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Objectives for Health Care Information Systems and Electronic Health Records in Primary Care

Introduction

From the outset, professional organizations of GPs have played an active role in setting guidelines for information systems in general practice and in assessing the systems available in the market. This active role was started in the early 1980s, when they identified the basic needs of GPs for using systems in their practices and set the first broad guidelines for systems tailored specifically for primary care. Few patients today deal with only one healthcare provider. This is particularly true for those who have complex health problems, for those who move frequently for work purposes and for travellers generally. In the absence of continuity of care, continuity of information is essential to optimise healthcare. There is a great deal of interest with both the public and private sectors in encouraging all health care providers to migrate from paper-based health records to a system that stores health information electronically and employs computer-aided decision support systems. In part this interest is due to a growing recognition that stronger information technology (IT) infrastructure is integral to addressing such national concerns as the need to improve the safety and quality of health care, rising health care costs, and matters of homeland security related to the health sector.

Network technology and communication (telematics) are now prominent developments in information technology and have a large impact on health care. By using standard communication networks and standard software, data interchange between the four levels of health care delivery (i.e., the region, the institution, the clinical department or outpatient clinic, and the individual physician, nurse, or patient) is more efficient. A fully operational exchange of patient data between systems, with proper authorization, is one of the present challenges in European health care.

There are significant privacy and security requirements which need to be satisfied. The needs of both patients and health care providers must be addressed. This is essential, challenging, and achievable. Information privacy in health involves optimising individual rights and public good. The benefits expected include:

- Improved clinical decision making
- Reduced duplication of diagnostic testing, imaging and history taking
- Better medication management
- Increased adoption of screening programs and preventive health measures

As a consequence of these projected benefits, the quality of individual care can be expected to improve substantially.

Definition of Health Informatics

"Health informatics is the knowledge, skills and tools which enable information to be collected, managed, used and shared to support the delivery of healthcare and promote health"

Principles

The Health Information System should:

- Be systematically developed in a coordinated manner to facilitate interconnectivity.
- Recognize the needs of primary health care.
- Guarantee all privacy and confidentiality requirements.
- Serve the needs of both the individual patient, the individual doctor and the national health care statistics, enabling monitoring of health care parameters and facilitating administration and management.
- Improve effectiveness and efficiency of health care services/delivery but also public health services.
- Enable quality assessment and quality improvement (expert systems, data analysis, etc)

Assumptions

- Communication between all healthcare providers involved in care of patients will be via electronic means.
- Healthcare providers will still be allowed to maintain detailed and confidential paper medical records.

IT within the Future Health Care System

The development of an IT infrastrucure has enourmous potential to improve safety, quality and efficiency of GPs' work. Computer assisted diagnosis and chronic care management programs can help clinical decision making, adherence to the best evidence based guidelines, often needed in patients with several chronic diseases.

Computer based expert systems both for patients and clinicians can improve preventive activities and patients' compliance.

Immediate access to computer based clinical information such as laboratory and radiology results can reduce redundancy and improve quality. Availability of complete patient health information at the point of care delivery, together with clinical decision support systems (e.g. diagnosis and medication order entry) reduce medical errors and adverse events.

If needed all participants in the health care process can share health information on the patient.

Advanced health information infrastructure is also vital for all kinds of research, education and health information.

Therefore we urge all UEMO countries to promote the implementation of health information technology and to become actively involved in its development. Our goal is to enable that patient's information and data become available to all healthcare providers involved in the medical care of patients.

Challenges to Implementation of Health Informatics

To facilitate the adoption of health informatics and health record systems the following challenges have to be addressed:

- Safeguarding privacy and security
- Technical problems
- Organizational barriers
- Financial costs
- Different policies
- Training programs for practitioners and other health care providers

The Electronic Health Record

General practitioners/family physicians should have access to all important health data of their patients. A Comprehensive Electronic Health Record System (EHRS), safe and effective comminication with other health care providers is the basis of quality and health care development.

The best model of key capabilities of the Health Information System (Electronic Health Record System included) must be defined. Most EHRS are enterprise-specific(e.g., operate within a specific health system or multy hospital organization), and only a few provide strong support from communication and interconnectivity accross the providers of the community. There have been different views of what constitutes certain types of data, such as medication and various results. Some EHRS provide decision support (e.g. in preventive services, alerts on potential drug interactions, clinical guidelines-driven prompts, etc). Thus EHRS are actively under development and will remain so for many years.

To be most useful, a functional model of a EHRS must also reflect a balance between what is desireable and what can feasably be implemented immediately or within in a short timeframe. It will be important to update the functional model from time-to-time to reflect the advancements in healthcare technology and care delivery.

Core Functionalities of the EHRS in Primary Health Care

The core functionalities of an electronic health record can be categorised into:

- Health information and data

- Results management

- Order entry - order management

- Decision making expert systems

- Electronic communication

- Patient support (Patient education/information)

- Administration processes

- Reporting & population health statistics

- Etc.

Electronic Health Record System with a defined dataset:

- Demographic (unchangeable, changeable data)

- Patient's problem list (i.e. medical/nursing diagnoses)

- Risk factors

- Medication list

- Allergies

- Laboratory tests

- Etc.

This ensures better access to the information when needed.

It is important to note that too much information and data can overwhelm or distract the user. Electronic Health Record Systems must therefore have well designated interfaces.

The main objectives of an EHRS in GP/FM are:

- To improve patient safety

- To support effective and efficient health care delivery

- To facilitate management of chronic conditions

Chronic diseases are now the leading cause of illness, disability and death in Europe. Many patients with chronic disorders may not receive the best possible care. They have different health care providers, and thus may receive conflicting information or undergo duplicate tests or/and procedures.

The program enables GPs/FPs to coordinate care of patients with chronic diseases, being aware of that lack of coordination may lead to poor outcome.


Summary

Good general practice/family medicine is the basis of efficient health care systems in Europe. It will require access to and widespread use of electronic information tools. An integrated health record and information system, although costly and not easy to implement, will offer benefits to doctors and to patients, but also to the national healthcare systems, because better data collection ensures better policy development and better resource allocation.

UEMO statement

High quality Health Informatics in the European Health Care Systems will:

- Improve communication between health professionals.
- Improve security and confidentiality of patient data and records.
- Speed up access to:
. appointments booked
. patient's data
. sources of knowledge
. diagnostic support
. diagnostic procedures ordered
- Reduce duplication of data and procedures/examinations, prescription or referrals.
- Reduce costs.
- Ensure better quality of care, education and research.

The UEMO calls on the European governments and health authorities to achieve a comprehensive coordinated and appropriately resourced approach to our health information needs. It will require the involvement and commitment of all the relevant stakeholder groups in health. It is a task to which we believe our governments should now make a firm policy commitment.

Annex 1

The use of Electronic Health Record Systems

Many potential uses of an EHR operate in primary health care. The EHR must include the following services (modalities):

Primary uses:

- Individual patient health care delivery data
- Individual patient health care management data
- Supporting processes (expert systems)
- Financial and administrative data management
- Information for patients
- Health statistics
- Research programs

Secondary uses:

- Education
- Regulation
- Research
- Public Health and Homeland Security
- Policy Support

Annex 2

Mandatory EHRS Capabilities in GP/FM

1. Health information and data:

- Demographical and individual data
- Patient's problem list
- Medication list
- Risk factors
- Allergies
- Procedures and test results
- Referrals and hospitalisations
- Preventive programs (with risk assessment modalities)
- Lifestyle interventions and recommendations
- Follow up schedule and control check- ups
- Issued prescriptions
- Issued expertises, certificates, etc

2. Results management/reporting:

- Laboratory
- Microbiology
- Pathology
- Radiology
- Consulted specialists

3. Order entry/management:

- Electronic prescribing
- Diagnostic procedures (laboratory, microbiology, X-ray....)
- Referrals to specialists
- Referrals to hospital
- Nursing
- Supplies

4. Decision support:

- Access to knowledge sources

- Drug alerts

. Drug dose defaults

. Drug dose checking

. Allergy checking

. Drug interaction checking

. Drug-lab checking

. Drug-condition checking

. Drug-diet checking

- Other rule based alerts
. Significant lab trends,

. Lab test because of drug

-  Reminders

. Preventive services (e.g. vaccinations, smear tests, etc)

. Clinical guidelines and pathway

. Passive

. Context-sensitive passive

. Integrated

- Chronic disease management
- Clinician work list
- Incorporation of patient and/or family preferences
- Diagnostic decision support
- Use of epidemiological data
- Automated real-time surveillance
. Detect adverse events and near misses

. Detect disease outbreaks

5. Electronic Communication & Connectivity

- Provider-provider
- Team cooordination
- Patient-provider (e-mail, secure web messages)
- Medical devices
- Trading partners (outside pharmacy, insurer, laboratory, radiology)
- Integrated medical record
. Within setting

. Cross-setting

. Inpatient-Outpatient

. Other cross-setting

6. Patient Support

-  Patient education

. Access to patient education materials

. Custom patient education

. Tracking

-  Family and informal caregiver education

-  Data entered by patient, family and or informal caregiver

. Homemonitoring

. Questionnaires

7. Administrative Processes

- Scheduling management
. Appointments

. Surgery/procedure schedule

- Eligibility determination

. Insurance eligibility

. Clinical trial recruitment

. Drug recall

. Chronic disease management

8. Reporting and Health Population Management

- Patient safety and quality reporting
. Clinical dashboards

. External accountablility reporting

. Ad hoc reporting

. Public health reporting

. Reportable diseases

. Immunizations

- Deidentifying data
- Disease registries


References

1. Key Capabilities of an Electronic Health Record System: Letter Report (2003)

http://www.nap.edu/catalog/10781.html


2. Informatics in Primary Care (2002) 10/ 2002 PHCSG, British Computer Society


3. An integrated electronic health record and information system for Australia? Christopher D Mount, Christopher W Kelman, Leonard R Smith and Robert M Douglas MJA 2000; 172: 25-27

4. http://books.nap.edu/books/0309055326/html/21.html#pagetop

 
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