Electronic
patient record
Records
A record is a group of separate related data fields/elements that
form a single unit information. A record may be of fixed length or
variable length, depending on the computer and the method and type
of storage media. A fixed-length record allows a fixed number of
spaces for a field or data element; a variable-length record takes only
the spaces it actually needs.
Fixed-length record Variable-length record
• Not flexible • Flexible
• Not efficient • Store data more efficiently
•Programs to process them • Difficult to prepare computer
are easier to be prepared programs using them
• Cost less • Cost more
Patient Record
The patient record is the major document that contains data
about the patient’s health care. It is used by all the providers
of health care services to record, store, and review information.
Patient Record System
A patient record system is the set of components that form the
mechanism by which patient records are created, used, stored
and retrieved.
The patient record may be a paper-based patient record
or an electronic patient record (computer-based).
The purpose of Healthcare Records (1)
The purpose of the Healthcare Record itself is faithfully to preserve the information recorded in it.
This implies that a Healthcare Record must support different purposes as:
Patient purposes
• make available information about the patient
• make available information to the patient
• protect the patient rights regarding their clinical and personal information
Professional purposes
• improve the capacities to reach a diagnosis, to state a prognosis and to prescribe an
adequate therapy
• provide a legal context for the collection of the data
• enable each care provider to authenticate their entry by signature
Ethical purposes
• serve the needs of the ethical context
• provide data which is sufficient for the purpose
The purpose of Healthcare Records (2)
Management purposes
• provide data for management at different levels of the care system
Statistics and Research purposes
• provide information about the disease episode
• provide a means for cumulative information about specific diseases and programmes
• aid in the optimisation of technologies for care
Training purposes
• provide data for training
Third party financial purposes
• meet the requirements of Insurance companies who are partly or completely paying for
care
• meet the requirements of Communes and Government organisations paying for care
• meet the requirements for audit of the care system at any level
CEN/TC251/PT011/N300/V.1.00
The Uses of the Healthcare Record
The information in the HR may be used for a variety of purposes:
Patient purposes
• For the diagnosis, prognosis, treatment and follow-up of the patient
• For planning and defining the care for the patient
• To ensure continuity of disease prevention and diagnosis, prognosis, and treatment
Professional purposes
• As a diary for the providers of care
• For protection of professionals
• For audit of the providing of care/quality control
• For efficient and effective providing of care
• For day to day management of the care system
Management purposes
• For providing the best quality of care
• As a basis for measuring resource use by the patient
• For billing when required
• For planning of the care system
Statistics and Research purposes
• For statistics/research at any level in the care system
Training purposes
• For trainining or updating clinical skills
Third-party financial purposes
• To meet the requirements of Insurance companies who are partly or completely paying for care
• To meet the requirements of Communes and Government organisations paying for care
• To meet the requirements for audit of the care system at any level
Paper-Based Patient Record (1)
Paper-based patient records differ from hospital to hospital,
and in some hospitals from patient unit to patient unit, as well
as varying for the different types of health care facilities
providing patient care. It is also difficult to process and access
information in paper-based patient records.
Paper-based Patient Records (2)
The pros:
1. Paper patient records are familiar to users who consequently
do not need to acquire new skills or behaviours to use them.
2. Paper records are portable and can be carried to the point of
care.
3. Once in hand, paper records do not experience downtime as
computer systems do.
4. Paper records allow flexibility (lack of standard vocabulary
and coding) in recording data and are able to record “soft”
(i.e. subjective) data easily.
5. Paper records can be browsed through and scanned (if they
are not too large). This feature allows users to organise data
in various ways and to look for patterns or trends that are not
explicitly stated.
Paper-based Patient Records (3)
The cons:
1. Problems with Patient Record content (missing, illegible,
excessive, redundant or inaccurate data)
2. Problems with format (data are fragmented within the record
and not sorted for relevance, usually are organised according
to the sources and chronology of data)
3. Problems with access, availability and retrieval
4. Problems with linkages and integration (discontinuity of care
among providers)
5. Problems with outpatient records (are great in number, scattered
among individual physisian offices and usually exhibit even
greater variance in quality)
Critical issues to be considered
1. The uses of and legitimate demands for patient data are growing. Part of this
growth can be attributed to increased concern about the content and value of
clinical therapies and a recent intense focus on health services research.
2. Powerful and affordable technologies to support computer-based patient records
are now available.
3. Increasingly, computers are being accepted as a tool for enchancing efficiency
in virtually all facets of everyday life.
4. Demographic such as an ageing population (which results in a growth in chronic
diseases) and the continued mobility of the population create greater pressures
for patient records that can manage large ammounts of information and are easily
transferable among health care providers.
5. Pressures for reform in health care are growing, and automation of patient records
crucial to achievement of such reform.
Electronic Patient Record
Automation provides a solution to many information gathering
and dissemination problems and can be used to more effectively
and efficiently provide data for outcomes research
Dick and Steen, 1991
The advantages of the electronic patient record are:
• More effective use of resources
• Improved access
• Reduces cost
• Enhances research
• Improves care
Electronic Patient Record Architecture
A health record shall be regarded as a logical data structure being
composed of the following contsructs:
• items
• items complexes
representing the content and the context of information in the
healthcare record
CEN/TC 251/PT 011/N 300
V.1.00
Data structures
• A structure of only one record item complex
• Tree structure (a data structure composed solely of original record
item complexes and a query record item complexes
• Directed acylic graph structure (the structural links of the View
record item complexes extend the pure tree structure into a directed
graph structure)
Record item
A record item is a construct that shall be used for the representation
of a healthcare record entry or a component of a healthcare record
entry where all such components are regarded as constituting
meaningful quantities of information when considered alone.
A record item shall be composed of a set of attributes that expresses
some characteristics of the item.
CEN/TC 251/PT 011/N 300
V.1.00
Record item attributes
1. The content attributes of record items capture the healthcare data themselves.
2. Each record item should have only one origin attribute specifying the original
record item complex regarded to be its original information context.
3. The unique record item instance identifier attribute.
4. The record item name.
5. Revised version attribute: Each record item may have attributes providing
references that link successive versions of an amended record item.
6. Each record item may have attributes establishing the status of the record item
(e.g. valid, modified, invalid.)
7. Subject of care identification: Each record item shall relate to the subject of
the record.
8. Date and time of recording.
9. Agent recording attribute (identifying the healthcare enterprise agent that
recorded the content)
10. Agent responsible for the record item content.
11. Signature.
12. Date and time of the signature.
13. A record item may have one or more comment attributes.
14. A record may have additional attributes (references).
Example of the Record item attributes
Let’s consider Jane Smith’s visit to City Health Centre December 12, 1993 for a fracture of femur:
City HC Jane Smith 561224-1234 #2 In this record, the diagnosis “Fracture of femur”
is an example of an entry that can be regarded as a
record item. In this case, “Fracture of femur”
931212 Diagnosis: Fracture of the femur
would constitute the content attribute of the
pH
record item.
Family history: Both parents died
from myocardial infarction
The content of the record item in this example
is not sufficient to correctly interpret it, it is
Patient history: Fell on slippery
necessary to know what the entry really is, whom
pavement in Oslo yesterday…
it concerns, who recorded it, when was recorded,
etc. All this is represented by the attributes of the
Status: Examination of the right leg
record item e.g.:
shows….etc.
• attributes covering reference to the place in the
record to which a record item is considered to
“belong” e.g. origin, instance identifier, revised
version, status.
• attributes to identify the content e.g. name
• attributes to describe the organisational context in
which the content was recorded.
Record item complex
Record item complexes are constructs that shall be used for the
representation of the structures of records.
The record itself must be regarded as a record item complex.
A defined set of records, e.g. the set of records belonging to an
electronic healthcare record system, may be regarded as a record
item complex.
A record item complex shall be composed of a set of attributes
that expresses some characteristics of the record item complex.
Record item complex attributes (1)
1. Record item complex type: A record item complex shall be of one of the following types:
Original, View, Query
2. Record item complex content: The content must be of the following type dependent on its
type: * An original record item complex shall contain zero or more record items and zero or
more record item complexes.
* A view record item complex shall contain one or more references.
* A query record item complex shall contain one or more criteria for the selection of
record items from the record.
3. Origin: Each complex shall have only one origin attribute specifying the original record
item complex. The original record item complex reffered by this attribute shall be regarded
as its parent node in the data structure.
4. Unique record item complex instance identifier: Each complex should be uniquely
distinguishable.
5. Record item complex name.
6. Revised version: Each complex may have attributes providing references that link successive
versions of an amended record item complex.
7. Status (e.g. valid, modified, invalid).
8. Presentation (may have one or more presentation attributes)
9. Data organisation: how the content of the complex is organised (e.g. sequentially,
alphabetical, chronological, increasing, decreasing).
Record item complex attributes (2)
10. Subject of care identification: Each record item complex shall relate to the subject of the
record.
11. Date and time of recording: Each record item complex shall have the date and time of
recording
12. It Healthcare enterprise Agent recording.
13. Healthcare enterprise Agent responsible for the record item complex content.
14. Signature (may have a signature of the agent responsible)
15. Date and time of the signature.
16. Comment (may have one or more comment attributes)
17. Additional attributes (these include additional attributes containing references to concepts
of conceptual models).
Original record View record
item complex item complex
City HC Jane Smith 561224-1234 #2 Jane Smith 561224-1234 Careplan #1
Medical Diagnosis Fracture of femur:
931212 Diagnosis: Fracture of the femur Nursing Difficulties managing activities of daily living
pH Problems Anxiety for her heart
Fear for how to manage home
Family history: Both parents died
from myocardial infarction Goals In three weeks Mrs Smith is able to take care
of daily activities
Patient history: Fell on slippery With professional help Mrs. Smith can recover
pavement in Oslo yesterday… whithout fear for her heart
Inter- Home health care nurse helps Mrs. Smith in the
Status: Examination of the right ventions first days 2 hours mornings and evenings using:
leg shows….etc. - Activity therapy
- Emotional support
- Rehabilitation exercises
- Self care assistance
- Training activities in daily living
Medical Record Fracture of femur Nursing Record
Content of a record item
The Healthcare record item complex
City HC Jane Smith 561224-1234 City HC Jane Smith 561224-1234 #2
#1
931201 Diagnosis: Heel spur syndrome 931212 Diagnosis: Fracture of the femur
ZP pH
Family history: Both parents died Family history: Both parents died
from myocardial infarction from myocardial infarction
Patient history: Experiensed pain Patient history: Fell on slippery
under heel when shovelling snow.. pavement in Oslo yesterday…
Status: Examination of ...etc Status: Examination of the right
leg shows….etc.
The set of items that, for some reason, is regarded as constituting a unit in a particular HR, is called a
Healthcare record item complex.
A Healthcare record described by the basic construct of the record architecture
Symbols:
Conceptual
models Coneptual models:
data model
terminology
coding sceme
Partial description Architecture terms:
of the architectural
aspects of the Attribute making
structure of one a Reference
(instance of a) HR
Healthcare
record item
Healthcare Original
record item
complex View
Query
(1)
The objectives of
a standard electronic healthcare record architecture
• To make possible the improvement of health care quality and the better use of resources
• To facilate the conformance of HRs to the ethico-legal practices and other policies applicable
• To facilitate safe understandable communication between different electronic healthcare record
systems and with other computer-based systems in the healthcare environment used for other
purposes
• To facilitate safe understandable communication between electronic healthcare record systems
and healthcare professionals
• To facilitate the changing of electronic healthcare record systems while keeping the data
• To promote competition between systems vendors and between health care providers
• To promote open systems, based on common components, data output, interfaces, structure and
data access
• To improve productivity of the Information Technology industry and quality of the software,
and enlarge the healthcare software market
• To facilitate the free movement of patients by improving the portability of the healthcare record
• To promote the use of common conceptual models, terminology and definitions.
Thus, the architecture must...
Thus, the architecture must (2)
• be compliant with other architectures within the healthcare framework
• promote healthcare records suitable for the clinical purposes in a closed or open clinical environment
for private or public systems of care
• facilitate inter-working among various healthcare enterprises for the benefit of the patient
• increase the security and safety of operations on the information in the record (both for the person in
question and for the healthcare professionals)
• satisfy the domain requirements of the healthcare professionals
• permit the representation of different kinds of content, including text, coded information, images,
graphics and sound
• enable the representation of context information
• enable the healthcare record to operate in theappropriate ethico-legal environment
• enable the operations on the record to be audited by the person in question, by the user of the record
or by a competent third party, if required
• enable each entry, decision, prescription or any other order to be appropriately signed by each legal
responsible person, if required
• facilitate the convergence of different terminology
• facilitate new functions of healthcare record systems, adapted to clinical circumstances, management
requirements, system needs, and advancing technology
• facilitate the interchange of records
• facilitate the tracking of the assembly of a healthcare record and its sub-components during active use
• ensure that the archived record is a safe and proper assembly of its components and subcomponents
provide a means for the safe control of copying one or more sections of the record and for regulation
of the lifetime of those topics
Paper-based patient record Electronic patient record
Inaccessibility (one user, one location often Decentralised, simultaneous access all the time
not always in the same place), parts of the
records are geographically distributed
Passive: unable to trigger certain actions Active: it can trigger certain actions according to data
Non-standardised information handling Standardised information storage, increasing legibility;
it allows communication between departmental
systems and can lead to an improvement of quality
assurance
“Manual” linkage “Increased” linkage with external health care providers
More risks of being incomplete (by lending, Can improve completeness by additional checking
less control of completeness) mechanisms at data entry
No flexible data representation (one Flexible representation of data following various views
representation only) tailored to the needs
Time consuming to explore for clinical or Excellent basis to conduct clinical and financial studies
financial studies
No risk of technical failure Risk of technical failure and unavailability depending
on the hardware/software
Lower cost(only entry cost not overall cost) Higher cost for installation, training and management
of the system
Enter handwritten data manually Probable resistance and fear of entering data into the
computer
Protection and confidentiality; easy to Protection and confidentiality more dificult to maintain
access
Critical issues to be considered
Maintaining Confidentiality
There is the absolute necessity to protect the patient privacy
by protecting the principle of confidentiality - the obligation
of health care professionals to avoid violating a patient’s right
to privacy. A significant challenge in creating future patient
record systems is to achieve an appropriate balance between
confidentiallity and access by users with a need to know.