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Electronic patient record in primary care

TDT4210 Health care informatics

Professor Anders Grimsmo, DMF, NTNU1935

2 2005

3 1935

4 2005

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Pasientjournal anno 1872

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- a challenge to NTNU:

• Five millions NOK for five years

Create a productive and viable competence community for research, development, implementation and knowledge sharing in conjunction with electronic patient record (EPR).

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People per month Level of care

2 Regional hospital 13 Local hospital

150 Primary care

500 Self-care

85 Symptoms, no treatment 250 No symptoms

1000 Risk population

Patients and Level of care

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National Insurance Administration (RTV)

Health centerNursing homes, physiotherapists, Care services

Pharmacy

Hospitals

SSB, NPR,misc. central regisgistres

Ministry of health and social affairs (SHD)

Central

Health company

Local

Specialists

Internett

Psychiatry

Cooperation in the health care services

The patient in center

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Collaborating partners of the general practitioner

SOSIALTJENESTERBoligBarnevern

2. LINJETJENESTENPoliklinikker, sykehusPrivatpraktiserendespesialister

TRYGDEKONTOR

ANDRE STATLIGEINSTITUSJONEROG REGISTREFolkehelsaStatens helseundersøkelserFødselsregistreStatistisk sentralbyråKreftregistremed mer.

POLITI

LABORATORIERKlinisk-kjemiskePatologiske

ALKOHOLISTOMSORG

FRIVILLIGEORGANISASJONER

ADMINISTRASJONHelsesjefHelse- og sosialstyre

PLEIE/OMSORGHjemmesykepleieSyke- og aldershjemPsykiatri

FOREBYGGENDE TJENESTER Helsestasjon/skolehelsetjenesteMiljørettet helsevernSkole/Barnehage/PP-tjenesteBedriftshelsetjeneste

The general practitioner

Municipal services

Specialist services

Governmental entities

REHABILITERINGFysioterapiErgoterapiVernepleie

BEREDSKAPLegevakt,AMK, ambulanse

HELSETILSYNETFylkeslege

APOTEK

See glossary avaliable from the web pages

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Information exchange in primary care

• 20 millons single bills to national assurance (contact bills).

• 1,9 millons referrals to hospital or specialist

• 3,8 millons epicrises from hospitals and out-patients’ clinics

• 1,0 millons physiotherapist requisitions

• 1,3 millons image requisitions

• 3,5 millons medical certificates and sickness benefit certificates

• 200.000 medical certificates on disablement

• 7 millons test requisitions to laboratories, each with 6-7 analyses

• 17 millons prescriptions per year

Is written and sent:

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Health service characteristics

Primary care service Specialist health service

Organisation Decentralized, autonomous Governed, hierarchical

Economy Price per unit, own risk, Framework, price per unitlow costs High costs

Services Large volume, broad-spectrum, Segragated and specialized

brief contacts

Patient-doctor Continous , persona, Short-lived, limitedrelationship and binding

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Work Technique Characterestics

Primary care service Specialist service

No of health problems Usually several Usually one

Clinical picture Early in the disease course Fully developed clin. picture

Disease prevalence Low and unselected High and selected

Diagnostic method Reductionistic Systematic completePattern recognition ”Puzzle”Probability evaluation

Tests and procedures Few and simple Numerous and advanced

Treatment Patient oriented Organ- and disease-orientedSimple, searchingly More advanced, based on

certain diagnosis

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The diagnostic process

Presented health problemReason for contact

Anamnesis, symptomsPattern recogn.

Hypotheses

Searching for caracteristics

(finds, results)

Dignosis

Treatment

Revision of hypothesis

Former knowledge about

the patient

Probability evaluation

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Prediction value in medical diagnostics

Prevalence, sensitivity, specificity

2 x 2 table:

Truepositive

Falsepositive

Truenegative

Falsenegative

Ill

Healthy

Positive test Negative test

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The meaning of sensitivity and specificity – an example:

• Prevalence: 1% (near-sighted at school start)• Sensitivity: 95%• Specificity: 95%• No of children: 65.000

Ill 617 33 650

Healthy 3 218 61 132 64 350

65 000

Positivetest

Negativetest

Examination of school children

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Prediction value of symptoms

Symptom Diagnosis

% av pasientene

General practice Internal medicinal dep.

PyrosisGastric catarrhGastric ulcerGastric cancer

90100,5

306010

SpinelessnessDepression

Leukemia

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0,05

General practice Hematologic pol

4

24

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100 100

60 60

40 40

% %

0 0

Share of true pos.

Falsepositives

Falsepositives

Truepositives

1 % 10 % 100 %

Prevalens of disease

Example: Test sens. = 95 % Test spec. = 95 %

Prevalence most important for the test result

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Diagnosis

- name of disease based on:

• Information from the patient• The anamnesis• Symptoms

• Clinical investigations

• Laboratory tests

To diagnose is to classify

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Migraine

Criteria: Recurrent episodes of headache with three or more of the following finds:

unilateral headache, nausea/vomiting, aura, other nevrological symptoms, migrain in the family

Inclusion: vascular headache with/without aura

Expulsion: cervikogen headache, cluster-headache, tension headache

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Classification of Diagnoses

Reason for contact/

hospitalization

Symptoms, clinical finds,

lab. resultsCode

Diagnostic process

Collect information

Name disease/-problem

Diagnosis criteria

Classify

Inclusion and expultion criteria

Arrange classes

Classification of diagnosis

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Systems for diagnosis class.

Hospitals and specialist services:

ICD (International Classification of Diseases)

Primary care services:

ICPC (International Classification of Primary Health Care)

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Chapter Component

General

conditons

Organ systems

14 chapters

Psychic

problems

Social

problems 1-2 Symptoms Pain, torment Worry 3-6 Process 7-9 Diagnoses Infection Neoplasme Injury Congenital Other

ICPC

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ICPC Diagnosis Prevalence per 1.000

New occurrences per 5. year

K86 Ukomplisert høyt blodtrykk 52 30

K74 Angina pektoris/hjertekrampe 36 23

T90 Diabetes mellitus/sukkersyke 30 14

L88 Reumatoid artritt/andre reum sykd 20 15

T86 Hypotyreose/lavt stoffskifte 17 10

N89 Migrene 15 7

L89 Hofteleddsartrose/-slitasjegikt 14 10

L90 Kneleddsartrose 13 9

T93 Høyt kolesterol 12 14

F93 Glaucom/grønn stær 10 6

H84 Aldersbetinget hørselsvekkelse 9 9

S91 Psoriasis 9 7

N88 Epilepsi 7 3

P85 Psykisk utviklingshemning 7 1

L95 Osteoporose/benskjørhet 6 8

R95 Kronisk obstruktiv lungesykdom 5 4

D94 Mb. Chron/Ulcerøs colitt 5 3

Prevalence of chronic diseases in the practice population

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Main objective of the patient record

• Medical, for the physician as a tool in diagnostics and treatment

• Juridical, for the patient according to rights.

- is now documentation:

- in the future also:

• Communication• Decision support

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Main functions in todays EPR:

• Pasient data/card file function

• Contacts and diagnosis

• Record notes (free text about symptoms, finds and considerations)

• Prescription module

• Laboratory module – requisitions and answers

• Correspondance – Referrals, certificates, word processing

• Schemes – archive, filling in

• Appointment book/waiting list

• Accounting module

• Simple statistics

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• Better overview and be adapted to the working methods of the general practitioner

• Support in diagnose and treatment

• Quality assurance of procedures

• Information sharing

• Information reuse

ERP challenges

A record which can give:

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Mirror the contents and process of the consultation

Subjective – symptoms (anamnesis)

Objektive – Signs and finds (clinical examination/tests)

Assessment – Considerations and conclusion (diagnosis)

Plan – effectuation of action (prescr, report sick etc.)

S

O

A

P

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"While the core of earlier patient records were schemes of book-keeping,the core of EPR ought to be the patient’s health problems represented by episodes of care"

Problem oriented record

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Episode of care

Episode of disease

Primary care Primary careHospital

Contacts: GP GP GP GP HGP Hospitalization

Care services

Nursing home

GP=General pract.H=Home nursing

GP

”Episode of care”

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Diabetes

Osteoarthritis

Depression

Appendix

Tendinitis

Pneumonia

T

Case history (episodes of care)

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Kroniske sykdommer Artrose kneledd Diabetes insulinavhengig Diabetisk nevropati Tidligere sykdommer Depresjon tilbakevendende Appendisitt akutt Tendinitt supraspinatus Pneumoni bakteriell

Problemliste Problemliste

Nytt problem:

Diagnose Kode

Søk

Problem list

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Information needs in daily work

• Questions arise regularly while working with patients:

• attached to treatment, most often medication • can be about much more than medical knowledge• passes usually unanswered

• Preferably physicians ask their colleagues – oral/on the phone

• Information utility value = relevance x validitythe effort needed to find the info

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• Use models and routines from ”best-practice” as foundation

• Convey models and systems from private sector and into the public health care sector

• Try to convey solutions developed in one county, to another

Guaranteed to create problems

Error?

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Mobile enheter Stemmegjenkjenning, Brukergrensesnitt, kurve

Helseinformatikk laboratorium Brukbarhetstesting, Drama og prototyping

Helhetlige forløp Problemorientert journalRepresentasjon av forløp

Beslutningsstøtte Integrering av retningslinjer og behandlingsplaner

SikkerhetRolle- og oppgavespesifikk tilgangskontroll,

Automatisert anonymisering

MeldingsutvekslingAlle til alle kommunikasjon (ELIN-prosjektet)

PasientdeltagelseTilgang til egen journal, rekvirere tjenester via nettet, Egenjournal

Gjenbruk av data ”Datagruvedrift” Helse- og sykdomsregistre

Deling av pasientinformasjon Legemidler, Individuell plan, Helsekort for gravide

Research at NSEPPasientjournalens rolle og funksjon

Implementering og anvendelseFeltmetodikk