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									  Electronic Record Keeping


          Xander D Harkness

             Medesol Limited


http://www sportsinjurymanager co uk/physio



                                   Sports Injury Manager
               Why am I here?
Degree in Medical Science
RHCE
Health Care for 6 years
Information Technology for 9 years
Information Security for 5 years
Electronic Patient Records for 2 years



                                         Sports Injury Manager
                Why are you here?
EPRs are not consumables
   Difficult to get
   Difficult to get rid of
You are responsible for your records
IT is boring to a lot of people, it is just a tool
There is currently a lot of poor IS practice
Physios are leading the progress in many Orgs


                                           Sports Injury Manager
                 Introduction
What is an electronic patient record (EPR)?
Types of electronic records
Why move to Electronic records?
Are EPRs legal?
Varieties of EPR
Security
Lies, Damn Lies and Statistics
Conclusion
                                        Sports Injury Manager
               What is an EPR?
Electronic Patient Record
  "anything that contains information (in any media) which
  has been created or gathered as a result of the work of NHS
  employees" (HSC 1999/053
  Attendance, treatment, advice, all contacts
Paper or Electronic
  Quality
  How comprehensive



                                             Sports Injury Manager
         Why do we need EPRs?
Technology for technology s sake
Improved sharing of data
Improved record keeping
Data analysis
Injury Surveillance
Treatment surveillance



                                   Sports Injury Manager
               Who Owns What
NHS
  Public record - Health and Social Care Bill allows Gov
  Access to all information
Corporate
  Corporate property, restricted views
Private
  Owned by the practice




                                            Sports Injury Manager
          Types of EPR systems
Why do I need to know this
Stand alone
Local network
Local network with secure access
Secure server / client
Secure distributed
Your rights!


                                   Sports Injury Manager
                  Your rights
Audit trail
Prove that the computer was not misused and was
operating properly at the time the record was produced
Concerted effort to ensure individual protection
Backups and disaster recovery
Availability




                                        Sports Injury Manager
    Why do you need to know this?
Physiotherapists are leading the way
More patient contact
Make the decisions on what is needed
Ability to stop solutions
Wrong system
  Will damage your reputation
  Cause more work
  ICL implementation for the NHS
Shiny sales people
                                       Sports Injury Manager
                 Stand alone
One computer
Multiple users
Single concurrent access
Good security
Poor at sharing data




                               Sports Injury Manager
       Local Area Network (LAN)
Practice level sharing of data
Multiple concurrent users
Host, network and physical security requirements
Email virii
Low difficulty to secure
Users must be trained, then practice the training



                                        Sports Injury Manager
        LAN with secure access
VPN, RAS, PPP, CHAP, MD5, CRAM, Bleugh
Similar to LAN
Must know who you are giving access
More expensive
Medium level difficulty to secure correctly
What type of access? modem, ADSL, LL
Get a demo


                                    Sports Injury Manager
                Server / Client
Similar to browsing web pages
Single point of failure
LAN or Wide Area Network (WAN)
There will be a database somewhere!
All access normally live
Good target to crack
Large systems are difficult to secure


                                        Sports Injury Manager
            Distributed Systems
Allow use off line - on tour
Good for poor connectivity
Very good reliability
Very difficult to secure
Difficult to implement and design
Extremely flexible
Data contention must be resolved early


                                         Sports Injury Manager
           Storage and Retrieval
Data format
  Open systems
  International Standards
  Documentation
Storage medium
Storage format
Interoperability


                               Sports Injury Manager
                Are EPRs legal
EPRs are legal and can be used as sole record
Do I still need paper records? - No
How do I ensure that I stay legal?
  Data Protection Act 1998
  Patient to access records within guidelines
  Layered access for individuals
Protect self against malpractice claims


                                                Sports Injury Manager
         Different Application Types
Client only
 Local application similar to word processor
Client / Server
 Similar to using webmail
Client / Server with distributed data
 Similar to video rentals




                                               Sports Injury Manager
           Security Background
1 in 10 online banks has been subject to blackmail in
US
Cracking has cost UK business in excess of 100m
Types of breach; social, electronic, physical
Centralised data is a better target honeypot




                                        Sports Injury Manager
        IT handles all security!?
Who do you trust?
Who is ultimately liable?
Do the emergency protocols work?
Have backups been successful?
I do not have time




                                   Sports Injury Manager
              Types of Security
Social
Application
Host
Network
Physical




                                  Sports Injury Manager
               Social Security
Social Engineering
Majority of leaks internal
Password security
Lack of training
Computer etiquette




                                 Sports Injury Manager
           Application Security
HSC 1998/153 username and password required
Backdoors
Default passwords
Pseudo security
  Microsoft word passwords
UI and data store must be secure



                                    Sports Injury Manager
                Host security
Who has access
Does your system have ACLs?
  Win95, Win98, WinMe, XP home do not
  UNIX (Solaris, Linux, AIX), NT4, W2K, XP Pro do
Bug fixes
Theft
Encryption
Backups – what format? what access?

                                        Sports Injury Manager
             Network Security
Who has access
Encryption
Switched network? Old networks probably not
Firewalls
Competent system administrators or absence of!
Wireless networks
Email
Training
                                      Sports Injury Manager
               Physical Security
International Sports Stars / Celebrity clinics
   Well known good targets
   Modern day rubbish thieves
Physical layers of security
Obvious security
   Lock doors, lock cabinets, remove laptop from car
Secure server room


                                             Sports Injury Manager
                     Statistics
Work with the clinical and management teams
   Differing requirements
   Vast gaps in knowledge regarding these systems
Automatic generation of coach s report
Automatic generation of insurance reports
Analysis for academic work
   Standards compliance
Ability to export data to third party systems

                                            Sports Injury Manager
       General Injury Surveillance
Nature and amount of Injury for an activity
Identify sub populations at greater risk
Allows planning of resources
Evaluate risk factors
Show differences in incidence
Governing body s commitment to safety
Justify greater resources for study and practice


                                          Sports Injury Manager
              Specific SIS systems
Injury incidence / prevalence / severity
   Equipment
   Play / tactics / manoeuvres e g Spear tackle
   Injury Prevention strategies
   Understand aetiology
   Good Practice Guidelines
   Economic results evaluation
      Direct
      Indirect costs


                                              Sports Injury Manager
                       Injuries by Position occuring in Match Play and
                               Training Eng U21 Squad 6 Nations
                Tighthead
                 Stand off
                Scrumhalf
               Right Wing
                   2nd row
           Outside Centre
Position




                 Openside
                 Number 8
               Loosehead
                 Left Wing
            Inside Centre
                   Hooker
                 Full Back
                Blindside


                               0                   2              4                         6                    8                       10          12
                                                                              Number of Injuries

                A-C (acromioclavicular) joint          Allergy Anaphylaxis                             Ankle impingement + other tendon pathology
                Ankle sprains and joint injuries       Calf strains                                    Concussion - Mild
                Dental inc tooth Avulsion              Dermatology problem                             Elbow sprains or joint injuries
                Foot sprains + dislocations            Gastro Intestinal                               Groin strain injuries
                Hamstring strains                      Head and neck soft tissue trauma                Illness
                Knee sprains (others)                  Lumbar and thoracic sprains                     Lumbar radicular inc disc nv impingement
                Neck sprains                           Patellofemoral joint + AKP inc Pat Tendonitis   Pelvic + Buttock + S I Soft tissue injuries
                Respiratory                            Rotator Cuff + Allied disorders                 Shin Splints etc
                Shoulder Instability                   Shoulder sprains and dislocations               Sports Hernia, Osteiitis etc
                Thigh haematomas                       Undiagnosed injuries                            Wrist and hand sprains and dislocations


                                                                                                                          Sports Injury Manager
                                                                                                                                                                                                             Sports Injury Manager
                                                                     Mechanism
Mechanism of traumatic Injuries during all Match




                                                                                                    Injured during Ruck or maul
                                                                            Injured during tackle


                                                                                                                                                                ies
                                                              Side-Step
                                                   Stamping




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            play 6 Nations Eng U21




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                                 Injuries by Surface all training and match play
                                                6 Nations Eng U 21
          25


                     2
Number of Injuries




          15


                     1


          05



                     0
                           Hard Turf             Indoor                Sandy Turf             Soft Turf         Uneven Turf      Waterlogged Turf
                                                                                    Surface
                         A-C (acromioclavicular) joint                                         Ankle impingement + other tendon pathology
                         Ankle sprains and joint injuries                                      Concussion - Mild
                         Elbow sprains or joint injuries                                       Foot sprains + dislocations
                         Groin strain injuries                                                 Hamstring strains
                         Head and neck soft tissue trauma                                      Knee sprains (others)
                         Lumbar radicular inc disc nv impingement                              Patellofemoral joint + AKP inc Pat Tendonitis
                         Pelvic + Buttock + S I Soft tissue injuries                           Rotator Cuff + Allied disorders
                         Shoulder Instability                                                  Shoulder sprains and dislocations
                         Thigh haematomas                                                      Undiagnosed injuries
                         Wrist and hand sprains and dislocations




                                                                                                                      Sports Injury Manager
                                       All injuries encountered during match play
                                                       Six Nations U21

                25



                     2
Number of Injuries




                15



                     1



                05



                     0

                            France 21               Ireland 21         Italy 21                  Scotland 21          Wales 21
                                                                       Opposition team


                         A-C (acromioclavicular) joint                            Concussion - Mild

                         Foot sprains + dislocations                              Groin strain injuries

                         Hamstring strains                                        Head and neck soft tissue trauma

                         Knee sprains (others)                                    Neck sprains

                         Pelvic + Buttock + S I Soft tissue injuries              Rotator Cuff + Allied disorders

                         Shoulder Instability                                     Shoulder sprains and dislocations

                         Thigh haematomas                                         Undiagnosed injuries

                         Wrist and hand sprains and dislocations



                                                                                                           Sports Injury Manager
Sports Injury Manager
          Buyer s Guide to EPR
Ensure it works as you do
Reliability / Availability
Total Cost of Ownership (TCO)
Security
Data formats




                                Sports Injury Manager
                 Conclusion
EPR is becoming more and more common
Allows more time to be spent with Athletes
Provides data that was unavailable
Provides better support for your work to management
Possibility to bring new treatments faster
Provides better data to manage your patients
Be involved with the system you choose


                                      Sports Injury Manager
               Electronic Record Keeping


                      Xander D Harkness

                         Medesol Limited


            http://www sportsinjurymanager co uk/physio



                                               Sports Injury Manager



Medesol Limited provides custom software for a wide
range of medical specialties, from the average hospital
department to elite athletes injury surveillance software

The URL listed provides all contact information and a
copy of the presentation
                         Why am I here?
          Degree in Medical Science
          RHCE
          Health Care for 6 years
          Information Technology for 9 years
          Information Security for 5 years
          Electronic Patient Records for 2 years



                                                   Sports Injury Manager



I have worked in fields allied to what I am here to discuss
today for the last 13 years

My degree and experience working in the health care
industry allow me a great insight into how IT must serve
the medical profession I also see the difficulties faced (I
spent four years working in the Far East and sub-continent
as a regional manager for a British Pharmaceutical
company)

XDH has specialised in Information Security for the last
five years In addition he has worked with EPRs and
network security since 1998 and has worked with the
companies pioneering EPRs on the Internet
                          Why are you here?
          EPRs are not consumables
             Difficult to get
             Difficult to get rid of
          You are responsible for your records
          IT is boring to a lot of people, it is just a tool
          There is currently a lot of poor IS practice
          Physios are leading the progress in many Orgs


                                                     Sports Injury Manager



Electronic Patient Records are not consumables, i e if it
does not work as you expected you will not be able to get
rid of it To change it will cost considerable amounts, the
IT contractor will make sure that is in the contract You
must make sure that ALL of your requirements are agreed
on paper before work starts

All medical staff are normally fully liable for the security
and integrity of their medical records Frequently this is
part of their employment contract

IT is a tool, just as you might not be interested in
gardening tools, if you were to buy a spade you would at
least make sure it would not break under a normal load
and meets your needs

There is a huge amount of very poor practice in IT More
companies are not sued because the public remains
relatively ignorant of what computers will do

Physios have the majority of contact with the players and
therefore write most notes and will be the main users of
any EPR system implemented They therefore must be
involved to ensure that it does what they need
                 Introduction
What is an electronic patient record (EPR)?
Types of electronic records
Why move to Electronic records?
Are EPRs legal?
Varieties of EPR
Security
Lies, Damn Lies and Statistics
Conclusion
                                        Sports Injury Manager
                         What is an EPR?
          Electronic Patient Record
            "anything that contains information (in any media) which
            has been created or gathered as a result of the work of NHS
            employees" (HSC 1999/053
            Attendance, treatment, advice, all contacts
          Paper or Electronic
            Quality
            How comprehensive



                                                       Sports Injury Manager



The EPR can take many different forms and can contain
many different forms of media It may contain text, audio,
video, MRI and letter The recommendations on the
relevant HSCs are that every contact with the patient are
recorded, telephone, consultation and letter (though
obviously letters may form that part of the record)

There obviously has to be a balance between how much
data would be interesting to have and how much is
recorded

We have found that there is a very fine margin between
having lots of really useful data for surveillance and
asking for too much data resulting in false data and even
no data being recorded This has taken a considerable
amount of trials with users and therefore it is important
when choosing a system that the companies tendering for
the implementation have considerable information of
medical informatics
                   Why do we need EPRs?
          Technology for technology s sake
          Improved sharing of data
          Improved record keeping
          Data analysis
          Injury Surveillance
          Treatment surveillance



                                             Sports Injury Manager



Some people like pressing buttons and having the latest
electronic gizmos It has been shown that paper filofaxes
are much faster for data retrieval than electronic PDAs
There are other conveniences for PDAs such as audible
reminders You must make sure that there are valid
reasons for the system you are seeking to implement
Most organisations will implement an EPR system Any
such system must fulfill all of your requirements, so do
not sit back and wait

Good EPR systems can improve medical care through
better team work and sharing of information A bad one
can ensure you waste a lot of your time

EPR systems are great at automating boring tasks such as
weekly insurance or coaches reports which can be
formatted and sent without human input

Once a minimum of data has been obtained injury and
treatment surveillance may be carried out easily to great
effect
                          Who Owns What
          NHS
             Public record - Health and Social Care Bill allows Gov
             Access to all information
          Corporate
             Corporate property, restricted views
          Private
             Owned by the practice




                                                       Sports Injury Manager



There is a Bill that is currently awaiting its final reading in
the Lords that will allow any government department to
access any medical records that are within the NHS If
patients are treated within the NHS ensure that your EPR
system can output data easily to comply with more and
more complex legal structures being put in place

Commercial Organisations own all records created on
their time or at their expense, patients are still able to
request a copy of their records
                    Types of EPR systems
          Why do I need to know this
          Stand alone
          Local network
          Local network with secure access
          Secure server / client
          Secure distributed
          Your rights!


                                             Sports Injury Manager



It is important for medical staff to know what is on offer
so that when reviewing systems they can assess the
inadequacies of each system

There are a number of different types of systems that will
be assessed
                            Your rights
          Audit trail
          Prove that the computer was not misused and was
          operating properly at the time the record was produced
          Concerted effort to ensure individual protection
          Backups and disaster recovery
          Availability




                                                  Sports Injury Manager



Unless you or your IT staff can prove that your records
have not been changed by a third party and that there is
no possibility of this then you will not be able to use them
in your defence in a malpractice trial

You should be secure in the knowledge that you need an
audit trail to show what was changed and edited and
when

There should be an effort to ensure that not only is the
network protected but the individuals and their computers
are protected

All medical staff should work closely with the IT teams to
ensure that there is a disaster recovery plan and that
backups are done and tested There is one premier league
club that lost 50% of medical records following a local
difficulty with severe weather All notes being kept in the
basement in cardboard boxes

Availability is something that is often skipped over or not
thought about It is always recommended to use UNIX
systems (these include Linux, BSD, AIX, Solaris and Mac
OSX) Microsoft crashes often and is unreliable at best
              Why do you need to know this?
          Physiotherapists are leading the way
          More patient contact
          Make the decisions on what is needed
          Ability to stop solutions
          Wrong system
            Will damage your reputation
            Cause more work
            ICL implementation for the NHS
          Shiny sales people
                                                 Sports Injury Manager



Physiotherapists as previously mentioned have the
majority of patient contact and they are in the forefront of
implementing EPR systems

There should be a body of common knowledge developed
within the available organisations to decide what the
requirements in general are for such systems

As physios have so much patient contact they will have
the ability to break any implemented systems This is
done by being gently uncooperative, putting poor data or
no data in Or by using the bugs that will be in the system
to corrupt the data

Having a system that does not meet your needs may well
impair your ability to do your job properly If you have
no idea what your patients history is, because the
computer is broken you will look foolish If the system
generates more work for you to do you will not have time
to do as many treatments as you used to, making it appear
as if you are slacking off ICL (who is a common
contractor for the NHS) provided a computer system for a
Legal firm I audited The computer network would
routinely stop working, a whole floor at a time We traced
it to the network cabling being run up the lift shaft and the
                           Stand alone
          One computer
          Multiple users
          Single concurrent access
          Good security
          Poor at sharing data




                                         Sports Injury Manager



A stand alone system is a single computer with a program
that may be used by one person at a time This system is
not networked, nor does it have access to the Internet to
collect or send email

It is very easy to get your computer cracked via the
Internet, especially as most people do not update or patch
their computer operating systems

These systems only allow one user and can only provide
output via printer or floppy disk
                 Local Area Network (LAN)
          Practice level sharing of data
          Multiple concurrent users
          Host, network and physical security requirements
          Email virii
          Low difficulty to secure
          Users must be trained, then practice the training



                                                  Sports Injury Manager



LANs may be connected to the Internet which means that
you need extra security as crackers then have the ability to
access all of the data on your network unless you make
considerable efforts to keep them out

Efforts have to be made to not only ensure that the
computers are physically secure but secure from crackers

Users should receive computer training as there is
normally a low level of knowledge of within the medical
community Very few users have ever received computer
training This includes basic applications and also
backups and information security
                  LAN with secure access
          VPN, RAS, PPP, CHAP, MD5, CRAM, Bleugh
          Similar to LAN
          Must know who you are giving access
          More expensive
          Medium level difficulty to secure correctly
          What type of access? modem, ADSL, LL
          Get a demo


                                              Sports Injury Manager



There are lots of acronyms that IT types throw around It
is important that all communication over untrusted
networks (such as your ISP) are encrypted

Having remote access to the company LAN over an
encrypted connection from home or connecting multiple
offices together can aid company communication It does
make it more difficult to secure the network

Get a demonstration of the network prior to installation to
ensure that the speed of the connection is sufficient for the
company s needs
                          Server / Client
          Similar to browsing web pages
          Single point of failure
          LAN or Wide Area Network (WAN)
          There will be a database somewhere!
          All access normally live
          Good target to crack
          Large systems are difficult to secure


                                                  Sports Injury Manager



Server client describes the type of application If there is
only one server then if this fails no access to history or
records is possible

This will work on LANs or WANs between sites Note
again that if the connection to a remote site is down then
again access will be denied This provides more points of
failure

This will normally be dependent upon a database server
which tend to be more expensive to staff

Because all the data is in one place it makes it a great
target for crackers The larger the system more more
difficult it is to secure
                      Distributed Systems
          Allow use off line - on tour
          Good for poor connectivity
          Very good reliability
          Very difficult to secure
          Difficult to implement and design
          Extremely flexible
          Data contention must be resolved early


                                                   Sports Injury Manager



Distributed systems have many advantages; however are
difficult to implement well The allow the use of the
system off line Hence they data may still be accessed
when off on an away game, or on a coach etc Many
places where you will be practicing will have no network
access at all, it is therefore important that you should be
able to access records wherever you need them

One of the more difficult difficulties to solve is data
contention This is where two or three people working off
line edit the same records the database may get confused
as to which new record to chose
                     Storage and Retrieval
          Data format
            Open systems
            International Standards
            Documentation
          Storage medium
          Storage format
          Interoperability


                                         Sports Injury Manager



The data format is important, many companies are now
having difficulty moving their data to new formats or
reading data that is only 4 to 5 years old Technology
moves quickly and if you do not use open standards and
even better open source you may well have difficulty in
the near future

Open systems document their data formats and
communication protocols so that they may be used by
anyone

Everyone had difficulty reading Microsoft Word 6
documents when other departments / companies moved to
Office 95 Microsoft used closed systems and are well
known to publish incorrect data to prevent compatibility
This means they can force people to pay for upgrades, this
again can cause problems Open Source software can be
supported for many years as all can see how data is stored
and the communication protocols It often costs much less
to implement too
                         Are EPRs legal
         EPRs are legal and can be used as sole record
         Do I still need paper records? - No
         How do I ensure that I stay legal?
           Data Protection Act 1998
           Patient to access records within guidelines
           Layered access for individuals
         Protect self against malpractice claims


                                                         Sports Injury Manager



EPRs are legal and may be the sole record

You have to make sure that any such system falls within
the law and is compliant within your organisation
                  Different Application Types
         Client only
          Local application similar to word processor
         Client / Server
          Similar to using webmail
         Client / Server with distributed data
          Similar to video rentals




                                                        Sports Injury Manager



The client server model is solely reliable upon the server,
if it breaks you have no access Hence similar to webmail

The Distributed model is similar to video rentals many
people can watch the same (access and edit the same data)
however unless there is some agreement prior to rental (in
the design of the database) then no one will know who
returned the video late and every one gets charged (Or the
database does not know whos data is correct and everyone
must enter again or possibly even end up with a corrupt
database)
                     Security Background
          1 in 10 online banks has been subject to blackmail in
          US
          Cracking has cost UK business in excess of 100m
          Types of breach; social, electronic, physical
          Centralised data is a better target honeypot




                                                  Sports Injury Manager



Cracking is very common, it is a case of when, not if

Putting your data into one location just makes cracker s
work easier

Most breaches are internal
                  IT handles all security!?
          Who do you trust?
          Who is ultimately liable?
          Do the emergency protocols work?
          Have backups been successful?
          I do not have time




                                             Sports Injury Manager



If people want to access sensitive information, they will
get a job with the organisation

The individual practitioner is liable If this means you
have to print out your notes then do so

Emergency protocols will NOT have been tested IT staff
do not have the time and you will not know until the worst
happens
                        Types of Security
          Social
          Application
          Host
          Network
          Physical




                                            Sports Injury Manager



There are a number of methods that crackers will use to
access
                         Social Security
          Social Engineering
          Majority of leaks internal
          Password security
          Lack of training
          Computer etiquette




                                           Sports Injury Manager



Social engineering is one of the most common
approaches It works as follows: Call to practice s
receptionist, from someone claiming to be the PA to
someone at another office Another user needs access and
has forgotten their password can they use X s username as
boss needs a report The username and password is often
given without question (surprising yes but if they come up
with a plausible story it will happen)

If someone really wants access they will get a job there
Cleaners have access to all areas and are generally
ignored The price of selling some salacious medical info
is worth it

Users need to be trained for what to look out for - this
includes Human resources when they are hiring
                      Application Security
          HSC 1998/153 username and password required
          Backdoors
          Default passwords
          Pseudo security
             Microsoft word passwords
          UI and data store must be secure



                                              Sports Injury Manager



HSCs state that usernames and passwords are required,
this does not include the pretend passwords on windows
95, 98, 98SE, ME which disappear when you press the
escape key You should also look out for presences of
security with any system you purchase

Default passwords should be changed, these are often
forgotten and great for crackers

Other pseudo security examples are items like Passwords
on Microsoft Word or Excel documents, these do not
present any difficulties and are easily opened using Star
Office or Open Office (http://www openoffice org)
products which are free, open source and are more
compatible with Microsoft documents that Microsoft
products are

There are at least two routes to get to the data, ensure that
the User Interface is secure and the data store is secure
                          Host security
          Who has access
          Does your system have ACLs?
            Win95, Win98, WinMe, XP home do not
            UNIX (Solaris, Linux, AIX), NT4, W2K, XP Pro do
          Bug fixes
          Theft
          Encryption
          Backups – what format? what access?

                                                  Sports Injury Manager



Security is important (to repeat myself) is important as
you may have to prove that no-one has had an opportunity
to edit your data

Who has access to your data, how well do you know them
Who else has an opportunity (cleaners ;-)

Does your system have access control lists?

Many operating systems have security systems that can be
easily by bypassed Does your computer have a floppy or
CD ROM drive? If so it takes approximately 30 seconds
to gain access with the correct tools

What happens if your laptop is stolen? Does it use
encryption?

Do you have backups? Do they work? What format are
they If the backups are a propriatory format they may not
be able to be accessed in five or six years time – it is a
legal requirement to be able to show this data
                       Network Security
          Who has access
          Encryption
          Switched network? Old networks probably not
          Firewalls
          Competent system administrators or absence of!
          Wireless networks
          Email
          Training
                                                Sports Injury Manager



Network security depends upon security at all points from
where the cable is routed and who has physical access to
the computers

In addition it is very difficult to obtain good system
administrators, these are essential to esure that you have a
secure system

If you have wireless networks please ensure they are
encrypted, most companies are foolish and do not It is
like publishing all of your records in a newspaper

Emails frequently go astray, emails containing patient
records should be encrypted Please note that currently
Microsoft email clients do not encrypt attachments (such
as spreadsheets or documents) One of the best clients at
present is Mozilla (http://www mozilla org) using
enigmail as the encryption tool
                         Physical Security
          International Sports Stars / Celebrity clinics
             Well known good targets
             Modern day rubbish thieves
          Physical layers of security
          Obvious security
             Lock doors, lock cabinets, remove laptop from car
          Secure server room


                                                       Sports Injury Manager



Physical security on your networks is important, this
includes laptops

Practitioners are well known and who is a practitioner for
which athletes is easily discovered so laptops in cars make
very easy targets

Even basic security can be useful such as locking the door
to the server room Try yourself - can you get direct
access to the server?
                               Statistics
          Work with the clinical and management teams
             Differing requirements
             Vast gaps in knowledge regarding these systems
          Automatic generation of coach s report
          Automatic generation of insurance reports
          Analysis for academic work
             Standards compliance
          Ability to export data to third party systems

                                                      Sports Injury Manager



Work with the rest of the clinical team and also the
management team to ensure that the system that is put in
place meets everyone s needs

You might find that management are already planning
something, hence if you do not ask you might find
something installed without consulting the medical team

Entering data on a computer probably will take longer, so
save time in other areas Ensure that the system can
automate boring tasks such as insurance reports or coach s
reports

The system must be standards compliance so that any
research work may be corroborated

You must also ensure that you can export your data or
interact with other systems
                 General Injury Surveillance
          Nature and amount of Injury for an activity
          Identify sub populations at greater risk
          Allows planning of resources
          Evaluate risk factors
          Show differences in incidence
          Governing body s commitment to safety
          Justify greater resources for study and practice


                                                    Sports Injury Manager



This is self explanatory
                        Specific SIS systems
          Injury incidence / prevalence / severity
             Equipment
             Play / tactics / manoeuvres e g Spear tackle
             Injury Prevention strategies
             Understand aetiology
             Good Practice Guidelines
             Economic results evaluation
                Direct
                Indirect costs


                                                        Sports Injury Manager



Sports Injury Surveillance systems can analyse many
different areas and improve safety and enjoyment for all

e g The Spear tackle is now banned in the US following
investigation based on good data The manoeuvre was
proved to cause too many injuries

It can also have economic effects, direct in that you may
end up using fewer supplies such as support bandages or
medications Reduction of indirect costs may be that the
players are injured less and play better, therefore get
increased revenues
                       Injuries by Position occuring in Match Play and
                               Training Eng U21 Squad 6 Nations
                Tighthead
                 Stand off
                Scrumhalf
               Right Wing
                   2nd row
           Outside Centre
Position


                 Openside
                 Number 8
               Loosehead
                 Left Wing
            Inside Centre
                    Hooker
                 Full Back
                Blindside


                               0                   2              4                        6                     8                       10          12
                                                                              Number of Injuries

                A-C (acromioclavicular) joint          Allergy Anaphylaxis                             Ankle impingement + other tendon pathology
                Ankle sprains and joint injuries       Calf strains                                    Concussion - Mild
                Dental inc tooth Avulsion              Dermatology problem                             Elbow sprains or joint injuries
                Foot sprains + dislocations            Gastro Intestinal                               Groin strain injuries
                Hamstring strains                      Head and neck soft tissue trauma                Illness
                Knee sprains (others)                  Lumbar and thoracic sprains                     Lumbar radicular inc disc nv impingement
                Neck sprains                           Patellofemoral joint + AKP inc Pat Tendonitis   Pelvic + Buttock + S I Soft tissue injuries
                Respiratory                            Rotator Cuff + Allied disorders                 Shin Splints etc
                Shoulder Instability                   Shoulder sprains and dislocations               Sports Hernia, Osteiitis etc
                Thigh haematomas                       Undiagnosed injuries                            Wrist and hand sprains and dislocations


                                                                                                                          Sports Injury Manager
                                                                                                                                                                                                           Sports Injury Manager
                                                                     Mechanism
Mechanism of traumatic Injuries during all Match




                                                                                                    Injured during Ruck or maul
                                                                            Injured during tackle




                                                                                                                                                               ies
                                                              Side-Step
                                                   Stamping




                                                                                                                                                           ur
                                                                                                                                                       inj
                                                                                                                                                  ed
            play 6 Nations Eng U21




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                                                                                                                                                                                         Injury Category
                                                                                                                                  Ne                   (o                       ra
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                                  Injuries by Surface all training and match play
                                                 6 Nations Eng U 21
          25


                     2
Number of Injuries

          15


                     1


          05



                     0
                           Hard Turf             Indoor                Sandy Turf             Soft Turf         Uneven Turf       Waterlogged Turf
                                                                                    Surface

                         A-C (acromioclavicular) joint                                         Ankle impingement + other tendon pathology
                         Ankle sprains and joint injuries                                      Concussion - Mild
                         Elbow sprains or joint injuries                                       Foot sprains + dislocations
                         Groin strain injuries                                                 Hamstring strains
                         Head and neck soft tissue trauma                                      Knee sprains (others)
                         Lumbar radicular inc disc nv impingement                              Patellofemoral joint + AKP inc Pat Tendonitis
                         Pelvic + Buttock + S I Soft tissue injuries                           Rotator Cuff + Allied disorders
                         Shoulder Instability                                                  Shoulder sprains and dislocations
                         Thigh haematomas                                                      Undiagnosed injuries
                         Wrist and hand sprains and dislocations




                                                                                                                      Sports Injury Manager
                                       All injuries encountered during match play
                                                       Six Nations U21

                25



                     2
Number of Injuries


                15



                     1



                05



                     0

                            France 21               Ireland 21         Italy 21                   Scotland 21          Wales 21
                                                                       Opposition team

                         A-C (acromioclavicular) joint                             Concussion - Mild

                         Foot sprains + dislocations                               Groin strain injuries

                         Hamstring strains                                         Head and neck soft tissue trauma

                         Knee sprains (others)                                     Neck sprains

                         Pelvic + Buttock + S I Soft tissue injuries               Rotator Cuff + Allied disorders

                         Shoulder Instability                                      Shoulder sprains and dislocations

                         Thigh haematomas                                          Undiagnosed injuries

                         Wrist and hand sprains and dislocations



                                                                                                            Sports Injury Manager
Sports Injury Manager
                     Buyer s Guide to EPR
          Ensure it works as you do
          Reliability / Availability
          Total Cost of Ownership (TCO)
          Security
          Data formats




                                          Sports Injury Manager



The system should work in line with your current
procedures

The system should be available and bug free 99 999% of
the time

Find out what other costs will be present, Internet costs,
Administrator costs, laptops, palms etc Etc

How much extra security is required

Training for staff

What format is the data stored in, can other people read it,
can your other applications read it? Will you be able to
read it in 5 years
                 Conclusion
EPR is becoming more and more common
Allows more time to be spent with Athletes
Provides data that was unavailable
Provides better support for your work to management
Possibility to bring new treatments faster
Provides better data to manage your patients
Be involved with the system you choose


                                      Sports Injury Manager

								
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