Taking medical records into the digital age

Solving traditional system challenges with OpenEMR

Traditional, paper-based medical record systems fail to keep up with the increasing demands placed on a healthcare industry already burdened by a growing and aging populations. Electronic Medical Record (EMR) systems promise to help fix these problems. In this article we examine the disadvantages in using traditional medical record systems and explore various open source medical record systems and how they handle the most pressing issues in data storage, maintenance, and security. We conclude by installing, configuring, and using the OpenEMR medical record system.

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Sreevidya Krishna (sreevidya.krishna@gmail.com ), Programmer and Business Analyst, Freelance

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



30 November 2010

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Introduction

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

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

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

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


Traditional methods in medical record systems

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

  • Paper-based system: Every test, medication, and visit for a patient is manually recorded on paper. These records are called charts. Each division of the hospital has its own set of records.
  • File system: The complete patient record is maintained in a single file on the computer.

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

Figure 1. Activity diagram for the traditional system
Activity diagram for the traditional system

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

The physician evaluates the patient's condition and determines whether they need any tests. If the patient requires any tests the hospital staff passes on the patient’s information to the administrative assistant using the traditional methods like the telephone, fax or post. The administrative assistant notifies the laboratory with the patient’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 for verification before the necessary tests are done. The results are sent to the physician (in most of the cases) or to the patient (in a very few cases) using the traditional methods. The hospital then contacts the patient to discuss the lab results and the medication.

The physician prescribes the necessary medication after verifying the patient’s complete medical record. This prescription is sent to the administrative assistant, who in turn sends it to the pharmacy using the traditional methods. Once the medication is ready the pharmacy notifies the administrative assistant, who notifies the patient. If the patient requests a prescription refill, the administrative assistant notifies the pharmacy. The patient’s data is again verified and the pharmacist check’s if the patient has any refills. If he has the refills for the prescription, once the medication is ready the pharmacy notifies the administrative assistant, who notifies the 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 the correct record. That information is recorded and stored within different departments in different formats. The communication between a department and the patient is through a traditional method like the telephone, fax or mail. In many cases the patient'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 growing population and exchange of huge medical data, the need for stronger security systems increased. Now let's examine some of the major challenges when using the traditional system.

Slow data exchange: Data is exchanged mainly through calls, fax, or mail. For every lab test and every medicine prescribed, the doctor has to pass the information to 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 are ready, the pharmacy or laboratory informs the assistant who in turn notifies the patient — a slow and error-prone process.

Scattered patient data: The patient's records are maintained in charts at various locations. The hospital administration updates its copy of patient records when the patient visits them; similarly, all the laboratories and pharmacies that the patient visits have their own set of paper records. In this scenario, if the patient changes doctors, the new doctor must hunt for information regarding previous conditions and treatments. As the records are scattered across various locations, important information 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 department at any given time. For example, if the patient's file is with the general medicine department, then the orthopedics department has to wait until the file is released by the general medicine department, wasting valuable time.

Difficult data storage and retrieval: It is very difficult to maintain a single file containing 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 of data storage and retrieval becomes very labor intensive for the hospital staff. An assistant has to go through the entire file to retrieve certain records and then be sure to re-file them at the appropriate place in the file. For example, consider a patient who has been going to a hospital for ten years. This hospital will have all of the information about the patient from the past ten years in a single file. If the doctor wants to compare the blood work of the patient from the past five years, imagine the time the assistant spends retrieving all the data and the time the doctor spends analyzing it. And after the records are reviewed, the doctor and the assistant must re-file every single piece of information properly.

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


Electronic Medical Record (EMR) systems and existing open source 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 insurance data but, as the rate of medical data exchange increased, these systems were developed for clinical use.

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

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

Figure 2. A simple EMR system
A simple EMR system

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

Figure 3. Percentage of office-based physicians using Electronic Medical Records in United States from 2001 through 2008 and preliminary 2009
Percentage of office-based Physicians using Electronic Medical Records in United States from 2001-2008 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 a period of time, the cost is much less than the traditional system. electronic data storage eliminates the paper storage costs.
  • Reduced waiting time: The data is available at your finger tips with EMR systems so you don't wait for the patient's data for the diagnosis and treatment. Also, since email is the main mode of communication, the data exchange is very fast and effective.
  • No repetition: The EMR systems stores the data centrally where all the departments can access it. This eliminates the repetition of patients data across the departments.
  • Effective communication: Since the patient, hospital, pharmacy, and laboratory are all centrally connected they can communicate with each other in a much faster way than the traditional system.
  • Higher quality treatment: Properly-stored electronic records cannot be misfiled or misplaced. With the entire patient history in hand, the physician can analyze the previous health conditions and provide better care.
  • 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 are free and offer high quality service. Many small institutions are adopting EMR systems using open source solutions. There is a huge variety of these 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 the federal government through the National Health Information Infrastructure. In this article, we will concentrate on the OpenEMR software and see how to overcome the challenges 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 retrieval of data. In recent years, the federal government started investing money and effort to promote EMR systems. The government wants to make sure that EMR systems are secure, that user privacy is well maintained, and that the data is shared only among authorized departments. To achieve this, the federal government laid out a certain set of rules and standards for the EMR systems. In this article, we will discuss the HIPAA, HL7, and the ANSI X12 EDI standards.

HIPAA (Health Information Portability and Accountability Act): The HIPAA standards focus mainly on the privacy and security of a patient's data. All developers of the EMR 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 dealing with health information. For the HIPAA compliant developers, it is very important to implement all the security rules laid out by HIPAA.
  • Privacy Rules: These rules deal with providing the patient with his own medical data. Until HIPAA included the privacy rules, patients did not have access to their own data. Now, not only can patients view all of their data, 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 this standard is a collection of various messages containing either a medical record or a patient's health information. The HL7 standards are a set of rules that allow a consistent and secure data exchange between different health care systems.

ANSI X12 EDI: ANSI X12 is the official designation of the U.S. national standards body for the development and maintenance of Electronic Data Interchange (EDI) standards. The EDI Standards define the vocabulary, the syntax rules, and the structure of electronic documents. These standards mainly focus on billing and invoicing. 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 a bridge between the systems.

Many of the EMR systems comply with these standards. The commercial and open source 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. It focuses on applications such as medical billing, prescription writing, and medical records. In this article, we will focus on the medical records.

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

  • Reduces the cost of the EMR systems as it is completely free.
  • Effectively supports the interoperability between different EMR applications.
  • Allows customization of the application at no cost.
  • Provides access to important medical information gathered from over 70 different medical software vendors. This reduces the time and cost for the hospital to gather information.
  • OpenEMR is compliant with HIPAA, HL7, and the ANSI X12 EDI standards. 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 versatile system that operates in Linux, FreeBSD, MacOS X, and Microsoft Windows. In this section 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). It is available for both Linux and Windows platforms. OpenEMR is built upon what is commonly known as the LAMP architectural platform. LAMP is an acronym for Linux, Apache, MySql and Php/Perl/Python. In this article we will focus on OpenEMR for the Windows platform. If you already have MySQL, Apache, and PHP installed, 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 the Windows OpenEMR XAMPP package (see Resources for a link), which allows you to install and configure the OpenEMR application along with Apache, MySQL, and PHP. In this article we will use the XAMPP package for installation. Download and install the appropriate version. Assuming that you have downloaded and installed OpenEMR, we will explore several features in detail.


Getting started

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

Figure 4. OpenEMR login screen
OpenEMR login screen

OpenEMR offers three navigation views: traditional, tree view, or radio buttons. In this article, we will use the tree view (the default view). (You can switch to one of the other 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 a default clinic already built in that you need to update with the correct information for your clinic. Select Administration > Facilities in the navigation tree on the left. Click Edit to the right of Edit Facilities, as shown in Figure 5.

Figure 5. Edit link in the facility administration page
Edit link in the facility administration page

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

Figure 6. Updating the default clinic's data
Updating the default clinic's data

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

There will be a number of users accessing the hospital information and you add them by clicking Administration > users, which will open the User Administration Screen as shown in Figure 7. Here you can enter the information about a user and also 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
User Administration screen

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

Figure 8. Settings Page to add the pharmacies to the hospital
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
Adding pharmacy data

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

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

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

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


Adding patient's data

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

Figure 11. A sample patient record with demographics
A sample patient record with demographics

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

Managing schedules

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

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

Figure 12. Adding a new event to the schedule of the practitioner
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 day can be viewed by the administrator as shown in Figure 13.

Figure 13. Sample schedule of the providers
Sample schedule of the providers

The features discussed above are some of the important features of the OpenEMR system. However, this is not a comprehensive list and there is still a lot to explore. Because the software is open source, virtually any part of the user interface can be customized for a particular organization. The customization can be done by making changes 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 is coming to an end with the help of EMR systems. In this section, we will see how to solve the challenges of a traditional system using OpenEMR.

Reduces space, cost and time:

OpenEMR enables the doctors to concentrate on patients instead of paperwork and information technology needs. By maintaining the records electronically, the hospitals 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 a button. As all of the departments, pharmacies, and laboratories are interconnected, they can share the patient's data electronically, thus eliminating the waiting time for data transfer.

Data is well organized:

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

Figure 14. Patient's demographics on a single page
Patient's demographics on a single page

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

Figure 15. Complete history of a patient
Complete history of a patient

OpenEMR also allows the doctors to search for a particular patient's record from the data 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 they are unique for every patient. Figure 16 shows the retrieval of a patient's record by external ID.

Figure 16. Retrieval of patient record by External ID
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 not be 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, which is not available in the traditional system. The OpenEMR system allows you to view and edit the schedules of all doctors when logged in as an administrator or as hospital staff, as shown in Figure 17. When logged in as a doctor, they can have access to their own schedule. Along with the date and time the duration of the appointment 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 the office or on vacation
  • Overbooking the appointments for a doctor
Figure 17. Complete overview of the schedules of all the doctors
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 getting lost. As all the data entered is analyzed, the system makes sure that the necessary information is entered before saving the file. For example, consider the data entry of a patient. If a vital piece of information like the Date of Birth (DOB) is missed, in a traditional system, unless the doctor realizes the missing data, there is no way that the information is re-recorded. The doctor has to wait for the nurse to gather this information from the patient, thus delaying the process of treatment. With the help of OpenEMR, on the other hand, the system prompts for missing data when the update button is clicked. An example is shown in Figure 18.

Figure 18. Example showing the missing data of a patient
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 misfiled records. This is eliminated by using the OpenEMR system since all records are electronically stored. Since all of the departments are centrally connected, they don't have to maintain individual records for the same patient. Each patient is identified by a 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 anywhere at any time. This allows the doctors to view and analyze patient's data even after hours. The doctors can log into OpenEMR with a valid user name and password from a system that has an Internet connection.

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


Conclusion

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

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

Resources

Learn

  • The National Ambulatory Medical Care Survey: The National Ambulatory Medical Care Survey (NAMCS) is a national survey designed to meet the need for objective, reliable information about the provision and use of ambulatory medical care services in the United States.
  • Health Level 7 International (HL7) is an all-volunteer, non-profit organization involved in development of international healthcare standards.
  • HIPAA Privacy Rule: The Office for Civil Rights enforces the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information.
  • About ASC X12: The Accredited Standards Committee (ASC) X12, chartered by the American National Standards Institute in 1979, develops electronic data interchange (EDI) standards and related documents for national and global markets.
  • HITECH Act: Learn about the Health Information Technology for Economic and Clinical Health Act (HITECH) Act
  • Open Health Tools' Web site: Open Health Tools is an open source community with a vision of enabling a ubiquitous ecosystem where members of the Health and IT professions can collaborate to build interoperable systems that enable patients and their care providers to have access to vital and reliable medical information at the time and place it is needed.
  • openexchange Project home page: OpenExchange platform provides standards based core infrastructure to exchange patient health information in a secure and timely manner, to advance the quality, safety and efficiency of healthcare delivery.
  • 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-related resources.
  • developerWorks podcasts: Listen to interesting interviews and discussions for software developers.
  • developerWorks technical events and webcasts: Stay current with developerWorks technical events and webcasts.

Get products and technologies

  • OpenEMR: OpenEMR is a free medical practice management, electronic medical records, prescription writing, and medical billing application.
  • The Windows OpenEMR XAMPP package: Installs and configures OpenEMR application along with the Apache, MySQL, and PHP.
  • openemr-3.2.0.zip : This is the original OpenEMR package for Windows if you already have MySQL, Apache and PHP installed.
  • XAMPP: XAMPP is an easy-to-install version of Apache, MySQL, and PHP rolled into one.
  • Downloads, trials, and cloud: Enhance your next open source development project with IBM trial software, available for download or on DVD.

Discuss

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