EMR
An electronic medical record (EHR) (also electronic healthcare record (EHR) or clinical information system (CIS)) is a data repository that digitally collects the medical reports of patients, exchanges such information with other healthcare provides, and makes a personal health record (PHR) for the patient to share with their doctor and other providers.
Contents
- 1 EMR benefits
- 2 Vendor selection criteria
- 3 Historically Important Electronic Medical Record Systems
- 4 EMR Components
- 5 EMR Training
- 6 Strategies for Improving EMR Adoption
- 7 Clinician Sign-out applications
- 8 Free and Open Source EMRs
- 9 Integrating Medical Devices into EMRs
- 10 Considerations for Specialists
- 11 EMR and Biometrics
- 12 Socio-technical Issues
- 13 Business Case for Improving Usability
- 14 New Technologies
- 15 Strategies of Clinical Data Entry
- 16 EHR system selection
EMR benefits
Electronic Medical Records have many benefits over an analogous paper record. Updates are done faster and files can be synchronized. Duplicate orders and illegible handwriting is less of a problem. [1]
See also: more in-depth discussion of EMR benefits
Privacy and security
Privacy is required by the federal law, Health Insurance Portability and Accountability Act (HIPAA). Electronic objects enhance privacy by providing different levels of security access to different governmental groups and individuals. However, it also lends itself to some false sense of security in that it doesn’t prevent humans from mislabeling, incorrectly granting access, or malicious tampering. A digital data trail is very durable and more difficult to erase than a paper trail. However, privacy breaches are possible.
Financial
Although initially implementing EMRs can be expensive [2], computer systems are more efficient and can save time and money. EMR systems can eliminate the paper chart. [3] Typing orders directly eliminates paper waste. Hard drives take up less space. Shared databases reduces the need for paper. [4]
Billing is also easier, as files are claimed faster, and bills are done optimally. Patients can be informed of generic drugs and doctors can know if insurances do not cover patients. Insurance and malpractice premiums can also be lowered. [5]) [6] The computer also can point out different drugs that can save hospitals money [7].
Man hours are also reduced. Dictation is automatic, e-prescribing reduces number of phone calls and visits, [8] [9] [10] and patients are automatically notified of test results and appointment times.
Clinical
EMRs make the hospital staff more productive. Nurses are more efficient. [11] A computer system reduces medication errors and checks for drug-drug interactions [12] [13] [14] [15], reduces redundant lab tests, and reduces time needed in information exchange. [16]
Reminders can increase underused preventative measures, [17] reduce duplicate laboratory tests, [18] [19] and increase compliance with medical protocol. A sufficiently sophisticated EMR can also deduce infections from a list of symptoms and help make doctors make good clinical decisions. [20] [21] [22] [23] The patient internet portal allows patients to know the most up to date information about healthcare. [24] There is also potential in telemedicine. [25]
EMRs also make it easy for large scale data exchange and information integration. National diseases registries exchange data more easily, and patients can pool all their medical data from multiple providers. [26] Surveillance and reporting of diseases is also much easier [27]. Scientists also research all information in the database easily. [28]
Vendor selection criteria
Selection of a vendor product is certainly important and potentially problematic. Physician resistance is one of the major barriers to adoption of electronic medical records. Although some elements, such as diagnoses and medication lists, are relatively easy to implement, others are very difficult. [29] It is important to look at demonstrations or do trial runs before deciding on an EMR.
Functionality
The vendor's EMR must meet some minimum requirements. Its source code must comply with regulatory laws, such as the Health Insurance Potability and Accountability Act, the Patient Safety and Quality Improvement Act (PSQIA), and the Certification Commission of Healthcare Information Technology (CCHIT) criteria.
The EMR software must have essential features [30][31]. These include
- standardized vocabulary standards, such as Unified Medical Language System (ULMS), SNOMED, NDC, LOINC, WHO Drug Dictionary, MeSH, CPT, DRG
- note creation: templates for documentation, dictation, voice recognition, hand writing recognition
- patient problem list compliant with Final Rule
- patient medication list
- reminders and alert system to assist clinical decisions
- user-friendly interface for viewing and sharing of data
- security: access control for data
- advanced reporting and analysis, data query and search functions
- accessibility for the disabled, such as vision and hearing impaired
- wireless access, internet access, outreach for public education
- efficient data transfer between departments (pharmacy, lab), interfaces (PCs, analog data), and institutions (personal health records (PHR), surveillance data)
Implementation cost
The total cost of ownership (TCO) and invest required to fully implement the vendor system is important. Although initially expensive, a good EMR system should pay for itself in time. A vendor should have a track record for successful system implementations. A company should have a detailed plan for implementation and training. All costs should be clearly identified: hardware, software, interfaces, text conversions, maintenance, human resources, networks, peripherals such as computers and printers, training, technical support, and facility renovation to accommodate EMR system changes. Specific software considerations include licenses fees, software upgrade and development timeline, and data integration from legacy systems.
Hardware and technical requirements
It is important to identify all hardware and software requirements to implement a full-scale EMR system. A vendor should meet the technical requirements of OS platforms, language, and databases. The system and licensing system should also be able to meet future technological standards in hardware and software. The debugging process should be efficient. The EMR system must also be scalable to a large number of users.
It is up to the buyer to decided whether to go with non-proprietary system or an established industry system, whether to have on-site or remote hosting; there are advantages and disadvantages to each. A hosted server requires the vendor to have adequate computing facilities. A remote server needs to have alternative plans for outages. Mobile and wireless clients also need consideration.
Information extraction should be fast and efficient.
Long term vendor partnership
The software company itself should be stable, growing, and profitable over a long time period. Its past history should include other successful contracts to similar health systems, a reputation for frequent check-ups, and few uninstalls. A vendor should provide regular and periodic updates. The EMR software must have provide sufficient, long-term, on-site customer support. The vendor should be quick to respond during emergencies, and have backup in case the system malfunctions. The legal agreements should include specifications and quantifiable measures of support, with appropriate penalties if evaluated negatively.
For an in-depth discussion of vendor selection criteria
Historically Important Electronic Medical Record Systems
Many EMRs have already been installed around the world. For a list of EMRs, see Historically Important Electronic Medical Record Systems.
EMR Components
Problem list
A problem list is a list of medical problems that patient has. Problems can be put on the problem list in two ways:
- explicit "promotion" of a clinical term, preferably standardized to Unified Medical Language System (UMLS)
- automatic addition because of clinical rules and protocol
The problem list always need to be filterable by attributes such as "active", "inactive", "resolved", etc.
The problem list should be composed of "actionable" entities, so that changes to the problem status are more easily rendered and so that an individual problem may be facilely linked to other activities such as ordered services. Another example of actions to be taken is creating the links between problems (see Dr Rose's discussion of "nesting" below); again, this should be specific to the logged in user since we all have varying ideas about how such nesting should be enacted - the important thing is to have the nesting tool within the user's grasp. Other actions can include attaching "comments" to the problem list entity (such as how could Dr Osler think that Mr Agony had "fibromyalgia", when it is clearly "somatization" disorder, signed Dr Jung (always electronically signed - no anonymous comments allowed!)
There should always be an opportunity to review a "composite" problem list for any patient within an enterprise (by the way, enterprise is very broadly defined; it could include a state-wide deployment). That composite list would be a listing of all problems that have been promoted to any authorized user's problem list. Display of that list should not be irritating; if 15 authorized users have "hypertension" on their problem lists, display "hypertension" once with a drill down for all of the instances of its instantiation. By the way, the display could/should also permit the logged in user to see any other clinician's problem list for the patient in focus.
If one adheres to these simple principles, the squabbling between users is both well documented but is non-intrusive. Dr Osler continues to have "fibromyalgia" on Mr Agony's problem list and user Dr Jung continues to have "somatization disorder" on Mr Agony's problem list. Neither has to see what the other has entered unless they choose to look at the composite list. Moreover, for Joint Commission reviews, there is a total problem list for any patient.
Moving on to discontinuing medications. In general, good housekeeping suggests that the following care team members receive notification of changes to prescribed medications (including dose changes as well as discontinuations): 1) prescribing clinician; PCP; listed supervisor of non MD clinician.
Medication List
The medication list is a single list of all medications. Medications are active prescription or are affirmed to be over the counter. All historically prescribed medications are also included. This makes it easier to see if medications are prescribed for the same problem (hypertension, analgesia, asthma, etc). Sorting the list by "reason for prescription" will be helpful.
EMR Training
Training clinicians to effectively utilize all the features of an EMR is difficult. Various methods include: classroom sessions, computer-based training modules, and one-on-one training. There is no clear cut best solution to this problem. Physicians are usually not willing to take classes outside of their usual work schedule. Physicians tend not to retain classroom training or understand the significance of what they are taught until they have a chance to try it out.
Physician Help Desks
A "physician help desk hotline" operates differently than a regular help desk line. First, a physician help desk line always gets a human being, never a bot or voice mailbox. Second, the "service level" for the help desk personnel is immediate. When it rings, the responders answer STAT.
Of course, we are still faced with the challenges of optimizing first call resolution (we are currently at ~60% which is pretty good), physicians who don't have time or want to troubleshoot with the Help Desk staff and providing adequate post-call follow up if the issue cannot be resolved immediately.
People also often create a special team specifically dedicated to providing more direct, face-to-face issue resolution for physicians....which may be analogous to the solution you're considering. What my docs would LOVE is to always have someone "right there" when they have a problem, i.e. someone sitting on every unit just waiting to help. But obviously this is not realistic (except possibly for some areas like Radiology.)
Post-live Physician Training & Support
"Super users" are clinical staff who are experts at using the electronic system and can help their colleagues in an ongoing way. Super users can teach the physicians more advanced techniques ("tips, tricks, etc"). The immediate, one-to-one assistance of super users works better than vendor resources for post go-live support. Housestaff pick things up very quickly!
Strategies for Improving EMR Adoption
Strategies for Improving EMR Adoption
Recent Changes to Support EHR Adoption in Solo/Small Practices
Clinician Sign-out applications
Clinician Sign-out applications
Free and Open Source EMRs
Integrating Medical Devices into EMRs
Integrating Medical Devices into EMRs
Quantitative data from medical devices in EMRs
EMR (EHR) Available Solutions and How to Choose the Right One
Considerations for Specialists
Specialists can have different EMR needs.
EMR and Biometrics
Socio-technical Issues
Definitions of Terms related to Patient Privacy, Confidentiality, and Security
Business Case for Improving Usability
Business Case for Improving Usability
New Technologies
- New Technologies
- WiSPER™ (Wireless Standardized Portable Electronic Records)
- Vocera -- Hands-free, wireless communication device
- Aionex PatientBoard -- a HIPAA-compliant, secure, web-based, patient status board
- FastAccess -- a biometric facial recognition solution to the repeat login problem
- Biometric Resource -- information about existing and cutting edge biometric technologies
- Omron Wrist Blood Pressure Monitor
- Iniatite Systems Identity Hub
- Internet Based EMR: Benefits & Costs
Strategies of Clinical Data Entry
Strategies of Clinical Data Entry
Natural Language Processing (NLP)
EHR system selection
See more for what Marl Mench thinks of EHR system selections
