The Medical record History and informations

The Medical Record History

Created by
dr Iwan suwandy,MHA

Copyright @ 2012



Medical record

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient‘s medical history and care across time within one particular health care provider’s jurisdiction.[1]. The medical record includes a variety of types of “notes” entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a fundamental requirement of health care providers and is generally enforced as a licensing or certification prerequisite.

The terms are used for both the physical folder that exists for each individual patient and for the body of information found therein.

Medical records have traditionally been compiled and maintained by health care providers, but advances in online data storage have led to the development of personal health records (PHR) that are maintained by patients themselves, often on third-party websites[2]. This concept is supported by US national health administration entities[3] and by AHIMA, the American Health Information Management Association.[4]

A medical record folder being pulled from the records

Because many consider information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal[5]. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request. [6].

[edit] Purpose

The information contained in the medical record allows health care providers to determine the patient’s medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient’s care.

The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes (SOAP notes), preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes.

Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.[5].

[edit] Auxiliary purpose

In addition, the individual medical record anonymised may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research.

[edit] Contents

A patient’s individual medical record identifies the patient and contains information regarding the patient’s case history at a particular provider. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient[7]. Further information varies with the individual medical history of the patient.

The contents are written by medical providers, and patients until relatively recently had no say in what was contained in it. Recent advances in health care records privacy and access rules have generally provided for a patient’s right to review and have recorded in the medical record objections to the accuracy of certain entries.

[edit] Media applied

Traditionally, medical records were written on paper and maintained in folders often divided into sections for each type of note (progress note, order, test results), with new information added to each section chronologically. Active records are usually housed at the clinical site, but older records are often archived offsite.

The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research.

Maintenance of medical records requires security measures to prevent from unauthorized access or tampering with the records.

[edit] Medical history

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.

Surgical history
The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did.
Obstetric history
The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies.
Medications and medical allergies
The medical record may contain a summary of the patient’s current and previous medications as well as any medical allergies.
Family history
The family history lists the health status of immediate family members as well as their causes of death (if known)[8]. It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient.
Social history
The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos).
Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation.
Immunization history
The history of vaccination is included. Any blood tests proving immunity will also be included in this section.
Growth chart and developmental history
For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child’s growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child’s behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth.

[edit] Medical encounters

Within the medical record, individual medical encounters are marked by discrete summations of a patient’s medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a “SOAP” method of documentation for each visit. Each encounter will generally contain the aspects below:

Chief complaint
This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored.
History of the present illness
A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention.
Physical examination
The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing.
Assessment and plan
The assessment is a written summation of what are the most likely causes of the patient’s current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.).

[edit] Orders and prescriptions

Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.

[edit] Progress notes

When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.

[edit] Test results

The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of X-rays, a written report of the findings is included in lieu of the actual film.

[edit] Other information

Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments.

There are several types of information needed to be recorded while tracing the state of a patient’s daily health:

  • vital signs: body temperature, pulse rate (heart rate), blood pressure and respiratory rate;
  • intake: medication, fluid, nutrition, water and blood, etc.;
  • output: blood, urine, excrement, vomitus, sweat, etc.;
  • observation of pupil size;
  • capability of four limbs of body.

[edit] Administrative issues

Medical records are legal documents, and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.

[edit] Demographics

Demographics include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupation. It may also contain information regarding the patient’s health insurance. It is common to also find emergency contacts located in this section of the medical chart.

[edit] Production

In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.

[edit] Informational self-determination

The informational self-determination is a basic human right. Hence a patient’s record should belong to the patient, but it seldom happens so.

[edit] Ownership for patient’s record

Ownership and keeping of patient’s records varies from country to country.

[edit] US law and customs

In the United States, the data contained within the medical record belongs to the patient[citation needed], whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the Health Insurance Portability and Accountability Act[9]. Therefore, patients have the right to ensure that the information contained in their record is accurate[citation needed]. Patients can petition their health care provider to remedy factually incorrect information in their records.[citation needed]

[edit] UK law and customs

In the United Kingdom, ownership of the NHS‘s medical records belong to the Department of Health,[10] and this is taken by some to mean copyright also belongs to the authorities.[11]

[edit] German law and customs

In Germany ownership of patient’s records is not explicitly codified. Hence traditional keeping of patient’s records is with the hospitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1995, patients are identified via a health insurance card that includes name and address information as well as an ID assigned by the insurance provider. An upgrade to advanced health insurance cards (Elektronische Gesundheitskarte) that can store additional medical information was planned for 2006. Discussion on the benefit, the associated cost, and on data privacy issues is still ongoing as of 2011.

[edit] Accessibility

In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health-care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.

When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient’s behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication.
Medical emergency
In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an advance directive)
Research, auditing, and evaluation
Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however.
Risk of death or harm
Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond[6].

In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000 gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient’s wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.

[edit] Destruction

In general, entities in possession of medical records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patient’s death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the Harold Shipman case).[12]

[edit] Abuses

  • The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data.
  • Falsification of a medical record by a medical professional is a felony in most United States jurisdictions.
  • Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

[edit] Standardization

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[edit] See also

Electronic health record

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Sample patient record view from an image-based electronic health record (VistA)

An electronic health record (EHR) refers to an individual patient’s medical record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a network. It may be made up of electronic medical records (EMRs) from many locations and/or sources. Among the many forms of data often included in EMRs are patient demographics, medical history, medicine and allergy lists (including immunization status), laboratory test results, radiology images, billing records and advanced directives.

EHR systems can reduce medical errors.[1] In one ambulatory healthcare study, however, there was no difference in 14 measures, improvement in 2 outcome measures, and worse outcome on 1 measure.[2]

EHR systems are believed to increase physician efficiency and reduce costs, as well as promote standardization of care. Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, less than 10 percent of hospitals as of 2006 have a fully integrated system.[3]


[edit] Overlap in Terminology

Multiple terms have been used to define electronic patient care records, with overlapping definitions.[4] Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some health informatics users assigning the term EHR to a global concept and EMR to a discrete localised record. For most users, however, the terms EHR and EMR are used interchangeably. An EHR system is also often abbreviated as EHR or EMR. Information in the section on EMRs electronic medical record may be more relevant to physician offices seeking a less expensive or comprehensive solution.

Health Information Technology is an even broader term that describes any computer-based electronic aid to healthcare delivery.

An electronic health record is a patient’s health record that has been compiled into a digital format.

[edit] Background

In his joint address to Congress in 2009, Obama stated that:

“Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down cost, ensure privacy, and save lives” [5]

[edit] Categories of information in a patient record

A patient record consists of 4 main categories of information. Some information requires digitization. Other forms of information are by nature digital but require an infrastructure designed for secure access through the EHR.

[edit] Textual information

Textual information in a patient record include notes and individual reports.

[edit] Data for Calculations

Data for calculations or graphing from laboratory reports are included in a patient record. This information is used for searching or decision support.

[edit] Multimedia

Multimedia information in a patient record such as diagnostic images are typically located in various departments in a healthcare facility. The large volume and disparate locations of this data make the electronic health record the only viable way for access.

[edit] Paperwork

Patient records include signed forms, hand drawn figures, photographs of wounds, and other various forms of paper-based documentation.

[edit] Advantages of electronic medical records

There are several benefits to wide scale usage of electronic health records.

[edit] Reduce healthcare costs

One of the major sources of rapid growth in healthcare costs comes from medical imaging. Medicare Part B spending on imaging rose from $6.80 billion in 2000 to $14.11 billion in 2006.[6] Access to a patient’s images in an EHR is an effecive way to avoid duplicating expensive imaging procedures. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.

[edit] Improve quality of care

An EHR system can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine enable proliferation of ongoing improvements in healthcare efficacy.

[edit] Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices.

These benefits may be realized in a realistic sense only if the EHR systems are interoperable and wide spread (e.g. national) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medial informatics must be deployed.[7]

EHRs also have the advantages of electronic medical records (EMR). In general, medical records may be on “physical” media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.

Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance.

In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic medical records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.[8][9]

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[10] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In contrast, EMRs can be continuously updated. The ability to exchange records between different EMR systems (“interoperability”[11]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[12]

[edit] Lack of adoption of EHRs in the United States

US medical groups’ adoption of EHR (2005)

Outside of the Veterans Health Administration system, the vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s.

As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Less than 10% of American hospitals had implemented HIT,[13] while a mere 16% of primary care physicians used EHRs.[14] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.[2][15] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.[15] However, less than one-tenth of these physicians actually had a “complete EMR system” (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).[16]

The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.[17][18][19]

The reasons for the lack of adoption of EHRs in the United States include:

[edit] Costly investment for providers

The selection, implementation and usage of an EHR system is expensive, time-consuming and burdensome. The success of the system has a lot of dependencies such as quality IT leadership and product reliability.

Until recently, with the American Recovery and Reinvestment Act of 2009, providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.

[edit] Problems with EHR products on the market today

Physicians find available health IT software frustrating due to its poor usability.[20] Today’s products lack interoperability and capabilities required to experience the benefits that outweight the risks.

[edit] Attempts to facilitate EHR compatibility in the United States

The Veterans Administration health care system in the United States, with over 155 hospitals and 800 clinics, represents one of the largest integrated healthcare delivery systems in the world. It relies on a single EHR system called VistA, which has been in use for years. Data exchange is facilitated by a protocol called BHIE (Bidirectional Health Information Exchange), and the VA healthcare network is being expanded in 2007 to integrate the Department of Defense healthcare facilities using the BHIE networking protocol.

This EHR has been made publicly available for download and has been adapted for use in many non-VA hospitals and healthcare networks. As BHIE becomes more widely available, a national healthcare network will be facilitated.

Outside of the VA’s EHR system, however, there are currently at least 25 major competing vendors of EHR systems, many selling software incompatible with competitors.

This lack of interoperability provides a significant barrier to a “National Health Information Network.”[21] In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer. Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. The US Congress is currently working on legislation to increase funding to these and similar programs.

[edit] Benefits of EHR standardization / National Healthcare Information Network

[edit] Improved billing accuracy

Although billing is now largely accomplished electronically in the United States, these claims often require additional documentation from a patient’s medical record. This is a tedious task when records are in an electronic format not compatible with the billing program, or when the records are in paper format. An integrated electronic medical record / billing system, therefore, both expedites and makes billing more accurate.

[edit] Reduction in duplication of services

Duplication of lab tests, diagnostic imaging, work-ups, and other services can be prevented by good record-keeping of any type. However, because electronic records can be available at many locations at once, integration of services and awareness of duplication is facilitated.

[edit] Facilitation of clinical trials

Clinicians and researchers suggest benefits to integrating electronic health records with data collection and analysis in clinical trials.[22]

[edit] Improved access to medical records

Records, once a few years old are typically put into long-term storage as records must be kept for as long as 21 years. Electronic medical records enable health organizations to access old records instantly, thereby allowing them to be sent to another health organization in the event of an emergency. Many EHR systems now offer integrated Patient Portal or Personal Health Record systems which allow patients and 3rd parties to access medical records with a secure username and password.

Potential clinical trial participants may be more easily identified, administrative overhead costs may be lessened, data errors may be reduced, and adverse outcomes may be more rapidly identified.[22]

Some institutions have already been partially successful in implementing and integrating co-ordinated data collection and analysis systems. For example, the Shared Pathology Network (SPIN) of the National Cancer Institute has effectively established a web-based network for locating pathological tissue samples at various institutions across the nation.[23] The electronic nature of reports within the system allows the use of search engines to find specific text with the reports, facilitating analysis.[24]

[edit] Organizations to evaluate standardization proposals

Several models of standardization for electronic medical records and electronic medical record exchange have been proposed and multiple organizations formed to help evaluate and implement them.[25][26]

[edit] Organizations

  • CHI (Consolidated Health Informatics Inititiative) – recommends nationwide federal adoption of EHR standards in the United States
  • CCHIT (Certification Commission for Healthcare Information Technology) – a federally funded, not-for-profit organization that evaluates and develops the certification for EHRs and interoperable EHR networks (USA)
  • IHE (Integrating the Healthcare Enterprise) – a consortium, sponsored by the HIMSS, that recommends integration of EHR data communicated using the HL7 and DICOM protocols
  • ANSI (American National Standards Institute) – accredits standards in the United States and co-ordinates US standards with international standards
  • Healthcare Information and Management Systems Society (HIMSS) – an international trade organization of health informatics technology providers
  • American Society for Testing and Materials – a consortium of scientists and engineers that recommends international standards
  • openEHR – provides open specifications and tools for the ‘shared’ EHR
  • Canada Health Infoway – a federally funded, not-for-profit organization that promotes the development and adoption of EHRs in Canada
  • World Wide Web Consortium (W3C) – promotes Internet-wide communications standards to prevent market fragmentation
  • Clinical Data Interchange Standards Consortium (CDISC) – a non-profit organization that develops platform-independent healthcare data standards
  • EHR-Lab Interoperability and Connectivity Standards (ELINCS) – run by the HL7 group to help provide lab data and other EHR interoperability

[edit] Standards

  • ANSI X12 (EDI) – transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
  • CEN‘s TC/251 provides EHR standards in Europe including:Continuity of Care Record – ASTM International Continuity of Care Record standard
    • EN 13606, communication standards for EHR information
    • CONTSYS (EN 13940), supports continuity of care record standardization.
    • HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
  • DICOM – an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
  • HL7 – a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
  • ISOISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures

[edit] Barriers to deploying an EHR system

[edit] Difficulty in adding older records to an EHR system

Older paper medical records ought to be incorporated into a patient’s electronic health record.

One method is to merely scan the documents and retain them as images. However, surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone rather than fully electronic data-based systems.[27] EHR systems with image archival capability (such as VistA Imaging) are able to integrate these scanned records (along with other types of image-based records) into fully electronic health records systems.

Another method to convert written records (such as notes) into electronic format is to scan the documents then perform optical character recognition. For typed documents, accurate recognition may only achieve 90-95%, though, requiring extensive corrections. Furthermore, illegible handwriting is poorly recognized by optical character readers.

Some states have proposed making existing statewide database data (such as immunization records) available for download into individual electronic medical records.[28]

[edit] Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives.

Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al have noted that “choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.”[29]

The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research “describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures.”[30]

In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that “the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information.”[31]

[edit] Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. This is a problem that plagues distributed computer records in all industries.

Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks).

In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.[32][33]

Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.

Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.[34][35][36]

[edit] Privacy

Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient’s records during a hospitalization, and 600,000 payers, providers and other entities that handle providers’ billing data have some access also.[37] Recent revelations of “secure” data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[38] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of implementation of these standards.

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[39]

Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law’s implementation.[40] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec.

Privacy and Security of the Electronic Health Record: As the ever-changing healthcare industry evolves, one key topic within the electronic health record (EHR) is privacy. The Federal government has set guidelines that all healthcare organizations will have to comply with in regards to electronic health transactions. Most supporters believe that the EHR will improve care and reduced costs, while transforming the health care system, but whether the privacy of the records will be upheld is yet to be determined. A successful partnership for administrative health data standards can promote the development of clinical data standards and their application in computer based patient record systems.[41]

One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. President Bush calls for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”[42]

The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while “hospitals keep careful tabs on who accesses the charts of VIP patients,” they are powerless to act against “a meddlesome pharmacist in Alaska” who “looks up the urine toxicology on his daughter’s fiance in Florida, to check if the fellow has a cocaine habit.”[43] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the U.S. Supporters of EHRs have argued that there needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records if adoption of an EHR is to occur.[44]

According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client’s knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes. Stanford had merged her notes with her general medical record, and the general medical record wasn’t covered by HIPAA restrictions.[45]

Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[44] Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[42] So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.

[edit] Hardware limitations

Computer access is required to use an electronic health record system. A sufficient number of workstations, laptops, or other mobile computers must be available to accommodate the number of healthcare providers at any one facility.[46] EHR software ought to be backwards compatible with older technology so that existing technology infrastructure can be used. Furthermore, most healthcare facilities have at least some degree of existing computerization, whether in the lab or in billing services. EHR systems need to interface with existing systems, again mandating a modular approach.[47]

In the past, poor networking technology was a limiting factor in the adoption of EHR software. There are now solutions which profit from new networking and mobile technology.[48][49]

[edit] Cost Advantages and Disadvantages

Most practitioners and healthcare organizations will agree that both quality healthcare and medical error reduction take precedence over many other healthcare concerns. Common knowledge to most, the U.S. allocates a vast amount of funds towards the health care industry—more than $1.7 trillion per year.[50] Unfortunately, these distributed funds have not significantly improved the U.S.’s quality of healthcare. The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.[50] Of course, such savings will not occur overnight and will require EHR adoption by most healthcare businesses. Obviously, these savings can lead to healthcare quality promotion. In addition, these savings are not limited to businesses alone: If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.[50] Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.[51] Furthermore, If patients are aware of their opportunities, they are more likely to comply with their doctors’ recommendations; thus, reducing future hospital visits and saving money. Despite the advantages, many providers have not adopted EHR due to its expensiveness: The cumulative cost for 90 percent of hospitals to adopt an EHR system is $98 billion [and] $17.2 billion for physicians.[50] The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[52] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[52] Overall, physicians in the focus groups did not see any financial incentives for adopting an EHR. In other words, if providers do use an EHR system, not only do they have to pay for it, but they also have to pay for the maintenance of the system and classes to train staff. Moreover, technology is not perfect. On occasion, systems crash and experience technical difficulties, which is very costly to repair. Such issues make providers question if EHR is a step they are willing to take. Overall, EHR systems provide more benefits than disadvantages to patients and the economy. These systems can improve savings and the quality of healthcare to a superior level.

The U.S. Congressional Budget Office concluded that the cost savings may only occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. “Office-based physicians in particular may see no benefit if they purchase such a product – and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR’s cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians.” If a physician performs tests in the office, it might reduce his or her income. “Given the ease at which information can be exchanged between health it systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used.”[53]

[edit] Start-up costs and software maintenance costs

In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.[54] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).[55][56][57] Vendor costs only account for 60-80% of these costs.[58]

There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 – $7500/provider and $67 – $750/month per provider.[59]

Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.[60] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.[61]

Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.[62][63]

Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.[64]

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[65]

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the VistA electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems eventually retire.

[edit] Inertia

Most large organizations resist change. The institutional stress of implementing any new large-scale system must be anticipated by management. According to the Agency for Healthcare Research and Quality‘s National Resource Center for Health Information Technology, EHR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself.

The healthcare industry has more licensed professionals with advanced degrees than any other industry. However, systems analysis and computer science has not, until recently, been an integral part of healthcare training. Most health administrators also lack training in computer science.

[edit] Legal barriers

[edit] Liability barriers

Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[66] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[67]

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[68]

This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[69] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.

In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital’s software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[70] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[71][72]

[edit] Ownership of electronic records

HIPAA standards allow patients the right to review the content of their medical records.

When records are centralized, it is often difficult to determine whose responsibility it is to maintain the records. If a company agrees to manage and maintain records but goes out of business, how does that impact the healthcare provider whose ultimate responsibility it is for record maintenance?

If a healthcare provider retires or goes out of business, what arrangements to convert records to archival formats are available?

If an individual physician and a hospital system share a record database system but then the individual physician leaves that healthcare system, how does she separate her practice’s records from the hospital’s central database to take them with her for archival, as often required by law?

Who determines the frequency of “purging” of records?

A patient may store a portion of his/her health records online or with an independent storage service (in a health record trust), in which case that subset of records is no longer under the control of the healthcare provider. This transfers HIPAA liabilities to the databank that stores the records for the individual. Concerns about loss of data integrity and lessened HIPAA adherence arise, because these records are no longer part of the health record maintained by the healthcare provider.

[edit] Unalterability of records, spurious records, and digital signatures

Medical records must be kept in unaltered form and authenticated by the creator. However, simple mistakes often create spurious documents. How are spurious documents identified so that they do not clutter the medical record without altering or disposing of them illegally?

Most national and international standards now accept electronic signatures.[73] However, a database of electronic signatures must be created as an EHR system is implemented.

[edit] Customization

Each healthcare environment functions differently, often in significant ways. It is difficult to create a “one-size-fits-all” EHR system.

An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.

This customization can often be done so that a physician’s input interface closely mimics previously utilized paper forms.[74]

At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[75] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[76]

Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.[77][78]

These hurdles make customizations that can be made publicly available through an open source model more desirable.

[edit] Comparison of EHR software solutions

Basic general information about major software solutions: creator/company, license/price etc., focusing on small-scale practice systems.

Software Name Creator Preferred Vendor Latest stable version Cost (USD) Software license
MedEZ MedEZ/ISS – MedEZ – 954-332-4700 6.0.4 Module Based with Electronic Document Management and Clinical Notes-Customizable Proprietary
Medisoft Clinical EMR McKesson Corp – JB Medical – 877-787-8686 9.3.1 $5480 First Doctor, $3400 Subsequent Proprietary
Unifi-Med Unifi Technologies 4.0 $500/mo Full Suite subscription Web-based service
Iasis Free EMR-ERM Practice Management
Online Doctors Community
Forums,Medical News
V1.0.0.306 $0.0 Freeware -Registration Required-Multi User, Customizable,All Specialties Supported Proprietary
Therapy Office EMR Asmakta Ltd   9.1   Proprietary
Document Busters Document Busters, Inc.   Proprietary
EDrawer LSSP Corporation 4.3.209   Proprietary
Medrecordonline EMR/EHR/PHR built it with medsystemonline Meddserve Ltd 10.1   web-based software as a service
Medsysonline EMR/EHR/PHR built it with medrecordonline Meddserve Ltd 10.1   web-based software as a service
eClinicalWorks eClinicalWorks,
EaseMD Systems, 866-321-2828
8.0 CCHIT Certified – Monthly fee; Direct Purchase: $10,000 for first doc, $5,000 for subsequent Proprietary
ICS National Medical Imaging 2.5 Initial Setup plus a Monthly Fee GNU GPL V2 and Proprietary
ClearHealth ClearHealth Inc. Clearhealth 2.2 EMR Scheduling/ Billing / PM GNU GPL V2
Amazing Charts EHR Jonathan Bertman   4.0 from $995 Proprietary
e-MDs Razor EMR e-MDs   6.3 from $2,995 Proprietary
Sevocity Conceptual MindWorks, Inc.   5.1 from $460 per month Proprietary
Praxis EMR Infor-Med  ? 4  ?
CureMD EMR CureMD Corporation   10 (custom pricing) Proprietary
Medscribbler Scriptnetics Inc.   5 from $2,899.99 (custom pricing) Proprietary
MedicWare EMR MedicWare  ?  ?  ? Proprietary
SOAPware SOAPware, Inc. SOAPware, Inc. 1-800-455-7627 2008.0 from $995.00 Proprietary
NextGen EMR NextGen MMIC Technology Solutions, 1-800-328-5532,  ?  ? Proprietary
SequelMed EHR SequelMed,
Sequel Systems 800-965-2728
7.5 from 5,000.00 Proprietary
MediNotes e EHR MediNotes AutoMED Software 516.369.7091, Medisys 304-204-3400 5.2 from 5,000.00 Proprietary
JonokeMed Jonoke Software Development Inc.   4.05.01  ? Proprietary
HealthHighway EMR HealthHighway Inc.  ? 3.1  ? Proprietary
HARMONY MedTec   5.21  ? Proprietary
OmniMD EMR OmniMD  ?  ? from $325/month (custom pricing) Proprietary
simplifyMD Matt Ethington  ? 3.0 Custom per Practice Proprietary
ICChart InteGreat Concepts, Inc.
6.1 See vendor web-based system
MedTrak MedTrak Systems, Inc. MedTrak Systems Continuously updated (web based system) Transaction based pricing based on type of visit Proprietary
Greenway PrimeSuite Greenway Medical Technologies Mds medical See vendor Proprietary
gGastro / gCardio / gUro gMed gMed ] See vendor Proprietary
Turbo-Doc Turbo-Doc Electronic Medical Records 11x $4000/doctor(associated staff included), Optional $600/yr maintenance/upgrade agreement. Proprietary
Medical and Practice Management Suite LSS Data Systems LSS Data Systems 5.6 See Vendor  
  Creator Preferred Vendor Latest stable version Cost (USD) Software license

Operating system compatibility (* using virtualization):

Client Windows Mac OS X Linux BSD Unix AmigaOS
MedEZ Yes No No No No No
Medisoft Clinical Yes No No No No No
Iasis Free EMR-EHR Practice Management Yes No No No No No
ICS Yes Yes Yes Yes Yes Yes
Amazing Charts Yes Yes* Yes* No No No
e-MDs ‘Razor’ EMR Yes Yes Yes Yes Yes Yes
eClinicalWorks EMR Yes No Yes No ? No
SequelMed EHR Yes Yes Yes No No No
Sevocity Yes Yes Yes No Yes No
Praxis EMR Yes No No No No No
CureMD EMR Yes No No No No No
Medscribbler Yes No No No No No
MedicWare EMR Yes No No No No No
SOAPware Yes Yes Yes No No No
NextGen EMR Yes No No No No No
MediNotes e EMR Yes No No No No No
JonokeMed Yes Yes No No No No
HealthHighway EMR Yes Yes Yes No Yes No
HARMONY Yes No Yes No Yes No
OmniMD EMR Yes No No No No No
simplifyMD Yes Yes Yes Yes Yes Yes
ICChart Yes No No No No No
Greenway PrimeSuite Yes No No No No No
gGastro / gCardio / gUro Yes No No No No No
MedTrak Yes Yes No No No No
Turbo-Doc Yes No No No No No
Client Windows Mac OS X Linux BSD Unix AmigaOS

[edit] Successful implementations of EHR systems

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or VistA. A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA’s over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.

The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.

As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT).[79]

Australia is dedicated to the development of a lifetime electronic health record for all its citizens. HealthConnect is the major national EHR initiative in Australia, and is made up of territory, state, and federal governments. MediConnect is a related program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[80]

The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.

[edit] Failures in Health Information Technology implementation

In 2002 at Cedars Sinai Medical Center in Los Angeles, physician dissatisfaction forced the administration to scrap a proprietary $34 million Central Physician Order Entry system that was developed within the medical center itself. Physicians were reported by nurses as being embarrassed by the number of errors the system caught and corrected, as well as being frustrated by the slow performance of the system.[81] It is notable that the system had never been used or tested outside of Cedars-Sinai.

As many as 30% of EHR implementation attempts have failed over the past few years, according to the National Health Information Network Co-ordinator, David Brailer.[81] Brailer’s Santa Barbara County Care Data Exchange failed for a variety of reasons including poor project management, technical challenges, and a failure to create a compelling business model for the participants.[82]

Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. As of October 2006, CCHIT had certified 34 ambulatory EHR products.[83][84]

[edit] Software criteria of interoperability

The Center for Information Technology Leadership described four different categories (“levels”) of data structuring at which health care data exchange can take place.[85] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are:[86]

Level Data Type Example
1 Non-electronic data Paper, mail, and phone call.
2 Machine transportable data Fax, email, and unindexed documents.
3 Machine organizable data (structured messages, unstructured content) HL7 messages and indexed (labeled) documents, images, and objects.
4 Machine interpretable data (structured messages, standardized content) Automated transfer from an external lab of coded results into a provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.

[edit] Related and supporting technologies

An unusual form of Health Information Technology is the VeriChip system, an RFID microchip that can be implanted under the skin to give instant access to a patient’s records. The tiny electronic device, produced by Applied Digital Solutions Inc. of Delray Beach, Florida, transmits a unique code to a scanner that allows doctors to confirm a patient’s identity and obtain detailed medical information from a database maintained by Applied Digital. Only the identification is provided by the implant, so the system remains limited to hospitals, doctors and patients having access to the scanner.[87]


[edit] References

  1. ^ [1]
  2. ^ [2]
  3. ^ National Institute for Health
  4. ^ American Health Information Management Association
  5. ^ Health Information Privacy
  6. ^ [3]
  7. ^ A Sample Health Record
  8. ^ [4]
  9. ^
  10. ^ Moyle R (30 November 1976). “Written Answers (Commons): SOCIAL SERVICES: Medical Records (Ownership and Storage)”. Hansard 921 (c91W). “Personal medical records, including X-rays, in respect of patients treated under the NHS are held to be the property of the Secretary of State. NHS hospital medical records are stored in premises designated by the appropriate health authority. Access to a patient’s medical records is governed in the patient’s interest by the ethics of the medical and allied professions.” 
  11. ^ “Policy and Procedure For Records: Retention & Disposal” (PDF). Mersey Care NHS Trust. December 2003. Retrieved 2008-07-05. “ownership and copyright in these records as a rule is with the NHS Trust or Health Authority, not with any individual employee or contractor.” 
  12. ^ “Government ‘Breached Ex-Soldier’s Human Rights'”. The Guardian. October 20, 2004.,11816,1331784,00.html

News from the International

Medical Informatics


IFHIMA Congress and Global News; AHIMA Changes

and Congress

The International Federation of Health Information Management (IFHIMA –,

formerly known as IFHRO, has announced that their next triennial Congress will be held in Montreal,

Canada on


May 13-15, 2013


. Full information will become available in due course at


IFHIMA supports national associations and health record professionals to implement and improve


health records, and the systems which support them.


IFHIMA’s “Global News” newsletter (current and past issues) is available at http://www.ifhima.


org/news.aspx). The latest issue (August 2011) contains a range of articles relating to health records/


information management in different countries.


IFHIMA is an Affiliate Member of IMIA and is entitled to be represented at the IMIA General Assembly.


The American Health Information Management Association (AHIMA) has recently appointed a


new CEO,





Lynne Thomas Gordon


, MBA, RHIA, FACHE. Full information on the full Board of Directors

of AHIMA is at The 83rd AHIMA Convention &


Exhibit finished in Salt Lake City, USA (see


Reports from the event are at


AHIMA is a Corporate Institutional Member of IMIA




3rd Annual Innovations in Healthcare Management and

Informatics Conference – Bangkok, Thailand, March 2012

The 3rd Annual Innovations in Healthcare Management and Informatics Conference, organised by

IQPC Worldwide Pte. Ltd., will take place on


13-15 March 2012


in Bangkok, Thailand. Full information

is available on the event website at there is also a


downloadable pdf version of the information.


The 3rd HIT 2012 brings together an international gathering of over 30 healthcare leaders and informatics


experts to present latest case studies and implementation experience from Europe, US,


Australia and Asia. One focus will be on gaining insights on the Thai government’s National Public


Health Information Reform experience.


Among the many speakers who will be known to IMIA members are:





Prof. Michael Legg


, Professorial Fellow, Centre for Health Informatics and e-Health Research,

University of Wollongong





Mike Bainbridge


, Clinical Architect, NHS Connecting for Health, UK




Prof. Jim Warren


, Professor and Chair in Health Informatics, University of Auckland




Yu-Chuan (Jack) Li


, Professor and Dean, College of Medical Science and Technology, Taipei

Medical University





Dr. Chun Por Wong


, Chief of Integrated Medical Services, Ruttonjee Hospital of Cataract and Refractive

Surgery, & International Council, International Society of Refractive Surgery





Pekka Ruotsalainen


, Research Professor, National Institute for Health and Welfare (THL) and

Adjunct Professor, University of Tampere




© 2011 published: October 26, 2011

© 2011 published: October 26, 2011 News from the International Medical Informatics Association




Applied Clinical Informatics





Prof. Michio Kimura


, Professor of Radiology, Hamamatsu Medical University, Japan




Dr. S. B. Gogia


, President, Society of Administration of Telemedicine and Healthcare Informatics,



IMIA members can enjoy an exclusive 15% discount when they register for the conference. A special


pricing for hospitals is also available through contacting the organisers directly to find out more at


+65 6722 9388 or · Contact: +65 6722 9388 /




Establishing an evidence base for e-health: WHO Bulletin –

Call Closes 20 November

The open call for contributions to a Special Theme Issue of the Bulletin, on the theme “Establishing

an evidence base for e-health” closes on


20 November, 2011


. We encourage all IMIA members and

colleagues to publicise this as widely as possible to their members, contacts, networks, etc. We also ask


all IMIA members and friends, especially those in low and middle income countries, to consider contributing


to this call.


The Editorial/Call can be found at (HTML


version) or downloadable PDF file at Manuscripts


should respect the Guidelines for contributors and mention the call for papers in a covering


letter. All submissions will go through the Bulletin’s peer review process. Please submit to:


IMIA President





Antoine Geissbuhler and Najeeb Al Shorbaji


(WHO Department of Knowledge

Management and Sharing) published the Editorial and Call for Papers in the June 2011 edition of the


Bulletin of the World Health Organization. Titled “Establishing an evidence base for e-health: a call


for papers”, the editorial is an open call for contributions to a Special Theme Issue of the Bulletin.


This is part of a joint project between IMIA and, among others, a range of US government agencies


(including PEPFAR, CDC, and USAID), IDRC, as well as the Global Health Informatics Partnership


(GHIP). In addition to the open call, commissioned papers on specific topics from within IMIA and


from among the wider global health informatics community are being developed.


As Antoine and Najeeb note: “Evidence is needed to promote equity of access to information and


health services, and to strengthen activities and programmes that support local, regional, national


and global health communities. There is a critical need to communicate evidence and to provide


examples of best practice in the development of effective and efficient solutions to major health challenges.”


The objectives of the theme issue of the Bulletin are


1. to provide an authoritative, critical and independent overview of knowledge about the appropriate,


transdisciplinary methods and applications in e-health;


2. to include contributors from developing countries who typically do not have the opportunity to


publish in international journals; and


3. to disseminate the key findings of this theme issue to high-level decision-makers, to promote a


stronger commitment on e-health interoperability issues and its wider application.


The Bulletin, one of the world’s leading public health journals, is a peer-reviewed monthly with a


special focus on developing countries. The Bulletin is one of the top 10 public and environmental


health journals. It is essential reading for all public health decision-makers and researchers who


require its special blend of research, well-informed opinion and news.


IMIA is a Non Government Organization (NGO) in special relationship with the World Health


Organization (WHO).




Turning Scientific Knowledge into Effective Action for Health

– PAHO/WHO Webinar, Nov. 3

The latest in the series of PAHO/WHO monthly live webinars on Equity and Health – Access to Information,

titled “Turning Scientific Knowledge into Effective Action for Health”, will be offered on



3rd November 2011


, from 10:00 AM to 12:30 PM WDC time (check the local time in your

own town at


With a hands-on approach, this two-hour online workshop will train participants on how to use


the online tools available through the Virtual Health Library (VHL), as well as from the National Library


of Medicine (NLM) Online Databases, effectively. Furthermore, this online workshop will


highlight other Web resources tailored to the public health workforce. Participants will be able to:







Identify resources to support public health programs and activities






Retrieve information in support of evidence-based public health






Obtain data sets and statistics relevant to public health on state, local, national, regional and world








Identify resources available to stay informed of developments related to public health and environmental








Lorely Ambriz Irigoyen


, M.S.I.S , PAHO/WHO U.S.-Mexico Border Office Knowledge

Management & Communications


The event is free, and no prior registration is required. To log in, simply type your name and


organization) of participants at


PAHO/WHO Webinars are free and open to interested people. You may attend virtually from your


personal or work computer anywhere in the world. In addition to watching live presentations, you


will have the option to ask questions and provide comments. You just need a computer, internet connection,


speakers and a mic/headphone. You will also be able to write comments and continue the


discussion after the webinar.


For additional information, please contact AnaLucia Ruggiero




HIMSS12 Keynote Speakers

HIMSS12, the Annual Conference and Exhibition of the Healthcare Information and Management

Systems Society, (HIMSS – will be held on


February 20-24, 2012


in Las

Vegas, Nevada, USA (Monday to Friday – note, this is a change from the schedule of previous years).


HIMSS12 will be held at the Sands Expo and Convention Center, adjacent to the Venetian and the Palazzo


hotels, Las Vegas. Full information about the event is at and


will be updated in coming months.


Symposia and Pre-Conference Workshops are being held on Monday, a day later than usual; the


Exhibits will be open on Tuesday – Thursday, and the Education Sessions will be on Tuesday – Friday.


HIMSS12 expects to offer more than 400 educational opportunities on hot topics and in excess


of 1,000 exhibits with cutting edge product solutions. Keynote presenters announced so far include:





Biz Stone


– co-founder, Twitter




Farzad Mostashari


, MD, ScM – National Coordinator for Health Information Technology, Office

of the National Coordinator for Health Information Technology, US Department of Health and


Human Services





Donna Brazile


– Political Strategist and Commentator, Vice Chair of Voter Registration and Participation,

Democratic National Committee





Dana Perino


– Political Commentator and Former White House Press Secretary




Dan Buettner


– Founder of Blue Zones and World Renowned Explorer.

IMIA is pleased to be a Conference Collaborator, supporting the event (see http://www.himssconfer and will have a booth at HIMSS12.







Applied Clinical Informatics




© 2011 published: October 26, 2011 News from the International Medical Informatics Association

Hospital Italiano de Buenos Aires Conference:

October 31 – November 02, 2011

VI Jornadas Universitarias de Sistemas de Información en Salud

The Department of Health Informatics at Hospital Italiano is celebrating it’s 10th anniversary and

the creation of the Medical Informatics Residency Training program. In order to continue sharing

the advances in the development of Health Information Systems in the Latin american region, the

department is organizing the Sixth Conference of Health Information Systems (VI Jornadas Universitarias

de Sistemas de Información en Salud) together with HL7 Argentina on




October 31, 1 and

November 2, 2011







at Hospital Italiano (Peron 4190, Buenos Aires, Argentina). The Conference is free

but requires previous registration and it will be available online.


Information about the event (in Spanish) is available at


fomed/index.php?contenido=ver_curso.php&id_curso=9435. Keynote Speakers:





W. Ed Hammond


, PhD, Director, Duke Center for Health Informatics at Duke University.

– Interoperability: bringing all the pieces together, what would be required, and what would be







Dean Sittig


, PhD, Professor, Biomedical Informatics at The University of Texas Health Science

Center at Houston.


– Monitoring EHRs to Ensure Safe and Effective Use: An Overview of What is Required. Rights


and duties of users of an EHR





Fernán González Bernaldo de Quirós


, MD MSc, Vice Director of Strategic Planning, Hospital

Italiano de Buenos Aires.


– Continuous Improvement Process, Quality and Information Systems


Panels will address issues including Security in Health Information Systems; Digital Agendas in Latin


America; HL7 and its relationship with the National Digital Agendas; Usability: an aspect to consider


in Information Systems; Education in Health Informatics; Clinical terminologies; Implementations


of Health Information Systems; Open Source Tools in Clinical Information Systems


Workshops will address issues including Lessons Learned; Grid Computing; Introduction to


health information systems; IT Project Management; Italica Project; HL7 (V2.CDA)


International Speakers will include





Alvaro Margolis (EviMed – Uruguay);


Carlos Arteta Molina



(Fundación Cardioinfantil – Colombia);


Claúdio Giulliano Alves da Costa


(SBIS & HL7 – Brasil);



Fernando Portilla



(HL7 – Colombia); Gabriela Villarreal (HL7 – México);


José Florez Arango


(Hospital Pablo Tobón Uribe – Colombia);


Maurizio Mattoli (ACHISA – Chile);


Selene Indarte



(HL7 – Uruguay);


Sergio Konig


(HL7 – Chile)

National Speakers (from Argentina) will include





Alejandro López Osornio (TermMed SA);








(Hospital Italiano); Carlos Otero (Hospital Italiano); Cesar Moreno (Griensu);








(Hospital Italiano); David Aguirre (Municipio de Benito Juárez); Diego Kaminker





Fernán González Bernaldo de Quirós



(Hospital Italiano); Fernando Campos


(Hospital Italiano);


Fernando Plazzotta



(Hospital Italiano); Humberto Mandirola (Biocom); Jorge Rodríguez




Martín Degreef



(Municipio de Benito Juárez); Martin Díaz (Hospital Alemán);


Myrna C.





(OPS); Pablo Guccione (Hospital Escuela de Agudos Dr. Ramón Madariaga);


Paula Otero



(Hospital Italiano);


Sergio Epstein (Ministerio de Salud Pública de Tucumán);


Sergio Montenegro



(Hospital Escuela de Agudos Dr. Ramón Madariaga).

More information at In person registration


Online registration:


Hospital Italiano de Buenos Aires is an Academic Institutional Member of IMIA.




Applied Clinical Informatics




© 2011 published: October 26, 2011 News from the International Medical Informatics Association

Call for Abstracts: Rutgers 30th Annual International

Interdisciplinary Technology Conference

On the 30th anniversary of its Annual International Nursing Technology Conference, the Rutgers

College of Nursing Center for Professional Development, in collaboration with other departments,

are organising a special interdisciplinary and international event, to reflect the Rutgers University

themes of ‘New Jersey Roots – Global Reach ‘ and ‘Technologies Without Borders’.

With the theme ‘Using Technology to Improve Healthcare Globally’, the Call for Abstracts invites

cutting edge presentations that document how technology has or will impact the safety and quality

of healthcare globally. Further information is at including

links to submission site and the Call for Abstracts.

The event will be held at the Hyatt Regency Hotel, New Brunswick, New Jersey, USA on





April, 2012










HINZ 2011 Conference and Exhibition – Auckland, Nov. 23-25

The HINZ (Health Informatics New Zealand) Annual Conference and Exhibition will be held at the

Aotea Centre, Auckland, New Zealand on


23-25 November, 2011



conference). With the conference theme “Working together … working smarter”, among the international


guest speakers this year will be Dr.





David Blumenthal, Prof. Enrico Coiera, Prof.








, Dr. Susan Newbold, Andrew Howard, and Baldhur Johnsen



The event features workshops on intelligent data analysis, and interoperability reference architecture,


while other sessions will include a broad set of topics, including health IT evaluation (













), mobile health (Robyn Whittaker), virtual health records (Tom Bowden


), post-Christchurch

earthquake emergency responses, and nurses’ electronic access to evidence.


A key feature of the event will be the ‘Clincians’ Challenge’ – an opportunity for clinicians and


vendors to work together to use information technology to solve an important and recurring problem


that health professionals face in their ‘day-to-day” practice (


conference-2011-challenge). Clinicians have presented the challenge by putting forward 56


problems they face in their day-to-day practice that the innovative use of information technology


could help solve. HINZ have chosen the three most interesting; now is the opportunity for vendors


to respond. Vendors are invited to choose one of these three challenges and describe their concept or


solution to solve the problem. All vendors are invited to participate. Submissions can be made by individual


vendors or groups. Submissions should be a Word document, no longer than 8 pages. Please


e-mail it to by





3pm on 31 October 2011


. There will be no extensions.

The winning problem case in 2010 came from a colorectal cancer care nursing service that ‘wants


to ensure a seamless and timely interface between hospital and community-based continued care


and social support systems’. The winning vendor, Orion Health, is working with the clinician to develop


a system and expects to have it completed by the end of this year.


HINZ is a Member Society of IMIA (




IMIA Yearbook 2011

Welcome to the 400th post since we moved IMIA News to this new format. It is appropriate that we

use this post to publicise one of IMIA’s most important products, the IMIA Yearbook of Medical Informatics.

With the theme “Towards Health Informatics 3.0, the 2011 IMIA Yearbook of Medical Informatics


2011.html) is the latest edition on the series that started in 1992. Some of the material in

the IMIA Yearbook is available as free download, whilst other is pay-per-view for individual items.

You can also order the Yearbook in paper and electronic format. The Paper Version includes online

access to the complete Full Electronic Version. Single copies can be ordered from Schattauer Verlag.

© 2011 published: October 26, 2011 News from the International Medical Informatics Association




Applied Clinical Informatics




They are available at a reduced rate for members of IMIA’s Member Societies, and to subscribers of

Methods of Information in Medicine.

Several IMIA Member Societies (including AMIA, COACH, FDH, FinnSHIA, HISI and HINZ)

subscribe to full (free) electronic access for their members as part of member benefits, and the Yearbook

is also included as a member benefit to Academic and Corporate Institutional Members of


The objectives of the IMIA Yearbook




To present an overview of the most original, excellent state-of-the-art research in the area of

health and biomedical informatics of the past year.







To provide surveys about the recent developments, and comprehensive reviews on relevant topics

in this field.







To provide information about IMIA.



The target audience




Health and biomedical informatics scientists in research, education, and practice worldwide






Health care professionals interested in current health and biomedical informatics research results.






Health and biomedical informatics students and postgraduates.






Scientists and professionals with shared interests in biomedical informatics.



Among freely available papers in the IMIA Yearbook 2011 are




President’s Statement – IMIA 3.0: Connecting and Sharing Knowledge






Editorial: Towards Health Informatics 3.0






IMIA Award Editorial: Back to the Future: What Have We Failed to Learn? How Does the Future








Information on IMIA






Information on IMIA Regions.

IMIA Yearbook of Medical Informatics : Editors: Geissbuhler A, Kulikowski C ISSN 0943–4747,


ISBN-13 978–3–7945–2651–2 (see also for more information






ACI eJournal is Seeking International Contributions

ACI, the official eJournal of IMIA (, is inviting INTERNATIONAL contributions

in its core editorial subject matters: clinical information systems (including electronic

medical records and systems, personal health records, physician/provider order entry, electronic prescribing,

clinical decision support, nursing information systems, patient scheduling and tracking

tools, lab information systems, radiology information systems, PACS, GP information systems), administrative

and management systems, eHealth systems, information technology development, deployment,

and evaluation, socio-technical aspects of information technology and health IT training.

Contributions from all parts of the world, and from international teams of authors, are sought.

The target group of ACI is an international and potentially very influential readership, e.g.: chief

information officers, chief executive officers, chief financial officers, medical informatics researchers,

nurse informaticians, consultants, public health officials, vendors, IT safety healthcare

providers, informatics trainees as well as organizations such as IMIA, AMDIS, AMIA, and HIMSS.

For further information on writing for this online journal, please contact the editor in chief,

Christoph U. Lehmann




, M.D., clehmann(at) – see also and in

particular the instructions for authors at








Applied Clinical Informatics




© 2011 published: October 26, 2011 News from the International Medical Informatics Association

2nd ACM SIGHIT International Health Informatics Symposium

(IHI 2012) – January 28-30, Miami

The 2nd ACM SIGHIT International Health Informatics Symposium (IHI 2012) will be held on





28-30, 2012







in Miami, Florida, USA. Full information is available at


 (mirror site:

IHI 2012 is the flagship symposium on health informatics promoted by the newly formed Association


for Computing Machinery Special Interest Group on Health Informatics (ACM SIGHIT). IHI


is designed to run as an annual showcase for exciting and innovative research on techniques and


technologies developed in universities, hospitals, research labs, and companies all over the world.


IHI 2012 will feature about 130 contributions from 37 countries, including keynote speeches,


regular papers, short papers, demonstrations, free tutorials, panels, extended abstracts, and doctoral


consortium. Selected regular papers and short papers will be presented in oral sessions. Other


papers and demos will be presented by the authors in an open setting, specifically designed to encourage


conversation and discussion. The symposium will cover the breadth of problems faced by


the community: health informatics education, telemedicine, systems for decision support, humancentered


design, information retrieval techniques for health applications, accessibility to personalized


predictive modeling techniques, and so on.


Online registration is now available at the conference website (,


mirror site: Staying at the conference hotel, pre-negotiated


conference rates are available. A direct link to the Miami Beach Resort and Spa hotel reservation


system is available at the conference website




3rd International eHealth Conference, Lahore, Pakistan;

January 21-22, 2012 – Call for Papers

eHealth Association of Pakistan (eHAP – http// will host its Third International

eHealth Conference 2012 with the main theme of “Road to National eHealth strategy for Pakistan”

to be held at Lahore on


21-22 January, 2012


. The aim of the conference is to identify and prioritize

areas of eHealth development in Pakistan that could lead to the formation of a National eHealth


Strategy for Pakistan. The deadline for the Call for submission of scientific abstracts is







15 November,









Interested researchers, graduates and scholars from universities, research institutes and industry


are invited to submit abstracts on the following themes:







Benefits of eHealth for developing world






Scalable eHealth Applications & Technologies






Planning & Managing eHealth in a Developing Country






Health Information and its Management through ICTs






eHealth in Health Systems Improvement






Importance of Policy and strategy for eHealth

Abstracts for the Conference will be selected for oral or poster presentation depending on the evaluation


of Scientific Committee. Authors should specify their preference of oral or poster presentation.


(PDF download of Call – conference website link)


Countries around the world are turning to eHealth to enhance service delivery in every aspect of


life. Developing countries like Malaysia, Sri Lanka, Bangladesh, India, Kenya and Rwanda have taken


bold steps towards revolutionizing their Health Sector with use of eHealth. Pakistan has built experience


with eHealth applications, but requires commitment and direction from all the stakeholders to


move this forward. The efforts for development of a National eHealth strategy come at an important


time when Pakistan is developing its new Health Policy. The Conference will build understanding on


the importance of eHealth strategy, and suggest a roadmap to achieve this endeavor by sharing the


knowledge and experience of eHealth experts and researchers.







Applied Clinical Informatics




© 2011 published: October 26, 2011 News from the International Medical Informatics Association




Applied Clinical Informatics




© 2011 published: October 26, 2011 News from the International Medical Informatics Association


International Medical Informatics Association (IMIA)

Head Office:

81 Boulevard de la Cluse

1205 Geneva



Dr. Peter J. Murray

E-mail: imia@imia-