Electronic Health Records (EHR, EMR)

Fiona McDonald, director of data sharing and online patient preference setting for Great North Care Record at NHS, recently spoke with Healthcare IT News about what the U.K. data exchange initiative means, described some of her ongoing projects there and explained what patient-centricity means to her as a digital clinical champion. Q. Could you tell us about more about your roles as Director at Great North Care Record and Digital Clinical Champion at the NHS in England? A. I am a clinician with a background in nursing with 12 years involvement in national programmes developing and promoting the use of digital solutions to improve healthcare and patient experience. In 2018 I became the workstream director for collecting citizen preferences for the Great North Care Record. The Great North Care Record is a new way of sharing medical information across the North East and North Cumbria which is accessed by authorised health and social care practitioners. It means that key information about patients’ health such as diagnoses, medications, details of hospitals admissions and treatments is shared between different healthcare services including hospitals, out of hours and ambulance services, all of whom may all be involved in caring for a patient. Currently, local health services hold different and/or duplicate pieces of information about patients, as information isn’t easily shared between different organisations. Through sharing this information electronically via the Great North Care Record, healthcare practitioners can then use it to access the most current patient details, which are consistent and up to date, 24/7. Getting the public to set their own data sharing preferences is a founding principle of the Great North Care Record. We want people to be in control over how their data is shared. We need the public to understand how their information will be used and the benefits it brings to them, others within their community and those with similar conditions.  We want patients to actively opt-in to the Great North Care Record. The value of healthcare data is enormous for the NHS and for researchers. As a high-level strategic goal, we want to be able to unlock the data held in healthcare IT systems. Through doing this we can make the North East and North Cumbria one of the best places in the world to carry out healthcare research. To ensure that all considerations around safety, security and user experience are worked through, an advisory group has been set up, which brings together clinicians, information governance experts, academics and people who have led on projects from around the North East and North Cumbria specialising in setting up and gathering data sharing preferences. The aim is to produce a user-friendly mechanism for the people of the North East and North Cumbria to set their data sharing preferences. The group meets on a regular basis, and has already explored the issues, and bringing in real life experience, around getting individual’s permission to share their data for purposes beyond their direct care. At the same time, we are asking people for their communication preferences, so that researchers can contact people directly to participate in research studies. We want the region to be a consent rich research environment.  In addition, I am a clinical advisor providing clinical leadership and clinical engagement for the Primary Care Digital Transformation programme at NHS England.  Recently, a large element of this has been the introduction of a safe and secure way for patients to order prescriptions, book online appointments and access elements of their GP record, including test results, to support self-management of long-term conditions and improve health literacy. We want patients to be able to access validated information rather than rely on google searches. Q. The term ‘patient-centric’ is quite commonly used now in the context of healthcare – in your experience, what does being patient-centric mean and how can the use of technology empower patients? A. In a nutshell, the health service has historically been set up to support staff and clinicians, often not focusing on patient pathways, patient journeys or ease of digital access for patients. We need to focus on these and ensure that the technology enables safe services and easy access; to me this is the essence of patient-centric. Technology already in use in primary care allows patients to set or change a community pharmacy ‘nomination’, allowing electronic prescriptions to be sent securely from the prescriber to the pharmacy of the patient’s choice. Add to this the option of ordering prescriptions online, which provides a more convenient (24-hour access), and time saving (not having to visit the practice to make the request) solution for the public. The profession also benefits from clear prescription requests, which are safer, quicker and easier to process, and an end to end audit trail for prescriptions, from ordering to dispensing and collection. Providing patients with access to their own GP record, enables them to be more involved in managing their own care, and making informed decisions about the care they choose to receive.  They can choose to share their information with other care professionals, which is particularly useful if they need to be treated when they are outside their geographical area or abroad.  Fundamentally, we need to develop systems based on patients’ requirements, listening to their feedback and input, and avoid trying to shoe horn elements of technology into often disparate and out of date systems. Q. You mentioned in an article by Digital Health that “digital transformation would not happen in the NHS unless it offered more equal representation across its workforce” – what do you think can be done to encourage more women to take up leadership roles in the NHS? A. I believe part of the issue within technology is the terminology used. When we talk about IT, digital or electronic, the assumption is often a very ‘technical’ IT and male preferred environment. We need to change the language to include ‘clinical system’ supporting and enabling safe care.  There are a number of strategies that organizations need to adopt, including flexible working, senior and managerial positions offered at part-time or job share arrangements.  Managerial and senior leadership in all organizations should loosely resemble the workforce. So if there are 60% women in the workforce, then this should be representative, without of course, compromising ability and suitability.  The opportunities for development need to be broadened, offering not just training and leadership courses but shadowing, peer review, and mentoring schemes. Q. You are going to share on the topic, “The path to patient self-care and management using online access in England” at the HIMSS Singapore eHealth & Health 2.0 Summit in April. Could you tell us about two key takeaways/lessons from the session that can be applied outside of the NHS? A. "Never underestimate the amount of workforce engagement required and the cultural change needed." While some of the systems we have deployed could be described as ‘a no brainer’ to save time and improve efficiency, unless this is supported by engagement, business change and wide communication the system will not be utilized to maximum efficiency.  "What’s in it for me?" Think about your audience, and what they will get from the system. If this is for patients or customers it needs to be easy to use, reliable, and available when they want to use it. The usability needs to be excellent, it is said that an app will be used or discarded within the first 30 seconds after download, so workflow needs to be seamless.  "Why" is an often-overlooked element, and needs to be fully explored and easily articulated, many projects fail because the why has not been fully developed.  It may be a non-cash releasing benefit such as improving safety, security and convenience.  It could also be time saving, in which case toolkits such as easy to use time saving calculators should be made available to demonstrate this benefit. All these must be supported by interactive, searchable and to the point guidance documents, which allows for quick access to the information the user is searching for. Fiona McDonald is a speaker at the upcoming HIMSS Singapore eHealth & Health 2.0 Summit from April 23-24. Registration is still open and you can register for the event here.

Royal Devon & Exeter and Great Ormond Street Hospital NHS foundation trusts also picked Epic as their EPR supplier in the past few years.

The National Coordinator talks 21st Century Cures, information blocking, Apple, consumerism, FHIR, open APIs and new business models he sees emerging amid the "overarching theme of human choice and freedom and dignity."

Case study: The EHR vendor's Happy Together technology enables the health system to incorporate data from patient portals from other healthcare organizations into its MyChart portal.

Cisco Systems is taking on the challenge of linking the enormous amount of data generated by EMRs as well as consumer and enterprise devices in the same clinical space, says Brendan Lovelock, health practice lead at Cisco.

Graham Grieve counters the case for smart eHealth cards with the argument that smartphones would work better. Several experts that presented to the senate panel investigating the My health Record in 2019 argued that instead of a central data repository, Australia should instead, invest in a smart card based infrastructure to store consumers’ health care records. These experts proposed an approach where each individual carries their own smart card, and healthcare providers load information to and read information from the card during encounters with health care providers. The experts claimed that using smart cards avoids the central problem of the My Health Record system: a single consolidated record of all health information, with dual consequences: All patients are held to a single set of policy choices about how their information is shared and managed The single repository is a large, attractive target for hackers and any successful hacks may yield many records.  Most of the focus was on the second point – a single gathering of such a large amount of healthcare information is a natural target for hackers of various kinds. Note that although the central system is highly secure and run by a security-focused team with high-discipline, provisioned to be able to make a rapid response to emerging issues, the same cannot be said of the many access points authorised to access data from the system. A hacker gaining control of such an access point (or, a legitimate user misusing the endpoint, as in the Medicare number breach in 2017) would have access to all the records, though the more indiscriminately the access is used, the more quickly it would be detected. The experts claimed that these problems could be resolved by using smart cards instead. SMART CARD EVALUATION It’s certainly true that smart cards would not have the same security challenge – hacking a single smart card, or even the system by which smart cards are accessed/updated would only grant access to the subset of smart cards encountered by the hacked system(s) during the time of the hack, since there is no central database to hack and get global access to. However, smart cards do not make any difference to the rest the of problems a system faces; they simply move them around. The problems of security, integrity, access control and security still arise in any architecture. The challenges for a smart card based approach are: Who has the right to read information on the smart card? How can a patient control how much information is accessed? Who has the right to put information on the smart card? And how is existing information reconciled with new information? Can systems updating records overwrite existing patient information? How do you secure smart cards against non-authorised readers, and still allow for back up?  How do you incentivise consumers to keep track of their health smart cards so they don’t lose them? (and how do you incentivise them to backup their information?) If they lose information, is it stored somewhere else like a new central store? How much information can you fit securely on a smart card? (And how much does the system cost?) Overseas, health smart cards generally store very little information – usually, enough to automatically identify the consumer that carries the card and to connect to a patient record stored elsewhere. In other words, it’s a token that provides access to a central record store. This does not avoid the problems of a central repository. All of these have possible solutions, but because the smart card itself is passive, the solutions must be imposed through rules made about the software that interacts with the smart card. Which means, in effect, the smart card system would hold patients to a single set of policy choices about how their information is shared and managed; at  least to the degree that the government can impose a single set of rules. But the patient doesn’t have any say about this – only the providers of the software to healthcare do. The current arrangements around the My Health Record – with the running problems related to certificates that the agency is not in a position to solve, but is still being held accountable for in public – demonstrate that a single organisation, or the health software ecosystem, cannot solve all these problems. Finally, using smart cards raise a real problem inherited from the “Australia Card” debacle – people are suspicious of government supplied cards that have an identifier.  In fact, this is such a serious perceptual problem that this might be the most important question: Would Australians accept any kind of smart card from the government? (even if it doesn’t serve as an identifying card) A patient controlled record will only truly be patient controlled when the patient holds the information. Unfortunately, smart cards will not get us there. A REALLY 'SMART CARD' All of these questions already have an answer; it’s called the smartphone. Smartphones are the correct package for acting as ‘local store’ for a patient’s information: 89 per cent of consumers already carry a smartphone Consumers part with their smartphones reluctantly  Most consumers backup their smartphones often and generally keep a close watch on them Smartphone vendors invest billions of dollars in making both a secure and usable smartphone ecosystem Rather than building a static framework, the government can specify the API formats used to exchange data between smartphones and the rest of the system, and let innovation bloom in the consumer space. The same APIs can be reused for other purposes in healthcare Applications on smartphones can manage storage/access/reconciliation/ownership issues to the degree that the consumer wants without a central authority having to make all their decisions for them Smartphones typically have plenty of storage space (note: it’s not known how much consumers would allocate to health, but the smartphones can proactively manage this question) Other countries (most notably the US) are already building ecosystems based on APIs that serve smartphones, with active support from the providers of the ecosystems.  In fact, it would be cheaper to buy the remaining 10 per cent of the population a smartphone than invest in a smart card ecosystem. Though many of that Australian population is not in a position to hold and use smartphones – mostly elderly patients and children under the age of two – they can depend on other people to manage their healthcare information. This is yet another challenge to resolve for smart cards. For this reason, the Australian Government should pay careful attention to the foundations of a healthcare information ecosystem to ensure that all consumers, not just digital literati, can leverage any API based system. And it should ensure a robust framework is set up for assessing policy and technical conformance for the APIs (though this no magic bullet). Of course, some consumers won’t want to use smartphones to store their health records at all. Others might want to take advantage of a centrally provided secure repository. The strong benefit of a web/API based framework is that consumers can choose how to engage with the system. As such, future developments for the My Health Record system should move away from the current document repository approach towards a web/API based ecosystem. Grahame Grieve is the Principal of Health Intersections, and a healthcare Interoperability consultant and developer.

Blood is a precious commodity nationwide, and often wasted. At University of Missouri Health Care, the mean red blood cell transfusion rate is now 22.4 percent below the original baseline rate. The medical director of transfusion services explains how that was accomplished.

A new KLAS and Arch Collaborative report finds that RNs generally like their electronic health records more than physicians, perhaps offering hints at improved usability.

The EHR vendor continues its tradition of April 1 gags.

New HIMSS Media research finds that nearly 75 percent of hospitals are beyond the basic level of interoperability, that best practices for information sharing are emerging and half are gearing up for APIs and FHIR.