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2 Types of Patient Records
A Patient Record is history of assessment and treatment that an epileptic patient generates during their interaction with a healthcare provider. Today this record will be a mixture of electronic data and paper forms under the control of the healthcare provider. The mix depends on the assessments and treatments undertaken and the patient record can become substantial especially in the case of people suffering from chronic diseases. If a patient is seen by another provider (referred to a specialist or moves to another city) the further treatment builds into a separate Patient Record.
In order to see the full Health Record of the subject we would have to combine all relevant Patient Records. Given the practical difficulties of managing and sharing paper it is not realistic to consider a paper-based Health Record that covers an individual for life and so we normally talk about an Electronic Health Record (EHR).
2.1 Electronic Health Records
The International Standards Organisation (ISO) provides a basic-generic definition of an EHR in ISO/TR20514 as a ??repository of information regarding the health status of a subject of care, in computer processable form.??. They recognise that the EHR maintained by an organisation can be split into a non-sharable part (due to incompatible data modelling or lack of interfaces) and a sharable part. The sharable content is then further defined as an Electronic Health Record for Integrated Care (ICEHR) - a repository of information regarding the health status of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users.
It has a standardised or commonly agreed logical information model which is independent of EHR systems.
Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent, and prospective.
By this definition the ICEHR may contain data from multiple organisations and that data is available on demand to multiple authorised organisations to support the future treatment of the subject.
An individual hospital or GP practice will have a Local-HR that contains the detailed information necessary for their staff to deliver front-line patient care. A regional or national authority may build a Shared-EHR to enable integrated care to be delivered by consolidating summaries of care and integrating workflows. It is not practical to deploy a new EHR application and expect all health-care providers to use it ?C the interoperability necessary to create a Shared-EHR comes from the Local-EHR applications sharing a common data model, data-encoding standards and integration technologies.
In the traditional healthcare landscape the Local-EHRs were created by healthcare providers to enable them to provide efficient services. Shared-EHRs would be created by regulatory or large insurance organisations to manage/increase efficiency across the healthcare industry in a region or country. The rise of the internet and increased standardisation of medical equipment/software have made it possible for 2 other categories of electronic records to become increasingly important.
2.2 Personal Health Records
Companies such as Google and Microsoft have created web applications that enable individuals to gather and store their medical history and so create a Personal Health Record. In a world where the EHRs are still not comprehensive, or where people can move freely across borders, many individuals will find themselves in a situation where their medical records are split. The Personal Health Record empowers individuals to take responsibility for building a complete health record to ensure better continuity of care when the engage with a new doctor. This can be especially important for people suffering from chronic conditions.
2.3 Population Health Records
Some organisations in the healthcare landscape are focussed on drawing conclusions from analysing the consolidated history of the medical treatments of whole populations. In these Population Health Records the data will have been anonymised so that the individual patients can no longer be identified. These databases can be generated by medical equipment and software for example and the results made available to clinical analysis organisations and to the original data providers (so that they can benchmark their performance against their peers).
One recent example of this is the GE Healthcare Medical Quality Improvement Consortium which consolidates data from the Cerity Electronic Medical Records application. Cerity EMR is used by more than 3,500 physicians to manage the care of 3.7 million patients. The US Centers for Disease Control and Prevention (CDC) has selected the MQIC to provide daily update on the spread of H1N1 and the seasonal flu.
3 ICEHR Architecture
The are 2 primary models and proposed for the architecture of a Shared-EHR:
Consolidated ?C data is transmitted from Local-EHRs within a short-time of the data being created. This model based essentially on data duplication is at the heart of Shared-EHR being deployed in Australia, Canada and England/Wales.
Federated ?C the Shared-EHR record is built on-the-fly by retrieving data from 2 or more Local-EHR extracts as it requested. This is an interesting theoretical approach but here are no examples of this architecture being deployed in practice.
The Shared Reference Model (SRM) is a variation on the Consolidated model. In an SRM the Shared-EHRs work independently and the patient's EHR data is copied and referenced from the SRM only when necessary. This model has been deployed in Canada to create a national database that acts as an umbrella for the Regional EHRs created in the Canada Health Infoway. The Infoway SRM is referenced typically when a citizen relocates to a different province. The first time a healthcare provider references the patient's history the EHR data from the old province will be copied via the SRM to the current EHR and then assessment/ treatment will proceed.
At a national or regional level the goal must be interoperability of diverse systems. This can only be achieved by creating a framework for software purchasers and suppliers that makes it easy to clearly state and meet requirements. For example Integrating the Healthcare Enterprise defines a set of profiles that can be included in RFPs. The profile defines a standard interaction that typically occurs between a number of parties providing healthcare services. Technology suppliers can build and test their products to support appropriate profiles. At special events called Connectathons vendors can do integration testing with the products of their peers in the industry and certify the performance of their products.
The EU is sponsoring research (see below) that will lead to certification of healthcare applications verifying that they meet certain usability and interoperabilty requirements.
Another approach has been implemented in Denmark over the past 15 years. Their 5.5m citizens receive primary care through 3,500 GPs and home care services managed by 98 municipalities. This is backed up by 60 public hospitals and approximately 10 private clinics. The GP practices use 15 different electronic patient management systems and there are 4 home care systems in use. Thanks to the Medcom program all patient management systems for the GPs, dentists, hospitals, home care services and pharmacies can communicate with standard electronic messages. In the month of March 2009, 100 applications exchanged 4.8 million messages (representing 98% of the available transactions). A key enabler of the Danish success is that a unique identifier is issued to all citizens at birth.
5 CURRENT DIRECTIONS
In 2000 the EU launched FP6, The Sixth Framework Programme, to create an internal market for research and development leading to the creation of a European Research Area. FP6 funded research in a number of areas including ''Life-sciences, genomics and biotechnology for health?? and ??Information society technologies??. This was followed by FP7, the Seventh Framework Programme, which is to direct EU funding on research from 2007-2013 and again Health, Biotechnology and Information and Communication Technologies were among the research themes to be supported. A number of the projects within FP6 and FP7 have been targeted at tactical or strategic electronic healthcare topics.
5.1.1 eHealth ERA
eHealth ERA (www.ehealth-era.org, last retrieved on 14.Nov.2009) is a strategic initiative aimed at increasing visibility of the nation-states research planning and leading to improved co-ordination and alignment within and across borders. Research in this scope covers basic, applied and implementation activities and so this project will have a direct impact on e-health infrastructure leading to long-term benefits.
Quality Labeling and Certification of Electronic Health Records Systems in Europe or Q-REC (www.eurorec.org, last retrieved on 14.Nov.2009) was funded in FP7. The main objective of Q-REC ??is to create an efficient, credible and sustainable mechanism for the certification of Electronic Health Record (EHR) systems in Europe??. This certification is seen as a critical enabler to the accelerated deployment of interoperable EHRs.
Based on the work of this project a Recommendation of the (European) Commission (July 2, 2008) on on cross-border interoperability of Electronic Health Record systems was issued. The recommendation sets out a number of considerations to help reach a stated goal of the ??achievement of overall European eHealth interoperability by 2015??. Quoting from the Recommendation:
??The ultimate goal of the Recommendation is, therefore, to contribute to creating a means whereby authorised health professionals can gain managed access to essential health information about patients, subject to the patients?? consent, and with full regard for data privacy and security requirements. Such information could include the appropriate parts of a patient??s electronic health or medication record, patient summary, and emergency data accessible from any place in the Community.??
Lead out. Architecture assessment is a high-level vision based on a functional view and user-driven view of hte systems. To be accepted and successful 2 key success criteria are Security and availability of Unique Identifiers.