Electronic Health Record

Standards, Coding Systems, Frameworks, and Infrastructures

Pradeep K. Sinha, Gaur Sunder, Prashant Bendale, Manisha Mantri, Atreya Dande

• Publisher: Wiley-IEEE Press
• Year: 2012
• ISBN:
  9781118479667
• Edition: 1
• Topic: Computer Science
• Subtopic: Information Technology
• Index: Computer Science

Discover How Electronic Health Records Are Built to Drive the Next Generation of Healthcare Delivery

The increased role of IT in the healthcare sector has led to the coining of a new phrase "health informatics, " which deals with the use of IT for better healthcare services. Health informatics applications often involve maintaining the health records of individuals, in digital form, which is referred to as an Electronic Health Record (EHR). Building and implementing an EHR infrastructure requires an understanding of healthcare standards, coding systems, and frameworks. This book provides an overview of different health informatics resources and artifacts that underlie the design and development of interoperable healthcare systems and applications.

Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures compiles, for the first time, study and analysis results that EHR professionals previously had to gather from multiple sources. It benefits readers by giving them an understanding of what roles a particular healthcare standard, code, or framework plays in EHR design and overall IT-enabled healthcare services along with the issues involved.

This book on Electronic Health Record:

• Offers the most comprehensive coverage of available EHR Standards including ISO, European Union Standards, and national initiatives by Sweden, the Netherlands, Canada, Australia, and many others
• Provides assessment of existing standards
• Includes a glossary of frequently used terms in the area of EHR
• Contains numerous diagrams and illustrations to facilitate comprehension
• Discusses security and reliability of data

Part One

Introduction

Chapter One

Introduction to EHR

1.1 Introduction

Use of Information Technology (IT) is common in all areas, including healthcare. Many healthcare organizations use IT-enabled healthcare applications for simplifying healthcare processes such as administration, managing health records across departments, and billing. On the other hand, some organizations are still struggling with conventional healthcare processes and paper-based health records.

Increase in population, complemented with new and complex treatments for diseases, have increased demand for better and more efficient healthcare services globally. Due to complexity of health problems, multiple healthcare providers are involved in treatment of a patient, making healthcare process more complex. Need for complete health information of a patient—such as patient's history, allergies, laboratory tests, medication, and so on—at one place for his/her better care is increasing. Researchers have now realized that increased application of IT to healthcare with Electronic Health Record (EHR) is a way to deal with these issues. Hence, many countries are promoting increased use of IT in healthcare services and use of EHR for enhancing continuity of care to patients.

In the fifth century b.c., Hippocrates developed the first known medical record with two specific goals [EHR Overview 2006]:

1. Preserving course of a disease

2. Indicating probable cause of a disease

These goals are still precise. However, with advancement in IT and introduction of EHR, expectations have increased, such as depicting healthcare workflow, secured and authorized access to health information, faster access to health records irrespective of place and time, and so on.

1.2 Definition of EHR

A simple generic definition of an EHR is health records of a patient in electronic form. However, this definition is not comprehensive. Some definitions of EHR and associated terminologies as found in the literature are:

An Integrated Care EHR defined by ISO/DTR 20514: “A repository of information regarding the health of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorized users. It has a standardized information model, which is independent of EHR systems. Its primary purpose is the support of continuing efficient and quality-integrated healthcare and it contains information, which is retrospective, concurrent, and prospective” [ISO/TR 20514]

An EHR defined by Health Information and Management Systems Society (HIMSS): “EHR is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface including evidence-based decision support, quality management, and outcomes reporting” [HIMSS 2011]

From both definitions it is clear that EHR is not owned by any single healthcare provider and contains complete records of encounters of a patient throughout the visited healthcare organizations for that particular encounter. EHR aims at providing care to a patient across healthcare organizations.

While surveying the literature, we came across many terminologies that have evolved together with EHR. These terminologies are either subsets of EHR or used by different groups to mean the same thing. However, our analysis indicates that the term EHR is more widely accepted globally, which defines the broadest scope of health information systems. Below we provide definitions of some commonly used related terminologies found in the literature [Diween and Garg 2006]:

• Electronic Medical Record(EMR). EMR is often used in parallel with EHR. It is a fully interoperable electronic health record of a patient within a healthcare organization. However, some people consider EMR as a set of records of a patient related to a single encounter or a single care episode. According to this view, EMR is a point-in-time view of a larger EHR. This approach considers an EHR to be sum total of all EMRs of a patient.
• Computer-Based Patient Record(CPR). CPR was first used to conceptualize the idea of EHR [Richard et al. 1997]. It is a lifetime health record of a patient, which includes information from all specialties. It requires full interoperability (potentially international interoperability) that may be achieved in the near future.
• Electronic Patient Record(EPR). EPR is similar to CPR, but does not necessarily contain a lifetime record and focuses on relevant information only.
• Personal Health Record(PHR). PHR is managed and controlled by a patient. It is mostly considered to be web-based. Usually, PHR is another patient-side view of an EHR/EMR maintained by a particular group of healthcare providers.

1.3 Functions of EHR

Margaret and Steven [Margaret and Steven 2005] described EHR as a system of hardware, software, people, policy, and processes that work together to collect data from multiple resources, thus providing information and decision support to multiple healthcare providers irrespective of time and place.

Accordingly, an EHR system should offer the following basic functions:

• Health Information and Data. It should store and provide access to health information of patients such as patient's history, allergies, laboratory reports, diagnosis, current medications, and so on, to healthcare providers for taking appropriate clinical decisions for better patient care. It should integrate data from various sources and make it available to the people involved in the care of a patient.
• Replicate the Workflow. It should be able to work in-sync with the original workflow of the healthcare organization.
• Efficient Interaction. It should be able to work effectively, saving time of care providers by keeping things concise.
• Clinical Decision Support (CDS). It should support provision of reminders, prompts, and alerts. Such features help in improving clinical and preventive practices and reduce frequency of adverse events.
• Patient Support. It should empower patients to access their health information, enabling them to be involved in their own healthcare.
• Messaging and Data Processing Capability. It should enable exchange of data in known/standard formats for interoperability of healthcare applications. Additionally, it should enable processing of incoming data in known/standard formats.
• Administrative Tools. It should provide administrative tools, such as scheduling systems, for improving efficiency of clinical practices and timely service to patients.

1.4 Significance of EHR

An EHR system helps to provide an integrated view of healthcare records by enabling integration of various healthcare applications such as Hospital Information Systems (HIS), Pharmaceutical Systems, Imaging Systems, and Health Insurance Systems. In turn, an EHR system plays a significant role in better healthcare services by offering the following advantages [IOM 2003]:

• Ease of Maintaining Health Information of Patients. An EHR system enables paperless medical treatment with less space required for storing health data of patients. Additionally, with proper backup policies, the lifespan of EHRs can be increased. This reduces the cost of generating, storing, and maintaining patient records in healthcare organizations.
• Efficient in Complex Environments. Large healthcare organizations have many specialty departments, laboratories, training and research centers, and so on. An EHR system helps in improving clinical processes or workflow efficiency across these units of a healthcare organization. For example, it enables an administrator to obtain data for billing, a physician to see progress of treatments, a nurse to report an adverse reaction, and a researcher to analyze efficacy of medications on patients.
• Better Patient Care. Often, multiple healthcare providers are involved in treatment of a patient. An EHR system allows sharing of the patient's information among them. Moreover, it enables point-in-time data insertion, retrieval, and update, thereby providing immediate access of patient data from any specialty center whenever required. This enables healthcare providers to make timely decisions for better patient care. Availability of health information, such as past medical history, family medical history, and immunization, through EHR helps in taking preventive measures and managing chronic diseases more effectively.
• Improve Quality of Care. EHR helps to decrease reporting and charting time during treatment, thereby improving quality of care. EHR also helps in improving risk management and accurate diagnosis, thereby improving quality of care.
• Reduce Healthcare Delivery Costs. Due to the availability of health information data from all healthcare organizations, a healthcare provider can refer to the required test reports, thus avoiding repetition of expensive tests.
• Accelerates Research and Helps Build Effective Medical Practices. EHR provides a large database at one place, enabling its use for disease surveillance for providing preventive measures. It also helps in analyzing treatment patterns of medicine, providing new ideas and ways of drug discovery. Decision support with EHR enables effective medical practices.
• Better Safety. Through access, audit, and authorization control mechanisms, an EHR system provides better safety to a patient's health records as compared to a paper-based system.

1.5 Factors Affecting Implementation of EHR

An EHR system needs to deal with multiple healthcare applications and various types of healthcare providers. Hence, its implementation is a complex task that usually requires more time and effort than implementation of several other IT applications. The following factors usually affect the implementation of an EHR system and need to be dealt with properly:

• Significant Changes in Clinical Workflow. Implementation of an EHR system in a healthcare organization often requires significant changes in the organization's clinical workflow. Hence, it is always good to make EHR a part of the strategic vision of the organization. Design of the system needs involvement of clinical staff with inclusion of organization's policies and workflow processes [Hamilton 2011].

Although an EHR can be customized for a specific medical practice, clinical workflow varies from one specialty to another. Thus, an EHR having a specific workflow for practicing medicine is usually not adaptable easily.

• Privacy and Security. An EHR implementation must deal with privacy and security issues with great care because health care providers are concerned about alteration of EHR without their knowledge, and patients are concerned about unauthorized access to their private data.

An EHR system must also meet the privacy and security regulations for health data imposed by regulatory bodies in the country. This provides assurance to patients and providers that the health data is securely stored and privacy is maintained, while healthcare applications deliver appropriate services. The system should audit log the accesses made to an EHR with strict access policies.

• Unique Identification. Duplication of EHR records of a patient in the same EHR system is an important issue in EHR usage. This issue arises because healthcare data of a patient is often coll...