Proceedings of IMIA-WG4 : Common Security Solutions for Communicating Patient Data (Osaka/Kobe), 1997.
A Japanese Approach to Establish an Electronic Patient Record System in an Intelligent Hospital
Hiroshi Takeda, Yasushi Matsumura, Takeo Okada, Shigeki Kuwata and
Michitoshi Inoue*
Department of Medical Information Science, Osaka University Medical Hospital
(2-15, Yamada-Oka, Suita, 565 Japan)
*Osaka National Hospital (2-1-14, Hoen-Zaka, Chuo-Ku, Osaka 540 Japan)
1. Introduction
In order to respond the growing needs for clinical, educational and academic needs, the Osaka University Medical School and its attached hospital were moved to the new campus in 1993. On this occasion the university hospital has planned to construct an "intelligent hospital". The new hospital consists of the 19 clinics for average 2200 outpatients visits per day and 1076 beds in 24 nursing units, 9 Hospital Service Divisions, Pharmacy Department, Nursing Department and Department of Administration.
Two aspects must be emphasized in the "intelligent" hospital ; 1) As human resources are limited, the hospital is required to introduce new technology which will save the man-power and reallocate the power into new section. Simultaneously, the hospital will provide amenities which will facilitate the human work. 2) Integration of various kinds of hospital information will be much more important. In order to support the decision making of the hospital manager and clinical staffs, hospital management data and patient data must be collected and integrated by means of information technologies.
One of the final goal in a intelligent hospital is to establish an electronic patient record system (EPR) which replace conventional paper medical record charts. In this paper, our approach is described and some barriers in terms of security and privacy issues will be discussed.
2. Conventional Medical Record Charts Management
Before reconstructing the university hospital, both inpatients and outpatients medical records were stored and retrieved in each clinical department and the way of management was so poor that patient records were utilized to limited purposes. In the new hospital, "one patient-one identification number (ID)-one medical record filing" method has been applied and the active and inactive record charts are stored in the central medical record library where automatic retrieval robot system and transportation system are well operated. Only the medical staffs are allowed to enter the reading room of the medical records. The entrance events have been recorded by opening the door by using staff ID card reader. The quality of the management and the filing method is dramatically improved. It is also emphasized that the change of medical record charts management system will make the paradigm shift from doctor-centered to patient-oriented medical record and will provide the emotional basis for sharing whole patient clinical record for education, clinical research as well as clinical practice without boundary among clinical departments and types of occupations.
3. Hospital Information System: HUMANE
In our hospital, the hospital information system (HIS) has been nicknamed as "HUMANE" (Human-oriented Universal Medical Assessment system by Network Environment) [1]. In the development of HUMANE, the initial goals to be achieved were 1) POE (Physicians order entry) and good MMI (man-machine interface), 2)quick response time at a micro frame and 3) MMD (multi-media database) and PACS (picture archiving and communication system).
3.1 Hardware of the HIS
The main-medium-micro frame link (MMML) is our original hardware configuration of HIS in Japan [2]. Although the system is so-called legacy one, we have chosen the vertical-horizontal-vertical distribution of the information processing in order to solve the problem for ensuring the quicker response time and good MMI within the nominal cost,. The role of main frame is to manage the database and on-line transactions. Medium frame works as a server of the micro frame and files basic patient clinical data and master tables. Micro frame function is to maintain a good MMI and assist POE. In the HUMANE, main frame is ACOS 3600/10 MP (main memory 64 MB, 16 GB hard disk), and forty workstations (EWS 4800 ,OS; UNIX, main memory 36 MB, 1.2 GB hard disk) as medium frames and about six hundred personal computers (PC9821, OS; MS-DOS 5.0, Windows 3.1, main memory 11.6 MB, 120 MB hard disk) as micro frames. This MMML configuration is installed with rental contract with NEC Co (Tokyo, Japan).
3.2 Software and application programs
The organizational approach to build up the software architecture of hospital information system is very important. Strategic level of HUMANE is to support for decision making. In this aspect, multi-dimensional electronic patient record system must be considered. To fulfil the strategic level, the operational level and tactical level must be established beforehand.
Tactical level of HUMANE is to create all digital information environment with intra- and inter-network. Hospital administrative database and clinical information database [3] are highly interactive and relational each other. PACS is already partially installed for test beds [4,5] to clear problems due to the large amount of information quantity. This will facilitate telemedicine [6] [7]in the regional health care and comprehensive health care.
The operational level of HUMANE is to reduce paperwork load, to enhance real-time communication, patient service improvement and quality control of patient care. The operational level features order entry and reporting system and the mission is almost completed in our university hospital except for non parental drug ordering.
Software menu of the HIS is divided into two categories. The one is interdepartmental or common application program (IDAP) and the other is department-specific application program (DSAP). Among IDAPs of the HUMANE are patient registration, accounting and billing system, order entry system (prescription, laboratory test, radiological examination admission order, surgical operation and meal service ), disease name registration, reporting system (laboratory test and radiological examination), reservation ( re-visit, special examination), admission management and nursing care system. DSAPs in the HUMANE are developed in the pharmacy department, laboratory department, radiological examination department (RIS, radiology information system), surgical operation department, meal service department and blood transfusion department.
As almost all orders will be filed in the patient management database, accounting calculation will be easily made and the loss of the billing has been decreased. The reporting system is the important part of the operational level of the hospital information system in the intelligent hospital.
4. Electronic Patient Record system of Osaka University Hospital (EPROU)
4.1 Concept
A successful installation of a totally integrated hospital information system of HUMANE follows up developing a comprehensive electronic patient record system (EPROU, electronic patient record system at Osaka University hospital) [8]. The concept of EPROU is illustrated in Figure 1. The output of the system will be converted into MML (Medical Markup Language) or SGML format which the Japanese national EPR project will adopt as data exchange standard [9].
In a EPR system, Data elements in a patient record are simplified as a model. It will be recognized that the fact, assessment, action, summary and message will be the contents of the clinical record and continuous link among fact, assessment and action moves time-serially in accordance with clinical process. Some fact and action data such as the results of lab tests and contents of prescription would be able to obtain with HIS database. However, important data for EPR system such as chief complaints, physical findings and problem list would be inputted by physicians and/ or nurses.
Since physicians' direct data entry is so common in Japan that an EPR system is required to enable faster input of necessary clinical data. Furthermore, the entered data should provide the basis for synthetic and analytic purposes in clinical research, education, hospital management as well as clinical care. To merge and balance the operability and the utility of an EPR system, we have developed a system (DTDES, "dynamic template" driven data entry system) [10] which allows users to select the desired data from a list of items by means of a graphical user interface.
4.2 Dynamic Template Driven Data Entry System
Some data may be simple or others may be complicated. If each entry item were to be displayed in the same manner, the user would have to follow the same procedure as imputing detailed information even for simplified data. In order to input simplified and detailed data more effectively, we have decided that entry items must be displayed in a template in which the size will be adjusted due to the quantity of the information, and that the system will need to be driven by a kind of navigation system which displays entry items based on the previously entered value or category. For example, if the chief complaint of a patient is pain, a template is appeared in the CRT display and the physician will choose second key words among pain-related word sets such as chest, abdomen and so on.
4.3 Display of Registered Data
There are two modes for the displaying registered data. One is a Progress Note where data entered from the template are translated into a form of natural language and described on the note of EPROU . The other is a Flow Sheet which summarizes the contents of the clinical record time- serially in a matrix form. By clicking a cell, the detailed data are displayed, and progress note will be shown by clicking date.
4.4 Template Master and its Maintenance Program
The contents and navigation method of templates and their translation method into natural language need to be created through repeated trial and error. The template master must have two parts in which controlling data for the template navigation and contents of items are registered. The master file may be generated and edited by end-users. Rules for translation into natural language are registered in the another master file. This file must be maintained by the system manager.
5. Discussions
Major premises for establishing the EPR system are maintainability of medical record charts management, quality control of the contents of the conventional medical record and the expansion of HIS. After clearing those hurdles, the launching for the electronic patient record system will be not a future story in Osaka University Hospital. However, the problems of privacy and security issues have not been solved yet.
The conventional medical charts are confined in the central medical record library. But for clinical care, only clinical staffs who carry authorized ID card are able to access the patient record with written form which will be presented to the staffs of the medical record management department. As long as the patient record would be described in the medical chart, the security and the protection of the privacy would be very confident. The rule of the management is controlled by the committee on the medical record management. It is worthy for note that one patient-one file management system where no segmentation of patient record among the medical records and time-serial description of whole record will potentiate the utility of the EPR system.
The general policy for accessing the hospital information system, HUMANE was decided in the rule of using HUMANE in the executive committee of the hospital management. The operational rule for accessing the hospital information system was in charge of department of medical information science. Present rule is summarized in the Table 1. The same policy as in the medical record chart reflects the accessibility of the HIS patient record without boundary of clinical departments. Although the rule is now well operated but is limited to our HIS, new rule would be necessary for forthcoming EPR system and telemedicine environment.
6. Conclusions
The EPR system of our university hospital (EPROU) is now under development and will operate in a few years. The quality and maintainability of both the conventional medical charts management and the HIS are closely connected each other to establish the EPR. With clearing the two condition, the EPR development such as the Dynamic template driven entry system (DTDES) which is one of the optimal solutions for physicians' direct data entry has been started. In order to make the EPR system practical, we are eager to establish the security and privacy protection rules and to develop related technologies in accordance with global and domestic harmonization of standardization.
References
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Figure 1. The concept of the EPR system in Osaka University Hospital (EPROU)
Table 1. Acess matrix for application menu of the Hospital Information System (HUMANE)