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Lack Of Standards For Ehr Health And Social Care Essay

In 21st century Information Technology played an exclusive role in maximum of the fields; however, healthcare is one noticeable exception. According to studies, U.S. hospitals and multiple-facility health systems are “only beginning to round out their clinical networks, but are much farther along than physician practices.” (David B. Meinert) While many inpatient or hospital facilities migrating from paper charts to electronic records, but a little progress has been made in the ambulatory or outpatient setting. Vast majority medical professionals including physicians have been reluctant to use electronic medical records and continue to rely on paper records. Paper medical records are data rich by nature, but information is poor as physicians and other health care providers have limited time to dig through volumes of paper to retrieve information, utilize it in decision-making and/or share it with patients. EMR/EHR systems hold tremendous promise for not only improving the quantity and quality of clinical data that can be recorded, but more importantly the ability to access health care data to improve quality of care.

This study will try to see the perception of medical professionals towards Electronic medical record. Study has been done as a comparative study among two different types of settings that is hospital which are using EMR (paperless hospitals that is category A) and hospitals which are having their own information system where the paper-based medical records are scanned and used (Category B hospitals).

Electronic Medical Record (EMR) According to the Healthcare Information and Management Systems Society (HIMSS), an EMR is a component of an electronic health record which is owned by the healthcare provider. (Dr. Chris Hobson)

This technology, when fully developed, meets provider needs for real-time data access and evaluation in medical care. EMR also provides the mechanism for longitudinal data storage and access. The content of an EMR is analogous to the paper record, but the electronic format creates usable data in medical outcome studies, improves the efficiency of care, and makes for more efficient communication among providers and easier management of health plans. (Electronic Medical Record: The Link to a Better Future, Texas Medical Association)

Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, These have been used extensively by general practitioners in many developed countries and include patient identification details, medications and prescription generation, laboratory results and in some cases all healthcare information recorded by the doctor during each visit by the patient. (Electronic health records: manual for developing countries. WHO)

EHRs are the next step in the continued progress of healthcare that can strengthen the relationship between patients and clinicians.  The data, timeliness and availability of it, will enable providers to take better decisions and provide quality care.

For example, the EHR can improve patient care by:

Reducing the incidence of medical error by improving the accuracy and clarity of medical records.

Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.

Reducing medical error by improving the accuracy and clarity of medical records.

Background:

Hospital information systems (HIS) and Electronic Medical Records (EMRs) are considered prerequisites for the efficient delivery of high quality health care in hospitals. However, a large number of legal and practical constraints influence on the design and introduction of such systems (Dick RS, Steen EB) Hence, many EMR implementation projects do not aim at introducing the EMR and eliminating the paper-based counterpart in one step (Laerum H). As a start, the EMR is introduced along with its paper-based counterpart, and both are kept updated. In such environments, health care workers have to deal with a hybrid electronic and paper-based solution. This probably limits the use of EMR (Laerum H). Furthermore, errors are prone to develop due to cumbersome maintenance of the medical record information in dual storage media.

In many countries, most hospital EMR projects have not passed beyond this phase (Dick RS, Steen EB)

Electronic Medical Records- the changing trend:

• Paper based records are being gradually replaced by computer based records (which is in existence in the West since 2 decades)

• It has not achieved the same penetration in healthcare as in finance or other industry. Deployment varies in countries

Objectives:

To review already existing information system of both category of hospitals

To find out actual versus perceptual difficulties while using EMR both categories hospitals

To study the overall perception of hospitals about EMR

To measure satisfaction from EMR in category A hospital

To produce a checklist for improvement

Methodology:

Overview: Various studies which has been done globally has been studies to find out statement of problem, since no such study has been found in Indian context, so all assumptions from other countries has been considered as relevant. Considering the less adaptation of EMR use, this study tries to find out actual versus perceptual advantages, disadvantages and functionality etc to get the clear picture.

Sample: total four hospitals have been selected under two different settings for comparison. Each setting has two hospitals of same kind. For ease both settings have been given name category A and category B. Category A hospital are EMR user hospital while category B hospital are having their own hospital information system in place along with the paper record. For ease terms category A and B in whole document instead of EMR user and EMR nonuser hospitals

Sample size: Excluding 4 IT heads, total 120 responses has been collected form clinical staffs, which includes doctors, residents, heads of departments and nurses etc. Thirty responses from each hospital have been collected.

Questionnaire: questionnaires had been used for collecting data from both category hospitals. Questions are of close ended, rated on the basis of likert scale from 1-5. Response recording has also been done for finding out the problems, so that better suggestions can be made.

Interviewing: in depth interviews has been taken by IT heads of all the four hospitals to understand all the factors from their point of view, and to understand their take on different problems addressed by their clinical staff.

Since none of the hospital is using EHR, so complete study had been done about EMR only.

Data collection had been done as follows-

Questionnaires have been used for collecting data from medical staff.

In depth interview with IT heads of all the four departments

Review of literature related to EMR

Review of the literature to understand perception of medical professionals regarding EMR use.

Inclusion criteria: to ensure validity of sample, two questions were set in questionnaire. According to that who were working in hospital for more than three months; were eligible. Another inclusion criterion was directly related to patient care. Those who were using computer for entering patient information/ retrieving patient information/ test result retrieval etc; were eligible.

Literature review

There are many functions associated with patient health records. This record is not only used to document patient care, but it also used for recording financial and legal information and research and quality improvement purposes. (Young, Kathleen M.)

The conventional paper-based medical record has several limitations. Though this traditional method is useful for recording patient’s details for solving medical issues, tracking down patients and for coordinating in healthcare process, but it has so many disadvantages. These types of records are often poorly indexed and sometimes illegible, fragmented, because these records are hand written. The most disadvantageous factor of using this method is that the medical record would be accessible to only one person at a time. These medical records cannot be made available to everyone at the same time. Last but not least there is the problem of storage of paper record, most of the times these are not stored properly, which in turn cause failure in retrieval of information, whenever required.

Medical record is systematic documentation of a single patient's medical history and care across time within one particular health care provider. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc.

The electronic health record (EHR) provides the opportunity for healthcare organizations to improve quality of care and patient safety. “The greatest challenge in the new world of integrated healthcare delivery is to provide comprehensive, reliable, relevant, accessible, and timely patient information to each member of the healthcare team, whether in primary or secondary care and whether a doctor, nurse, allied health professional, or patient/consumer” (Schloeffel)

An electronic medical record (EMR) is a computerized medical created in an organization that delivers care, such as a hospital or physician's office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.

Some definitions: According to National Alliance for Health Information Technology (NAHIT)

EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.

EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.

Purpose of medical record:

The principal purpose of medical records and medical notes is to record and communicate information about patients and their care. If notes are not organised and completed properly, it can lead to frustration, debate, clinical misadventure and litigation. medical records are now used not only as a comprehensive record of care but also as a source of data for hospital service activity reporting, monitoring the performance of hospitals and for audit and research. Many of the causes of inaccurate clinical coding of this secondary data are rooted in the quality of medical notes

History of Electronic Medical Records: Physicians are expected to document encounters they have with patients to ensure crucial information for decision-making is recorded and actions taken are also recorded. Documentation is also required as an archival record of what happened in cases of dispute. To a great extent, physicians resent the task of documentation, as it detracts from their primary task: taking care of patients. Physicians also resent the duplication of effort required with documentation, as every medication that is written on a prescription pad, every lab test ordered, every x-ray ordered has to be re-written in the chart to maintain a good record. Communication between practitioners is difficult as in many cases the information collected is fragmented, frequently redundant and voluminous. Finally, physicians are constantly inundated with new information and have no tools to help them incorporate new techniques and treatments into their day-to-day activities, other than using their memories or having to lug around large textbooks.

The idea of recording patient information electronically instead of on paper –the Electronic Medical Record (EMR) –has been around since the late 1960‘s, when Larry Weed introduced the concept of the Problem Oriented Medical Record into medical practice. Until then, doctor‘s usually recorded only their diagnoses and the treatment they provided. Weed‘s innovation was to generate a record that would allow a third party to independently verify the diagnosis. In 1972, the Regenstreif Institute developed the first medical records system. Although the concept was widely hailed as a major advance in medical practice, physicians did not flock to the technology.

In 1991, the Institute of Medicine, a highly respected think tank in the US recommended that by the year 2000, every physician should be using computers in their practice to improve patient care and made policy recommendations on how to achieve that goal.

Advantages OF THE EHR: advantages of EHR can be divided as following-

1) Clinical outcomes

a) Quality of care: Improving quality of care is one of the main focuses of many EHR studies. Quality of care has been defined as “doing the right thing at the right time in the right way to the right person and having the best possible results”, in short “a process for making strategic choices in health systems”. Quality of care includes six dimensions, effectiveness, efficiency, patient safety, accessibility or timeliness, equitable access, and patient-centeredness or acceptability, but most EHR research has focused on the first three. Last three components needed more research in their corresponding fields.

Sometime patients may not adhere to best practice guidelines; even the providers have best intention. This kind of situation can arise due to various factors like-

Clinicians are not aware with the guidelines.

Clinicians may not realize that a particular guideline applies to a given patient.

Lack of time during the patient visit.

EHR systems proved quite effective in handling such kind of issues and improved adherence rates. For example, researchers found that computerized physician reminders increased the use of influenza and pneumococcal vaccinations from practically 0% to 35% and 50%, respectively, for hospitalized patients (exter PR, Perkins S, Overhage JM, et al.). Similarity other studies with computerized reminders on vaccination rates, shows significant improve adherence to immunization guidelines.

Lowers the risk of disease outbreaks in communities: There are many other researches have conducted that focused on other preventive services and studied effect of EHRs on different outcomes to improve care effectively. Willson et al found in his study on hospitalized patients that after implementing computerized reminders targeted to hospital nurses, there is 5% reduction in the development of pressure ulcer after 6 months. It proves a significant association between computerized reminders and risk of disease.

Effective health care delivery: Researchers have also found that there is a profound relation between EHRs and efficiency in health care delivery. Here efficiency refers to the avoidance of wasting resources, including supplies, medical equipment, money, ideas, and energy. One such form of waste involves redundant diagnostic testing. Performing redundant tests is costly and may lead to more false-positive results, which will then lead to even more costs. Tierney et al found a 14.3% decrease in the number of diagnostic tests ordered per visit and a 12.9% decrease in diagnostic test costs per visit when using an EHR with CDS and CPOE components. Other, unrelated studies found an 18% decrease in tests ordered for medical visits in the emergency department, a 27% decrease in redundant laboratory tests of antiepileptic medication levels in hospitalized patients, and a 24% reduction in redundant laboratory tests in a hospital.

Reduced medication errors: A well-known study group found in their study that only introducing CPOE system reduced serious medication error by 55% in the hospital setting. Whereas later in follow-up study the same group expert found that, these medication errors can be reduced as much as 86% by adding CDS system together with CPOE system. A similar, more recent study in the outpatient setting found that computerization resulted in an error rate reduction from 18.2% to 8.2%.( Devine EB, Hansen RN, Wilson-Norton JL, et al.). On the other hand many other studies have concluded that by introducing computerised system, the number of appropriate medication orders involving dosing levels or dosing frequency can be increased.

Better clinical outcome: Many of the studies also focused on clinical outcomes. Randomized trial research design used for conducting these studies in a clinical setting. An additional body of literature has examined, observationally, comparison of performance in between hospitals that implemented EHRs and other computerized capabilities with its counterparts that have not. For example, Menachemi et al found that Florida hospitals with greater investments in EHR technologies had more desirable rates on a variety of commonly used quality indicators.

Patient Safety: The challenge of reading handwritten notes, orders, and prescriptions has been eliminated with the EHR. Patients’ chart information is clear and legible. Reports and letters to other specialists and patients are comprehensive, professional, and easy to create. Chart information is always accessible and found in the same place. Paper charts, on the other hand, can become cluttered with a lot of necessary but misplaced information.

2) Organisational outcomes:

Studies examining organizational outcomes have focused on EHR use in both the inpatient and outpatient settings. Such outcomes have frequently included increased revenue, averted costs, and other benefits that are less tangible, such as improved legal and regulatory compliance, improved ability to conduct research, and increased job/career satisfaction among physicians. Increased revenue comes from multiple sources, including improved charge capture/decrease in billing errors, improved cash flow, and enhanced revenue. Several authors have asserted that EHRs assist providers in accurately capturing patient charges in a timely manner (Schmitt KF, Wofford DA)

Electronically available patient information generated so many efficiencies, which directly help in averting cost. Some of these efficiency includes increased utilization of tests, reduced staff needed for patient management, decreased transcription costs, reduced costs relating to supplies needed to maintain paper files, and the costs relating to chart pulls. EHRs also reduce the redundant use of test or the need to mail hard copies of test report to all providers that save money and time of organization. (Chen P, Tanasijevic MJ, Schoenenberger RA, et al).

Studies have also shown that having an EHR can reduced transcription costs through electronically available structured documentation procedures rather than a paper file. (Agrawal A.)

In addition, researchers in Massachusetts have found that physicians using an EHR had fewer paid malpractice claims. They found a physician without EHR have much higher (10.6%) history of paid malpractice claims compared to those physicians with EHRs (6.1%). This reduction is potentially the result of better communication among caregivers, increased legibility and completeness of patient records, and increased adherence to clinical guidelines.

3) Societal outcomes:

Another less tangible benefit associated with EHRs is an improved ability to conduct research. As patient data stored electronically that makes availability of data much easier which leads too many quantitative analyses to identify evidence-based best practices more easily ( Aspden P. ). Moreover, public health and other interdisciplinary researchers are actively using electronic clinical data that are real data aggregated across populations to produce good research finding, which is beneficial to society.

Till today availability of clinical data is much limited but as providers will start using EHRs, this dataset will also start growing. Later by combining this clinical data with more data from other sources like over-the-counter medication purchases and school absenteeism rates, our researches and public health organization can better monitor disease outbreaks and improve surveillance of potential biological threats (Kukafka R, Ancker JS, Chan C, et al).

Researchers have also found an association between EHR use and physician satisfaction with their current practice, together with their career satisfaction. According to many studies, physician satisfaction should be a priority in health care organizations, because it is associated with better quality of care, better prescribing behaviours, and increased retention in medical practices, particularly those in underserved areas. ( Elder KT, Wiltshire JC, Rooks RN, et al. )

Chaudhry et al noted that a large proportion of the studies that found benefits from EHR were conducted in a selected number of academic medical centres in hospital setting. Due to this reason many researchers are also putting a question about the generalization of identified benefits of EHR in real world where they may neither have similar financial and human resources nor a decades-long commitment to health information technology. More research on the varying types and degrees of benefits associated with EHR is warranted, especially in community settings such as physician practices and non-academic hospital settings.

BARRIERS TO THE EHR

Although Electronic Health Records (EHRs) bring tremendous benefits to patient care and to the health-care provider, use of the ambulatory EHR instead of the paper chart did not become widespread among the independent physicians during the 1990s. Even though the motivation of improved patient care and availability of medical data was present, health-care providers were hesitant to begin using this medical tool. Specii c reasons have been hypothesized for the lack of EHR implementation, and they are outlined below.

A Lack of Standards for EHR Systems

The content within the systems did not have uniformity for compatibility or interoperability. Various programs offered different features and the exchange of data was not possible. Also, standards for the security of confidential information through encryption or data integrity had not been set. The quality of EHR programs and computer networks was not sufficiently reliable to prevent downtime, thus resulting at times in the lack of access to patient information or medical information. Data for clinical protocols, management of patient care, and decision support through algorithms were not yet standard for EHRs.

Unknown Cost and Return on Investment

Health-care providers found it difficult to accurately calculate costs and Return on Investment (ROI) with the use of an EHR. The full cost of an EHR includes the software purchase price, additional computer hardware, implementation including the training of staff, customization of the system, ongoing technical support, system maintenance, and future program upgrades. Measuring ROI includes intangible, immeasurable, and nonfinancial information, such as improved patient care, patient safety, and more efficient processes. Measurable ROI includes increase in income from more accurate coding, greater time efficiency as a result of rapid chart documentation, expanded patient load because of this efficiency, and reduced office supply costs such as paper, charts, and printing supplies. It was difficult to accurately calculate costs and ROI with the use of an EHR.

Difficult to Operate

Doctors perceived that it took more time for data entry than handwriting. A physician order form may have been simpler to handwrite than to process through a computer system. Learning where the information should be entered or accessed was complicated and computers were not always accessible at the point of care. System warnings and medical alerts containing vital information had not been developed. The long-term benefit were difficult for some healthcare providers to value over the perceived difficulties of operation

Significant Changes in Clinic Processes

Although an EHR can be customized for specific medical practices, there is always some process change required by the provider and medical staff. An EHR may bring a more rigid structure for entering information than flipping through a paper chart. Adapting to new standards of operation for entering and locating information can be difficult initially. Some EHRs have specifications or specific routines for practicing medicine that the provider may not adapt to easily. The health-care provider may not be able to address and analyze problems in the same ways that may have been done in the past, even though the information in an EHR is more thorough and instantly available. New tools for improved patient care require retraining, new processes, and changes in the medical practice culture.

Lack of Trust and Safety

A concern for the security of the medical record stored electronically instead of on paper is common. Health-care providers may be concerned that the electronic medical record could be altered without their consent or knowledge. Providers must have the assurance that the medical records are safely stored for future accessibility. Power outages, computer “crashes,” viruses, concerns about adequate backup, and so on are issues providers must overcome to be confident in using an EHR.Use of EHR programs, particularly in the small- to medium-sized practices, is expanding rapidly. Nearly 78 percent of physicians in private practice are within this market group of eight or fewer doctors. With the explosive growth of EHR implementation in this segment of the medical community, a great need has been generated for both clerical and clinical support staffs that have professional training and exposure to the EHR. Concerns about the transition from traditional paper charts to EHRs are now being overcome. Many of the concerns expressed about EHRs have been addressed more fully in recent years. Although the motivations vary from a practice wanting to simply “become paperless” to another practice wanting to improve patient care, medical clinics are quickly recognizing the incredible tool the EHR is bringing to the medical practice.

Disadvantages of EMR

On the contrary of advantages some authors have identified several potential disadvantage of using EHRs. These include financial issues, changes in workflow, temporary loss of productivity associated with EHR adoption, privacy and security concerns, and several unintended consequences.

Significant cost: A major reason for disincentive for adopting and implementing EHR is its cost. It includes loss of revenue associated with temporary loss of productivity, declines in revenue, adoption and implementation costs and ongoing maintenance costs. Here EHR adoption and implementation costs includes purchasing and installing hardware and software, converting paper charts to electronic ones, and training of end-users. Different studies documented this cost in both inpatient and outpatient settings. Like a study conducted in 2002 at a 280-bed acute care hospital, the projected total cost for a 7-year-long EHR installation project was approximately US$19 million. In the outpatient setting, early researchers estimated an average initial cost of US$50,000–US$70,000 per physician for a three-physician office. However, as EHR technologies have become more commonplace over the past decade, the initial cost of systems has come down dramatically (Schmitt KF), (Agrawal A)

Maintenance cost also can be cumbersome as hardware needs to replace time to time and software needs to upgrade on regular basis. In addition, providers must have ongoing training and support for the end-users of an EHR. According to one study conducted on 14 solo or small-group primary care practices, estimated ongoing EHR maintenance costs averaged US$8412 per FTE provider per year. Out of total cost around 91% of this was related to hardware replacement, vendor software maintenance and support fees, and payments for information systems staff or external contractors (Fleming NS, Culler SD, McCorkle R, et al)

Disruption of work-flows for medical staff and providers: Another major disadvantage of implementing EHRs is disruption of routine work-flow for medical-staff or provider, which results to loss of temporary productivity. This disruption may be because of training of end-users which potentially leads to loss in revenue. One study that involved several internal medicine clinics estimated, a productivity loss of 20% in the first month, 10% in the second month, and 5% in the third month before productivity return to its original levels as in starting (Wang SJ, Middleton B, Prosser LA, et al.)

Researchers also have estimated that EHR end-users spent around 134.2 hours on implementation activities that includes getting and learning a new system. These hours spent on nonclinical responsibilities had an estimated cost of US$10,325 per physician (Fleming NS, Culler SD, McCorkle R, et al.)

Risk of patient privacy violations: Another potential drawback of EHRs is the risk of patient privacy violations, which is an increasing concern for patients due to the increasing amount of health information exchanged electronically between providers. To confront such kind of situations, policymakers have taken measures to ensure safety and privacy of patient data. For example, recent legislation has imposed regulations specifically relating to the electronic exchange of health information that strengthen existing Health Insurance Portability and Accountability Act privacy and security policies. Although few electronic data are 100% secure, the rigorous requirements set forth by the new legislation make it much more difficult for electronic data to be accessed inappropriately. (Zurita L, Nohr C. Patient opinion: EHR assessment from the users perspective.(Stud Health Technol Inform.)

Not only acts make exchanging electronic health data secure but also many hospitals and physicians are implementing strict rules like no tolerance penalties for employees who access files inappropriately. For example, a hospital in Arizona terminated several employees after they inappropriately accessed the records of victims who were hospitalized after the January 2011 shooting involving a US Congresswoman. (Innes S.)

Although privacy will likely continue to be a concern for patients, many steps are being taken by policymakers and individual organizations to ensure that EHRs comply with the strict laws and regulations intended to ensure the privacy of clinical information.

Decrease face-to-face time with patients, depersonalize encounters

EHRs may cause several unintended consequences, such as increased medical errors, negative emotions, changes in power structure, and overdependence on technology. (Campbell EM, Sittig DF, Ash JS, et al. ) Researchers have found an association between increased medical errors and CPOE due to faulty system or untrained end-user. Additionally, end-users of an EHR may experience strong emotional responses as they struggle to adapt to new technology and disruptions in their workflow. Changes in the power structure of an organization may also occur due to the implementation of an EHR which makes it quite more automated. For example, a physician may lose his or her autonomy in making patient decisions because an EHR blocks the ordering of certain tests or medications. Overdependence on technology may also become an issue for providers as they become more reliant upon it

Innovation acceptance:

The origins of attitude and behavior date back to as early as 1862, when psychologists began developing theories showing how attitude impacted behavior. Those studies by social psychologists continued and in 1925, many new theories emerged suggesting that “attitudes could explain human actions” (Ajzen & Fishbein, 1980, p. 13)

Several models have been developed and utilized to analyze the acceptance of technology. Some of the important models are as follows-

Theory of Reasoned Action (TRA)

According to this model, a person’s behavior is determined by his/her behavioral intentions (BI) to perform that behavior. That BI is itself determined by both a person’s attitude toward the behavior and subjective norm concerning the behavior.

Theory of Planned Behavior (TPB)

The theory of planned behavior was proposed by Icek Ajzen in 1985 through his article "From intentions to actions: A theory of planned behavior." The theory was developed from the theory of reasoned action, which was proposed by Martin Fishbein together with Icek Ajzen in 1975. According to the theory of reasoned action, if people evaluate the suggested behavior as positive (attitude), and if they think their significant others want them to perform the behavior (subjective norm), this results in a higher intention (motivation) and they are more likely to do so.

Technology Acceptance Model (TAM)

Based on the theory of reasoned Action, Davis ( 1986 ) developed the Technology Acceptance Model which deals more specifically with the prediction of the acceptability of an information system. This model suggests that the acceptability of an information system is determined by two main factors: perceived usefulness and perceived ease of use. Perceived usefulness is defined as being the degree to which a person believes that the use of a system will improve his performance. Perceived ease of use refers to the degree to which a person believes that the use of a system will be effortless

Unified Theory of Acceptance and Use of Technology (UTAUT) The UTAUT aims to explain user intentions to use an information system and subsequent usage behavior. The theory holds that four key constructs (performance expectancy, effort expectancy, social influence, and facilitating conditions) are direct determinants of usage intention and behaviour. Gender, age, experience, and voluntariness of use are posited to mediate the impact of the four key constructs on usage intention and behavior.

Factors Affecting EMR Acceptance

Acceptance is defined as the willingness within a user group to employ information technology to the tasks it is designed to support (Dillon & Morris, 1996). Many researchers have stressed the importance of acceptance study. For example, Kirk (2003)

urged urgent actions on providing legal and social framework for acceptance andintroduction of EMR. Likewise, Gefen (2003), Zdon (1998), Anderson (1997), Moore(1996), Baroudi (1986), Bardram (1997), Bowers (1995), Graham (1996), and Hubona (1996), all discussed similar issue. Moreover, past experiences show that the effort to introduce EMR will result in failure and unanticipated consequences if their technical aspects are over emphasized and their social and organizational factors such as the user acceptance and the diffusion of information system are overlooked (Gefen, 2003,Anderson, 1999, Moore, 1996). Kirk (2003) has noted that currently there is no social framework for EMR acceptance.

The closest framework model, which measures perceived usefulness and perceived ease of use, that can be adopted is the Technology Acceptance Model (TAM) proposed by Davis (1989). Tsiknakis (2002), Einarson (1993), and Neilder (1997) added that poor presentation of patient’s data can lead to poorly informed clinical professionals,medication errors, inappropriate repetition of investigation, unnecessary referrals, and waste of clinical time and other resources. Indeed, poor presentation of patient’s data is an interface issue, which warrants more investigation.In obtaining the user acceptance of health care, particularly its system interface,

Rosenbaum (1998) proposed six successful techniques:

Involving the user community in needs analysis and requirements definition.

Designating members of the user community who are involved in the system design as preceptor (people who receive first training and extensive training).

Conducting task analysis of the entire work process, not just the partsinvolving the clinical information system.

Performing user studies of preliminary paper and pencil prototypes with typical users.

Conducting iterative usability testing of successive prototypes.

Visiting hospitals and other settings of use to observe the work process, use of predecessor systems, and beta-test installation

Studies statistics: There is scarce of studies regarding EMR use in Indian context. Results of some relevant studies are as follows-

Result of a research done by Sequist et al was as follows- The overall response rate was 56%. Of responding clinicians, 66% felt that the EHR implementation process was positive. One-third (35%) believed that the EHR improved overall quality of care, with many (39%) feeling that it decreased the quality of the patient–doctor interaction. One-third of clinicians (34%) reported consistent use of electronic reminders, and self-report that EHRs improve quality was strongly associated with increased utilization of the EHR (odds ratio 3.03, 95% confidence interval 1.05–8.8). The majority (87%) of clinicians felt that information technology could potentially improve quality of care in rural and underserved settings through the use of tools such as online information sources, telemedicine programs, and electronic health records.

In a study conducted in the United States, the most commonly cited barriers to use of EMR systems in hospitals were inadequate capital for purchase (74%), maintenance costs (44%), resistance on the part of physicians (36%), unclear return on investment (32%), and lack of availability of trained staff (30%). Hospitals that had adopted EMR systems were less likely to cite four of these five concerns (all except physicians' resistance) as major barriers to adoption than were hospitals that had not adopted such systems.

When most of the hospitals or professionals talking about high cost of EMR, a cost benefit analysis of EMR in primary care done by Wang et al shows, In the 5-year cost-benefit model (Table 3), the net benefit of implementing a full electronic medical record system was $86,400 per provider. Of this amount, savings in drug expenditures made up the largest proportion of the benefits (33% of the total). Of the remaining categories, almost half of the total savings came from decreased radiology utilization (17%), decreased billing errors (15%) and improvements in charge capture (15%).

Though not all benefits of an electronic medical record are measurable in financial terms; other benefits include improved quality of care, reduced medical errors, and better access to information.

CURRENT SCENARIO IN INDIA

The Department of Information Technology (DIT), Ministry of Communication an Information Technology (MCIT) have funded several projects during the past decade for development of IT based Healthcare solutions. During the course of these projects, the need for a standard EHR for the nation has been strongly felt for interoperable health-care solutions. During the meetings of the National Knowledge Commission for creating the national health informatics vision for India, the need for standard EHR with secure storage and access of EHRs in a storage system spanning.

The current way of developing and using healthcare information store systems has led to a chaotic state of affairs due to following reasons:

• They have been developed independently and do not easily interoperate with each other.

• They follow their own convention of creating, maintaining, and storing Electronic Health Records (EHRs) of patients.

• If a patient is treated at different hospitals at different instances, different EHRs are generated and stored for the same patient by the two different information systems in use at the two hospitals. A single EHR for an individual is desirable irrespective of his/her time and place of treatment.

• Each system has its own way of creating and managing its storage of EHRs. Obviously,   such   an   information   store   is   based   on   both   relational   database technology,   due  to its   ubiquity   and   maturity   in   managing   large   volume   of information, and media storage  software,  for example Xray picture archiving. Different systems use different relational databases and different media storage software making data transfer across systems impossible/inconvenient.

• Most of the existing systems use centralized storage, leading to limited scalability and poor reliability (single point of failure).

As a result, it has become difficult to exchange EHRs across different systems and to have a unified information system to deal with one EHR per individual, irrespective of the time and place of treatment of an individual.

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