Electronic Health Records (EHR, EMR)

According to Executive Director PAH-QEII Network at Princess Alexandra Hospital, Dr Michael Cleary, the hospital was identified as a “lead site” in the early days of strategy for the implementation of software. The rollout involved two stages of implementation. The first stage was in 2015, involving the clinical records system but excluding the medications management, anaesthetics and research support (MARS) modules. The second phase occurred in 2017, adding over it the more complex components of the modules that were initially left out. In March 2017, as the Princess Alexandra Hospital rolled out the MARS system release, it marked its place as the first hospital in Queensland, Australia with advanced ieMR capability. “We were implementing software that needed to be tested and have gone through all the usual processes for assessment, validation for workflow, etc,” Cleary said. “We were looking at how it would work in the Queensland environment, within a hospital system and we felt that it was safer to roll out all the base level systems and then put the rest in as a secondary step.” And it was not treated as any ordinary ICT implementation. Webinar: How to Protect EHRs at Scale and With Crypto-Agility “We had a different strategy – our approach was to drive this as a clinical implementation instead of as an ICT implementation because of its enormous clinical requirement. Everything revolved around improvements in patient care and maintaining patient safety and therefore, we had senior clinicians embedded in the project and process,” Cleary said. “For example, we had four specialists involved in various components. We had quite a number of pharmacists and clinicians embedded in the teams that were designing and developing the software, effectively looking at organisational change.” But the rollout didn’t come without its own set of challenges. “Very often, we had to re-engineer the way clinical systems were operating. For example, we had to move to the universal application of insulin pens, moving away from historical insulin injections,” Cleary said. “We also had to replace our entire fleet of vital signs monitors so that we had devices that could be integrated with the systems.” The team persevered through the rollout, reaping flow-on benefits that revolved around integration capabilities for a closed loop of applications. “We’ve seen improvements in our data management, in terms of information and reporting. That has also led to changes including drawing information out of the Electronic Records System and the development of information tiles that provide a detailed summary of a particular type of illness or condition,” he said. “These information tiles form the basis of the operations of our command centre in the hospital, around patient safety, informed clinicians, and operational management.     “The information we’re receiving is almost real-time, as opposed to weeks or months before a report is extracted or presented to us. This lets us make practical, real-time decisions instead of reflecting on historical data and having to infer on what might needs to be done. Our digital transparency has improved as well.” In addition, the new systems have reduced the administrative workload on nurses, allowing them to spend more time with patients. The success of the rollout for Princess Alexandra Hospital resulted in a project to digitise medical records at four other hospitals – Logan, QEII Jubilee, Redland and Beaudesert hospitals – using ieMR. “As a consequence of the rollout at Princess Alexandra, over the last three years, we’ve implemented the same stack and systems and dominoed the same processes at these four hospitals,” Cleary said. The deployment at these five hospitals recently resulted in Queensland’s Metro South Health cementing its reputation for trailblazing digital health innovation by being recognised as a global leader at the International Hospital Federation Awards. Queensland Health aims to deliver ieMR with advanced capability to a total of 27 sites by June 2020. This article first appeared on Healthcare IT News Australia. As part of HIMSS AsiaPac18 in Brisbane in November, the conference is offering a hospital tour of the Princess Alexandra Hospital. Learn more here.  

The new tier, known as Nursery, comes as the EHR vendor has also reduced pricing for its more expensive tiers by 33-80 percent.

In 1995, the Singapore Armed Forces (SAF) Medical Corps introduced a large scale Electronic Medical Records (EMR) system, the first of its kind in Singapore. In less than a decade, the improved second generation of the EMR was implemented and most recently, the latest generation of its EMR system was rolled out in April 2016. In an interview with Healthcare IT News Asia Pacific, RADM (Dr) Tang Kong Choong, Chief of the SAF Medical Corps, gave an update on the recent developments at the organisation as well as some of the lessons learnt behind the implementation of the third generation EMR system. Could you share with us briefly about your role as Chief of Medical Corps (CMC)? How has it been thus far since your appointment in May 2015? As the Chief of the SAF Medical Corps (CMC), I am overall responsible for the provision of quality healthcare services to all SAF servicemen and women and robust medical support to enable the SAF to conduct safe and realistic training. Since assuming the appointment of CMC in May 2015, I have had the privilege of setting the vision and driving the implementation of projects and initiatives to improve the quality of care and medical support provided to our servicemen and women. In April 2016, the 3rd generation of the SAF’s Electronic Medical Records System, known as the PAtient Care Enhancement System 3 or PACES 3, was rolled out. PACES 3 is an entirely new EMR system that connects seamlessly with Singapore’s National Electronic Health Records (NEHR) system. PACES 3 contains clinical decision support features and enhances patient safety by allowing the SAF to share allergy information and other key medical information with Singapore’s healthcare providers through the NEHR. Its user-friendly mobile eHealth portal has allowed our soldiers to conveniently book their own medical review appointments, retrieve information about their health visits and investigations, and enabled greater health ownership amongst our soldiers. In 2017, the SAF Medical Corps reviewed the SAF’s approach to the promotion of health. We collaborated with external partners such as the Health Promotion Board on useful national-level health initiatives such as the National Steps Challenge (Corporate) and introduction of healthier dietary choices for the SAF. The SAF Medical Corps also hosted the 3rd Asia Pacific Military Health Exchange, which saw more than 500 participants from the military medical services of Asia-Pacific nations gather in Singapore to share and learn from one another in the field of military medicine. We also enhanced our cooperation with the Singapore Civil Defence Force (SCDF), with the SAF Medical Corps embarking on a pilot partnership with the SCDF; 12 SAF medics were deployed to work alongside SCDF personnel on their ambulances for three months from October to December 2017. The SAF’s new Electronic Medical Records (EMR) System – PAtient Care Enhancement System (PACES) 3 was launched in April 2016 and was the winner of the “Digitalised Care to Support One Healthcare System” category at the National Health IT Excellence Awards 2017. Unlike its predecessors which was hosted internally on the SAF intranet, PACES 3 is now also connected to national healthcare systems such as the National Electronic Health Record (NEHR) and Critical Medical Information System (CMIS). What were some the considerations and challenges behind implementing an EMR that could easily integrate with other health systems/infrastructures? The key impetus for hosting PACES 3 on an Internet-facing platform was to integrate our medical care records with that of the national healthcare system. Introduced in 1995, PACES was upgraded to PACES 2 in 2005 to have networked capabilities over a secured intranet system. The Ministry of Health’s articulation of the national vision of “One Patient, One Record” and the introduction of the National Electronic Health Record (NEHR) in 2011 was a strong impetus for us to develop PACES 3 onto an Internet-facing platform that is integrated with the national healthcare system. This provided a seamless and safe transition of medical care between healthcare providers. The choice of the health IT solution and the partner agencies was a key consideration in the SAF’s EMR System. After an open tender and robust evaluation process, the SAF Medical Corps awarded the contract jointly to Allscripts and National Computer Systems (NCS). Prior to this partnership with the SAF, Allscripts had partnered Singhealth for their electronic medical records system and had a strong presence in Singapore, while NCS had worked with the SAF Medical Corps for both earlier versions of PACES. With PACES 3 on an Internet-facing platform, we had to ensure the security of the medical data. To address this challenge, the project team built in multiple layers of protection and defences to ensure the robustness of the system against cyber threats. A second challenge was the migration of 20 years’ worth of electronic medical records stored over the lifespan of PACES and PACES 2, to PACES 3. The project team worked closely with our vendors to ensure the fidelity of data transfer as this was important in patient care and safety. Looking to the future, even as PACES 3 was rolled out in April 2016, it is necessary to start thinking about PACES 4 and the next generation of EMR systems for the SAF. I am cognisant that PACES 3 will need to be upgraded or refreshed to meet the health needs of the SAF in the next decade. The SAF Medical Corps will keep abreast of the developments in medical IT through participation in relevant medical IT events and conferences, development of our people in medical IT literacy, and also putting in place a system of continual review and improvements. Are there any collaborations /projects between SAF and other medical organisations with regards to health IT? The SAF Medical Corps is currently in dialogue with the Singapore Ministry of Health to better understand the development and implementation of Smart Healthcare initiatives for Singapore. We want to ensure that the SAF’s future developments in medical IT continue to be aligned with the nation’s push towards Smart Healthcare. RADM (Dr) Tang Kong Choong is a speaker at the inaugural International Military Health IT (IMHIT) track at HIMSS AsiaPac 18 in Brisbane this November.

The EHR’s capabilities also enabled a 15 percent decrease in days in accounts receivable.

The use of Electronic Patient Records (EPRs) is now an accepted part of modern medicine, as many now recognise that using EPRs is safer and more productive than using paper. EPRs or Electronic Medical Records (EMRs), as they are known outside of the UK, are frequently associated with improved simultaneous access, improved legibility, and, most importantly, improved patient safety, especially in areas such as clinical decision support, prescribing and computerised order entry - using the EPR to request blood tests, imaging examinations, and therapy assessments. EPRs come in all shapes and sizes and range from the wall-to-wall "one size fits all" monolith approach, to the best of breed/ best of suite to the "home brew" in-house development approach, particularly popular in Spain. The approach is often defined by the hospital’s historical investment, the availability of resources - now and in the future, the views and preferences of clinicians, and the ability of the CIO to influence the chief executive and the members of the senior management team. One would hope that whatever the approach looks like, it has come, as a result, of detailed analyses which has thoroughly examined all the pros/ cons and benefits to both clinician and patient. Data collected by HIMSS Analytics from over 800 European hospitals (excluding Turkey) tell us that 22 per cent of EPRs are provided as wall to wall "one size fits all" (80 per cent or more applications from the same vendor), 23 per cent of EPR systems are best of breed (less than 50 per cent of applications from the same vendor), 42 per cent are best of suite (when 50 to 79 per cent of applications are from the same vendor), and 13 per cent of EPR systems are in-house developments (50 per cent or more of applications are self-developed). Whilst choice of system and the degree of variability in approach is interesting, even unusual, given that most acute care hospitals are all providing healthcare in very much the same way, EPRs all have one thing in common - they all contain structured data fields that "do things".  Hospitals invest in IT but see no additional value or benefit from a patient safety or quality of clinical care perspective The clue is in the "E", the "E" being an abbreviation for Electronic. If the EPR system collects the height and weight of the patient the system should be able to calculate the patient’s Body Mass Index (BMI). If the BMI is collected, the doctor can be assisted by a "weight based dosing" algorithm, which, together with the patients date of birth, may prevent the doctor from prescribing an adult dose of a drug to a child or help the doctor by ensuring that the dose of the drug is in accordance with the patients BMI. If the EPR is capturing laboratory results the doctor can be assisted to prescribe the appropriate dose of an anti-coagulant because the system is able to recognise the latest INR result. EPR systems can also assist members of the nursing team to provide nursing tasks that are commensurate and aligned with different levels of risk. For example, should a falls risk assessment determine that the patient is at high risk of falling, the care plan is automatically populated with nursing interventions that are only associated with this level of risk. This goes some way to ensure that care is standardised and reduces the possibility of low risk interventions being offered when the risk of falling is high. To be clear, scanned paper, electronic forms, systems that contain large amounts of unstructured data or 100 per cent free text with no alerts, no warnings, and no clinical decision support are not EPR systems. The abbreviated "E" in this case probably stands for Electric. Sadly, we see hospitals that have invested significantly in information technology, more systems than sense, multiple clinical data stores, little connectivity, robots in all the right places, but no additional value or benefit from a patient safety or quality of clinical care perspective.  So, if you are a Chief Information Officer or a Chief Clinical Information officer reading this, make yourself a note to review all the data fields within your clinical application(s) to make sure that first of all those clinical data fields are capable of receiving structured data and then that those data fields actually do something to help clinicians. If your EPR is helping clinicians with clinical decision support, well calibrated alerts and warnings your EPR is likely to be electronic, if not, it’s an electric record.  Finally, if you have persuaded the Chief Executive and members of the Senior Management Team to invest in scanning facilities and an Electronic Document Management system as an alternative to an EPR system, you may be at some point be asked to explain why.

KLAS sees health system decision makers wanting vendors to give them needed functionalities: point of care access to PDMPs, specific clinical decision support and more.

The cooperative aims to bring stakeholders together to find new and pragmatic approaches to data sharing, and come up with ways to combat information blocking.

Chad Wilson, director of information security at Children’s National, explains how timely access to applications in a healthcare setting is measured in seconds so the balance between usability and security is a big challenge.

CarePort customers can now receive automated medical reviews sent straight to their Care Management workflow, thereby reducing administrative burden.

The IT journey in clinical systems in Singapore dates back to the 1980s and by the early 2000s, two distinct electronic medical record (EMR) systems emerged from the two integrated clusters. However, this meant that sharing of patient information, especially those moving from different clusters, was a big challenge. In 2008, the National Electronic Healthcare Record (NEHR) was conceived out of a “one patient, one record” vision based on a concept paper. Critically, NEHR differs from previous EMR systems as it is a repository of visit summaries specific to an individual. While EMR systems contain detailed information of a patient in their respective institutions, NEHR collects key subsets of health information from these multiple healthcare encounters. NEHR went live in 2011, with the successful uploading of healthcare information from public hospitals in the same year. By the first year, all restructured hospitals, specialist centres and polyclinics, six community hospitals, eight nursing homes, and an increase from an initial 50 to 250 GP clinics had access to NEHR. HealthHub, a one-stop portal and mobile application for Singaporeans to access a wide range of health content, rewards and e-services was launched in 2015. Users can also log-in to HealthHub through their SingPass to view their health records and medical appointments across different polyclinics, public hospitals and other public health institutions. The information from HealthHub is drawn from a few IT systems, which include the NEHR, the School Health System, School Dental System and National Immunisation Registry. As of November 2017, only three percent of the more than 4,000 private healthcare providers – including specialist clinics, nursing homes and hospices – contribute to the NEHR scheme. Additionally, a study of private healthcare institutions done by the Integrated Health Information Systems (IHiS), the national technology agency for healthcare, found that two in 10 private GPs and specialist clinics still use written medical record systems, rather than an electronic one. At the time of writing, the Ministry of Health (MOH) website has a list of 1230 healthcare institutions/organisations (public and private) who are participating in NEHR. Due to the slow uptake by private healthcare sector in the NEHR, MOH wants to make it compulsory for all healthcare providers to upload data to the NEHR. Early adopters who start contributing data by June 2019 will be able to claim a one-off from MOH to offset their costs of upgrading their systems and a S$20 million fund has been set aside by the ministry for this purpose. One of the unique developments is that the latest generation of the Singapore Armed Forces (SAF)’s EMR system, Patient Care Enhancement System (PACES) 3, which was launched in April 2016, connects to healthcare infrastructure outside of Ministry of Defence (MINDEF)/SAF via the internet, such as the NEHR. This helps to provide more holistic care for SAF servicemen. Traditionally, the first two generations of PACES operated independently on their own with no ability to connect to external healthcare infrastructures. While there has been a progressive development in health IT in Singapore in terms of the NEHR and HealthHub, the nation-state suffered a setback in its goal to becoming a Smart Nation when a cyberattack occurred to SingHealth, Singapore’s largest group of healthcare institutions, which consists of 4 public hospitals island wide, 5 national specialty centres and a network of 9 polyclinics in July 2018. Described as one of the worst cyberattacks in the country, the incident saw the personal information of 1.5 million SingHealth patients being copied and stolen. Plans for compulsory contribution to NEHR has been suspended temporarily after the SingHealth incident and a four-member Committee of Inquiry (COI) was set up promptly to look into the events and factors that led to the attack. In response to the incident, Prime Minister Lee Hsien Loong shared, “If we discover a breach, we must promptly put it right, improve our systems, and inform the people affected. This is what we are doing in this case. We cannot go back to paper records and files. We have to go forward, to build a secure and smart nation.” PM Lee’s response reflects Singapore’s ongoing journey in continually advancing healthcare IT infrastructure – in fact, there are already plans to develop and implement the Next Generation Electronic Medical Record (NGEMR) by 2020.