This blog is the first of a series of extracts from a long paper on Electronic Health Records that I have been maintaining and revising since 2008. It’s been shared on a limited basis and has benefit from review and input by a number of individuals, particularly fellow members of the BCS Primary Health Care Specailists Group www.phcsg.org
I have been prompted to share this ahead of the NHS #CCIO Tweetchat 7-8 pm BST on 8th May
This first extract deals with the purpose and content of EHR’s and I hope will help inform the debate.
1 Purpose of Health Records
Health Records need to support a wide range or purposes, which can be divided into three broad areas these are described below.
1.1 Directly supporting the delivery of care to individuals
This category includes both clinical and administrative activities that are necessary for the delivery of care to identifiable individuals including:
- The provision of an aide-memoire for those responsible for the delivery care.
- As a means of communication within teams responsibly for the delivery of an aspects of care.
- As a means of communication between teams responsible for the delivery of different aspects of care.
- The provision of the data need by decision support tools design to facilitate the delivery of quality care.
- The provision of data to support workflows and clinical processes required for the delivery of care.
The record has to support the needs of all those involved in the delivery of care which includes healthcare professionals, administrative personnel, family and informal carers and patients themselves.
1.2 Supporting the Health of Populations
The category includes all those uses that are concerned with the health of populations and the development of health knowledge. These uses don’t offer a direct and immediate benefit to individuals, often don’t require identifiable personal information and are often referred to as secondary uses. These uses include:
- Healthcare planning and commissioning
- Public health and epidemiology
- Risk stratification and risk scoring
- Predictive modelling
- Drug safety surveillance and pharmacovigilance
- Clinical audit and outcome measurement
- Population based healthcare research
- Identification of subjects for clinical trials
1.3 Providing a Medico-Legal Record
Those providing care need to be able to demonstrate that they did so with due professional care, recording relevant information appropriately and acting reasonably on the basis of the information available to them. The medical legal record needs to meet the requirements laid down by statue and common law for the admissibility of evidence in both civil and criminal proceedings (principally the “Civil Evidence Act 1995” and “Police and Criminal Evidence Act 1984”. A medico-legal record needs to:
- Be able to reliable represent the record as it would have been at any particular point in time
- Securely represent the provenance of information recorded
- Ensure that information once recorded cannot be repudiated
- Provide an audit trail of additions, changes and access to the record
2 Content of EHRs
The electronic health record is probably the most complex entity that anyone has sought to computerise (it is certainly the most complex entity with wide applicability) and is much more complex than records found in the financial sector, eCommerce or aerospace.
Health records contain all data types and much of the information is implied by the context and relationship of data items within the record.
Health records also have a much greater working life than most records in other domains with some information recorded early in life remaining highly significant in old age.
Health Records include information about the patient including:
- Reasons for encounter
- Presenting problems
- Physiological measurements and vital signs
- Results of tests and investigations
- Allergies, adverse reactions and intolerances (to drugs, foodstuff, and other substances)
- Family history, genealogy, genetics and relationships
- Social circumstances
- Health beliefs and preferences
- Employment and occupational exposures
In addition, it may be appropriate to record some items of history that were not recorded contemporaneously in the record (i.e. history of surgical procedures.)
Records will also contain data about the process of care including:
- Encounters and episodes of care
- Tests and investigations ordered
- Treatments order, prescribed and or administered
- Procedures ordered and carried out
- Advice given
- Appointments scheduled
- Goals and care plans
- Details of entitlements to care
- Cost of care
Data types include:
- Narrative text, typical sections of 10 to 300 words, but sometimes longer
- Items represented using controlled terminologies sometimes using multiple terms in combination (the leading terminology SNOMED contains three hundred thousand concepts and over one million term)
- Quantitative information ranging from items with a single value to items with 10 or more associated numeric values.
- Images ranging from simple (but important) sketches, through standard resolution photographs, video, still and moving x-ray and ultrasound images to very large high resolution, 3D images from body scanners.
- Sounds including speech and clinical body sounds.
- Analogue and digital signal data from diagnostic and monitoring equipment