Transcript tutorial on EMR

The Electronic Medical
Record
Department of Medical Informatics and
Education
by
Lorna Duddy.
Existing Hospital Records .......
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Paper Charts of Patient Medical Records are the
norm worldwide for recording patient information.

All relevant patient information is documented in
one file for reference - including Lab. results, test
results and progress notes.
These charts are easy to use.
The same file is used on subsequent admission to
the same institution.
And as source of reference for medicolegal cases.
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By now most large health care institutions have a
computer database of patients which matches :
* Patient’s Hospital I.D. Number
* Name
* Date of Birth
* Address ....
This provides a rapid search
to match a patient name
with a chart no. when
retrieving a record from storage.
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The source of the Electronic Medical Record is
simply expanding on this database creating an
“on-line” record for each Patient.
The Electronic Medical Record.
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The Electronic Medical Record (EMR) is the
future of patient record documentation.
There is very wide scope for applications and
additions around a centralized record.
The EMR can be accessed conveniently by
appropriate health professionals to ensure ultimate
maximum and optimal patient care.
This tutorial discusses the following :
Description of a typical EMR.
 Potential applications.
Problems associated with its use.
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There are many aspects contributing to a typical
EMR.
PATIENT
HOSPITAL
ADMISSION
GENERAL
PRACTITIONER
DIAGNOSIS
LABORATORY
RESULTS
DECISIONS
TREATMENTS
PROGRESS
NOTES
At Hospital Admission...
Admission Details :
 Patient History
 Physical Exam.
 Observations - weight
- b.p.
- temp.
- pulse
are easily updated and
reviewed at
subsequent hospital
admissions.
LABORATORY RESULTS GRAPH
Different variables at different dates can be seen at a glance.
Variations from the normal values are also easily seen.
350
Glucose
Cholesterol
300
250
200
Glucose Normal
150
100
50
0
08/01/95
15/02/95
31/05/95
28/09/95
Lab. results can be received directly from the laboratory and
are entered directly, available for the doctor to review.
A S.M.A.C. result may look
like....
Creatinine
8
Glucose
300
7
6
Calcium
3
2
Phosphate
1
0
200
Alk phos
u/l
150
LDH u/l
100
AST u/l
50
ALT u/l
urea
5
4
250
Uric Acid
umol/l
Cholesterol
0
GGT u/l
A Centralised Record can be accessed easily by various
hospital departments as illustrated below.
Care/Treatment Unit
Hospital Ward
Patient Location
Laboratory
Pathology
Bacteriology
Radiology
Physiotherapy
Unit
Pharmacy
PHARMACY ACCESS
A Medication Guide such
as the one in the next slide
gives a comprehensive
overview of :
 Patient Drug History
 Drug Allergies
 Reasons for prescription
 Dose
Through inclusion of an online guide such as BNF or
MIMS, warning of
impending drug
interactions and contraindications may be given.

MEDICATION MANAGER
Patient Name :
I.D. No.
:
Consultant
CURRENT
: DRUG HISTPORT
CURRENT DRUG HISTORY
DIAGNOSIS :
Urinary Tract Infection
Include : All current and expired drugs.
OTHER ACTIVE PROBLEMS
DRUG
Becotide 250
ASTHMA
Drugs Available for Diagnostic Profile :
CODE
AMPICILLIN
AMPICILLIN-SODIUM
SELECT
CANCEL
DOSE
2/day
Drug Allergies :
NONE KNOWN
PRESCRIBE
RESULTS....
Processing results
CT Scan and X-ray results such as this (see next slide)
can be processed, reviewed and entered directly into
the patient file.
The results may be sent to other specialists by the
Internet network for consultation.
Display Graphics...
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The index of an Electronic Medical Record
may look like.....
Applications of the E.M.R.
COMMUNICATION ...
One of the advantages of a central record is the ease of
communication between
- Hospital Departments e.g. for booking of diagnostic tests.
-G.P. and hospital physician by email.
Standardised, structured messages may be sent from
one person to another both of whom are familiar with
the format, by the Edifact system (Electronic Data
Interchange For Administration, Commerce and
Transport).
Communication can be made easier via email
services
Hospital Physician
Patient
Specialist
Surgeon
Anaesthetist
Other health care personnel
General Practitioner
Referee
TELEMEDICINE...
This is the practice of medicine using any data transfer linked
with the process of care, in which some aspects of the care
are assisted by remotely located professionals.
Specialist communications may be made by Video-link.
Components of Telemedicine
PATIENT SITE
PATIENT
DATA
COMMUNICATION
NETWORK
TREATMENTS
PHYSICIAN
IN-CHARGE
EXPERT SITE
SPECIALIST
CONSULTATION
EXPERT
DATA
Telemedicine at Work...
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The Eastern Health Board has introduced patient “Smart
Cards” on a pilot basis, where a patients medical record
may be carried by the patient as a plastic card and may be
inserted into a special decoder, read and updated at
hospitals and GP practices participating.
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This Autumn British Airways are introducing a satellite
communication with a doctor on the ground as a back-up
to Flight Attendants with basic medical skills.
Vital signs are communicated and doctors can manage
patient care from the sky and decide whether an emergency
landing is necessary.
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“Net To The Rescue”.....
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It was recently reported that two Chinese students at Peking
University sent an appeal for help to find a diagnosis for their
Chemistry student colleague who had developed a severe illness to
which the doctors at Peking Union Medical College hospital had no
cure.
The medical information was sent to Sci.med newsgroups and
within 24hrs was read by a doctor in Washington who recognized
the girls serious condition could be due to thallium poisoning.
Phoning the hospital in Beijing he advised to check for thallium
poisoning.
To the initial annoyance of the physicians over 600 email messages
were received in reply to this appeal and the general consensus
pointed to the same and correct diagnosis.
An Internet page is established to monitor the patient - Zhu Ling’s
recovery. This can be accessed at
http://www.radsci.ucla.edu/telemed/zhuling.
THE EMR AS AN INFORMATION SOURCE
FOR STATISTICAL RESEARCH.
 Specific information gathered from a
large number of patients for a
certain disease with regard to
Severity
Duration of symptoms,
can be represented graphically or
scored.

This can be used as a reference for
aids to diagnosis .
A “Relational Database “ would
be of this form and could be
incorporated into the EMR.
QUESTIONNAIRE ON LIVER DISEASE
Conventions : Please mark all items
P = Present O = Absent
s = Unknown/doubtful
Lines ___= Enter Text
General Screen
Yellow Sclerae
.....Age in years
Male sex
Weight loss
Jaundice
....Duration (days)
Deep
Increasing since
onset
Decreasing
Constant
...= Enter number
Anorexia
Nausea/vomiting
Symptoms preceded
jaundice
Haemetamesis
pale stool
diarrhoea
urine dark
Abdomen
palpable spleen
palpable gallbladder
tender gallbladder
Ascites
liver definitely enlarged
liver hard
liver tender
liver irregular
obvious mass
Other
Fatigue
Weight loss
......Doctors experience in
yrs
History taken from patient
History taken from chart
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Charts such as the sample in
the previous slide are
completed and the
information is coded into
computers.
From these standard form
findings, accumulated from
thousands of patients, it is
possible to set up a data
base.
Through the use of Artificial
Intelligence and applying
statisitcal rules, the condition
of a given patient - on which
the same findings are
available, can be predicted.
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In the I.C.U. this type of
correlation, analysis of
Laboratory results and
biochemical readings from
monitors may be
incorporated to predict a
patient’s progress and
forecast how long a patient
may have to stay in
intensive care.
This is important to
hospital staff and
management as to how
many places will be
available at a given time.
APPLICATIONS FOR HOSPITAL MANAGEMENT.
CENTRAL RECORDING OF :
•number of bed days
•procedures and tests obtained by the patient,
•units of treatment given
in addition to
CODING OF DIAGNOSIS, PROCEDURES AND
MEDICATIONS
will make auditing of patient accounts easier and
also more accurate.
TRANSMISSIBLE RESULTS MAY CUT
DOWN ON THE NEED TO REPEAT TESTS.
Difficulties Associated.....
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It is clear from the previous slides that the technology is
available to support far ranging possibilities for an
Electronic Medical Record.
However there are enormous problems to be overcome
with regard to its use.
Designers of EMR’s must adhere to existing laws and
legislation must be put in place to govern the appropriate
use of data collected.
Access - Patient confidentiality must be preserved at all
times. Coded access e.g. by PIN would be a necessity.
Different types of codes could be given to personnel who
access the record for different purposes :
~ Doctors
~ Secretarial
~ Paramedical
~ Administrative
Data
The quality of data stored is also a problem of paper records.
Data is a man-made artifact. Each individual has a method for
recording relevant patient data within a framework.
Marked discrepancies may occur between information reported
during patient interview and that which is contained in the record.
Not all patient facts reported may fit neatly into a structured
record
Such “misinformation” may be contained in the EMR due to
misunderstanding of definitions and terms used.
Standardization
Is a definite requirement for widespread use of electronic records.
This would include Lab. results units and precise medical terms.
On-line dictionaries would help.
Standardization of support software to link one system to another
would also be necessary.
Cost
The introduction of such a record would involve phenomenal
financial expense
~ Hardware and Software equipment
~ Staff Training - would demand time and money which could
be spent alleviating waiting lists.
Although expensive test results available centrally would be a
saving in health service costs.
Complexity
The EMR allows for increased processing of medical data.
and enhances data analysis, which may ultimately complicate
research with flawed data.
The reasons why and the circumstances under which data is
collected is not accounted for by simply coding observed facts
into a structured computer programme.
Conclusion
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The aim of the EMR is to encompass all underlying
structures of paper record in a structured user-friendly
format.
Good history and physical exam. and clinical observation
skills are the key to achieving information which is
managed to support clinical decisions and actions taken in
patient care.
A Centralised record including lab. and procedure results
and medication records will enhance patient record
interpretation.
Coding of Diagnoses, Procedures and Medications will
benefit ~ Research
~ Auditing
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Many of the programmes concerning the EMR are still in
the pilot stage.
Legislation is needed to
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– Promote patient confidentiality
– Govern the use of data collected.
Efficiency in the management of patient information,
leading to more competent clinical action is the aim and
should not be lost in megabytes of data input.