Electronic health record

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The electronic health record (EHR) is defined as a "computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record."[1]

Personal health record (PHR) is a variation in which the patient maintains the data rather than the health care provider maintaining the data.[2][3] Examples of PHR include Dossia (http://www.dossia.org) and Microsoft HealthVault (http://www.healthvault.com).

In the future it is hoped that EHRs across different health care systems will be able to exchange patient information in regional health information organizations (RHIOs); however, this goal has been elusive.[4]

EHRs in the outpatient setting hopefully save costs after an initial period of cost loss.[5] EHRs cost about $15,000 per privider in 2002 American dollars.

Features

Problem lists

One study noted that less than half of patients with splenectomy had it recorded in their problem lists. However, "among these patients, the pneumococcal vaccination rate was 17%, as compared with 54% among patients whose splenectomy was included on the problem list"[6]

Interventions may increase completeness of problem lists.[7]

Medical order entry system (CPOE)

For more information, see: Medical order entry system.

Medical order entry systems, also called computerized provider order entry systems (CPOE) are "information systems, usually computer-assisted, that enable providers to initiate medical procedures, prescribe medications, etc. These systems support medical decision-making and error-reduction during patient care."[8]

Clinical decision support

For more information, see: Clinical decision support system.

Links to medical knowledge

For more information, see: information retrieval.

Content in the EHR that is codifiable with a standard taxonomy can be linked to medical knowledge that is indexed with the same taxonomy. As example is Infobuttons that automatically displays links from the EHR to external knowledge sources.[9] One trial studied the effects of adding a feature to the EHR that allows the clinical to request assistance with information retrieval from an informationist.[10]

Natural language processing

Computers can use text mining to analyze text to in order to create structured data. Attempts at text mining include identifying section headers in clinical notes[11], identifying smoking status of patients[12][13], sequences of events[14], categorization of physical examination findings[15] and use of medications for specific diseases.[16]

In the United States, the National Cancer Institute has established the Open Health Natural Language Processing Consortium to promote natural language processing.

Interoperability

Ideally, patient data should be able to be transferred across different EHRs as patients move across health care systems. Networked EHRs are call to a health information exchange (HIE) or regional health information organization (RHIO).

In 1999 the Santa Barbara County Care Data Exchange was initially funded by $10 million dollars from the California HealthCare Foundation in order to be HIE demonstration project.[4] By fall 2006, two organizations within the HIE were able to exchange some information. However, in December 2006 the project's board decided to close the project due to funding problems.

Other RHIOs include The Indiana network for patient care (INPC)[17][18][19], the Massachusetts eHealth Collaborative (MAeHC)[20] funded by $50 million dollars from Blue Cross Blue Shield of Massachusetts[21], and Inland Northwest Health Services (Spokane).[22]

In the United States, the Department of Veteran Affairs and the Department of Defense are creating data exchange between their EHRs.[23]

Uses

Clinical care

Unintended consequences

Unintended consequences, that are a mix of positive and negative, may occur to computerized provider order entry.[24]

Adverse effects

Most all of the adverse effects are due to just the computerized provider order entry component of the electronic medical record.

Implementation of the computerized provider order entry has been associated with medication errors[25] This may be due to computer interfaces that are not intuitive to use.[26]

Computerized provider order entry has been associated with causing a number of unintended consequences with "new work/more work, workflow, system demands, communication, emotions, and dependence on the technology" being most severe.[24] In this study, shifts in power ("The presence of a system that enforces specific clinical practices through mandatory data entry fields changes the power structure of organizations. Often the power or autonomy of physicians is reduced, while the power of the nursing staff, information technology specialists, and administration is increased") were also observed.

The introduction of computerized provider order entry has been associated with increased hospital mortality in some[27], but not all studies.[28][29]

Copy and pasting of notes

Copying and pasting of text from an older note to a newer note is common and may lead to incorrect information.[30]

Quality management

There have been very few studies assessing the quality content [1].

Standards

There are some international efforts going on to ensure that standards are followed. Common Standards are:

Rapid system learning

The electronic health record may allow rapid system learning for events such as disease outbreaks.[31]

Research

The electronic health record can provide data for health research. One issue is protecting the privacy of patients.[32][33]. It may also be used for creating a clinical data warehouse.

Benefits

Hospitals with high use of information technology may provide better health care.[34][35]

Physicians with complete an electronic health record tend to better follow-up on abnormal diagnostic tests[36] and perform higher on HEDIS measures.[37]

Kaiser Permanente found that implementing an EHR was associated with a reduction in office visits as clinical interactions shifted to new methods such as email.[38]

Implementation

Inpatient

As of 2008, few a minority of hospitals have adopted EHRs in the United States.[39]

Successful implementations

The United States Department of Veterans Affairs has successfully implemented an electronic health record system, "VistA", across a very large health care system.[40][41] Although it has been an early innovator, this system occasionally has problems.[42] VISTA has been promoted for use outside of the VA system by groups such as WorldVistA.

Unsuccessful implementations

  • Kaiser - Hawaii[43]
  • Limpopo (Northern) Province, South Africa[44]

Outpatient

As of 2008, few clinics in the United States had adopted EHRs.[45]

EHRs in the outpatient are estimated to provide $86,000 net revenue in 2002 United States dollars which includes an initial cost of $13,100 per provider and a loss during the first year of $8200 per provider.[5] EHRs cost about $15,000 per privider in 2002 American dollars.

A case study describes barriers to implementing an EHR in a private clinic in the United States.[46]

While EHRs may allow doctors to conduct quality improve, the process is difficult.[47]

Incentives

In the United States, the Department of Health and Human Services and the Centers for Medicare and Medicaid Services (CMS), have created financial incentives to encourage the adoption of EHRs by health care providers and hospitals who are engaged in "meaningful use of certified electronic health records (EHR) technology".[48][49] This is mandated by the HITECH Act.[50][38] The ability of the Centers for Medicare and Medicaid Services to implement these incentives has been questions.[51]

Privacy

Maintaining privacy of personal health information (PHI) is important goal of the Health Insurance Portability and Accountability Act (HIPAA). Various attempts at automated the de-identification of records are ongoing.[52]

References

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See also