WEBVTT 1 00:00:00.690 --> 00:00:01.590 Hi everyone, 2 00:00:01.590 --> 00:00:03.210 and welcome to this week's lecture 3 00:00:03.210 --> 00:00:05.313 on Information Technology for Healthcare. 4 00:00:10.020 --> 00:00:11.040 In this module, 5 00:00:11.040 --> 00:00:14.130 we're going to be talking about health informatics 6 00:00:14.130 --> 00:00:16.200 and electronic health records. 7 00:00:16.200 --> 00:00:18.930 Health informatics is the application of information 8 00:00:18.930 --> 00:00:20.940 in computer science to healthcare, 9 00:00:20.940 --> 00:00:23.730 and electronic health records, or EHRs, 10 00:00:23.730 --> 00:00:25.380 combined with clinical support 11 00:00:25.380 --> 00:00:28.233 to improve the quality of care that patients receive. 12 00:00:29.730 --> 00:00:32.790 We will note that IT has become a strategic driver 13 00:00:32.790 --> 00:00:35.043 rather than a support service in healthcare. 14 00:00:35.970 --> 00:00:39.000 One other key theme is that the interoperability 15 00:00:39.000 --> 00:00:42.513 between EHR vendors and EHR systems is challenging, 16 00:00:43.350 --> 00:00:45.930 and we'll also talk about the applications of e-Health 17 00:00:45.930 --> 00:00:48.510 or the use of electronic means to deliver information, 18 00:00:48.510 --> 00:00:50.610 resources, and services related to health. 19 00:00:51.450 --> 00:00:54.150 Some key aspects of this is that information is 20 00:00:54.150 --> 00:00:56.490 at the right place at the right time, 21 00:00:56.490 --> 00:00:58.140 and we'll also talk about some examples 22 00:00:58.140 --> 00:00:59.823 of Denmark's use of e-Health. 23 00:01:01.740 --> 00:01:03.183 So to begin with, 24 00:01:04.320 --> 00:01:09.320 it's clear that IT, information technology, 25 00:01:09.450 --> 00:01:12.510 and innovations related to information technology provides 26 00:01:12.510 --> 00:01:14.823 cost-effective global healthcare solutions. 27 00:01:16.110 --> 00:01:18.270 The book lists several fields of innovation, 28 00:01:18.270 --> 00:01:20.820 including telemedicine or teleconsulting, 29 00:01:20.820 --> 00:01:23.100 public health and patient self-management, 30 00:01:23.100 --> 00:01:26.013 and hospital management and clinical information systems. 31 00:01:27.330 --> 00:01:31.470 One example of telemedicine or teleconsulting being 32 00:01:31.470 --> 00:01:35.010 an innovation in the global context comes 33 00:01:35.010 --> 00:01:38.670 from my time working in Cameroon this past summer 34 00:01:38.670 --> 00:01:41.580 where I was working with a team 35 00:01:41.580 --> 00:01:44.610 that had put together a telehealth service 36 00:01:44.610 --> 00:01:47.580 for people living outside of the capital, Yaounde. 37 00:01:47.580 --> 00:01:49.590 This service was called iDoctor. 38 00:01:49.590 --> 00:01:52.200 And it allowed for telehealth visits 39 00:01:52.200 --> 00:01:55.260 for patients living in more rural parts of the country 40 00:01:55.260 --> 00:01:57.360 that didn't have the same access to specialty care 41 00:01:57.360 --> 00:01:59.260 that people living in the capital had. 42 00:02:00.780 --> 00:02:02.060 The textbook also gives an example 43 00:02:02.060 --> 00:02:03.690 of a system called WELCOME, 44 00:02:03.690 --> 00:02:05.910 or Wearable Sensing and Smart Cloud Computing 45 00:02:05.910 --> 00:02:08.733 for Integrated Care to COPD Patients. 46 00:02:09.660 --> 00:02:12.720 That is a telehealth project 47 00:02:12.720 --> 00:02:15.120 that uses a wearable vest with sensors 48 00:02:15.120 --> 00:02:19.923 to monitor different signs and symptoms of COPD. 49 00:02:21.180 --> 00:02:23.373 This uses cloud computing technology. 50 00:02:24.540 --> 00:02:26.640 The book also spends some time discussing 51 00:02:26.640 --> 00:02:29.190 what it calls the Internet of Things. 52 00:02:29.190 --> 00:02:31.380 And this relates to the idea 53 00:02:31.380 --> 00:02:36.060 that many health devices are connected to the internet 54 00:02:36.060 --> 00:02:38.430 or have wireless compatibility. 55 00:02:38.430 --> 00:02:41.190 For example, blood glucose meters, scales, 56 00:02:41.190 --> 00:02:43.860 devices to measure blood pressure, et cetera, 57 00:02:43.860 --> 00:02:46.533 all can have some wireless internet connection. 58 00:02:47.370 --> 00:02:48.270 This is significant 59 00:02:48.270 --> 00:02:52.110 because it allows for the uploading and downloading of data 60 00:02:52.110 --> 00:02:56.250 and the connection of devices to wider networks, 61 00:02:56.250 --> 00:02:59.760 to the connection both to other devices 62 00:02:59.760 --> 00:03:04.263 and also a connection to healthcare providers. 63 00:03:06.240 --> 00:03:08.430 So to talk a little bit about the history 64 00:03:08.430 --> 00:03:09.880 of electronic health records, 65 00:03:10.950 --> 00:03:13.410 they began in the 1960s and 1970s 66 00:03:13.410 --> 00:03:15.360 in academic medical centers 67 00:03:15.360 --> 00:03:17.883 and the Veterans Administration in the US. 68 00:03:18.750 --> 00:03:20.880 When EHRs were first being built, 69 00:03:20.880 --> 00:03:23.790 they were largely built as separate components. 70 00:03:23.790 --> 00:03:25.320 There were some electronic systems 71 00:03:25.320 --> 00:03:27.240 dealing with patient information, 72 00:03:27.240 --> 00:03:28.710 others dealing with billing, 73 00:03:28.710 --> 00:03:31.410 and others dealing with progress notes. 74 00:03:31.410 --> 00:03:32.910 It's also interesting to note 75 00:03:32.910 --> 00:03:35.520 that some electronic health systems failed. 76 00:03:35.520 --> 00:03:39.570 And the textbook gives some good examples of systems 77 00:03:39.570 --> 00:03:43.860 that were developed to considerable cost 78 00:03:43.860 --> 00:03:46.200 that were not used in the end 79 00:03:46.200 --> 00:03:50.910 due to the lack of utility and the lack of added benefit 80 00:03:50.910 --> 00:03:52.980 to the hospital systems 81 00:03:52.980 --> 00:03:54.480 for which they were developed. 82 00:03:56.031 --> 00:03:57.930 So now when we look at EMR, 83 00:03:57.930 --> 00:04:00.390 or electronic medical record, definitions, 84 00:04:00.390 --> 00:04:03.450 we see that there's three main kind of records, 85 00:04:03.450 --> 00:04:06.480 electronic medical records, electronic health records, 86 00:04:06.480 --> 00:04:08.430 and personal health records. 87 00:04:08.430 --> 00:04:13.430 These all are different in terms of their ability to conform 88 00:04:13.980 --> 00:04:16.860 to the nationally recognized interoperability standards, 89 00:04:16.860 --> 00:04:19.923 the record manager, and information sources. 90 00:04:21.090 --> 00:04:25.140 One key piece here is that different individuals 91 00:04:25.140 --> 00:04:27.780 or different groups manage these systems. 92 00:04:27.780 --> 00:04:30.330 So, for example, the electronic medical record is managed 93 00:04:30.330 --> 00:04:32.100 by a single healthcare organization, 94 00:04:32.100 --> 00:04:35.370 whereas the health record, or the electronic health record, 95 00:04:35.370 --> 00:04:37.623 is managed by multiple organizations. 96 00:04:39.630 --> 00:04:43.290 So now this slide is very important, 97 00:04:43.290 --> 00:04:44.910 discussing the different functions 98 00:04:44.910 --> 00:04:46.770 of electronic health records. 99 00:04:46.770 --> 00:04:50.040 There's 10 primary functions, though there are others, 100 00:04:50.040 --> 00:04:54.873 and each of these functions has sub goals or sub functions. 101 00:04:56.010 --> 00:04:57.600 They're electronically managing 102 00:04:57.600 --> 00:05:00.570 patient demographic information, physician notes, 103 00:05:00.570 --> 00:05:03.360 nursing assessments, patient problem lists, 104 00:05:03.360 --> 00:05:06.570 patient medication lists, discharge summaries, 105 00:05:06.570 --> 00:05:09.240 electronically viewing laboratory reports, 106 00:05:09.240 --> 00:05:11.790 radiologic reports, diagnostic test results, 107 00:05:11.790 --> 00:05:14.460 and electronically ordering medications. 108 00:05:14.460 --> 00:05:15.630 And I'm not sure, 109 00:05:15.630 --> 00:05:20.190 but I would expect that many of you have seen physicians 110 00:05:20.190 --> 00:05:22.020 or nurses or other clinicians 111 00:05:22.020 --> 00:05:26.010 utilizing electronic health records on visits 112 00:05:26.010 --> 00:05:29.073 to units of the healthcare system. 113 00:05:31.110 --> 00:05:34.200 So now let's talk a little bit about the architecture 114 00:05:34.200 --> 00:05:36.000 of electronic health records. 115 00:05:36.000 --> 00:05:38.460 And there's two main types. 116 00:05:38.460 --> 00:05:39.750 So as we talked about before, 117 00:05:39.750 --> 00:05:42.090 there's different components or different aims 118 00:05:42.090 --> 00:05:44.760 of electronic health records. 119 00:05:44.760 --> 00:05:46.440 There's the billing, 120 00:05:46.440 --> 00:05:51.440 the results of laboratory tests and scans, 121 00:05:51.690 --> 00:05:53.820 patient notes, nursing assessments, 122 00:05:53.820 --> 00:05:55.893 patient demographic information. 123 00:05:57.270 --> 00:05:59.400 And this slide really gets at the distinction 124 00:05:59.400 --> 00:06:02.010 between those different functions. 125 00:06:02.010 --> 00:06:05.880 So best of breed describes an EHR architecture 126 00:06:05.880 --> 00:06:08.310 in which a hospital system 127 00:06:08.310 --> 00:06:12.060 or another healthcare organization purchases 128 00:06:12.060 --> 00:06:17.060 or creates a contract with a company 129 00:06:17.220 --> 00:06:18.960 or with a number of companies, 130 00:06:18.960 --> 00:06:21.630 and each provides an EHR system 131 00:06:21.630 --> 00:06:24.540 to address a specific aspect of care. 132 00:06:24.540 --> 00:06:26.520 So, for example, a company might use, 133 00:06:26.520 --> 00:06:29.100 or a healthcare organization might use one company 134 00:06:29.100 --> 00:06:30.540 to handle the billing 135 00:06:30.540 --> 00:06:33.483 but another company to handle the patient demographics. 136 00:06:35.040 --> 00:06:38.610 Other hospital systems might use monolithic infrastructure. 137 00:06:38.610 --> 00:06:41.310 And some common EHRs that you might have heard of are 138 00:06:41.310 --> 00:06:43.110 Epic or Cerner. 139 00:06:43.110 --> 00:06:44.940 In these monolithic systems, 140 00:06:44.940 --> 00:06:46.290 they will have functions, 141 00:06:46.290 --> 00:06:48.780 or they will have pieces or aspects 142 00:06:48.780 --> 00:06:50.490 to the electronic health record 143 00:06:50.490 --> 00:06:52.410 that address all of the functions 144 00:06:52.410 --> 00:06:54.390 or all of the primary functions. 145 00:06:54.390 --> 00:06:57.000 So, for example, Epic has billing functions, 146 00:06:57.000 --> 00:06:59.913 and it also has a database to manage patient information. 147 00:07:01.410 --> 00:07:03.930 Some benefits of monolithic infrastructure is 148 00:07:03.930 --> 00:07:06.300 that they have monolithic data standards, 149 00:07:06.300 --> 00:07:10.200 and they help to facilitate interoperability 150 00:07:10.200 --> 00:07:12.150 between healthcare systems. 151 00:07:12.150 --> 00:07:15.120 For example, if a healthcare system in Utah 152 00:07:15.120 --> 00:07:18.150 and a healthcare system in Vermont are both using Epic, 153 00:07:18.150 --> 00:07:21.300 it's likely that they'll be able to communicate 154 00:07:21.300 --> 00:07:23.733 and be very interoperable between each other. 155 00:07:25.440 --> 00:07:26.430 Book also notes 156 00:07:26.430 --> 00:07:30.213 that these monolithic health systems are more common, 157 00:07:31.410 --> 00:07:36.410 but when there is third-party vendor access to EHR data, 158 00:07:38.490 --> 00:07:39.540 which was facilitated 159 00:07:39.540 --> 00:07:42.663 by the Fast Healthcare Interoperability Resources, 160 00:07:43.860 --> 00:07:48.570 that also allows for further innovation and improvements 161 00:07:48.570 --> 00:07:51.000 to different electronic health records. 162 00:07:51.000 --> 00:07:53.070 You can think about these 163 00:07:53.070 --> 00:07:55.300 as almost like apps on an app store 164 00:07:56.190 --> 00:07:58.320 or something like that, 165 00:07:58.320 --> 00:08:01.290 in which people, companies, individuals, 166 00:08:01.290 --> 00:08:03.180 groups are able to develop 167 00:08:03.180 --> 00:08:08.180 their own additional functions for EHRs 168 00:08:08.970 --> 00:08:12.780 and then plug them into or download them into the framework 169 00:08:12.780 --> 00:08:15.123 or the structure that an EHR provides. 170 00:08:17.340 --> 00:08:18.173 Now, when we talk 171 00:08:18.173 --> 00:08:20.280 about advanced electronic health record systems 172 00:08:20.280 --> 00:08:23.520 and clinical support systems, or CSS's, 173 00:08:23.520 --> 00:08:25.290 we see that some of their functions are 174 00:08:25.290 --> 00:08:27.180 the real time utilization of information 175 00:08:27.180 --> 00:08:28.953 while patients are undergoing care. 176 00:08:29.820 --> 00:08:33.390 Some additional benefits of electronic health records 177 00:08:33.390 --> 00:08:37.860 beyond simply storing patient data are 178 00:08:37.860 --> 00:08:42.860 these additional functions like checking medications 179 00:08:42.960 --> 00:08:44.580 or checking the contents of medications 180 00:08:44.580 --> 00:08:48.723 against a list of known allergies that a patient has. 181 00:08:50.490 --> 00:08:54.840 It's also common for electronic health record systems to, 182 00:08:54.840 --> 00:08:57.930 you know, provide a suggested course of care for a patient 183 00:08:57.930 --> 00:09:01.200 who might present with a certain set of symptoms. 184 00:09:01.200 --> 00:09:04.650 Throughout this chapter and throughout this module, 185 00:09:04.650 --> 00:09:08.070 conversations of artificial intelligence 186 00:09:08.070 --> 00:09:10.980 and machine learning are very important. 187 00:09:10.980 --> 00:09:13.500 And unfortunately, the textbook was published 188 00:09:13.500 --> 00:09:17.400 before artificial intelligence really came into its heyday 189 00:09:17.400 --> 00:09:18.600 in the past couple of years. 190 00:09:18.600 --> 00:09:20.450 So there's not much discussion of it. 191 00:09:21.390 --> 00:09:24.750 But please look into other resources 192 00:09:24.750 --> 00:09:26.460 and the resources included in the module 193 00:09:26.460 --> 00:09:30.090 that discuss the importance of artificial intelligence 194 00:09:30.090 --> 00:09:33.573 for electronic health records and healthcare. 195 00:09:35.730 --> 00:09:40.470 So electronic health records are being quickly adopted 196 00:09:40.470 --> 00:09:42.300 in healthcare settings. 197 00:09:42.300 --> 00:09:45.060 The rates range from 41% to 98% 198 00:09:45.060 --> 00:09:49.410 with the Netherlands being at nearly complete adoption. 199 00:09:49.410 --> 00:09:52.560 Nearly all hospitals in the US have adopted EHRs. 200 00:09:52.560 --> 00:09:55.560 Though there are many challenges for EHR adoption 201 00:09:55.560 --> 00:09:59.410 in less developed countries 202 00:10:00.480 --> 00:10:02.880 due to numerous factors like cost, 203 00:10:02.880 --> 00:10:06.783 lack of electricity or wireless internet among others. 204 00:10:09.270 --> 00:10:10.830 This module also discusses 205 00:10:10.830 --> 00:10:13.200 the standards for clinical coding. 206 00:10:13.200 --> 00:10:14.940 And when you think about it, 207 00:10:14.940 --> 00:10:17.430 when one is developing these electronic systems, 208 00:10:17.430 --> 00:10:19.740 it's important to have standard measures 209 00:10:19.740 --> 00:10:23.100 or standard terms and definitions 210 00:10:23.100 --> 00:10:28.080 for the different signs, symptoms, and health events, 211 00:10:28.080 --> 00:10:30.660 or health states that a patient can present with. 212 00:10:30.660 --> 00:10:32.220 For that reason, 213 00:10:32.220 --> 00:10:34.320 the most common utilization 214 00:10:34.320 --> 00:10:37.230 or the most common terminology used is 215 00:10:37.230 --> 00:10:41.010 that found in the ICD-10, or the ICD-11, 216 00:10:41.010 --> 00:10:43.447 which was published in 2019. 217 00:10:43.447 --> 00:10:47.070 And the ICD-11 gives names or codes 218 00:10:47.070 --> 00:10:50.160 to all of the different health issues 219 00:10:50.160 --> 00:10:53.343 or health states that a patient might present with. 220 00:10:54.870 --> 00:10:59.870 SNOMED CT is another standard dictionary 221 00:11:01.860 --> 00:11:06.860 of terms that are used when describing clinical things 222 00:11:07.368 --> 00:11:12.368 or clinical descriptions in an electronic health record. 223 00:11:13.080 --> 00:11:15.420 It's used in more than 50 countries. 224 00:11:15.420 --> 00:11:17.700 And it's suitable for use in day-to-day clinical practice, 225 00:11:17.700 --> 00:11:20.370 unlike the ICD-10 or 11, 226 00:11:20.370 --> 00:11:21.900 which really presents more 227 00:11:21.900 --> 00:11:24.600 kind of final health status issues 228 00:11:24.600 --> 00:11:26.283 or disease classifications. 229 00:11:29.580 --> 00:11:32.460 It's also very important to think about security and privacy 230 00:11:32.460 --> 00:11:34.623 when digitizing patient information. 231 00:11:35.700 --> 00:11:40.080 It's hard to define management and policy of information, 232 00:11:40.080 --> 00:11:41.480 though countries have tried. 233 00:11:42.360 --> 00:11:46.350 And there are also large differences 234 00:11:46.350 --> 00:11:49.470 between countries and regions in the world 235 00:11:49.470 --> 00:11:53.310 for how they decide to protect the privacy 236 00:11:53.310 --> 00:11:55.833 and security of patient healthcare information. 237 00:11:57.450 --> 00:11:58.800 In the United States, 238 00:11:58.800 --> 00:12:00.870 HIPAA regulations define the rights of a patient 239 00:12:00.870 --> 00:12:03.060 to protect their medical information. 240 00:12:03.060 --> 00:12:04.350 It tells you what you should do, 241 00:12:04.350 --> 00:12:05.800 but not how you should do it. 242 00:12:06.690 --> 00:12:08.490 And finally, HIPAA is a congressional regulation, 243 00:12:08.490 --> 00:12:10.053 and it's very slow to change. 244 00:12:13.200 --> 00:12:15.540 Related to these issues of privacy and security are 245 00:12:15.540 --> 00:12:18.240 the PCI-DSS requirements, 246 00:12:18.240 --> 00:12:21.033 or the Payment Card Industry Data Security Standard. 247 00:12:22.170 --> 00:12:25.620 The PCI Security Standards Council states 248 00:12:25.620 --> 00:12:28.560 that PCI-DSS applies to all entities 249 00:12:28.560 --> 00:12:32.370 that store, process, and/or transmit cardholder data, 250 00:12:32.370 --> 00:12:34.680 and covers technical and operational practices 251 00:12:34.680 --> 00:12:36.450 for system components included in 252 00:12:36.450 --> 00:12:38.950 or connected to environments with cardholder data. 253 00:12:40.320 --> 00:12:44.490 The requirements and the goals are listed in the textbook. 254 00:12:44.490 --> 00:12:46.770 But for now, we'll just say 255 00:12:46.770 --> 00:12:49.290 that the number and size of transactions determines 256 00:12:49.290 --> 00:12:50.583 the level of compliance. 257 00:12:53.610 --> 00:12:55.260 There's also the EU Agency 258 00:12:55.260 --> 00:12:58.500 for Network and Information Security, or ENISA. 259 00:12:58.500 --> 00:13:01.140 And here we see that, 260 00:13:01.140 --> 00:13:03.480 this is an example of different countries 261 00:13:03.480 --> 00:13:06.453 managing data privacy and security differently. 262 00:13:08.790 --> 00:13:11.370 So now when we think about security, 263 00:13:11.370 --> 00:13:14.230 we see the PCS-DSS framework in the US 264 00:13:15.450 --> 00:13:16.710 as an example of something 265 00:13:16.710 --> 00:13:18.150 that should be used to develop standards 266 00:13:18.150 --> 00:13:20.580 based on international consortium of vendors 267 00:13:20.580 --> 00:13:23.580 to protect patient information across international borders. 268 00:13:24.720 --> 00:13:27.510 Some recommendations that the textbook authors present are 269 00:13:27.510 --> 00:13:30.480 to establish an international certification body 270 00:13:30.480 --> 00:13:32.130 to make the rules accessible and clear 271 00:13:32.130 --> 00:13:33.903 and to have appropriate deterrents. 272 00:13:37.320 --> 00:13:39.660 Finally, we'll conclude with a discussion 273 00:13:39.660 --> 00:13:43.260 of selecting an appropriate vendor for an EHR. 274 00:13:43.260 --> 00:13:44.550 And it's really important, 275 00:13:44.550 --> 00:13:47.250 as we mentioned before, as we touched upon before, 276 00:13:47.250 --> 00:13:49.350 to consider the specific characteristics 277 00:13:49.350 --> 00:13:50.220 of the clinical setting 278 00:13:50.220 --> 00:13:52.800 in which you plan to implement the EHR. 279 00:13:52.800 --> 00:13:55.380 So early in the chapter, or early in the module, 280 00:13:55.380 --> 00:13:58.080 we discussed the examples 281 00:13:58.080 --> 00:14:00.510 of healthcare systems spending millions of dollars 282 00:14:00.510 --> 00:14:03.760 on EHR development just for their clinicians 283 00:14:04.800 --> 00:14:08.400 to find the system useless 284 00:14:08.400 --> 00:14:11.100 and not appropriate for their daily tasks. 285 00:14:11.100 --> 00:14:12.510 For that reason, 286 00:14:12.510 --> 00:14:15.540 it's important to encourage appropriate buy-in 287 00:14:15.540 --> 00:14:18.900 and understanding of the pros and cons of EHR implementation 288 00:14:18.900 --> 00:14:21.993 among the staff of a healthcare organization. 289 00:14:24.240 --> 00:14:26.130 When considering an appropriate EHR, 290 00:14:26.130 --> 00:14:27.480 there's functional requirements, 291 00:14:27.480 --> 00:14:31.140 like stakeholder, financial considerations, 292 00:14:31.140 --> 00:14:33.480 and systems assessments. 293 00:14:33.480 --> 00:14:36.930 And finally, here are some ideas for the best way 294 00:14:36.930 --> 00:14:39.210 to identify and select an EHR vendor 295 00:14:39.210 --> 00:14:41.810 that's appropriate for your healthcare organization. 296 00:14:42.870 --> 00:14:45.540 When you're approaching the vendor, 297 00:14:45.540 --> 00:14:50.540 it's a good idea to include a request for information 298 00:14:50.730 --> 00:14:52.053 and a request for a quote, 299 00:14:52.890 --> 00:14:55.443 and to estimate the total cost of ownership. 300 00:14:56.820 --> 00:14:59.790 Finally, we see that healthcare innovation technology is 301 00:14:59.790 --> 00:15:00.623 a variant.