000 descriptors
• MeSH contains 19,000 main subject headings• UMLS Metathesaurus: 730,000 concepts, 1.5 million terms
Dr Dipak Kalra
Health Records
The need to share more health care dataThe need to The need to shareshare more health care datamore health care data
• within clinical teams– clinical firms, practice partnerships or nursing shifts
• between healthcare professions– doctors, nurses, physiotherapists, midwives, dieticians...
• between disciplines– a diabetic patient may also be under: ophthalmology,
nephrology, orthopaedics, chiropody, wheelchair clinic..• between enterprises• with patients and their families
Dr Dipak Kalra
Health Records
Scale of the communications challengeScale of the communications challenge
England and Wales
» 2,500 hospitals» 10,000 GP practices (40,000 GPs)» 800,000 staff
At least 40 million shared care communications per annum
Dr Dipak Kalra
Health Records
High risk areas of clinical High risk areas of clinical communication breakdowncommunication breakdown
Percent of GPs reporting problems
Shared care communications survey (Kalra, D. London, 1997)
Dr Dipak Kalra
Health Records
Perceived benefits of the computerPerceived benefits of the computerPerceived benefits of the computer
• duplicate data entry is avoided• data entry templates can be adapted as ideas evolve• the data can be viewed in many different ways• data may be accessed from any terminal on a network,
and communicated electronically• it is easier to analyse the data
– to produce summaries, tables and graphs– to use alongside protocols and decision support systems– for clinical audit and resource management
Dr Dipak Kalra
Health Records
…into this…into this
Dr Dipak Kalra
Health Records
Changing this...Changing this...
Dr Dipak Kalra
Health Records
It’s difficult to get to a clear desk!It’s difficult to get to a clear desk!It’s difficult to get to a clear desk!
• Workstations are too slow and clumsy for real-time use (or just not available!)
• Structured templates and term sets are resented by clinicians– patient encounters rarely follow a consistent pattern
• Duplication of data entry still occurs– existing paper records are usually retained
• There is a lack of agreed standards for the electronic transfer of records between systems
Dr Dipak Kalra
Health Records
Why are EHR standards so difficult?Why are EHR standards so difficult?Why are EHR standards so difficult?
• Comprehensive models are– difficult to agree– difficult to maintain
• System designers need to respond to specialist needs, but systems need to remain interoperable
• It is difficult to standardise the information requirements of one health domain – without becoming too prescriptive– whilst permitting the future evolution of health care
Dr Dipak Kalra
Health Records
EHR and other informatics standards are vitalEHR and other informatics standards are vitalEHR and other informatics standards are vital
• to enable the exchange of health records between systems
• to enable interoperability with modern terminology systems and medical knowledge databases
• to enable the integration of protocols and guidelines electronically
Medical Knowledge Health RecordsHealth Records
The clinical information environment
Medical Knowledge Health RecordsHealth Records
Clinical practice needs to share this informationconsistently and faithfully
Ambulatory & secondary
care systems
GP systems
Tertiarycare
systems
Ambulatory & secondary
care systems
GP systems
Tertiarycare
systems
A combinatorial explosion:of interfaces or of messages
Ambulatory & secondary
care systems
GP systems
Ambulatory & secondary
care systems
GP systems
Tertiarycare
systems
Tertiarycare
systems
Common clinical middleware:physical or logical
Ambulatory & secondary
care systems
GP systems
Ambulatory & secondary
care systems
GP systems
Tertiarycare
systems
Tertiarycare
systems
We need interoperability of data and services within this clinical middleware
Terminologyservices
Decision supportsystems
ArchetypeArchetypelibrarylibrary Communications Communications
interfacesinterfaces
Access control filterAccess control filter
Request query handlerRequest query handler
GP systems
Ambulatory & secondary
care systems
Tertiarycare
systems
EHR repositoryEHR repository
The EHR middleware “kernel”
DemographicDemographicservicesservices
EHR entryEHR entry validatorvalidator
These services build on a generic EHR Information Architecture
AuditAudittrailtrail
Other integrating services
Workflow
Metadata
Personsregistries
Billing
Comms& security
Terminology
Onlineknowledge
Learningresources
Interoperability of some of these services is the scope of HISA
OpenGALEN OpenEHROpenEHR
3 Open Source Foundationsare working towards this interoperability
The EHR Information Architecture is one cornerstone of this interoperability
Evidence Based Information
Systems
Electronic guidelinesand
decision support applications
Patient and health professional education products
Health record systems
Clinical outcomesdatabases
Epidemiologicaland auditdatabases
Patient-foussedclinical outcomesassessment tools
Hospital & primary care patient management
systems(persons registries,
workflow, billing etc.)
Dr Dipak Kalra
Health Records
What makes a “good” EHR ?What makes a “good” EHR ?What makes a “good” EHR ?
VALUES• Faithfulness to the needs and wishes of patients• Faithfulness to the clinical care process
Dr Dipak Kalra
Health Records
Faithfulness to the needs and wishes of patientsFaithfulness to the needs and wishes of patientsFaithfulness to the needs and wishes of patients
• Person centred– but recognising that indiviuals are part of families and communities
• Appropriately confidential• Longitudinal
– following them through their lifetime, across regional and national boundaries (i.e. portable and distributed)
• Accessible and educating• Empowering
– respecting autonomy and inviting active participation
• Supporting a diversity of cultures, health expectations, hopes and goals
Dr Dipak Kalra
Health Records
Faithfulness to the clinical care processFaithfulness to the clinical care processFaithfulness to the clinical care process
• Enable clinical competence to be demonstrated– representing the provenance of information– incorporating clinical reasoning, justifications for actions,
the expression of hypotheses and of uncertainty– ensuring that medico-legal safeguards are met
• Support safe and effective practice– fostering high quality teamwork (e.g. via care pathways)– reducing clinical error (e.g. via alerts) – enabling continuing professional development and lifelong learning
(e.g. through audit, and links to medical knowledge)
Dr Dipak Kalra
Health Records
Key messagesKey messagesKey messages
• We need to uphold the values of a good EHR rather than rushing to tick the box
• Realising the EHR is a long learning journey for all of us: clinicians, vendors, engineers, managers, patients
• Interoperability is a key missing ingredient in today’s clinical systems
• Good informatics standards must be underpinned by user requirements, and evolve through experience of implementation and real clinical use
