ID _________

http://www.medical-record.blogspot.com/

Instructions: Please review the infant and maternal medical records

Please review the maternal medical record for questions 1-15:

1.    What is the mother’s month and year of birth?   ___/_________

2.    What is the ethnicity of the mother?

 Hispanic or Latino                     Not Hispanic or Latino        unknown

3.    What is the race of the mother? Please check all that apply.

 White  African American   Asian   American Indian or Alaska

Native  Native Hawaiian or Other Pacific Islander  Other or unknown

4.    Mother’s Insurance Status?

 Private  Medicaid  Other or Unknown

5.    Please indicate admission date ___/___/_____  and time ___:___ am/pm

 

6.    Was there a prenatal HBsAg (hepatitis B surface antigen) test performed prior to admission?

 Yes              No                         

7.    What was the prenatal HBsAg test date? ___/___/_____   Not documented

8.    What was the prenatal HBsAg test result?

 Positive  Negative  Not documented     

9.    How was HBsAg status of mother documented?

 Copy of laboratory report

 Clinician transcription of information into medical record from other source

 Other, describe: _____________________________________

10.  Was there an HIV test performed prior to admission?

 Yes              No                                      

11.  What was the prenatal HIV test date? ____/___/____  Not documented

Consider adding additional questions on syphilis, GBS, etc.

12.  Was there an HBsAg test performed during the hospital stay?

 Yes              No                                                 

13.  What was the result of the HBsAg test performed during the hospital stay?

 Positive       Negative     Not documented

14.  Was there an HIV test performed during the hospital stay?

 Yes              No             

15.  Type of attending provider

 Obstetrician  Family practitioner  Other or unknown

Please review neonatal medical record for Questions 16-29:

16.  Please indicate infant’s date of delivery ___/___/_____  and time of delivery ___:___ am/pm

17.  Did the infant weigh <2,000 grams at birth?

             Yes                          No                         

18.  Is there a recorded maternal HIV test result?

 Yes                          No             

19.  Is there a recorded maternal HBsAg test result?

 Yes                          No                         

20.  What was the maternal HBsAg test result?

 Positive                   Negative

21.  Was HBIG (hepatitis B immune globulin) given to the infant?

 Yes; date ___/___/_____   Time ___:___ am/pm

 No

22.  Was infant HBIG administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

23.  If there were no hospital pre-printed admission orders*, was infant HBIG administered as a result of a specific physician order?

 Yes                                No                         

24.  Was hepatitis B vaccine given to the infant?

 Yes                                No             

25.  Please indicate date of hepatitis B vaccine  ___/___/_____  and time of  administration ___:___ am/pm

26.  Was hepatitis B vaccine administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

27.  If there were no hospital pre-printed admission orders*, was hepatitis B vaccine administered as a result of a specific physician order?

 Yes                                No                         

28.  Was there any specific order in the neonatal medical record not to vaccinate against hepatitis B virus?

 Yes                                No; end survey     

29.  If there was an order not to vaccinate, what was documented as the reason for not vaccinating? Please check all that apply.

 Infant was <2,000 grams at birth

 Infant was not medically stable

 Mother was HBsAg negative

 Guardian refused

 No reason documented

 Other reason; please specify below:

Thank you for your participation!

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Penyelenggaraan sistem rekam medis pada institusi pelayanan kesehatan sangat variatif mulai dari yang sangat sederhana hingga yang sangat canggih dan kompleks. Salah satu model sistem rekam medis yang ada adalah POMR (problem Oriented Medicai Record) yang diprakarsai oleh Dr. Lawrence L. Weed (the father of POMR).

http://www.medical-record.blogspot.com/

 

Dr. Lawrence L. Weed mengemukakan “Weed System” yang menjadi inti dari Problem Oriented Medical record yaitu:

o Mendefinisikan database

o Menyusun daftar masalah

o Membuat catatan yang berorientasi pada daftar masalah

Secara sederhana teori mengenai Problem Oriented Medical record ini digambarkan dalam “The Four Boxes of Dr. Weed”:

Dari bagan di atas dapat dilihat bahwa Problem Oriented Medical Record terdiri dari 4 bagian utama yaitu databases(basis data), problem list(daftar masalah), plans(perencanaan) dan progress note(catatan kemajuan).

Database atau basis data adalah kumpulan segala informasi pasien yang berobat ke institusi pelayanan kesehatan. Informasi atau data mengenai pasien tersebut dapat dikategorikan menjadi 2, yaitu:

 

o Data Sosial

Terutama terdiri atas identitas soaial pasien seperti nama, tanggal lahir, jenis kelamin, alamat, pendidikan, status perkawinan, dll.

 

o Data Medis

Terutama terdiri dari riwayat medis pasien, catatan pemeriksaan fisik, hasil lab, dll.

Problem list atau daftar masalah adalah dasar acuan dari rekam medis yang berorientasi pada masalah. ”Problem list” bukan merupakan komposisi yang bersifat statis atau tetap melainkan suatu ”table of contents” yang dinamis dari grafik pasien yang dapat di-update setiap saat. Ketelitian mengenai jenis masalah, catatan kemajuan yang berorientasi masalah dan kesimpulannya secara langsung berhubungan dengan ketelitian dan integritas dimana masalah pertamakali diidentifikasikan. Tidak pernah ada kata benar atau salah dalam keputusan sepihak mengenai kasus yang sulit, yang ada hanyalah keputusan yang ilmiah dan logis atau tidak ilmiah dan tidak logis yang dikeluarkan dengan hati-hati atau tidak hati-hati(Weed, 1968).

 

Problem List antara lain mengacu pada masalah:

o medical (biological)

o psychiatric

o social

o demographic

o diagnosis

o physiologic finding

o symptom

o physical finding

o lab abnormality

o social issue

o demographic issue

 

Plans atau perencanaan dibuat saat pertama kali pasien yang bersangkutan berobat ke institusi pelayanan kesehatan terkait. Dari data pasien dan daftar masalah yang sudah diidentifikasi dapat dibuat suatu perencanaan, pada umumnya perencanaan ini terdiri dari:

o Diagnostic

Perencanaan mengenai studi lebih mendalam tentang diagnosis.

 

o Therapeutic

Perencanaan mengenai tindakan/pengobatan yang akan diberikan.

 

o Patient education

Perencanaan mengenai penyampaian informasi medis kepada pasien.

 

Progress note atau catatan kemajuan berisi data tentang perkembangan kondisi pasien selama proses perawatan. Catatan kemajuan dapat dirumuskan dengan SOAP:

o Subjective (the patient’s observations)

o Objective (the Doctor’s observations and tests)

o Assessment (the Doctor’s understanding of the problem)

o Plans (Goals, action, advice etc.)

 

Kelebihan POMR:

o Pasien ditangani berdasarkan prioritas masalah.

o Data tersusun terklasifikasi berdasarkan masalah.

o Memudahkan evaluasi rekam medis.

o Memudahkan penelitian terhadap masalah tertentu.

 

Kelemahan POMR:

o Perlu penyesuaian yang lama jika baru pertama kali menerapkan sistem tersebut.

o Perlu pelatihan intensif dan komitmen dari seluruh staf untuk melaksanakan POMR secara terpadu.

o Kekurangtelitian merugikan pelayanan.

 

references:

http://en.wikipedia.org/wiki/medical_record

http://www.bmj.com/cgi/reprint/322/7281/275

http://www.yoyoke.web.ugm.ac.id

K. Huffman, Edna.1994.Health Information Management.

http://www.medical-record.blogspot.com/

Draft Pro forma

For Development of Your Health Service’s Own Policy

(Insert Health Service Name Here)

Health Information and Medical Records

The ........HS has obligations under the Commonwealth Privacy Act - Privacy Amendment (Private Sector) Act 2000 to maintain the privacy of personal health information. This includes medical records which may be paper and/or electronic files and includes correspondence, faxes and email that contain medical information.

http://www.medical-record.blogspot.com/

All staff are responsible for protecting medical records against unauthorised access where those records are stored or transmitted.

All staff are responsible for the creation of and maintaining accurate, legible and reliable records and protecting them against loss.

All staff are responsible for ensuring pathology test results and any other papers containing personal health information are not left where they may be accessed by unauthorised persons.

All staff are responsible for ensuring the safe and secure storage of medical records.

Medical records are the property of ......HS.

Clients have a right to access their medical records.

Content

• Every client has an individual client health record containing all clinical information relating to him/her.
• Every client health record includes a health summary.
• Client information such as address, contact person in an emergency, health summary is updated regularly so the record remains current and accurate.
• Allergy (known/no known) status is recorded. Alerts are recorded.
• Client information is recorded in a way that allows other staff to read, understand and continue client care.
• Information is entered into the health record at the time of each consultation (including after hours, home visits, telephone calls) or as soon as possible after.

Access

• Access to patient medical records is available to ......HS clinic workers only.
• Paper files are not left exposed on the reception desk, in waiting room or other public areas.
• Medical information is filed and/or scanned as soon as possible.
• Paper records are returned to filing cabinet/compactus/other as soon as possible.
• Computers are positioned to prevent unauthorised viewing of patient information. Screen savers are in use.
• Electronic records are only accessed by clinical staff via secure login/password.
• Electronic records are closed when not in use.
• Clinics are locked after hours.

Procedure – Paper Files

• Use tracer card when removing a medical record from the filing location.
• Return the records to the filing system as soon as possible after use.

 

Procedure – Electronic/Computer Files

• Record closed after use.
• Regular backups undertaken.

 

Filing

• All medical records must be filed for easy retrieval, ongoing use and maintenance.
• ·All staff are responsible for filing and for the safe storage of medical records.
• .......HS currently uses the numerical/alphabetical/other ...... system for filing paper medical records.
• .........HS patients have the following file numbers
• Paper file
• Electronic record
• Hospital registration number (HRN)

Medical Information

• Information such as results (pathology, x-ray etc), correspondence or specialist reports are dated and checked prior to being filed within the appropriate medical record as soon as possible. It is important to ensure confidentiality of material waiting to be filed is maintained.
• Medical correspondence is scanned/ kept in patient paper file. Once scanned the original copy is shredded.
• Electronic results are checked and appropriate action marked.

Errors

• Errors in a paper file are corrected by crossing a single line through the entry. This is then initialled, dated with a brief explanation written beside or below.
• Errors in an electronic record are noted, recorded and dated by referring to the wrong information.
• A client may have their personal information amended if they can prove the information is untrue.

Storage

• Clinics are locked after hours.
• Backups are performed ........................
• Backups are kept in a secure place.
• An IT Information Disaster Plan policy is in place.
• Paper records are kept in vermin-proof storage when not in use.

 

Transfer of information

• Transfer of information to and from another provider is only by patient consent.
• Information includes name and address of client, date of birth, medicare number, name and address of provider.
• Information may only be sent via email if it is securely encrypted.

Faxes must have confidential written on cover sheet. Always check number before being sent.

• Mail requiring to be posted must be left in a secure area out of public view and access.

Removal

Paper/electronic records are not removed from the clinics except in the following circumstances:

i. Attending to a patient outside the clinic if a clinic consultation is not possible.

ii. Outstation visits.

iii. Subpoenaed medical records or other valid written warrant requesting the medical record.

Retention of Records

Recommendation 21 of the “Bringing them home. Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families”, This Recommendation 21 has been adopted by the Federal Government to assist in researching Stolen Generation family links.

“That no records relating to Indigenous individuals, families or communities or to any children, Indigenous or otherwise, removed from their families for any reason, whether held by government or non-government agencies, be destroyed.”

Archiving

• Where clients have not been seen for between 7 to 15 years, client files can be archived and stored off-site in a secured location.
• All clients who are 28 years of age or younger, regardless of the last time they presented for a consultation.
• Records are culled annually.
• Records of deceased patients are marked, “DECEASED” on the record and filed in a separate/inactive section of the storage area.
• Records of Drugs of Addiction stock and administration are retained for a minimum of 3 years.

Disposal

Medical information that has been scanned into a patient file is shredded in the clinic.

RACGP 3^rd Edition 1.7; 4.2

ISO: Australian Standard for Records Management (AS ISO 15489).

Associated P&P: Confidentiality; Client Access to Personal File; 3^rd Party Access to Clinical File; Computer Policy

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Medical Record Coronary Abstracting Instructions

Indicator: Comprehensive Coronary Artery Disease

               (Clinical Indicator)

Reporting for Year: 1999

 

Description:	The percentage of members between 18 and 75 years of age as of 12/31 of the reporting year who were continuously enrolled during the reporting year, have a diagnosis of coronary artery disease and who are up-to-date for all appropriate services. Also reported is the percentage of components up-to-date.
Required sample size:	Sample size of 60 records per medical group
Data elements provided for medical record abstraction tool:	· Member’s medical group · Member’s clinic location as of 12/31 of reporting year · Member’s current clinic location · Member name · Member’s date of birth (DOB) · Member identification number (DEC#, TD#) · Date of last LDL level test · Pharmacy (Rx) benefit · Measurement set · Sort by medical group, clinic, alpha sort by patient name
Record exclusions:	· Member does not have CAD (Column K, 1=yes) · Member was a nursing home resident, hospice resident or died but was not disenrolled during 1999, (Column L, 1=yes)
Data to be collected:	(A) Smoker/advice to quit (A1); smoker/no advice to quit (A2) (1=yes, 0=no) (B) Nonsmoker (1=yes, 0=no) (C) Unknown tobacco user (1=yes, 0=no) (D) LDL Date (may be prepopulated) (E) LDL level (record actual LDL value) (F) Lipid Rx (1=yes, 0=no, N/A) (G) ASA Use (1=yes, 0=no, N/A=contraindicated) (H) Blood Pressure (H1) systolic; (H2) diastolic (I) Exercise assessment (1=yes, 0=no) (J) Nutrition assessment (1=yes, 0=no) (K) Record indicates the number did not have CAD (1=yes) (L) Nursing home resident, hospice resident or member died in 1999 (1=yes) (M) Record exists; not available for review (1=yes) (N) Record does not exist (1=yes)
Location of data in medical record:	· Medical history/problem list · Preventive summary/risk assessment tools · Provider progress notes · Laboratory data · Smoker/advice to quit/no advice to quit: Most recent visit progress note (up to 12/31/99) · Non-smoker: Label, general form, most recent visit progress note
Data required to generate a positive result:	A. Smoker: advice to quit (A1) Most recent visit progress note of ’99. Information at the most recent visit progress note that shows that a user was asked about use at that visit. The visit must be a face-to-face encounter with a health care provider. A provider is defined as an MD, DO, NP, CNM, or PA. Tobacco use includes cigarettes, cigars, pipes or “chew.” If the patient is a child or adolescent (<13), a similar identification should be used to show that the child is not exposed to smoke from a parent, guardian or child care provider (i.e., if the child is breathing the smoke of others regularly, s/he is a smoker). If a special tobacco flowsheet is used, a notation consistent with the date of the last progress notes is adequate. Documentation in the progress note or tobacco flowsheet from the latest visit with a clinician of either advice to quit, or information about the user’s current interest or readiness to quit must exist. “Smoking discussed” is adequate. Smoker/no advice to quit (A2): Most recent visit progress note of ’99. Information at the most recent progress note that shows a user was asked about use at that visit. The visit must be a face-to-face encounter with a health care provider. A provider is defined as an MD, DO, NP, CNM, or PA. Tobacco includes cigarettes, cigars, pipes or “chew.” If the patient is a child or adolescent (<13), a similar identification should be used to show that the child is not exposed to smoke from a parent, guardian, or child care provider (i.e., if the child is breathing the smoke of others regularly, s/he is a smoker). If a special tobacco flowsheet is used, a notation consistent with the date of the last progress notes is adequate. If neither advice to quit nor an expression of the user’s interest in quitting is documented, consider no advice given. B. Non-Smoker: A label or mark anywhere on the chart, or on general forms like a problem list, or on the most recent visit progress note that shows the patient has been asked at least once and reported not using tobacco. If the patient is a child/adolescent (<13), similar documentation should be used to show that the child is not exposed to smoke from a parent, guardian or childcare provider. C. Unknown with Medical Record: No label or mark on the chart, or a known user with no documentation at the most recent visit as to the current use status. The visit must be a face-to-face encounter with a health care provider. If a discrepancy exists in the chart (e.g., non-smoking sticker on chart and also a note indicating the patient is a smoker) with no documentation at the most recent visit as to the current use status, status should be considered unknown. D. LDL drawn in reporting year: · LDL must be drawn during a 12-month reporting period ending December 31, 1999.

Data required to generate a positive result (cont):

· Field will be prepopulated with date of last test from claims, etc. files. If no date is entered, check for LDL within reporting year and record date of most recent. · If you find a more recent LDL within 1999 than the date given, you may change the date and enter the level of most recent LDL in Column D. · If no LDL can be found in 1999, Column D = 0. E. LDL Level · If multiple LDLs have been drawn over the reporting period, record level of most recent test. · If no LDL level from the reporting period can be found in the medical record, enter “0” in Column E. · If lab result = ULDL indicating triglycerides are too high to calculate a LDL level, enter a LDL level of 300 in Column E. · If no LDL level, the following test values can be recorded on the back of your worksheet to allow us to calculate the LDL level. (We can only calculate the LDL if triglycerides <400): Total cholesterol value, HDL value, Triglycerides value. If lipoprotein is also measured, record this value also. We don’t need this value to calculate the LDL; however, if it is given this value will be used to modify our calculation. F. Lipid Rx · Evidence in the medical record that member is using a lipid-lowering drug (drug list attached) at any time during the reporting year. G.ASA Use · Evidence in the medical record that member is currently on ASA therapy. Any reference in 1999 for ASA use will be sufficient as long as there is no subsequent evidence in 1999 the member was advised to discontinue ASA. · List of contraindications for ASA use attached. H.Blood Pressure · Blood pressure at the most recent visit of the reporting year. Record systolic in (H1), and record diastolic in (H2). Guidelines for multiple blood pressure readings from a single visit: · Multiple BPs in different positions–Use sitting BP measurement; if no sitting BP then use supine BP; if no supine then use standing BP. · Multiple BPs in a given position–Count the lowest BP; the position hierarchy above would still apply. · Multiple BPs without an indication of position–Use the lowest BP. I. Exercise assessment · Exercise assessment documented within reporting year. Example: Risk assessment tool, phone consultation, progress note. J. Nutrition assessment · Nutrition assessment documented within reporting year. Example: Risk assessment tool, phone consultation, progress note. K. Documentation in the medical record must indicate the patient has CAD (see attached list for operational definition of coronary artery disease). If no CAD, enter 1 in Column K.

Data elements required:	· Member’s medical group · Member’s clinic location as of 12/31 of reporting year · Member’s current clinic location · Member’s name · Member’s date of birth (DOB) · Member identification number · Date of last LDL level test · Pharmacy (Rx) benefit · Measurement set
	(O) Smoker/advice to quit (A1); smoker/no advice to quit (A2) (1=yes, 0=no) (P) Nonsmoker (1=yes, 0=no) (Q) Unknown tobacco user (1=yes, 0=no) (R) LDL Date (may be prepopulated) (S) LDL level (record actual LDL value) (T) Lipid Rx (1=yes, 0=no, N/A) (U) ASA Use (1=yes, 0=no, N/A=contraindicated) (V) Blood Pressure (H1) systolic; (H2) diastolic (W) Exercise assessment (1=yes, 0=no) (X) Nutrition assessment (1=yes, 0=no) (Y) Record indicates the number did not have CAD (1=yes) (Z) Nursing home resident, hospice resident or member died in 1999 (1=yes) (AA) Record exists; not available for review (1=yes) (BB) Record does not exist (1=yes)

The CPT-4 codes that include LDL are:

80061 Lipid panel

83715 Lipoprotein segmentation

83716 High resolution fractionation and quantitation of lipoprotein cholesterols

83717 Lipoprotein centrifuge (deleted CPT code in 1999-will include this year)

83721 LDL

Operational Definition of CAD:

The following ICD-9 diagnosis codes are used for identification of CAD:

410.XX AMI

411.XX Post Myocardial Infarction Syndrome

412 Old AMI

413.XX Angina Pectoris (except 413.1 Printzmetal angina)

414.0X Coronary Artherosclerosis

414.10 Aneurysm of Heart Wall

414.8 Other Chronic Ischemic Heart Disease

414.9 Chronic IHD

 

CMS Report 10 - A-00

(June 2000)

 

Subject:	Electronic Medical Records Systems
Presented by:	Eugene Ogrod, MD, Chair

http://medical-record.blogspot.com/

 

At the 1998 Annual Meeting, the House of Delegates adopted the following recommendation in Council on Medical Service Report 1:

That the AMA define the critical elements that an electronic medical record (EMR) system should have the capacity to record, although some of these elements may not be used by all parties and/or may require refinement for effective use.

The following report, which is presented for the information of the House, summarizes electronic medical record trends; addresses issues such as health data element standards and data sets; outlines and discusses some of the characteristics and features of key inter-related core components of ambulatory EMRs; reviews the results of the AMA’s core clinical data elements survey; discusses some of the barriers or obstacles to implementation of EMRs; and presents current information related to security and interoperability.

 

ELECTRONIC MEDICAL RECORD TRENDS

When describing an electronic medical or patient records system, different associations, vendors, and institutions use varying terminology and definitions. Some organizations make a clear delineation between the definitions, whereas others use terminology interchangeably.

According to the Medical Records Institute (MRI), the EMR is an upgraded version of the computerized medical record that has essentially the same structure, scope, and information as the paper-based record. However, the information is rearranged for computer use. In addition, the MRI believes such a system should be capable of appropriately capturing, processing, and storing information and be interoperable with other related systems such as billing and administration.

Furthermore, the MRI believes that the electronic medical record is a concept that has a number of criteria, such as being paperless, complying with documentation rules (e.g., data integrity, authenticity, availability, and auditability, etc.) as well as being platform and institution-independent. Systems may comply with some or all of these concept requirements.

A survey of electronic health record trends and usage was recently conducted by the MRI that reveals a number of the following insights into the motivations driving the need for EMRs, the major barriers, and associated security concerns:

Major management/administrative factors driving the need for EMRs include the need to share comparable patient data among different sites within a multi-entity health care delivery system as well as the need to establish a more efficient and effective information infrastructure as a competitive advantage.

Major clinical factors driving the need for EMRs include improving the ability to share patient record information among providers as well as improving the quality of care.

Major barriers to implementation include lack of adequate funding or resources and inadequate or incomplete health care information standards, data sets, or code sets.

Major concerns regarding the security of patient record information include access to patient record information by unauthorized users as well as inappropriate access to patient record information by authorized users inside the organization.

Complete results of the survey are available at www.medrecinst.com.

DATA ELEMENT STANDARDS AND DATA SETS

There are few established health data element standards for electronic medical records are few. Two known core data sets, each published in 1996, are the National Committee for Vital and Health Statistics (NCVHS) Core Health Data Elements and the American Society for Testing and

Materials (ASTM) Minimum Essential Data Set. The core health data set proposed by NCVHS for standardization consists of 42 elements. Twenty-six of the 42 elements are identified

as being “ready for implementation,” whereas “substantial agreement has been reached, but some additional work is needed” on 10 of the elements. The remaining six are “recognized as significant, but considerable work remains to be undertaken.” The data set, included as part of a complete report on core health data elements, can be downloaded directly from the NCVHS Web site at: http:// www.ncvhs.hhs.gov/ncvhsr1.htm.

The ASTM data set is part of the ASTM American National Standard E 1384-96: Standard Guide for Content and Structure of the Computer-Based Patient Record (recently revised to E 1384-99 Standard Guide for Content and Structure of the Electronic Health Record) and consists of 116 data elements divided into the following entities:

Patient

Encounter

Problem

Order-Care/Treatment Plan

Provider

Observation-History

Observation-Assessment/Exams

Observations-Diagnostic Tests

Observation-Encounter/Episode Detail

Service Instance

Information regarding ASTM standards can be found on its Web site: http://www.astm.org. The number of computer software vendors that have incorporated either the ASTM standard or NCVHS data set remains unknown. In addition, the overall lack of a solution for standards for data recording and transmission, and the assurance of security, privacy, and confidentiality in record storage and transmission, have prohibited professional organizations from endorsing or truly supporting either of these data sets.

 

KEY COMPONENTS OF ELECTRONIC MEDICAL RECORD SYSTEMS

Although the availability of the full range of core clinical data elements is perhaps the area of most concern to practicing physicians as they evaluate potential EMR systems, ambulatory electronic medical record systems are comprised of a set of several inter-related key components. These components together form the technical and clinical requirements of an optimal paperless patient record and the evaluation of an EMR system for an ambulatory setting demands attention to each component. Review of the literature identified a total of seven key component categories of ambulatory electronic medical record systems as necessary for evaluation:

Data entry:

Provides flexible data entry options

Supports a choice of data entry devices

Provides modifiable templates to facilitate direct data entry at the point of care

Provides pick lists for common responses

Provides data merging from templates to progress notes

Provides drawing tools for genograms

Provides drawing tools with templates to document the presence of lesions, injuries, etc.

Supports a wide range of coding options

Provides mechanism for entry and validation of electronic signatures

Allows direct data entry by physicians, nurses and other providers

Allows entry of transcribed provider notes

Allows multiple providers to view and write to the same chart simultaneously

Data display:

Provides practical data presentation formats

Allows automatic text generation

Provides custom views of results

Communications/connectivity:

Standards compliant

Bi-directional interfaces

Ability to transmit documents via facsimile

Ability to transmit documents via email

Internet capabilities

Integrated Web browser

Technical features:

Database type

Structured data content/data elements

Data warehouse capabilities

Data access-decision support software

Network

Operating system

Performance

System security and privacy of data/data integrity

Workflow and record management:

Facilitates patient record management

Supports patient scheduling

Records patient information and demographics

Clinical documentation and decision support functions

Summary screen

Problem lists

Clinical decision support tools

Medications/prescriptions support

Imaging

Labs

Reminders and alerts

Consultations

Health care maintenance-preventive care

Order entry capabilities

Letters and forms

Health status and functional level measurement

Patient educational resources

Quality management and reporting capability

Managed care/insurance support

Core clinical data elements:

Patient Identification and Demographic Data

Special Patient Health Conditions

Allergies

Immunizations

Health Promotion/Disease Prevention

Past Medical History

Family and Social History

Encounter/Visit Administrative Information

Encounter/Visit Clinical Information

Laboratory Tests Orders and Results

Other Diagnostic Procedures Orders and Results

Therapeutic Services and Procedures Orders and Results

Medications Prescribed and Results

Consultations and Referrals

Correspondence/Release of Information

 

AMA CORE CLINICAL DATA ELEMENTS SURVEY

The Council believes that of the key EMR components described in the previous section, the category of most concern to practicing physicians is core clinical data elements. In addition, this is the area where practice management software vendors continue to fall short in development of their products. Therefore, on behalf of the AMA, Medical Systems Development, a firm specializing in market analyses of electronic medical records and practice management systems, developed a report identifying a comprehensive list of core clinical data elements that an electronic medical record system should have the capacity to record. These data elements were derived from a large number of diverse resources including uniform data sets, accrediting and licensing agency requirements, industry standards, selected EMR literature, and EMR vendor system specifications.

The AMA then developed a survey tool based on the market analysis to gather the opinions of 29 external advisors with expertise in paper-based medical record systems, computer applications in clinical care, and experience developing electronic medical record systems in academia and the government. The list of core clinical data elements included in the survey was not intended to represent a minimum data set. In addition, the survey tool indicated that the data for each listed data element did not have to be recorded for every patient. However, the 500-plus elements included on the survey were intended to represent a comprehensive listing of data elements that should be available in an optimal EMR system. Therefore, the advisors were asked to review the data elements and assess the appropriateness of each data element for inclusion in a final list of recommended core clinical data elements for an ambulatory EMR system.

General feedback from the survey revealed that all the presently listed core clinical data elements, along with a few suggestions from the advisors, should be further analyzed by a standards group to determine their functionality (required or conditional). The survey tool, including comments to the overall survey, is available on the AMA Web site at http://www.ama-assn.org. The Council believes that the results of this survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, two standards development organizations, ASTM and Health Level Seven (HL7), have already expressed interest in the outcome of this survey

BARRIERS TO EMR IMPLEMENTATION

One of the biggest barriers in health care information technology remains the lack of standards. A standard is a clearly defined and agreed-upon convention for the operation and behavior of specific computing functions, formats, and processes. Standards are deficient for an EMR in a number of areas, including but not limited to medical vocabulary, common identifiers, data exchange, and privacy and confidentiality. In addition, standards are lacking in the categories of system interfaces and interoperability. This latter deficiency is especially troublesome because the underlying technology and infrastructure of an EMR must incorporate the ability to communicate between one system and another.

Many organizations are addressing standards and issues related to the EMR. However, no organization is focusing on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting. Since there is no agreed upon standardized EMR system for ambulatory care, the vendor community is creating a variety of EMR systems that are often incompatible. This situation leaves little guidance for physicians in selecting an EMR.

As stated previously, the Council believes that the results of the AMA core clinical data elements survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, and both ASTM and HL7 have expressed interest in the survey outcome, the results will be shared with the standards developing organizations.

SECURITY AND INTEROPERABILITY

In CMS Report 7 (I-98), the Council recommended that the AMA work to establish consensus on industry security guidelines for electronic storage and transmission of medical records as an important means of protecting patient privacy. The AMA is currently working with Intelâ Corporation on a system to provide digital certificates to physicians for use on the Internet. It will protect physician and patient privacy and confidentiality when they use the Internet to send and receive medical information. The AMA will begin issuing digital certificates to physicians by the third quarter of 2000. The digital certificates will uniquely identify individuals over the Internet, providing a more reliable authentication technique than do passwords for secure Internet transactions. Digital certificates function in the online world in the same way driver licenses, passports, and other trusted documents function in the paper world.

The AMA and Intel believe that the potential for physicians to use the Internet as a tool to obtain data such as lab results, or to send prescriptions to pharmacies, in addition to storing and retrieving patient files, makes it vitally important that systems are in place to ensure that the patient’s privacy and confidentiality are protected. Furthermore, by authenticating the identity of the physician, this system will allow for a wide and growing variety of routine medical transactions to occur online. Ultimately, this development will enable better patient care and lessen the administrative burden on busy physicians and their staffs.

Additional information regarding the AMA and Intel Digital Credential Management System to identify physicians on the Internet can be found in Board of Trustees’ Report, “Health Data and Modern Medical Professionalism” (A-00).

CONCLUSION

It is clear that physicians and their patients can derive important benefits from broader use of EMR systems that adequately address the dimensions that are identified in this report. At the same time, the Council recognizes that there are important issues related to potential impact on physician time, cost, patient care, and confidentiality. In addition, the Council realizes that current EMR systems are not fully supporting physician needs.

Based on the current marketplace and obstacles, the Council believes that it is premature for the AMA to suggest a specific standardized EMR system for use in the ambulatory setting. The Council also believes that, based on substantial input from practicing physicians, accelerated progress in the EMR area is imperative. This progress should address the need for greater standardization and the specific EMR dimensions identified previously in this report.

Furthermore, the Council believes that the component of the EMR that is of most concern to practicing physicians is in the area of core clinical data elements. Moreover, this is the area where practice management software vendors continue to fall short in development of their products. However, as stated previously, standards work presently does not exist in this area. Therefore, the Council believes that results of the survey tool including the comprehensive list of core clinical data elements should be shared with the appropriate standards development organization(s), since the true functionality of each element could be better determined within the standards community. AMA participation in this project is crucial in order to make the computer a useful tool for creating a more efficient work environment for the physician. Without the AMA efforts, standards will be modified to medicine rather than developed specifically for the profession.

http://medical-record.blogspot.com/

 

CMS Report 10 - A-00

(June 2000)

 

Subject:	Electronic Medical Records Systems
Presented by:	Eugene Ogrod, MD, Chair

http://medical-record.blogspot.com/

 

At the 1998 Annual Meeting, the House of Delegates adopted the following recommendation in Council on Medical Service Report 1:

That the AMA define the critical elements that an electronic medical record (EMR) system should have the capacity to record, although some of these elements may not be used by all parties and/or may require refinement for effective use.

The following report, which is presented for the information of the House, summarizes electronic medical record trends; addresses issues such as health data element standards and data sets; outlines and discusses some of the characteristics and features of key inter-related core components of ambulatory EMRs; reviews the results of the AMA’s core clinical data elements survey; discusses some of the barriers or obstacles to implementation of EMRs; and presents current information related to security and interoperability.

 

ELECTRONIC MEDICAL RECORD TRENDS

When describing an electronic medical or patient records system, different associations, vendors, and institutions use varying terminology and definitions. Some organizations make a clear delineation between the definitions, whereas others use terminology interchangeably.

According to the Medical Records Institute (MRI), the EMR is an upgraded version of the computerized medical record that has essentially the same structure, scope, and information as the paper-based record. However, the information is rearranged for computer use. In addition, the MRI believes such a system should be capable of appropriately capturing, processing, and storing information and be interoperable with other related systems such as billing and administration.

Furthermore, the MRI believes that the electronic medical record is a concept that has a number of criteria, such as being paperless, complying with documentation rules (e.g., data integrity, authenticity, availability, and auditability, etc.) as well as being platform and institution-independent. Systems may comply with some or all of these concept requirements.

A survey of electronic health record trends and usage was recently conducted by the MRI that reveals a number of the following insights into the motivations driving the need for EMRs, the major barriers, and associated security concerns:

Major management/administrative factors driving the need for EMRs include the need to share comparable patient data among different sites within a multi-entity health care delivery system as well as the need to establish a more efficient and effective information infrastructure as a competitive advantage.

Major clinical factors driving the need for EMRs include improving the ability to share patient record information among providers as well as improving the quality of care.

Major barriers to implementation include lack of adequate funding or resources and inadequate or incomplete health care information standards, data sets, or code sets.

Major concerns regarding the security of patient record information include access to patient record information by unauthorized users as well as inappropriate access to patient record information by authorized users inside the organization.

Complete results of the survey are available at www.medrecinst.com.

DATA ELEMENT STANDARDS AND DATA SETS

There are few established health data element standards for electronic medical records are few. Two known core data sets, each published in 1996, are the National Committee for Vital and Health Statistics (NCVHS) Core Health Data Elements and the American Society for Testing and

Materials (ASTM) Minimum Essential Data Set. The core health data set proposed by NCVHS for standardization consists of 42 elements. Twenty-six of the 42 elements are identified

as being “ready for implementation,” whereas “substantial agreement has been reached, but some additional work is needed” on 10 of the elements. The remaining six are “recognized as significant, but considerable work remains to be undertaken.” The data set, included as part of a complete report on core health data elements, can be downloaded directly from the NCVHS Web site at: http:// www.ncvhs.hhs.gov/ncvhsr1.htm.

The ASTM data set is part of the ASTM American National Standard E 1384-96: Standard Guide for Content and Structure of the Computer-Based Patient Record (recently revised to E 1384-99 Standard Guide for Content and Structure of the Electronic Health Record) and consists of 116 data elements divided into the following entities:

Patient

Encounter

Problem

Order-Care/Treatment Plan

Provider

Observation-History

Observation-Assessment/Exams

Observations-Diagnostic Tests

Observation-Encounter/Episode Detail

Service Instance

Information regarding ASTM standards can be found on its Web site: http://www.astm.org. The number of computer software vendors that have incorporated either the ASTM standard or NCVHS data set remains unknown. In addition, the overall lack of a solution for standards for data recording and transmission, and the assurance of security, privacy, and confidentiality in record storage and transmission, have prohibited professional organizations from endorsing or truly supporting either of these data sets.

 

KEY COMPONENTS OF ELECTRONIC MEDICAL RECORD SYSTEMS

Although the availability of the full range of core clinical data elements is perhaps the area of most concern to practicing physicians as they evaluate potential EMR systems, ambulatory electronic medical record systems are comprised of a set of several inter-related key components. These components together form the technical and clinical requirements of an optimal paperless patient record and the evaluation of an EMR system for an ambulatory setting demands attention to each component. Review of the literature identified a total of seven key component categories of ambulatory electronic medical record systems as necessary for evaluation:

Data entry:

Provides flexible data entry options

Supports a choice of data entry devices

Provides modifiable templates to facilitate direct data entry at the point of care

Provides pick lists for common responses

Provides data merging from templates to progress notes

Provides drawing tools for genograms

Provides drawing tools with templates to document the presence of lesions, injuries, etc.

Supports a wide range of coding options

Provides mechanism for entry and validation of electronic signatures

Allows direct data entry by physicians, nurses and other providers

Allows entry of transcribed provider notes

Allows multiple providers to view and write to the same chart simultaneously

Data display:

Provides practical data presentation formats

Allows automatic text generation

Provides custom views of results

Communications/connectivity:

Standards compliant

Bi-directional interfaces

Ability to transmit documents via facsimile

Ability to transmit documents via email

Internet capabilities

Integrated Web browser

Technical features:

Database type

Structured data content/data elements

Data warehouse capabilities

Data access-decision support software

Network

Operating system

Performance

System security and privacy of data/data integrity

Workflow and record management:

Facilitates patient record management

Supports patient scheduling

Records patient information and demographics

Clinical documentation and decision support functions

Summary screen

Problem lists

Clinical decision support tools

Medications/prescriptions support

Imaging

Labs

Reminders and alerts

Consultations

Health care maintenance-preventive care

Order entry capabilities

Letters and forms

Health status and functional level measurement

Patient educational resources

Quality management and reporting capability

Managed care/insurance support

Core clinical data elements:

Patient Identification and Demographic Data

Special Patient Health Conditions

Allergies

Immunizations

Health Promotion/Disease Prevention

Past Medical History

Family and Social History

Encounter/Visit Administrative Information

Encounter/Visit Clinical Information

Laboratory Tests Orders and Results

Other Diagnostic Procedures Orders and Results

Therapeutic Services and Procedures Orders and Results

Medications Prescribed and Results

Consultations and Referrals

Correspondence/Release of Information

 

AMA CORE CLINICAL DATA ELEMENTS SURVEY

The Council believes that of the key EMR components described in the previous section, the category of most concern to practicing physicians is core clinical data elements. In addition, this is the area where practice management software vendors continue to fall short in development of their products. Therefore, on behalf of the AMA, Medical Systems Development, a firm specializing in market analyses of electronic medical records and practice management systems, developed a report identifying a comprehensive list of core clinical data elements that an electronic medical record system should have the capacity to record. These data elements were derived from a large number of diverse resources including uniform data sets, accrediting and licensing agency requirements, industry standards, selected EMR literature, and EMR vendor system specifications.

The AMA then developed a survey tool based on the market analysis to gather the opinions of 29 external advisors with expertise in paper-based medical record systems, computer applications in clinical care, and experience developing electronic medical record systems in academia and the government. The list of core clinical data elements included in the survey was not intended to represent a minimum data set. In addition, the survey tool indicated that the data for each listed data element did not have to be recorded for every patient. However, the 500-plus elements included on the survey were intended to represent a comprehensive listing of data elements that should be available in an optimal EMR system. Therefore, the advisors were asked to review the data elements and assess the appropriateness of each data element for inclusion in a final list of recommended core clinical data elements for an ambulatory EMR system.

General feedback from the survey revealed that all the presently listed core clinical data elements, along with a few suggestions from the advisors, should be further analyzed by a standards group to determine their functionality (required or conditional). The survey tool, including comments to the overall survey, is available on the AMA Web site at http://www.ama-assn.org. The Council believes that the results of this survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, two standards development organizations, ASTM and Health Level Seven (HL7), have already expressed interest in the outcome of this survey

BARRIERS TO EMR IMPLEMENTATION

One of the biggest barriers in health care information technology remains the lack of standards. A standard is a clearly defined and agreed-upon convention for the operation and behavior of specific computing functions, formats, and processes. Standards are deficient for an EMR in a number of areas, including but not limited to medical vocabulary, common identifiers, data exchange, and privacy and confidentiality. In addition, standards are lacking in the categories of system interfaces and interoperability. This latter deficiency is especially troublesome because the underlying technology and infrastructure of an EMR must incorporate the ability to communicate between one system and another.

Many organizations are addressing standards and issues related to the EMR. However, no organization is focusing on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting. Since there is no agreed upon standardized EMR system for ambulatory care, the vendor community is creating a variety of EMR systems that are often incompatible. This situation leaves little guidance for physicians in selecting an EMR.

As stated previously, the Council believes that the results of the AMA core clinical data elements survey could provide standards development organizations, as well as electronic medical record system software vendors, with a coveted and viable source of information they can use in the development of future standards and products. Since specific standards work does not exist in this area, and both ASTM and HL7 have expressed interest in the survey outcome, the results will be shared with the standards developing organizations.

SECURITY AND INTEROPERABILITY

In CMS Report 7 (I-98), the Council recommended that the AMA work to establish consensus on industry security guidelines for electronic storage and transmission of medical records as an important means of protecting patient privacy. The AMA is currently working with Intelâ Corporation on a system to provide digital certificates to physicians for use on the Internet. It will protect physician and patient privacy and confidentiality when they use the Internet to send and receive medical information. The AMA will begin issuing digital certificates to physicians by the third quarter of 2000. The digital certificates will uniquely identify individuals over the Internet, providing a more reliable authentication technique than do passwords for secure Internet transactions. Digital certificates function in the online world in the same way driver licenses, passports, and other trusted documents function in the paper world.

The AMA and Intel believe that the potential for physicians to use the Internet as a tool to obtain data such as lab results, or to send prescriptions to pharmacies, in addition to storing and retrieving patient files, makes it vitally important that systems are in place to ensure that the patient’s privacy and confidentiality are protected. Furthermore, by authenticating the identity of the physician, this system will allow for a wide and growing variety of routine medical transactions to occur online. Ultimately, this development will enable better patient care and lessen the administrative burden on busy physicians and their staffs.

Additional information regarding the AMA and Intel Digital Credential Management System to identify physicians on the Internet can be found in Board of Trustees’ Report, “Health Data and Modern Medical Professionalism” (A-00).

CONCLUSION

It is clear that physicians and their patients can derive important benefits from broader use of EMR systems that adequately address the dimensions that are identified in this report. At the same time, the Council recognizes that there are important issues related to potential impact on physician time, cost, patient care, and confidentiality. In addition, the Council realizes that current EMR systems are not fully supporting physician needs.

Based on the current marketplace and obstacles, the Council believes that it is premature for the AMA to suggest a specific standardized EMR system for use in the ambulatory setting. The Council also believes that, based on substantial input from practicing physicians, accelerated progress in the EMR area is imperative. This progress should address the need for greater standardization and the specific EMR dimensions identified previously in this report.

Furthermore, the Council believes that the component of the EMR that is of most concern to practicing physicians is in the area of core clinical data elements. Moreover, this is the area where practice management software vendors continue to fall short in development of their products. However, as stated previously, standards work presently does not exist in this area. Therefore, the Council believes that results of the survey tool including the comprehensive list of core clinical data elements should be shared with the appropriate standards development organization(s), since the true functionality of each element could be better determined within the standards community. AMA participation in this project is crucial in order to make the computer a useful tool for creating a more efficient work environment for the physician. Without the AMA efforts, standards will be modified to medicine rather than developed specifically for the profession.

http://medical-record.blogspot.com/