The electronic patient record in primary care

1. The electronic patient record in primary care TDT4210 Health care informatics Professor Anders Grimsmo, DMF, NTNU 1935

2. 2005

3. 1935

4. 2005

5. Pasientjournal anno 1872

6. - a challenge to NTNU: Create a productive and viable competence community for research, development, implementation and knowledge sharing in conjunction with electronic patient records (EPR). • Five million NOK per year for five years

7. People per month Level of care Patients and Level of care • 2 Regional hospital • 13 Local hospital • 150 Primary care • 500 Self-care • 85 Symptoms, no treatment • 250 No symptoms • 1000 Risk population

8. Cooperation in the health care services Internett The patient in the centre Ministry of health and social affairs (SHD) National Insurance Administration (RTV) SSB, NPR,misc. central registries Central Psychiatry Health service company Hospitals Specialists Local Health centre Pharmacy Nursing homes, physiotherapists, Care services

9. PREVENTIVE SERVICES Child health centre/school health care Environmental health care SOCIAL SERVICES School/day care centre/educational-psychological service Housing Occupational health service Child care REHABILITATION NURSING/CARE Physiotherapy Occupational therapy Social education Home nursing care Nursing and retirement home Psychiatry ADMINISTRATION EMERGENCY SERVICES Health manager Casualty clinic, Emergency ward, ambulance Health- and social board SECOND LINE SERVICES Polyclinic, hospitals Specialists in private practice Collaborating partners of the general practitioner See glossary available from the web pages Municipal services VOLUNTARY ORGANISATIONS The general practitioner PHARMACY ALCOHOLIC CARE Specialist services LABORATORIES Clinical-chemical Pathological SOCIAL SECURITY OFFICE POLICE BOARD OF HEALTH County medical officer OTHER PUBLIC INSTITUTIONS AND REGISTERS Norwegian Institute of Public Health Public health surveys Birth registers Statistics Norway Cancer registers Etc. Governmental entities

10. Information exchange in primary care Is written and sent: • 20 million single bills to national assurance (contact bills). • 1,9 million referrals to hospital or specialist • 3,8 million discharge notes from hospitals and out-patients’ clinics • 1,0 million physiotherapist requisitions • 1,3 million image requisitions • 3,5 million medical certificates and sickness benefit certificates • 200.000 medical certificates on disablement • 7 million test requisitions to laboratories, each with 6-7 analyses • 17 million prescriptions per year

11. Health service characteristics Primary care service Specialist health service Organisation Decentralized, autonomous Governed, hierarchical Economy Price per unit, own risk, Framework, price per unit low costs High costs Services Large volume, broad-spectrum, Segregated and specialized brief contacts Patient-doctor Continuous , personal, Short-lived, limited relationship and binding

12. Work Technique Characteristics Primary care service Specialist service No of health problems Usually several Usually one Clinical picture Early in the disease course Fully developed clin. picture Disease prevalence Low and unselected High and selected Diagnostic method Reductionistic Systematically complete Pattern recognition ”Puzzle” Probability evaluation Tests and procedures Few and simple Numerous and advanced Treatment Patient oriented Organ- and disease-oriented Simple, searchingly More advanced, based on certain diagnosis

13. Revision of hypothesis Diagnosis Presented health problem Reason for contact The diagnostic process Former knowledge about the patient Anamnesis, symptoms Pattern recog. Hypotheses Probability evaluation Searching for characteristics (finds, results) Treatment

14. Prediction value in medical diagnostics Prevalence, sensitivity, specificity Positive test Negative test True positive False negative Ill 2 x 2 table: False positive True negative Healthy

15. Positive test Negative test Ill 617 33 650 Healthy 3 218 61 132 64 350 65 000 Examination of school children The meaning of sensitivity and specificity – an example: • Prevalence: 1% (near-sighted at school start) • Sensitivity: 95% • Specificity: 95% • No of children: 65.000

16. Prediction value of symptoms % of patients General practice Internal medicinal dep. Symptom Diagnosis Gastric catarrh Gastric ulcer Gastric cancer 90 10 0,5 30 60 10 Heartburn General practice Haematological pol Depression Leukaemia 37 0,05 4 24 Spinelessness

17. % % 100 100 60 60 40 40 0 0 Prevalence most important for the test result • Example: Test sens. = 95 % • Test spec. = 95 % False positives False positives Share of true pos. True positives 1 % 10 % 100 % Prevalence of disease

18. Diagnosis - name of disease based on: • Information from the patient • The anamnesis • Symptoms • Clinical investigations • Laboratory tests To diagnose is to classify

19. Migraine Criteria: Recurrent episodes of headache with three or more of the following findings: unilateral headache, nausea/vomiting, aura, other neurological symptoms, migraine in the family Inclusion: vascular headache with/without aura Expulsion: Cervicogenic headache, cluster-headache, tension headache

20. Diagnostic process Name disease/-problem Arrange classes Collect information Classify Reason for contact/ hospitalization Symptoms, clinical finds, lab. results Inclusion and exclusion criteria Diagnosis criteria Code Classification of diagnosis Classification of Diagnoses

21. Systems for diagnosis class. Hospitals and specialist services: ICD(International Classification of Diseases) Primary care services: ICPC(International Classification of Primary Health Care)

22. ICPC

23. Prevalence of chronic disease in the practice population

24. Main objective of the patient record - is now documentation: • Medical, for the physician as a tool in diagnostics and treatment • Juridical, for the patient according to rights. • in the future also: • Communication • Decision support

25. Main functions in today's EPR: • Patient data/card file function • Contacts and diagnosis • Record notes (free text about symptoms, finds and considerations) • Prescription module • Laboratory module – requisitions and answers • Correspondence – Referrals, certificates, word processing • Forms – archive, filling in • Appointment book/waiting list • Accounting module • Simple statistics

26. EPR challenges A record which can give: • Better overview and be adapted to the working methods of the general practitioner • Support in diagnose and treatment • Quality assurance of procedures • Information sharing • Information reuse

27. Mirror the contents and process of the consultation S Subjective – symptoms (anamnesis) Objective – Signs and findings (clinical examination/tests) Assessment – Considerations and conclusion (diagnosis) Plan – effectuation of action (prescr, report sick etc.) O A P

28. Problem oriented record "While the core of earlier patient records were schemes of book-keeping, the core of EPR ought to be the patient’s health problems represented by episodes of care"

29. ”Episode of care” Care services Primary care Hospital Primary care Nursing home Contacts: GP GP GP Hospitalization GP GP GP H GP=General pract. Episode of care H=Home nursing Episode of disease

30. Case history (episodes of care) Diabetes Osteoarthritis Depression Appendix Tendonitis Pneumonia T

31. Problem list

32. Information needs in daily work • Questions arise regularly while working with patients: • attached to treatment, most often medication • can be about much more than medical knowledge • passes usually unanswered • Preferably physicians ask their colleagues – oral/on the phone relevance x validity • Information utility value = the effort needed to find the info

33. Guaranteed to create problems ? Error • Use models and routines from ”best-practice” as foundation • Convey models and systems from private sector and into the public health care sector • Try to convey solutions developed in one county, to another

34. Research at NSEP Role and function of EPR Implementation and use Field methodology Sharing of patient information Medication, Individual plan, Health card for pregnant women Health informatics lab Usability testing, Drama and prototyping Message exchange All to all communication (the ELIN project) Mobile devices Voice recognition, User interfaces, curves Data reuse Data mining Health and disease registers Continuity of care Problem-orientated record Course of disease/treatment representation Patient participation Access to own record, requisition services via the net, personal record Decision support Integration of guidelines and treatment plans Security Role and task specific access control, Automated anonymization