electronic medical record utilization on improving care, and proposals for an integrated electronic...
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Electronic Medical Record Utilization on Improving Care, and
Proposals for an Integrated Electronic Medical Record System
in the United States
Mark DimskiSoc 4353: Sociology of Medicine
Dr. Diana Kendall20 April 2011
Abstract: Electronic Medical Records (EMR) utilization has been identified as oneavenue to improve healthcare in the United States. Through a literature search of severaldatabases, studies examining the efficacy of improving care were found and reviewed.Also goals of the United States Federal governments recent pushes for forming anintegrated network of EMR was evaluated and compared to existing nationwide EMRnetworks, and suggestions for and key implications of a successful EMR system are
discussed. While many studies disagree about impact of EMR systems impacts on patientcare, medical efficiency, and cost-benefits, the United States are proceeding down the pathto EMRs. However an effective system would improve on current models, and allow forbetter health outcomes and ease of access to medical information for patients.
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Introduction
Electronic medical records (EMR) have become one of the hotbeds of investment,
innovation, debate, and implementation over the past decade in hospitals, clinics,
professional organizations, and governing bodies around the world. Electronic medical
record systems (EMRs) are a system that integrated electronically originated and
maintained patient-level clinical information, derived form multiple sources into one point
of access, and replaces the paper record as the primary source of patient information
(Kazley and Ozcan 209-216). The current interest in establishing EMRs is to determine if
these networks can reduce costs, increase patient safety, increase medical staff efficiency,
and allow greater portability of medical information. The system of pen and paper charts
and orders that exists without EMRs is wrought with difficulties and flaws: the time
requirement of manually recording information and reviewing old records to discern
pertinent information, the often illegible writing on pen and paper charts, missing and lost
pages and charts, difficulty (and often impossibility) of transferring paper charts to another
location quickly, and the possibility of duplicate testing at different sites (Joan Solomon
Zolot pp. 64+66+68-69). Also, with paper and pen charts, old treatment information is
legally authorized for destruction after ten years, so valuable information previously
available to a provider may become destroyed. A 2000 Institute of Medicine report
estimated that medical errors annually cause 44,000 to 94,000 deaths, mainly involving
prescription errors 29% of which were due to lack of patient information (Wu and Straus
26-5). It is estimated that more than $1.2 trillion healthcare dollars in the United States is
wasted, about half of the total healthcare spending, much of it as a result of disorganization
and lack of accurate information (Ali 8-10). Advocates for EMRs believe that by
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implementing these systems, physicians will have access to much more medical history
information about their patients, in a quick and searchable format.
Improving Medical Care
The scope of impact that EMRs have on the medical field is not easily quantifiable,
and many studies disagree about whether EMRs aid in patient care, or if they actually put
patients at risk. Karsh, Beasley and Hagenauer (2004) examine the perception of the
quality of medical records kept by users of EMRs (Karsh, Beasley and Hagenauer 327-
335). This cross-sectional survey of 1482 family physicians in a Midwestern state in the
US investigated a possible relationship between EMR usage with working conditions and
quality of life. First, this study looked at the physicians beliefs about their own records
up-to-datedness, accessibility, the record keeping systems adaptability to suit the
physicians needs and the overall quality of the record keeping system, whether they used
an EMRs or pen and paper charts. Then, the Karsch, Beasly, and Hagenauer inquired
about the physicians sense of freedom to spend time with patients, freedom to control
ones work schedule, satisfaction with ones ability to provide continuity of care,
satisfaction with patient relationships, satisfaction with the ability of the primary clinical
assistant to support the physician appropriately, how often the physician worked under time
pressure, and to what extent the physician felt the amount of paperwork typically processed
was reasonable. Third, the researchers asked about the physicians perceptions about their
own quality of life, measured with a 1-5, ranging Not Satisfied to Very Satisfied, in
response to their perceived: satisfaction with their work group, satisfaction with their
parent organization, to what extent one is able to achieve overall professional goals within
the current practice situation. And finally on 1-5, from Poor to Excellent, to the question
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Given your work situation in total, how would you rate the overall quality of medical care
you are able to provide?(Karsh, Beasley and Hagenauer 327-335). One hundred and
forty-three physicians (23.6%) responded that they do use an EMRs at their clinic. The
researchers looked for possible confounders between EMR and gender, age, minority
status, and practice location, and found none. However, they did find a relationship
between EMRs usage and belonging to a larger health care system or hospital that used
EMR, with 26% of respondents using EMRs, while only 6.8% of respondents in
independent clinics used EMR, and adjusted all of the results for this difference. What the
results then found was that use of an EMRs predicted all four medical record outcome
variables. However upon both univariate and multivariate analysis, EMRs usage did not
predict any of the seven working condition questions. When EMRs usage was placed
against the quality of life questions, EMRs users were actually found to be less satisfied
with being a physician than non-EMRs users, but more likely to report being able to
achieve their own professional goals. Although when adjusted for membership in a larger
health care organization or any other working condition variables that were related to the
outcome, there was no relation between the quality of life measures and EMR usage.
In a 2005 study by Garrido et al. organizational structure changes including
implementation of an EMRs showed a decrease in office rate visits at ambulatory care
clinics in two markets (Garrido et al. pp. 581-584). The researchers looked at the Colorado
and the Northwest regions of the Kaiser Permanente medical system. These regions
separately implemented comprehensive EMRs, and Garrido et al. performed a
retrospective, serial, cross-sectional study on selected measures of use and quality of
ambulatory care. Previous to the EMRs, paper records were delivered to multiple sites
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throughout the Kaiser Permanente system, and records for same day or unscheduled care
was unreliable. While the Colorado and the Northwest regions used different systems, both
EMRs had several features in common: 1. integrated documentation and reporting of
clinical results reporting, including comprehensive recording of use of primary and
specialty care, telephone contact, urgent care, and emergency departments 2.
computerized prescription, physician orders, and test orders 3. 24 hour availability of
medial records at the point of care, 4. immediate availability for all potential users for
example, staff in telephone advice centers, pharmacists, and staff reporting clinical results
and 5. easy search features throughout the system (Garrido et al. pp. 581-584). At the time
of analysis, Colorados EMRs was only two years old, and the Northwest region had been
utilizing their system for four years. However, both regions exhibited significant decreases
of 9% in the total office visits, and a decrease of 11% of primary care visits, both adjusted
by age, by two years after implementation. In the Northwest region, with EMRs, telephone
contacts by the physician with the patient increased from 1.26 per member per year to 2.09
by year two. During the EMRs implementation in Colorado, call center staffing shifted
from primarily nurses to include physicians for a brief period, and during that time, office
visits after phone consultations decreased by 7%, and rose again when staffing went back
to nurses. The EMRs creation decreased the office visit rates for both primary and
specialty care services, partially due to the substitution for telephone consultations to
traditional office visits, while quality of care measures remained stable or increased. The
physicians and researchers attribute the decrease in office visits to the availability of
comprehensive clinical information, so physicians were able to identify and resolve
patients health issues in the first contact or with fewer contacts (Garrido et al. pp. 581-
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584). However, after further analysis of quality of care measures, contrary to the
perception of increasing measures, EMR did not affect the quality of care. These levels
remained relatively stable, with only occasional improvements on select measures.
However, from this study, the authors conclude that electronic health records and the
resulting effects on usage do not reduce the quality of care and may in fact increase
appropriate use of healthcare services (Garrido et al. pp. 581-584).
In The Electronic Patient Record in Primary Care Regression or Progression? A
Cross-Sectional Study, Hippisley-Cox et al. examine the amount and quality of medical
information contained within traditional paper charts and new computerized charts
(Hippisley-Cox et al. 1439-1443). Their sample pool was of 25 general practices in Trent
region of England, where 53 British general practitioners, 25 using EMR and 28 using
paper charts, each provided the records of ten consultations. The records from these 53
physicians were then scored using the terms legible, for records which the words or
characters could be read in full, in part, or not at all by another physician, medically
understandable, whether the clinical content of the record could be understood or followed
in full, in part, or not at all by another physician, and medically appropriate, referring to
whether the clinical decision was deemed appropriate based on the information in the
record. Diagnosis, chief complaint, symptoms, family history, medical history, social
history, lifestyle, patient beliefs/views, physical exam vital signs, issuance of a sick note,
referrals, investigations, referrals (and their specialty), and prescription information (drug
name, dose, and frequency) were all collected on each consultation, as well as the number
of words, abbreviations, symbols, numbers, and values that were present in the record. All
of the EMR were qualified as fully legible, whereas 6% of the paper charts were ruled as
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completely illegible, and 30% as only partially legible. The EMR contained more words,
abbreviations and symbols than the paper charts, but unsurprisingly the paper charts
contained seven diagrams. EMR were shown to be more likely to be fully understandable
(89% v 69%), contain at least one diagnosis (48% v 34%) to record that advice had been
given (24% v 11%), to contain details of the specialty of a referral when made (77% v
60%), and to have drug dosage details when a prescription had been given (87% v 66%)
(Hippisley-Cox et al. 1439-1443). Family history was more likely to be included in the
EMR versus the paper chart, however the vast majority of both types of charts omitted
family history (4% v 2%). EMR were demonstrated to be easier to understand, and contain
more specific information about a consultation. Hippisley-Cox et al. concluded that there
is likely then no detriment to continuity of care as a result of the usage of EMRs in general
practice.
Existing Integrated EMR Systems
Integrated EMRs is a system of electronic medical records that is maintained by the
central government and has the capability of being accessed nationally. There have been
several attempts by other developed nations to establish an integrated EMR network.
Norway is an example of a country that is struggling with their integrated EMRs, whereas
Denmark is the gold standard for integrated EMR.
Lrum, Ellingsen, and Faxvaag performed a cross-sectional survey of Doctors
usage of EMR in three of the largest hospitals in Norway (Lrum, Ellingsen and Faxvaag
pp. 1344-1348). By January 2001, 53 of the 72 hospitals in Norway have purchased
licenses for EMR software, representing 77% of all hospital beds in Norway. However,
none of the largest hospitals had completed their implementation of EMRs in all
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departments. The authors developed a questionnaire of twenty-three clinical tasks that
could be accomplished on EMRs, asking physicians how often they utilized the EMRs to
accomplish the tasks. These ranged from reviewing patient problems, to ordering x-rays, to
writing prescriptions and sick leave notes. There are three main EMRs in use in Norway,
DocuLive, DIPS, and Infomedix. None of these systems are capable of performing all
twenty-three clinical tasks, DocuLive, the system in the five largest hospitals, supports only
eleven tasks, while Infomedix and DIPS support sixteen and nineteen tasks, respectively.
Only two tasks, reviewing a patients problems and seeking out specific information from
patient records, were performed with the EMRs by at least half of the respondents. On user
satisfaction data, based on content, accuracy, format, ease of use, and timeliness, none of
the systems were well rated, with DocuLive receiving the worst rating, a 61.4. Norwegian
physicians mainly used the EMRs for reading patient data, and doctor used the systems for
less than half of the tasks that the systems were functional. Some of the most underutilized
functions were repetitive tasks such as writing prescriptions and sick leave notes. Some of
the barriers to the full utilization of EMRs in these hospitals include the concurrent
operation of a paper system. Physicians can choose whether to use the EMRs or paper
charts. The DocuLive system was mainly used solely for checking and signing medical
records, which could be explained by the lack of integration with other components in
hospital departments. DocuLive is in the largest hospitals, and thus the infrastructure of the
hospital is more complex, and more likely to be fragmented.
Denmark is a success story of EMRs implementation. 98% of primary care
physicians, all hospital physicians, and all pharmacists are part of the integrated EMRs
(Harrell, Crumley and Kirchner 36-39). This EMRs also has a web-based component,
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where patients can actually have access to their health records with detailed records back to
2000 and basic records back to 1977. The system also alerts the patient by email if a
doctor, pharmacist or nurse views their records, and allows patients to make appointments,
make end-of-life decisions, and even email their physician for advice for an illness not
requiring an appointment. The implementation of the Danish integrated EMRs was not a
seamless transition however; there was an early system established in 1999 of a common
coding system that required physicians and health care providers to input all information in
alphanumeric form. However, by 2006, the system had been discarded after complaints
from physicians and nurses. Now, instead of a single record keeping system, there are
multiple systems, which are all inter-compatible, and linked by regional health agencies.
HER adoption must be done by evolution rather than revolution, says Jens Andersen of
sunded.dk, the state run web portal. You have to work with the systems already in place
(Harrell, Crumley and Kirchner 36-39). While Denmarks system has achieved many
goals, it does not mean that this system could directly cross over to a United States system,
Denmark only has a population of 5 million people, roughly the population of Chicago,
Illinois and Houston, Texas, and these 5 million people are well educated, and technology
savvy. Secondly, the citizens have high trust in the government, and, most importantly, the
entire healthcare system is public run. Denmark also has had a long-term history with
centralized medical information centralization; in 1977 the countrys health service began a
patient registry, where physicians were required to file information about each visit with
the government health service in order to be reimbursed. The EMRs in Denmark has
greatly improved efficiency, saving physicians an average of 50 minutes a day on
administrative work.
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An American Integrated EMR System
Several medical systems in the United States have already instituted EMRs that
comply with these federal guidelines: Kaiser Permanente (Scott et al. pp. 1313-1316), The
Veterans Administration (VA)(Ali 8-10), and members of The Premier Health Care
Alliance (DeVore and Figlioli 664).
In 1999, Kaiser Permanente (Kaiser), the largest non-profit healthcare system in the
United States, began looking at two different EMRs: EpiCare and Clinical Information
System (CIS). CIS was a joint project between Kaiser and IBM computers, and was
eventually selected as the software to be rolled out in October 2000. However, due to
problems with the software, the rollout did not begin until October 2001. However by
2003, Kaiser decided that CIS did not meet their needs, and halted the nationwide
implementation of CIS and began the process to utilize EpiCare. Scott, Rundall, Voight,
and Hsu conducted a qualitative study on the implementation of EMRs in Kaisers Hawaii
region (Scott et al. pp. 1313-1316). The authors interviewed twenty-six senior clinicians,
managers, and project team members about their attitudes on the implementation processes
of EMR systems, and the brief, twenty-eight month, use of CIS. At the time of the 2003
announced switch from CIS to EpiCare, a third of Kaisers Hawaiian sites had fully
implemented CIS, and the rest had read-only access, some with order entry functionality.
The authors focused on four themes that came up in the interviews: Critical processes in
the implementation of CIS, Roles played by organizational leadership during
implementation, Organizational culture changes, and Conflict over the selection and
implementation process. From these themes, seven key findings were identified: 1. Users
believed that the CIS selection was not made with the local environment (the clinics and
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hospitals) in mind, instead it was made by some corporate head thinking of profits. 2.
Software design and development issues increased local resistance 3. CIS reduced
clinicians productivity 4. CIS initially clarified job roles and then changed roles and
responsibilities 5. Culture had varying effects: corporate values minimized resistance to
change early on but also inhibited feedback during implementation 6. Leadership had
varying effects: participatory leadership was valued for selection decision, but hierarchical
leadership was valued for implementation. 7. An overall effect was a counter-climate of
conflict in the company, which the withdrawal of CIS resolved (Scott et al. pp. 1313-1316).
Scott et al. drew several conclusions from these findings that could be applied to other
organizations implementing EMRs, that a participatory, grassroots process in selection and
fine tuning of the EMR software is important, considering local needs. While a corporate
culture of support for the EMR implementation is important, there must also be a channel
for feedback and criticism of the EMRs. Creating this culture requires different styles of
leadership at different times: participatory leadership at selection, but decisive hierarchical
leadership during the implementation. Clear regular communication from the top levels of
management is important to drive the adoption of the new system and workflows, however
there should also be horizontal communication from clinical champions physicians,
nurses, and other providers and involve these team members in the process of design,
implementation, and improvement (DeVore and Figlioli 664). Implementing a EMRs
represents a sweeping change away from business as usual to an entirely new approach in
health care one that will require process and behavior changes from nearly all health care
workers (DeVore and Figlioli 664).
In 1995 the VA, launched a major re-engineering of its healthcare system that
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included better use of information technology, measurement and reporting of performance,
integration of services, and realigned payment policies(Ali 8-10). This restructuring
resulted in 1999 with the VA Computerized Patient Record System (CPRS) being
implemented nationwide. The CPRS allows clinicians nationwide to log into a secure
network and access complete patient records from inpatient visits, specialty consults,
primary care and emergency room visits, laboratory results, radiology reports, medication
history since the 1980s, surgical notes, and discharge summaries. This creates a single
EMR, which every physician that interacts with the patient uses to manage the patients
care. This allows communication among care providers, makes data collection more
efficient, and because of the digital format, removes the possibility of illegible handwriting.
The CPRS can provide the physician with clinical guidelines, patient data, clinical
reminders, and makes relevant information accessible in real time. The system keeps track
of when veterans are due for preventative care, as well as tracking their history. It alerts
providers when a patient is due for vaccinations, diagnostic screenings, or laboratory tests.
In 2000, the quality of care provided by Veterans Health Administration was measured,
and compared to 1994 (pre-restructuring) levels, the quality of care had greatly improved in
every measured area. In fact, compared to quality of care data from Medicares fee-for-
service program, from 1997 to 1999 the VA was significantly better Medicare on all eleven
similar health quality indicators. In 2000, the VA outperformed Medicare on 12 of 13
indicators, and other health systems in the community on standard measures of health care
quality (Ali 8-10). The EMR has supported this performance improvement throughout the
system. Two strategies tied across all performance indicators and impacted patient care
most were clinical reminders and computer based standing orders. Which are proven
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interventions to enhance preventative care like immunizations and cancer screenings. By
re-engineering the way the VA System practiced medicine, and implementing an system
wide EMR network, they drastically improved the quality of care provided to veterans.
The Institute of Medicine now recommends many of the principles adopted by the VA in
order to improve quality of care, especially emphasis on use of health information
technology and performance measurement and reporting.
With the passage of the new American Recovery and Reinvestment Act (ARRA),
and the Health Information Technology and Clinical Health Act (HITECH Act) began a
federally funded push for adoption of EMRs in hospitals and clinics across America. Since
January 2011, physicians who begin to implement and have meaningful use of certified
EMRs are eligible for up to $44,000 in bonus payments over the years 2011-2014 (JONES
and KESSLER 39-68). In order for a physician to qualify for meaningful use they must
meet three criteria, which stem from the VAs system: 1. Be able and utilize electronic
prescriptions 2. Use a certified EMRs with the ability to exchange health information with
other healthcare providers and hospitals. 3. Provide statistical data on quality of care to the
government. The Certification Commission for Healthcare Information Technology is
responsible for EMR management software certification. In order for an EMRs to be
certified it must include patient demographic and clinical health information, have clinical
decision-making support built in that includes physician order capture, and be able to
exchange information with, and integrate into itself from, other sources.
Strategy for a Successful Integrated EMR System in the Untied States
From the experiences from closed networks, like Kaiser and the VA, and foreign
nations, there is a plan to create a meaningful, effective integrated EMR system in the
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United States. However, there are obstacles that must be overcome. Both healthcare
workers and the public have different hesitations about the creation of an American
integrated EMRs. Bronstra and Broekhuis identify eight key barriers to the acceptance of
EMR by physicians: Financial, Technical, Time, Psychological, Social, Legal,
Organizational and Change Process (Boonstra and Broekhuis 231-247). An EMRs is an
investment, and many times physicians are unable to see past the costs of implementing a
system. There are high start up costs, high ongoing costs to maintain the EMRs,
uncertainty of return on investment, and lack of financial resources. However, with the new
federal incentives to implement EMRs, much of the costs can be repaid back from the
Federal Government. Technical concerns include lack of computer skills, lack of technical
training and support, complexity of use of the system, limitations of the system, lack of
customizability, lack of reliability, interconnectivity and standardization, and lack of
computers and hardware. Time to select, purchase, learn, set up, and implement systems
often deters potential EMR users, along with fear of loss of efficiency. Psychological
barriers include lack of faith in EMR, and a need for control. Social barriers include
uncertainty of the EMR software vendor, lack of support from external parties, interference
with the doctor-patient relationship, lack of support from colleagues, and lack of support
from management. Legal barriers consist of privacy or security concerns. Patients have
trusted their physician with confidential information, and the physician could be held
legally liable for a breach of information. Organizational barriers include organization
size, and organization type. Finally the change process is the final barrier. The process be
deterred by lack of support from the organizational culture, lack of incentives, lack of
participation, and lack of leadership. The two types barriers that pose the greatest obstacles
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are the organizational and change process barriers. Organizational category barriers
determine the relative importance of the other barriers even before implementation has
started, as characteristics of a practice can affect the height of certain barriers. Barriers in
the change process category can mediate other identified barriers during the
implementation process by restricting the ability to overcome them and achieve successful
EMR adoption. Dixon proposes a roadmap to EMR adoption; first there must be a
foundation, a strong business case for providing evidence for justification of investing
money in EMR technology (Dixon pp. 3-13). Then there are three parallel avenues that
must be developed: Best Practices, Workforce Development, and Sustainability. Sharing
best practices represents a constant commitment to providing quality care, and constantly
looking for opportunities for improvement. It is imperative to develop a skilled workforce,
who is able to use the EMRs technology to deliver quality, safe, and effective care.
Finally, the growth and use of EMR technology relies on the sustainability of the
momentum and adaptability of EMR technology. Then and only then, will there be
widespread adoption and use. Dixon models this roadmap into a house: the foundation is
the business case, best practices and workforce development are three pillars, supporting
the roof of widespread EMR use and adoption.
Currently, the role of the medical profession is changing. Physicians are becoming
interconnected, no longer operating as a single practitioner with a patient. By utilizing
EMR technologies, and helping create a integrated EMRs in the United States, physicians
can better help their patients, by helping ensure a safe, ever improving, and efficient
medical system.
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