An Electronic Medical Record (EMR) is a digital record of a patient’s medical history and test results. A record which is kept digitally allows for ease of transfer between physicians and readability, not relying on the old system of papers which need to be physically transferred, or at best, faxed between offices. EMR systems have existed for a number of years already, yet many hospitals and physicians still rely on paper records. However, a complete EMR system is complex, facilitating transfer of information between connected systems whether or not they are part of the same organization rather than being simply a flat file on a desktop with data entered. Many employees and physicians resist change and privacy issues are often at the forefront of concerns dealing with electronic media. This paper discusses the impacts of implementing and operating an EMR and some of the difficulties which may arise that health care providers cite as reasons not to go digital.
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The world of medical technology today abounds with news of breakthroughs and innovation using the latest science and techniques. Technology allows us to perform operations and treat patients in ways not thought possible just 20 years ago. The field of medical information systems however is lagging far behind the rest, with many medical records and communications between physicians still accomplished via paper. Why is there such a disparity between the procedures of performing medicine on patients and the way the records of the procedures on those same patients are kept? In this world of international travel where one can travel halfway around the globe in less than a day, should the medical records of the traveler not be able to arrive digitally if he or she needs it while out of the country?
Implementation of Electronic Medical Records (EMRs) across the country and interconnecting them with the rest of the world, unfortunately, is a long and intensive process. Converting over to an EMR may adversely affect daily operations and increase risk if the proper steps are not taken. The cost may be prohibitive, costing up to $7 million for a 200 bed hospital. However, long term benefits outweigh the investment. Estimates show that implementation of an EMR system could save hospitals from $142 to $371 billion a year, increase the efficiency and reduce errors (Venkatraman, Bala, Venkatesh & Bates, 2008, p.141). The planning and execution of the plan requires the support of both the management and the doctors and nurses who will be using the system on a daily basis.
For a system to be considered useful, the various components and interfaces must be accessible. In a study by Ilie, Slyke, Parikh and Courtney (2009), individuals often select the method of information entry and retrieval which is most accessible. The basis for these actions can be described using the “least-effort” model (p.218). Essentially whichever method is easier or more familiar is the method preferred. Hospitals and doctor’s offices have, for years, used a paper records system. The advantages of paper charts are that the charts are placed near each patient and allow for free form notation. Converting over to an EMR system requires training and convenient placement of terminals for physician and nurses. The most convenient may be placing a terminal in each office and station, in or just outside each patient location, or allowing portable units for information entry and retrieval; but implementation of this may not be within the budget or timetable. In instances where accessibility of terminals were not convenient, it was found that physicians and nurses fell back to documenting on paper charts and then later on reentering the data online (Spetz & Keane, 2009, p.342). To reduce the tendency of users falling back on paper, strategic planning is required in choosing a system which is user-friendly and in placement of units for retrieval and entry of data.
Accessibility also means the ability to retrieve needed information about a patient from locations where he or she does not have a previous record. In a world where EMR systems (which can interface with each other) are the norm, travelers would not have to worry that something may be overlooked simply because previous medical records were not available. In addition, cases where medical records were wiped out due to disasters and backups were not available, treatment of patients can become very difficult. After Hurricane Katrina, many physicians did not have medical records for patients needing emergency treatment; often the patients were themselves in no condition to answer questions or simply did not know enough to give meaningful answers (Brooks & Grotz, 2010, p.73). Even when a hospital or doctor’s office installs an EMR system, thought should be given to how portable the data is. Due to the many different vendors available, EMR systems may or may not be able to transfer data effectively. If a patient moves and requires treatment in another location, an incompatible EMR interface may require that the records be printed out and manually transferred to the new location, effectively negating one of the primary benefits of storing the information electronically.
There are many benefits to implementing an EMR system, both tangible and intangible. One benefit, as mentioned above, could be the ability to share the information between different locations easily. Another benefit which is important to management but often takes time to realize is monetary, in the form of savings from increased efficiency and reduced errors. Increased efficiency also may translate to increased patient satisfaction, leading to increased business and reputation.
Most people think of reducing the amount of paper used when a system migrates to going digital, but paper is a comparatively cheap medium though it takes up a large amount of space. On the other hand, take the case of the radiology department. The film used has to be specially prepared prior to use and it requires special equipment both to take the image and to process for viewing. Moving from hardcopy radiological images to one produced and stored digitally reduces both costs and facilitates transfer of images (Ayal & Seidmann, 2009, p.45, 47).
In the case study of the rural hospital, a number of systems were implemented to try and improve efficiency. The vision was “to create an integrated IT system with an electronic medical record (EMR) and computerized physician order entry (CPOE).” (Spetz & Keane, 2009, p.338). Combining these two would make it possible for the patient to receive tests and treatments by the hospital, then the prescription would be relayed to the pharmacy electronically. The nurse would be able to scan the wristband of the patient and the labels on the prescriptions to verify the correct medicine goes to the correct person. A part of the system which had been implemented in the first month was a bar-coding system for supplies resulting in a decrease of patient care units running out of supplies due to improved inventory control (Spetz & Keane, 2009, pp.338-340).
The reduction of errors is also a key concern and the use of electronic records and a central database reduces the chances of duplication and mid-identification. As cited by Venkatraman, Bala, Venkatesh and Bates (2008) in their introduction to their paper, “The Institute of Medicine (IOM) in 1999 shocked the nation by reporting that as much as 98000 people die in hospitals every year due to medical errors. These errors are also said to cost hospitals as much as $29 billion every year.” Many costly mistakes might have been prevented if physicians had better information available or were not mislead by incorrect information, for example getting the wrong charts for the wrong person.
In the process of proposing an EMR solution, the most common way is show benefits using monetary values and time/productivity savings. However, there are intangible benefits which are not so easily identified or measured. A desirable factor sometimes overlooked is increase in satisfaction, both for the customers and for the physicians (Ayal & Seidmann, 2009, p.49). The ability to process results quickly affects the views the public has of the hospital or office and faster processing allows physicians to accomplish more. One of the most frustrating parts of health care is the wait necessary: patients waiting to be seen or waiting for doctors to diagnose the tests, doctors and nurses waiting for tests to be run or film to be developed. A byproduct of increasing the efficiency of processes is reduced frustration and improved satisfaction. After all, a patient at a hospital with an unknown problem should not have to wonder “what is taking so long” in addition to “what’s wrong with me?”
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Once the decision has been made to acquire an EMR system, the next step is to decide which to use. Many medical technology and software companies are offering EMRs with many different specifications. Would a complete integrated system be better than a modular system? Are there partners requiring the ability to interface with the system? What is the degree of technological sophistication of the users? These questions and many other need to be addressed in deciding what type of EMR system would be the best fit.
One key note in the implementation of a EMR system is that there is always a learning curve involved. Expect productivity to fall upon initial deployment with an increase in productivity once users are familiar with the system. A temporary decline of as much as 50% could be expected initially with productivity ramping back up to pre-implementation levels by six weeks, although some organizations required at least a year (Brooks & Grotz, 2010, p.81). Often this period of decreased efficiency is what many users complain about: they cannot document as fast as they used to, they have to stop often to respond to system alerts, equipment is not working (possibly due to incorrect settings or improper use). Training for users of the system is thus an important part of the implementation plan. Enough time must be set aside for learning the system and support must be available if needed.
Where terminals were placed is often important to the privacy of patients. In a case where an EMR system was implemented in a rural hospital, nurses and their managers had given input on locations for installation of computers and scanning cabinets. Once the nurses started using the system, however, issues of privacy came up. Some of the rooms were multi-bed and with only one computer, the nurse sometimes had to talk across one patient to get information from another (Spetz & Keane, 2009, p.341). Obviously another method needed to be implemented to prevent violation of patient confidentiality; however such changes are not easily accomplished, especially if the system is already in place.
Developing a policy for accessing the system is also paramount to protection of patient privacy in addition to business and financial records. There are several types of access levels available to a system as potentially complex as an EMR. The most obvious are access to medical and financial information. Also included are access to configure the hardware and software, especially the granting of permissions for other users to access various parts of the system. Imagine for example, the nurse who may need to collect financial or insurance information and enter it such that the billing department can access it. What if this same privilege inadvertently gave access to hospital financial records also? Also if an extranet is setup to interface with insurance companies for billing, how much access should they have? If policies are not set up correctly, insurance companies may be able to access records on patients under other insurance company’s policies (Wilcox & Brown, 2005, p.47).
Past employees also need to have access to the system terminated and a policy should be in effect as to what a reasonable timeframe for access termination. Wilcox and Brown (2005) suggested that normal terminations, such as retirement, resignation and employee transfer, should be within one day and urgent terminations, such as a “status change of an employee under hostile circumstances such as a firing, suspension, or other disciplinary action or any time there is reasonable cause to suspect that a user may try to harm or misuse data or system resources,” should happen within an hour.
Medical identity theft is now becoming more of a concern due to the abilities of hackers to access electronic systems. Just as someone could park outside a store and wirelessly tap into the credit card authorization process, someone could attempt to intercept communications between hospitals or even between departments within a hospital. Kieke cites a study by the Federal Trade Commission that states that “medical identity theft accounts for 3 percent of identity theft crimes” (Kieke, 2009). The theft may be used to fraudulently obtain health care services, file false claims, or attempt to secure drugs (Kieke, 2009, pp51-52). Once the identity has been compromised, it may be sold and resold multiple times, costing the patient time and money to clear the claims and establish their own identity again.
In many ways, implementation of an EMR system will be beneficial to hospitals and doctor’s offices. The degree of implementation is dependent on the requirements of the particular establishment. Specialized hospitals and many doctor’s offices do not require the whole gamut of software to run, often a subset or certain key modules would suffice. However, the ability to organize and display medical data in a meaningful way which follows some type of standardization and the ability to transfer records to other locations in times of need should be a requirement of any EMR implementation. Along with the technology needed comes a need to look at the human requirements behind using the system. The users, doctors and nurses in particular, are important to the overall success of any implantation. Not addressing issues which arise from this set of users may render the whole implementation moot.
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