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The electronic patient record

The electronic patient record. The patient record. Notes made by physician Long history. Lloyd George envelope Can be very large Advantages Simplicity Availability Economy Durability. Problems Availability Legibility Analysis. Paper records. Message types. Data-oriented

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The electronic patient record

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  1. The electronic patient record

  2. The patient record • Notes made by physician • Long history

  3. Lloyd George envelope Can be very large Advantages Simplicity Availability Economy Durability Problems Availability Legibility Analysis Paper records

  4. Message types • Data-oriented • Different data types kept separate • Task-oriented • Different tasks kept separate • Template-oriented • Hybrid • Cross-reference task <-> data

  5. Record structures • Integrated or time oriented • What happened at each episode • Data-oriented • Source oriented • Examination notes • X-ray reports • Lab tests • Also data-oriented

  6. The Problem-oriented medical record • Lawrence Weed • SOAP • Subjective • Objective • Assessment • Plan • Separate section for each problem • Template-driven (partially)

  7. Protocol-driven • Standard procedure (e.g. diabetes) • Template • Always record same sequence of data • Task-oriented

  8. The electronic patient record • Definition : the Patient Record held in electronic form whose Custodian(s) work within a single autonomous organisation • Can be active : …support users by [providing] alerts, reminders, decision support… medical knowledge etc.

  9. Issues • Standards especially in terminology • Narrative text vs coding • Privacy and confidentiality • Data entry by health professionals • Integration • Decision support • (Shortliffe)

  10. EPR structure • Source oriented • Data from many sources are combined • Time oriented • Time is stamped on each piece of data • Problem oriented • Data should be linked to show physicians reasoning and progress of problem • Protocol driven

  11. Predecessors of EPR • HISS – Hospital information support systems • PAS – Patient administration systems • Demographic details • Admission • Discharge • Departmental systems

  12. EPR in general practice • Well-established (since 1970’s) • Widely-used (90% of practices) • Useful • Prescribing • Registers • Clinical information

  13. EPR in hospitals • Plans since Information for Health – 1998 • Few successful implementations (3%)

  14. EPR level 1 • Clinical administrative data • Patient administration • Departmental systems (separate)

  15. EPR level 2 • Integrated clinical diagnosis and treatment support • Level 1 plus: • Patient master index integrated with Departmental systems

  16. EPR level 3 • Clinical activity support • Level 2 plus: • Clinical orders • Results reporting • Prescribing • Multi-professional care pathways

  17. EPR level 4 • Level 3 plus • Electronic access to knowledge bases • Embedded guidelines • Rules • Electronic alerts • Expert system support

  18. EPR level 5 • Level 4 plus • Special clinical modules • Document imaging

  19. EPR level 6 • Level 5 plus • Telemedicine • Multi-media applications • Picture archiving and support systems

  20. Targets • 2002 – 35% at EPR level 3 • 2005 – all at EPR level 3

  21. The Electronic Health Record ISO/DTR 20514 A repository of information regarding the health status of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users. It has a standardised or commonly agreed logical information model which is independent of EHR systems.

  22. EHR continued Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent, and prospective

  23. Further reading •  ISO/CEN TC 251 13606http://www.prorecireland.ie/Gerard%20Freriks.ppt • http://www.prorecireland.ie/4%20Thomas%20Beale.ppt • HL7 Reference Information Model • http://www.hl7.org.au/HL7-V3-Resrcs.htm • OpenEHR • http://www.openehr.org/getting_started/t_openehr_primer.htm

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