Computerization of the practice

Grzegorz Margas, M.D., Ph.D.Department of Family Medicine

Jagiellonian University Medical College

EHR Electronic Health Record

“An aggregate electronic record of health-related information on an individual that is created and gathered cumulativaly accros more than one health organization and is managed and consulted by licensed clinicians and staff involved in the individuals’s health and care.”

National Alliance for Health Information Technology (NAHIT)

Components of EHR

• Health information and data– Patient demographics– Patient problem list– Electronic lists of medication taken by patients– Clinical notes– Medical history and follow-up

Components of EHR

• Order-entry management– Prescriptions– Laboratory tests– Radiology tests– Electronic prescriptions– Orders sent electronically

Components of EHR

• Results management– Viewing laboratory results– Viewing imaging results

• Clinical decision support– Warning of drug interactions/contraindications– Out-of-range test levels highlighted– Reminders regarding screening, vaccinations

Primary Care Doctors’ Use of Electronic Patient Medical Records

Schoen C et al. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries. "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009." Health Affairs Web Exclusive 2009 Nov 5; w1171–w1183

Practice Use of IT on a Routine Basis for Core Tasks: Electronic entry of clinical notes

Schoen C et al. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries. "A Survey of Primary Care Physicians in Eleven Countries: Perspectives on Care, Costs, and Experiences, 2009." Health Affairs Web Exclusive 2009 Nov 5; w1171–w1183

Electronic Medical Record System Access

Practices with Advanced Electronic Health Information Capacity

Percent of primary care doctors reporting at least 9 of 14 clinical IT functions*

*The 14 functions include: electronic medical records; the ability to prescribe medicine and order tests electronically; electronic access to test results, Rx alerts, clinical notes; a computerized system for tracking lab tests, guidelines, alerts to provide patients with test results, preventive/follow-up care reminders; and a computerized list of patients by diagnosis, medications, and due date for tests or preventive care.

Practices with Advanced Electronic Health Information Capacity

Percentage of primary care doctors reporting at least 7 of 14 clinical IT functions*

Notes: The 14 Clinical IT functions include: EMR, EMR access to other doctors, outside offices and patients; the routine use of ordering tests, writing prescriptions, accessing test results, accessing hospital records electronically; using the computer for reminders, Rx alerts, prompt tests results; diagnoses, medications and patients due for care that are easy to check.

Steps to computerization:Administrative

1. Billing

2. Word-processing

3. Internal e-mail & non-clinical external e-mail

4. Appointments

5. Statuatory requirements for data entry & reporting

Steps to computerization:Clinical

1. Prescribing

2. Decision support (prescribing)

3. External clinical data capture / remote links

4. Consultation data

5. Care protocols

6. Clinical audit

7. Patient education