In 2023 the new Electronic Health Record should come into operation. However, there are many obstacles to overcome. While waiting for the new one, the existing one could be strengthened. The report of my intervention at the Assister workshop on the ESF.
The new ESF must not only be the technological evolution of the current one but represent a real paradigm shift in the way of conceiving and planning it, starting from the objectives and priorities, in order not to risk a new failure. This is my speech at the Assinter Academy event entitled “Architecture and design of the new FSE“, which was held yesterday in Bologna in the Aula Magna of the Faculty of Engineering. For those who are interested and have not participated, I report here the contents of my presentation.
What role for the ESF?
Although ESF can, in theory, be used for several purposes, its primary purpose is or should be to support clinical practice (prevention, prophylaxis, diagnosis, treatment and rehabilitation). This assertion has profound implications on the characteristics, functions and services that the ESF must possess which are certainly conditioned by the chosen architecture but which are independent of it on a conceptual level. For this reason, I think it is useful to begin my reflection on the ESF starting from the current one and then extend the discussion to the future one.
Medicine is not an exact science but a practice that is based on scientific knowledge, on those deriving from research and experience (evidence) and on information from the patient and the environment in which he lives and works. The more knowledge, the better the quality of care. What role can the ESF play in this scenario? In other words how can the ESF increase the knowledge of doctors?
Before answering this question, we need to reflect on the implications of using the ESF as a support tool for clinical practice.
The ESF does not have to be a stand-alone system
Doctors use different systems in clinical practice. In addition to the medical record, they often use a front-end for accessing the company’s clinical documentation – repository or electronic health dossier – (if not integrated into the first), an order system, in the future a telemedicine system and so on. Street. If the EHR is to be a frequently used tool in clinical practice, it must be fully integrated into the workflow performed with the electronic medical record (CCE) and use the User Interface (UI) of the latter.
Therefore, it is not enough to recall the FSE UI from the CCE, perhaps forcing doctors to log in again and look for the patient they are operating on; a real functional and informative integration is needed. Yet even in the new tender specifications for Consip’s specific digital health contracts, this aspect is neglected or described in a superficial way, with emphasis on feeding the ESF rather than on its use within the EHR.
Using the FSE in this context implies the presence of specific functions for consulting documents / data to simplify research and support collaboration between clinicians such as an acknowledgment mechanism that allows new documents to be highlighted compared to those already seen or read ( like any e-mail client or forum platform that indicates new threads or with unread messages), a notification system to be notified of new documents or the update of already read ones (for example a revision of a report already visa), the ability to grade the importance or priority of documents, report a document to a colleague.
La User eXperience del FSE
The current ESF UIs are really poor in terms of the knowledge they are able to provide and the experience they provide to the user. The information representation model is based on lists of documents with the date and structure that produced them; for example hospitalization, emergency room access, pharmaceutical prescription. To find out more, the doctor must access the documents to read their content.
The level of knowledge that the first level provides is of very little value. What improvements could then be made, even to the current ESF? It would be enough to extract the most relevant information from the documents and include them in the lists, as shown in the following figure.
There is no doubt that this second list is much more useful than the first and more effective. Then there is an area where some improvements can really make a difference: pharmacological therapies. We know that it was decided to digitize the referrals and not the therapy process, a conceptual error, but even in the current situation, a lot can be done, starting from what the ESFs show doctors today.
Also in this case the usefulness of these indices is almost nil. Let’s see how it would be possible to change its structure.
This representation mode allows doctors to immediately see which drugs have been prescribed to the patient, for how long and for how many times. The doctor can see if there have been any changes in dosages and whether the number of prescriptions is appropriate (the patient may not be taking his medication regularly). But let’s make one more addition.
We enter the pathology for which the drug may have been prescribed. I bet some of you are thinking it’s superfluous because doctors know the drugs. In reality, this statement is not always true (especially in the case of very specific or newly introduced drugs). In any case, the addition of the diagnosis allows us to further evolve.
In the presence of reports or structured data, it is possible to report, for each pathology, the relevant measures (for example blood glucose and hemoglobin for type 2 diabetes mellitus), with the date of the last examination and the trend, the pertinent visits (for example the fundus or the diabetes visit). In this way, already on the initial page, the doctor has a set of information capable of revealing the effectiveness of the therapy.
By clicking on the icon the doctor could then access guidelines, protocols and useful information on the disease without leaving his work environment.
The drug risk
Let’s go one step further and think about the drug risk. As is known, the concomitant use of drugs, even those without a prescription, can lead to serious risks and adverse effects such as bleeding, falls, constipation, sedation and others. Concomitant use of multiple drugs significantly raises the risk of adverse reactions (ADRs). Patients taking two drugs at the same time have a 13% risk of an adverse interaction, rising to 38% for four drugs and 82% for seven or more drugs prescribed at the same time. If seven drugs seem like a lot to you, know that half of the elderly population takes 5 to 9 drugs a day, 11%, equal to 1.4 million people, take more than 10.
Adverse drug reactions (ADRs) are responsible for 3.1 – 6.2% of hospital admissions. Among in-patients, severe ADRs range from 2.2 to 4.6 per 100 admissions. For every 1,000 emergency room visits, it is estimated that 2.4 – 3.4 are due to severe ADR. The cost of ADR alone varies between 8,000 and 12,000 euros for every 100 hospitalizations.
What contribution can the ESF make in reducing and managing drug risk? The inclusion of a pharmacological Decision Support System can be very useful for doctors.
The icons at the top indicate, from left to right, the presence of serious interactions, the inappropriateness of one or more drugs for the patient’s age (elderly), any risks in case of impaired renal and hepatic function, the relevant risk of bleeding. By clicking on any of the icons, you could access a dashboard for risk analysis and management such as the one shown in the following figure.
What’s really interesting is that all this could already be done in the current ESF! (provided you have the binding data either directly in the file or via SAR).
Why think about the current ESF
But why spend time on the current ESF when all attention is on the new? What’s the point of still talking about the first when we have to realize the second? There are two answers to these questions. The first is that implementing the new ESF will not be easy and the times will be longer than anticipated (we will come back to this). So why not think about an ESF 1.5? A series of developments, starting from the services and the UI, could be used, with few modifications, also on the FSE 2.0.
Then there is a deeper reason and that concerns the mental attitude with which to look at the new ESF. If we don’t change our approach, if we don’t set ourselves clear objectives and focus our efforts on them, we risk repeating the failure of the current dossier, albeit in a more modern and complex technological framework.
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