Medical Informatics



good afternoon ladies and gentlemen welcome to this lecture on chronic medical records my name is Ashok Singh and I'm from the Department of telehealth at the Nelson our Mandela School of Medicine in South Africa in this lecture we're going to actually speak to you about what electronic medical records are we're going to describe some disadvantages of the current way in which we practice medicine that is paper-based record and in fact show you the advantages of electronic medical records we have two videos which are examples of electronic medical record systems used and you're going to discuss very briefly how you would assess the benefit of a computer-based record system or electronic medical record all videos used in this presentation is freely available from you to so the data that is stored when a clinician stores or writes information about an interaction between himself and a patient is called a medical chart for a medical record and in fact this idea stems from the Greeks the Greeks used to record this information whenever a commission had an interaction with a patient but when they record the information they had to actually chisel the information onto stone slabs so you can actually imagine how difficult it was to be a doctor in those days imagine carrying all your patients charts with you each time you want to see them thanks to the invention of paper by the Chinese this actually it became much much easier to actually record patient information on paper of course we can imagine writing on a piece of paper is much easier than chiseling information on a stone slab so why should these conditions actually record this information and basically it's to recall observations to inform others that's communication in case you want a second opinion to instruct students and gain knowledge that education to monitor performance as well as to justify interventions and this was actually discussed in the introduction to medical informatics lecture so what is lucky in the current way in which we're doing things now in this new tip not technological century we have computers we have technology we have different ways in which we can communicate with people and we find that the use of paper is becoming very problematic and that's because of the inherent disadvantages that are in the paper itself and these disadvantages can actually be divided into four sections organizational logistical research and passive nature of paper organizational basically deals with how we store the data in the chart how do we structure the data in such a way that we can actually retrieve it to this organizational how do we organize the data in such a way that it can filled logistical refers to the actual use of the data research is actually quite self-explanatory is how do we use the data for research and the passive nature of of paper is the fact that the paper cannot actually tell if you're making a mistake or not so let's discuss these four aspects with an example this example might be a little over time but I will throw in a few things that actually happened to me I'm from Newcastle and I once went to the doctor and I go to the doctor I go to the deception Asst I asked the receptionist can at least the doctor she says yes and she didn't ask my name and she goes and tries to find my child now imagine her looking for a chart in a room where there are thousands and thousands of paper-based charts what are the chances of those charts actually been in alphabetical order and think about it at the end of the day the nurses are tired they frustrated they have seen many many cranky doctors and patients and then they are actually expected to prepare the charts hundreds of them back in the correct order I myself can't even keep my own small filing cabinet organized I can imagine how difficult it would be to keep a room for a paper charts or bananas so Steve starts looking for my paper child what happens he doesn't find it if she can't find it she has to create a new paper track for me and all of the information in the old paper chart is now lost my medical history is lost all of the information that is actually required for a proper diagnosis of certain types of diseases are lost so let's say she find it she finds my record she takes it she gives it to the doctor now in in the actual incident that I have had when this receptor is actually found my record and she was walking to the doctor she actually dropped my easy and while I was walking to his room I saw it and I picked it up and I saw it had my name on it and it was my ECG now imagine if I didn't pick it up okay an ECG maybe that's not so bad but what if it was the results from an HIV test what if I was into a positive and now my wife or my parents or stop or my boss looks at it that is an invasion of my privacy those are security advantages to paper-based records confidentiality privacy disadvantages to paper-based record so eventually I made my way to the doctor's table and there were tens of charts just lying on his table piece of paper everywhere he's he looks at this chart he asked me what's wrong I tell him the symptoms he starts paging to this paper truck trying to find maybe a piece of information a doctor's handwriting is notoriously terrible we all know that now imagine him trying to understand his writing way we're used actual rushing and writing and how he can't understand it that's another disadvantages disadvantage of paper-based rakaats doctors write badly and they cannot actually leave their own handwriting so let's say now paging through this thick chart of my of my medical history we can assume I have somewhat of chronic disease I'm diabetic and therefore my child is actually quite thick he eventually finds this piece of it this piece of information that you're looking for of course he could understand his handwriting he realized whatever of treatment I need he writes it again on a piece of paper and he lets put it into the file he doesn't put it in any chronological order maybe it's a small piece of paper and like my ECG and while it gives it to the nurse the nurse will drop it down it'll get lost maybe the file gets misplaced in his table under all of everyone else's files there are lots of organizational and logistical disadvantages when it comes to paper-based records well and tail ends of Africa is after a law that states that a paper-based record needs to be kept for a certain number of years and I think it's actually ten years people as you all know is something that is very very fragile we've all written on a piece of paper and have left it in the sunlight for a few hours only to find that the paper becomes Brown the ink has faded imagine keeping this record for 10 years how do we ensure that we will still be able to actually read the writing on this piece of paper but that the paper designer hat doesn't have dog ears and is torn that the paper does not become brittle wood age backups backups of paper-based records or paper-based systems are tremendously difficult clinicians don't have time they're in a high paced and very very frustrating field because they need to see a lot of patients in a very small amount of time you can't expect them to write in triplicate even if you have carbon paper so making backups of paper is very difficult the other disadvantage is associated with this is also cost if we do make a backups but there's tremendous cost in terms of buying paper storing paper creating the environment where people can papers life time can actually be improved paper can also be used only at one place at one time if you in fact want to use paper somewhere else you have to make a copy of it unless you are creating your tendencies research imagine trying to do research if you only had paper information it is so difficult imagine going into a hospital a public hospital where there are six seven eight thousand paper files and you now want to do a study that's that tries to find out if there's any correlation between smoking and heart disease so you go to each and every one of these papers to find all the people that have heart disease to find all of the people that are smokers and then you've got to find all people that had heart disease and there were smokers so retrospective studies are very very difficult when you only use paper the passive nature of paper is also a very big disadvantage especially in the high highly paced field that many conditions find themselves in public hospitals if you are making a mistake paper cannot scream at you and tell you listen you're making a mistake paper will not tell you you know putting in a person's height as 16 meters might not be right maybe you meant 1.6 meters paper is passive it can't it can't inform you that you're making mistakes or suggest to you other alternative in terms of therapy or subjects what patients may be suffering from so these are basically the four categories of disadvantages of paper based across organizational logistical research and the passive nature of paper so seeing that it is a technological century we can actually create or use technology to overcome many of these problems and that leads to the advent of electronic medical records and this field is actually an evolving field and it it an electronic medical record in fact has no clear definition of what should constitute it I will speak more about this later but very basically an electronic medical record can be defined as a systematic collection of electronic health information about an individual or a population of individuals it is in fact a record in a digital format in an electronic format and it is capable of being accessed in different healthcare environments answered mainly because of networks internet the tcp/ip port calls etc again the an electronic medical record makes comprehensive use of data so the data that is stored has a very very wide range and depending on who you are depending on your own definition of electronic medical record they can be made things made pieces of information that can be stored in these electronic medical records you could have demographic information you could have medical history medications allergies lab tests radiology images of vitals pulling information administration information etc etc in our local context we actually have a difference between what is called a computer based patient record and an electronic medical record basically a computer-based patient record is patient orientated so it only has an electronic version of the paper-based record but an electron but an electronic medical record not only has the electronic paper based version of the paper recalled but it also has other things that help the patient like a clinical decision support system etc coming back to the slide I just want to bring your attention to the different names that we can call an electronic medical record you can call it an electronic patient record being called an electronic health record etc etc I think for the purpose of this lecture let's just assume that all of these different names actually first the same thing it is a collection of electronic health information with other tools that a clinician can actually use to improve quality of care for a patient so the next was the next two things that I would actually want to show you videos by clinicians and these videos actually describe to you what electronic medical records are they are two examples of them being used in Prior practices in Hawaii I want you to pay careful attention to how it is used to how it is organized to how it actually makes the lives of the clinicians the admin staff and everyone else who is involved in this clinical environment much much easier please watch the two videos now these videos are called video 1 and video 2 and you'll find a link to it on the left hand side of the off screen also these videos are actually provided with the lecture so let's talk a little bit about these two videos that you've seen where they have taken technology and actually created an intervention so by using this database technology we find that we have many many many advantages compared to using paper-based records and the most obvious one is the information retrieval from these videos we found how easy it is to actually retrieve information if it is in a database we can actually create links between information that we want to normally see we can clearly this database asking absolutely obscure pieces of information anything good and we what actually gets information back but instantly we go back to our example of trying to trying to find a association between smoking and heart disease by using a database we can easily select all patients who had some sort of cardiac disease and smoked and these records as patient names that identifiers and all the information you want will be easily displayed on your screen in a matter of seconds it's also important to realize that there are different levels of uses when it comes to electronic medical records and again this is because there is no clear-cut definition of what an electronic medical record is we found that in the first video they there were two electronic medical records described one was where the clinician simply scanned piece of the paper into an electronic medical record and the other where the person actually typed out information into the pot and this brings us to the discussion of structured verse unstructured data structured data the first data that is stored in a very meticulous way in a way that can be easily processed like typing up the information whereas unstructured data is data expanding a piece of paper and storing that in a in an electronic medical record or maybe saving an audio of an interaction and saving that in in medical record structured data is much much more easily processed it is much more in an easily analyzed which means the most structured data is stored in an electronic medical record the more useful it becomes you can analyze the data more you can ask more questions you can find out more interactions between the data whereas an unstructured although it is possible to handle engines using various types of complex software it is in fact difficult and takes time an important part that came out in these elections is the point of scheduled backups it is so much easier to make backups using technology this can all be done automatically at midnight at particular days the entire database can be backed up and even automatically sent to another location where it can be stored and if we think about the amount of space that is required to store large volumes of information when it comes to technology and when it comes to paper-based files really realize that the entire roomful of paper-based files can be stored in a small a portable USB device that's no bigger than 10 or 20 centimeters compared to entire rooms for rooms full of shelves the other important things that came out of these two videos was the fact that technology can be designed and used in such a way that you can actually create modules and these modules make the use and design of electronic medical records much much simpler you choose which modules you need to use in your system and you only add those you reduce the complexity and you in fact save space and you actually make the electronic medical record more efficient you just use whatever you need if you remember the first lecture we said the simplest form of technology to solve a problem just use what you need there are different modules we just load on the modules that you actually require delicate data could be added into the electronic medical record either automatically or semi automatically you could for instance have a mic attached to your ear and mouth you could speak while computer software would actually write or record those words in Microsoft Office for instance you could have handwriting recognition you could have other types awful for a second issue you can even just record the voice directly into the electronic medical record you could have direct entries to via a keyboard or a leg scribe as you've seen in some of in these two examples in these two videos templates also play an important part when it comes to we know that clinicians actually get used to writing on a piece of paper they no longer see what a certain page or what a certain place actually needs they know exactly where to write what piece of information without looking at the question associated with that space so when you create templates in a trike templates you've got to make sure that these templates monic the table based records exactly and this will actually help in terms of recording data data communication is made so much more easily you can have a record medical record being at many places at one time where people can actually read the record see the record but not edit it upon using the internet using other type of technology satellite 3G cards etc etc you can have people from all over the world looking at the certain record having a patient security we find that many clinicians have unwarranted fear when it comes to applying technology to medicine when it comes to using electronic medical record and this probably is due to many movies that we've seen where we find people with a small laptop sitting in a dingy corner somewhere hacking into the CIAA of body or the FBI and the truth is that this fear is actually very unwarranted it is very difficult to break into a secure system if you take the right precautions it will be very difficult to break into an electronic medical record and get this information if you take the right precautions so what are the right precautions well we have physical and we have software precautions negative physical precautions are things like ensuring that the locks on the doors time to complete it down having timers so computers have come on in a certain time or offered a certain time it's like software software solutions will be things like having strong passwords so having a password that is made up of both capital and small letters as well as numbers we can have encryption digital signatures we can have fireworks anti viruses etc etc all of these things put together would actually ensure that this information is actually very very secure when you are thinking about security in terms of the electronic medical record it's always good to actually think about how different security is compared to what is currently being done with paper-based records how secure are people based records leaning I mean records are kept in a filing cabinet maybe there's a door in front of me was captain Astro room with the door and a lock failing campus can be easily broken people record taken out but if you compare that to destroying it in a computer which is also locked in a room which can be broken into like the paper-based record but you've got to be an expert to put the computer on to break through any timers that after their that have could be too and at certain times you've got to activate the password once you break the password is a encryptions you were to break the encryption if they're digital signatures you could break digital signatures and in fact it makes it very very difficult other advantages clinical decision support systems these can actually be used to tell you listen you are making a mistake you are you are recording the wrong data maybe there L is it can help in medication errors it will tell you you are prescribing the wrong medication for this disease the dosage may be wrong etc etc savings using electronic medical record actually save a lot of money in the wrong in the long run yes initially they will be the cost of buying the technology transferring the data training etc etc but in the long run it says thousands thousands of rams of dollars in fact in a paper published in 2005 in health affairs by the state richard he actually mentioned that the u.s.a will save 23 billion u.s. dollars a year if clinicians actually use electronic medical records it improves quality of care and that's true because it will ensure that the minimum standard of care is actually done for each patient it will also ensure that follow-ups are done you can have and thus provide better continuity of care it also promotes evidence-based medicine the culture is such a large amount of real data in the electronic medical record this data can be mined and information knowledge can be taken out from it so basically needs to suicide summarize that advantages some of the issues with electronic medical records in the two videos that you've seen so we spoke about the disadvantage the paper-based of course we showed how technology can actually overcome is the city of antigens but is it easy to actually implement technology in clinical environments is it easy to actually implement electronic medical records and the answer is no it isn't and there are many many problems that are associated with electronic medical records being implemented especially in developing countries the technology itself poses a problem because many developing countries don't have infrastructure and it reminds me of a story which I read in a journal it was a story it was an article that actually spoke about the experience of implementing an electronic medical record in a province in South Africa the hospital managers wanted to implement an electronic medical record in that hospital so they brought experts from many developed countries to South Africa the province to actually do this do you develop these experts are actually well respected they come from a company that whose major contribution is actually building innovative technology so when they came they brought down big servers but lotta backup backups with this system that was actually very very technologically advanced they installed the system in a small world hospital in a provinces of Africa everyone had meetings about workflows they thought everything was correct and they were bought so turn it on and left and let the system run so they had a big ceremony they turned on the electronic medical record and they waited the first day worked the second day the third day the fourth day maybe yes but a week later they found that the system suddenly went down the power suddenly got cut so these experts thought and they said you know we need more technology to active preventers they felt the systems are overheating because of the heat in South Africa and they spent even more money actually creating an environment which will remain cool at the end of this they probably spent a couple billion brands 40 million rounds in creating the system started working again it worked for a few days and again on Monday at the certain time it went off that takes a lot and this continued happening and eventually they didn't know why they couldn't understand the reason why the power selling is cut off at 6 o'clock on particular days until a nurse who was speaking to one of these experts actually gave them the reason why it's been cut off and she said that this system is on a grid that is on a grid that a baker is actually using so the Baker down the road puts on his ovens at 6 o'clock in the month of a pig that overloads the grid and it's hard now if you are not aware of the problems in a developing country you wouldn't have realized that this could have been one of the reasons why the system is actually failing training and expertise in developing countries there are very few expertise when it comes to this type of technologies people need to be trained many people are in fact completely illiterate then work in clinical environments so not only do you have to train them to actually use it Peter you've got to train them to understand what electronic medical records are to use the electronic medical record and then get benefit from the electronic medical records the perception we spoke about the the security perception the unwarranted courage perception that many people have in developing countries but one of the biggest challenges to implementing electronic medical records is in fact the human factor we find that in a developing country implementing electronic medical records can actually cause discord among technical staff and let me give you an example why many senior nurses are actually quite old in developing countries but in here in South Africa these senior nurses are really completely different they are 50 50 or 60 years old and they really don't have any inclination towards using an end electronic medical record but the newer nurses that come out of the universities are actually very computer savvy so when you introduce an electronic medical record in its environment you'd find that the younger ones the younger nurses were taped to the so much easier compared to the older more mature nurse or nurses that are in skinnier positions so the senior nurses were feel threatened by the fact that they can't use this electronic medical record as easily as the junior nurses and this causes that is why change management is such an important part in implementing electronic medical record whether it's in a small practice where they didn't a big Hospital I another important problem that to one faces when implementing electronic medical record is the fact that many people feel that this causes a dehumanization of the relationship between a clinician and a patient and of course they may be justifying this but my own personal opinion is that this dehumanization does not have to happen if the right technology is used it will just be used as a tool a tool for the doctor to use it will not be an obstacle in the relationship between doctors and clinicians for instance a doctor can use a leg scribe pen and write down his interaction with the patient he can use a small PDA and type off quickly and as he is interacting with his patient if he can't technically he can recall his audio voice and saying that oh he could have voice recognition software built into his small portable net-net network book what is not so there are technologies that can actually prevent this whole dehumanization of the doctor-patient relationship so all electronic medical records beneficial and I am sure by now you know the answer to this No so how do we assess it there are various ways to actually assess the benefit of an electronic medical record and we actually have an entire lecture on that but briefly speaking there are certain things that you should keep in the back of your mind the first one is comprehensiveness of the information does the electronic medical record store all the information that you require to treat your patient to ensure standard of care for your patients to improve continuity of care for your patient so what so does the electronic medical record store the information that you require how long does it store this information that is the duration and attention after as I said before some governments have a minimum amount of time the data needs to be stored does the electronic medical record do this what is the degree of the structure of data the more structured the data the better it is to analyze the more value you will get out of the electronic medical record can you access the information when you need the information does the electronic medical record change the workflow for the sake of changing the workflow or does it change it just because the computer scientists or the designer couldn't design anything else yes again if workflow has to change so that there's more advantage advantages to the patient then where are means change the workflow but never have a system that changes your workflow just because it works that way this is an important thing to actually analyze components of an electronic medical record what are the components that make up this record and again because there is no clear-cut definition of what an electronic medical record is many people will give many components their own components or their own opinion that what should be in an electronic medical record this five components actually comes from and with chocolate he says that they must be an integrated view of the patient data so you should be able to see the patient data from different aspects all the different aspects must be integrated together they must be clinical decision support systems there has to be a clinical audit entry system you must have access to knowledge basis to knowledge resources and they must be integrated communication they're of course very they are of course other issues with computer-based patient records or electronic medical records and we'll speak about one of them now and that's a data entry data entry is an important problem with issue that you must keep in mind when you are implementing your electronic medical record how are you going to capture the data are you going to capture the data in real time okay are you going to have the doctor type out the the interaction while he's seeing the patient or is the doctor with a regiment piece of paper and have a gator capture of capture the data and of course there is no right answer it all depends on the environment that you are in and this game reminds me of another problem that we face when we try to implement an electronic medical record here in South Africa data captures there has to be some way in which you can encourage data captures to actually capture the data correctly when we first installed an electronic medical record because of time and because of computer literacy we thought it would be best for doctors to actually write on a piece of paper that's given to a data capture and the data capture captures data this happened for a few while we started trying to analyze data and we found that there were lots of mistakes and we realized that those mistakes are mistakes from the data captures part of you so we thought on ways in which we can try and encourage data captures to actually capture the data better just being out of university and arrogant as we were we thought people actually scold them so we call the meeting we threaten them but telling them that we know exactly who's in general wrong data and that they shouldn't do it became face back or mistakes to a certain person and we sort of tennis throw our weight around this helped but it helped for like a few weeks and we found that the quality of data got worse than we thought threatening them we didn't help maybe we could actually provide so we told them listen from from our power of focus of course of posting all this we will give them airtime if they could actually record the data without any mistake right and of course it's worked for one week and work for two weeks and again we found that the quality of the data recording was actually getting worse and worse and then we thought you know we can't fit in them that didn't work we can't bribe that wasn't working so how can we encourage them to actually record the data correctly and then we realized something every single human being wants to feel important they want to know that they're making a difference that is fundamental to actually being a human and there was a post that we took we sat them down we spoke to them we told them how important their job is we told them without them the system will does not work that if they recalled the wrong data they in fact actually killed patients and this in fact made the difference after that the months the few months it's that the system was actually Bacolod all of the data was excellent quality they were very very very few mistakes and those were actually mistakes that anyone could have actually made so this is a very interesting to try to actually tell you guys if you think about data captioning or capturing data for electronic medical record how to prevent errors and data in another issue that we should actually think about is the display I display like the one shown on the left is very very bad this place should be assessed based on how busy they are the colors that they use based on how intuitive it is the I would assess the display on the right much much better because it's less cluttered it's more intuitive if doing charting instead of having raw data etc etc so those who are in fact how you would assess or what you should think about when you're trying to assess the benefit of electronic medical record thank you very much for your time

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