Health Records EPJ-Observatoriet o Arskonference 2002, Nyborg
The clinician in the information age
Dr Dipak Kalra
Clinical Senior Lecturer Centre for Health Informatics and Multiprofessional Education (CHIME) University College London [email protected]
Dr Dipak Kalra Health Records RealisingRealising thethe EHR:EHR: whatwhat areare wewe concernedconcerned about?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 IfIf realisingrealising thethe EHREHR isis aa journey…journey…
…then
• Where are we heading ?
• Why are we going there ?
• Why is the journey so difficult ?
Dr Dipak Kalra Health Records InformationInformation needsneeds inin healthhealth carecare
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
Dr Dipak Kalra { Jennings, Miller, Materna 1997} Health Records ChallengesChallenges facingfacing today’stoday’s healthhealth recordrecord
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 TheThe needneed toto recordrecord moremore healthhealth carecare datadata
• 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 19991999 USUS Dept.Dept. ofof CommerceCommerce studystudy
• health care is the fourth most information reliant industry sector after: – telephone & telegraph – radio & television – security brokerage
Dr Dipak Kalra Health Records UKUK AuditAudit CommissionCommission SurveySurvey (1995)(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 ScaleScale ofof thethe problemproblem
• 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 TheThe needneed toto analyseanalyse moremore healthhealth carecare datadata
• 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 ExploitingExploiting goodgood clinicalclinical datadata
• 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, Dr Dipak Kalra Taylor et al. 2000} Health Records 19951995 AuditAudit CommissionCommission ReportReport onon PatientPatient HealthHealth RecordsRecords
• 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 ImportanceImportance ofof datadata qualityquality andand itsits availabilityavailability
• 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 RequirementsRequirements ofof evidenceevidence basedbased medicinemedicine
• 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 GrowingGrowing numbersnumbers ofof conceptsconcepts
• 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 GrowingGrowing numbersnumbers ofof conceptsconcepts
• 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 TheThe needneed toto shareshare moremore healthhealth carecare datadata
• 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 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 communication breakdown
Shared care communications survey (Kalra, D. London, 1997)
Dr Dipak Kalra Percent of GPs reporting problems Health Records PerceivedPerceived benefitsbenefits ofof thethe computercomputer
• 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
Dr Dipak Kalra Health Records
Changing this...
Dr Dipak Kalra Health Records It’sIt’s difficultdifficult toto getget toto aa clearclear desk!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 WhyWhy areare EHREHR standardsstandards soso difficult?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 EHREHR andand otherother informaticsinformatics standardsstandards areare vitalvital
• 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
Dr Dipak Kalra The clinical information environment
Medical Knowledge Health Records Clinical practice needs to share this information consistently and faithfully
Medical Knowledge Health Records A combinatorial explosion: of interfaces or of messages
GP GP systems systems
Ambulatory Ambulatory & secondary & secondary care care systems systems
Tertiary Tertiary care care systems systems Common clinical middleware: physical or logical
GP GP systems systems
Ambulatory Ambulatory & secondary & secondary care care systems systems
Tertiary Tertiary care care systems systems We need interoperability of data and services within this clinical middleware
GP GP systems systems
Ambulatory Ambulatory & secondary & secondary care care systems systems
Tertiary Tertiary care care systems systems The EHR middleware “kernel”
GP Terminology EHR repository systems services EHR entry validator Archetype Ambulatory library & secondary Demographic Communications care services interfaces systems Audit trail Request query handler Decision Tertiary support care systems Access control filter systems
These services build on a generic EHR Information Architecture Other integrating services
Workflow Learning Comms resources & security
Online Persons knowledge registries
Terminology Billing Metadata
Interoperability of some of these services is the scope of HISA 3 Open Source Foundations are working towards this interoperability
OpenGALEN OpenEHR
The EHR Information Architecture is one cornerstone of this interoperability Patient and Patient-foussed health professional clinical outcomes education products assessment tools
Clinical outcomes Health record databases systems Evidence Based Information Systems Epidemiological Hospital & primary and audit care patient databases management systems (persons registries, Electronic guidelines workflow, billing etc.) and decision support applications Health Records WhatWhat makesmakes aa “good”“good” EHREHR ??
VALUES • Faithfulness to the needs and wishes of patients • Faithfulness to the clinical care process
Dr Dipak Kalra Health Records FaithfulnessFaithfulness toto thethe needsneeds andand wisheswishes ofof patientspatients
• 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 FaithfulnessFaithfulness toto thethe clinicalclinical carecare processprocess
• 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 KeyKey messagesmessages
• 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
Dr Dipak Kalra Health Records
ThankThank youyou
Dr Dipak Kalra