1. Medical informatics Lecture 1 electronic patient records

2. The big picture Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Clinical engagement, post- marketing surveillance, data mining Manage safe workflow, professional communication, security Patient-specific Decision-making to optimise and personalise treatment Standards based formalisation of clinical data and research results

3. Course objectives Provide an overview of the main development areas in health informatics. Understand the role of informatics in translating medical research into clinical practice Look at Electronic patient records topics in more depth.

4. Biomedical informatics (1): Bio-informatics Rapidly developing branch of biology: highly interdisciplinary, using techniques and concepts from IT, statistics, mathematics, chemistry, biochemistry, physics, and linguistics! Seeks knowledge from computer analysis of –biological data (e.g. genomics, proteomics) –experimental results –patient statistics –scientific literature. Research in bioinformatics includes development of methods for storage, retrieval, and analysis of data, modeling and simulation of cellular/molecular systems.

5. Biomedical informatics (2): Health-informatics Also known as medical or clinical informatics It is applied to primary and specialist patient care, nursing, dentistry, pharmacy, public health etc. Deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in delivery of healthcare services A particular focus is on services at the point of care and emphasis is increasingly being placed on informatics for patients and carers as well as professionals.

6. Topics in health informatics (1): traditional perspective Architectures for electronic medical records and other health information systems used for billing, scheduling, and research Standards (e.g. DICOM, HL7) … to facilitate the exchange of information between healthcare information systems - these specifically define the means to exchange data, not the content Controlled vocabularies … used to allow a standard, accurate exchange of data content between systems and providers Software for specialist services and devices

7. Topics in health informatics (2): new drivers Quality and safety –US Institute of Medicine “To err is human” “Crossing the quality chasm” McGlynn data on service delivery Fineberg lecture on YouTube –NHS Emergence of clinical decision support and workflow management systems

8. Topics in health informatics (3): Contemporary multidisciplinary view Traditional “engineering” topics –Hardware and software service architectures –Specialist technical services –Digital signal processing Human and organisational factors in quality and safety –User interface design (Tang lecture on YouTube) –Organisational memory –Learning from experience –Change management Formal representation of data and knowledge –Controlled vocabularies, “ontologies” –Applying knowledge to data: logic and description logics, decision theory, guidelines and workflows

9. The key challenges (adapted from Coiera p 104) How do we apply knowledge to achieve a particular clinical objective? How do we decide how to achieve a particular clinical objective? How do we improve our ability to deliver clinical services?

10. Medical research, clinical practice Understanding diseases and their treatment Understanding diseases and their treatment Ensure right Patients receive right intervention Ensure right Patients receive right intervention Service delivery, performance assessment Service delivery, performance assessment Develop and test treatments Develop and test treatments Health Records

11. First … Capture your data, accurately, completely Make the data readily accessible

12. The paper record, pros Portable Familiar and easy to use –Exploits everyday skills of visual search, browsing etc Natural: “direct” access to clinical data –Handwriting –Charts, graphs –Drawings, images…

13. The paper record: cons Can only be used for one task at a time –If 2 people need notes one must wait –Can lead to long waits (unavailable up to 30% of time in some studies) Records can get lost Consume space Large individual records are hard to use Fragile and susceptible to damage Environmental cost

14. Electronic health records An electronic health record is a repository of information about a single person in a medical setting, including clinical, demographic and other data. The repository resides in a system specifically designed to support users by –providing accessibility to complete and accurate data –may include services to provide alerts, reminders, links to medical knowledge and other aids to clinical practice.

17. The electronic medical record

18. Examples

19. Driving Factor to Adopt an EMR Different charting methods in different offices Growing practice – adding new docs Rising transcription costs - $250k/year in 1998 and going up Need to enhance quality of care Reduce practice overhead

20. Goals of Using the EMR Provide a single, uniform medical record. Ability to access medical records from any location. Improve documentation and coding. Improve research / clinical trials data / enhance quality. Reduce transcription and other rising costs.

21. Functions of the EHR (1) 1.Supports structured data collection using a defined vocabulary. 2.Accessible at any or all times by authorized individuals. 3.Contains a problem list - patient’s clinical problems and current status 4.Supports systematic measurement and recording of data to promote precise and routine assessment of the outcomes of patient care 5.States the logical basis for all diagnoses or conclusions as a means of documenting the clinical rationale for decisions about the management of the patient’s care.

22. Functions of the EHR (2) 1.Can be linked with other clinical records of a patient—from various settings and time periods—to provide a longitudinal (i.e. lifelong) record of events that may have influenced a person’s health. 2.Can assist the process of clinical problem solving by providing clinicians with decision analysis tools, clinical reminders, prognostic risk assessment and other clinical aids. 3.Can be linked to both local and remote databases of knowledge, literature and bibliography or administrative databases and systems so that such information is readily available to assist practitioners in decision making. 4.Addresses patient data confidentiality. 5.Can help practitioners and health care institutions manage the quality and costs of care.

23. Benefits Realized Staff to physician ratio decreased below national ratio average. Practice overhead costs will be reduced. Patient perception of practice improved. Better patient coverage during off hours since information was more consistent, complete and accessible.

24. Benefits continued… e-Prescribing improves patient safety (instructions, warnings and legibility) Sharing data efficiently outside the practice. improves quality of care at other provider organizations Rewards (financial) for documenting clinical performance Improved quality of life for physicians

25. Electronic health records: pros Compact Concurrent use Easily copied/archived Portable (handheld and wireless devices) Secure Supports many other services –Decision support –Workflow management –Performance audits –Research

26. Electronic health records: cons High capital investment –Hardware, software, operational costs –Transition from paper to computer Training requirements Continuing security debate –Stealing one paper record is easy, 20 is harder, 10,000 effectively impossible – the security risks are very different for electronic data. Power outs – the whole system goes down!

27. Ad hoc view

28. User view

29. Service architecture view Terminologies Ontologies Clinical guideline repository Clinical trials repository Acute services Primary Care services Point of care services Federated EHR Search and analysis services Clinical data “Organisational Memory” Chronic care services Communication & Coordination services

30. Functional view