St. Petersburg's journey towards an integrated EHR system

Home to the Hermitage Museum and five million residents, St. Petersburg is the second-largest city in Russia. The city also includes around 30,000 doctors, 250 public hospitals and 3,000 private clinics, translating to about 50 million healthcare encounters per year. 

“This produces a huge amount of data. This data was distributed between different healthcare organizations,” Eugene Kogan, Chief Technical Officer of Center for Healthcare Informatics and Analytics in St. Petersburg, said during the HIMSS20 Digital webinar Problem-Oriented Regional Patient Summary. “However, this data must be shared across organizations because it is needed to achieve continuative care when the patient comes to the next organization.”

In St. Petersburg, each organization is able to implement its own electronic health record system. However, Kogan and his team began to look into ways to help link these records. 

“In 2014 we started to create a regional central database to collect the data. We started with a laboratory data exchange. Why laboratory data?” Kogan said. “Because we needed to create an incentive for doctors to use the information systems, so we had to give them something vital, which was laboratory results.” 

Kogan’s team looked into a number of options before choosing HL7 FHIR. 

“Every hospital information system is integrated by FHIR. Lab orders are sent to the central system. The laboratory receives the order,” Kogan said. “When tests are ready, the lab sends the diagnostic report to the central system. That report becomes visible to the doctor who ordered this test, every doctor who sees the patients and to the patient himself.” 

The next step, in 2018, was launching a regional integrated EHR system. 

“All healthcare institutions now must send patient health records to a patient regional database,” Kogan said. “We collect patient documents from all levels of healthcare organizations. We are therefore able to give an integrated record to a doctor and achieve the continued care, at least that is what we thought.”

This meant a lot of digital paperwork coming at the doctors left and right – and not all of it was useful. 

“We supplied our doctor with all the patient medical records. Did we help him? Not so much,” he said. “Theoretically EHRs are a great instrument for continuative care. When we look at it in detail in the real physician’s workflow we see that it is nearly impossible to use. So unfortunately, EHR itself gives nearly no difference to the paper medical record.”

The records were being organized by source – so, for example, all of the lab records were in one bucket, all of the images were in another and so on. 

“A doctor trying to find answer to specific questions sees a mixture of records, both relevant and irrelevant, because they are structured by source and not by purpose,” he said. 

In order to remedy this the team began to use an alternative approach called problem-oriented medical records. This mean that the reports would each represent a problem, in theory making it easier for a doctor to find files related to the aliment he or she is trying to treat. Historically, this type of organization has a number of hurtles, he said. The issues range from not all headings being actual problems to some information belonging in two categories.

“As we decided to make our EHR problem orientated, we decided to overcome this limitation with two instruments: an author-generated patient summary and problem summary,” he said. 

They decided to build a system that would allow for creating an automated patient summary, using the codes that a doctor uses to describe an ailment. Kogan noted that different doctors may diagnose a condition differently, but the system takes it all into account. 

“Why were the codes different? Maybe one doctor is right and the other is wrong,” he said. “Maybe both are right but the patient’s condition has changed. It is important that our algorithm doesn’t decide whether opinions are right or not. It aggregates opinions into problem.”

The team also created a problem-summary list, which needed more specifics on a condition and required a consensus on what a condition was. It was similar to a clinical registry, where there is a list of agreed parameters for each condition and the doctors registers the data. In the problem summary, it will also include a timeline and relevant history. 

“We have discussed the three tools for continuative care, integrated EHR, patient summary and patient-problem summary. We see these tools, being brought together, can support continuative care, not just in theory, in the real physician workflow,” he said. 

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