Electronic patient records and the impact of the Internet

The term electronic patient record (EPR) means the electronic collection of clinical narrative and diagnostic reports specific to an individual patient. A true EPR should allow physicians and nurses to practice in a paperless fashion. The wide adoption of Internet technologies should allow truly distributed sharing of patient data across traditional organizational barriers. Hence, the meaning of an EPR, as a representation of documents, should be transformed into a collaborative environment that supports workflow, enables new care models and allows secure access to distributed health data. This paper reviews the current realization of EPRs in the context of paper-based medical records. The Internet architecture that Boston-based medical informatics researchers refer to as W3-EMRS is described in the context of a successful implementation of CareWeb at the Beth Israel Deaconess Medical center. Finally, we describe how this Internet-based approach can be extended beyond the boundaries of traditional care settings to help evolve new collaborative models of eHealth.     

Advanced tool kits for EPR security

Responding to the challenge for efficient and high quality health care, the shared care paradigm must be established in health. In that context, information systems such as electronic patient records (EPR) have to meet this paradigm supporting communication and interoperation between the health care establishments (HCE) and health professionals (HP) involved. Due to the sensitivity of personal medical information, this co-operation must be provided in a trustworthy way. To enable different views of HCE and HP ranging from management, doctors, nurses up to systems administrators and IT professionals, a set of models for analysis, design and implementation of secure distributed EPR has been developed and introduced. The approach is based on the popular UML methodology and the component paradigm for open, interoperable systems. Easy to use tool kits deal with both application security services and communication security services but also with the security infrastructure needed. Regarding the requirements for distributed multi-user EPRs, modelling and implementation of policy agreements, authorisation and access control are especially considered. Current developments for a security infrastructure in health care based on cryptographic algorithms as health professional cards (HPC), security services employing digital signatures, and health-related TTP services are discussed. CEN and ISO initiatives for health informatics standards in the context of secure and communicable EPR are especially mentioned.     

Cross-institutional data exchange using the clinical document architecture (CDA)

PROBLEM: Although electronic communication of clinical data between various actors in the healthcare domain seems crucial for a cost-effective patient treatment, it is mostly restricted to paper based documents. In order to meet the growing need for improved data communication, it is necessary to overcome the barriers of software heterogeneity and lack of standards, especially in cross-institutional shared care communication. HL7's clinical document architecture (CDA) is a new and promising tool to exchange any clinical document. In this paper we show how CDA can be used to (1) share electronic discharge letters and other clinical data generated and stored in the hospitals electronic patient record (EPR) with general practitioners and (2) to transfer these clinical data to a personal electronic health record (EHR). The latter scenario is in routine use. Ease-of-use and data security and integrity were the main design principles in both scenarios. METHODS: Within the electronic patient record a data extraction and exporting mechanism has been built. For both scenarios appropriate data processing and transmission methods have been developed, and the receiving information systems have been prepared for the CDA based data input. RESULTS: Although there still remain technical and organizational issues to be solved, this is a promising method in order to enhance data exchange between hospital and primary care and to move towards an electronic patient record (EPR) and an electronic health record (EHR) crossing institutional borders. This paper describes the design and current implementation and discusses our experiences.     

Integrated multimedia electronic patient record and graph-based image information for cerebral tumors

Current electronic patient record (EPR) implementations do not incorporate medical images, nor structural information extracted from them, despite images increasing role for diagnosis. This paper presents an integration framework into EPRs of anatomical and pathological knowledge extracted from segmented magnetic resonance imaging (MRI), applying a graph of representation for anatomical and functional information for individual patients. Focusing on cerebral tumors examination and patient follow-up, multimedia EPRs were created and evaluated through a 3D navigation application, developed with open-source libraries and standards. Results suggest that the enhanced clinical information scheme could lead to original changes in the way medical experts utilize image-based information.     

Integrating case-based reasoning with an electronic patient record system

Electronic patient records (EPRs) contain a wealth of patient-related data and capture clinical problem-solving experiences and decisions. Excelicare is such a system which is also a platform for the national generic clinical system in the UK.

Objective

This paper presents, ExcelicareCBR, a case-based reasoning (CBR) system which has been developed to complement Excelicare. Objective of this work is to integrate CBR to support clinical decision making by harnessing electronic patient records for clinical experience reuse.

Methods

CBR is a proven problem solving methodology in which past solutions are reused to solve new problems. A key challenge that we address in this paper is how to extract and represent a case from an EPR. Using an example from the lung cancer domain we demonstrate our generic case representation approach where Excelicare fields are mapped to case features. Once the case base is populated with cases containing data from the EPRs database a standard weighted k-nearest neighbour algorithm combined with a genetic algorithm based feature weighting mechanism is used for case retrieval and reuse.

Conclusions

We conclude that incorporating case authoring functionality and a generic retrieval mechanism were key to successful integration of ExcelicareCBR. This paper also demonstrates how the application of CBR can enable sharing of lessons learned through the retrieval and reuse of EPRs captured as cases in a case base.     

The mantra of modeling and the forgotten powers of paper: A sociotechnical view on the development of process-oriented ICT in health care

The recognition that restructuring care processes is central to effective and efficient health care will result in the emergence of process-oriented electronic patient records (EPRs). How will these technologies come into being? Within informatics, it is often stated that to informate something, we should first model it. This paper queries whether a detailed modeling of work processes and data flows is the primary step that needs to be completed before such EPRs can be developed or tailored. Building upon a sociotechnical understanding of ICT development, we argue for a reinterpretation of 'models' in such development processes. We do so through a reverse engineering of parts of the paper-based medical record, which has received little attention in medical informatics. In process-oriented EPR design, we argue, modeling should not be conceived as the crucial first step in this design, but rather as an intervention in the organizational change-processes that constitute proper ICT development.     

Electronic healthcare record; a way to empower the patient

BACKGROUND: Patients are demanding a bigger role in the management of their own health and health care. METHODS: The Dutch Federation of Patient and Consumer Organizations (NPCF) has initiated several projects in this area. One project started in 2001 and aims at contributing to the development of a nation-wide EPR system. RESULTS: the NPCF participates in the National Institute for the Care Sector (NICTIZ). The NPCF plays an important role in defining the requirements regarding authorization and security of the EPR as well as for the legal framework in which optimal use can be made of the EPR. NPCF strongly promotes an active role of NICTIZ in developing a master plan for the EPR and an active role in its implementation. CONCLUSION: Patients and their organizations have to play an active role in designing and implementation of an ICT infrastructure for health care and in particular of the EPR.     

Security of the distributed electronic patient record: a case-based approach to identifying policy issues

The growth of managed care and integrated delivery systems has created a new commodity, health information and the technology that it requires. Surveys by Deloitte and Touche indicate that over half of the hospitals in the US are in the process of implementing electronic patient record (EPR) systems. The National Research Council has established that industry spends as much as $15 billion on information technology (IT), an amount that is expanding by 20% per year. The importance of collecting, electronically storing, and using the information is undisputed. This information is needed by consumers to make informed choices; by physicians to provide appropriate quality clinical care: and by health plans to assess outcomes, control costs and monitor quality. The collection, storage and communication of a large variety of personal patient data, however, present a major dilemma. How can we provide the data required by the new forms of health care delivery and at the same time protect the personal privacy of patients? Recent debates concerning medical privacy legislation, software regulation, and telemedicine suggest that this dilemma will not be easily resolved. The problem is systemic and arises out of the routine use and flow of information throughout the health industry. Health care information is primarily transferred among authorized users. Not only is the information used for patient care and financial reimbursement, secondary users of the information include medical, nursing, and allied health education, research, social services, public health, regulation, litigation, and commercial purposes such as the development of new medical technology and marketing. The main threats to privacy and confidentiality arise from within the institutions that provide patient care as well as institutions that have access to patient data for secondary purposes.     

Health care in the information society. A prognosis for the year 2013

Our society is increasingly influenced by modern information and communication technology (ICT). Health care has profited greatly by this development. How could health care provision look in the near future, in 10 years, or more precisely, in the year 2013? What measures must be undertaken by political and self-governing health institutions, and by medical informatics research, to ensure an efficient, medically advanced and yet affordable future health care system? Three factors will greatly influence the further development of information processing in health care within the near future: the development of the population, medical advances, and advances in informatics. These factors have motivated us to set up 30 theses for health care provision in the year 2013. The theses cover areas of health care, such as its people, its information systems, and its ICT tools. Three major goals requiring achievement have been identified: patient-centered recording and use of medical data for cooperative care, process-integrated decision support through current medical knowledge, comprehensive use of patient data for research and health care reporting. In consequence, political institutions should provide a framework for networked, patient-centered health care. They are called on to regulate the storage and exchange of health care data and of appropriate information system architectures. Finally, the health care institutions themselves must emphasize professional information management more strongly. Relevant research topics in medical informatics are: comprehensive electronic patient records, modern health information system architectures, architectures for medical knowledge centers, specific data processing methods ('medical data mining'), and multi-functional, mobile ICT tools.     

Chief medical officer actions on information security in an Italian rehabilitation centre

In a multi-speciality rehabilitation centre, where child neuropsychiatrists, neurologists, physical rehabilitators, psychologists, nurses, therapists and other health care professionals actively care for patients, the moment will arrive when information security takes high priority on the chief medical officer (CMO) agenda. This has happened at the La Nostra Famiglia Institution. Local push to high priority arose from several concurrent forces, like privacy both on the patient and on the doctor side, legal and ethical aspects. Recommendations on the protection of medical data require appropriate technical and organisational measures to be taken to protect personal data against unauthorised access, alterations or any other form of inappropriate processing. In the same time quick and easy access to patient information should be granted to authorised personnel to ensure proper and in time treatment of patients. A long lasting sequence of co-operative negotiation meetings between the CMO and the chief information officer (CIO) led to appropriate outline of policies. We developed a suitable and modular architecture for designing systems that can simultaneously manage an increasing number of healthcare actors, objects and related access levels taking into account temporal conditions. Actions for keeping the prototype in use on an everyday basis are directly taken by the CMO.     

as standard for communicating in a document-based electronic patient record: a 3 years experiment

During the past few years, the eXtensible Markup Language ( ) has progressively become a gold standard for accessing, representing and exchanging information, especially in the health care environment. This paper presents an implementation of the use of for the electronic patient record (EPR) and discusses more specifically its growing use in two areas of the EPR: first, as a format for the exchange of structured messages, and second, as a comprehensible way of representing patient documents. These statements rely on a 3 years experiment conducted at the Geneva University Hospital as part of its document-centered EPR.     

XML as standard for communicating in a document-based electronic patient record: a 3 years experiment

During the past few years, the eXtensible Markup Language (XML) has progressively become a gold standard for accessing, representing and exchanging information, especially in the health care environment. This paper presents an implementation of the use of XML for the electronic patient record (EPR) and discusses more specifically its growing use in two areas of the EPR: first, as a format for the exchange of structured messages, and second, as a comprehensible way of representing patient documents. These statements rely on a 3 years experiment conducted at the Geneva University Hospital as part of its document-centered EPR.     

Telematics enabled virtual simulation system for radiation treatment planning

In this paper, GALENOS, a Telematics Enabled Virtual Simulation System for Radiation Treatment Planning (RTP) is described. The design architecture of GALENOS is in accordance with the dual aim of virtual simulation of RTP, i.e. to allow (a) delineation of target volume and critical organs, and (b) placement of irradiation fields. An important feature of GALENOS is the possibility for on-line tele-collaboration between health care professionals under a secure framework. The advantages of GALENOS include elimination of patient transfers between departments and health care institutions as well as availability of patient data at sites different than those of his/her physical presence.     

Instant availability of patient records,but diminished availability of patient information: A multi-method study of GP's use of electronic patient records

Background  

In spite of succesful adoption of electronic patient records (EPR) by Norwegian GPs, what constitutes the actual benefits and effects of the use of EPRs in the perspective of the GPs and patients has not been fully characterized. We wanted to study primary care physicians' use of electronic patient record (EPR) systems in terms of use of different EPR functions and the time spent on using the records, as well as the potential effects of EPR systems on the clinician-patient relationship.     

Patient-centered communication in the era of electronic health records: What does the evidence say?

ObjectivePatient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known.MethodA comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis.ResultsResults indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management.ConclusionMore rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care.Practice implicationsTraining alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians’ and patients’ abilities to effectively communicate.     

Empowerment of patients and communication with health care professionals through an electronic health record

Objective: The aim of this project was to design and develop a personal electronic health record (EHR) in order to support patient empowerment and additionally to enhance their communication and information exchange with health professionals through this EHR. Method: The functionality of a personal Electronic Healthcare Record (EHR) may vary from a simple web-based interface for interactive data entry and data review up to a much more powerful system additionally supporting electronic data/document communication between clinical information systems of primary care practitioners or hospitals and even reminder based support for the empowered citizen, to actively take care of his health, based on relevant disease management programs. It is one means to support patient empowerment, additionally supported by tools for building a patient community. Since storage and communication of data in an EHR comprises sensible personal health data, each of those functions needs specific security and access management requirements to be considered and implemented. Result: Clinical pilot projects are already done or under development.     

Beyond the EPR: Complementary roles of the hospital-wide electronic health record and clinical departmental systems

Background  

Many hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR.     

A model driven approach for the German health telematics architectural framework and security infrastructure

Shared care concepts such as managed care and continuity of care are based on extended communication and cooperation between different health professionals or between them and the patient respectively. Health information systems and their components, which are very different in their structure, behavior, data and their semantics as well as regarding implementation details used in different environments for different purposes, have to provide intelligent interoperability. Therefore, flexibility, portability, and future orientation must be guaranteed using the newest development of model driven architecture. The ongoing work for the German health telematics platform based on an architectural framework and a security infrastructure is described in some detail. This concept of future proof health information networks with virtual electronic health records as core application starts with multifunctional electronic health cards. It fits into developments currently performed by many other developed countries.     

基于医疗健康信息集成规范-跨企业级文档共享技术的区域双向转诊互操作的研究与实现**

背景：双向转诊可提高现有资源的有效利用率及卫生服务的社会效益,已成为解决社区卫生服务可持续发展的重要手段。 目的：实现区域内不同医疗机构间患者医疗信息与医疗资源共享,构建双向转诊系统,推动区域卫生信息化建设。 方法：从信息交互的互操作特点和重要性入手,深入分析了跨企业级文档共享技术框架下的角色和事务,研究具体的共享流程和实现方案,提出文档存储池和数据存储执行的策略,并在此基础上进行技术实现,构建双向转诊系统。 结果与结论：在医疗健康信息集成规范-跨企业级文档共享技术的基础下,实现了双向转诊系统的构建,并在不同系统和机构之间进行了测试,结果证实该双向转诊系统可以有效和快捷的共享患者信息。