History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a – Early EHR Prototypes This material Comp5_Unit6 was developed by The University of Alabama Birmingham, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000023

History of Electronic Health Records Learning Objectives 2 Describe some early examples of electronic medical records Discuss lessons learned from the early EHR implementations Discuss how the attributes that were identified for a computer-based patient record in the 1991 Institute of Medicine Report relate to the concept of meaningful use Discuss differences between the terms electronic health record (EHR) and personal health record (PHR) Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Names Associated with EHRs Medical Information Systems Computer-based Patient Record Electronic Medical Records Electronic Health Records Personal Health Records Sources: (Collen, 1986) (Dick et al., 1991) 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Electronic Medical Record “An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.” Source: (The National Alliance for Health Information Technology, 2008) 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Electronic Health Record “An electronic record of health-related information on an individual that conforms to nationally-recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.” Source: (The National Alliance for Health Information Technology, 2008) 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Personal Health Record “An electronic record of health-related information on an individual that conforms to nationally-recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.” Source: (The National Alliance for Health Information Technology, 2008) 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

1960s — 1990s Problems with paper records –Inaccessible/unavailable –Illegible –Incomplete Prototypes –EMRs –Multimedia EMR –Portable PHRs Sources:(Collen, 1995) (Smith, et al., 2005) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

COSTAR COmputer-STored Ambulatory Record Development begun in the 1960s at Massachusetts General Hospital G. Octo Barnett and colleagues Developed MUMPS computer language Design goals: –Accessibility for clinicians –Administrative and financial needs –User queries –Quality assurance Source:(Barnett, et al., 1982 ) 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

COSTAR Features –Directory/Data dictionary –Modular design/User configuration –Structured encounter form for data capture –Queryable database –Integrated administrative, financial and clinical data Expanded to other sites Still in use today 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

TMR The Medical Record Developed at Duke in the 1970s W. Edward Hammond and William Stead and colleagues Originally developed as obstetric history taking program Expanded to other departments and other functions Source:Hammond, Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

TMR Features –Modular design –Data definition dictionaries –Problem-oriented and time-oriented formats –Multiple input modes—computer, paper, dictation –User configuration, choice of data collection content and methods Expanded to other sites 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

RMRS Regenstrief Medical Record System Development begun in the 1970s at the Regenstrief Medical Institute Clement McDonald, William Tierney and colleagues Begun in Regenstrief Diabetes Clinic Expanded to other outpatient and inpatient units Goals –Data capture –Automated reminders and clinical decision support Source:(McDonald, et al., 1992) 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

RMRS Features –Data capture Electronic interfaces if possible, e.g. devices Dictation/manual coding and entry Structured forms/manual coding and entry Direct computer entry 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

RMRS Features –Data capture Electronic interfaces if possible, e.g. devices Dictation/manual coding and entry Structured forms/manual coding and entry Direct computer entry –Clinical decision support Hundreds of rules to generate reminders and alerts Provided since 1974 Studies of impact on costs and patient health outcomes 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

RMRS Integrated administrative and financial functions Still in use today Expanded to multiple inpatient and outpatient facilities 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Lessons Learned Incremental build –Modular –Start small with easy to capture data Configure for different settings, user needs Multiple methods of data input Coded data for storage and retrieval Data dictionary Standards for sharing information Source:(Hammond, 2001) 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Lessons Learned Integrate administrative and clinical functions, especially in outpatient setting Data entry –Challenges for direct physician data entry Orders more structured and easiest for physicians Clinical documentation more challenging User training and support 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Barriers to Use Cost of hardware and software Inability to accommodate all types of data –Unstructured data Design not optimal –User interface –Support physician cognition –Data entry difficult Lack of physician acceptance/interest Source: (Collen, 1996) 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

Goals Accessibility Improve efficiency/reduce costs Improve quality of patient care Facilitate health services research Facilitate claims processing Source: (Collen, 1996) 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

HITECH Vision (2009) Improved individual and population health outcomes Increased transparency and efficiency Improved ability to study [healthcare] Improved care delivery Source:(Blumenthal, 2010) 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

History of Electronic Health Records Summary – Lecture a 21 EHR terminology over time Examples of early EHRs Struggle to define requirements Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a

History of Electronic Health Records References – Lecture a 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 History of Health Information Technology in the U.S. History of Electronic Health Records (EHRs) Lecture a References Barnett GO, Zielstorff RD, Piggins J, et al. COSTAR: a comprehensive medical information system for ambulatory care. Proc Annu Symp Comput Appl Med Care Nov 2; 8–18. Blumenthal D. Launching HITECH. N Engl J Med Feb 4;362(5): Collen M. A history of medical informatics in the United States, Washington, DC: American Medical Informatics Association; Collen MF. Origins of medical informatics. Medical informatics [special issue]. West J Med.1986 Dec;145: Dick RS, Steen EB, Detmer DE. The computer-based patient record: an essential technology for healthcare. Washington, DC: National Academy Press; Hammond WE. How the past teaches the future: ACMI distinguished lecture. J Am Med Inform Assoc May- Jun;8(3): McDonald CJ, Tierney WM, Overhage JM, Martin DK, Wilson GA. The Regenstrief Medical Record System: 20 years of experience in hospitals, clinics, and neighborhood health centers. MD Comput Jul-Aug;9(4): The National Alliance for Health Information Technology. Report to the Office of the National Coordinator for Health Information Technology on defining key health information technology terms. The National Alliance for Health Information Technology Apr 28. p. 6. Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA Feb 2;293(5):