Electronic Health Record System - University of Toronto



Electronic Health Record System

Analyzing Information Systems

2005-10-21

Faranak Farzad

Maral Imani

Waseem Sher

Katherine Mcconnell

In the first two assignments we studied the Shoppers Drug Mart Pharmacy and its system for dispensing prescription medication. By interviewing the pharmacists and technicians, as well as reviewing related documents on pharmacy systems, we realized that the most important problem the pharmacies are facing is the fact that they do not have proper access to patient’s medical history or an error-free method for reading prescriptions from doctors. Even different branches of the Shoppers Drug Mart Corporation do not share patient’s medication records. Many other vital activities also directly depend on providers receiving the correct medical history of patients, such as health clinics, emergency rooms, senior’s homes and community care activities such as home care1. Technology can play a huge role in improving the integration among health services and improving a patient’s chances of obtaining the best care.

The twentieth century is characterized by a revolution in provision of health care services. Advances in medical science and management have created an entirely new system of health care. People are not cared for by a single physician any longer. Instead, it is a collective process that includes pharmacies, nurses, many consulting physicians, laboratory technicians, diagnostic technologists and administrative staff. Moreover, a patient is no longer treated by one organization. A person can be admitted to one facility, transferred to another for treatment, and then require extended or home care. Therefore, it is necessary to uniquely identify patients across multiple providers and be able to access their full histories in order to support continuity of care1. A reliable system for patient identification, coupled with comprehensive policies and/or legislative acts protecting the privacy of individuals and the security of personally identifiable information, are necessary components of any electronic health record implementation process.

While many projects are planned for the time ahead, two of the most significant are to create a unique identification number for every Ontario patient, and to create a province-wide Electronic Health Record Database.

An Electronic Health Record (EHR) provides each individual with a secure and private lifetime record of their key health history and a record of their care within a health system. The record is available electronically to all authorized health care providers who deal with the patient (e.g. Doctors, pharmacies, emergency rooms) and to the individual, anywhere, anytime, in support of the best quality care.

Recognizing the importance of the EHR in improving the quality and efficiency of health care, the federal government of Canada, in 2001, established Canada Health Infoway. Its mandate is to support and accelerate the development and adoption of interoperable electronic health records solutions across the country. Four core components have been identified as the key building blocks of an EHR by Infoway: (1) a unique personal identifier/client registry; (2) a pharmacy network; (3) a laboratory network; and (4) a diagnostic imaging network.2

Although the Ontario Health Care system is now legally allowed to share a patient’s information among providers, an integrated system has not yet been created. Wide-area networks have been established in a few provinces (e.g. Saskatchewan, Newfoundland) however it is still a To-Be scenario for the Ontario Health care system.

Despite the benefits on an integrated health record system, it has its drawbacks. It can violate a patient’s privacy, physicians might not adopt the technology, and it would have to be very reliable to be of use. In addition, pharmacies such as Shoppers Drug Mart Pharmacy, with a relatively good system for tracking patient’s medication records, are concerned about their comparative advantage; it will cost them some capital to institute a new system but it will not give them any competitive advantage. It may negatively affect any advantage they currently have.

In this report we will model the current methods for moving health information around the wider health care system and propose two possible alternatives. We hope to show how our

2nd alternative, a province-wide, integrated electronic health record system (HER) will satisfy the most number of stakeholders and provide the best treatment for the patient. See below for an As_IS Context Diagram.

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AS IS Scenario:

Looking at an As_Is strategic dependency model we see that that every actor depends upon several other actors for, at times, competing goals. The patient depends on the doctor to obtain treatment, to get the prescription, to keep the medical history of patient for future use, and for satisfactory treatment. The doctor depends on the patient to provide the OHIP card and to describe the health related concerns in the diagnostic interview. In an emergency situation at the emergency room (ER) of a hospital, a patient depends on the ER professionals to get the treatment needed, whereas the ER depends on the patient to provide the OHIP card and to provide the health related information in the diagnostic interview. Actually, the ER staff is left to scramble around and find out a patient’s history from any source that they can, as fast as they can. The patient’s ultimate goal is to be well, with the protection of his privacy a close second. The ER’s and the family doctor’s ultimate goals are to be quick and to provide the best care; to move the patients through the ER or the clinic as fast as is reasonable and safe.

Another intentional dependency is between the patient and the pharmacy. The patient depends on the pharmacy to get the drugs and to keep a record of his medication history. The pharmacy, in turn, depends on the patient to provide the prescription, to provide the insurance policy number or the payment, and for repeat business. One more patient dependency is between the insurance company and the patient, where patient (client) depends on the insurance company to cover the prescription, while the insurance company depends on the patient (client) to pay the premium and be satisfied with the prescription coverage.

The As-Is diagram also shows that pharmacy depends on doctors for an accurate and understandable prescription. If the prescription contains ambiguity, from the pharmacy’s perspective, the pharmacy communicates with the doctor, either by phone or by fax to clarify the uncertainty. As well, pharmacy also depends on the insurance company to get a confirmation of the patient’s prescription coverage and, afterwards, payment of prescription. The insurance company depends on the pharmacy for its soft goal to be charged for only the allowed amount, to nullify the immoral practice of overcharging the insurance company to increase a patient’s remittance. The pharmacies ultimate goal is to be profitable. To be profitable they need repeat business and to limit the risk of litigation. See the As_Is SD diagram below.

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In the As Is strategic rationale model below, we can see that a lot of work goes into making sure the pharmacists have a readable and accurate prescription. The prescription is usually delivered, in print format, to the pharmacy by the patient. The pharmacist then verifies that the prescription is readable. If it isn’t, the pharmacist must then contact the doctor and verify the script. The pharmacist also needs to double-check with the patient that the patient does not have any contra-indicating conditions that would preclude him or her from taking this drug. This can be a slow and inexact process. By taking excess staff time and by not allowing for a more effective way of double-checking for contra-indications, these AS IS methods do not ultimately contribute to the goal that the pharmacy be profitable. This method, as we see from the diagram, traditionally meets the patient’s goal of privacy but negatively impacts on his ability to obtain the best treatment. Writing off quick, print prescriptions is, however, a fast and economical process for the family doctor. The doctor’s goal is met. Doctor’s do not have to invest in any additional technology which may be the case for them when we present our Alternatives 2 and 3.

The current practice of housing a patient’s medical history with the family doctor is highly problematic. On one hand, the patient’s privacy is protected. On the other, the patient’s life may be in danger. The patient has competing goals. If emergency room staff cannot get an accurate enough history of the patient to treat him at any time of the day or night it may negatively impact on their ability to provide care. Currently, emergency rooms have to get information either from the patient (assuming the patient is conscious), or from the family doctor

(assuming the office is open) or they can try and get a medication history from the pharmacy (assuming they know which one to call). This practice does not lend itself to the economical running of an ER; it slows down their ability to move patients through quickly. Their ultimate goal, to be quick, is not met. See the As_Is SR diagram below.

(Please note that some of the less critical goals mentioned in the SD diagrams will be left out of the SR diagrams. Whereas it is important to be aware of many of the agent’s goals, they clutter the SR diagrams and do not help in analyzing the support or lack of support for the main goals.)

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To Be Scenario. Alternative 1

The first alternative we propose is a relatively simple one which satisfies a few goals for the patient, the pharmacy and the doctor, while not forcing the family doctors to invest in costly, not-yet-standardized software. It is merely to have the doctors send their prescriptions to the pharmacies electronically, by e-mail, or by fax, or by some sort of secure internet form. This might negatively impact the patient’s goal of privacy, should a fax be intercepted, but he is more likely to achieve the goal of receiving the best treatment (by limiting the risk of mistakes in the reading of the script). It is a relatively inexpensive change for the doctors, but is not as quick as dashing off a shorthand print prescription. Their goal is somewhat negatively impacted. This change would save the pharmacy from the staff time and expense involved in contacting the doctor for verification. The pharmacist is still bound, by professional ethics, to double-check with the patient about contra-indications and might still take the time to interview the patient. This first alternative does nothing to assist emergency room personal in obtaining accurate patient histories. Their goals are still not met. See the As_Is SR diagram below.

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To Be Scenario: Alternative 2

In our Alternative 2 we propose one new actor, an Electronic Health Record System. The proposed EHR will be a province-wide system that is responsible for storing, updating and transferring the entire patient health history and medication record. All the health related information of a patient will be specified by one unique Health Record ID.

As the Alt 2 SD and SR models show, the new EHR has direct dependency relationships with three of our actors, the Doctor, the Emergency Room and the Pharmacy. Input all from all of these actors is required to update the EHR database. Doctors, pharmacies and emergency rooms must send in and update the pieces of the medical histories that they hold. Conversely, these actors depend on the EHR to deliver updated patient histories back to them in a fast and reliable way. Prescriptions will be sent from the doctors to the EHR. The pharmacies will retrieve the prescription information from the EHR. Emergency rooms will obtain patient histories from the EHR.

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Notice below in the Alt_2 SR model that the pharmacist and the ER staff now have access to the full patient history, impacting negatively on the patient’s goal for privacy but impacting positively on the patient’s goal to receive the best care.

The pharmacies goal to be profitable is supported. The prescription comes in directly from the EHR along with an accurate and up-to-date patient history. The risk of litigation is reduced, as is the staff time needed to dispense the medications. The goals of the ER are also supported; they have the information they need to provide the best care and to move the patients through the ER as quickly as is possible.

The Family doctors, at least initially, do not have their ultimate goal met. They usually already have the patient record so they gain little from the EHR. Conversely, they are charged now with updating the EHR after every patient visit. This is an additional task for them and it may require new software or hardware and/or extra staff time. Their goal to run a doctor’s office economically is negatively impacted.

We also see from the Alt 2 SR that the ultimate goal of the EHR is that it be used. In order to ensure that it will be used, the database must be fast and reliable. It should also be relatively economical to run. (Please note that the EHR has other dependencies on the government for funding and maintenance. In order not to confuse our diagrams with even more graphical elements we have elected not to show these. Needless to say, in a real case scenario, these funding dependencies could not be ignored.)

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Note:

There is no change in the insurance company dependencies from the As Is strategic dependency model to the Alt_2 strategic dependency model in that the dependencies between patient (client) to insurance company and insurance company to pharmacy do not change. The insurance companies will have no access to data in the EHR and the EHR will not contain any information on the patient’s insurance coverage. It is for these reasons they have been left out of the SR models. Please see the Appendix for an As_Is Data Flow Diagram for more information on the role of the insurance companies.

Conclusion

From our analysis of the competing goals of each of our agents and a look at how well their main goals are currently achieved, and how well they might be achieved, we conclude that, assuming government funding, that creation of an Electronics Health Records system supports the most number of goals.

The End

End Notes

1. Canada Health Care System website

2. Neville, D., et al., Towards an Evaluation Framework for Electronic Health Records: An Inventory of Electronic Health Records Initiatives, Electronic Health Records Initiatives, 2004

Appendix

As-Is DFD: Medical Information Flow:

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To-Be DFD: EHR System

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