Difference between revisions of "EMR Benefits and Return on Investment Categories"

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The [[EMR|Electronic Medical Record]] may consist of computer order entry, decision support, electronic medication administration, documentation, and so much more. Commonly cited benefits of EMRs include:
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The sections below detail the benefits, costs, and barriers in evaluating EMR implementations. Selecting, financing, and launching an EHR system is difficult.
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* lower number of doctor visits (from the payer's perspective)
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* communication, coding, efficiency, safety improvements
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* transformation of healthcare delivery
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Better Coordination of care
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Improved management of chronic conditions
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However, quantifying these benefits is not a simple task. Issues that have hampered Return on Investment (ROI) studies and affected their validity include:
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* pressure to justify expense
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* shoddy collection of "before" comparison data after the implementation
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* application of multiple simple statistical tests (the more statistical tests you run, the more likely you are to find something significant)
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The sections below detail the benefits, costs, barriers to and evaluation of EMR implementations.
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== Informational ==
 
== Informational ==
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[[EMR Benefits: Informational]]
  
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=== Storage and retrieval ===
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== Security ==
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[[EMR Benefits: Security]] is an advantageous attribute which comes with EMR systems. Centers for Medicare and Medicaid Services (CMS) published a privacy, security & [[Meaningful Use|meaningful use]] guidelines which computer systems that store patient information need to conform to imply to [[Health Insurance Portability and Accountability Act (HIPAA)|HIPAA]] privacy guidelines. <ref name="Privacy-Standards-CMS">Centers for Medicare & Medicaid Services. Privacy and Security Standards. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/PrivacyandSecurityStandards.html</ref>
  
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EMRs improve the storage and retrieval of patient information in the following ways:
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== Environmental ==
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# Reduces the amount of physical storage space required to house charts.
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[[EMR Benefits: Environmental]] positive impact through Electronic Health Records has the potential to improve the environmental footprint left by the health care industry. <ref name="turley 2011">Turley, M., Porter, C., Garrido, T., Gerwig, K., Young, S., Radler, L., & Shaber, R. (2011). Use of electronic health records can improve the health care industry’s environmental footprint. Health affairs, 30(5), 938-946.</ref>
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# Protected from fire, natural disaster, or theft.
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# Records can be backed up to off-site facilities
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# Instant access to records.
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# More controlled access, including a record of who accessed the record.
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# Eliminates “lost” or incomplete charts.
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# More than one provider can access the record at one time. Ability to identify who modified the record.
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# Ensures business continuity and uninterrupted medical service.
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# EMRs store patient data, including but not limited to, patient medical history, medication history, vital signs, lab tests results, as well as other pertinent information in a single location, and is readily available to anyone directly involved in the patient’s care, regardless of location. It eliminates time and cost from paper chart pulls and transcription and re-file of paper charts (Wang at al, 2003). 
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== Quality Outcomes ==
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# They reduce the likelihood that tests will be unnecessarily duplicated.
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# Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data.
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# EMRs can promote early intervention in disease processes because all the health data- vital signs, lab results, imaging, physician notes, nursing notes, etc.- of a patient are accessible in the same record (6).
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# They are vital to improved quality of care at the bedside or point of care because less time is spent doing non-caring activities and more time spent actually caring for the patient (6).
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# EMRs reduce the number of lost or missing reports.
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# They reduce variability of care.
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# Timely delivery of critical services
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# Ensures business continuity and uninterrupted medical service.
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# Facilitates patient self-service and increases patient's engagement.
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# Enforces data confidentiality and improves compliance.
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=== Increased Security of Patient Information ===
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Confidential patient information can be better protected from misuse by the use of well-protected electronic medical records. Based on the Centers for Medicare and Medicaid (CMS) Privacy, Security & [[Meaningful use|Meaningful use]] guidelines, computer systems storing patient information need to conform to strict [[Health Insurance Portability and Accountability Act (HIPAA)|HIPAA]] privacy guidelines [46]. System developers have the option of using biometric data or multi-factor authentication to ensure that only authorized personnel have access to such data. Further, this method would allow for a data-trail to monitor this access.
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=== Mobile EMRs ===
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Ease of access to EMRs using mobile technologies such as iPAD and smartphones has decreased resistance to EMR use and implementation in busy settings such as Emergency Departments (EDs). A recent study has shown that use of iPADs in EDs has shown the following advantages in addition to those observed for EMRs in general (29).
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# Enhanced patient education and satisfaction
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# Increased mobility of the device provides a better fit of technology to the application setting
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# The iPAD touch screen enables easy use even without excessive knowledge of computers
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# Mobile devices was similar to paper charts in that they are extremely portable allowing physicians to carry it around in EDs easily
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# Remote patient monitoring and diagnosis
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# Ability to cross-reference medical terminology and provide multi language support.
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# Supports globalization of medical care.
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=== Improving workflow ===
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EMR has tremendous effects on changing workflow by several ways such as reducing time spent in getting medical histories, ease of data retrieval, greater remote access, and providing auto-produced sign-out documents to support handoff workflow.
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According to a study performed by Julia Driessen and ects. They estimated EMR assist an employee to reduce about 17 min per working day (28%) in transcription time.
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Although the volume of work initially required to achieve the goal of digitizing a healthcare office may seem overwhelming, the end result is well worth the effort.
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Every medical office has its own "system" for organizing patient data, the majority of these facilities could use a little help in improving their processes. Searching through physical file folders for a specific patient's medical record and then being required to sift through paperwork to find the document(s) necessary for a certain task are time-consuming tasks that could be eliminated through the implementation of electronic medical records. A digitized records database can solve problems associated with human filing errors and misplaced documentation. Instead, all authorized medical staff will have immediate and accurate access to the exact information needed through just a few clicks of a mouse.
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An EMR service that fully analyzes and streamlines the patient workflow, and works to support a lean practice operation, can actually improve efficiency. Providers can be more productive, spend more time with patients, and even enjoy increased patient visits.
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=== Improved care coordination ===
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EMRs can decrease the fragmentation of care by improving care co-ordination among clinical and administrative staff.  Better care coordination can improve transparency among overall processes. EMRs have the potential to integrate and organize patient health information and communicate this information accurately among everyone that is involved in a patient's care. Better availability of patient information can reduce medical errors and redundancy in health care.
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== Health Information Exchange (HIE) ==
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With better information integration capability, it allows for healthcare institutions to facilitate better quality care, contain costs, and better manage risks. Thus, by having healthcare organizations that incorporate an EMR, it enables for both clinical and business advantages by in turn creating a clinical healthcare system that helps to unite crucial patient information with various departments. As a result, this helps to create a central clinical information repository and resource used throughout the integrated delivery network of the institution. This in the long run allows for the different information of patients to be coalesced together in a timelier manner, which can reduce errors in diagnosis. EMRs allow for interoperability such that multiple clinicians and facilities may use or add to a patient’s record, even at the same time.
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The advent of the [[HIE|Health Information Exchange (HIE)]] allows for sharing of patient information electronically within an organization, system, community, region or state. This helps in monitoring not just a patient's health but health in certain subsets of populations, whether for a certain diagnosis group or within a social demographic or a geographic region. Stratifying the data to look for trends over areas, ethnicities or over time has helped in development of software models which help in predicting the health of not only a patient but also patient populations over time.
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Metrics such as 30 day readmission are used commonly in healthcare to gauge the quality of care of a patient and is an example of where predictive modeling is being used. EMR has allowed for transparency, and the analysis of data has helped to establish trends and patterns. Big Data is another commonly used term in healthcare and refers to the availability of large amounts of data available from the collection of patient EMR records.
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=== Facilitated referral for multidisciplinary care ===
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Electronic medical record (EMR) systems have the potential to facilitate referral of patients from one physician to another physician for provision of well-integrated multidisciplinary care [17]. Such an advantage of EMRs is best served when the referring physician and the physician(s) to whom the patient is referred have direct and full access to the EMR system containing the patient’s file. In such a scenario, viewing and modification of the patient’s EMR file by the physician to whom the patient is referred is immediate and secure [17]. In the absence of direct and full access, referral to other physicians can still be facilitated by EMRs if the relevant data contained within the patient’s EMR file can be transferred electronically, securely, and rapidly between physicians [17].
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=== Better Integrated Care by Hospitals and Long-Term Facilities/Rehabilitation Centers ===
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EHR plays an important role in improving the health care quality and safety and reducing the costs of providing care in long-term care facilities.[http://www.ihealthbeat.org/perspectives/2010/electronic-health-records-hold-great-promise-for-longterm-care-facilities] The relationship-building between the hospitals and long-term facilities is essential in reducing readmissions and improving patient satisfaction. EHR helps in '''improving the transition''' from one care setting to next and hence prevents any gaps in care provided to the patient.
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According to Jenq (Program Director for the Greater New Haven Coalition for Safe Transitions and Readmission Reductions, or GNH CoSTARR)"Nursing facilities frequently do not receive the information they need to properly care for patients discharged from the hospital. From the hospital side, we presume that our paperwork makes it to the skilled-nursing facility and that they have all the material necessary," Jenq says. "But we're finding that our paperwork actually doesn't make it in a timely, efficient manner." Hospital clerical workers often do not recognize all the components of the discharge paperwork; historically, there has been no protocol for laboratory results, such as urine cultures, to be sent to nursing facilities.[http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG]
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Skilled nursing facilities (SNF) nurses do not know how to get information from the hospital. "Sometimes the nursing facility will call back to the hospital, but the hospital RN they reach will say, 'I don't know the patient,' and essentially end the conversation there," Jenq says. "We are going to have to lay out roles and responsibilities for all the people involved in the transition of care to make sure they are held accountable for this type of communication." When a problem arises, nursing facilities may not share the hospital's goal of keeping patients out of the hospital. "Right now, the skilled-nursing facilities don't get penalized for the readmission, so they are not affected if the patient goes to the emergency department and gets admitted," Jenq says. "In the future, when penalties apply to them as well, both the SNF and the emergency department will be forced to develop care plans that can work at an SNF."[http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG]
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EHR also helps in '''Improving the communication'''between the hospital staff and assisted living or the long-term care facility staff when the patient is transferred from one setting to other. [http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG].
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=== Facilitate Health Information Exchange ===
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Health information exchange (HIE) is the electronic transfer of healthcare information between various organizations. This has become an important topic because it improves the quality, safety and efficiency of healthcare. Electronic health records (EHR) helps to facilitate the electronic exchange between hospitals, clinics, and patients much more possible.  According to the Department of Health and Human Services, 84% of hospitals that adopted EHR and participated in regional HIO exchanged information w/ providers outside organization.
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==== The Direct Project ====
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Standards of information exchange are beginning to take hold for purposes of summarizing a patient record or event or allowing a provider to query for records across a community.  The Direct Project aims to utilize these standards as well to replace methods of information exchange such as fax, courier, postal mail, and patients themselves that continue to slow down and predominate the health care field for transferring lab results, x-ray results, reminders for Dr. visits, etc.
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The project is sponsored by the Office of the National Coordinator for Health IT (ONC) but led by volunteers in the industry. The Direct Project offers a simple, non-proprietary solution for direct information exchange between two healthcare entities. [51]
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EHR’s can be utilized to generate reports on quality measures in the effort to improve quality and patient satisfaction. With the ability to produce reports from EHR’s, clinicians can easily compare data to baseline data and quickly identify areas in need of improvement. Once areas in need of improvement have been identified, clinicians can compare data to manual reports and similar data to validate the reported information.  Once an area of improvement has been identified it can be delivered to the performance improvement department where informatics professionals can perform gap analysis and identify methods to improve overall quality. , <ref name="Stefan 2011">Stefan, Susan (2011). Using clinical EHR metrics to demonstrate quality outcomes.http://ovidsp.tx.ovid.com.ezproxyhost.library.tmc.edu/sp-3.16.0b/ovidweb.cgi?QS2=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
  
 
== Medical Education ==
 
== Medical Education ==
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[[EMR Benefits: Medical education]]
  
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While clinical and operational benefits of EMRs are obvious, their effect on medical education and trainees are not well documented. The few studies that have analyzed such effects have shown that there are advantages inherent in EMRs that can be leveraged and disadvantages in the current EMRs to education that need to be addressed in the future [22]. Implementation of EMRs in academic environments can benefit education of trainees by:
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In a teaching facility EMRs can be a very useful tool for medical education and training. EMRs can be used to monitor how much time each trainee spends with patients and therefore their clinical experience in terms of patient diagnosis and procedures can be tracked and reported to enable optimization of workflow for both trainee and training programs. <ref name= "Tierney 2013">Tierney et al, Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions http://tmclibrary.summon.serialssolutions.com/search?s.q=tierney+m+j#!/search?ho=t&l=en&q=Medical%20education%20in%20the%20electronic%20medical%20record%20(EMR)%20era:%20Benefits,%20challenges,%20and%20future%20directions.%20Academic%20Medicine</ref>
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# Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR
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# Training the students to follow accepted clinical guidelines (best practices) using CDS
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# Monitoring clinical experience of trainees more efficiently in real time to optimize workflow for trainees and training programs. Use of EMRs to track patient care milestones achieved by trainees will identify that can be then addressed more efficiently in a prospective manner.
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# EMRs have been used to help physicians improve the quality of their clinical skills. An example of this has been in Radiology. Radiologists do not routinely receive information on clinical outcomes of patients for whom they provide radio-diagnoses. Alkasab et.al created an automated outcome tracking system for radiologists which allows them to review clinical outcomes of the patients whose images they reported on. Such a system can allow radiologists to improve self-assessment, accuracy and relevance of their reporting, and study interventions in their processes to improve outcomes [47].
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The disadvantages of EMRs to education were noted by the following issues:
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# Problems with student access into the facilities systems such as obtaining log-ins and passwords
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# Concern that students will not learn skills of independently recognizing items that need to be documented, but rather the students would only choose from drop down boxes and pick lists.
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# Instructor's concern that EMRs allow portions or entire sections of notes to be copied and pasted, which in turn leads to ethical concerns with plagiarism and documenting procedures that were never performed.
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=== Improving interpersonal and communication skills ===
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EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.
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=== Enhancing professionalism ===
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In addition the use of EMRs in a teaching environment allows trainees access to the most up to date information. “Point-of-care education accessed via CDS allows for easy access to relevant and up-to-date medical literature from which students and residents can draw to formulate diagnosis and management plans".<ref name= "Tierney 2013">Tierney et al, Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions http://tmclibrary.summon.serialssolutions.com/search?s.q=tierney+m+j#!/search?ho=t&l=en&q=Medical%20education%20in%20the%20electronic%20medical%20record%20(EMR)%20era:%20Benefits,%20challenges,%20and%20future%20directions.%20Academic%20Medicine</ref>
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Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.  
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== Financial ==
 
== Financial ==
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[[EMR Benefits: Financial]]
  
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By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for:
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"Implementing an EMR system could cost a single physician approximately $163,765. As of May
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2015, the Centers for Medicare and Medicaid Services (CMS) had paid more than $30 billion in
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financial incentives to more than 468,000 Medicare and Medicaid providers for implementing
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EMR systems. With a majority of Americans now having at least one if not multiple EMRs
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generated on their behalf, data breaches and security threats are becoming more common and are
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estimated by the American Action Forum (AAF) to have cost the health care industry as much as
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$50.6 billion since 2009." <ref name="O'Neill"> O'Neill, T. (2015, August). Are Electronic Medical Records Worth the Cost of Implementation.</ref>
  
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# Increase in the pace of information flow including service delivery.
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Some of the ways that EMR systems can cut healthcare costs are due to savings based on "time-consuming paper-driven and labor-intensive tasks":<ref name="Medical Cost"> Kumar, S., & Bauer, K. (2011). Medical Practice Efficiencies & Cost Savings.http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings</ref>
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# Coding/billing accuracy.
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# Better documentation of patient encounters.
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# Reduction in overall administrative and maintenance costs of healthcare institutions.
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# Reduction in costs for the patient.
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# Reduction in transcription costs [http://jamia.bmj.com/content/18/2/169.full.pdf+html].
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# Decrease in malpractice insurance premiums.
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# Decrease in paper consumption has the potential to lead to yearly estimated savings of $1.3 billion in the U.S. [http://jhi.sagepub.com/content/16/4/306.full.pdf+html].
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The efficiency of increased information flow and documentation allow for measurable time and cost savings. The amount of time support staff save during patient encounters has been directly demonstrated in a clinical setting [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513660/pdf/261.pdf].
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* Reduced transcription costs<ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
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Furthermore, the integration of EMR systems enables for a more consistent application of medical protocols, such as those that provide guidance on the use of specific or expensive drugs.  As a result, the availability of information 24 hours a day, 7 days a week, helps to contribute significantly to reduced errors, better decision-making, improved outcomes, and lower malpractice risk. In a study done by Harvard researchers, 6.1% of physicians with electronic records had malpractice settlements, compared to 10.8% without electronic records [3].
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* Reduced chart pull, storage, and re-filing costs <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
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* Improved and more accurate reimbursement coding with improved documentation for highly compensated codes <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
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* Reduced medical errors through better access to patient data and error prevention alerts <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
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* Improved patient health/quality of care through better disease management and patient education <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
  
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One financial benefit of improving care through the use of Health IT might be to lower malpractice insurance costs for providers. A number of firms that sell liability insurance for physicians are offering discounted premiums to practices that use EHRs.(Congress of the United States Congressional Budget Office. (2008). Evidence on the costs & benefits of health information technology (). Washington, DC: Government Printing Office.) P. 13
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There are few comprehensive estimates of savings from Health Information Technology (HIT) at the national level. At 90 percent adoption, it is estimated that the potential HIT – enabled efficiency savings for both inpatient and outpatient care could average more than 77 billion per year.<ref name=”Hillestad 2005”> </ref> <ref name=”Hillestad 2005”> Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs, 24(5), 1103-1117.</ref>
  
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=== Quantitative Benefits ===
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Although the full extent of EMR advantages may not become apparent until further implementation and research is carried out, a clear benefit is the reduction of cost. Major administrative costs can be eliminated or reduced. Providers can do away with the costs of “chart pulls,” while substantially reducing dictation costs through the use of EMRs. Healthcare providers can also receive decision support regarding selection and costs of medications, radiographic studies, and laboratory tests.<ref name="Bates 2003"> Bates, D. W., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic medical records in US primary care. Journal of the American Medical Informatics Association, 10(1), 1-10.</ref>
  
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These are financial benefits that are clearly measurable and are attributable to the use of a particular technology. E.g. the use of EMR technology to submit claims has resulted in widely quantified cost savings for provider and payer organizations.
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===Billing Accuracy===
  
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In 2009, the Medical Group Management Association(MGMA) reported the results from surveying 1,324 primary care and specialty practice members. These results found that independent practices reported a median of $49,916 more revenue per full-time physician than paper-based practices. In addition, hospital-owned multi-specialty facilities reported a median of $42,042 more than their paper-based counterparts.[36]
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The benefits for small to medium private practices that have implemented EMR systems integrated with the practices' billing and prescription systems, can be increased efficiency and accuracy thanks to automatic coding leading to improved profitability. "Since installing the EMR, Medicare has audited only one of my charts. I had billed out as a level four and Medicare said it should have been billed as a level five, which, in essence, said that we should have been paid more. My EMR system gave the chart a level four and I believe it was right.” "Since adopting an EMR system, my practice receipts have increased about $4,000 per month."<ref name="Sonnenberg 2007">EMR ROI: A Pennsylvania family practice's investment in an EMR pays off three-fold. http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?p=HRCA&u=txshracd2509&id=GALE|A163469720&v=2.1&it=r&sid=summon&userGroup=txshracd2509</ref>
  
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One of the most widely touted financial benefits for physician offices is elimination of transcription services, which can save several thousand dollars per physician, per year. A 2010 article published by the American Health Information Management Association urges practices to realistically gauge their probability of eliminating transcription altogether. Many practices instead opt to retain some transcription, or implement voice recognition software in its place, mitigating the effect of this factor on actual vs expected ROI (10).
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A nuanced view is appropriate here, however; improved billing can coincide with fewer patients seen. "EHR implementation ... increased reimbursements but reduced long-term practice productivity across all specialties"<ref name="Howley 2015">Howley et al, 2015. "The long-term financial impact of electronic health record implementation" http://jamia.oxfordjournals.org/content/22/2/443</ref> according to one study. This may be a net financial positive for the practice: "an EHR should greatly enhance physician effectiveness even if fewer patients are seen by the physician"<ref name="Howley 2015"></ref> due to gains in billing efficiency, but this also represents an artificial reduction in the supply of services.
  
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=== Reducing cost ===
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=== An EMR Cost Benefit Analysis ===
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EMR can help hospitals or patients to reduce some redundant tests. For example, EMR could reduce the number of tests conducted at KCH by 7% according estimate by Julia Driessen’s report. A 1998 study at Brigham and Women's Hospital concluded that 8.6% of the tests sampled were redundant, and if those tests were not performed, charges would be reduced by $930,000 annually. (30)  A review of studies looking at possible benefits of CPOE found significant evidence of reduced laboratory test ordering in multiples studies [38].   
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Also, by SWOT analysis performed by Sameer Kumar. He said that nationally applied EMR can reduce paper to maintain medical records about 1.3 billion with a cumulative savings over 15 years of $19.9 billion.
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Samsung Medical Center (SMC) performed a cost benefit analysis (CBA) on the cost benefits of implementing an electronic medical record (EMR) system. Costs of implementing the EMR system involved both '''direct costs''' to build the system infrastructure and '''induced costs''' to make a smooth transition to the new system.  Benefits of implementing the EMR system include both cost reductions and increased revenue. Five types of cost reductions, mentioned by the authors, include:
  
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Clinical support alerts and reminders can also assist with offering alternatives to expensive medications and updates on drug dosage recommendations. A clinical decision to utilize a generic drug substitution or decrease a drug dosage frequency from twice a day to once a day can offer additional savings to a healthcare institution, estimated at $16,400 annually per provider (Wang at al, 2003). Interventions to switch the twice-daily dosing of ceftriaxone to once-daily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).
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# Reduction of supplies for paper charts
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# Disposal of storage facilities used for paper chart storage
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# Reduction of full-time equivalent (FTE) employees for the paper chart management
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# Reduction in staff for outpatient clinics
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# Decreased supplies for medical devices
  
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=== Investment Flexibility ===
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The FTE's responsible for paper management were greatly reduced from 28 FTE's (2007) to 1 FTE (2009).
  
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Another potential benefit from an EMR implementation is the increase in available operating budget. Reduce in staff expenses or lower drug and maintenance costs, for example, could significantly impact a hospital or clinic operating budget (Kaushal at al, 2006).
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This CBA was based on an eight year period post EMR implementation.  SMC determined the EMR system became cost effective shortly after 6 years. The outcomes of the CBA were calculated using the following formulas:
  
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The meaningful use of certified EHR technology is a core requirement for healthcare providers looking to qualify for the incentive payments. In July 2010, the CMS issued the final rules, setting criteria that providers need to meet, and the schedule to meet them, to qualify for the subsidies. (15)
+
* The primary outcome is the Net Present Value (NPV)
 +
** '''NPV = Present Value (PV) of benefit for the eight year period - PV of cost'''
 +
* The second outcome is the Benefit Cost Ratio (BCR)
 +
** '''BCR = PV of the benefit / PV of the cost'''
 +
* The third outcome is the Discounted Payback Period (DPP). 
 +
**'''This is the time to reach the breakeven point'''.
  
−
=== Management Risk Disposition ===
+
This CBA does not include clinical benefits of the EMR implementation such as decreased medication errors, improved workflow, and reduced length of stay.<ref name="Choi 2013">Choi, J., Lee, W., Rhee, P. (2013). Cost-Benefit Analysis of Electronic Medical Record System at a Tertiary Care Hospital, Health Informatics Research;19(3):205-214. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3810528/</ref>
  
−
Willingness to invest in experimental efforts.
+
== Improving Patient Care ==
 +
[[EMR Benefits: Healthcare quality]]
  
−
*Provide users with real time knowledge
+
Many EMRs have alert systems that ensure physicians do not forget to request important tests.  As well as the legal benefits that this provides, EMR alerts remind physicians of the "preventive care needs for patients, which helps improve quality of care and office income by reminding us to do appropriate testing and provide vaccinations" recommended for some patient conditions e.g. asthma, emphysema or diabetes. <ref name= Block 2008">How We Improved Our Practice and Our Bottom Line With a New EMR System.Fam Pract Manag, 15(7), 25. http://www.aafp.org/fpm/2008/0700/p25.html</ref>
−
*Reduce non-clinical time
+
−
*Increase patient doctor time
+
−
*Investment Motivation
+
  
−
To reduce cost, position for capitation/managed care, and gain market share.
 
  
−
To enable providers to take advantage of financial incentives under the HITECH Act related to "Meaningful Use". [https://www.cms.gov/EHRIncentivePrograms/01_Overview.asp#TopOfPage]
+
[[EMR Benefits: Reduction in no shows]]
  
−
== Patient Safety Outcomes ==
+
EMR system was used to improve on automated calls made to patients to remind them of their appointment which reduced the number of no call shows and improved patient satisfaction.
 +
<ref name= Block 2008">How We Improved Our Practice and Our Bottom Line With a New EMR System.Fam Pract Manag, 15(7), 25. http://www.aafp.org/fpm/2008/0700/p25.html</ref>
  
−
# Improve the quality of patient care.
+
[[EMR Benefits: Medication Management]]
−
# Insures practice of better evidence-based medicine.
+
−
# Allows flawless health information exchange between health care providers.
+
−
# Decreased cost due to change in drug frequency, dose or route (Wang at al, 2003).
+
−
# Improved communication and engagement with patients and their care (55)
+
  
−
EMRs help to increase patient safety in a number of ways. Evidence-based clinical reminders as well as reminders based on Good Clinical Practice guidelines can be prompted during the patient encounter . Also, medical errors due to illegible handwritings is drastically reduced. Alerts can be posted on the screen for the provider in instances where a drug that the patient is allergic to may be ordered, or in a situation where the drug(s) being ordered are incompatible with medications the patient is currently taking. Also, alerts may be posted for adverse effects for medications based on the patient’s profile and medical history.
+
"Rational antibiotic use resulted in a lower mortality of 0.0644 % during the post-implementation period compared to 0.179 % during the pre-implementation period (p = 0.018). The comprehensive EMR system contributed to a significant reduction in antibiotic consumption and an improvement in rational antibiotic use."<ref name= journal of medical systems">The Meaningful Use of EMR in Chinese Hospitals: A Case Study on Curbing Antibiotic Abuse 15(7),</ref>
  
−
EMRs have tremendous potential for improving medication safety by implementing computerized provider entry forms (CPOE). Medication errors are common and are mainly attributed to illegible handwritten orders, incomplete information about the patient or communication breakdowns between clinicians. EHRs can greatly reduce such errors when clinicians would enter medical orders directly into the system. While the clinicians are entering the orders, the system allows automated checks for allergies and other drug-to drug interaction.  
+
EMR systems have the ability to make evidence-based suggestions regarding patient care. With these suggestions, EMRs are able to use a patient’s information to identify preventative services that specific patient may need. The system is able to remind doctors that the patient is due for certain screening exams or other services which allows the doctor to discuss it with the patient and also allows the patient to decide whether or not they would like to schedule an appointment for that specific exam. This reminder has proven to benefit patient care by increasing compliance with preventative care.  
  
−
Use of traditional peer-reviewed approaches as a model for developing standardizations could serve as models for a foundation for new CPOE tools and as a benchmark for existing CPOE tools. For practically all major disease states, there are publicly accessible treatment guidelines that have been established by experts, undergone peer review, and are updated on a periodic basis. Using these review standards for development of protocols for drug-drug interactions, etc. improved accuracy and up-to-date information would be available and utilized to assist in protecting patients. [54]
+
EMRs also benefit patient care by assisting in long-term chronic disease prevention and management. Case management systems in EMRs allow patients to communicate with a variety of specialists, which better enables them to manage their care. This system also allows healthcare providers to keep track of patient data, such as vital signs, and allows case management nurses to quickly respond to any issues that may occur. The system benefits the patient because it allows the patient’s acute issues to be handled promptly before they become bigger issues that may lead to a hospital admission.
  
−
In other words, EMRs allow for Decision Support Systems (DSS) to be utilized. DSS detect critical values or errors in care and notify the clinician immediately. DSS may provide knowledge-based information and/or reminders to support or aid in finding a solution to a clinical problem (7).
+
EMRs have the ability to eliminate up to 200,000 adverse drug events with the use of CPOE. Using reminders and alerts CPOEs are able to notify physicians about possible drug interactions that may occur when a new medication order is placed.
  
−
=== Improving patient care ===
+
EMRs have a direct correlation with the quality of healthcare offered to a patient. Problems in healthcare quality fell into three categories as stipulated by the National Roundtable on Health Care Quality. These three categories are the underuse, overuse, and misuse of healthcare services. Reducing overuse and misuse of healthcare services, as noted by the Roundtable, leads to an increase in health care quality while simultaneously lowering costs. In addition, reducing the underuse of healthcare services increases quality, but may in turn increase costs. “Computerized physician order [CPOE] entry may affect all three categories of health care quality problems, as well as inefficiencies in the health care system.” <ref name="Kuperman 2003">Kuperman, G. J., & Gibson, R. F. (2003). Computer physician order entry: benefits, costs, and issues. Annals of internal medicine, 139(1), 31-39.</ref>
  
−
EMR can optimize workflow for trainees and training programs by reviewing reports of trainees’ clinical activity and notes. We can more easily and efficiency identify deficiencies of trainees and training program compared to paper-based system. Thus, EMR can provide a safer environment for patient.
+
== Research ==
−
According to a study performed by Julia Driessen and ects. They said about 10.5% reduction in length of stay of inpatients in USA because EMR provides a better mechanism for analyzing and reviewing patient outcomes. Its flexible output formats could be customized to meet the needs of patients, payers, referral sources, and other parties who use health information.
+
[[EMR Benefits: Research]]
  
−
When it comes to patient care, the more information that a doctor has at his or her fingertips, the better the results will be for everyone involved. If a notation made from a previous visit regarding a patient's drug allergies or condition cannot be read or goes missing from their paper medical file, a physician could be in the dark and make a grave decision with regards to treatment. With electronic medical records, a patient's entire healthcare history can be viewed with ease in order to help doctors make the best judgment calls.
+
Researchers can use EHRs to retrieve up-to-date data from various sources around the country to advance their studies. EHRs can compute a report to show researchers certain trends in the population or common side effects of medications. <ref name="Enormous Benefits"></ref>
  
−
=== Improved quality and convenience of patient care ===
+
== Health Information Exchange (HIE) ==
 +
[[EMR Benefits: HIE]]
  
−
With the implementation of EMRs, patients' health information is available in one place and can be accessed when and where it is needed. Complete access to health information is essential for safe and effective care of patients which can lead to better patient outcomes and high quality care. Health care providers with busy practices and patients with busy lives can conveniently manage their health care transactions with EMRs.  Besides, the 'clinical information distribution framework' (paper processes) is antiquated and does not support the modern practice of medicine as it migrates increasingly to evidence-based practice.  Four signs that these outmoded processes need to change:
+
== Personal Health Records ==
−
* Paper based systems are not viable - patient care should be driven by point of care information available to clinicians when and where they need it.  This is typically not available in paper based processes but is in the EHR.
+
[[EMR Benefits: PHR]]
−
* Human memory is unreliable: so much research is being published that clinicians do not have time to read it all and the unaided mind is hard-pressed to recall all the detailed knowledge that current studies can impart.  Computer based alerts, reminders and similar tools are needed! 
+
−
* Capturing clinical data is a new business imperative - clinically based information needs to be utilized for better responsiveness to unaffordable high costs of care and for use in disease management; EHRs are better adapted at these tasks than are paper based processes.
+
−
* Rising consumer expectations - increasing numbers of consumers have high expectations of IT in various facets of their lives and this includes healthcare where they are increasingly responsible for managing their care [39]. Paper charts controlled by the provider do not meet consumer expectations for control of their information and convenient access.
+
  
−
=== Engage and improve communication with patients ===
+
===Patient Participation===
−
Electronic health records can improve the relationship between healthcare providers and their patients. EHR systems make it easier for patients to access their medical records as opposed to the time consuming and expensive way of copying stacks of paper health records. Patients appreciated the ability to review their patient files which allowed them to be more comfortable and knowledgeable about their own health [25].
+
Patients can use personal health record (PHR) to keep track of information from doctor visits, record health-related information, and link to health-related resources. PHR, is an electronic application used by patients to maintain and manage their own health information. Connected PHRs are linked to a specific health care organization's EMR system that can increase patient and family participation in their own care.               <ref name="PHR">http://www.healthit.gov/providers-professionals/patient-participation</ref>
  
−
With the increase in use of patient portals, more patients are physicians are communicating via secure online messaging. Patients can request refills, labs, or ask general questions about their health via online portals. Engagement of patients with their care is a benefit of these portals and the education they receive due to this engagement is also profound [55].
+
== Electronic Dental Records ==
 +
[[EMR Benefits: EDR]]
  
−
=== More effective preventive care ===
+
==Telehealth==
 +
[[EMR Benefits: Telehealth]]
  
−
EMR systems have the potential to enhance preventive care through integration of an automated alert system that reminds physicians and/or patients when preventive care procedures such as vaccinations, screening tests, or well or follow up visits are recommended [18].
+
== E-Prescribing ==
 +
[[EMR Benefits: E-Prescribing]]
  
−
The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].
+
E-Prescribing has many benefits, some of them include: <ref name="E-Prescribing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
* reduce illegibility <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
* providing warning and alert systems, which reduce medication errors  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
* access to patient's medical history  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
* reduces or eliminates phone calls and call-backs to pharmacies  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
*eliminates faxes to pharmacies  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
*streamlines the refill and authorization processess  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
 +
* increases patient compliance  <ref name="E-Prescibing">Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing </ref>
  
−
=== More effective urgent care ===
+
== Mobile EMRs ==
 +
[[EMR Benefits: mHealth]]
  
−
EMR systems have the potential to facilitate and enhance urgent care when the emergency room or urgent care physician has access to the patient’s EMR file as would occur when a patient seeks urgent care within the healthcare system where the patient receives routine care or when the patient’s EMR file is available in a local, regional, national EMR system [19]. In such a scenario, the emergency room or urgent care physician could consult the patient’s EMR file to view the patient’s current medications, diagnoses, recent surgeries or procedures, and medical history, allowing the emergency physician to be better informed about the patient’s status and urgent needs [19]. In terms of specific chronic illnesses such as heart failure, an EHR may have the potential to be a valuable adjunct in the care of heart failure patients [28].  Information security and privacy concerns will have to be addressed, however, in order for shared EMRs to gain widespread public acceptance [19]
+
== Physicians ==
 +
[[EMR Benefits: Physicians]]
  
−
=== Increased patient participation in their care ===  
+
===Physicians Benefit===
  
−
EMRs can give full and accurate information to patients about all of their medical evaluations and follow up information such as an office visit or a hospital stay, self-care instructions, reminders and other helpful information.
+
EMRs can greatly improve communication between physicians by allowing each full access to the patient’s medical record and by making it easier for physicians to follow up with patients. The electronic record provides up to the minute information on the patient allowing more efficient collaboration between disciplines.  EMRs allow multiple providers to simultaneously access a patient’s record from any authorized computer.<ref name="MD">http://www.usfhealthonline.com/resources/healthcare/benefits-of-ehr/#.VfjJDXktDmQ
 +
</ref>
  
−
EMRs also provide patient online scheduling and patient preparatory instructions for specific interventions such as blood and other laboratory testing (Kaushal at al, 2006).  Effective communication with patients can enhance informed decision making and high quality care.
+
== Nurses ==
 +
[[EMR Benefits: Nurses]]
  
−
The use of Personal Health Records (PHRs) is allowing patients to be more educated and involved with their care. PHRs are often integrated directly with the EMR so that information flows seamlessly between the two systems. Patients can easily monitor their own health and learn more about how their condition is cared for [55].
+
Nurses use the EMR to identify newly admitted patients, track their location, and document admission information. The nursing SWAT team harnessed the power of EMR technology, and successfully re-organized nursing workflow to expedite the admission process, while maintaining patient and family centered care.<ref name="Journal of pediatric nursing ">http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S0882596314002413
 +
</ref>
  
−
=== Improved accuracy of diagnoses and health outcomes ===  
+
== Versatile capabilities of EHRs in healthcare settings ==
 +
There are many studies showed that EHRs are capable to integrate with various standards systems such as billing codes, clinical notes, ICD diagnose codes, and medications, which essentially enhances effectiveness and efficiency of care and results in superior phenotyping performance compared with paper-based medical record systems.  <ref name=" Wei 2015"> Wei, W.Q., Teixeira, P. L., Mo, H., Cronin, R. M., Warner, J. L., & Denny, J. C. Combining billing codes, clinical notes, and medications from electronic health records provides superior phenotyping performance. Journal of the American Medical Informatics Association: JAMIA. http://doi.org/10.1093/jamia/ocv130 </ref>.
  
−
EMRs provide reliable access to a patient's comprehensive health information which in turn helps diagnose patients' problems efficiently. EMRs can improve the ability to diagnose diseases, improve patient safety, support better patient outcomes and reduce or even prevent medical errors. Of the latter problem, medication errors are the most common cause of clinically induced injuries and CPOE has been shown to reduce these errors, by as much as 55% according to one study.  Evidence shows that when combined with Clinical Decision Support, CPOE is particularly effective in reducing medication errors and also helps improve laboratory and imaging test utilization, among other benefits [42].EMRs can also have beneficial effects on the public health by identifying and working with patients to manage specific risk factors or combinations of risk factors to improve patient outcomes.  
+
==  Improvement of Spontaneous Reporting System for drug post-marketing safety surveillance ==
 +
In the healthcare settings, Spontaneous Reporting Systems (SRSs) are critical systems for monitoring drug post-marking safety and adverse drug reactions (ADRs).  Although widespread utilization of SRSs has played a fundamental role in drug safety monitoring, there are certain limitations that hinder their efficacy and accuracy in practices. For example, multiple sources of data are needed for confirmation and validation; the nature of passive reactions to ADR events makes SRSs perform poorly in terms of pharmacovigilance.  The integration of an SRS system into EHRs could have potential to improve efficiency and effectiveness of detection for ADR events.  The combination of an SRS with EHRs could help collect data and information related to ADRs dynamically while avoiding the need of data validation from multiple sources and potentially reducing the costs. <ref name=" Pacurariu  2015"> Pacurariu, A. C. Useful Interplay Between Spontaneous ADR Reports and Electronic Healthcare Records in Signal Detection. Drug Safety. http://doi.org/10.1007/s40264-015-0341-5. </ref>
  
−
=== Qualitative Benefits ===  
+
== Improvement of healthcare outcomes through interactive collaboration among stakeholders ==
 +
It has been reported that the integration of a Network-Based Learning Health System with EHRs can potentially improve a variety of healthcare outcomes. For example, integrating chronical care management, quality improvement, patients and their family engagement, and comparative research.  <ref name=" Marsolo  2015"> Marsolo, K., Margolis, P. A., Forrest, C. B., Colletti, R. B., & Hutton, J. J.  A Digital Architecture for a Network-Based Learning Health System: Integrating Chronic Care Management, Quality Improvement, and Research. EGEMS (Washington, DC), 3(1), 1168. </ref>.  Therefore, EHRs can serve as an effective platform and infrastructure that fascinates online learning for all stakeholders, and patient-centered quality care and evidence-based medical research. 
  
−
The EMR will improve patient care by reducing medication error and wait time. Clinical processes will be standardized and there will be less variation in clinical care provided at one place from another. Records would be easily shared among the providers, which will reduce the process time and over all improve disease management. It will also improve the communication among the care providers and the administrative staff and administrative activities.
 
  
−
These are directly and indirectly attributed to the technology but are more difficult to quantify. E.g. implementation of a clinical nursing system may lead to increased case in recruiting efforts, better nurse retention, more rapid access to clinical nursing data, and decreased charting time. Quantification and measurement – of benefits usually is difficult because of the task complexity of the nursing function.
+
== Costs ==
  
−
Pinsonneault and associates found that data from before and after EHR integration, from a matched set of 15,626 patients with electronic integration and 15, 626 patients in a control group, who visited over 95 physicians in a large North American health network, show that patients treated through the electronically integrated system had better quality of care in the follow-up period and a higher continuity of care, compared to the control group [29].
+
[[Return on investment]]
  
−
Another overview of an attempt to quantify quality outcomes and cost reporting measures benefits of EHRs was published by the Healthcare Information and Management Systems Society in 2010 and can be found here: http://www.himss.org/content/files/QPRWhitePaper.pdf
+
It is estimated that purchasing and installing an EMR can cost a provider anywhere from $15,000 to $70,000.  There are several things to consider when looking for an EMR for your organization or practice.  The prices vary based on number of providers using the EMR and whether it is a select on-site EHR deployment or web-based EHR deployment. Other factors to take into consideration of what costs you will incur include these 5 components of implementation: <ref name="How much is this going to cost me?">HealthcareIT.gov http://www.healthit.gov/providers-professionals/faqs/how-much-going-cost-me http://www.healthit.gov/providers-professionals/faqs/how-much-going-cost-me </ref>
  
 +
*Hardware: Hardware costs may include database servers, desktop computers, tablets/laptops, printers, and scanners. <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
  
−
== Administrative and Management Benefits ==
+
*EHR Software: Potential software costs include an EHR application, interface modules and upgrades to your EHR application. Remember, software costs vary depending on whether you select an on-site EHR deployment or a SaaS EHR deployment. <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
  
−
By moving beyond the paper records, EMR can help Heath Care Providers do a better job at managing patient care. A vast amount of information can be easily used and shared. When fully functional and exchangeable, EMRs can offer far more benefits than managing paper records can.  At a higher level of EMR implementation and functionality, Computerized Provider Order Entry (CPOE) can help standardize the clinical practice and eliminate variation.  Some examples of benefits of CPOE are:
+
*Implementation Assistance: Potential implementation assistance costs include IT contractor, attorney, electrician, and/or consultant support; chart conversion; hardware/network installation; and workflow redesign support. <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
−
* help improve communication amongst care givers
+
−
* expedite patient transfer to other levels of care
+
−
* capture data for quality assurance and administrative purposes
+
−
* aid practice and care in a complex care environment through the use of alerts and reminders
+
−
* provides some level of assurance to patients that technology is being applied to their safety [38].
+
−
* Better strategic planning - The data generated from using electronic medical records can be used for strategic management by the administration. EMRs can help identify trends in utilization, identify bottlenecks in productivity for staff, and monitor patient needs and satisfaction. This would allow the management team to make better decisions on capital investments, staffing levels and workforce redeployment. They can use this data to implement process improvement projects. EMRs have the potential to help medical facilities design and reach their strategic vision.
+
  
−
=== Establishing a learning chance to improve healthcare system ===  
+
*Training: Your organization will need to train your physicians, nurses, and office staff before and during EHR implementation.  <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
  
−
EMR can assist people to review the outcomes of populations under care. Managers can find a more Meaningful Use criteria applied on quality improvement, research, outreach, and reduction of disparities.
+
*Ongoing Network Fees and Maintenance: Potential ongoing costs include hardware and software license maintenance agreements, ongoing staff education, telecom fees, and IT support fees. <ref name="Medical Cost">Medical Cost http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings </ref>
  
−
===Increased practice efficiencies, cost savings, and reimbursement===
+
*Although the initial cost of an EMR may (and typically does) result in an immediate increase in administrative cost, through the reduction of other “removable and or defunct items or process the implementation of the EMR showed a positive improvement in the BCR and NPV. <ref name= "Removable or defunct"> Removable or Defunct http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810528/ </ref>
 +
    examples: remodeling of paper-chart storage areas, medical transcriptions, shorter chain of communication, reduction of administrative material
  
−
EMRs help improve medical practice management by increasing practice efficiencies and cost savings. A practice can be made more efficient by using integrated EMR systems that can be used for scheduling, automated coding, and managing claims which save time as well. As one example, a clinic or physician practice can expect to increase revenue and decrease costs by converting the encounter form to digital format to reduce billing errors and revenue loss. Prompts for fields that need to be completed will reduce errors by an average of 78% according to one study [40].  Communication is enhanced among clinicians, labs and health plans as information can be accessed from anywhere. EMRs save money by reducing redundancies in medical care, by eliminating costly tasks of creating paper charts and labor intensive management of paper charts. Very simply, the EHR eliminates paper chart pulls and staffing expenses can be reduced as a result. One study estimated that an average of $5 per pull would be saved considering the time and cost of medical records staff to retrieve and then re-file the paper chart.  The clinic studied expected it would reduce paper chart pulls by approximately 600 annually and transcription costs would be reduced by 28% [41]. 
+
==Cost vs Time == (A reduction of time spent on a common process can lead to reduced cost and better efficiency)
 +
*EMRs can greatly reduce or make more efficient use of time.  
 +
A recent study (July-2015)EMR decision support systems where proven to have reduced and or made more efficient use of the time needed for “Colorectal cancer screening where the immediate harms are balanced with longer-term benefits.” By providing a “personalized benefit/harm assessment”. <ref name="Cost vs Time"> Cost vs Time http://www.ajmc.com/journals/issue/2015/2015-vol21-n7/Pilot-of-Decision-Support-to-Individualize-Colorectal-Cancer-Screening-Recommendations/</ref>
  
−
There is significant evidence to show that while initial costs remain an issue, switching from paper records to EHR systems will ultimately reduce overall health care expenses. Research indicates that Medicare and private payers could save tens of billions of dollars every year. To incentivize EMR adoption, the federal government has established a plan to provide $44.7 billion during 2010-2019 to financially assist health care providers in the EMR implementation process [4]. However according to Himmelstein, Wright & Woolhandler, as currently implemented, the use of Electronic Medical Records could moderately advance metrics related to quality measures, it  does however not reduce the cost of administration of ‘overall’ costs. “Hospitals on the ‘Most Wired’ list performed no better than others on quality, costs, or administrative costs” (Himmelstein, Wright & Woolhandler, 2009). Forecasts of potential improvements in efficiency and cost-savings from implementation of computerized health care and the use of Electronic Medical Records seem premature at the time the authors published their data in 2009 [12].
 
  
−
EMR implementations could affect physician and health system reimbursement in a number of ways. Some have argued that increased clinical documentation as a result of using an EMR will lead to increased billing and therefore reimbursement.  An increase in emergency department billing among Medicare patients has been attributed to more complete documentation that allows for higher levels of billing [43]. However, given the pay-for-service model present in many facets of the American healthcare system, some of the cost savings possibly generated by the introduction of an EMR – such as eliminating unnecessary and duplicated tests and ineffective procedures – could lead to decreased reimbursement for the physicians and health systems.
 
  
  
−
== Clinical decision support ==
+
==Implementaion==
 +
For a proper return on investment a proper implementation of EHR is needed.
 +
lots of things have to be kept in mind for a successful implementation of an EHR.
  
−
[[CDS|Clinical decision support (CDS)]] has been shown to increase quality and patient safety, improve adherence to guidelines for prevention and treatment, and avoid medication errors.
+
*Benefits and risks of the EHR.
 +
*cost
 +
*specifications of our needs and what we want and what the EHR have.
 +
*vendor certifications.
 +
*preparations for implementation and after.
 +
The journal of Emergency medicine titled with "computers in Emergency medicine" talks about all aspects of EHR implementation. <ref name="implementation"> IMPLEMENTING ELECTRONIC HEALTH RECORDS IN THE
 +
EMERGENCY DEPARTMENT. http://www.jem-journal.com/article/S0736-4679(08)00321-1.</ref>
  
−
=== Improved Reporting Capabilities ===
 
−
An EMR has the capability of providing a more robust reporting environment with integrated clinical and adminstrative data, standardized clinical assessments and calculation of outcome measures[http://ptjournal.apta.org/content/86/3/434.full.pdf+html].
 
  
−
Facing more and more complicated situation in clinical areas, doctors and other people need more up-to date data and knowledge to help them make decision. Thus, they use clinical decision support system (CDSS) to help them getting up-to-date information and selecting more appropriate remedy. EMR and facilitate this process by providing just-in-time data. In the end, practitioners can apply evidence-based medicine by EMR and CDSS.
 
−
For example, surveys performed in resources-constrained areas like Kenya about HIV show that EMR based CDSS by many ways like Increasing Guideline adherence, reducing data errors, decreasing patient visit time, and ects.
 
  
  
−
== Research ==
+
=== Neonatal Informatics and CPOE ===
 +
 +
Computerized physician order entry (CPOE) can be considered one of the major contributions to patient safety and health care quality from an EMR system implementation. CPOE and clinical decision support (CDS) systems have the potential to impact care of the critically ill neonatal patients to an even greater extent than other patient groups.  Implementation of CPOE with CDS has been shown to specifically benefit Neonatal care intensive care units (NICU) with improved medication turnaround times, decreased medication errors, reduced adverse drug effects, and improved radiology turnaround times.<ref>Corder, L., Kuehn, L., Kumar R.R., Mekhjian, H.S. Impact of computerized physican order entry on clinical practice in a newborn intensive care unit. J Perinatol. 2004;24:88-93. [Pubmed: 14872207].</ref>
 +
 +
While studies have shown these benefits to be consistent with CPOE and CDS equipped institutions, the effects of these systems on morbidity and mortality have been ambiguous.  A 2005 article reported an increase in mortality rate with the implementation of an EMR system with CPOE in a pediatric intensive care unit (PICU).<ref>Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.  Pediatrics. 2005;116:1506-1512. [PubMed: 16322178].</ref>  The informaticists and hospital administration, determined that errors with the implementation process of the CPOE system resulted in these negative results.  They stressed that a change in the workflow design was essential for a safer CPOE implementation.  A more recent 2010 article reported a decrease in neonatal mortality rate using the exact same CPOE system.<ref>Longhurst, C.A., Parast, L., Sandborg, C.I. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2010;126:14-21. [PubMed: 20439590].</ref>These findings indicate that the implementation of the CPOE system needs to include careful consideration of workflow analysis.  However, even with the utmost attention being given to ensure the safety of a new CPOE system, inadvertent issues may still arise with human error. An example of such would be a physician order entry on the wrong patient.<ref name="Palma 2011">Palma, J.P., Sharek, P.J., Classen, D.C., & Longhurst, C.A. (2011). Neonatal Informatics: Computerized Physician Order Entry. Neoreviews. 12:393-396. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3146345/</ref>
  
−
=== Informatics ===
 
  
−
The EMR allows researchers to efficiently search patient medical information by medical condition, date of treatment, physician name and test category. Researchers can quickly focus their attention on medical information that will support their research efforts, develop databases to study patient outcomes, and cross-check complex medical information.
+
== Specialty clinics ==
  
−
Researchers can use the EMR to analyze large amounts of patient data more efficiently, quickening the use of new research findings to improve patient care [5].
+
EHR’s can significantly improve the productivity for specialty physician clinics such as for ophthalmology. Incorporating an EHR, a clinic can reduce process and time spent on recording patient data, as most diagnostic equipment can communicate with EHR’s.  With medical and diagnostic equipment communicating with EHR’s, staff and technicians can focus more on the patient.  <Ref name== "Misch, 2012"> Misch, D.M. Specialty-specific EHR system benefits both practice, patients: technologic innovation: how using EHR, practice management platform can improve standard of care and efficiency. http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?p=HRCA&u=txshracd2509&id=GALE|A312290264&v=2.1&it=r&sid=summon&userGroup=txshracd2509</ref>
  
−
* EMR's increase the quality of medical data by recording coded rather than textual data. This, alongside the application of UMLS coding, will facilitate processes like data mining, data warehousing, ''[http://en.wikipedia.org/wiki/In_silico in silico]'' clinical trials, predictive modeling and any other mainstream research which requires data analysis. Also, by paving the way for automating data acquisition from other systems (like lab machines, imaging devices, barcode/RFID readers, bio-data sensors) error resulting from duplicate data entry procedures, manual file search and patient identification will decrease.
+
== Benefits Database ==
−
* While EMRs have shown an increase in the quality of medical data, research is still conflicting on the cost benefits and efficiency gains of EHRs. A study of HIMSS Analytics Database data from California medical-surgical units showed a decrease in cost efficiency for Stage 1 and Stage 2 EMR implementation, and no efficiency correlation for State 3 EMR implementations (http://www.ncbi.nlm.nih.gov/pubmed/20812460).
+
[[EMR Benefits: Benefits Database]]
−
*EMRs contain large amounts of structured and free-text data which can be de-identified and used for research without disclosing patient information. Pantazos, K., Lauesen, S., Lippert, S. 2011. [http://www.ncbi.nlm.nih.gov.ezproxyhost.library.tmc.edu/pubmed/21893869 De-identifying an EHR Database - Anonymity, Correctness and Readability of the Medical Record]. Stud Health Technol Inform. 2011, 169, 862-866. 
+
−
* In addition to structured vocabulary searches of EMR databases, free-text search algorithms within and EMR can generate additional information critical to the identification of epidemics.  Often, critical information is omitted by the clinical team when only structured vocabulary is analyzed.  [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2954790/?tool=pubmed DeLisle S, South B, Anthony JA, Kalp E, Gundlapalli A, Curriero FC, Glass GE, Samore M, Perl TM. Combining Free Text and Structured Electronic Medical Record Entries to Detect Acute Respiratory Infections. ''PLoS One''. 2010 Oct 14, 5(10):e13377]
+
  
−
=== Bioinformatics ===
+
A national repository of EMR benefits data is needed to help stakeholders make more informed decisions about EMR implementation and to facilitate monitoring and corrective redesign of existing EMR implementations.  A framework for reporting data should be developed that will enable meaningful comparisons, provide uniform benefit categories and standardized methods of measurement and evaluation.<ref name=”Thompson 2006”>Thompson, D. I., Osheroff, J., Classen, D., & Sittig, D. F. (2006). A review of methods to estimate the benefits of electronic medical records in hospitals and the need for a national benefits database. Journal of healthcare information management: JHIM, 21(1), 62-68.</ref>
  
−
* Genome-wide association studies have become commonplace for the identification of risk and causative genetic variants.  The power of these studies is highly dependent on accurate phenotypic classification of both control and test populations.  Application of natural language processing algorithms to free-text clinical narrative, in addition to structured data, can significantly benefit these studies. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995686/?tool=pmcentrez Kullo IJ, Fan J, Pathak J, Savova GK, Ali Z, Chute CG. Leveraging informatics for genetic studies: use of the electronic medical record to enable a genome-wide association study of peripheral arterial disease. ''J Am Med Inform Assoc.'' 2010 September, 17(5): 568-574.]
+
==Compliance==
 +
[[EMR Benefits: Compliance]]
  
−
=== Enhance public health surveillance ===
 
−
In addition to improving patient hospital outcomes, electronic health records can also improve public and population health outcomes as well. EHRs can accomplish this by improving reporting capabilities, ease the exchange of information across organizations, and improve communication between healthcare providers and public health officials. In 2013, New York City Public Health Department is set to launch a project to aggregate EHR data into a surveillance tool to improve public health in the city [24]. This project will monitor the prevalence of conditions such as obesity, hypertension, smoking rates, and flu vaccinations.
 
  
−
=== Tracking Epidemics ===
+
18. Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings,      And Costs. Health Affairs, 1103-1117. doi:10.1377/hlthaff.24.5.1103 Health Aff September 2005 vol. 24 no. 5 1103-1117
  
−
Electronic Medical records have the potential to help patients get better care and hospitals leverage best practices on a large scale. But the ability to quickly and efficiently compile and analyze vast amounts of patient data is also of critical importance when it comes to spotting patterns in a health emergency or in fast spreading outbreaks, such as a flu pandemic or salmonella. The U.S. Centers for Disease Control and Prevention (CDC) and GE Healthcare are working on just that — with the official start of a project to evaluate putting EMR data to use in public health alerts.[http://www.gereports.com/using-emrs-to-help-the-cdc-track-outbreaks-faster/]
 
  
−
=== Better Evidence Based Practices ===
 
  
−
The patient data stored electronically increases the availability of data, which may in turn lead to more quantitative analyses to identify evidence-based best practices more easily. With availability of the aggregated electronic clinic data, more public health researchers are using it for the research purposes to benefit the society. The availability of clinical data is limited, but as providers continue to implement EHRs, this pool of data will grow. By combining aggregated clinical data with other sources, such as over-the-counter medication purchases and school absenteeism rates, public health organizations and researchers will be able to better monitor disease outbreaks and improve surveillance of potential biological threats. [44]
 
−
 
−
EHR's use of clinical decision support systems could also decrease the time elapsed between acceptance of evidence-based research and actual practice of evidence-based medicine.  A report from the Institute of Medicine, ''To Err is Human'', states that 15 years was the time frame that elapsed between acceptance of the evidence and practice.  This time frame could be drastically reduced with electronic health resources. [52]
 
−
 
−
== National and international effects ==
 
−
 
−
=== Growth, Job creation, and enhancement in the Commercial Clinical IT sector ===
 
−
 
−
The commercial marketplace for clinical IT products has evolved dramatically
 
−
in recent years through corporate mergers, acquisitions, and other challenges to fledgling startup companies. Cerner Corporation and Eclipsys Corporation, two vendors of clinical IT solutions, have acquired the greatest share of the market. Other major participants include Epic Systems Corporation (Madison, WI), IDX (Burlington, VT), McKesson (San Francisco, CA), Siemens Medical Solutions (Erlangen, Germany), and Meditech (Westwood, MA).2,3 Industry analysts estimate that only 5% of the health care IT market has been penetrated, and this estimate has led to optimistic  growth forecasts for vendors of clinically focused IT products as the market continues to mature.
 
−
 
−
== Barriers to EMR Implementation ==
 
−
 
−
===  System Selection ===
 
−
 
−
Based on the application the type of system selected will vary based on current research, size of practice, institution, academic affiliation, vendors and their ability to demonstrate compliance with current research “by identifying funded and published research(Kannry  Mukani& Myers , 2006)” and ultimately the assessment and analysis of the total cost of ownership.
 
−
 
−
According to Kannry  Mukani& Myers in their 2006 article Using an Evidence-based Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital . The authors note the technology requirements of educational institutions vary greatly from the needs of the private sector.  Although both the private sector and academia have concerns with accurate documentation, patient safety and patient care, educational institutions focus on “education, training and research, (Kannry  Mukani& Myers, 2006).  The need of residents and compliance with regulatory requirements is significant and cannot be minimized. [13}
 
−
 
−
The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities [30].
 
−
 
−
* In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system.
 
−
* Conflicting research findings on the cost and efficiency benefits of EMR implementations will make it difficult, if not impossible, for administration staff to be confident in choosing an EMR for their facility. Until there is adequate research on multitudes of EMR systems that shows causal relationships between facility characteristics and the related EMR components there will not be a sufficient method of EMR selection and implantation.
 
−
* If it is true that implementations of EMRs cause a decrease in efficiency and an increase in quality of medical care then further research must take both of these repercussions into account and determine if there is an overall net benefit of EMR implementation.
 
−
*The use of EMR and the afforded efficiencies may not provide immediate cost savings to some office-based physicians. These physicians may not be able to reduce their office expenses sufficiently to offset the revenue decreases they may see as a result of increasing efficiency. For example, a physician who is paid, as many laboratory or treatment centers are, per service rendered would see a direct decrease in revenue were they to reduce the number of duplicated diagnostic tests.[http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/91xx/doc9168/05-20-healthit.pdf ]
 
−
* The reported barriers to adoption and MU of EHRs were not associated with serving a predominately Medicaid-insured population, and were consistent with barriers that health care professionals in other studies had previously reported. In fact, barriers to adopting and using EHRs that could be associated with Medicaid providers were issues specific to provider types who were eligible for the Medicaid EHR Incentive Program but not the Medicare EHR Incentive Program, specifically, dentists and pediatricians. However, all findings were useful in generating a set of recommendations that are specific to promoting MU of EHRs among health care professionals eligible for the Medicaid EHR Incentive Program. [http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5]
 
−
* The variability of results of similar studies on the monetary and efficiency benefits of EHRs indicates that there is no single approach to EMR implementation that will fit all settings. Variables such as hospital size, setting, specialty, prior computer integration, etc will determine the effectiveness of an EMR dramatically and must be considered in all cases.
 
−
*The high cost of basic infrastructure of clinical information technology
 
−
is a substantial hurdle for many health care organizations, many of whose income margins have deteriorated after years of decreasing reimbursement (from Medicare and other sources) and whose access to capital for new medical technology is extremely scarce. Financial instability and scarce capital resources for IT infrastructure similarly affect small to mid-sized
 
−
independent practice associations (IPAs) and independent physician offices, the practice venues for most physicians in the United States.
 
−
*Diversity of products as well as lack of standards for common architecture of basic infrastructure of clinical information technology constitutes a barrier and further complicates EMR Implementation.
 
−
 
−
=== Costs ===
 
−
 
−
For more information, see [[EMR Cost Categories]].
 
−
 
−
=== Challenges to Identifying a Return on Investment (ROI) ===
 
−
 
−
Evidence of a strong ROI business case for EHR implementation is confounded by anecdotal evidence in peer reviewed research and trade journals. Furthermore, environmental differences across provider settings make it challenging to replicate information system strategies and dependence on disparate legacy applications [48].
 
−
 
−
Additional barriers include:
 
−
 
−
*Vendor supplied benefits data may not be objective
 
−
*Few vendors maintain a structured database of benefits information
 
−
*Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings.
 
−
*Differences in system architecture
 
−
*Trade journals tend to focus on anecdotal evidence rather then empirical evidence
 
−
*No standardized domain method exists to measure the ROI of electronic health records
 
−
*Lack of information regarding maintenance and optimization costs [48]
 
−
 
−
Consequently, providers frequently lack the necessary information to make sound financial decisions regarding Health IT capital investments. Uncovering the true cost and benefit of EHR adoption will require a national effort to standardize and centralize evidence in a national database. [48]
 
−
 
−
== Return on Investment (ROI) ==
 
−
 
−
=== Sittig's Postulates ===
 
−
 
−
Dean Sittig, professor at UT Houston's School of Biomedical Informatics, has suggested a new set of criteria for determining ROI for an EMR implementation. Based on Koch's Postulates and Hill's criteria for causation, these criteria are designed specifically for EMR evaluation.
 
−
 
−
* Must have the hardware and software available before the effect is identified.
 
−
** Need to at least estimate state of affairs before system is implemented…manual review
 
−
* Show that clinicians are actually using the system that could produce the effect.
 
−
* Show that the effect increases with increasing availability and usage of the system.
 
−
* Show that all obvious “alternative explanations” for the effect are false.
 
−
* Show the effect goes away when the system goes away.
 
−
* Show that a similar effect occurs when a similar system is installed and used at a similar facility.
 
−
 
−
=== Quality Care ===
 
−
 
−
One could approach the ROI from the perspective of the Institute of Medicine Report, ''Crossing the Quality Chasm''
 
−
# Safe:  Reducing adverse drug events, inappropriate testing
 
−
# Effective:  Reducing drug costs through appropriate prescribing
 
−
# Efficient:  Reducing drug, laborotory, or radiologic utilization
 
−
# Timely:  Reducing wait times
 
−
# Patient-centered:  Reducing length-of-stay while hospitalized
 
−
# Equitable:  Provides data to demonstrate equal delivery
 
−
 
−
=== Strategic Benefits === 
 
−
 
−
These offer substantial benefits to the organization, but at some future date. E.g. investments in networking and telecommunications offer significant future strategic benefits, positioning organizations to utilize enterprise-wide patient indexing and EMR or distributed case management technologies as they emerge.
 
−
 
−
== Incentive Programs ==
 
−
 
−
In recent years, many providers have factored government  incentive payments into the cost analysis and final decision to purchase an EHR.  The Medicare EHR Incentive Program provides incentive payments of $44,000 over five years to eligible professionals, eligible hospitals, and CAHs that demonstrate meaningful use of certified EHR technology. There's an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HPSA). Medicare eligible professionals who predominantly furnish services in an area designated as a Health Professional Shortage Area (HPSA) will receive a 10% increase in their annual EHR incentive payments.(29)
 
−
 
−
The Medicaid EHR Incentive Program provides incentive payments to eligible professionals, eligible hospitals, and CAHs as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years. Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program. (11)
 
−
 
−
Beginning in 2015, Medicare eligible professionals who do not successfully demonstrate meaningful use will be subject to a payment adjustment. The payment reduction starts at 1% and increases each year that a Medicare eligible professional does not demonstrate meaningful use, to a maximum of 5%.(29)
 
−
 
−
The American Reinvestment and Recovery Act  law creates two key concepts to determine whether providers qualify for the health IT incentives: they must make "meaningful use" of IT and use a "qualified or certified EHR" (electronic health record). Besides incentives to providers and hospitals, the law also creates $2 billion in health IT funding administered by the Office of the National Coordinator for Health Information Technology (ONC). A significant amount of this $2 billion should lay important groundwork to help providers use health IT meaningfully toward the goals of improving the nation's health.  (14)
 
−
 
−
=== Sources of Funding ===
 
−
 
−
# Organizational Reserves – provider organization make investments in affiliated organizations
 
−
# Bank and other financial service – short term loans
 
−
# Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment
 
−
# Vendor discounts and incentives – requires something in return
 
−
# Joint venture or partnership – tighter relationship
 
−
# Health plans and plan sponsors – contractual arrangement
 
−
# Private philanthropy – fellowships or university chairs
 
−
# Pharmaceutical companies – willing to conduct clinical trials
 
−
# Public grants – government initiatives
 
−
# State legislative initiatives – local and state initiatives
 
  
 
== References ==
 
== References ==
 +
<references/>
  
−
Committee on Quality of Health Care in America, Institute of Medicine. "Front Matter." ''Crossing the Quality Chasm: A New Health System for the 21st Century''. Washington, DC: The National Academies Press, 2001.  [http://www.nap.edu/openbook.php?isbn=0309072808 Full text]
+
[[Category: EHR]]
−
 
+
[[Category: EMR]]
−
# http://www.msdc.com/EMR_Benefits.htm
+
−
# http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm
+
−
# http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php
+
−
# http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm
+
−
# http://www.mayoclinic.org/emr/benefits.html
+
−
# http://www.philblock.info/hitkb/e/EMRs_and_EHRs.html
+
−
# Integrated Centre for Care Advancement through Research (iCARE); Canada Health Infoway (Infoway); Canadian Patient Safety Institute (CPSI). (2007). The Relationship Between Electronic Health Records and Patient Safety: A Joint Report On Future Directions For Canada. 1-31.
+
−
# Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67
+
−
# Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958
+
−
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429
+
−
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp
+
−
# http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf
+
−
# http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf
+
−
# http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act
+
−
# http://www.cdc.gov/ehrmeaningfuluse/
+
−
# http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5
+
−
# Evidence on the Costs and Benefits of Health Information Technology. A Congressional Budget Office Paper. Congress of the United States. Congressional Budget Office. Available at: http://www.cbo.gov/publication/41690. Acessed September 30, 2013.
+
−
# Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.
+
−
# Shapiro JS, Kannry J, et al. Approaches to patient health information exchange and their impact on emergency medicine. Ann Emerg Med. 2006 Oct;48(4):426-432.
+
−
#Wang, S. J., Middleton,, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P., … Bates, D. W. (2003). A Cost-Benefit Analysis of Electronic Medical Records in Primary Care. Excerpta Medica Inc, (114), 397–403. doi:10.1016/S0002-9343(03)00057-3
+
−
#Kaushal R, Jha AK, Franz C, Glaser J, Shetty KD, Jaggi T, Middleton B, Kuperman GJ, Khorasani R, Tanasijevic M, Bates DW; Brigham and Women's Hospital CPOE Working Group. (2006). Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 13(3):261-6.
+
−
#Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future DirectionsMichael J. Tierney, MD, Natalie M. Pageler, MD, Madelyn Kahana, MD, Julie L. Pantaleoni, MD, and Christopher A. Longhurst, MD, MS Acad Med. 2013 Jun;88(6):748-52. doi: 10.1097/ACM.0b013e3182905ceb.
+
−
# http://www.hhs.gov/news/press/2013pres/08/20130805a.html
+
−
# http://www.fierceemr.com/story/new-york-looks-ehrs-enhance-public-health-surveillance/2013-08-27
+
−
# http://ehrintelligence.com/2012/12/10/engaging-patients-through-ehr-access-open-notes/
+
−
# The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review Tom Oluocha,*,Xenophon Santasb, Daniel Kwaroc, Martin Wered, Paul    Biondichd,
+
−
# Driessen J,CioffiM, Alide N,et al. J Am Med Inform Assoc 2013;20:743–748.
+
−
# Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study Sameer Kumar, Krista Aldrich
+
−
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html
+
−
# http://www.ncbi.nlm.nih.gov/pubmed/9576410
+
−
# Study of the factors that promoted the implementation of electronic medical record on iPads at two emergency departments. Rao AS, Adam TJ, Gensinger R, Westra BL. AMIA Annu Symp Proc. 2012;2012:744-52. Epub 2012 Nov 3.
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# Connelly, D. P., Park, Y. T., Du, J., Theera-Ampornpunt, N., Gordon,B. D., Bershow, B. A., ... & Speedie, S. M. (2012). The impact of electronic health records on care of heart failure patients in the emergency room. Journal of the American Medical Informatics Association, 19(3), 334-340.
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# Pinsonneault, A., Dakshinamoorthy, V., Reidel, K., & Tamblyn, R. (2012, January). The impact of IT on quality of care: Evaluation of an integrated chronic disease management system. In System Science (HICSS), 2012 45th Hawaii International Conference on (pp. 2947-2956). IEEE.
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# McGinn, C. A., Grenier, S., Duplantie, J., Shaw, N., Sicotte, C., Mathieu, L., ... & Gagnon, M. P. (2011). Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review. BMC medicine, 9(1), 46.
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# Mintz, MD, M., Narvarte, MD, H. J., OBrien, MD, K. E., Papp, PhD, K. K., Thomas, MD, M., & Durning, MD, S. J. (2009). Use of electronic medical records by physicians and students in academic internal medicine settings. Academic Medicine, 84(12), 1698-1704.
+
−
# http://www.practicefusion.com/ehrbloggers/2010/10/return-on-investment-for-emrs.html
+
−
# http://jama.jamanetwork.com/article.aspx?articleid=1737043#ArticleInformation
+
−
# Kuperman, G.J. and Gibson, R.F. (2003) “Computer Physician Order Entry: Benefits, Costs & Issues” Am Intern Med 2003; 139:31-39
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# Crane, R.M. and Raymond, B. (2003) “Fulfilling the Potential of Clinical Information Systems: The Permanente Journal Winter/2003/Vol.7No1
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# Wang, S.J.; Middleton, B.; Prosser, L.A.; et al. (2003) “A Cost Benefit Analysis of Electronic Medical Records in Primary Care” The    American Journal of Medicine Vol.114 p 397-403
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# Wang, Middleton, Prosser et al. (2003)
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# Kaushal, R.; Jha, A.K.; Franz, C. et al. (2006) J Am Med Inform Assoc 2006;13:261-266 doi 10.1197/jamia.J1984
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# Menachemi N, Collum H.T. Benefits and drawbacks of electronic health record systems.Risk Manag Healthc Policy. 2011; 4: 47–55.
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# Thompson, D., Osheroff, J., Classen, D., & Sittig, D. (2007). A Review of Methods to Estimate the Benefits of Electronic Medical Records in Hospitals and the Need for a National Benefits Database. Journal of Healthcare Information Management, 21 (1), 62-68.
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Latest revision as of 18:33, 22 September 2015

The sections below detail the benefits, costs, and barriers in evaluating EMR implementations. Selecting, financing, and launching an EHR system is difficult.

Informational

EMR Benefits: Informational

Security

EMR Benefits: Security is an advantageous attribute which comes with EMR systems. Centers for Medicare and Medicaid Services (CMS) published a privacy, security & meaningful use guidelines which computer systems that store patient information need to conform to imply to HIPAA privacy guidelines. [1]

Environmental

EMR Benefits: Environmental positive impact through Electronic Health Records has the potential to improve the environmental footprint left by the health care industry. [2]

Quality Outcomes

EHR’s can be utilized to generate reports on quality measures in the effort to improve quality and patient satisfaction. With the ability to produce reports from EHR’s, clinicians can easily compare data to baseline data and quickly identify areas in need of improvement. Once areas in need of improvement have been identified, clinicians can compare data to manual reports and similar data to validate the reported information. Once an area of improvement has been identified it can be delivered to the performance improvement department where informatics professionals can perform gap analysis and identify methods to improve overall quality. , Cite error: Closing </ref> missing for <ref> tag

In addition the use of EMRs in a teaching environment allows trainees access to the most up to date information. “Point-of-care education accessed via CDS allows for easy access to relevant and up-to-date medical literature from which students and residents can draw to formulate diagnosis and management plans".[3]

Financial

EMR Benefits: Financial

"Implementing an EMR system could cost a single physician approximately $163,765. As of May 2015, the Centers for Medicare and Medicaid Services (CMS) had paid more than $30 billion in financial incentives to more than 468,000 Medicare and Medicaid providers for implementing EMR systems. With a majority of Americans now having at least one if not multiple EMRs generated on their behalf, data breaches and security threats are becoming more common and are estimated by the American Action Forum (AAF) to have cost the health care industry as much as $50.6 billion since 2009." [4]

Some of the ways that EMR systems can cut healthcare costs are due to savings based on "time-consuming paper-driven and labor-intensive tasks":[5]

  • Reduced transcription costs[5]
  • Reduced chart pull, storage, and re-filing costs [5]
  • Improved and more accurate reimbursement coding with improved documentation for highly compensated codes [5]
  • Reduced medical errors through better access to patient data and error prevention alerts [5]
  • Improved patient health/quality of care through better disease management and patient education [5]

There are few comprehensive estimates of savings from Health Information Technology (HIT) at the national level. At 90 percent adoption, it is estimated that the potential HIT – enabled efficiency savings for both inpatient and outpatient care could average more than 77 billion per year.[6] [7]

Although the full extent of EMR advantages may not become apparent until further implementation and research is carried out, a clear benefit is the reduction of cost. Major administrative costs can be eliminated or reduced. Providers can do away with the costs of “chart pulls,” while substantially reducing dictation costs through the use of EMRs. Healthcare providers can also receive decision support regarding selection and costs of medications, radiographic studies, and laboratory tests.[8]

Billing Accuracy

The benefits for small to medium private practices that have implemented EMR systems integrated with the practices' billing and prescription systems, can be increased efficiency and accuracy thanks to automatic coding leading to improved profitability. "Since installing the EMR, Medicare has audited only one of my charts. I had billed out as a level four and Medicare said it should have been billed as a level five, which, in essence, said that we should have been paid more. My EMR system gave the chart a level four and I believe it was right.” "Since adopting an EMR system, my practice receipts have increased about $4,000 per month."[9]

A nuanced view is appropriate here, however; improved billing can coincide with fewer patients seen. "EHR implementation ... increased reimbursements but reduced long-term practice productivity across all specialties"[10] according to one study. This may be a net financial positive for the practice: "an EHR should greatly enhance physician effectiveness even if fewer patients are seen by the physician"[10] due to gains in billing efficiency, but this also represents an artificial reduction in the supply of services.

An EMR Cost Benefit Analysis

Samsung Medical Center (SMC) performed a cost benefit analysis (CBA) on the cost benefits of implementing an electronic medical record (EMR) system. Costs of implementing the EMR system involved both direct costs to build the system infrastructure and induced costs to make a smooth transition to the new system. Benefits of implementing the EMR system include both cost reductions and increased revenue. Five types of cost reductions, mentioned by the authors, include:

  1. Reduction of supplies for paper charts
  2. Disposal of storage facilities used for paper chart storage
  3. Reduction of full-time equivalent (FTE) employees for the paper chart management
  4. Reduction in staff for outpatient clinics
  5. Decreased supplies for medical devices

The FTE's responsible for paper management were greatly reduced from 28 FTE's (2007) to 1 FTE (2009).

This CBA was based on an eight year period post EMR implementation. SMC determined the EMR system became cost effective shortly after 6 years. The outcomes of the CBA were calculated using the following formulas:

  • The primary outcome is the Net Present Value (NPV)
    • NPV = Present Value (PV) of benefit for the eight year period - PV of cost
  • The second outcome is the Benefit Cost Ratio (BCR)
    • BCR = PV of the benefit / PV of the cost
  • The third outcome is the Discounted Payback Period (DPP).
    • This is the time to reach the breakeven point.

This CBA does not include clinical benefits of the EMR implementation such as decreased medication errors, improved workflow, and reduced length of stay.[11]

Improving Patient Care

EMR Benefits: Healthcare quality

Many EMRs have alert systems that ensure physicians do not forget to request important tests. As well as the legal benefits that this provides, EMR alerts remind physicians of the "preventive care needs for patients, which helps improve quality of care and office income by reminding us to do appropriate testing and provide vaccinations" recommended for some patient conditions e.g. asthma, emphysema or diabetes. [12]


EMR Benefits: Reduction in no shows

EMR system was used to improve on automated calls made to patients to remind them of their appointment which reduced the number of no call shows and improved patient satisfaction. [12]

EMR Benefits: Medication Management

"Rational antibiotic use resulted in a lower mortality of 0.0644 % during the post-implementation period compared to 0.179 % during the pre-implementation period (p = 0.018). The comprehensive EMR system contributed to a significant reduction in antibiotic consumption and an improvement in rational antibiotic use."[13]

EMR systems have the ability to make evidence-based suggestions regarding patient care. With these suggestions, EMRs are able to use a patient’s information to identify preventative services that specific patient may need. The system is able to remind doctors that the patient is due for certain screening exams or other services which allows the doctor to discuss it with the patient and also allows the patient to decide whether or not they would like to schedule an appointment for that specific exam. This reminder has proven to benefit patient care by increasing compliance with preventative care.

EMRs also benefit patient care by assisting in long-term chronic disease prevention and management. Case management systems in EMRs allow patients to communicate with a variety of specialists, which better enables them to manage their care. This system also allows healthcare providers to keep track of patient data, such as vital signs, and allows case management nurses to quickly respond to any issues that may occur. The system benefits the patient because it allows the patient’s acute issues to be handled promptly before they become bigger issues that may lead to a hospital admission.

EMRs have the ability to eliminate up to 200,000 adverse drug events with the use of CPOE. Using reminders and alerts CPOEs are able to notify physicians about possible drug interactions that may occur when a new medication order is placed.

EMRs have a direct correlation with the quality of healthcare offered to a patient. Problems in healthcare quality fell into three categories as stipulated by the National Roundtable on Health Care Quality. These three categories are the underuse, overuse, and misuse of healthcare services. Reducing overuse and misuse of healthcare services, as noted by the Roundtable, leads to an increase in health care quality while simultaneously lowering costs. In addition, reducing the underuse of healthcare services increases quality, but may in turn increase costs. “Computerized physician order [CPOE] entry may affect all three categories of health care quality problems, as well as inefficiencies in the health care system.” [14]

Research

EMR Benefits: Research

Researchers can use EHRs to retrieve up-to-date data from various sources around the country to advance their studies. EHRs can compute a report to show researchers certain trends in the population or common side effects of medications. [15]

Health Information Exchange (HIE)

EMR Benefits: HIE

Personal Health Records

EMR Benefits: PHR

Patient Participation

Patients can use personal health record (PHR) to keep track of information from doctor visits, record health-related information, and link to health-related resources. PHR, is an electronic application used by patients to maintain and manage their own health information. Connected PHRs are linked to a specific health care organization's EMR system that can increase patient and family participation in their own care. [16]

Electronic Dental Records

EMR Benefits: EDR

Telehealth

EMR Benefits: Telehealth

E-Prescribing

EMR Benefits: E-Prescribing

E-Prescribing has many benefits, some of them include: [17]

  • reduce illegibility [18]
  • providing warning and alert systems, which reduce medication errors [18]
  • access to patient's medical history [18]
  • reduces or eliminates phone calls and call-backs to pharmacies [18]
  • eliminates faxes to pharmacies [18]
  • streamlines the refill and authorization processess [18]
  • increases patient compliance [18]

Mobile EMRs

EMR Benefits: mHealth

Physicians

EMR Benefits: Physicians

Physicians Benefit

EMRs can greatly improve communication between physicians by allowing each full access to the patient’s medical record and by making it easier for physicians to follow up with patients. The electronic record provides up to the minute information on the patient allowing more efficient collaboration between disciplines. EMRs allow multiple providers to simultaneously access a patient’s record from any authorized computer.[19]

Nurses

EMR Benefits: Nurses

Nurses use the EMR to identify newly admitted patients, track their location, and document admission information. The nursing SWAT team harnessed the power of EMR technology, and successfully re-organized nursing workflow to expedite the admission process, while maintaining patient and family centered care.[20]

Versatile capabilities of EHRs in healthcare settings

There are many studies showed that EHRs are capable to integrate with various standards systems such as billing codes, clinical notes, ICD diagnose codes, and medications, which essentially enhances effectiveness and efficiency of care and results in superior phenotyping performance compared with paper-based medical record systems. [21].

Improvement of Spontaneous Reporting System for drug post-marketing safety surveillance

In the healthcare settings, Spontaneous Reporting Systems (SRSs) are critical systems for monitoring drug post-marking safety and adverse drug reactions (ADRs). Although widespread utilization of SRSs has played a fundamental role in drug safety monitoring, there are certain limitations that hinder their efficacy and accuracy in practices. For example, multiple sources of data are needed for confirmation and validation; the nature of passive reactions to ADR events makes SRSs perform poorly in terms of pharmacovigilance. The integration of an SRS system into EHRs could have potential to improve efficiency and effectiveness of detection for ADR events. The combination of an SRS with EHRs could help collect data and information related to ADRs dynamically while avoiding the need of data validation from multiple sources and potentially reducing the costs. [22]

Improvement of healthcare outcomes through interactive collaboration among stakeholders

It has been reported that the integration of a Network-Based Learning Health System with EHRs can potentially improve a variety of healthcare outcomes. For example, integrating chronical care management, quality improvement, patients and their family engagement, and comparative research. [23]. Therefore, EHRs can serve as an effective platform and infrastructure that fascinates online learning for all stakeholders, and patient-centered quality care and evidence-based medical research.


Costs

Return on investment

It is estimated that purchasing and installing an EMR can cost a provider anywhere from $15,000 to $70,000. There are several things to consider when looking for an EMR for your organization or practice. The prices vary based on number of providers using the EMR and whether it is a select on-site EHR deployment or web-based EHR deployment. Other factors to take into consideration of what costs you will incur include these 5 components of implementation: [24]

  • Hardware: Hardware costs may include database servers, desktop computers, tablets/laptops, printers, and scanners. [5]
  • EHR Software: Potential software costs include an EHR application, interface modules and upgrades to your EHR application. Remember, software costs vary depending on whether you select an on-site EHR deployment or a SaaS EHR deployment. [5]
  • Implementation Assistance: Potential implementation assistance costs include IT contractor, attorney, electrician, and/or consultant support; chart conversion; hardware/network installation; and workflow redesign support. [5]
  • Training: Your organization will need to train your physicians, nurses, and office staff before and during EHR implementation. [5]
  • Ongoing Network Fees and Maintenance: Potential ongoing costs include hardware and software license maintenance agreements, ongoing staff education, telecom fees, and IT support fees. [5]
  • Although the initial cost of an EMR may (and typically does) result in an immediate increase in administrative cost, through the reduction of other “removable and or defunct items or process the implementation of the EMR showed a positive improvement in the BCR and NPV. [25] 
   examples: remodeling of paper-chart storage areas, medical transcriptions, shorter chain of communication, reduction of administrative material

==Cost vs Time == (A reduction of time spent on a common process can lead to reduced cost and better efficiency)

  • EMRs can greatly reduce or make more efficient use of time.

A recent study (July-2015)EMR decision support systems where proven to have reduced and or made more efficient use of the time needed for “Colorectal cancer screening where the immediate harms are balanced with longer-term benefits.” By providing a “personalized benefit/harm assessment”. [26]



Implementaion

For a proper return on investment a proper implementation of EHR is needed. lots of things have to be kept in mind for a successful implementation of an EHR.

  • Benefits and risks of the EHR.
  • cost
  • specifications of our needs and what we want and what the EHR have.
  • vendor certifications.
  • preparations for implementation and after.

The journal of Emergency medicine titled with "computers in Emergency medicine" talks about all aspects of EHR implementation. [27]



Neonatal Informatics and CPOE

Computerized physician order entry (CPOE) can be considered one of the major contributions to patient safety and health care quality from an EMR system implementation. CPOE and clinical decision support (CDS) systems have the potential to impact care of the critically ill neonatal patients to an even greater extent than other patient groups. Implementation of CPOE with CDS has been shown to specifically benefit Neonatal care intensive care units (NICU) with improved medication turnaround times, decreased medication errors, reduced adverse drug effects, and improved radiology turnaround times.[28]

While studies have shown these benefits to be consistent with CPOE and CDS equipped institutions, the effects of these systems on morbidity and mortality have been ambiguous. A 2005 article reported an increase in mortality rate with the implementation of an EMR system with CPOE in a pediatric intensive care unit (PICU).[29] The informaticists and hospital administration, determined that errors with the implementation process of the CPOE system resulted in these negative results. They stressed that a change in the workflow design was essential for a safer CPOE implementation. A more recent 2010 article reported a decrease in neonatal mortality rate using the exact same CPOE system.[30]These findings indicate that the implementation of the CPOE system needs to include careful consideration of workflow analysis. However, even with the utmost attention being given to ensure the safety of a new CPOE system, inadvertent issues may still arise with human error. An example of such would be a physician order entry on the wrong patient.[31]


Specialty clinics

EHR’s can significantly improve the productivity for specialty physician clinics such as for ophthalmology. Incorporating an EHR, a clinic can reduce process and time spent on recording patient data, as most diagnostic equipment can communicate with EHR’s. With medical and diagnostic equipment communicating with EHR’s, staff and technicians can focus more on the patient. [32]

Benefits Database

EMR Benefits: Benefits Database

A national repository of EMR benefits data is needed to help stakeholders make more informed decisions about EMR implementation and to facilitate monitoring and corrective redesign of existing EMR implementations. A framework for reporting data should be developed that will enable meaningful comparisons, provide uniform benefit categories and standardized methods of measurement and evaluation.[33]

Compliance

EMR Benefits: Compliance


18. Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, And Costs. Health Affairs, 1103-1117. doi:10.1377/hlthaff.24.5.1103 Health Aff September 2005 vol. 24 no. 5 1103-1117



References

  1. ↑ Centers for Medicare & Medicaid Services. Privacy and Security Standards. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/PrivacyandSecurityStandards.html
  2. ↑ Turley, M., Porter, C., Garrido, T., Gerwig, K., Young, S., Radler, L., & Shaber, R. (2011). Use of electronic health records can improve the health care industry’s environmental footprint. Health affairs, 30(5), 938-946.
  3. ↑ Tierney et al, Medical Education in the Electronic Medical Record (EMR) Era: Benefits, Challenges, and Future Directions http://tmclibrary.summon.serialssolutions.com/search?s.q=tierney+m+j#!/search?ho=t&l=en&q=Medical%20education%20in%20the%20electronic%20medical%20record%20(EMR)%20era:%20Benefits,%20challenges,%20and%20future%20directions.%20Academic%20Medicine
  4. ↑ O'Neill, T. (2015, August). Are Electronic Medical Records Worth the Cost of Implementation.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Kumar, S., & Bauer, K. (2011). Medical Practice Efficiencies & Cost Savings.http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings
  6. ↑
  7. ↑ Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., & Taylor, R. (2005). Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs, 24(5), 1103-1117.
  8. ↑ Bates, D. W., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic medical records in US primary care. Journal of the American Medical Informatics Association, 10(1), 1-10.
  9. ↑ EMR ROI: A Pennsylvania family practice's investment in an EMR pays off three-fold. http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?p=HRCA&u=txshracd2509&id=GALE%7CA163469720&v=2.1&it=r&sid=summon&userGroup=txshracd2509
  10. ↑ 10.0 10.1 Howley et al, 2015. "The long-term financial impact of electronic health record implementation" http://jamia.oxfordjournals.org/content/22/2/443
  11. ↑ Choi, J., Lee, W., Rhee, P. (2013). Cost-Benefit Analysis of Electronic Medical Record System at a Tertiary Care Hospital, Health Informatics Research;19(3):205-214. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3810528/
  12. ↑ 12.0 12.1 How We Improved Our Practice and Our Bottom Line With a New EMR System.Fam Pract Manag, 15(7), 25. http://www.aafp.org/fpm/2008/0700/p25.html
  13. ↑ The Meaningful Use of EMR in Chinese Hospitals: A Case Study on Curbing Antibiotic Abuse 15(7),
  14. ↑ Kuperman, G. J., & Gibson, R. F. (2003). Computer physician order entry: benefits, costs, and issues. Annals of internal medicine, 139(1), 31-39.
  15. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Enormous_Benefits
  16. ↑ http://www.healthit.gov/providers-professionals/patient-participation
  17. ↑ Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 18.6 Healthcare IT News http://www.healthcareitnews.com/directory/e-prescribing
  19. ↑ http://www.usfhealthonline.com/resources/healthcare/benefits-of-ehr/#.VfjJDXktDmQ
  20. ↑ http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S0882596314002413
  21. ↑ Wei, W.Q., Teixeira, P. L., Mo, H., Cronin, R. M., Warner, J. L., & Denny, J. C. Combining billing codes, clinical notes, and medications from electronic health records provides superior phenotyping performance. Journal of the American Medical Informatics Association: JAMIA. http://doi.org/10.1093/jamia/ocv130
  22. ↑ Pacurariu, A. C. Useful Interplay Between Spontaneous ADR Reports and Electronic Healthcare Records in Signal Detection. Drug Safety. http://doi.org/10.1007/s40264-015-0341-5.
  23. ↑ Marsolo, K., Margolis, P. A., Forrest, C. B., Colletti, R. B., & Hutton, J. J. A Digital Architecture for a Network-Based Learning Health System: Integrating Chronic Care Management, Quality Improvement, and Research. EGEMS (Washington, DC), 3(1), 1168.
  24. ↑ HealthcareIT.gov http://www.healthit.gov/providers-professionals/faqs/how-much-going-cost-me http://www.healthit.gov/providers-professionals/faqs/how-much-going-cost-me
  25. ↑ Removable or Defunct http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810528/
  26. ↑ Cost vs Time http://www.ajmc.com/journals/issue/2015/2015-vol21-n7/Pilot-of-Decision-Support-to-Individualize-Colorectal-Cancer-Screening-Recommendations/
  27. ↑ IMPLEMENTING ELECTRONIC HEALTH RECORDS IN THE EMERGENCY DEPARTMENT. http://www.jem-journal.com/article/S0736-4679(08)00321-1.
  28. ↑ Corder, L., Kuehn, L., Kumar R.R., Mekhjian, H.S. Impact of computerized physican order entry on clinical practice in a newborn intensive care unit. J Perinatol. 2004;24:88-93. [Pubmed: 14872207].
  29. ↑ Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116:1506-1512. [PubMed: 16322178].
  30. ↑ Longhurst, C.A., Parast, L., Sandborg, C.I. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2010;126:14-21. [PubMed: 20439590].
  31. ↑ Palma, J.P., Sharek, P.J., Classen, D.C., & Longhurst, C.A. (2011). Neonatal Informatics: Computerized Physician Order Entry. Neoreviews. 12:393-396. http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pmc/articles/PMC3146345/
  32. ↑ Misch, D.M. Specialty-specific EHR system benefits both practice, patients: technologic innovation: how using EHR, practice management platform can improve standard of care and efficiency. http://go.galegroup.com.ezproxyhost.library.tmc.edu/ps/i.do?p=HRCA&u=txshracd2509&id=GALE%7CA312290264&v=2.1&it=r&sid=summon&userGroup=txshracd2509
  33. ↑ Thompson, D. I., Osheroff, J., Classen, D., & Sittig, D. F. (2006). A review of methods to estimate the benefits of electronic medical records in hospitals and the need for a national benefits database. Journal of healthcare information management: JHIM, 21(1), 62-68.
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