Medical Charts & the EHR

Today's post is a continuation of the Intelligent Healthcare theme. We're going to talk about the current relationship between Electronic Healthcare Records (EHRs) and the practice of using medical charts.

• Intelligent Healthcare Scenarios
• Intelligent Healthcare Capabilities
• What is Intelligent Healthcare
• Intelligent Healthcare: EHR Assumptions
• Intelligent Healthcare and Integration
• Federal Healthcare IT Initiatives
• The Intelligent Healthcare Manifesto
• Understanding Healthcare Inter-operability

Even with the advent of new technologies, processes are slow to change, most healthcare is still managed using medical charts (although often now supplemented by or delivered through EHR systems). Ordinary diagnostic and care-related tasks such as data correlation, symptom evaluation and patient management remain part of an intuitive process with only partial system level support. In most cases healthcare system support has not led to widespread process transformation. The possibility for wide variations in both the types and quality of patient care is likely in this type of purely ‘intuitive’ environment. While there are now and have been a wide variety of diagnostic algorithms and treatment paths available to medical practitioners to choose from, determining which ones to apply has always been problematic and the lack of consistent standards in this regard is one of the main reasons for the relatively large number of quality of care issues.

The medical chart as a non-technical entity has never been fully standardized in Healthcare practice. The chart is both an information “form” for individual case incidents and is also used as the folder for iterative versions of the form across cases and related patient documents. Depending on the nature of a patient’s condition or conditions the size and complexity of the paper folder can become quite intimidating.

While there are federally mandated standards for Medical Records Information Privacy (The HIPAA Act), there are still no universally recognized standards for healthcare record data capture and exchange. The closest emerging standards are HL7 Clinical Document Architecture (CDA) and the Continuity of Care Record (CCR). While the vast majority of EHR solutions do not follow the same set of standards, there are in fact generally a number of similarities between most EHR/EMRs. A typical Electronic Medical Record application like a medical chart tends to include the following elements:

• Some level of patient demographic information.
• Patient medical history, examination and progress reports of health and illnesses.
• Medicine and allergy lists, and immunization status.
• Radiology images (X-rays, CTs, MRIs, etc.), Laboratory test results.
• Photographs, from endoscopy or laparoscopy or clinical photographs.
• Medication information, including side-effects and interactions.
• Evidence-based recommendations for specific medical conditions
• A record of appointments and other reminders, Billing records.
• Advanced directives, living wills, and health powers of attorney

The reality is that a complex case can very easily overwhelm a traditional chart or even an EMR. The amount of information collected can in some cases rival a mid-sized database. A single patient can have multiple problems, be served by multiple specialists and can have variations of their care record which extends across multiple case instances over the years.

Copyright 2012  - Technovation Talks, Semantech Inc