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Electronic health record

ELECTRONIC HEALTH RECORD

 

An electronic health record (EHR) (also electronic patient record (EPR) or computerised patient record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting

Terminology

The terms EHR, EPR and EMR (electronic medical record) are often used interchangeably, although a difference between them can be defined. The EMR can be defined as the legal patient record created in hospitals and ambulatory environments that is the data source for the EHR.[3] It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health care providers, employers, and payers or insurers access to a patient’s medical records across facilities.[4]

A personal health record is, in modern parlance, generally defined as an EHR that the individual patient controls.

Philosophical views of the EHR

Within a meta-narrative systematic review of research in the field, Prof. Trish Greenhalgh and colleagues defined a number of different philosophical approaches to the EHR.[5] The health information systems literature has seen the EHR as a container holding information about the patient, and a tool for aggregating clinical data for secondary uses (billing, audit etc.). However, other research traditions seen the EHR as a contextualised artefact within a socio-technical system. For example, actor-network theory would see the EHR as an actant in a network (e.g. [6]), while research in computer supported cooperative work (CSCW) sees the EHR as a tool supporting particular work. Prof. Barry Robson and OK Baek also reviewed these aspects and see the EHR as pivotal in human history.

History

Although many[by whom?] think the creation and use of Medical record is very modern and associated early use of computer, some sources indicate that medical record was first developed by Hippocrates, in the fifth century B.C. for two goals: to accurately reflect the course of disease and indicate the probable cause of disease.[citation needed] These goals are still appropriate, but electronic health records systems can also provide additional functionality, such as interactive alerts to clinicians, interactive flow sheets, and tailored order sets, all of which can not be done with paper-based systems. Because of these advantages starting late 1960s many universities in the United States started developing different software to help capturing and maintaining EHR. For example, in the 1960s, Dr. Lawrence Weed proposed a type of electronic medical record system that he called a problem-oriented medical record. His idea was to integrate the medical information of patients from different physicians to be able to provide better health care.[citation needed] In the mid 1980s, IOM initiated a study to be conducted to improve the healthcare delivery because of the unhappiness with the paper medical record. In 1991 this study titled “The computer-based Patient Record: An essential Technology for Health Care.” was released. This study has a landmark effect on the advancement of EHR.[citation needed] This study alone did not play much role in the advancement of electronic health record as expected so the IOM conducted more studies to come up with more recommendations and find out what the obstacle were. In 1999, a landmark work called To Err is Human that was a wake-up call was released.[8] This study highlighted 44,000-98.000 people die in the United States because of medical errors. Some of these death happened because of unreadable physician handwriting that could be easily prevented by using EHR

Advantages

Several possible advantages to EHRs over paper records have been proposed, but there is debate about the degree to which these are achieved in practice (e.g. [9]).

Reduction of cost

In the U.S. a vast amount of funds are allocated towards the health care industry—more than $1.7 trillion per year.[10] If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.

Improve quality of care

The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.[10] Information Technology is being used today to automate day-to-day processes, thus helping to reduce administration costs which then in turn can free up time and money for patient care.[11]

EHR systems can help reduce medical errors by providing healthcare workers with decision support.[12] Fast access to medical literature and current best practices in medicine are hypothesised to enable proliferation of ongoing improvements in healthcare efficacy.[13]Improved usage of EHR is achieved if the presentation on screen or on paper is not just longitudinal, but hierarchically ordered and layered. During compilation while hospitalisation or ambulant serving of the patient, easing to get access on details is improved with browser capabilities applied to screen presentations also cross referring to the respective coding concepts ICD, DRG and medical procedures information[citation needed].

Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.

Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices.

Realistically, these benefits may only be realized if the EHR systems are interoperable and wide spread (for example, national or regional level) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medical informatics must be deployed.

Record keeping and mobility

EHR systems have the advantages of being able to connect to many electronic medical record systems. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.

Disadvantages

Critics point out that while EHRs may save the “health system” money, physicians, those who buy the systems, may not benefit financially. EHR price tags range widely, depending on what’s included, how robust the system is, and how many providers use it. Asked what they paid in an online survey, about a third of respondents paid between $500 and $3,000 per physician. A third paid between $3,001 and $6,000, and 33 percent paid more than $6,000 per physician for their EHR.[16] Physicians do tend to see at least short-term decreases in productivity as they implement an EHR. They spend more time entering data into an empty EHR than they used to spend updating a paper chart with a simple dictation. Such hurdles can be overcome once the software has some data, as physicians learn to use templates for data entry, and as workflow in the practice changes, but not every practice gets that far.

Studies also call into question whether, in real life, EHRs improve quality.[17][18] 2009 produced several articles raising doubts about EHR benefits.[19][20][21]

Costs

The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[22] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[22]

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. “Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR’s cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians.” If a physician performs tests in the office, it might reduce his or her income. “Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used.

Time

Often, doctors do not want to spend the time to learn a new system. Some doctors believe that adopting a system with EHRs could reduce clinical productivity.[25]

Governance, privacy and legal issues

Privacy Concerns

In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.

Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient’s records during a hospitalization, and 600,000 payers, providers and other entities that handle providers’ billing data have some access also.[28] Recent revelations of “secure” data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[29] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of these standards.[30]

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[31]

Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law’s implementation.[32] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec.

One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. Former US president Bush called for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”[33]

The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while “hospitals keep careful tabs on who accesses the charts of VIP patients,” they are powerless to act against “a meddlesome pharmacist in Alaska” who “looks up the urine toxicology on his daughter’s fiance in Florida, to check if the fellow has a cocaine habit.”[34] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the U.S. Supporters of EHRs have argued that there needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records if adoption of an EHR is to occur.[35]

According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client’s knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes. Stanford had merged her notes with her general medical record, and the general medical record wasn’t covered by HIPAA restrictions.[36]

Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[35] Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[33] So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.

Legal issues

.         Liability

Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[37] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[38]

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[39]. Similarly, it’s important to recognize that the implementation of electronic health records carries with it significant legal risks. [40]

This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[41] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.

In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital’s software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[42] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[43][44]

.         Legal Interoperability

In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions.

Technical issues

Standards

• ANSI X12 (EDI) – transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
• CEN’s TC/251 provides EHR standards in Europe including:
  • EN 13606, communication standards for EHR information
  • CONTSYS (EN 13940), supports continuity of care record standardization.
  • HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• Continuity of Care Record – ASTM International Continuity of Care Record standard
• DICOM – an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
• HL7 – a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
• ISO – ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures

The U.S. federal government has issued new rules of electronic health records.[46]

Open Specifications

• openEHR: an open community developed specification for a shared health record with web-based content developed online by experts. Strong multilingual capability.
• SMArt Platforms: an open platform specification to provide a standard base for healthcare applications.

Customization

Each healthcare environment functions differently, often in significant ways. It is difficult to create a “one-size-fits-all” EHR system.

An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.

This customization can often be done so that a physician’s input interface closely mimics previously utilized paper forms.[47]

At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[48] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[49]

Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.

Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives[citation needed].

Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that “choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.”[52]

The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research “describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures.”[53]

In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place[citation needed].

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that “the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information.

Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion.

Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks).

Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.

Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.

eHealth and teleradiology

The sharing of patient information between health care organizations and IT systems is changing from a “point to point” model to a “many to many” one. The European Commission is supporting moves to facilitate cross-border interoperability of e-health systems and to remove potential legal hurdles, as in the project www.epsos.eu/. To allow for global shared workflow, studies will be locked when they are being read and then unlocked and updated once reading is complete. Radiologists will be able to serve multiple health care facilities and read and report across large geographical areas, thus balancing workloads. The biggest challenges will relate to interoperability and legal clarity. In some countries it is almost forbidden to practice teleradiology. The variety of languages spoken is a problem and multilingual reporting templates for all anatomical regions are not yet available. However, the market for e-health and teleradiology is evolving more rapidly than any laws or regulations.[58]

National contexts

United States

US medical groups’ adoption of EHR (2005)

As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Fewer than 10% of American hospitals had implemented HIT,[59] while a mere 16% of primary care physicians used EHRs.[60] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.[61][62] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.[62] However, less than one-tenth of these physicians actually had a “complete EMR system” (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).[63]. The CDC more recently reported that the EMR adoption rate has steadily risen to 48.3 percent at the end of 2009.[64]

The healthcare industry spends only 2% of gross revenues on HIT, which is low compared to other information intensive industries such as finance, which spend upwards of 10%.[65][66][67]

Incentives and Penalties

Until recently, with the American Recovery and Reinvestment Act of 2009,[68] (ARRA) providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.

The HITECH Act, part of the 2009 economic stimulus package (ARRA) passed by the US Congress, aims at inducing more physicians to adopt EHR. Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use “certified EHRs” of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to show “meaningful use” of an EHR system. As of June 2010, there are no penalty provisions for Medicaid.[3]

Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve “meaningful use” and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level[citation needed].

Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.

Meaningful Use

The meaningful use of EHRs intended by the US government incentives is categorized as follows:

• Improve care coordination
• Reduce healthcare disparities
• Engage patients and their families
• Improve population and public health
• Ensure adequate privacy and security

The Obama Administration’s Health IT program intends to use federal investments to stimulate the market of electronic health records:

• Incentives: to providers who use IT
• Strict and open standards: To ensure users and sellers of EHRs work towards the same goal
• Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards

The detailed definition of “meaningful use” is to be rolled out in 3 stages over a period of time until 2015. Details of each stage are hotly debated by various groups. Only stage 1 has been defined while the remaining stages will evolve over time

Start-up costs

In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.[70] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).[71][72][73] Vendor costs account for 60-80% of these costs.[74] There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 – $7500/provider and $67 – $750/month per provider.[75]

Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.[76] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.[77]

Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.[78][79]

Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.

Software maintenance costs

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training costs

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[81]

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Older practitioners who are less experienced in the use of electronic health record systems will retire over time.

Implementations

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA’s over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.[82]

The 2003 National Defense Authorization Act (NDAA) ensured that the VA and DoD would work together to establish a bidirectional exchange of reference quality medical images. Initially, demonstrations were only worked in El Paso, Texas, but capabilities have been expanded to six different locations of VA and DoD facilities. These facilities include VA polytrauma centers in Tampa and Richmond, Denver, North Chicago, Biloxi, and the National Capitol Area medical facilities. Radiological images such as CT scans, MRIs, and x-rays are being shared using the BHIE. Goals of the VA and DoD in the near future are to use several image sharing solutions (VistA Imaging and DoD Picture Archiving & Communications System (PACS) solutions).

Electronic Health Records Flow Chart

Clinical Data Repository/Health Data Repository (CDHR)is a program that allows for sharing of patient records, especially allergy and pharmaceutical information, between the Department of Veteran Affairs (VA) and the Department of Defense (DoD) in the United States. The program shares data by translating the various vocabularies of the information being transmitted, allowing all of the VA facilities to access and interpret the patient records.[84] The Laboratory Data Sharing and Interoperability (LDSI) application is a new program being implemented to allow sharing at certain sites between the VA and DoD of “chemistry and hematology laboratory tests.” Unlike the CHDR, the LDSI is currently limited in its scope.

One attribute for the start of implementing EHRs in the States is the development of the Nationwide Health Information Network which is a work in progress and still being developed. This started with the North Carolina Healthcare Information and Communication Alliance founded in 1994 and who received funding from Department of Health and Human Services.[86]

The Department of Veterans Affairs works with Kaiser Permanente to further develop a software which allows to share information with private health care providers.[87] This software called ‘CONNECT’ uses Nationwide Health Information Network standards and governance to make sure that health information exchanges are compatible with other exchanges being set up throughout the country. CONNECT is an open source software solution that supports electronic health information exchange.[88] The CONNECT initiative is a Federal Health Architecture project that was conceived in 2007 and initially built by 20 various federal agencies and now comprises more than 500 organizations including federal agencies, states, healthcare providers, insurers, and health IT vendors.[89]

The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.

England

As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT).[90] However, the plan has been greatly delayed and frequently criticised.[91][92][93]

Australia

Australia is dedicated to the development of a lifetime electronic health record for all its citizens. HealthConnect is the major national EHR initiative in Australia, and is made up of territory, state, and federal governments. MediConnect is a related program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[94]

Canada

The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.

Estonia

Estonia is the first country in the world that has implemented a nationwide EHR system, registering virtually all residents’ medical history from birth to death.[95]

UAE

Abu Dhabi is leading the way in using national EHR data as a live longitudinal cohort in the assessment of risk of cardiovascular disease.[96]

Saudi Arabia

Arab Health Awards 2010 recognizes Saudi Arabia National Guard Health Affairs for greatest advancement in EHR development

 

 

 

 

 

 

 

About the Author

Author

ODOEMENAM JOSEPH CHIMEZIE

Nickname

ESTACY

phone

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email:

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Health care reform: Envisioning a different future (Mercer’s Linda Havlin)

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Can health be planned?: Or, why doctors should do less & patients should do more : forecasting the future of health system agencies (The Michael M. Davis lecture) …

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Imagine: Animal Doctor Care Center PRE-OWNED – Nintendo DS $24.99 SynopsisHelp care for some of the cutest animals as a veterinarian in Imagine: Animal Doctor Care Center. Diagnose and nurse sick animals back to health, then find them the perfect family to love and adopt them. Keep up the good work and, one day, you could be running the baby animal department the most fun place in the world. Get ready to live out your dream career in Animal Doctor Care Center as you take charge of your own virtual veterinarian’s office. It’s up to you to diagnose and treat animals who need your help. Nurse these sweet, lovable animals back to health and keep them happy by playing with them, petting them and making sure they are clean and fed. Customize the animals’ playpens and the office waiting room with a wide range of color palettes and art to create a homey atmosphere. Make sure your patients stay healthy by setting them up for regular check-ups just like a real doctor and spend time with them to create positive relationships.

Prostate Care™ (42 medium tablets) $20.49 Complete nutritional formula for prostate health. Pro Health's Prostate Care is a comprehensive formula designed to provide vital nutritional support for optimal prostate health. Prostate Care includes potent saw palmetto, pygeum extract and pumpkin seed extract, plus eleven other prostate supporting ingredients to provide the most well rounded prostate health formula on the market.

Neurological Health Formula by Holistic Health (180 tablets) $29.9 Complete Multi-vitamin Formula. A complete multi-vitamin formula with 38 vitamins, minerals and nutrients.

Equine Joint Health Granules (60 Doese) 720.00 $29 Equine Joint Health for unbeatable prices at TotalPetSupply.com Today’s trusted online pet store that dispenses the best quality pet medications.

Equine Joint Health Soft Chews 120.00 $34 Equine Joint Health for unbeatable prices at TotalPetSupply.com Today’s trusted online pet store that dispenses the best quality pet medications.

EvoraPlus® by Oragenics (30 mints) $14.49 The First Probiotic Mints for Complete Oral Care. EvoraPlus® is a unique probiotic mint that contains the patented beneficial bacteria blend, ProBiora3®. EvoraPlus® represents a whole new level of oral care, one in which good oral health is supported and maintained with good bacteria – just the way nature intended.

Canine Joint Health Soft Chews 120.00 $45 Canine Joint Health from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Canine Joint Health Granules (120 Doese) 750.00 $31 Canine Joint Health from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Tribeca Chicago Cubs Earbud Headphones $24.99 Listen to your favorite music with these Tribeca MCUBAEP03 Chicago Cubs earbud headphones that feature a built-in microphone and remote for hands-free conversation and one-touch control of your music.

Rico Chicago Cubs Power Decal $24.99 Show your team pride with this Rico PWR5301 Chicago Cubs LED-backlit power decal that shines when your vehicle is in motion. The battery-powered design and motion sensor ensure long-lasting use.

Monte Carlo MC13OC 4 Light Fan Light Kit in Old Chicago $28 Fan Light Kit in Old Chicago by Monte Carlo.

Monte Carlo MC14OC 4 Light Fan Light Kit in Old Chicago $22.75 Fan Light Kit in Old Chicago by Monte Carlo.

Baseline Chicago Bears Video Chair $99.99 Get your game on with this Chicago Bears Video Chair. Designed for relaxing in front of the TV and keeping you comfortable while you maul the final boss or score a touchdown in the final seconds of the game, this game chair not only supports you, it shows your support of the Chicago Bears. The team’s colors and logo look great on the microfiber and mesh fabric. When not in use, the chair folds in half so you can transport and store it easily.

Gibson Care Kit $34.99 This care kit helps you keep your Gibson guitar in optimal condition and includes premium fretboard conditioner, low-abrasive metal cleaner, pump polish, 3 polishing cloths and a Gibson woven strap.

Rico Chicago Blackhawks Power Decal $24.99 Show off your team pride with this Rico PWR7701 Chicago Blackhawks power decal that uses motion-sensing technology and LED lighting to illuminate an officially licensed team logo in your car window. Sensors help to conserve battery life.

Memory Company Chicago Bears Neon Clock $79.99 This stylish neon clock features chrome accents for a classic look and the Chicago Bears logo and colors so you can show off your team spirit.

Memory Company Chicago Cubs Neon Clock $79.99 This stylish neon clock features chrome accents for a classic look and the Chicago Cubs logo and colors so you can show off your team pride.

Enzadent Oral Care Chews Large Dog 18.00 $15 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Enzadent Oral Care Chews Medium Dog 18.00 $14 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Enzadent Oral Care Chews Petite Dog 30.00 $9 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Enzadent Oral Care Chews Small Dog 18.00 $11 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Synovial-Flex Joint Care for Dogs Chewable 120.00 $47 Synovial-Flex Joint Care for Dogs medication at an affordable price! Total Pet Supply offers pet medications online with exceptional service to pet owners across the United States of America

Synovial-Flex Joint Care for Dogs Chewable 180.00 $51 Synovial-Flex Joint Care for Dogs medication at an affordable price! Total Pet Supply offers pet medications online with exceptional service to pet owners across the United States of America

Fabrique Innovations Chicago Bears Pillow Snuggie $24.99 Stay warm while working on other tasks with this Snuggie that features fleece material for a comfortable feel. The Chicago Bears logo allows you to show your team pride.

Tribeca Chicago Blackhawks Netbook Sleeve – Black $24.99 Keep your netbook safe on the go with this sleeve that features durable neoprene material to guard against shocks and a full-color Chicago Blackhawks team logo to help you show off your team spirit.

Tribeca Chicago White Sox Earbud Headphones $24.99 Listen to your favorite music with these Tribeca MCWSAEP03 Chicago White Sox earbud headphones that feature a built-in microphone and remote for hands-free conversation and one-touch control of your music.

Tribeca Chicago Cubs Deluxe Stylus – Black $24.99 Show your team pride with this Tribeca MCUBASY02 Chicago Cubs deluxe stylus that is designed for use with most devices with a capacitive touch screen, so you can sketch, type and navigate with precision accuracy.

Tribeca Chicago White Sox Deluxe Stylus – Black $24.99 Show your team pride with this Tribeca MCWSASY02 Chicago White Sox deluxe stylus that is designed for use with most devices with a capacitive touch screen, so you can sketch, type and navigate with precision accuracy.

Tribeca Chicago Bears Shield for Apple iPad – Black $44.99 Display your team spirit with this shield that features a Chicago Bears design for a stylish look. The silicone rubber material protects your Apple iPad against bumps and scratches while you’re on the go.

Team Golf Chicago Bears Medalist Bag $249.99 Show your team pride on the links with this licensed golf bag that features 14-way full-length dividers to protect your clubs and a Chicago Bears design for a striking appearance.

Trademark Games Chicago Bulls Billiard Ball Rack $12.99 This Trademark Games NBA5000-CB Chicago Bulls rack holds up to 15 regulation-size billiard balls and features styrene construction for durability. The officially licensed art allows you to show your team pride.

Memory Company Chicago Cubs Chrome Clock – Chrome $19.99 This Memory Company 12″ chrome clock features a Chicago Cubs design, so you can show off your team spirit. Display the clock on the wall or use the built-in easel on your desk.

Baseline Chicago White Sox Video Chair – Black $99.99 This video chair features microfiber and mesh for durable construction and a collapsible design for easy moving and storing. The Chicago White Sox logo lets you show your team spirit.

Rico Chicago White Sox Power Decal $24.99 Show your team pride with this Rico PWR4101 Chicago White Sox LED-backlit power decal that shines when your vehicle is in motion. The battery-powered design and motion sensor ensure long-lasting use.

Team ProMark Chicago Bears Laptop Sleeve – Black $29.99 This laptop sleeve features a 3.3mm neoprene inner core to protect your laptop while on the go and a jersey-style mesh fabric outer core with an embroidered Chicago Bears logo to display your team pride.

Skullcandy Ink’d Chicago Bulls Earbud Headphones $24.99 Enjoy your music with these sound-isolating headphones, featuring powerful 11mm drivers and a neodymium magnet for high-quality sound. The colorful Chicago Bulls logo helps you show off your team spirit.

Memory Company Chicago Cubs Let’s Go Light $34.99 Showcase your team spirit with this Memory Company Chicago Cubs Let’s Go light that features a flashing team graphic and team colors. Rotating lenses allow simple placement on a wall, desk or shelf.

Wild Sales Chicago Bears Wireless Mouse $39.99 This wireless mouse features a lightweight, comfortable design for ease of use and a USB 2.0 nano interface for reliable operation. The Chicago Bears design offers a stylish touch to your computer setup.

Wild Sales Chicago White Sox Wireless Mouse $39.99 This wireless mouse features a lightweight, comfortable design for ease of use and a USB 2.0 nano interface for reliable operation. The Chicago White Sox design offers a stylish touch to your computer setup.

Wild Sales Chicago Cubs Wireless Mouse $39.99 This wireless mouse features a lightweight, comfortable design for ease of use and a USB 2.0 nano interface for reliable operation. The Chicago Cubs design offers a stylish touch to your computer setup.

Pangea ProToast Chicago White Sox 2-Slice Toaster $34.99 This toaster accommodates 2 slices of bread at a time and brands each piece with the Chicago White Sox logo, so you can proudly display your team spirit. The removable crumb drawer allows for easy cleanup.

Memory Company Chicago White Sox Neon Clock $79.99 This stylish neon clock features chrome accents for a classic look and the Chicago White Sox logo and colors so you can show off your team pride.

Daily Health ProPack™ (30 day supply) $43.49 Advanced nutritional support for a healthy foundation. Go beyond the A, B, Cs of daily vitamins, and reach for advanced nutrition in simple, easy packets: essential daily nutrients, from amino acids to green superfoods, antioxidants to essential fatty acids, digestive enzymes to multivitamins and more. This is a rock-solid foundation you can augment should you have additional nutrient needs. You won't find a comparable daily-packet product on the market!

Game Time Chicago White Sox Tube Watch $13.99 Show around-the-clock support for your team with this Game Time Chicago White Sox tube watch made from soft, silicone rubber material for a comfortable fit. Your team’s logo shows off your loyalty, while the digital display helps you stay on time.

Game Time Chicago Cubs Tube Watch $13.99 Show around-the-clock support for your team with this Game Time Chicago Cubs tube watch made from soft, silicone rubber material for a comfortable fit. Your team’s logo shows off your loyalty, while the digital display helps you stay on time.

Boelter Chicago Bears Portable Party Fridge $199.99 Take your tailgating party to the next level with this portable party fridge that holds up to 24 cans of your favorite beverage. The Chicago Bears logo adds a stylish look to the fridge and allows you to show your team pride before or after the game.

Tribeca Chicago Cubs USB Wall Charger – Black $19.99 Keep your device charged and ready for use with this Tribeca MCUBACH04 Chicago Cubs wall charger that is compatible with most devices with USB connectivity and features an officially licensed team logo, so you can showcase your team spirit.

Boelter Chicago Cubs Portable Party Fridge $199.99 Take your tailgating party to the next level with this portable party fridge that holds up to 24 cans of your favorite beverage. The Chicago Cubs logo adds a stylish look to the fridge and allows you to show your team pride before or after the game.

Boelter Chicago Blackhawks Portable Party Fridge $199.99 Take your tailgating party to the next level with this portable party fridge that holds up to 24 cans of your favorite beverage. The Chicago Blackhawks logo adds a stylish look to the fridge and allows you to show your team pride before or after the game.

Boelter Chicago White Sox Portable Party Fridge $199.99 Take your tailgating party to the next level with this portable party fridge that holds up to 24 cans of your favorite beverage. The Chicago White Sox logo adds a stylish look to the fridge and allows you to show your team pride before or after the game.

Memory Company Chicago Cubs Mouse Pad $9.99 Represent your team at the office or at home with this Memory Company mouse pad that features the Chicago Cubs logo and colors to mark your fan status. The neoprene material offers an ideal rolling surface to make your mouse easier to control.

Memory Company Chicago White Sox Mouse Pad $9.99 Represent your team at the office or at home with this Memory Company mouse pad that features the Chicago White Sox logo and colors to mark your fan status. The neoprene material offers an ideal rolling surface to make your mouse easier to control.

Tribeca Chicago Blackhawks 4GB USB 20 Flash Drive $19.99 Store your digital data on this 4GB flash drive that features a laser-engraved Chicago Blackhawks design. The included lanyard allows for easy carrying.

Tribeca Chicago White Sox 4GB USB 20 Flash Drive $4.99 Store your digital data on this 4GB flash drive that features a laser-engraved Chicago White Sox design. The included lanyard allows for easy carrying.

Boelter Chicago Bears 32 Cu Ft Compact Refrigerator $499.99 Show your team support with this compact refrigerator that holds up to 84 cans of your favorite beverage and features Chicago Bears color graphics for a stylish look.

Pangea Fanjams Chicago Cubs Over-the-Ear Headphones – Blue/White $69.99 Show your team pride with these headphones that feature a Chicago Cubs design. The neodymium magnet delivers brilliant audio and leatherette ear cushions provide comfortable use.

Boelter Chicago Cubs 32 Cu Ft Compact Refrigerator $499.99 Show your team support with this compact refrigerator that holds up to 84 cans of your favorite beverage and features Chicago Cubs color graphics for a stylish look.

UVZ Health Systems Family Toothbrush Sanitizer – White $59.99 This family toothbrush sanitizer accommodates up to 5 toothbrushes and can also be used to sanitize small health and grooming appliances to kill up to 99.9% of contagions including SARS, hepatitis, bacillus, staph, cold and flu viruses.

Fatigued to Fantastic!™ Energy Revitalization System – Tropical Citrus (30 day supply) $35.49 Vitality, Health and Lasting Energy. Boost your energy with Dr. Jacob Teitelbaum's Fatigued to Fantastic!™ Energy Revitalization System. This unique supplement system of more than 50 vitamins, minerals and other crucial nutrients will help you to reclaim your life from the overwhelming fatigue and brain fog that drag you down. Dr. Teitelbaum's clinical experience indicates that after using this energy formula for three months in conjunction with his individualized health care program, most people will notice a 76% improvement in their quality of life.

Fatigued to Fantastic!™ Energy Revitalization System – Berry Splash (30 day supply) $35.49 Vitality, Health and Lasting Energy. Boost your energy with Dr. Jacob Teitelbaum's Fatigued to Fantastic!™ Energy Revitalization System. This unique supplement system of more than 50 vitamins, minerals and other crucial nutrients will help you to reclaim your life from the overwhelming fatigue and brain fog that drag you down. Dr. Teitelbaum's clinical experience indicates that after using this energy formula for three months in conjunction with his individualized health care program, most people will notice a 76% improvement in their quality of life.

Enzadent Oral Care Chews Cats Fish Flavoured 24.00 $14 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Enzadent Oral Care Chews Rinse with Chlorhexidine 0.12% and Zinc 8.00 $8 Enzadent Oral Care Chews from a trusted online pet pharmacy. Total Pet Supply offers free shipping all orders over $100

Synovial-Flex Joint Care for Dogs Soft Chews 120.00 $39 Synovial-Flex Joint Care for Dogs medication at an affordable price! Total Pet Supply offers pet medications online with exceptional service to pet owners across the United States of America

Synovial-Flex Joint Care for Dogs Soft Chews 240.00 $66 Synovial-Flex Joint Care for Dogs medication at an affordable price! Total Pet Supply offers pet medications online with exceptional service to pet owners across the United States of America

Synovial-Flex Joint Care for Dogs Soft Chews 60.00 $20 Synovial-Flex Joint Care for Dogs medication at an affordable price! Total Pet Supply offers pet medications online with exceptional service to pet owners across the United States of America

Panasonic Pedicure Care Heel Buffer – Pink $39.99 Take care of your feet with this heel buffer that features a narrow file for in between toes and smaller areas and a regular file for larger areas, such as your soles and heels.

Monte Carlo MC22OC 4 Light Fan Light Kit in Old Chicago $103 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 5.75 H 12.38 W

Monte Carlo MC37OC-L 4 Light Fan Light Kit in Old Chicago $31 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 3.25 H 12.00 W

Monte Carlo H3OC-L 3 Light Fan Light Kit in Old Chicago $28.5 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 3.13 H 6.25 W

Monte Carlo MC183OC-L 4 Light Fan Light Kit in Old Chicago $39.9 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 5.70 H 11.00 W

Monte Carlo H4OC-L 4 Light Fan Light Kit in Old Chicago $26.6 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 3.13 H 6.25 W

Monte Carlo 5WF52OC Weatherford 5 Blade Ceiling Fan in Old Chicago $150.1 Traditional Ceiling Fan in Old Chicago from the Weatherford Collection by Monte Carlo. Dimensions: 12.65 H

Monte Carlo MC66OC-L 4 Light Fan Light Kit in Old Chicago $66.5 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 6.50 H 10.50 W

Monte Carlo MC73OC-L 4 Light Fan Light Kit in Old Chicago $76 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 9.00 H 9.50 W

Monte Carlo MC76OC 4 Light Fan Light Kit in Old Chicago $73.5 Fan Light Kit in Old Chicago by Monte Carlo. Dimensions: 5.50 H 11.50 W

Monte Carlo 5CY60OC Cyclone 5 Blade Ceiling Fan in Old Chicago $300.2 Traditional Ceiling Fan in Old Chicago from the Cyclone Collection by Monte Carlo. Dimensions: 13.95 H

Monte Carlo 5PE56NO Peninsula 5 Blade Ceiling Fan in Old Chicago $419 Tropical Ceiling Fan in Old Chicago from the Peninsula Collection by Monte Carlo. Dimensions: 14.31 H

Monte Carlo 5MXOC Maxima 5 Blade Ceiling Fan in Old Chicago $149.99 Traditional Ceiling Fan in Old Chicago from the Maxima Collection by Monte Carlo. Dimensions: 15.94 H

Dale Tiffany TT90179 Chicago 2 Light Table Lamp in Antique Bronze $234 Tiffany Glass Table Lamp in Antique Bronze from the Chicago Collection by Dale Tiffany. Dimensions: 23.00 H 15.75 W

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