Unit III

COMPUTERISED PATIENT RECORD

 What Is a Computer-Based Patient Record?
Definition:
• A computer-based patient record (CPR) is a repository of
electronically maintained information about an individual's lifetime
health status and health care, stored such that it can serve the
multiple legitimate users of the record.
• A computer-based patient-record system adds information-
management tools to provide clinical reminders and alerts, linkages
with knowledge sources for health-care decision support, and analysis
of aggregate data.
• To use a paper- based patient record, the reader must manipulate
data either mentally or on paper to glean important clinical
information. In contrast, a CPR system provides computer-based tools
to help the reader organize, interpret, and react to data.
Purpose of a Patient Record:
• Stanley Reiser (1991) wrote that the purpose of a patient
record is
"to recall observations, to inform others, to instruct
students, to gain knowledge, to monitor performance, and to
justify interventions."

• The many uses described in this statement, although diverse,

have a single goal-to further the application of health sciences
in ways that improve the well-being of patients.z
Ways in Which a Computer-Based Patient Record
Differs from a Paper-Based Record
1. CPRs are flexible and adaptable, allowing data entry and retrieval in various formats.

2. They extend the usefulness of patient data by applying information management tools.

3. Paper records often have inaccessibility, requiring special permission and extra effort to
locate and retrieve.

4. Computer-stored records allow all authorized personnel to access patient data immediately.

5. Remote access to CPRs is possible, enabling clinicians to make timely informed decisions from
various locations.

6. Documentation in CPRs is more legible and organized, with automatic validity checks on data.

7. Interactive systems can prompt users for additional information, enhancing data
completeness.

8. Data entered into a computer can be reused, increasing efficiency and quality of data.
 Computer-Stored Medical Record System
Disadvantages and Challenges
• Large initial investment due to hardware, software, training, and support costs.

• Time-consuming for key personnel to learn and redesign workflow.

• Changes in physician's workflow and patient interactions.

• Technical challenges due to human and organizational factors.

• Potential for subtle and catastrophic failures. Redundancy measures can decrease risk of CPR

outages.

• Dictation option for data entry. High time cost of physician input.

•Scanned documents solve availability problems but occupy 50,000 bytes. Slow downloading

time and no option for searching or analyzing the content of a scanned document without an

abstraction step.
 Functional Components of a
Computer-Based Patient-Record System
The five functional components are:
• Integrated view of patient data
• Clinical decision support
• Clinician order entry
• Access to knowledge resources
• Integrated communication support
 1. Integrated view of patient data
• Integrated View of Patient Data in Clinical Practice (CPR)

• CPRs aim to provide integrated access to all patient data from various sources.

• The growing volume of data makes this task challenging.

• Interface engines are used to translate data content and formats from the sending system to ones acceptable to
the receiving system.

• Differences among implementations of Health Level 7 (HL7) must be resolved by interface engines.

• The database interface maps the terminology of the sending system to a common vocabulary.

• The interface engine often provides a technical and translation buffer between systems manufactured by
different vendors.

• Code systems such as LOINC and SNOMED help overcome the barriers to integration of medical-record data.

• Clinicians need a specific view of patient data, based on the context of the patient and their data-analysis task.

• Cross-platform browsers provide tools to view patient data from remote systems.

• Advanced security features are required to ensure the confidentiality of patient data transmitted over the
public Internet.
 2. Clinical Decision Support
• Decision Support in Healthcare

• Effective decision support occurs during patient assessment and ordering

decisions.
• Computer-assisted decision support allows physicians to override system-provided
recommendations and choose alternative actions.
• Compliance with suggested actions is easy with a brief rationale provided.
• A large HIS software module presents recommendations on antibiotic choice,
dose, and treatment duration.
• Feedback is solicited when clinicians choose not to follow the recommendations,
improving the clinical protocol and software program.
• Online advice on antimicrobial selection has improved clinical and financial
outcomes for patients.
• Reminders and alerts can be raised during outpatient encounters.
• Computer-based suggestions on health-maintenance topics and potentially
effective medications are derived from rules examining patient's problems and
laboratory-test orders.
 3. Clinician Order Entry
• Clinician Order Entry in CPR Systems

• CPR systems should present relevant information during order entry

to aid clinicians in making informed decisions.
• Electronic chart racks can provide decision support during the
order-entry process.
• WIZ Order screen integrates patient's active orders, clinical alerts,
and literature abstracts.
• Clinical alerts attached to laboratory-test results can suggest
appropriate actions.
• Summary information about patient's status compared to eligible
protocols provides feedback.
• Adoption of a physician order-entry system can significantly change
physician ordering behavior, clinical quality, and financial costs.
 4. Access to Knowledge Resources
• Knowledge Resources in Healthcare

• Knowledge resources are often used in the context of a

specific patient.
• Access to these resources is most effective during clinician's
decisions or orders.
• Preformatted queries can anticipate clinicians' queries,
influencing their decisions.
• Knowledge resources can help clinicians decide if a referral
is appropriate and which pre-consult tests may speed-up the
consult process.
 5. Integrated Communication Support
• Effective Communication in Multidisciplinary Healthcare

• The distribution of care function among healthcare professionals affects

the coordination and timeliness of care.
• Communication tools should be integrated with the CPR system to
electronically attach messages to a patient's record.
• Networked communication is needed across all sites where providers
make decisions on patient care, including providers' offices, hospitals,
emergency rooms, and homes.
• Connectivity to the patient's home allows for health monitoring and
routine communication.
• Notification messages provide continuity information and allow
proactive follow-up on unscheduled encounters.
• A CPR system aids in routine patient handoffs, allowing covering
clinicians to understand the patient's problems.
 What is Intranet?
Intranet is :
– A computer network that uses Internet standards (HTML,
HTTP & TCP/IP protocols) & software.

– Accessed only by authorized persons, especially members

or employees of the organization

The main purpose of an intranet is:

To share company information and computing resources among
employees.

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 Usage of Intranet
Many companies use intranets for tasks as:
• Distributing a company newsletter
• Sharing information
• For facilitating the workgroups accordingly.
• Instant knowledge about important news and memos.
• Relationship building.
• Increasing productivity.
• Recommendations and suggestions.
• Project management.

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 Intranet Characteristics
• In general it looks like a private version of the Internet
• Uses some (TCP/IP,HTTP) or all of the protocols of the
internet.
• Nodes interact in a client server relationship.
• Nodes are identified by using Internet Protocol (IP) addresses
• Files are identified by universal resource locators (URLs).
• The data being exchanged are typically formatted using HTML
and is controlled and displayed using a browser.
• It may consist of many interlinked local area networks.

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 Intranet Characteristics
• The users of intranet network may access the Internet via proxy
server and firewall server, or it may be totally separate
• It includes connections through one or more gateway to the
outside Internet.
• With tunneling, companies can send private messages through
the public network, using encryption/decryption and other
security safeguards to connect one part of their intranet to
another.
• When part of an intranet is made accessible to customers,
partners, suppliers, or others outside the company, that part
becomes part of an extranet.

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Intranet Diagram

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 Proxy Server
• Is a server that acts as an intermediary between a
workstation user and the Internet .
• A proxy server is associated with or part of a gateway server
that separates the enterprise network from the outside
network.
• The enterprise can ensure security, administrative control,
and caching service by using a proxy server.

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 Firewall
• Firewall : A firewall is a set of related programs, located at a
network gateway that protects the resources of a private
network from users from other networks.
• Firewall used in an intranet have the ability to screen
messages in both directions so that company security is
maintained.
• A firewall surrounding an intranet fends off unauthorized
access.

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Proxy Server and Firewall

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 Gateway
• A gateway is a network point that acts as an entrance to
another network.
• On the Internet, a node can be either a gateway node or a
host (end-point) node.
• Both the computers of Internet users and the computers that
serve pages to users are host nodes.
• The computers that control traffic within your company's
network or at your local Internet service provider (ISP) are
gateway nodes.

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 Gateway
• In the network for an enterprise, a computer server acting as
a gateway node is often also acting as a proxy server and a
firewall server.
• A gateway is often associated with:
– a router, which knows where to direct a given packet of
data that arrives at the gateway,
– and a switch, which furnishes the actual path in and out of
the gateway for a given packet.

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Gateway

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 Intranet for computerized patient records
An intranet for computerized patient records refers to a private, internal network
used by a healthcare organization to store, manage, and access patient records
electronically. Unlike the internet, which is public, an intranet is restricted to
authorized users within the organization, such as doctors, nurses, administrative staff,
and other healthcare professionals. Here's how an intranet functions in the context of
computerized patient records:
Key Features of an Intranet for Computerized Patient Records:
1. Private and Secure Network :
- The intranet is accessible only within the healthcare facility or organization,
providing an additional layer of security.
- Access is typically restricted to authorized personnel to ensure patient data
confidentiality and privacy in compliance with health data regulations like HIPAA or
GDPR.
2. Centralized Data Management :
- Patient records are stored in a centralized database that can be accessed by various
departments (e.g., outpatient, inpatient, labs, billing) via the intranet.
- It allows for real-time access to patient information, ensuring that healthcare
professionals have up-to-date records when making clinical decisions.
3. Access Control and User Authentication :
- Intranet systems often use secure logins and role-based access controls, meaning only certain users
can access or modify specific types of data, enhancing security.
- For example, a doctor may have access to detailed medical records, while administrative staff may
only have access to billing or appointment information.

4. Efficient Workflow :
- Staff members can quickly access and share patient records without needing to leave their
workstations, speeding up processes like diagnosis, treatment planning, and record updates.
- Inter-departmental communication is improved, as doctors, nurses, and lab technicians can all access
the same records from different locations within the organization.

5. Interoperability :
- The intranet can be integrated with other healthcare systems (e.g., laboratory information systems,
imaging systems, pharmacy databases) to ensure that all patient data is available in one place.
- It supports the seamless sharing of information between various systems, reducing data duplication
and errors.
6. Backup and Redundancy :
- Intranet systems often include regular backups of patient records to ensure data is not lost in case of
system failures or disasters.
- They may have redundant systems in place to ensure uptime and availability of records at all times.
7. Customization for Healthcare Needs :
- The intranet can be tailored to meet the specific needs of a healthcare facility, such as customized
interfaces for different departments, specialized data fields, or specific reporting tools.
Advantages:
- Enhanced Data Security : By keeping patient records within the organization’s private
network, there is a reduced risk of external threats like hacking compared to using public-
facing systems.
- Faster Access : Intranets generally provide faster access to records because the data does not
travel over the public internet, which can be slower and less reliable.
- Cost-effective for Large Organizations : Once set up, intranets are a cost-effective solution
for managing patient data, particularly in large hospitals or healthcare systems with many
users.

Use Cases:
- Hospitals : Doctors and nurses can access patient charts, lab results, and imaging through
the intranet during rounds.
- Clinics : Receptionists can check appointment schedules and manage billing information,
while doctors update treatment notes within the same system.
- Laboratories : Lab technicians can upload test results, and doctors can review them in real-
time through the intranet.

In summary, an intranet for computerized patient records is a powerful tool for healthcare
organizations, enabling secure, efficient, and centralized access to patient data while
safeguarding privacy and improving workflow.
 Application Service Provider
• Business that provides computer-based services to
customers over a network
• Also called On-demand software or software as a
service (SaaS)
• Providing access to a particular application program
using a standard protocol such as HTTP
– CRM (Customer Relationship Management)
– E-Mails management
– Documents management
 Application Service Provider

• Data is stored in the provider’s data

warehouse
• Only need a web browser
– No need of powerful hardware
– No need of specific architecture
– No need of any other software
• Data is secured
– Do not be afraid of loosing it on a break-in
 Types of ASP
• A specialist or functional ASP delivers a single application
– Credit card payment processing
– Timesheet services
• A vertical market ASP delivers a solution package for a
specific customer type
– Industry
– Medical
– CRM
• An enterprise ASP delivers broad spectrum solutions
• A local ASP delivers small business services within a limited
area
 The ASP model Common features
• ASP fully owns and operates the software
applications.
• ASP owns, operates and maintains the servers
that support the software
• ASP makes information available to customers
via the Internet or a "thin client"
• ASP bills on a "per-use" basis or on a
monthly/annual fee
 The ASP model advantages

• Software integration issues are not managed by the client

• Software costs for the application are spread over a number
of clients
• Key software systems are kept up to date, available, and
managed for performance by experts
• Improved reliability, availability, scalability and security of
internal IT systems
• Reduction of internal IT costs to a predictable monthly fee
 The ASP model disadvantages

• Accessibility can be broken

– Network problems
– Provider’s problems

• Relying on Provider to ensure an essential

function
• Clients must generally accept the application
as it is provided by the provider
 Some examples of ASP
• Google (no customizations)
– Google Documents
– Google Mails
– Google Analytics
• Zoho (no customizations)
– Zoho Projects
– Zoho CRM
• Paypal (no customizations)
– Credit card operations
• Altervisions.com (customizations possible)
– CRMs
• IBM
 ASP for computerized patient records
An Application Service Provider (ASP) for computerized patient records
refers to a third-party company that hosts and manages software applications
related to electronic health records (EHRs) or electronic medical records
(EMRs) on behalf of healthcare providers. These providers typically access the
software and patient records remotely via the internet.

Characteristics of an ASP for computerized patient records:

1. Remote Hosting: The ASP hosts the software on its own servers, so
healthcare providers do not need to maintain the infrastructure
themselves.
2. Access: Healthcare providers access the EHR/EMR system through a web
browser or client software over the internet, enabling them to view and
update patient records from different locations.
3. Data Security : The ASP is responsible for securing patient data, complying
with regulations like HIPAA (Health Insurance Portability and
Accountability Act) in the U.S. or GDPR in Europe, ensuring confidentiality
and data protection.
 ASP for computerized patient records
4. Cost Efficiency : By outsourcing the IT infrastructure and software
management, healthcare organizations can reduce upfront costs related
to purchasing and maintaining hardware, software, and IT staff.
5. Scalability : ASPs offer scalable solutions that can accommodate the
needs of various healthcare providers, from small clinics to large
hospitals, without significant changes in infrastructure.
6. Regular Updates and Maintenance : ASPs handle software updates,
bug fixes, and maintenance, ensuring that healthcare providers have
access to the latest features without downtime or technical issues.
 ASP for computerized patient records

Examples of ASPs for healthcare records:

Examples of ASPs for healthcare records include companies
like Cerner, Epic, and Athenahealth, which provide cloud-
based EHR/EMR services to healthcare providers.
 Application Service Provider
• Pros and Cons of ASPs for Practice Management and Clinical Software Applications

• High-speed Internet Connections: Availability and reliability of high-speed internet

connections are crucial for timely communication. Some communities may require
more secure or direct lines for secure connections.
• Electronic Security Technologies: Despite advancements, encryption and
authentication are not foolproof. Consider the type of transaction and data you are
comfortable transmitting over the internet.
• ASP Vendor's Longevity: Vendors should be compliant with the Privacy Rule
components of HIPAA and the newly published Security Rule.
• ASP Vendor's Treatment of Patient or Practice Data: Ensure easy and cost-efficient
data recovery if the ASP goes out of business or is sold.
• Data Agreement: If you are entering into a lease with an ASP, a data agreement
should be in place to ensure a backup of your data and a usable format.
 Computerized prescriptions for patients
Electronic Prescribing or E-Prescribing is:

• Computer based mode of communication

• Electronic mode of generating prescriptions
• Part of the growing Electronic Medical Record (EMR)
• Designed for improved communication with pharmacies and
to reduce errors.
• Commercially available software- can be used with or without
EMR.

(Finkelstein, 2006)
 Main Goals of E-Prescribing:
• Reduce medication errors

• Improve patient safety

• Increased access to medical information

• Improved reporting ability

• Cost and time effectiveness

( Barber, Cornford, Klecun 2007)

 Hardware for E- Prescribing
Can be used with :

• Laptops

• Desktop PC’s

• Pocket PC’s

• Tablet PC’s

• PDA’s utilizing a wireless network

 Personal Digital Assistant (PDA)

• Handheld computer with many similar functions

• Works with an operating system
• Personal computer needed for syncing data and updating.
• Organizing while mobile
• Compatible with innumerous programs and software titles.

(Carmack, Freudenrich, 2003)

 PDA’s in E-Prescribing

• Valuable tool to have all information needed at hand

• Information can be saved to sync with office computer
• Software easily compatible with PDA’s
• Time saving
• Helps eliminate written errors
• Great start for streamlining to the EMR
• Electronic communication between physicians and
pharmacists
 Software for E-Prescribing
• Commercially available software
• Physician or provider chooses based on preference
• Many assist with patient tracking, ICD-9 codes,
interactions, pricing, and warnings.
• Work with desktop computers, laptops, PDA’s, and
tablet pc’s.
• Accurate drug databases in tune with health
insurances
• (nationalerx, nd)
 Commercial Software Vendors

• SureScripts
• RxHub
• ProxyMed
• MedicWare
• National E Rx
 eRX Software:
• National ePrescribing Patient Safety Initiative (NEPSI) was
enacted due to the large number of medical errors in the
healthcare system.
• Free program to all physicians and medication prescribers
• Created through an advocacy initiative – with
• Claims to be simple, safe, and secure
• Designed to increase patient safety and reduce errors.
• Designed from funding to assist physicians in the advanced
technology without the high costs to them.
• (nationalerx, nd)
 Information System
• E-prescribing is an information system that is
available as a stand alone configuration.
• It is also part of a larger information system-
Electronic Medical Record (EHR)
• Many use e-prescribing as a starter or part of
the electronic transition into the EMR.
 Clinical Information System: EMR
• EMR is an electronic record with ability to
generate a complete record of a clinical
patient & supporting care related activities
through an computerized interface.
• Use specific software to personalize specific
needs.
HealthPlix, an AI-powered electronic medical record (EMR) platform for doctors,
recently released a report titled, EMR Adoption Landscape-India view-2020-22.