What is an electronic medical record and how should it be evaluated?

1. The Norwegian University of Technology and Science What is an electronic medical recordand how should it be evaluated? Hallvard Lærum, MD Ph.D. fellow

2. What is an electronic medical record? One institution, periodic health care • Norwegian definition of a medical record (KITH 1996) • ”the health personnel or instiution’s continous records of information about each patient and elements of importance for the needed health care” • Electronic Patient Record (NHS/ERDIP 2001) • ”[The term] Electronic patient record describes the record of the periodic care provided mainly by one institution” • Electronic Health Record (NHS/ERDIP 2001) • ”..concept of a longitudinal record of a patient’s health and healthcare – from cradle to grave. It combines both the information about patient contacts with primary healthcare as well as subsets of information associated with the outcomes of periodic care held in the EPRs” • Computer-based patient record (IOM 1997) • “electronically stored information about an individual’s lifetime health status and health care… ” • “...an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids.” Multiple institutions, "cradle to grave"

3. EPJ – The Norwegian Term Hospital information system • As a legacy from the paper-based patient record, "EPJ" has been considered containing clinical data and information only, not patient administration data • The "EPJ" is related to periodic care in single institutions, no personal health record included. • ”EMR” was the closest match for the ”Elektronisk pasientjournal” term in 1999 Electronic Medical Records Patient Administration data

4. Clinical biochemistry Blood, Urine, Spinal fluid, etc. RadiologyX-ray, Ultrasound, CT, etc. Pathologyhistopathological examinations, autopsies MikrobiologyMicrobe identification Antibiotic resistance Paper-basedClinical photos, old medical records, letters Clinical physiologyECG, EEG, Heart valve ultrasound OtherNMR, Scintigraphy, etc. Integration of various sources of clinical data and information EMRMedical narratives, e.g. discharge reportsdaily notes, etc.

5. Using the EMR to locate non-patient information By exploiting the information found here... ...we may quickly get the right information here: Medical knowledgeTextbooks, clinical reminders, decision support EMRClinical problemDiagnosisTreatmentSex, age, weight,etc. Population statistics Information to patient Logistic informationHow to get the job done Social influences/Local ProceduresHow others get the job done Gorman PN. Information Needs of Physicians. Journal of the American Society for Information Science 1995;46:729-36.

6. The difference between the EMR and the EMR system • In simplistic terms: • An EMR is the electronic clinical data and information • An EMR system is the system handling them That means: making them available to multiple legitimate users, offering results management, order entry, decision support, electronic communication and connectivity, patient support, interdisciplinary work flow and planning

7. Reality (year 1999) • Continuous textual medical records updated by and accessible to physicians • admission reports, progress notes, surgery reports, discharge reports and other documents • Access to clinical biochemical lab data and radiological results • The paper-based medical record is still being updated, thank you very much

8. EMR systems in Norwegian hospitals • DocuLive EPR • Integrates with third party PAS • DIPS • PAS included • Infomedix • PAS included

9. Norwegian EMR systems and the IOM’s Core functionality of an Electronic Health Record System Key Capabilities of an Electronic Health Record System:Letter Report (2003) (preliminary version, illustrative purposes) 0 - 25% 25-49% 50-74% 75-100% IOM Functionality elements involved:

10. Hospitals with EMR systems

11. Hospitals Others 6 % None 4 % DIPS 32 % InfoMedix 29 % DocuLive EPR 29 % EMR systems in Norwegian somatic hospitals, September 2002 Hospital beds Others 0 % None DIPS 19 % 6 % InfoMedix 32 % DocuLive EPR 43 % *In use by the physicians

12. EPR DocuLive EPR Desktop Prescriptions Record explorer

13. DIPS Schedule Desktop Criticalinformation Record Explorer

14. IMx Desktop Gastro module Prescriptions

15. EPR Properties of the three systems ...but they are not complete

16. ”The clinical gateway”at Rikshospitalet Demographicinformation Document-basedinformation Radiology reports Lab reports Activity planning

17. How should the EMRsystem be evaluated?

18. What is evaluation? No single accepted definition of evaluation exist Evaluation is an empirical process – data is collected Evaluations may be performed to: • judge merit and worth of an object • reach consensus and lead to deeper understanding of the object • make improvement of the object possible A comparative element may be involved • Pre-post studies • Control and intervention studies • Comparing to a predefined goal

19. Roles in evaluation of EMR systems • Evaluators • Development team • Users and patients • Stakeholders • Funders of development team • Funders of the evaluation project • Users of similar systems in other settings • Various public or political groups • Others

20. Why evaluate EMR systems? • To establish the feasibility of a new project • To make organizational investment decisions • To review progress of information system projects • To assess the impact of an information system on the organization • To assess value added by the information system function as a service providing department Jayasuriya 97: Friedman & Wyatt 96: • To encourage the use of information systems in medicine • To uncover the principles of medical informatics • To develop and test more effective techniques and development methods • To make sure it is safe, and to make sure it is better than the resource it replaces.

21. What to evaluate Evaluation questions should cover a wide range of perspectives

22. When to evaluate – Phases Before implementation After implementation Formative methods Summative methods Continous or at specific time points

23. How to evaluate – choice of data collection methods and/or study design • Methods and study design should be adapted to the chosen evaluation questions and the phase it is to be performed in. • Chose the wrong method, and you answer a different question than intended • Quantitative and qualitative methods in combination • The "what" by: • F.ex. questionnaires, system logs, work sampling, business case, etc. • The "how and the "why" by: • F.ex. observations, focus groups, document studies, interviews, etc. • Both formative and summative methods are needed • Results from formative investigations (f.ex. usability studies) may guide the development process directly in an phase ideal for modification of the system. • Modifying the EMR system after implementation is much more expensive • Summative investigations of operational systems may provide the most convincing descriptions of merit and worth.

24. However... • The ideal evaluation involves multiple methods used to answer multiple evaluation questions in an accurate way in repeated investigations • Will the ideal evaluation cost more than the stakeholders are willing to pay? • Are the hospitals who are buying the EMR systems willing to pay the costs of even modest evaluations? • No evaluations of EMR systems published in Norway as of 1999 • Stakeholders need a wake-up call