Jack Carew: Hi everyone,
and welcome to this week's lecture
on Information Technology for Healthcare.
In this module,
we're going to be talking about health informatics
and electronic health records.
Health informatics is the application of information
in computer science to healthcare,
and electronic health records, or EHRs,
combined with clinical support
to improve the quality of care that patients receive.
We will note that IT has become a strategic driver
rather than a support service in healthcare.
One other key theme is that the interoperability
between EHR vendors and EHR systems is challenging,
and we'll also talk about the applications of e-Health
or the use of electronic means to deliver information,
resources, and services related to health.
Some key aspects of this is that information is
at the right place at the right time,
and we'll also talk about some examples
of Denmark's use of e-Health.
So to begin with,
it's clear that IT, information technology,
and innovations related to information technology provides
cost-effective global healthcare solutions.
The book lists several fields of innovation,
including telemedicine or teleconsulting,
public health and patient self-management,
and hospital management and clinical information systems.
One example of telemedicine or teleconsulting being
an innovation in the global context comes
from my time working in Cameroon this past summer
where I was working with a team
that had put together a telehealth service
for people living outside of the capital, Yaounde.
This service was called iDoctor.
And it allowed for telehealth visits
for patients living in more rural parts of the country
that didn't have the same access to specialty care
that people living in the capital had.
The textbook also gives an example
of a system called WELCOME,
or Wearable Sensing and Smart Cloud Computing
for Integrated Care to COPD Patients.
That is a telehealth project
that uses a wearable vest with sensors
to monitor different signs and symptoms of COPD.
This uses cloud computing technology.
The book also spends some time discussing
what it calls the Internet of Things.
And this relates to the idea
that many health devices are connected to the internet
or have wireless compatibility.
For example, blood glucose meters, scales,
devices to measure blood pressure, et cetera,
all can have some wireless internet connection.
This is significant
because it allows for the uploading and downloading of data
and the connection of devices to wider networks,
to the connection both to other devices
and also a connection to healthcare providers.
So to talk a little bit about the history
of electronic health records,
they began in the 1960s and 1970s
in academic medical centers
and the Veterans Administration in the US.
When EHRs were first being built,
they were largely built as separate components.
There were some electronic systems
dealing with patient information,
others dealing with billing,
and others dealing with progress notes.
It's also interesting to note
that some electronic health systems failed.
And the textbook gives some good examples of systems
that were developed to considerable cost
that were not used in the end
due to the lack of utility and the lack of added benefit
to the hospital systems
for which they were developed.
So now when we look at EMR,
or electronic medical record, definitions,
we see that there's three main kind of records,
electronic medical records, electronic health records,
and personal health records.
These all are different in terms of their ability to conform
to the nationally recognized interoperability standards,
the record manager, and information sources.
One key piece here is that different individuals
or different groups manage these systems.
So, for example, the electronic medical record is managed
by a single healthcare organization,
whereas the health record, or the electronic health record,
is managed by multiple organizations.
So now this slide is very important,
discussing the different functions
of electronic health records.
There's 10 primary functions, though there are others,
and each of these functions has sub goals or sub functions.
They're electronically managing
patient demographic information, physician notes,
nursing assessments, patient problem lists,
patient medication lists, discharge summaries,
electronically viewing laboratory reports,
radiologic reports, diagnostic test results,
and electronically ordering medications.
And I'm not sure,
but I would expect that many of you have seen physicians
or nurses or other clinicians
utilizing electronic health records on visits
to units of the healthcare system.
So now let's talk a little bit about the architecture
of electronic health records.
And there's two main types.
So as we talked about before,
there's different components or different aims
of electronic health records.
There's the billing,
the results of laboratory tests and scans,
patient notes, nursing assessments,
patient demographic information.
And this slide really gets at the distinction
between those different functions.
So best of breed describes an EHR architecture
in which a hospital system
or another healthcare organization purchases
or creates a contract with a company
or with a number of companies,
and each provides an EHR system
to address a specific aspect of care.
So, for example, a company might use,
or a healthcare organization might use one company
to handle the billing
but another company to handle the patient demographics.
Other hospital systems might use monolithic infrastructure.
And some common EHRs that you might have heard of are
Epic or Cerner.
In these monolithic systems,
they will have functions,
or they will have pieces or aspects
to the electronic health record
that address all of the functions
or all of the primary functions.
So, for example, Epic has billing functions,
and it also has a database to manage patient information.
Some benefits of monolithic infrastructure is
that they have monolithic data standards,
and they help to facilitate interoperability
between healthcare systems.
For example, if a healthcare system in Utah
and a healthcare system in Vermont are both using Epic,
it's likely that they'll be able to communicate
and be very interoperable between each other.
Book also notes
that these monolithic health systems are more common,
but when there is third-party vendor access to EHR data,
which was facilitated
by the Fast Healthcare Interoperability Resources,
that also allows for further innovation and improvements
to different electronic health records.
You can think about these
as almost like apps on an app store
or something like that,
in which people, companies, individuals,
groups are able to develop
their own additional functions for EHRs
and then plug them into or download them into the framework
or the structure that an EHR provides.
Now, when we talk
about advanced electronic health record systems
and clinical support systems, or CSS's,
we see that some of their functions are
the real time utilization of information
while patients are undergoing care.
Some additional benefits of electronic health records
beyond simply storing patient data are
these additional functions like checking medications
or checking the contents of medications
against a list of known allergies that a patient has.
It's also common for electronic health record systems to,
you know, provide a suggested course of care for a patient
who might present with a certain set of symptoms.
Throughout this chapter and throughout this module,
conversations of artificial intelligence
and machine learning are very important.
And unfortunately, the textbook was published
before artificial intelligence really came into its heyday
in the past couple of years.
So there's not much discussion of it.
But please look into other resources
and the resources included in the module
that discuss the importance of artificial intelligence
for electronic health records and healthcare.
So electronic health records are being quickly adopted
in healthcare settings.
The rates range from 41% to 98%
with the Netherlands being at nearly complete adoption.
Nearly all hospitals in the US have adopted EHRs.
Though there are many challenges for EHR adoption
in less developed countries
due to numerous factors like cost,
lack of electricity or wireless internet among others.
This module also discusses
the standards for clinical coding.
And when you think about it,
when one is developing these electronic systems,
it's important to have standard measures
or standard terms and definitions
for the different signs, symptoms, and health events,
or health states that a patient can present with.
For that reason,
the most common utilization
or the most common terminology used is
that found in the ICD-10, or the ICD-11,
which was published in 2019.
And the ICD-11 gives names or codes
to all of the different health issues
or health states that a patient might present with.
SNOMED CT is another standard dictionary
of terms that are used when describing clinical things
or clinical descriptions in an electronic health record.
It's used in more than 50 countries.
And it's suitable for use in day-to-day clinical practice,
unlike the ICD-10 or 11,
which really presents more
kind of final health status issues
or disease classifications.
It's also very important to think about security and privacy
when digitizing patient information.
It's hard to define management and policy of information,
though countries have tried.
And there are also large differences
between countries and regions in the world
for how they decide to protect the privacy
and security of patient healthcare information.
In the United States,
HIPAA regulations define the rights of a patient
to protect their medical information.
It tells you what you should do,
but not how you should do it.
And finally, HIPAA is a congressional regulation,
and it's very slow to change.
Related to these issues of privacy and security are
the PCI-DSS requirements,
or the Payment Card Industry Data Security Standard.
The PCI Security Standards Council states
that PCI-DSS applies to all entities
that store, process, and/or transmit cardholder data,
and covers technical and operational practices
for system components included in
or connected to environments with cardholder data.
The requirements and the goals are listed in the textbook.
But for now, we'll just say
that the number and size of transactions determines
the level of compliance.
There's also the EU Agency
for Network and Information Security, or ENISA.
And here we see that,
this is an example of different countries
managing data privacy and security differently.
So now when we think about security,
we see the PCS-DSS framework in the US
as an example of something
that should be used to develop standards
based on international consortium of vendors
to protect patient information across international borders.
Some recommendations that the textbook authors present are
to establish an international certification body
to make the rules accessible and clear
and to have appropriate deterrents.
Finally, we'll conclude with a discussion
of selecting an appropriate vendor for an EHR.
And it's really important,
as we mentioned before, as we touched upon before,
to consider the specific characteristics
of the clinical setting
in which you plan to implement the EHR.
So early in the chapter, or early in the module,
we discussed the examples
of healthcare systems spending millions of dollars
on EHR development just for their clinicians
to find the system useless
and not appropriate for their daily tasks.
For that reason,
it's important to encourage appropriate buy-in
and understanding of the pros and cons of EHR implementation
among the staff of a healthcare organization.
When considering an appropriate EHR,
there's functional requirements,
like stakeholder, financial considerations,
and systems assessments.
And finally, here are some ideas for the best way
to identify and select an EHR vendor
that's appropriate for your healthcare organization.
When you're approaching the vendor,
it's a good idea to include a request for information
and a request for a quote,
and to estimate the total cost of ownership.
Finally, we see that healthcare innovation technology is
a variant.