Creation and Use of the Electronic Medical Record

This description of the EMR is fundamentally different from what is perceived by most people. I believe the means to create it as advocated here is already there in current computerized HIS, waiting only for acceptance of the concept.

TRADITIONAL VS ELECTRONIC MEDICAL RECORD

The traditional function of the paper-based Medical Record is to:

  1. document and share information about a patient during the current patient care session or visit
  2. make available the completed record to subsequent clinical users for continuity of care
  3. maintain a  permanent record for medico-legal and professional reasons
  4. make possible the qualitative audit of an individual case (for inquiries, case review etc.) and the aggregation of data from many cases for non-clinical uses such as research, audit, epidemiology etc.

In a computerized environment, most of the functions of the paper record (i.e. the capture, storage, distribution and communication of information)  is taken over by the Patient Information Database and the various sub-systems of the Hospital Information System (HIS) especially the Clinical Information System (CIS). Instead,  the Electronic Medical Record (EMR) is generated by extracting relevant data from the  Patient Information Database.  While HIS applications and the database are designed primarily to support the operations of patient care, the content and arrangement of the data are also dictated by the legal and professional requirements of the Medical Record as a permanent record of all events and activities that happen during patient care. In other words, the EMR is an important driver in the design of HIS.

The Patient Information Database rather than the EMR is eminently more suitable for extraction and aggregation of data. An analytical database of replicated but anonymized patient data can be used for creating standard as well as ad hoc reports.

THE NEED FOR THE (E)MEDICAL RECORD

Various legal and professional requirements  (laws, regulations, statutes, rules and ethics)  dictate that data of a single patient is presented as an accurate and complete chronological record (log) of events i.e. the Medical Record. The EMR is a document created and constituted through the extraction of data stored in the Patient Information Database. The EMR contains relevant data captured through the CIS and other applications of HIS. Built within the HIS is a facility to present the EMR on demand as an interim document at any time during the visit but more importantly, the completed record at the end of a visit. From the legal standpoint, the institution where the care is given is responsible to maintain and make available a record of the care given and events that occur during entire care episode. Increasingly, to facilitate the continuity of care, there is demand for data from all visits (whether from the same or different institutions) to be put together as the vertical medical record or the Lifetime Health Record.

USE OF MEDICAL RECORD

The EMR contains historical data and is used as:

  1. A source of condensed information regarding the patient, during the visit, within the same care episode  and across episodes
  2. A comprehensive, relevant historical record of events for  use as:
    • evidence (in medico-legal and professional settings)
    • reference (study)

The EMR of each patient, being data derived from the main database, is stored in a separate data repository as a document with a defined content and structure. For most users it is mainly a read only document (in a word processor document format, PDF or any other easily readable format).

As the EMR contains only pertinent data it also represents the mandatory clinical data that has to be retained and migrated if a new system is developed or acquired.

For primary users, the EMR is less useful during an active visit. Instead the CIS application software is used to enter and view patient data. However there are instances when the availability of an interim EMR is an advantage. It may be required for purposes such as overall case review by a person not familiar with the patient (e.g. doctor or any care provider to whom the patient is referred) and for qualitative audit or inquiry during the care episode. The interim EMR is updated incrementally through the addition of new data (as in paper record) instead of being extracted en masse from the CIS at the end of a visit.
By converting the structured data of the database to text (descriptive) format, the EMR is more readable, easier to understand, and more amenable for use in inquiries and qualitative research. Quantitative data for research and other secondary uses should be obtained through queries of the database rather than from the EMR (will be discussed later).

CHARACTERISTICS OF THE ELECTRONIC MEDICAL RECORD (EMR)

While the Clinical Information System (CIS) is seen as the system that facilitates direct patient care, the data generated by all clinical care activities are captured, and stored in the Patient Information Database, a defined portion of the data is extracted and put together as the Electronic Medical Record (EMR). The EMR integrates all the relevant information from various sources including those from Clinical Administration Services (described earlier) and Clinical Support Services (described in more detail in other articles on this website).
Records are kept for all instances of clinical care given. These instances includes visits or attendances for:

  1. Care at the emergency department, any outpatient clinic, the day-care service or inpatient service
  2.  Laboratory test(s) on a specimen obtained from him/her even if not attending any of the other clinical services
  3. Imaging examination(s) performed on any part of his body even if this is the only service given to the patient.
  4. Obtaining any drug dispensed from the hospital’s pharmacy service even if not consequent to a consultation (e.g. encounter to collect repeat medication.

Each patient has a single integrated record relating to the services provided and the events that happen in the health care institution where he/she is being cared for. He/she is given a single medical record number which can be the same as patient’s unique identifier in the Patient Information Database when he/she registered as a client or another number (alias) mapped to it. 

To ensure that each patient has only one medical record, the system enables the person performing registration to search for an existing record by the medical record number if it is available or otherwise any other unique identifier such as national registration number or name.
The entire medical record is an aggregation of records of individual visits, each visit being defined by the period between the registration and discharge or check-out. Each visit should be given a unique identifier (the visit number) which may be equivalent to the financial number.
Notwithstanding the above, means are provided for providers to enter or modify data for a short defined extended period after the visit ends. This allows for incomplete records to be updated if necessary. Care providers providing care during the visit are responsible for ensuring that medical record entries are accurate and complete.
There is also a mechanism for care providers to make notes outside of visits (reminders, communications, “sticky notes” etc.). These may be considered as part of the EMR if they relate to actions relating to patient care e.g advice or communications given via phone or e-mail.

The CIS should not be considered or designed only as a system to generate the EMR. It has many more functionalities beyond the function of an EMR and contains data that may not necessarily be considered as part of EMR (for example data used for communications, automation, quality control and administration).
The Electronic Medical Record (EMR), being a record of data generated as a result of clinical care processes (tasks) and clinical events, is a product of the Clinical Information System (CIS) and the Clinical support systems. The term ‘EMR System’ is inappropriate.

Data Generation and Capture in CIS

Data Acquisition
Data Generation and Capture in CIS

Presenting Patient Data as the EMR

The structure and content is not unlike paper medical records and follows specifications of the medical record agreed by authorities (e.g. the Ministry of Health or Medical Council) or mandated by law. However, unlike in paper records, the instruments used to collect data such as forms or questionnaires do not become part of the EMR. They are only the means of obtaining data. Whether the data truthfully represents what the care provider has documented will have to depend on data integrity mechanisms built into the database. Exception is made for certain legal documents such as consent and notification forms which may be made available in the format prescribed by regulations.

Using Forms to Record Clinical Data

Recording Symtoms
Recording Data in CIS – Symptoms

Methods must be found to display data acquired during the course of clinical care in chronological order to reflect the EMR as a log of events.

Transformation of Data from Forms in CIS to Text in EMR

Form to Text
From Forms to Text

In the end, the presentation of data in the EMR will be quite similar to that in the paper record.

Presenting Clinical Data in Chronological Order

Chronology in EMR
Presenting Clinical Data in Chronological Order

 

While data in the CIS is necessarily structured, data in a medical record is better understood in text format. However as opposed to paper records which are written freehand, as it were, the electronic medical record would be created by converting structured data into a text format i.e. it should use all the capabilities of structured text. It is important that the words and phrasing used by the care provider who documents the data is retained. For the purpose conversion to structured text, fillers and interpolations such as conjunctions may be used. Rules regarding their use need to be spelled out and agreed by the clinicians.

Derivation of EMR from Various Systems of HIS and the Database of Patient Data (Patient Information Database)

Data Flow in CIS
Data Flow in the Clinical Information System

STRUCTURE OF THE MEDICAL RECORD

The structure of the EMR is different from the CIS in certain parts but is similar in many parts. As a historical record, the whole EMR should be arranged in a strictly chronological order regardless of the data source (discussed further later).
The content of the entire medical record is predictable and defined. A major portion of EMR data is a record of events that are either planned or unplanned. Planned events are proactive clinical care processes or interventions. These include technical as well as cognitive processes. Unplanned events can be incidents or developments that are part of the disease process or responses to interventions and actions taken. The event itself need to be described by accompanying facts such as:

  1. what happened,
  2. when,
  3. where and
  4. who are involved

Because of the need to be chronological, time elements (such as episode, visit, date, time by the clock) forms the basic framework of the EMR template. Tasks, events and encounter types need to be named specifically and indicated as headings.  Care providers involved and the person who documents need to be identified. The context within which the task is performed (e.g. indications) or events that happened (e.g relationship to procedures or drugs) need to be clarified. As care processes follow an iterative (cyclical) pattern, headings in the EMR are also repeated until the care episode ends.

Reference for Content and Structure of Medical record can be reached here:

http://www.emblemhealth.com/Providers/Provider-Manual/Medical-Record-Guidelines/Content-and-Format.aspx

http://www.wpro.who.int/publications/docs/MedicalRecordsManual.pdf

http://www.aomrc.org.uk/doc_view/9702-standards-for-the-clinical-structure-and-content-of-patient-records

Content of EMR  and Data Sources

In principle, each EMR is a collection of data that:

  • is a collection of data concerning a single patient
  • contains information generated as the result of Clinical Patient Care
  • is documented by health care professionals taking care of the patient and the phrasing, words used remain true to the way they are recorded
  • is arranged in chronological sequence (a log of events)

The EMR contains the following groups of data:

  1. identification data and profile of the patient
  2. visit and encounter information (visit/encounter types, dates and time)
  3. information gathered regarding the patient’s illness and health status (symptoms, signs, test results)
  4. decisions and plans both immediate and long term (diagnosis, treatment plan)
  5. activities (tasks) performed for or on the patient (the time, the person performing it, the location, the method, the equipment used)
  6. events (incidents) that occurred (planned and unplanned)
  7. results or findings emanating from these activities and events (numerical, text or images)
  8. communications between care providers i.e. instructions, opinions, referrals and advice

The EMR derives data from the following sources :

  1. Patient Management System (identification, demographic and communications data)
  2. Data from elsewhere (referral notes, visit summaries, results from other institutions)
  3. Results of care processes performed in the Clinical Information System (main source)
  4. Results of investigations or processes obtained from Clinical Support Systems (Laboratory, Radiology,Pharmacy etc.)

The same identification data from Patient Management System is used throughout the EMR.
Data obtained from other care providers from outside of the hospital are indicated as such. They are  uploaded from portable storage media (flash dives, thumb drives, portable hard disks and CD-ROMS) or directly via interfaces with  central regional/national data repository. Data in hard copy is converted to scanned images and appended to the EMR (rather than transcribed).
The main source of EMR data is from the CIS where data is actively documented as part of the clinical processes (clinical documentation). The clinical support systems are the other major sources where results destined for the EMR is automatically transferred. Results produced by clinical support systems (laboratory test results, imaging reports, supplies by Pharmacy and Dietary unit) are inserted in the chronology of events at the time they are performed and when results are available.

Radiology images are considered as part of the EMR. If they are stored separately there should be mechanisms to indicate their existence and relationship to the events recorded within the EMR. They should be retrievable as and when required.

System for Incorporation of Paper Records as Part of EMR

The CIS application should also allow various hard-copy documents such as referral letters, printed results, and summaries whether produced by the hospital or supplied by other health care institutions to be scanned using a document scanner and stored in a standard image format(s) and kept in the Patient Information database or a repository linked it.
The system should have in-built mechanisms for ensuring that images are matched with the patients that they belong to.
In the EMR such images should be made available as part of the record.

Chronological Structure of EMR

The EMR being a log of events is chronological. Some data may be divided into temporal segments with each segment representing a visit or the intervening period. There are differences between outpatient and inpatient visits; mainly in terms of duration of visit and number of encounters per visit. Periods of visits are defined by date and times of registration and discharge. Encounters are interactions between the patient and various care providers. Events can be planned or unplanned tasks carried out by the provider during each encounter. Events can also be unexpected happenings (incidents) that occur during the visit.

Traditionally, the EMR may describe events within a disease episode or a care episode within one health care organization. However, it can also be merged with the EMR of another health care facility and health promotion and disease prevention activities, in which case it may considered to as a life-time health record or a vertically integrated medical record.

Content and Arrangement for a Visit

The challenge of arranging patient data as a chronologically sequenced record can be resolved by considering the record as a diary or log. Each entry refers to an encounter and the data relates to various care processes (tasks) and events. The structure mimics that of paper records.

Just as in paper records, the main body is a log of the clinical care processes performed or events that happened as documented by clinicians. All findings and descriptions of care processes and events for this section must be chronologically sequenced and contiguous i.e. there should not be gaps in between. It includes:

  1. Administrative processes (admission, transfer, discharge)
  2. Assessment
  3. Progress Notes
  4. Diagnosis
  5. Plans
  6. Treatment given (medical, procedural, psychological etc.)
  7. Monitoring
  8. Outcome

Example of Content and Arrangement of EMR for an Outpatient Visit

Outpatient EMR
EMR for an Outpatient Visit

Content and Arrangement for an  Episode

The basic unit of a record is data collected during a visit at a particular healthcare institution. To ensure coherence, data collected at multiple visits are also arranged in chronological order. Each visit is identified by the date and time, the care location, and the the type of service.

Traditionally, medical record data have  kept by putting together data from different visits in two ways:

  1. All data for all health problems during  a time period (the fully integrated Medical Record)
  2. All data pertaining to the care of the patient for a particular health problem (record kept separately by different departments or units)

The CIS enables all data to be captured into and made available from a single database. From this fully integrated record, it is also possible, through a query of the database, to separate out data essential to a particular specialty or the care o a particular illness/health problem. However, from a medico-legal standpoint, it is the responsibility  of the health care institution  to keep a record of data (Medical Record)  for every visit and encounters made at the institution. Use of CIS and EMR and a common databse puts a stop to record keeping by individual departments.

Integrated Health Record

The use of computerization and information management technology has enabled the pooling of data (complete or summarized) in a central  shared database. Access to EMR, generated at visits at different institutions or a summary of it, enables the clinician to know the whole picture about each patient’s health and illness. This leads to better continuity of care. Such an arrangement require cooperation between institutions and another body to manage the shared database.

Relationship between Data from a Single Institution and Shared Common Database

Constituent Parts and Functions of HIS

Supplementary Segments

Again similar to paper records, besides the temporal segments separate documentation may be provided as sections pertaining to a subject matter. This is indicated for multiple and repetitive findings where knowing trends and deviations are especially useful for example in case reviews. Each section is discreet and presented as lists or in tabular format with chronological sequence. These separate sections include:

  1. Monitoring parameters
  2. Lists of Procedures
  3. Medication given
  4. Laboratory results
  5. Diagnosis made (the Problem List)

RECONCILIATION OF MEDICAL RECORDS

If for some reason more than one entity had been inadvertently created for the same person in the Patient Information Database and therefore the EMR, there must be a facility for the data belonging to the same person to be merged. Care must be taken to ascertain that the data belongs to that patient. This facility needs to be a front-end tool easily utilized by authorized person who can be record officers or IT personnel. There should also be a facility to unmerge the records if necessary.

PORTABILITY OF EMR OR PORTIONS OF IT

The EMR document is a good means of passing information from to a care provider to another provider that do not have access to the same HIS. It should be written and published in a standard portable document format (PDF, XML, Open document or XPS) readable by commonly used document reading applications (e.g. Adobe Reader or Microsoft XPS Viewer). Each EMR should be stored as a document file in a separate filing system and from where it can be downloaded and written to commonly available transportable storage media (USB drive, DVD-ROM, portable Hard Disk) and printed on paper; or exported via a secure web area network. The same is true for visit or episode summaries.

SECONDARY USE OF RECORDED PATIENT DATA

is discussed in another article.

Primary users of patient data are mainly care providers who would use the CIS to perform their work. Secondary users would be given privileges to use the EMR. The medical record data is used in two main forms i.e.

  1. Use of data from a single record
  2. Use of aggregated data

Secondary Use of a Single Record

A single record may be used in Qualitative reviews of the care of a patient for instances such as:

  1. Mortality or Morbidity Reviews
  2. Inquiries
  3. Quality audit
  4. Qualitative research

Because these are in-house activities, the CIS application may be used to sift through the record but an ongoing EMR would serve the purpose better. The most important use of Medical record is as a Medico-legal document. For this purpose the record need to be complete, presented in an orderly manner and easily understood.

Secondary Use of Aggregated Data

The medical record and the DBMS that supports it should be designed so as to allow the extraction and analysis of aggregated structured data for use by secondary users such as Managers, Quality Management, Record officers, Researchers) for purposes of:

  1. medico-legal inquiries (what went on, who were involved, when, where)
  2. review of entire care (audit, qualitative research)
  3. calculation of incidence/occurrence/prevalence for epidemiological and clinical research
  4. creation of registers,
  5. assessment of resource utilization,
  6. performance of audits,
  7. measurement of productivity / efficiency/ quality indicators
  8. risk assessment,

All of the above is done from the database rather than the EMR. For some purposes, it may be detrimental to extract data from the operations database. To serve this purpose, a duplicate copy of the CIS database is made and utilized as the analytical database.
To enable sharing of data, there should be technical data compatibility to enable flow across systems and where necessary across organizations and semantic data compatibility such that data is understood by all users.
This requirement is detailed further under the section on Data Extraction, Analysis and Interpretation.

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