EMR

From Clinfowiki
Revision as of 17:00, 20 October 2011 by Annathehybrid (Talk | contribs)

Jump to: navigation, search

An electronic medical record (EMR) (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.

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:

  1. explicit "promotion" of a clinical term, preferably standardized to Unified Medical Language System (UMLS)
  2. automatic addition because of clinical rules and protocol

The problem list should have "actionable" statuses next to each problem. Status can be linked to actions, such as resolved, active, or unresolved. Problems should also be able to be nested, or hierarchical. Comments should also be allowed. Comments and statuses need to be searchable and filterable. For example, if a patient had been noted to have hypertension by 15 doctors, then a display for the term hypertension should be show the inputs from all 15 doctors. Thus, conflicts between physicians is well-documented, but non-intrusive. For example, Dr. Osler can diagnose Mr. Agony with "fibromyalgia," while Dr. Jung can diagnose "somatization disorder." Neither physician 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.

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.

An alert for medications changes, such as dose or prescription changes, should be made to the prescribing clinician or primary care physician (PCP) and the listed supervisor of non MD clinician.

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]

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]

See also: more in-depth discussion of EMR benefits

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 for Health Information Technology (CCHIT) criteria.

The EMR software must have essential features [30][31]. These include

Implementation cost

The total cost of ownership (TCO) 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

Request for Proposal

Comparing Vendors

The process of an EMR system selection incorporates several factors: [32]

  1. Review of medical informatics literature to develop a mission statement, determine objectives, and guide the demonstration process
  2. Investigation of vendor statements collected during the Request for Proposal phase, industry statements, other institution’s views of vendors,
  3. Development of a user-centric selection and survey instrument specifically designed to assess user feedback,
  4. Scientific analysis of validated findings and survey results at all steering committee meetings,
  5. Assessment of the vendor's ability to support research by identifying funded and published research projects that were based on the vendors system,
  6. Employing meticulous total cost of ownership analysis to assess and compare estimated costs of implementing vendor solution, and
  7. Iterative meetings with stakeholders, executives and users to understand their needs, address their concerns and communicate the vision.

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 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.

The challenges of optimizing first call resolution is at 60%. There is also physician resistance because they neither want to troubleshoot with the Help Desk staff, nor be provided a 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!

Additional resources

  1. Landauer, T. K. (1995). The Trouble with Computers; Usefulness, Usability, and Productivity. Cambridge, MA; London, England, The MIT Press.
  2. Karat, C.-M. (1994). A business case approach to usability. Cost-Justifying Usability. R. Bias and D. Mayhew. New York, Academic Press: 45-70.
  3. Chapanis, A. (1991). The business case for human factors in informatics. Human Factors for Informatics Usability. Shackel, Brian and Richardson. Cambridge, U.K., Cambridge University: 39-71.
  4. Zhang (1999). Usability Problems with electronic medical record. AMIA Fall Conference, Washington, DC.

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

Clinician sign-out systems are communications that have traditionally been called “sign-outs," but more recently been generalized into “handoff communications” or “transfer-of-care communications." [33] Sign-out communications provide a provider with enough relevant clinical information about a given patient that they can make decisions about that patient’s care. Sign-outs are becoming more important as inpatient medicine is becoming more reliant on hospitalists, who typically work in shifts and care transitions. [34]

Free and Open Source EMRs

Free and Open Source EMRs

OpenEHR

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

Biometrics

Socio-technical Issues

Genetic Non-Discrimination

Terms related to privacy, confidentiality, and security

Business Case for Improving Usability

Business Case for Improving Usability

New Technologies

Strategies of Clinical Data Entry

Strategies of Clinical Data Entry

Natural Language Processing (NLP)

Coding Data

EHR system selection

See more for what Marl Mench thinks of EHR system selections

List of EMR companies

EMR models for small and medium sized practices


Additional stuff

The huge increase in coded health data generated by electronic medical records has an enormous potential to increase our ability to do clinical research. Compared to traditional research methods, there are many potential benefits and detriments to secondary use of clinical data.

Benefits

Benefits include increased simultaneous entry of clinical and research data, increasing the number of subjects and the amount of data collected, ultimately increasing the generalizability of research. In traditional clinical research, data is collected on paper forms separately from clinical documentation, requiring double entry of data. This adds cost and may limit accuracy if data collection is performed by non-clinical personnel. The number of subjects enrolled and the amount of data collected is limited by cost and time. If data can be collected simultaneously with clinical documentation, costs can be reduced and data may be more accurate when entered immediately by the clinician caring for the patient. More patients can participate in studies and research findings become more generalizable to a diverse population.

Limitations

Limitations of secondary use of clinical data are that of retrospective research, and which is inherently subject to many sources of bias and error. With prospective study design, a research question is posed and the study designed to be able to accurately measure and analyze the data required to answer the question. Inconsistencies of medical terminology are a recognized challenge to research validity (misclassification bias), and each research plan requires careful attention to the definitions necessary to answer the question. The conditions to be studied, the treatments rendered, and the outcomes to measure are carefully defined. Templates are designed to enhance accuracy and minimize missing data. Potential sources of bias and confounding are considered and managed.

Case study

The studies of estrogen therapy after menopause are an excellent example of bias and erroneous findings in retrospective studies. Briefly, before the Women’s Health Initiative (WHI) results were published 2002 (Rossouw JE, JAMA, 2002) (a randomized trial of estrogen therapy in menopausal women), there were numerous retrospective studies indicating that women who used menopausal hormone therapy had a 50% reduction in death from heart disease. Women were encouraged to take estrogen by clinicians as a strategy for reducing heart disease. A question posed by many researchers was “Did this finding occur because 1) estrogen improves cardiovascular function or 2) healthier women choose estrogen more often than less healthy women?” (selection bias). The randomized trial found that estrogen did NOT confer a cardiac benefit, and now estrogen is NOT recommended as a strategy for reducing heart disease. This story emphasizes the magnitude and impact of potential errors that may result from retrospective research. Note--this illustration is simplified, and does not represent the complexities of an individual woman’s benefit or risk of taking hormone therapy.)

Understanding the potential limitations of secondary use of data will facilitate changes to mitigate the risks. Already there is much emphasis on improving the clarity of medical terminology. Research questions can be “designed in” to EMR’s to accurately capture the data needed to answer the question, using templates, drop-down menus with definitions provided (research decision support). Currently the risks of secondary use of data are large, but it is within the realm of EMR design to mitigate these risks. When such design changes have been implemented, EMR’s will be able to provide a rich source of data for analysis for clinical research to enhance human health.

Amanda Clark

Retrieved from "http://www.clinfowiki.org/wiki/index.php?title=EMR&oldid=12611"