Taking medical records into the digital age

Taking medical records into the digital ageSolving traditional system challenges with OpenEMR

Skill Level: Intermediate

Sreevidya Krishna ([email protected] )Programmer and Business AnalystFreelance

30 Nov 2010

Traditional, paper-based medical record systems fail to keep up with the increasingdemands placed on a healthcare industry already burdened by a growing and agingpopulations. Electronic Medical Record (EMR) systems promise to help fix theseproblems. In this article we examine the disadvantages in using traditional medicalrecord systems and explore various open source medical record systems and howthey handle the most pressing issues in data storage, maintenance, and security. Weconclude by installing, configuring, and using the OpenEMR medical record system.

Introduction

With a growing population and an increase in the number of patients, the pressureon doctors and hospital staff has increased drastically in the last decade. It hasbecome very difficult for a physician to track a patient's medical history (includingpast visit information, lab results, previous medications, and drug allergies) througha traditional system. It is not uncommon for patients to have labs repeated becauseof improper lab records.

The solution is an Electronic Medical Record (EMR) system that allows doctors tofind and store information instantly. This technology has changed thepatient-physician relationship dramatically over the last several years. An EMRsystem helps physicians and hospitals function in a smoother, safer, and moresecure manner, allowing hospital personnel to retrieve and update the information ofany patient with a click of a button. The doctors and administration can thenconcentrate more on the patient's problem than on the patient's records and

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administrative tasks.

An EMR system promotes the evolution of healthcare transactions from aninefficient, paper-based system to a more reliable, real-time paperless system.Transcription cost, dictation time, manual note taking, and prescription writing arevirtually eliminated. It can allow the physician to be more efficient, and can help themoffer much better service to more patients.

With open source software solutions readily available, you can easily use the EMRsystem to overcome the traditional system's challenges. Most of the EMR systemscomply with HIPAA standards, thus reducing medical errors and ensuring dataprivacy and security.

Traditional methods in medical record systems

In a traditional medical record system, the patient's information is stored in one oftwo ways:

• Paper-based system: Every test, medication, and visit for a patient ismanually recorded on paper. These records are called charts. Eachdivision of the hospital has its own set of records.

• File system: The complete patient record is maintained in a single file onthe computer.

Let's take a detailed look at how the traditional system works in the activity diagramshown in Figure 1. For simplicity's sake, let's eliminate emergency situations in ahospital and concentrate on how the system works on a regular basis.

Figure 1. Activity diagram for the traditional system

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When the patient calls or comes to the hospital the administrative assistant asks thepatient for personal information. Based on the information provided by the patientthe assistant pulls the medical record. The patient can request for the type of serviceneeded like appointment with physician, prescription refill or the administrativeservices. If the patient wants to meet the physician, the assistant checks if he has anappointment. If the patient does not have an appointment the assistant books a newappointment and notifies the patient. If the patient has an appointment then theassistant notifies the physician.

The physician evaluates the patient's condition and determines whether they needany tests. If the patient requires any tests the hospital staff passes on the patient’sinformation to the administrative assistant using the traditional methods like thetelephone, fax or post. The administrative assistant notifies the laboratory with thepatient’s details and the list of tests to be carried out.

After arriving at the lab, the patient is again asked for his or her information forverification before the necessary tests are done. The results are sent to thephysician (in most of the cases) or to the patient (in a very few cases) using thetraditional methods. The hospital then contacts the patient to discuss the lab resultsand the medication.

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The physician prescribes the necessary medication after verifying the patient’scomplete medical record. This prescription is sent to the administrative assistant,who in turn sends it to the pharmacy using the traditional methods. Once themedication is ready the pharmacy notifies the administrative assistant, who notifiesthe patient. If the patient requests a prescription refill, the administrative assistantnotifies the pharmacy. The patient’s data is again verified and the pharmacistcheck’s if the patient has any refills. If he has the refills for the prescription, once themedication is ready the pharmacy notifies the administrative assistant, who notifiesthe patient. If he does not have the refills the pharmacist notifies the physician.

The patient is asked to verify personal information at every department to access thecorrect record. That information is recorded and stored within different departmentsin different formats. The communication between a department and the patient isthrough a traditional method like the telephone, fax or mail. In many cases thepatient's information is either misplaced or misfiled.

All this leads to delay in the treatment of the patient and to potential mistakes.

Challenges with a traditional system

Security of the data is the main concern in the traditional systems. With growingpopulation and exchange of huge medical data, the need for stronger securitysystems increased. Now let's examine some of the major challenges when using thetraditional system.

Slow data exchange: Data is exchanged mainly through calls, fax, or mail. Forevery lab test and every medicine prescribed, the doctor has to pass the informationto an administrative assistant who in turn informs the pharmacy or the laboratory.Then the assistant notifies the patient. When the prescription or the test results areready, the pharmacy or laboratory informs the assistant who in turn notifies thepatient — a slow and error-prone process.

Scattered patient data: The patient's records are maintained in charts at variouslocations. The hospital administration updates its copy of patient records when thepatient visits them; similarly, all the laboratories and pharmacies that the patientvisits have their own set of paper records. In this scenario, if the patient changesdoctors, the new doctor must hunt for information regarding previous conditions andtreatments. As the records are scattered across various locations, importantinformation such as drug allergies or recent surgeries is not easily accessible.

Patient data cannot be accessed by multiple departments within the hospital:In this system the patient's data cannot be accessed by more then one departmentat any given time. For example, if the patient's file is with the general medicinedepartment, then the orthopedics department has to wait until the file is released bythe general medicine department, wasting valuable time.





Difficult data storage and retrieval: It is very difficult to maintain a single filecontaining all the different forms of medical records such as X-rays, CT scan reports,blood work, and prescriptions. With a paper-based system, the whole process ofdata storage and retrieval becomes very labor intensive for the hospital staff. Anassistant has to go through the entire file to retrieve certain records and then be sureto re-file them at the appropriate place in the file. For example, consider a patientwho has been going to a hospital for ten years. This hospital will have all of theinformation about the patient from the past ten years in a single file. If the doctorwants to compare the blood work of the patient from the past five years, imagine thetime the assistant spends retrieving all the data and the time the doctor spendsanalyzing it. And after the records are reviewed, the doctor and the assistant mustre-file every single piece of information properly.

Space, cost, and time: A paper-based system requires a lot of physical space tostore all the patient records. The hospitals spend an enormous amount to maintainall of the hard copies. This system works very poorly in an emergency situation. Thedoctor cannot start the diagnosis or treatment until the assistant pulls the medicalrecord. This delays treatment and may even cost the life of a patient.

Electronic Medical Record (EMR) systems and existing opensource solutions

The increasing challenges in the traditional system led to the rise of EMR systems.EMR systems were initially developed to manage a patient's billing and insurancedata but, as the rate of medical data exchange increased, these systems weredeveloped for clinical use.

Now let's take a look at EMR systems in detail and their advantages over traditionalsystems.

EMR systems efficiently and reliably store patient data electronically in a central datarepository that can be accessed by various people at the same time, as seen in theexamples in Figure 2.

Figure 2. A simple EMR system





With data being readily available to any one at any given point of time, the responsetime is reduced dramatically and the quality of treatment for patients is improvedaccordingly. According to the Centers for Disease Control and Prevention (CDC),the National Ambulatory Medical Care Survey conducted by the National Center forHealth Statistics (NCHS) showed that, in 2008, 41.5 percent of office-basedphysicians reported using an all electronic or partially electronic medical recordsystem while, in 2004, it was 20.8 percent (see Resources). Figure 3 provides adetailed picture of the percentage of the office-based physicians using EMR systemsin the United States from 2001 through 2008 and part of 2009. This survey showsthat there was a 23.1 percent increase in the use of EMR systems from 2001 to2008 as physicians switched from traditional systems to EMR systems.

Figure 3. Percentage of office-based physicians using Electronic MedicalRecords in United States from 2001 through 2008 and preliminary 2009





Let's look at some of the major advantages of using an EMR system:

• Long term cost reduction: Even though the setup cost is high, over aperiod of time, the cost is much less than the traditional system. electronicdata storage eliminates the paper storage costs.

• Reduced waiting time: The data is available at your finger tips with EMRsystems so you don't wait for the patient's data for the diagnosis andtreatment. Also, since email is the main mode of communication, the dataexchange is very fast and effective.

• No repetition: The EMR systems stores the data centrally where all thedepartments can access it. This eliminates the repetition of patients dataacross the departments.

• Effective communication: Since the patient, hospital, pharmacy, andlaboratory are all centrally connected they can communicate with eachother in a much faster way than the traditional system.

• Higher quality treatment: Properly-stored electronic records cannot bemisfiled or misplaced. With the entire patient history in hand, thephysician can analyze the previous health conditions and provide bettercare.

• Data accuracy: An EMR system eliminates the issue of understanding





the illegible hand writing of the doctors or nurses.

• Open source software solutions: Open source software solutions arefree and offer high quality service. Many small institutions are adoptingEMR systems using open source solutions. There is a huge variety ofthese solutions available for EMR systems (see Resources).

Some of the notable open source offerings include:

• OpenEMR

• OpenMRS

• VistA

• GNUmed

Most of these systems comply with the software medical standards advocated by thefederal government through the National Health Information Infrastructure. In thisarticle, we will concentrate on the OpenEMR software and see how to overcome thechallenges of the traditional system using this open source system.

Software medical standards

The key aim of EMR systems is the efficient, secure, and safe storage and retrievalof data. In recent years, the federal government started investing money and effortto promote EMR systems. The government wants to make sure that EMR systemsare secure, that user privacy is well maintained, and that the data is shared onlyamong authorized departments. To achieve this, the federal government laid out acertain set of rules and standards for the EMR systems. In this article, we willdiscuss the HIPAA, HL7, and the ANSI X12 EDI standards.

HIPAA (Health Information Portability and Accountability Act): The HIPAA standardsfocus mainly on the privacy and security of a patient's data. All developers of theEMR system should make sure that they work within the scope of HIPAA standards.The major sections in HIPAA include:

• Security Rules: Data security is one of the main concerns while dealingwith health information. For the HIPAA compliant developers, it is veryimportant to implement all the security rules laid out by HIPAA.

• Privacy Rules: These rules deal with providing the patient with his ownmedical data. Until HIPAA included the privacy rules, patients did nothave access to their own data. Now, not only can patients view all of theirdata, they also have information about how to access their data.

HL7 (Health Level Seven): HL7 focuses on the standard format for electronic





information exchange between medical applications. The information sent using thisstandard is a collection of various messages containing either a medical record or apatient's health information. The HL7 standards are a set of rules that allow aconsistent and secure data exchange between different health care systems.

ANSI X12 EDI: ANSI X12 is the official designation of the U.S. national standardsbody for the development and maintenance of Electronic Data Interchange (EDI)standards. The EDI Standards define the vocabulary, the syntax rules, and thestructure of electronic documents. These standards mainly focus on billing andinvoicing. With the help of EDI Standards, the data transfer between two (or more)computers systems using different data formats is made possible. The EDI acts as abridge between the systems.

Many of the EMR systems comply with these standards. The commercial and opensource solutions ensure the data security, efficient medical information exchange,and standard medical terminology at every level in the application.

OpenEMR system

The OpenEMR system is an open source software solution for EMR systems. Itfocuses on applications such as medical billing, prescription writing, and medicalrecords. In this article, we will focus on the medical records.

OpenEMR is one of the more widely used software solutions in more than thirteencountries including the United States. It is designed to make the EMR systemsavailable to more and more people. Let's take a look at some of the advantages ofthis system.

• Reduces the cost of the EMR systems as it is completely free.

• Effectively supports the interoperability between different EMRapplications.

• Allows customization of the application at no cost.

• Provides access to important medical information gathered from over 70different medical software vendors. This reduces the time and cost for thehospital to gather information.

• OpenEMR is compliant with HIPAA, HL7, and the ANSI X12 EDIstandards. This ensures the quality of service offered by the system.

• OpenEMR is licensed under the GNU General Public License.

The OpenEMR system has a lot of user and developer support. This is a versatilesystem that operates in Linux, FreeBSD, MacOS X, and Microsoft Windows. In thissection we will download, install, configure, and explore the OpenEMR System.





Downloading and installing OpenEMR

OpenEMR software is available for free as a download (see Resources for a link). Itis available for both Linux and Windows platforms. OpenEMR is built upon what iscommonly known as the LAMP architectural platform. LAMP is an acronym forLinux, Apache, MySql and Php/Perl/Python. In this article we will focus onOpenEMR for the Windows platform. If you already have MySQL, Apache, and PHPinstalled, you can install OpenEMR using the original Windows package,openemr-3.2.0.zip. If not, OpenEMR has an all-in-one package, known as theWindows OpenEMR XAMPP package (see Resources for a link), which allows youto install and configure the OpenEMR application along with Apache, MySQL, andPHP. In this article we will use the XAMPP package for installation. Download andinstall the appropriate version. Assuming that you have downloaded and installedOpenEMR, we will explore several features in detail.

Getting started

Open a Web browser to the OpenEMR software at http://servername/openemr/. Thiswill take you to the login screen as shown in Figure 4. In this article, we will log in asadministrator with a default username admin and default password pass. You canchange the password by selecting the Password from the navigation bar on the left.

Figure 4. OpenEMR login screen

OpenEMR offers three navigation views: traditional, tree view, or radio buttons. Inthis article, we will use the tree view (the default view). (You can switch to one of theother views by editing the file openemr/interface/globals.php.)





Setting up the hospital data

A successful login will take you to the appointment calendar. OpenEMR has adefault clinic already built in that you need to update with the correct information foryour clinic. Select Administration > Facilities in the navigation tree on the left. ClickEdit to the right of Edit Facilities, as shown in Figure 5.

Figure 5. Edit link in the facility administration page

This will open the Edit Facilities page where you can update your clinic data, asshown in Figure 6.

Figure 6. Updating the default clinic's data





After you have updated the default clinic, you can add all of the different facilitiesassociated with it by clicking Facilities under Administration in the Navigation tree.

There will be a number of users accessing the hospital information and you addthem by clicking Administration > users, which will open the User AdministrationScreen as shown in Figure 7. Here you can enter the information about a user andalso their Access Control role. Click the Update button to save the user information.Add another user by clicking Administration > users again.

Figure 7. User Administration screen





There are a number of pharmacies and insurance companies associated with thehospital. In this article you will see how an OpenEMR system links the pharmacies tothe hospitals. The information about the pharmacies can be entered by clickingAdministration > Practices; this will open the settings page as shown in Figure 8.

Figure 8. Settings Page to add the pharmacies to the hospital





Click Add a Pharmacy to enter the contact information for your hospital's pharmacy.The pharmacy data can be added as shown in Figure 9.

Figure 9. Adding pharmacy data





Click the Update button to save the record. After successfully adding the record thesame page is then available for another entry.

Next, you add hospital staff information to the address book in the OpenEMRsystem. The address book can be opened by clicking Miscellaneous>Addr Book inthe navigation tree. This will show all the contacts stored in the address book, asshown in Figure 10. You can add a new record or search the existing records byclicking the Add New or Search buttons.

Figure 10. Address book showing all the existing records in the system





Once you have entered all of the necessary clinical information you can go aheadand add the patient records.

Adding patient's data

To add new patients, click Patient/Client>Management>New/Search. This willopen the Search or Add Patient screen. Here you can enter various demographicsfor the patient including basic information, the contact information, employerinformation, and so on. More demographics can be added by navigating to theMedical Record section under Patient/Client. A sample patient record withdemographics is shown in Figure 11.

Figure 11. A sample patient record with demographics

Some patient information is in documents such as lab reports, medical records, andpatient ID cards that are scanned or saved on the system. You can add these byclicking Patient/Client>Medical Record>Documents.

Managing schedules





OpenEMR allows you to manage and schedule appointments in a very effectiveway. When logged in as an administrator, you can view the schedules of all thepractitioners.

You can add an appointment by clicking on the time of the appointment under theprovider's name. This will open the Add Event window where you can add the detailsof various kinds of appointments for the providers. A sample event is shown inFigure 12.

Figure 12. Adding a new event to the schedule of the practitioner

Once the events are added, the schedule of all of the providers on a particular daycan be viewed by the administrator as shown in Figure 13.

Figure 13. Sample schedule of the providers

The features discussed above are some of the important features of the OpenEMRsystem. However, this is not a comprehensive list and there is still a lot to explore.



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Because the software is open source, virtually any part of the user interface can becustomized for a particular organization. The customization can be done by makingchanges to openemr/interface/globals.php and openemr/includes/config.php.Anyone with a basic knowledge of PHP will be able to extend the system.

Solving the traditional system challenges with OpenEMR

The physicians' frustration with keeping track of a patient's medical records iscoming to an end with the help of EMR systems. In this section, we will see how tosolve the challenges of a traditional system using OpenEMR.

Reduces space, cost and time:

OpenEMR enables the doctors to concentrate on patients instead of paperwork andinformation technology needs. By maintaining the records electronically, thehospitals cut down the cost and space involved in maintaining the records on paper.The time involved in searching for a piece of information is reduced to the click of abutton. As all of the departments, pharmacies, and laboratories are interconnected,they can share the patient's data electronically, thus eliminating the waiting time fordata transfer.

Data is well organized:

OpenEMR maintains the complete data of the hospital and the patient's record in acentral data repository. The patient's demographics pop up on a single page whenthe patient's details are opened, as shown in Figure 14. Hospital administration canfind the patient's data more quickly.

Figure 14. Patient's demographics on a single page





The complete history of the patient including the lab reports and medication can befound at a single place. Figure 15 shows an example of a patient's history. Thedoctors have access to the complete history of the patient just by the click of abutton. This information helps the doctors analyze the patient's health in a moreefficient way.

Figure 15. Complete history of a patient





OpenEMR also allows the doctors to search for a particular patient's record from thedata base. For example, consider that a doctor is searching for a patient named"Bobby Flay". The doctor can search the record by either External ID or SSN as theyare unique for every patient. Figure 16 shows the retrieval of a patient's record byexternal ID.

Figure 16. Retrieval of patient record by External ID





Patient records can be searched based on various fields in "Search or Add Patient"page like SSN, DOB, Last Name and others. In the traditional systems, this can notbe achieved. The hospital staff has to manually search the files based on name,which is time consuming.

Effective scheduling:

OpenEMR Systems provides a complete overview of the doctor's schedules, whichis not available in the traditional system. The OpenEMR system allows you to viewand edit the schedules of all doctors when logged in as an administrator or ashospital staff, as shown in Figure 17. When logged in as a doctor, they can haveaccess to their own schedule. Along with the date and time the duration of theappointment can also be entered while adding an event in the schedules.

This eliminates the following errors:

• Scheduling more patients than providers at a given time

• Scheduling the appointments for the doctors when they are out of theoffice or on vacation

• Overbooking the appointments for a doctor





Figure 17. Complete overview of the schedules of all the doctors

No misplaced or missing data:

With the use of OpenEMR systems there is less or no chance for any data gettinglost. As all the data entered is analyzed, the system makes sure that the necessaryinformation is entered before saving the file. For example, consider the data entry ofa patient. If a vital piece of information like the Date of Birth (DOB) is missed, in atraditional system, unless the doctor realizes the missing data, there is no way thatthe information is re-recorded. The doctor has to wait for the nurse to gather thisinformation from the patient, thus delaying the process of treatment. With the help ofOpenEMR, on the other hand, the system prompts for missing data when the updatebutton is clicked. An example is shown in Figure 18.

Figure 18. Example showing the missing data of a patient

No repetition of data:





The traditional system involves a lot of data repetition, due to misplaced or misfiledrecords. This is eliminated by using the OpenEMR system since all records areelectronically stored. Since all of the departments are centrally connected, they don'thave to maintain individual records for the same patient. Each patient is identified bya unique ID, and the patient's record can be updated using this unique ID.

Access to records from multiple locations:

Because OpenEMR is a Web-based solution, data can be accessed from anywhereat any time. This allows the doctors to view and analyze patient's data even afterhours. The doctors can log into OpenEMR with a valid user name and passwordfrom a system that has an Internet connection.

OpenEMR is a low cost, extensible, and flexible medical record system that tacklesthe major challenges of the traditional system, and exceeds what can be done with atraditional system. It improves the hospital staff's efficiency by reducing manualerrors and maintaining the integrity of the system.

Conclusion

EMR systems are smart, reliable and efficient. In this article we have briefly exploredhow the paper based traditional system works. We have seen that traditionalsystems are more error prone, insecure, and unreliable. In today's world with itshuge volume of medical data, the traditional system affects the quality of serviceoffered by doctors. We have seen how EMR systems are overtaking the traditionalsystems.

We discussed the standards like HIPPA and HL7 mandated by the U.S. FederalGovernment for EMR systems. We introduced OpenEMR, an open source solutionfor EMR systems, downloaded, configured, and installed the software, and brieflydiscussed important features. Finally, we have seen how we can overcome thechallenges of the traditional system using an OpenEMR system.





Resources

Learn

• The National Ambulatory Medical Care Survey: The National AmbulatoryMedical Care Survey (NAMCS) is a national survey designed to meet the needfor objective, reliable information about the provision and use of ambulatorymedical care services in the United States.

• Health Level 7 International (HL7) is an all-volunteer, non-profit organizationinvolved in development of international healthcare standards.

• HIPAA Privacy Rule: The Office for Civil Rights enforces the HIPAA PrivacyRule, which protects the privacy of individually identifiable health information.

• About ASC X12: The Accredited Standards Committee (ASC) X12, chartered bythe American National Standards Institute in 1979, develops electronic datainterchange (EDI) standards and related documents for national and globalmarkets.

• HITECH Act: Learn about the Health Information Technology for Economic andClinical Health Act (HITECH) Act

• Open Health Tools' Web site: Open Health Tools is an open source communitywith a vision of enabling a ubiquitous ecosystem where members of the Healthand IT professions can collaborate to build interoperable systems that enablepatients and their care providers to have access to vital and reliable medicalinformation at the time and place it is needed.

• openexchange Project home page: OpenExchange platform provides standardsbased core infrastructure to exchange patient health information in a secure andtimely manner, to advance the quality, safety and efficiency of healthcaredelivery.

• IBM developerWorks Industry Zone: Find the latest industry-specific technicalresources for developers.

• IBM developerWorks SOA and Web services zone: Explore articles, tutorials,standards, and other technical resources for Web services and SOA.

• developerWorks Information Management zone: Find a wealth of DB2-relatedresources.

• developerWorks podcasts: Listen to interesting interviews and discussions forsoftware developers.

• developerWorks technical events and webcasts: Stay current withdeveloperWorks technical events and webcasts.

Get products and technologies



http://www.cdc.gov/nchs/ahcd.htm

http://www.hl7.org/

http://www.hhs.gov/ocr/privacy/

http://www.x12.org/

http://www.hipaasurvivalguide.com/hitech-act-text.php

http://www.openhealthtools.org/

https://openexchange.projects.openhealthtools.org/

http://www.ibm.com/developerworks/industry/

http://www.ibm.com/developerworks/webservices/

http://www.ibm.com/developerworks/data/

http://www.ibm.com/developerworks/podcast/?S_TACT=105AGX44&S_CMP=ART

http://www-128.ibm.com/developerworks/offers/techbriefings/?S_TACT=105AGY06&S_CMP=art



• OpenEMR: OpenEMR is a free medical practice management, electronicmedical records, prescription writing, and medical billing application.

• The Windows OpenEMR XAMPP package: Installs and configures OpenEMRapplication along with the Apache, MySQL, and PHP.

• openemr-3.2.0.zip : This is the original OpenEMR package for Windows if youalready have MySQL, Apache and PHP installed.

• XAMPP: XAMPP is an easy-to-install version of Apache, MySQL, and PHProlled into one.

• Downloads, trials, and cloud: Enhance your next open source developmentproject with IBM trial software, available for download or on DVD.

Discuss

• developerWorks blogs: Participate in the developerWorks community.

About the author

Sreevidya KrishnaSreevidya is a programmer turned business analyst. In the past 6years, Sreevidya helped healthcare, automotive, and constructionclients develop their software. With her computer science and MBAbackground, she aims to bridge the gap between businesses andtechnology. Sreevidya is proficient in the practice of Agile fundamentalsto provide real value to customers.



http://www.oemr.org/

http://sourceforge.net/projects/openemr/

http://downloads.sourceforge.net/openemr/openemr-3.2.0.zip

http://www.apachefriends.org/en/xampp.html

http://www.ibm.com/developerworks/downloads/

http://www.ibm.com/developerworks/blogs

