Ebook: Electronic Health Records and Communication for Better Health Care

The annual EuroRec Working Conference has become the traditional gathering of all the partners involved on the scene of Electronic Health Records (EHRs). Twenty countries, ranging from South to North, from East to West, and from Europe and beyond, have been represented in its 2001 edition.

Naturally, a EuroRec conference follows the overall objectives of the European PROREC initiative: to promote the use of EHRs, in order to support the delivery of good quality health care.

What are the blockages impending the practical and effective implementation of communicating EHRs, both in hospital and in ambulatory care (general practice, ambulatory secondary health care, community care)? The issue has multiple facets that have to be dealt with at the same time.

While the existence of relevant technical specifications is acknowledged as of utmost importance, ahead or beyond the technical concern lie key issues that are of cultural, economic, ethical, and political nature: each one of these specific lines must be paid great attention to.

“Which incentives, which business model, which solutions for communicating EHRs in hospital and ambulatory care?” These key questions have been the thread for a series of specific workshops that have taken place over the two conference days, each one addressing a specific topic:

Does the use of EHRs reveal a cultural gap?

EHRs have to find their right place in the face to face dialogue between patients and health care professionals. To what extent does their introduction bring significant changes in the everyday process of health care delivery? How much does it interfere with the face to face dialogue between patients and health care professionals? Would educational programmes facilitate the transition?

An ethical concern: security, privacy and data protection

The outburst of the telematics era and of the internet raises new fears that privacy might prove increasingly difficult to protect. Confidentiality and security issues are now put on the front line.

How can privacy be protected? How can confidentiality and security issues be dealt with? Which control is granted to patients over the transfer, interchange, and use of their personal health data stored in EHRs? Are there limitations to the concept of a virtual patient record?

An economic concern: are there business models?

For the industry, what can be the return on investment for the development of new communicating EHR products? For the managers, and for the end users, what can be the return on investment for the purchase, learning, and use of communicating EHRs?

Today, in most countries, there is no business model for communicating EHRs, because there is no business model for integrated care (nor for co-ordinated care and continuity of care either).

A political concern: managing the change

Communicating EHRs are at the core of integrated health care networks. How and by whom are they to be organised, implemented, managed and controlled? Beyond the conventional and fashionable speech, is there a true interest in continuity of care?

Which incentives for an enhanced communication process between health care agents, based on EHRs? Eventually, who will pay for it? How, and how much? In most countries, end users still prove unwilling to do so. To support their marketing efforts, the pharmaceutical drugs industry is partly interested in retrieving data that reflect the clinical activities. Are public authorities ready to take the challenge?

The technical concern

What are the current specifications and standards, encompassing terminology and security issues that support EHR communication?

What is the importance of the European pre-standard ENV 13606 “EHRcom” for the future of communication between dissimilar systems?

What is the actual perspective for solutions based on open source developments?

A special “Industry Forum” has also been provided, where selected software developers and vendors have been invited to express their views, and present innovative and performing solutions.

May the speakers, chairpersons, and all those who have brought any contribution of a kind or another to the success of this EuroRec '01 conference, be thanked again here.

Each EuroRec conference gets something special.

Even with the endeavour of the authors of the papers that form this book, the proceedings can in no way be sufficient to capture and recall the exceptional atmosphere of these two days of active work and warm friendship.

Let me grasp this opportunity to invite all the readers of this book to join in the PROREC initiative, and attend the future EuroRec Working Conferences, that will undoubtedly be even greater successes.

They prove the right place to initiate or strengthen partnerships between the various parties whose endeavour concur to the implementation and actual use of top quality EHCR systems throughout Europe. EuroRec conferences represent a special opportunity to meet, to exchange ideas and experiences, to acquire a better knowledge of market trends, new policies at national and European levels, new initiatives, and on-going projects.

We all look forward to meeting you over the coming years.

Dr. François Mennerat MD PhD

Chairman of PROREC-Franee

A general assumption has been made within the health care community that the introduction of an Electronic Health Record (EHR) is beneficial and improves clinical care [1]. However, it is my contention as both a Health Informatician, and more importantly a patient, that this assumption is not supported by evidence, either scientific or anecdotal. However, to my mind of more importance than this is the complete lack of understanding about how using an EHR effects &\underline{my}$ consultation. This paper discusses this issue and identifies four lessons to be learned by the EHR community.

In this article, we present an overview of the work being carried out by the EC-funded project IS4ALL (1ST-1999-14101). Specifically, we describe the methodological frame of reference, which drives the project's objective to introduce universal access principles into the design of Health Telematics applications and services. Health Telematics is chosen due to some distinctive characteristics, such as the variety of end users involved, the changing healthcare contexts of use and the penetration of new computer-mediated activities, which re-shape the way in which healthcare practices are structured and organized.

This paper concentrates on the disincentives that discourage particularly doctors from readily adopting new health informatics techniques and suggests that health project management is a different model of management from that used in other industries.

Electronic Health Records (EHR) are moving towards the core application of health information systems. Enabling informational interoperability of shared care environment including EHR, structure and function of components used have to follow open standards and publicly available specifications. This comprises also methods and tools applied. Security services needed have to be an integral part of architecture and operation of the specified and implemented components.

Starting with basic architectural paradigms the Magdeburg Medical Informatics Department was involved in at the early nineties, the secure behaviour of components has been derived. For establishing the required trustworthiness, security models have been introduced and presented in the paper. Beside communication security services based on standardised Public Key Infrastructure (PKI) and security token such as Health Professional Cards (HPC), policy-defined application security services such as authorisation, access control, accountability, etc., of information recorded, stored and processed must be guaranteed. In that context, appropriate resource access decision services have to be established.

As the HARP project result, a component-based EHR architecture has been specified and demonstrated for enforcing fine-grained security services by binding certificates to application components, by the way enforcing policies.

The paper discusses the changes in the delivery of Healthcare and the ways in which individuals need to be protected by protecting their Electronic Health Records. A Code of Ethics is needed for health Information Professionals, Data Protection and Security issues need to be taken more seriously. Health Informatics needs to address the issues of safety in the delivery of Healthcare so that it provides solutions to healthcare safety problems rather than increasing the problems to be addressed.

The confidentiality and security issues related to the European Electronic Health Care Records have been approached in the United States as well. This paper synthesizes several solutions and comments on these issues from the legal viewpoint in the United States, as well as some preoccupations of the academic world to improve and standardize the quality of the security and confidentiality of data from studies involving human subjects.

This paper describes the information models that have been used to implement a federated health record server and to deploy it in a live clinical setting. The authors, working at the Centre for Health Informatics and Multiprofessional Education (University College London), have built up over a decade of experience within Europe on the requirements and information models that are needed to underpin comprehensive multi-professional electronic health records. This work has involved collaboration with a wide range of health care and informatics organisations and partners in the healthcare computing industry across Europe though the EU Health Telematics projects GEHR, Synapses, EHCR-SupA, SynEx and Medicate. The resulting architecture models have fed into recent European standardisation work in this area, such as CEN TC/251 ENV 13606. UCL has implemented a federated health record server based on these models which is now running in the Department of Cardiovascular Medicine at the Whittington Hospital in North London. The information models described in this paper reflect a refinement based on this implementation experience.

This paper has been submitted by Tom Marley. Tom was a member of the project team which produced ENV13606 Part 1: and acted as liaison to the Part 4 project team. Tom is currently writing up the document on General Purpose Information Components.

This paper examines the current state of the art in standards for the electronic health record (EHR) and messaging, and proposes a theoretical design basis for the EHR which is formal yet flexible, and which takes into account many of the difficulties experienced in the past. Recommendations are given for how convergence of EHR specifications might occur, in order to achieve a unified standard suitable for all clinical and cultural contexts.

Increasing cooperation among health professionals — within and across organizations — require a suitable sharing of clinical information from heterogeneous (electronic) documentation. Information originates from healthcare activities and may be organized within record systems in relation to health issues, episodes of care, episodes of illness, etc. Implementation of record systems depends on tasks and attitudes within each particular healthcare environment, that determine (i) the balance among functions of the record system, e.g. supporting human memory and decision making, supporting workflow management, recording circumstances about stored data, (ii) the particular organization of a record, (iii) the details of clinical statements that should be explicit or understood.

In this paper we present a set of features of record systems and of their context that affect sharing of clinical information.

WG 11 is one of the Working Groups of the EDISANTE Association. First, his mission was to define message models with two parts:

- The envelope of the message, including a header, the characteristics of the transmitter, of the receiver, and of the patient concerned

- The contents of the message, including medical data which could be exchanged between different middleware. This second part was halted by the “Reseau Sante Social”, public network for all the healthcare professionals, who want to have a structured content for his «medical message format»

The prupose of EDISANTÉ is essentially to promote the use of EDI in health care. In a second time, this association decide to include work about envelope in a larger domain concerning all exchanges in medical domains, so the GT 11 centred his action on content.