Lakewood Resource and Referral Referral Center 212 2nd Street Lakewood NJ, 08701
Introduction to EMRs
Why do we need Electronic Electronic Medical Records (EMRs)? Many problems Many problems with the current healthcare healthc are system (underuse and overuse)
30% of children receive excessive antibiotics antibiot ics for otitis 20-50% of surgical procedures are not necessary 50% of back pain x-rays not necessary 50% of elderly patients patie nts don’t don’t get a pneumovax
Introduction to EMRs
Why do we need EMRs?
Clinical practice is a data intensive operation Inadequate data communication causes medical errors Human cognition is good at pattern recognition but not at remembering lists or evaluating multiple business rules. rules.
Why do we need EMRs?
Available 24 x 7 Can be viewed by more than one user at a time Is available from remote locations
To covering MDs Others with appropriate needs
Data can nearly always be found Is legible
Why do we need EMRs?
Enhances Communication:
Between providers--clinical messaging Can tag EMR location with message Referrals
Half of specialists didn’t know what the main question was A third of the time no information came back to PCP
Why do we need EMRs?
Cost Savings:
Dictation Dictati on cost cost savings
Chart pull savings
$170/FTE/month $217/FTE/month
Savings accrue to practice, apply to all payers
Why do we need EMRs?
Assist with Decision Support:
Many domains—cost and selection of: Drugs
Lab tests
18% reduction found by Researchers 10-15% reduction in cost for charges, last result, probability of abnormal
Radiological studies
Why do we need EMRs?
Decision Support: In inpatients, computerizing ordering decreased
Serious medication errors by 55% All medication errors by 81%
EMR can help by
Structuring medication orders
34% error rate with paper vs. 6% with electronic
Alerting about
Allergies Duplicate medications Many other issues
Introduction to EMRs
Do EMRs make a difference?
UNEQUIVOCALL UNEQUIVOCAL LY YES, BUT AT A COST! COST! In multiple multip le studies, EMRs have have been shown to:
Shorten Length of Stay in a Hospital setting Decrease Adverse Drug Events (ADEs) Improve Readability, Consistency and Content of the medical record Improve Continuity of Care Reduce practice variation
Most benefits benef its come come from Decision Support. Support.
EMR Use in the United States
Even Even though the US Health Care system is the costlies costliestt in the world, its performance pe rformance ranks ranks 37 th in the world according to the World Health Organization Only 5% of US primary care providers providers use EMRs (Bates et. Al., JAMIA 2003), 7% of all physicians (W ( Wang, Bates, et. Al., American Journal of Medicine, April 2003)
EMR Use Around the World
Use PCs Use EMR Australia 90% 53% Denmark 95% 62% Netherlands 95% 88% Sweden 95% 90% United Kingdom 95% 58% (c) 2001 Harris Interactive
Breakdown by Function - 2002
Use EMR Of Those:
Australia 90%
Prescription 100% Notes Unknown Reminders Unknown Clinical Vocabulary ocabular y 15% (ICPC) Paperless Unknown
UK 99% 80% 45% 70% 100% (Read) 45%
$2B initiative by UK to get all physicians all physicians online
What is an EMR?
At their heart, heart , EMRs are just a database This database hold many kinds of information (coded and not coded) This database is organized by date, time, patient ID and contains:
Patient registration data (name, contact info, DOB, SSN, etc.) Test results (laboratory, (laboratory, radiology radiolog y, nuclear nuc lear med etc.) etc. ) Medications (active, inactive) and Allergies Current list of diagnoses and problems Appointment Data Clinical Notes Billing Information
What is an EMR?
So if an EMR is just a database, database, how is it different from other databases, and why is it so useful? Value Added:
A Clinical Knowledge Heirarchy (term dictionary )
How do clinical clinic al concepts work together Ex: Digoxin toxicity can occur occur with hypokalem hypokalemia ia
A List of Current Clinical Recommendations A List of Appropriate Medication Indications, Doses, Adverse Effects and Interactions and Cost Estimates Costs, Indications Indi cations and Utility of Tests Tests
What is an EMR?
What are some typical EMR Components: Lab System: Contains all lab tests ordered and their results and stored as coded results in many systems Radiology System: Stores test reports Pharmacy System:List of current medications, inactive meds and when they were last dispensed or o r ordered ordered Billing System : A list of diagnostic of diagnostic codes used for billing Registration System: Names, Contact Info, Personal Info, etc. for patients
What is an EMR?
Additionally, many EMRs have:
An Order Entry Entr y System (where physicians enter orders, prescriptions, notes etc. online) A Decision Support System
Often linked linked to the order order entry system to provide guidance at the point of care ca re Contains databases for clinical knowledge, guidelines, list of medication indications, doses etc.
What is an EMR?
The spectrum of EMRs
EMRs target specific user bases, from solo office-based practices to large, multispecialt multisp ecialtyy care centers Many features are thus directed at managing managin g workflows workf lows specifically to these user bases
For example, large commercial EMRs unbundle services such as clinical documentation, results display etc. while office systems typically integrate in tegrate all of these under the same interface.
How do Clinicians Interact with EMRs Patients
Clerks
REGISTRATION SYSTEM
LAB SYSTEM Nursing Staff PHARMACY SYSTEM Physicians RADIOLOGY SYSTEM Coding Staff
BILLING SYSTEM
Insurance Co. Order Entry/Results Reporting
Different Types of EMRs
EMRs don’t don’t necessarily need to be expensive and complicated or require that a computer be used to enter data Can have hybrid computer/paper based approaches
Ex: In the t he CHICA™ CHICA™ System, paper pape r is used to interact with an electronic data repository Standardized paper forms are printed and then “scanned” Characters are recognized recognized and the electronic data so generated interacts with the data repository
Different Types of EMRs
At Indiana University University,, pediatric pediatric clinics use this system:
A data repository was was developed using Microsoft Mi crosoft SQL Server S erver A clinical guideline gui deline system was written in Arden Syntax An optical character cha racter recognition system called Cardiff Teleforms is used to process handwritten numerical data on preprinted scanned forms The data so generated generated is stored in i n the database and dynamic reminders are generated generated for the physician These are printed on the clinic cli nic computer The entire operation takes < 2-3 minutes!
Different Types of EMRs
The Mosoriot Medical Record System System™
Indiana University has an HIV Effort Effor t in Kenya A Simple MS Access based database holds all patient records (3 years worth!) Provides forms for data entry, entry, standard standard term dictionary dictionar y, medication listings, registration system, clinical documentation system etc. Created by 1 programmer over over 2-3 weeks! Highly effective, easy to maintain, inexpensive!
Data Sources
So how can EMRs populate populate their databases? Data can come from many many sources:
Admission/Discharge/Billing Anesthesia Systems Cytology Systems Diagnostic Imaging Management Systems EKG Carts Endoscopy Systems ER Systems
Data Sources
More Data Sources:
Home Care Systems ICU Monitoring Systems IV Fluid Infusion Control Systems Laboratory Systems Nurse Triage Order Entry Systems Pharmacy Systems (Inpatient/Outpatient) Pulmonary Function Systems
Data Sources
More Data Sources
Radiology systems Risk Management systems Registration Systems Scheduling and an d Clinic Charge Cha rge Systems Transcription ranscript ion Systems Unit Dose Dispensing machines Ventilator entilator Management systems s ystems
Than Thank k You You Q&A
Acknowledgments: William Tierney, MD Atif Zafar, MD AHRQ PBRN Resource Center
