1 / Übersicht / Prof. Dr. P. Haas / FH Dortmund / Nov. 2000/ Seite 1 ...

LV Medizinische Informationssysteme Prof.Dr.Haas
recognition (ICR) which scan text line by line, and allow the operator to change or delete text, are not
acceptable under these Level 2 guidelines due to the user's ability to modify the information. The
requirements of Electronic Medical Records described in Level 3 would apply to these imaging methods.
Stufe 3: The Electronic Medical Record (page1)
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The electronic medical record is the upgraded version of the computerized medical record. Remember, the
computerized medical record is achieved by using traditional medical records documents and images and
transferring them into computer format. Complete documents with their legal attributes such as date and
signature are converted as a whole from the paper medium to computer. The computerized medical record
can be characterized as having essentially the same structure as the paper-based medical record. The
electronic medical record, on the other hand, has the same scope of information but the information is
rearranged for computer use. This means that it is still governed by the enterprise, may it be a hospital, a
clinic, or other provider, an integrated delivery system, or a network. The enterprise has control over (1) how
the patient is identified, (2) what information is recorded and how (terminology and structure), (3) retention
period (similar or extended from the retention period of paper-based medical records), (4) security (including
access control, electronic signatures, data integrity, and availability), and (5) functionality (determination of
which functions the enterprise would like to have included). Within this context, an enterprise has to design a
system that requires each care giver to use the computer for the accessing and for the recording of
information. The goal of the electronic medical record is to make the various systems within the enterprise
interoperable. Several criteria make up the electronic medical record.
The first and difficult part is to create the enterprise’s infrastructure for appropriate capture, process and
storage of information. For appropriate capturing, users need to be identified and given authorization
according to their status. For instance, when a prescription is issued, the system has to ensure that it was
issued by an authorized individual (a physician) and that it has not been changed. Second, the electronic
medical record is arranged in a very different way than the medical record. Its structure is defined by
computer processes rather than time-sequenced encounter documents. Third, it can be active when used
within the computer-based patient record system. It must be remembered that the paper-based medical
record is a passive storage device. The electronic patient record system can provide interactive aiding of the
decision making processes by knowledge coupling, providing decision support, and many other functions.
Stufe 3: The Electronic Medical Record (page 2)
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Fourth, the electronic medical record can seemlessly encompass and link financial and management
functions. The success of electronic medical records depends on two system capabilities. One capability is
user friendliness and user acceptance. The other is system design and functionality. Systems must combine
these two capabilities, if they are to be appealing enough to convince care givers to switch from traditional
ways of handling patient information to using a computer. The electronic medical record has the following
essential functions:
Enterprise-wide system of identifying all patient information available within the enterprise (enterprise-wide
master-patient index). Making all enterprise-wide patient information available to all care givers. This
involves data harmonization, data of warehousing, data mining techniques, interface engines, networking,
etc. The purpose is to achieve a certain stage of interoperability within the enterprise.
Implementing a common medical workstation approach that is to be used by all care givers. This involves an
enterprise-wide consensus on common medical record software, structures and interfaces. The major task is
to get physicians, nurses, and care givers to get used to using the computer during the encounter process
for direct computer input or interaction.
Creating a security system. In the absence of national legislation, an enterprise should define policies in
regard to rights (privacy, patients’ right to access and alter patient information). This should lead to concrete
confidentiality measures.
Stufe 3: The Electronic Medical Record (page 3)
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Directly linked but (almost) more important are the system security features to be implemented. They
include:
Access Control: Either with secure passwords or (better) with a token and/or biometric access control
system that is linked to a care giver's authentication system which classifies users according to their
authorization to access information and to perform certain functions (physicians’ privileges and others).
Electronic Signatures: Implementation of a system that allows the originator (care giver or device) to affix
an electronic signature to an entry and detect if such an entry has been altered.
Data Integrity: After the editing process, no information may be lost or altered in any way; corrections are
made as amendments.
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