Electronic health records (EHRs)

A holistic view of an e-patient record

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Introduction

See also Canada Health Infoway, Google health and Informationists

Electronic health records (EHRs) - electronic medical records (EMRs) or electronic patient records (EPRs) - refer to online health records for individual patients that are accessible across a network. Apart from the obvious format differences, EHRs are conceptually different from print records in that they are bound by strict standards of access. Print records are not, of course, as convenient as online records, or as accessible. In the digital age, this becomes a major issue especially when patient data resides in multiple, distributed locations and in more than one patient record system.

Health informatics is a related discipline examining national and local infrastructure, standards and other issues affecting creation of EHR systems. It is standard practice that health records are made available via large clinical systems in hospitals and health care organizations. Generally they are closely monitored for security, what might be called 'silo'd' - ie. behind firewalls or private virtual networks. However, protections are never absolute due to data management in web 2.0. EHRs have not been easily or openly web-accessible but are seen to be increasingly important for health consumers wanting to manage their own care. EHRs are now seen by Microsoft and Google to be important enough for web users to warrant significant investments of time and money. (See Google health and Microsoft Vault projects).

Computer-based patient records were discussed in an early report of the Institute of Medicine. The 1997 report made a recommendation to form an Institute to promote and develop standards for CPRs. During a ten year run, the Computer-Based Patient Record Institute (CPRI) played an important role in promoting online health records. One of the early definitions for EPRs was "The electronic health record is a computer-stored collection of health information about one person linked by a person identifier."

• Digital Medical Records - http://www.insidehighered.com/audio/academic_pulse/digital_medical_records podcast

• University of Notre Dame professor explores attitudes about digitization of medical records

Data in an electronic medical record

• Patient demographics
• Medical history, examination and progress reports of health and illnesses
• Medicine and allergy lists, and immunization status
• Laboratory test results
• Radiology images, x-rays, computed tomography - CTs, MRIs, etc)
• Photographs, from endoscopy or laparoscopy or clinical photographs
• Medication information, including side-effects and interactions
• Evidence-based recommendations for specific medical conditions
• A record of appointments and other reminders
• Billing records
• Eligibility
• Advanced directives, living wills, and health powers of attorney

Issues

Interoperability

The many systems that co-ordinate the storage and retrieval of EHRs are complex and not wholly interoperable. Typically, they are made up of medical records from many systems, locations and/or sources. A variety of healthcare-related information may be stored and accessed electronically but not all storage and retrieval issues have been resolved, particularly those records with no descriptive or metadata.

Medical errors

Some studies suggest that EHRs reduce the incidence of medical errors. In one study, however, there was no difference between print and electronic systems over fourteen different measures, there was improvement in 2 outcome measures, and worse outcome on 1 measure. (See also Electronic Health Record Use and the Quality of Ambulatory Care in the United States Linder et al. Arch Intern Med. 2007.)

Increased efficiency

EHRs are said to increase physician efficiency, to reduce costs and to promote standardization of treatment and patient care. Even though EHR systems with computerized provider order entry - some health librarians will remember this as CPOE - have existed for more than 30 years, fewer than 10 percent of American hospitals currently have fully integrated systems. This statistic is even lower in the Europe, the United Kingdom and Canada.

Confidentiality & privacy

Privacy is a right for all Canadian citizens who find themselves interacting with health professionals. The right to privacy is protected by professional codes of ethics, provincial and federal legislation and the Charter of Rights and Freedoms. The federal government created the Personal Information Protection and Electronic Documents Act (PIPEDA) which established principles for the collection, use and disclosure of information that is part of commercial activities in health, such as private lab results and pharmacies. PIPEDA has been superseded by provincial legislation in many provinces in Canada, including in Ontario where there is a separate Health Information Protection Act.

Overlap in terminology

Multiple terms and overlapping definitions have been used to explain electronic patient records. (see Status Report 2002: Electronic Health Records. Medical Record Institute 2002). Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some medical informatics users assigning the term EHR to a global concept and EMR to a discrete localized one. EHR and EMR are often used interchangeably. An EHR system is also often abbreviated as EHR or EMR. Health information technology is a broader term used to describe computer-based electronic aids to healthcare delivery.

Standards

• DICOM is an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by National Electrical Manufacturers Association, NEMA
• Electronic Data Interchange, EDI are transaction protocols used for transmitting patient data
• HL7 is a standardized messaging and text communications protocol between hospital and physician record systems
• ISO TC 215 provides international technical specifications for EHRs; ISO18308 describes EHR architectures
• European Committee for Standardization's TC/251 provides EHR standards in Europe including:

• EN 13606, a set of communication standards for EHRs
• CONTSYS (EN 13940), supports continuity of care record standardization
• HISA (EN 12967), a services standard for inter-system communication

The role of health librarians

Health librarians should be finding ways to link primary research, medical evidence and individual EHRs. Several American health librarians have written about the possibilities represented by EHRs, particularly in collocating relevant medical literature with health issues arising within the records themselves. Some health librarians are already working with health professionals on various hospital committees in implementing EHRs with links to electronic library collections - but health librarians are not universally involved.

Some health librarians suggest that we have some advocacy work ahead of us before we get involved in EHRs. First, we have traditionally not ventured into the private realm of patient records; we may want to work even more closely with physicians and other health professionals to demonstrate why including us in building EPR systems is important; perhaps we can link the notion of providing library services and building EPR systems to hospital accreditation issues. Where patient safety and confidentiality are concerned, perhaps health librarians can help to build EPR systems by masking individual patient identities.

Canadian context

The development and implementation of effective, interoperable EPR solutions in Canada is a priority of Canada Health Infoway. The Infoway is an independent, not-for-profit corporation initiated as the result of the Canadian federal government's announcement in September 2000 to accelerate the development and adoption of modern information technologies in health.

References