http://clinfowiki.org/wiki/api.php?action=feedcontributions&user=Adlai&feedformat=atomClinfowiki - User contributions [en]2024-03-28T12:43:48ZUser contributionsMediaWiki 1.22.4http://clinfowiki.org/wiki/index.php/Public_keyPublic key2014-11-13T03:51:31Z<p>Adlai: Created page with "A '''Public Key''' is a cryptographic key that can be obtained and used by anyone to encrypt messages intended for a particular recipient, such that the encrypted messages can..."</p>
<hr />
<div>A '''Public Key''' is a cryptographic key that can be obtained and used by anyone to encrypt messages intended for a particular recipient, such that the encrypted messages can be deciphered only by using a second key that is known only to the recipient (the [[Private key|private key]]). <ref name="wiki">Public-key cryptography http://en.wikipedia.org/wiki/Public-key_cryptography</ref><br />
<br />
== Security ==<br />
<br />
Some encryption schemes can be proven secure on the basis of the presumed difficulty of a mathematical problem, such as factoring the product of two large primes or computing discrete logarithms. Note that "secure" here has a precise mathematical meaning, and there are multiple different (meaningful) definitions of what it means for an encryption scheme to be "secure". The "right" definition depends on the context in which the scheme will be deployed.<br />
<br />
The most obvious application of a public key encryption system is confidentiality – a message that a sender encrypts using the recipient's public key can be decrypted only by the recipient's paired private key. This assumes, of course, that no flaw is discovered in the basic algorithm used.<br />
<br />
Another type of application in public-key cryptography is that of digital signature schemes. Digital signature schemes can be used for sender authentication and non-repudiation. In such a scheme, a user who wants to send a message computes a digital signature for this message, and then sends this digital signature (together with the message) to the intended receiver. Digital signature schemes have the property that signatures can be computed only with the knowledge of the correct private key. To verify that a message has been signed by a user and has not been modified, the receiver needs to know only the corresponding public key. In some cases (e.g., RSA), a single algorithm can be used to both encrypt and create digital signatures. In other cases (e.g., DSA), each algorithm can only be used for one specific purpose.<br />
<br />
To achieve both authentication and confidentiality, the sender should include the recipient's name in the message, sign it using his private key, and then encrypt both the message and the signature using the recipient's public key.<br />
<br />
These characteristics can be used to construct many other (sometimes surprising) cryptographic protocols and applications, such as digital cash, password-authenticated key agreement, multi-party key agreement, time-stamping services, non-repudiation protocols, etc. <ref name="wiki">Public-key cryptography: Security http://en.wikipedia.org/wiki/Public-key_cryptography#Security</ref><br />
<br />
<br />
== References ==<br />
<references/><br />
<br />
[[Category: Definition]]</div>Adlaihttp://clinfowiki.org/wiki/index.php/Vendor_Selection_CriteriaVendor Selection Criteria2014-09-17T22:35:54Z<p>Adlai: /* Meaningful use gap analysis */</p>
<hr />
<div>Choosing an [[EMR|electronic medical record (EMR)]] vendor is an important task, with many aspects to consider. An EMR can completely redesign a hospital's practice, but can also optimize it in ways a [[Removing Paper|paper-based system]] could not. With over 400 EMR vendors in the market, selecting the best option could be overwhelming. After clearly defining the needs of the company, the next step is to evaluate which vendors more closely match your list of priorities.<ref name="Selecting a vendor">Selecting the right EMR vendor. http://www.himss.org/files/HIMSSorg/content/files/selectingemr_flyer2.pdf </ref><br />
Here is a list of some of the important considerations when choosing, installing, implementing and upgrading an EMR system. <ref name="factors selecting vendor"></ref><br />
<br />
== Core Clinical Features ==<br />
<br />
In 2003, the DHHS asked the IOM to provide guidance on the basic functionalities of electronic health records systems. The committee concluded that the core functionalities should address the following areas:<br />
* Improvement of patient safety<br />
* Support delivery of effective patient care<br />
* Facilitate management of chronic conditions<br />
* Improve efficiency<br />
* Feasibility of implementation and <br />
* Integration of hospital services<br />
In the Journal of Healthcare Information Management Kranny et. al discussed the importance of an application in the EHR which will promote continuity of care. During the selection of a vendor it is imperative for the decision committee to find out if there is an integration of inpatient, clinical and outpatient interface systems. (8) The patient's progress in house and discharge summary should be accessible by his primary care provider upon discharge. Medications that were discontinued during hospitalization should be updated in the patient's outpatient medication profile so worng medications are not refilled by the patient. IN addition, when new medications are added to the patient medication regimen it should be accessible by the primary care provider and outpatient pharmacist.<br />
<br />
Based on these areas, the IOM committee identified eight categories of core functionalities, including: <ref name="johnson 2006">Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g</ref><br />
* Health information and data<br />
* Results management<br />
* [[CPOE|Order entry/management]]<br />
* [[CDS|Decision support]]<br />
* Electronic communication and connectivity<br />
* Patient support; administrative processes<br />
* Reporting and population health management<br />
<br />
== Analyzing Business(EHR) requirements ==<br />
* Assemble an Evaluation Team<br />
The Evaluation team or decision Team should consist of clinicl healthcare professionals including house staff, tech support professionals, administrators, and financers from all areas of the institution. Each person brings to the table a differnt perspective of usage from their daily job responsibilites. Insitution-wide involvement creates awareness and knowledge of EMRs and their benefits. AS well as, an understanding of the upcoming modifications in work flows. <br />
* Define the Product, Material or Service<br />
* Define the Technical and Business Requirements<br />
* Define the Vendor Requirements<br />
* Publish a Requirements Document for Approval<br />
<br />
=== EMR software ===<br />
<br />
* Health Information & Data Management (Demographics, Problem list [CC, Conditions, Acute/Chronic, Worsening/Resolving, Injuries, Present Illness] with [[ICD|ICD-9 or ICD-10 numbering]], Procedures, Diagnoses, Medications, Allergies, Family medical history, Consultations, Signs & Symptoms and Vitals, Progress Notes and Discharge Summaries, Appointments/Admissions/Visits, Advance Directives, Clinical Reminders [Immunizations, Screenings, Risks])<br />
** EHR that allows for the creation and maintenance of patient specific problem lists that are dated and organized by diagnosis, problem, and problem type and associates encounters, orders, medications and notes to one or more problems. Once a problem is resolved, the EHR provides an automated algorithm that closes that problem.<br />
* Is the Software configuration flexible to customize for future needs.<br />
* Result Management (lab, imaging, other diagnostic measurements, pictures, multimedia)<br />
** Review and search results easily by sorting test types, test time, test administers, test results and so on<br />
** Choose one or several test types, such as HGB, and/or WBC, and/or blood sugar and chart on their results for showing trends.<br />
* The proposed EMR software should bring minimal to no new limitations to the institution. Selectors must be certain that the EMR system meets all required operational tasks.<br />
* How much customization to the EMR can the vendor offer to meet the institution’s needs? Will there be a surplus of unusable or insufficient components to the EMR?<br />
* Ensure that the EMR software is tested prior to finalizing the vendor contract.<br />
* Proposed EHR should allow for expandability to mobile devices, mobile medical applications and upcoming mobile technology.<br />
* Does the EHR have integrated practice management to avoid having to interface with a 3rd part practice management system?<ref name"himss-ama-pms">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* Does the software provide a tool for workflow mapping/charting? <br />
* Can the software be easily configured/adapted to changing workflows?<br />
* Does the EHR/EMR system allow multiple terminals (physician, nurses' station, X-ray, labs, etc.) to log in to the same patient's record simultaneously? Certain systems only allow one terminal to access a patient record at a time - they must log out before any other terminal can access patient EHR/EMR. (For example, if a nurse forgets to log out at their station, the lab cannot access that patient's record.)<br />
<br />
=== Privacy and Security ===<br />
<br />
* Does the system provide roadmaps for adherence to organizational policies (such as HIPAA)?<br />
* The system shall allow an authorized administrator to enable or disable auditing for events or groups of related events to properly collect evidence of compliance with implementation-specific policies. Note: In response to a [[Health Insurance Portability and Accountability Act (HIPAA)|HIPAA-mandated risk analysis]] and management, there will be a variety of implementation- specific organizational policies and operational limits.[1]<br />
* Internet Connectivity and Redundancy Contract - There are three main types of connections for clinical data connections: business class digital subscriber line (DSL), business class cable, and T1 connection. Redundant back up systems and procedures to ensure your data will be backed up in multiple locations and securely stored off-site. <br />
* Will the system allow staff administrators to create and manage users and [[Data security|user security profiles]]?<br />
* The system restore functionality shall result in a fully operational and secure state. This state shall include the restoration of the application data, [[Security|security credentials]], and log/audit files to their previous state. [1]<br />
* If the system includes hardware, the system shall include documentation that covers the expected physical environment necessary for proper secure and reliable operation of the system including: electrical, HVAC, sterilization, and work area.<br />
* How well does the EMR work with antivirus, antispyware and other security software?<br />
* What is the vendor’s history with cyber attacks? <ref name="mit cybersecurity">MIT Geospactial Data Center: Protecting EMR Data (1 of 2) http://cybersecurity.mit.edu/2012/11/protecting-emr-data-1-of-2/</ref><br />
* Does the system allow for off-site access to files/data and how does the technology protect against external breech or diversion of patient information?<br />
<br />
=== CPOE ===<br />
<br />
* [[CPOE| Computerized Physician Order Entry (CPOE)]], [[Electronic prescribing| e-Prescribing]]<br />
* Computerized Physician Order Entry system that integrates and provides for two-way communication with the Pharmacy, Laboratory, Registration systems, and that allows for scanning and downloading of health information as needed. The EHR system should have a completely understood interface and provide for [[HIE|interoperability]] with all current and future systems and between clinics and providers.<br />
* CPOE will generally allow for the organization to specify a default dose for a medication order. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* The CPOE team will need to review what happens when non-formulary items are entered. The workflow for non-formulary items will also need to be determined. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* The EHR should have the capabilities to interface with the various labs the hospital or physician uses to order and receive patient lab work automatically.<br />
* Does the EHR have a referral management system so that within large organizations, specialty and primary care departments can easily communication with each other and have similar information on a patient that is using both offices to treat their illness?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
<br />
=== Clinical decision support (CDS) ===<br />
<br />
* [[CDS|Decision Support]] (Drug Interaction, Drug information and other Prescription Supports, Clinical Guidelines [Plans & Protocols] and disease information, Diagnosis and differential diagnosis Support, Risk Assessments, Clinical Checklists, Medical References, etc)<br />
* Formulary Database Support<br />
* Electronic Communication (Provider-Provider & Patient-Provider Direct Communication, Health Data Exchange, Interface to Medical Devices, Notifications, Clinical Documentation such as Nursing Notes)<br />
* Patient Administration (ADT [Admit, Transfer, Discharge], Reservation & Scheduling, Billing, Waiting List Management, Records of Patient Activity, Master Patient Index across the Healthcare Organization)<br />
* Querying & Reporting (Research & Analysis, Statistics [Vital Statistics, National Statistics], External Accountability Reporting)<br />
* Telecare, Telehealth, and Telemedicine functionality. Home Monitoring device input/linking.<br />
* [[PHR|Patient Portal for online personal health record access]]<br />
* Clinical policies and procedures guidelines<br />
* Produce visit summary and complete medical record printout and data export on demand for patient use.<br />
* Electronic Health Record (EHR) systems should be capable of accommodating multiple users working concurrently within the system and within the same patient file or document [2]. EHR systems should also be capable of protecting the integrity of data in the system so that no data loss occurs when multiple users are working concurrently with the same patient file or document [2].<br />
** Provide direct decision support explanation link to [[EBM|evidence based knowledge]] (through such as "infobutton",etc) about needed test information, such as purpose and methods of conducting that test, normal range of that test, clinical indications when abnormal results occurred and suggestions what to do, etc.<br />
** Provide abnormal alerts to providers and/or patients through various ways, such as online display, cell phone text messages, etc if the patients/doctors register for this service.<br />
* The organization will need to strike a balance between displaying so many alerts that it causes clinical care to slow. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
*Does the EHR have an aspect of the CPOE that can manage patient protocols and treatment plans? <ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the software have “Clinical/Business Intelligence” capability based on local clinic medical trends, e.g. if there is above normal upper respiratory infection clinic visits, perhaps a flu season is imminent and may warrant stocking of flu vaccine in the clinic?<br />
<br />
=== Data storage and retrieval ===<br />
* EHR systems should be capable of capturing, storing, indexing, retrieving and displaying externally created documents [2]. Indexing of captured documents should include not only patient identifiers and descriptive information, but also date/time stamps and document type [2].<br />
* EHR systems should be capable of retaining all system data until such data is archived or intentionally purged from the system [2].<br />
* The system should load patient records in a timely manner to not interrupt workflow. <br />
* This system should present chronological data of patients like medicine history, progress of diseases. <br />
* Also, system provides gene information or drug allergies of patients to avoid [[Adverse drug event|ADE]].<br />
* System should be compatible with old system to reduce re-entry time.<br />
* System should update regularly.<br />
* system should be able to have Patient prescription plan eligibility, prescription product formulary and external medication history.<br />
* System should be able to have insurance retrieval capabilities (i.e. insurance firms, sum insured, premium dues, etc.).[11]<br />
* Capability to integrate with other products such as practice management software, billing systems and public health interfaces.<br />
<br />
=== Other Clinical Functionality ===<br />
<br />
* Does the system promote delivery of safe care?<br />
* The system shall require documentation of the audit support functionality in the vendor provided user guides and other support documentation, including how to identify and retrospectively reconstruct all data elements in the audit log including date, time. [1]<br />
* Can the system identify the chronic disease management subgroups?<br />
* Is the EHR scalable to different medical specialties and practice demographics (i.e., Neurology vs. Cardiology, small satellite practice vs. intensive care unit) <br />
* Can the system support future clinical models (i.e., Medical Home)?<br />
* Does the EHR system support accurate, consistent and effective clinical documentation by appropriately balancing data auto-population, structured data entry, and unrestricted physician entry of natural-language narrative?<br />
* Does the EMR have the capability to display data over time graphically, such as growth charts?<br />
* The system shall provide the ability to query for a patient by more than one form of identification<br />
* Can it integrate with external knowledge sources such as links to journal references or other knowledge base systems (such as [http://www.hopkinsguides.com/ John Hopkins Guidelines System]) to provide more academic information and update on particular patient problem?<br />
* Does the EHR store the identity of the user and associate the ID with the additions or changes made to the system?<br />
* Can the EHR system be used to capture clinical trial data? How the clinical trial specific data is managed?<br />
* Does the EHR system have the ability to import and export data (interact) in a standard format to EHR systems from other vendors?<br />
*In outpatient departments, does the EHR have a patient-to-physician email and/or web access abilities for the outpatient department to communicate directly with the patient in case more information is needed or the office needs the patient to take some action?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the vendor’s product provide the key functionality needed to achieve the organization vision?<br />
* Does the EHR provide outcomes data in terms of key metrics (cost savings, medication error reduction, disease management) in line with the vision of the organization?<br />
* How does the system import data from personal health devices?<br />
* Can patient data be directly imported from patient portals or [[PHR|personal health records]]?<br />
* Does the vendor provide an EHR system that can be integrated with and is interoperable with other systems?<br />
* Can the vendor provide an EHR system with standard terminology that is cross platform with other EHR systems?<br />
* Does the vendor provide safe log in for patients and clients?<br />
* Does the EMR could provide appropriate information on screen without cramming too much information?<br />
* If the EMR/EHR system allows users to access through mobile devices (through the web or an app), is the mobile version similar to the computer-based version? Is it user-friendly? Will mobile access require additional training, or will user feel comfortable with it after training on the computer-based version?<br />
<br />
=== Nursing Functionality ===<br />
# Supporting eMAR: supporting real-time electronic medication administration record and bar code medication administration technology [http://www.ncbi.nlm.nih.gov/pubmed/20445181[Link to reference]]<br />
# Supporting bedside automation in medication delivery: Support data interface and real-time monitoring of smart pumps and home infusion pumps [http://www.ncbi.nlm.nih.gov/pubmed/15753744[Link to reference]]<br />
=== Pharmacy operation ===<br />
====Formulary management====<br />
# Data repository for formulary information, maintain real time update of medication information with national drug information database<br />
# Support periodic update of formulary, restricted formulary, and nonformulary medications<br />
# Cross reference patient’s insurance formulary list to allow for generic medications to be selected when e-prescribing.<br />
<br />
====Drug dispense and delivery====<br />
# Support outpatient pharmacy operation functionality: <br />
## Maintain outpatient prescription data<br />
## Management of prescription fill, refill and dispense activities<br />
## Support billing protocols with governmental and private insurance<br />
# Support inpatient pharmacy operation functionality<br />
## Maintain inpatient medication ordering data<br />
## Real-time monitoring of IV and oral medication compounding and delivery<br />
## Support real-time data interface with automatic dispensing cabinet<br />
<br />
== Research Functionality ==<br />
<br />
* Does the vendor bid include the product's ability to be used as a tool for research. If "no", is an add-on solution for research capability needed and will it entail extra cost. <ref name="kannry 2006">Kannry J 2006: 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. http://www.ncbi.nlm.nih.gov/pubmed/16669592</ref><br />
* Does the EMR have informed consent alerts and documentation systems for clinical research?<br />
* If the proposed installation site is a research hospital, what are the research capabilities of the EMR?<br />
* How is research achieved?<br />
* How are reports produced?<br />
* How is data exported from the production system?<br />
* Which database is used for reporting? For research? Vendor or other?<br />
* Does the vendor provide [[Natural language processing (NLP)|natural language processing for entry data]] or document?<br />
* Support for research billing including research orders (6)<br />
* Does the EHR system provide data mining capabilities to support clinical research?<br />
** Are there limits on the fields that researchers can use?<br />
** How difficult is it to interface with the database?<br />
** Does the EMR have smart search abilities to search through physician notes for specific keywords while extracting research data.<br />
** Does the vendor assist in research endeavors, or is it left up to the institution?<br />
* Does the EMR have the flexibility to capture documents necessary for specific clinical trials like adverse events, enrollments, and etc? [9]<br />
* If research involves use of pathological/histological samples, does the EMR system tie into the laboratory management systems and database to allow for retrieval and processing of samples?<br />
* Does the EMR system provide functionality to identify clinical related concepts?<br />
* Does the EMR provide the flexibility to normalize the clinical concepts found in the document?<br />
* Does the EMR provide the assistance to automatically generate the de-identified document for research purpose? <br />
* Does EMR system provide functionality to implement study-screening parameter into patients’ registration, scheduling, medication lists, diagnostic codes (ICD) and clinical notes? <ref name="sixteen"> Integrating Electronic Health Records and Clinical Trials http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf <br />
.</ref><br />
<br />
* Does EMR system provide functionality to contact potential candidates and notify the patient’s providers of potential study eligibility? <ref name="sixteen"></ref><br />
* Does EMR system provide capability to systematically captured study specific data and electronically exports deidentified study data to clinical trial electronic data capture system? <ref name="sixteen"></ref><br />
<br />
=== Meaningful use gap analysis ===<br />
* The ONC’s Regional Extension Centers (RECs), located in every region of the country, serve as a support and resource center to assist providers in EHR implementation and HealthIT needs. As trusted advisors, RECs “bridge the technology gap” by helping providers navigate the EHR adoption process from vendor selection and workflow analysis to implementation and meaningful use. <ref name="regional extension center">Regional Extension Centers (RECs) http://www.healthit.gov/providers-professionals/regional-extension-centers-recs </ref><br />
* Does the system provide relevant reports for data for compliance with meaningful use of the EHR.[11]<br />
* Does the EHR vendor provide any guarantees regarding the ability of a practice to meet meaningful use requirements? (http://www.americanehr.com/Home.aspx)<br />
*Does the vendor support data documentation and capture of future government mandated measures such as Meaningful Use, ACO measures, CMS measures for Patient Quality, population health etc?<br />
* Make sure the vendor's product is able to document the [[meaningful use]] <ref name="factors selecting vendor"></ref><br />
* Is the EMR CCHIT Certified?<br />
* Is there a way for the organization to monitor the usage of EMR components?<br />
* Will the EMR user potentially qualify for the [[ARRA|American Recovery Health and Reinvestment Act]] or [[ARRA|Health Information Technology for Economic & Clinical Health Act]] funding opportunities?<br />
* Be certain that the organization has a way to transfer pertinent data from the current EMR to proposed EMR. Create a plan that is not only financially safe, but also allows the organization enough time for implementation.<br />
* Does the vendor provide training and resources specific to Meaningful Use compliance? <br />
* Does the vendor provide any consulting services to assist with workflow modifications and attestation for Meaningful Use?<br />
* Is the EHR capable and certified to send PQRS (Physician Quality Reporting System) data to CMS to fully meet the requirements of meaningful use?<br />
<br />
******Will the EHR help the hospital to meet the following requirement of Meaningful Use:<br />
1. Use CPOE for medication, laboratory, radiology ordering by licensed professionals<br />
2. Automatically track medications from order to administration using assistive technologies such as bar coding in conjunction with an electronic medication administration record (eMAR)<br />
3. Generate and transmit permissible prescriptions electronically (eRX)<br />
4. Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities.<br />
5. Implement drug-drug, drug-allergy checking. <br />
6. Maintain up-to-date problem/diagnosis list.<br />
7. E-Prescribing<br />
8. Maintain active medication list and medication allergy list<br />
9. Record demographics: Gender, Race, Date of Birth, Ethnicity, Preferred Language<br />
10. Record and chart changes in vital signs: Height, Weight, Blood Pressure, Calculate and Display, BMI, Plot and display growth charts for children 2-20 years, including BMI<br />
<br />
=== Patient quality improvement ===<br />
* Link to patient education materials database or service and the ability to load practice specific documents for patient handouts. Must be able to access and print these from visit encounter interface.<br />
* Does EHR system provide better integration among providers by improved information sharing, viewable and up-to-date medication and allergy lists and order entry at point of care or off-site ?<br />
* Will the EHR system provide standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine ?<br />
* Does EHR system provide access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine ?<br />
* Can EHR system manipulate and provide feedback on population management trended data and treatment and outcome studies for more convenient, faster, and simpler disease management?<br />
* Can the system pull from clinical documentation for billing, quality reporting and patient safety reporting?<br />
* How does the vendor use certified EHR technology in ways that can be measured significantly in quality and in quantity?<br />
* Will the system support utilization review with the Milliman and Interqual clinical criteria for Quality Management and discharge planning.<br />
* Does EMR system provide capability to aggregates data on the impact of specific evidence based/cost effectiveness intervention as compared to current population in management practice?<br />
<br />
=== Public Health research ===<br />
* Does the vendor support the ability to send de-identified bio-surveillance data to population health agencies to support epidemiologic research?<br />
* Does the vendor have the ability to send patient specific public health disease report(s) to a disease registry, as a part of a Public Health Information Network (PHIN)?<br />
* Does the vendor have the ability to report on Quality Improvement, such as infection control measures (i.e., Hospital Acquired Infection rates) or patient safety measures?<br />
* Does the vendor have the ability to report to the State, CDC Registry and external sources<br />
<br />
== IT and Technical Requirements ==<br />
<br />
* For already existing software functionality, does the vendor employ reliable and trustworthy software like an open-source MySQL or Apache server? Or do they develop their own system, or do we have to license a proprietary one (extra cost)?<br />
* How the vendor estimates the total amount of users and licenses needed? Will they be concurrent user licenses or asynchronic?<br />
* Will technical support remain active even if the Hospital is running a non-upgraded system? For how long?<br />
* Does the system use [http://medical.nema.org/ DICOM] standards for the transmission of image data?<br />
* Does the system provide an imaging database or allow customized program attachments of imaging needs of specific departments in the hospital?<br />
* What are the hardware requirements? [1]<br />
* How frequently does the vendor provide patch upgrades for the product?<br />
*Is the system using standards such as Snomed, [http://www.who.int/classifications/icd/en/ ICD 10]; [http://hl7book.net/index.php?title=HL7_version_2 HL7 Version 2] or [http://hl7book.net/index.php?title=HL7_version_3 3]; HL7 infobutton…)<br />
*How does the system handle multiple logins of the same user at different locations/instances?<br />
*How does the system handle user inactivity? (auto-logout, discarding\saving changes, draft creation)<br />
* Is the software capable of using biometric data for rapid login by providers who are mobile between patients/sites?<br />
* How does the system lend itself to automated back-ups? Does the vendor provide IT support team to implement specific back-up plans that will work with the hospital's IT team? <br />
* Can the system allow login remotely – off site transcription or home or other clinic?<br />
* Does the system provide the ability to identify all users who have accessed an individual's chart over a given time period, including date and time of access?<br />
* Does the vendor offer a Software as a Service (SaaS) solution, also know as an Application Service Provider (ASP), or a client-server solution?<br />
* With existing systems, how tightly integrated will the new EHR system be and what prep work is required to make the integration possible?<br />
* Does the system have modules for automatic update of knowledge sets at regular intervals, more like automatic update of antivirus definitions?<br />
* How often does the software need to be upgraded? [1]<br />
* Does the software allow generation of customized reports such that desired information can be extracted periodically for performance improvement projects or performance monitoring.<br />
* Does the vendor utilize the desired technology?<br />
* Is remote access available for mobile devices?<br />
** Is this web-access or a dedicated app?<br />
** In what way is this mobile access limited? Does it have access to all functionality?<br />
** What devices can access the mobile apps? (e.g. iPad, iPhone, Android, etc.)<br />
* Is remote access cross platform? The use of open standards (e.g. HTML5, [[Extensible Markup Language (XML)|XML)]] allows users on any platform, including smartphones and tablets, to have equivocal access to the system.<br />
* Does the system support web-based working environment?<br />
* Does the system provide extension package or software for IT engineers or users? <br />
* Does the system comply with HIMMS standard?<br />
* Can the system be installed on Windows or IOS operating systems?<br />
* How does the system’s IT infrastructure requirement align with the institution’s current infrastructure and the institution’s infrastructure five-year strategic road map?<br />
* What hardware technology (Server) does the database support? And does the supported hardware provide built-in high availability?<br />
* Does the system’s application (not database) support virtual environments? Will it run on a virtual server? <br />
* Is your ticketing system capable of interfacing with [name of ITSM software utilized by your institution]?<br />
* Negotiate the terms and prices of the interface system: to/from PM system, scanner, fax machine, laboratory, health information exchange partners such as hospitals, ambulatory surgical centers, radiology, ePrescribing.<br />
* Can the system be hosted and supported remotely by the vendor? <br />
* How scalable is the IT infrastructure? Is there a peak limit on the number of concurrent users utilizing the system? (this comes in handy during mergers & acquisitions in which you may exponentially increase in size of user base) <br />
* Does the system support dictation function?<br />
* Does the system support speech recognition?<br />
<br />
=== Legacy systems ===<br />
<br />
* How does the vendor compare in [http://www.klasresearch.com/ KLAS] rankings of similar systems and applications?<br />
* How will legacy patient record data be integrated into the new system?<br />
* Does the vendor provide services to convert and transfer data from legacy systems into the new system, and if so, what is the cost?<ref name="himss-ama-legacy">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* How does a legacy Practice Management System integrate with the EHR system? Is there a list of successful PM vendor integrations? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
*Make sure the vendors give accurate information for the Request for Proposal. So the stakeholders can make informed decisions on the comparison of vendors.<br />
-Zoker 9/17/2011<br />
* What is the legacy Practice Management System conversion process for legacy data import into the EHR system? Time/cost and loose-ends? What reference clients are there for particular legacy PM systems? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
* Does the vendor have a List of Lessons Learned from previous implementations?<br />
* Does the vendor have a legal license to essential code sets, such as the [http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page? AMA Current Procedural Terminology] (CPT®) file? Will the vendor maintain this license annually as part of your service or maintenance agreement?[http://www.ama-assn.org American Medical Association]<br />
* How does the vendor manage diagnosis documentation and coding? Does the system require specific coding terminology or does it allow provider synonyms for coding terms? How is that updated and maintained? <br />
* Does the vendor offer a “test environment” in which upgrades are loaded to allow you time to test and learn their functionality without affecting your live system? [http://www.ama-assn.org American Medical Association]<br />
* What is the vendor's rate for on time & under budget implementations?<br />
* Are other consulting firms certified to implent the vendor's product? If so will the vendor provide system updates and customer service if system issues (not related to implementation) arise?<br />
* Check whether the vendors EMR products are [http://www.cchit.org/ CCHIT] certified (http://www.cchit.org/products/cchit)<br />
* What services does the EHR vendor offers for post-implementation optimization of the system with respect to training and system customization? (http://www.americanehr.com/Home.aspx)<br />
* What is the company policy regarding data ownership for the ASP EHR? <br />
* The EHR product should be certified for the standards and certification criteria issued by the Office of the National Coordinator for Health Information Technology (ONC-HIT)? How many criteria does it satisfy?<br />
<br />
=== Troubleshooting ===<br />
<br />
* Immediate trouble shooting ability.<br />
* Regular connect with customers about their problems<br />
* The system shall include documentation that describes the patch (hot-fix) handling process the vendor will use for EHR, operating system and underlying tools (e.g. a specific web site for notification of new patches, an approved patch list, special instructions for installation, and post-installation test).[1]<br />
* The system shall include documented procedures for product installation, start-up and/or connection.[1]<br />
* What options does the EMR have for upfront abstraction and scanning? Are these costs included in the purchase of the EMR?<br />
* Can the vendor support the organization desired implementation strategy?<br />
* How can the EHR technology be useful for electronic exchange of clinical health information among providers and patient authorized entities? (http://en.wikipedia.org/wiki/Electronic_health_record#Quality)<br />
* Is implementation of the new EHR system going to be in stages or at once based on the size and complexity of the purchasing institution?<br />
<br />
=== EHR Disaster Recovery ===<br />
<br />
Either internal hardware problems or external sources (especially in EHR systems that store data in the cloud) may cause unexpected EHR system failures. The EHR may be unavailable for a few hours or for a week or more. Disaster recovery must always be considered when selecting a vendor to ensure that data is secure in these emergency situations. Questions to consider include:<br />
<br />
* Does the EHR use internal hosting or an ASP model? <ref name="himssdisaster">EHR and Disaster Recovery. http://www.himss.org/News/NewsDetail.aspx?ItemNumber=6469</ref><br />
* Is the EHR system adherent to the HIPAA Security Rule and provides both a contingency plan and secure data back-up reserves in case of system failure? <br />
* Has the EHR provided users with a detailed disaster plan during implementation of the EHR that includes how to cope with unexpected system failure?<br />
* Has the EHR provided training packets and educational materials for end users to study to prepare for unscheduled downtime of the EHR?<br />
* Will the EHR notify users immediately when system failure occurs and provide information about the breadth of the failure and the time anticipated before the EHR will be restored?<br />
<br />
**** Some of the criteria I will like to see in an EHR system in the event that it crashes or during downtime*****<br />
1. What backup system does it have in place during such an event so that patient care continues without reverting to a paper system? <br />
2. How is data updated into the system when it is back up and running again?<br />
3. Where is the data stored so that in the event of a catastrophic crash historical data is not lost?<br />
<br />
=== Health information exchange, connectivity, and standards ===<br />
<br />
* Does it meet the following connectivity standards: [[HL7]], HL7 CDA, CCR, HL7 CCD, ELINCS and Vendor software specifications? <ref name="whitepaper emr connectivity">What is Your EHR Connectivity Strategy? http://www.corepointhealth.com/sites/default/files/whitepapers/emr-connectivity-strategy-healthcare-interoperability.pdf </ref><br />
* How flexible is there connection framework? Can it negotiate multiple standards?<br />
* How quickly can you build and implement an interface within the interface engine?<br />
<br />
== Implementation ==<br />
<br />
* Implementation Project Manager – A project manager is necessary to bring vendor experience and guidance to the implementation process and should hand off the implementation to your internal team within 12 to 15 months.<br />
* Will the vendor be readily available to conduct training for all shift and service line?<br />
* Service Agreement - A service agreement identifies what the EMR vendor will do to maintain the software, including software maintenance, technical support, and upgrades. <br />
* IT Support Agreement - Hardware installations are your responsibility, not the EHR vendor. However, if you do not have onsite IT support, request an estimate for the following: <br />
** Installation charges for electrical requirements, cable and phone connections for the system<br />
** Monthly fees to provide access to patient data on a remote server<br />
** Networking design and administration charges related to the set-up and service of client's network<br />
** Hardware onsite installation and maintenance<br />
** Third-party software maintenance for products not provided by the vendor<br />
** Correcting errors that result from changes you or a third-party made to the software. This applies primarily to client-server agreements<br />
** Backup capabilities. This applies primarily to client-server agreements.<br />
* Terms and Conditions - Irrespective of the contract length, ask about penalties for withdrawing your data. Any vendor interested in preserving its reputation will provide you with data in a common format able to be transitioned to another system, but there is a withdrawal fee. [13]<br />
<br />
=== Configuration ===<br />
* Does the vendor factor the number of users as part of their implementation cost? <br />
* Does the vendor provide their own hardware or use a third-party company for their hardware needs? Based on the practice size and niche, is a well-established vendor with all software and hardware in-house preferable?<br />
* If you have an existing system, what kind of difficulties will the vendor encounter? Will it be possible to transfer existing data to the new system? <br />
*In calculating the Total Cost of Ownership (TCO), the break out costs should include who pays for the additional costs due to delays in implementation, especially those due to the Vendor. In fairness, the Vendor's rate for successful, on-time and under-budget implementation should be discussed as well.<br />
•Does the TCO include lifecycle costs that include milestone payment scheduling to back up promises made by EHR implementation? [8]<br />
* Does the system minimize or ease the data input, so that doctors spend more time with their patient?<br />
* Does the vendor qualify under the organization acquisition policies?<br />
* How will current policies and procedures change once implementation takes place?<br />
* Is there a dedicated support team?<br />
* If implementation of the system fails, what steps is the EHR willing to take to make it successful?<br />
* Will the license cost for updated versions of the EHR be borne solely by the purchasing institution or will there be cost sharing between the institution and the vendor for updates?<br />
* How often the possibility of system break out?<br />
* Does the fee include pre-training and post-training?<br />
* How long and including of the warranty of infrastructure and system? Do we pay for accident damage for system or hardware?<br />
* What system configurations are available? How does the vendor involve the client in the configuration of the system?<br />
<br />
=== Training of users ===<br />
* How many hours of initial training is provided for administrators? For users?<br />
* When is the initial training provided, during or after implementation?<br />
* How large a virtual environment will be required to provide training for staff, and how much time should be allocated. <br />
* What are the time requirements to train the trainers?<br />
* Is the initial training included in the costs of the tool?<br />
* If additional training is required post-implementation, how is it priced – lump sum or hourly rate?<br />
* How many hours of post-implementation support is included?* Will the vendor provide technical training to the IT Department of the purchasing institution to handle minor non-critical hardware problems?<br />
* How long is the training that is required for each subgroup to fully implement the system?<br />
* What are the training requirements for the vendor? For the clinic/hospital?<br />
* What is the vendor's track record for successfully training a new system for your clinic/hospital size?<br />
* What training manuals, user guides, on-line training assets, and any other training materials will be made available to the clinic/hospital?<br />
* What training mechanisms are used by the EHR Vendor? (http://www.americanehr.com/Home.aspx) <br />
* Does the vendor provides training instructors at beginning?<br />
* Are the training staff familiar with both the technical aspects of the product and the clinical needs of the department of interest? (i.e. subject matter specialist, clinical informatic specialist)<br />
* Does the vendor has well-organized and reliable training courses?<br />
* Training Contract - Training should be included in the licensing and service agreement, but some vendors provide separate online and onsite training contracts.<br />
* Does the EHR vendor provide a test version of EHR product for training and quality assurance (QA) purposes as well as the full production environment that is installed in the clinic? (The test version is a segmented area where users can make changes to templates or forms without it affecting the live environment) (http://www.americanehr.com/Home.aspx)<br />
* Are training materials provided by the vendor or is the organization responsible for producing in-house? If the training material will be developed in-house, does the vendor stipulate specific training requirements (i.e. classroom-based vs. web-based, mandatory competency examinations)?<br />
* What kind of on-going training and support will be provided after implementation? Is the cost of post-implementation training and support clearly specified?<br />
* If there are major updates to the system, will the vendor provide ample support and training for the users? And how much will this additional training cost?<br />
* Does the EHR/EMR vendor offer the option to have their staff available to be present at the hospital/clinic/facility during training and then "go-live" implementation? This would allow the EHR/EMR staff to offer hands-on support for any obstacles that come up during training and "go live" implementation. <br />
<br />
<br />
<br />
'''* Spell out pricing before selecting and Electronic Medical Record (EMR/Electronic Health Record (EHR) system such as hardware, software, maintenance, upgrade costs, lab and pharmacies interfaces, customized quality reports, expenditure to connect to health information exchange (HIE)Bold text'''== Future relationships: vendor partnership ==<br />
<br />
* Talk to vendor's existing customers, making sure to also contact some vendor customers independently, as the vendors tend to only provide contacts to their most satisfied customers.<br />
*Research available EMR systems and vendors: determine if your jurisdiction has a "pre-approved" vendor list; develop checklists & questionnaires to assist with product comparison; and prepare a Request for Proposals (RFP). <br />
*An important consideration is whether the vendor or any of its industry partners have done an analysis of processes in healthcare<br />
*Ensure there will be well-laid out contractual agreement regards the 'source code' that will satisfy/cover necessary conditions: "When does the company get the 'source code?, How does the company get the source code?"<br />
*If there are workflow changes within the organization, after the product is implemented, is the product flexible enough to allow for changes without major outages or disruptions to daily activity?<br />
*What are the vendors’ contingency plans if technical glitches occur, post implementation?<br />
*Is technical support offered by the vendor 24 hours per day/ 7 days a week?<br />
*In the event of need for support from the vendor, what is the approximate response time to calls that vendor the projects?<br />
* What is the cost of providing this technical support per hour?<br />
* What size, in terms of employees, is the EHR vendor? Do they have the staff to fully address the support needs of their current client base and, can they accommodate the added support load of your institution?<br />
*In terms of clinical decision support, how often are drug list and drug interaction list updated? Once updated, how long will it take for the changes to be accessible by the end users?<br />
* When code sets and medical vocabularies, ontologies, etc. are updated, how long after will the tool be updated?<br />
*In "EMR Vendor Selection" on Health Technology Review.com (http://www.healthtechnologyreview.com/emr-vendor-selection.php) it states an old adage in the Software industry that consumers will buy a product based on features, but will leave the vendor based on a lack of support. Therefore, it is important to check references for the vendor related to post-implementation technical support satisfaction.<br />
* Aside from providing source code in the event the company undergoes changes, how and when can the organization acquire the "raw" data?<br />
* Will the source code be placed in escrow so that the system could be maintained and modified by internal IT staff in the event that the vendor ceases operation.<br />
* Does the vendor have local support personnel or will all issues be handled by a distant team?<br />
* What is an average time for installing and testing upgrades to the system? If an upgrade is missed or skipped, does the subsequent upgrade(s) have all prior changes included or just the current fix or feature for that version?<br />
* Is there going to be a vendor-institution confidentiality agreement or can the vendor share institutional information and dealings with other establishments?<br />
<br />
'''* Does the vendor's produce meet our needs and goals for our practice? Carryout a test drive of our specific needs with the vendor's product and provide the vendor with patient and office scenarios or mock trial that they may use to customize their produce demonstration.Bold text'''=== Upgrades ===<br />
<br />
* Does the vendor share the organization's '''vision''' for the EHR?<br />
* Does the product provided by the vendor has all the '''key functions''' needed to fulfill the vision of the organization?<br />
* Is the vendor utilizing the desired technology?<br />
* Compare retail broker workstation alternatives, including proprietary and third party packages, based on user requirements and technology/operational considerations. Project included EMR development and response evaluation<br />
* Does the vendor plan to offer interoperability options in the event of a nationally implemented CIS?<br />
* Upon the termination of a license or agreement, is there an orderly process for you to extract your data? This is applicable if you access the vendor’s software within an application service provider (ASP) model.[http://www.ama-assn.org American Medical Association]<br />
* Ability to have HIE compatibility<br />
* Improved billing accuracy and charge capture<br />
* Electronic replacement for traditional reportable disease notifications to health departments, may become part of biosurveillance in the future.[1]<br />
* Is it possible to virtualize or [http://en.wikipedia.org/wiki/Sandbox_(software_development) sandbox] the system to test updates? This functionality would allow site specific testing of new features and systems with less risk of corruption of the current system. It would also allow testing of new features functionality and allow easy rollback if features end up being unwanted.<br />
* Does the system allow outreach/growth to affiliates as a "subset" of the existing clinical provider group? Does that outreach include full or limited functionality? How does that data interface with the existing clinical record?<br />
*How does the system scale? Is the vendor able to provide support and functionality as a practice grows or can they provide functionality to a small, regional branch?<br />
* Provision of EHR systems that support the capture of public health data from Clinical Information Systems.<br />
* Does the system can combine with EHR in long term health care area as a reminder of senior people?<br />
* Ensure that your vendor will be around when you need help. While specific vendor qualifications vary, generally information to be considered in the vendor vetting process, besides functional and technical details, includes vendor reputation, staff experience and qualifications, and financial solvency. (Chao, C., & Goldbort, J. (2012). Lessons Learned from Implementation of a Perinatal Documentation System. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), 599-608. doi:10.1111/j.1552-6909.2012.01378.x)<br />
*Does the vendor allow discrete data capture and easy reporting of critical data that needs to be submitted for reimbursement by the national and state policies on healthcare?<br />
*Is the vendor at the forefront of research in healthcare and does the software offer clinical dashboards and predictive models for easy tracking and analysis of patient data and efficient decision making by clinicians.<br />
*Does the vendor require hiring of outside consultants for training?<br />
<br />
== Contracts ==<br />
<br />
Contracts are as much a business tool as they are a purchasing agreement. <ref name="ehr contract">Carolyn Hartley - signing an EHR contract http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
<br />
* Project Payments<br />
* Contract Terms [http://calhipso.org/documents/ehr_contracting_terms_final_508_compliant.pdf]<br />
* All costs, current and future, associated with the implementation<br />
Details of the total cost incurred by the institution also called total cost of ownership (TCO) is an important consideration in the selection process. It helps to predict the longevity of the program. The request for proposal to vendors should include a request for information about vendor license and implementation costs. Vendors should deliniate the assumptions made when preparing the TCO so the decision committee is able to verify that they are parallel to the goals and objectives of the insitutions. If the same assumptions are encorporated in all request for proposals one can better compare the applications.(8)<br />
Institutions must also consider the intangible return on their investments such as reduced adverse events, decreased hospital stay, accurate and timely billing and improved management of supplies. <br />
* Time commitment from vendor with regard to implementation and training<br />
* Penalties for delays in implementation<br />
* Code escrow - be sure code will be available if vendor goes out of business<br />
* Indemnification and hold harmless clauses <br />
* Confidentiality and nondisclosure agreements <br />
* Warranties and disclaimers <br />
* Limits on liability <br />
* Dispute resolution <br />
* Termination and wind down<br />
* Intellectual property disputes <br />
* IT support agreement<br />
* Training Contract<br />
* Applied area contract<br />
* User and vender liability<br />
* Disputation judgment <br />
* Attorney of vender and clients<br />
* User License - The person who has access to data using a user ID and password. Pricing structures vary according to the definition of user.<br />
* Consider variation of user licenses according to the needs: one price per MD, tiered price (MD, nurse or administrator), site license (25+ providers in the same facility), and enterprise license (multiple users in multiple departments). <ref name="user license">Signing an EHR contract. Tips to control costs. http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
* Interface - The EHR vendor's contract includes the cost of interfaces. These include interfaces such as those with your scanner or fax machine; and more complex interfaces such <br />
* Hardware Contract - Review the EHR vendor's hardware quote, but research may lower costs. Check the vendor's website for hardware specifications the vendor supports. Hardware includes servers, high-speed scanners, computers, handhelds, computer on wheels (COW), wall mounts, etc. Hardware installation to a wholesaler means assembling the server and software to make it work at their location prior to delivering it to you. It usually does NOT mean the installation at your location, a difference that will create a significant budget surprise. Clarify the term "installation" with any hardware wholesaler before making the purchase.<br />
* Third Party Software Contracts – Software includes encryption, speech-recognition, password management, Microsoft™ suite, anti-virus, golden image, bar-coding or webcams.<br />
* Business Associate Agreement - To be HIPAA-compliant you will need a business associate agreement with the vendor, and must ensure the vendor meets HIPAA security and privacy requirements.<ref name="HIMSS-AMA-BAA">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Check Vendor References ===<br />
<br />
*Each vendor being considered should provide minimal of three (3) references, to include a) physician users, b) IT person, and c) senior manager of the facility or practice.<br />
* Vendor provided references may be considered 'happy customers' with biased viewpoints.<br />
* Ask supplied list of references how they acquired the EHR system, eg did they purchase the system or was it provided by the vendor?<br />
* Ask each reference to rate the vendor on a scale from 1 (very dissatisfied/strongly disagree) to 5 (very satisfied/strongly agree) for each criterion<br />
* Each vendor reference should provide reference on background information such as version of system currently being used, duration using current system, length of implementation, number of interfaces practice currently installed and estimated time to install, training provided on-site or remote.<br />
* Each vendor reference should provide reference on current system overview such as system reliability, satisfaction with vendor, and overall satisfaction with system.<br />
* Research references the vendor did not mention, visit facility to get an unbiased viewpoint<br />
* Must use list serves, internet searches and networking to identify other users to interview to get more objective viewpoint.<br />
* All interviewers should utilize the same questionnaire approved by the project manager or steering team.<br />
* Notes must be recorded by each interviewer for each customer interviewed.<br />
* These notes should be made part of the overall evaluation process, ideally kept by the project manager [7].<br />
* Is the vendor currently involved in or have a history of any litigation with customers?<ref name="himss-ama-litigation">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Transparency ===<br />
<br />
EHR vendors may enter contracts with confidentiality or non-disclosure terms that can prevent transparency. Examples include:<br />
<br />
* Disclosures required by law or regulation, sometimes with an obligation to give the other party advance notice and the opportunity to oppose the disclosure or seek confidential treatment.<br />
<br />
*Disclosure of information that has been independently developed by the disclosing party<br />
<br />
*Disclosure of information that is available to the general public or has been provided separately to the disclosing party without violation of an agreement. <br />
<br />
The definition of confidential information may be broad and could restrict your ability to share access to the EHR technology developer’s software in order to compare different EHR technology developer systems, provide access to researchers, or even address possible patient safety concerns. You should review the confidentiality and non-disclosure language carefully to make certain it does not inhibit your ability to conduct activities you value. <ref name="westatterms">EHR Contracts: Key Contract Terms for Users to Understand. http://www.healthit.gov/sites/default/files/ehr_contracting_terms_final_508_compliant.pdf </ref><br />
<br />
== Misc considerations ==<br />
<br />
* It is not uncommon for developers or implementers to impose lock-in features in order to protect their IP rights. How mature is the support community for the particular vendor and is there a marketplace for support and services to their product or is support limited to their own team?<br />
* A multidisciplinary team, usually a subset of the decision team consisting of a physician, IT personnel and a senior management must conduct a site visit to one of the vendor customer sites and vendor headquarters. Informal discussions at this level were quite informative as they bridged the gap between theory and practice for actual software implementation and usage.<br />
* An unstructured “drive-by” demonstration of the system must be arranged for, wherein the vendors conduct product demos, demonstrate product futures and distribute promotional materials for a majority of the employees to get the feel of the new systems. It facilitates building a comfort level and relationship with the vendor and the product offered.<br />
* Can the company demonstrate tangible ways that use of the product can increase hospital revenue? If yes, can you validate this/these claims?<br />
* Is the vendor willing to contract to go "at risk" for any part(s) of the contract?<br />
* What other services does the company offer (especially useful for rural or small hospitals or practices)? e.g. consultants to do special projects, data transmission/claims, billing<br />
*Can the record be accessed at home by clinicians and patients, or do they have to be on-site at the facility?<br />
* Is the vendor capable of adapting to emerging technology such as open source programming, cloud computing, "tablet" PCs/Macs, demand for smartphones (e.g. iPhone), and Web 2.0 technology?<br />
* Is the vendor capable of integrating its system with a personal health record and allowing more patient control?<br />
* Can the company provide return on investment analysis?<br />
* Vendors may not be chosen if the current managers have been convicted of or have had a civil judgment for the following: fraud, antitrust violations, embezzlement, theft, etc.<br />
* Reduced pharmaceutical costs derived from having information available at the time it is needed<br />
* How can this EHR be an asset for the solo practitioner who sees this technology primarily as a financial drain?<br />
* How much extra financial cost will it be to train outpatient clinics that are a subset of the system?<br />
* Does the vender return loss money if their system can not complete established goal in scheduled time?<br />
* Can the company provide a multi-background consult team from doctors, nurses, IT engineer, to attorney?<br />
* Does the vendor qualify the organization's acquisition policies? Is the vendor '''CCHIT certified'''?<br />
* Certification can be verified at the Certified Health IT Product List (CHPL) <ref name="onc ehrcert">Certified Health IT Product List (CHPL) list of EMRs. http://oncchpl.force.com/ehrcert </ref><br />
* Is the vendor active in national EMR leadership task forces, such as the Electronic Health Records Vendors Association <ref name="HIMSSEHRA">HIMSS Electronic Health Record Association http://www.himssehra.org/ASP/index.asp </ref><br />
* Will the vendor be supporting the organization's desired implementation strategy?<br />
* Check the track record of vendor for operations and maintenance support?<br />
* Will the vendor sell or monetize of our clinical data for research or any other purposes? <br />
* Is Application Support provided by on-shore resources? <br />
* Clarify the roles, responsibilities and costs for data migration if desired. <ref name="factors selecting vendor"></ref><br />
* Does the Vendor demonstrate financial and management stability?<br />
* Does the vendor have experience with implementing the product in a similar type of organizations? How many?<br />
* Conduct a site visit <ref name="factors selecting vendor">What factors should I consider when selecting a vendor? http://www.healthit.gov/providers-professionals/faqs/what-factors-should-i-consider-when-selecting-vendor </ref><br />
* Ensure that the site is similar to you - similar number of beds, acuity, rural/urban setting<br />
*'''Flexibility that allows for significant changes in product or order lines'''. Thus, this enables for businesses to modify orders, if necessary, without having to face a penalty from the vendor. Not always do things go as planned and if any modifications are needed, there should not be any consequences that inhibit this from occurring. <br />
* '''The ability to provide all the products/services required and/or the complete solution.''' This in turn can provide the whole picture in allowing for the consumer more transparency in terms of being able to distinguish between the products/services that a particular vendor is offering. As a result, this can save time and money in terms of a consumer being able to choose a certain business that can provide everything that is needed instead of wasting time and effort in purchasing products/services from individual vendors that have a small selection available.<br />
* '''The ability to have a consistent supply of products or services readily available for the business to purchase at all times.''' There is always a need for products and services to be provided on a regular basis; thus a business does not want to have a vendor that has supply issues. If a vendor is not reliable, then it can affect the business’s ability to in turn supply and provide for its customers, which can have a dramatic effect on the reputation and finances of the business.<br />
* Does vendor volunteering disclose adverse events or near misses data involving vendor’s EMR system to potential buyers? Are there protocol designed to notify federally designated patient safety organizations of IT related adverse events or near misses? <ref name="seventeen"> Better Patient Safety is Goal of Confidential EHR Error Reports http://www.amednews.com/article/20130724/profession/130729986/8/ .</ref><br />
<br />
== EHR Evaluation Resources ==<br />
<br />
* American Academy of Family Physicians [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrvendorrating.Par.0001.File.tmp/ehrvendorrating.pdf Vendor Rating Tool]<br />
* American Academy Of Family Physicians HR Demonstration Rating Form EHR Demonstration Rating Form [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrdemorateform.Par.0001.File.tmp/ehrdemorating.pdf<br />
* American Academy of Family Physicians vendor's references verification form [http://www.aafp.org/fpm/2005/0200/p55.html#fpm20050200p55-bt4]<br />
* American College of Physicians [http://www.acponline.org/acp_press/electronic_health_records/checklist.pdf EHR Feature Checklist]<br />
* Bureau of Primary Health Care. BPHC Electronic Medical Record Resources page. [http://bphc.hrsa.gov/chc/CHCInitiatives/emr.htm]<br />
* Doctor's Office Quality - Information Technology [http://www.healthinsight.org/Internal/REC_Event_Resources/MU_Boot_Camp_Materials_Resources/Guidelines%20for%20Evaluating%20Systems.pdf Guidelines for Evaluating EHR Vendors]<br />
* www.purchasing-procurement-center.com/selecting-a-vendor.html<br />
* The National Learning Consortium Vendor Evaluation Matrix Tool. <ref name="NLCmatrix">The National Learning Consortium Vendor Evaluation Matrix Tool. http://www.healthit.gov/providers-professionals/implementation-resources/vendor-evaluation-matrix-tool</ref><br />
<br />
<br />
*California Health Care Foundation, EMR Evaluation Tool and User Guide - A Guide for Small Physician Practices: [http://www.chcf.org/publications/2003/10/emr-evaluation-tool-and-user-guide]<br />
*American Medical Association - 15 questions to ask before signing an EMR/EHR agreement<ref name"AMA-HIMSS-15Questions">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
'''Select/upgrade to a certified electronic health record vendor<br />
Retrieved from http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr<br />
text'''==References (old, to edit) ==<br />
<br />
# RI Regional Extension Center. 2011. Vendor members and applicants. Retrieved from http://www.docehrtalk.org/selecting-ehr/for-vendors<br />
# The Certification Commission for Healthcare Information Technology (CCHIT). CCHIT Certified 2011 Ambulatory EHR Certification Criteria. May 17, 2011. Available at: https://www.cchit.org/documents/18/158304/CCHIT+Certified+2011+Ambulatory+EHR+Criteria.pdf.<br />
#http://mhcc.dhmh.maryland.gov/hit/ehr/Documents/sp.mhcc.maryland.gov/ehr/cmsdemo/februarycmsehrdemonstrationarticle.pdf<br />
#McDowell SW, Wahl R, Michelson J. Herding Cats: The Challenges of EMR Vendor Selection. Journal of Healthcare Information Management. 2003; 17(3):17.<br />
# Weber, M. (January 2008). "Selecting an EHR, Now What????" wwww.healthconsultingstrategies.com<br />
# Eastaugh, S. R. (2013). Electronic Health Records Lifecycle Cost. J Health Care Finance, 39(4), 36-43.<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361387/<br />
# Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23(42), 1-4.<br />
# Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24<br />
# Hoyt, R. (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals. Informatics Education<br />
<br />
== References ==<br />
<references/></div>Adlaihttp://clinfowiki.org/wiki/index.php/Vendor_Selection_CriteriaVendor Selection Criteria2014-09-17T22:32:16Z<p>Adlai: /* CPOE */</p>
<hr />
<div>Choosing an [[EMR|electronic medical record (EMR)]] vendor is an important task, with many aspects to consider. An EMR can completely redesign a hospital's practice, but can also optimize it in ways a [[Removing Paper|paper-based system]] could not. With over 400 EMR vendors in the market, selecting the best option could be overwhelming. After clearly defining the needs of the company, the next step is to evaluate which vendors more closely match your list of priorities.<ref name="Selecting a vendor">Selecting the right EMR vendor. http://www.himss.org/files/HIMSSorg/content/files/selectingemr_flyer2.pdf </ref><br />
Here is a list of some of the important considerations when choosing, installing, implementing and upgrading an EMR system. <ref name="factors selecting vendor"></ref><br />
<br />
== Core Clinical Features ==<br />
<br />
In 2003, the DHHS asked the IOM to provide guidance on the basic functionalities of electronic health records systems. The committee concluded that the core functionalities should address the following areas:<br />
* Improvement of patient safety<br />
* Support delivery of effective patient care<br />
* Facilitate management of chronic conditions<br />
* Improve efficiency<br />
* Feasibility of implementation and <br />
* Integration of hospital services<br />
In the Journal of Healthcare Information Management Kranny et. al discussed the importance of an application in the EHR which will promote continuity of care. During the selection of a vendor it is imperative for the decision committee to find out if there is an integration of inpatient, clinical and outpatient interface systems. (8) The patient's progress in house and discharge summary should be accessible by his primary care provider upon discharge. Medications that were discontinued during hospitalization should be updated in the patient's outpatient medication profile so worng medications are not refilled by the patient. IN addition, when new medications are added to the patient medication regimen it should be accessible by the primary care provider and outpatient pharmacist.<br />
<br />
Based on these areas, the IOM committee identified eight categories of core functionalities, including: <ref name="johnson 2006">Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g</ref><br />
* Health information and data<br />
* Results management<br />
* [[CPOE|Order entry/management]]<br />
* [[CDS|Decision support]]<br />
* Electronic communication and connectivity<br />
* Patient support; administrative processes<br />
* Reporting and population health management<br />
<br />
== Analyzing Business(EHR) requirements ==<br />
* Assemble an Evaluation Team<br />
The Evaluation team or decision Team should consist of clinicl healthcare professionals including house staff, tech support professionals, administrators, and financers from all areas of the institution. Each person brings to the table a differnt perspective of usage from their daily job responsibilites. Insitution-wide involvement creates awareness and knowledge of EMRs and their benefits. AS well as, an understanding of the upcoming modifications in work flows. <br />
* Define the Product, Material or Service<br />
* Define the Technical and Business Requirements<br />
* Define the Vendor Requirements<br />
* Publish a Requirements Document for Approval<br />
<br />
=== EMR software ===<br />
<br />
* Health Information & Data Management (Demographics, Problem list [CC, Conditions, Acute/Chronic, Worsening/Resolving, Injuries, Present Illness] with [[ICD|ICD-9 or ICD-10 numbering]], Procedures, Diagnoses, Medications, Allergies, Family medical history, Consultations, Signs & Symptoms and Vitals, Progress Notes and Discharge Summaries, Appointments/Admissions/Visits, Advance Directives, Clinical Reminders [Immunizations, Screenings, Risks])<br />
** EHR that allows for the creation and maintenance of patient specific problem lists that are dated and organized by diagnosis, problem, and problem type and associates encounters, orders, medications and notes to one or more problems. Once a problem is resolved, the EHR provides an automated algorithm that closes that problem.<br />
* Is the Software configuration flexible to customize for future needs.<br />
* Result Management (lab, imaging, other diagnostic measurements, pictures, multimedia)<br />
** Review and search results easily by sorting test types, test time, test administers, test results and so on<br />
** Choose one or several test types, such as HGB, and/or WBC, and/or blood sugar and chart on their results for showing trends.<br />
* The proposed EMR software should bring minimal to no new limitations to the institution. Selectors must be certain that the EMR system meets all required operational tasks.<br />
* How much customization to the EMR can the vendor offer to meet the institution’s needs? Will there be a surplus of unusable or insufficient components to the EMR?<br />
* Ensure that the EMR software is tested prior to finalizing the vendor contract.<br />
* Proposed EHR should allow for expandability to mobile devices, mobile medical applications and upcoming mobile technology.<br />
* Does the EHR have integrated practice management to avoid having to interface with a 3rd part practice management system?<ref name"himss-ama-pms">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* Does the software provide a tool for workflow mapping/charting? <br />
* Can the software be easily configured/adapted to changing workflows?<br />
* Does the EHR/EMR system allow multiple terminals (physician, nurses' station, X-ray, labs, etc.) to log in to the same patient's record simultaneously? Certain systems only allow one terminal to access a patient record at a time - they must log out before any other terminal can access patient EHR/EMR. (For example, if a nurse forgets to log out at their station, the lab cannot access that patient's record.)<br />
<br />
=== Privacy and Security ===<br />
<br />
* Does the system provide roadmaps for adherence to organizational policies (such as HIPAA)?<br />
* The system shall allow an authorized administrator to enable or disable auditing for events or groups of related events to properly collect evidence of compliance with implementation-specific policies. Note: In response to a [[Health Insurance Portability and Accountability Act (HIPAA)|HIPAA-mandated risk analysis]] and management, there will be a variety of implementation- specific organizational policies and operational limits.[1]<br />
* Internet Connectivity and Redundancy Contract - There are three main types of connections for clinical data connections: business class digital subscriber line (DSL), business class cable, and T1 connection. Redundant back up systems and procedures to ensure your data will be backed up in multiple locations and securely stored off-site. <br />
* Will the system allow staff administrators to create and manage users and [[Data security|user security profiles]]?<br />
* The system restore functionality shall result in a fully operational and secure state. This state shall include the restoration of the application data, [[Security|security credentials]], and log/audit files to their previous state. [1]<br />
* If the system includes hardware, the system shall include documentation that covers the expected physical environment necessary for proper secure and reliable operation of the system including: electrical, HVAC, sterilization, and work area.<br />
* How well does the EMR work with antivirus, antispyware and other security software?<br />
* What is the vendor’s history with cyber attacks? <ref name="mit cybersecurity">MIT Geospactial Data Center: Protecting EMR Data (1 of 2) http://cybersecurity.mit.edu/2012/11/protecting-emr-data-1-of-2/</ref><br />
* Does the system allow for off-site access to files/data and how does the technology protect against external breech or diversion of patient information?<br />
<br />
=== CPOE ===<br />
<br />
* [[CPOE| Computerized Physician Order Entry (CPOE)]], [[Electronic prescribing| e-Prescribing]]<br />
* Computerized Physician Order Entry system that integrates and provides for two-way communication with the Pharmacy, Laboratory, Registration systems, and that allows for scanning and downloading of health information as needed. The EHR system should have a completely understood interface and provide for [[HIE|interoperability]] with all current and future systems and between clinics and providers.<br />
* CPOE will generally allow for the organization to specify a default dose for a medication order. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* The CPOE team will need to review what happens when non-formulary items are entered. The workflow for non-formulary items will also need to be determined. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* The EHR should have the capabilities to interface with the various labs the hospital or physician uses to order and receive patient lab work automatically.<br />
* Does the EHR have a referral management system so that within large organizations, specialty and primary care departments can easily communication with each other and have similar information on a patient that is using both offices to treat their illness?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
<br />
=== Clinical decision support (CDS) ===<br />
<br />
* [[CDS|Decision Support]] (Drug Interaction, Drug information and other Prescription Supports, Clinical Guidelines [Plans & Protocols] and disease information, Diagnosis and differential diagnosis Support, Risk Assessments, Clinical Checklists, Medical References, etc)<br />
* Formulary Database Support<br />
* Electronic Communication (Provider-Provider & Patient-Provider Direct Communication, Health Data Exchange, Interface to Medical Devices, Notifications, Clinical Documentation such as Nursing Notes)<br />
* Patient Administration (ADT [Admit, Transfer, Discharge], Reservation & Scheduling, Billing, Waiting List Management, Records of Patient Activity, Master Patient Index across the Healthcare Organization)<br />
* Querying & Reporting (Research & Analysis, Statistics [Vital Statistics, National Statistics], External Accountability Reporting)<br />
* Telecare, Telehealth, and Telemedicine functionality. Home Monitoring device input/linking.<br />
* [[PHR|Patient Portal for online personal health record access]]<br />
* Clinical policies and procedures guidelines<br />
* Produce visit summary and complete medical record printout and data export on demand for patient use.<br />
* Electronic Health Record (EHR) systems should be capable of accommodating multiple users working concurrently within the system and within the same patient file or document [2]. EHR systems should also be capable of protecting the integrity of data in the system so that no data loss occurs when multiple users are working concurrently with the same patient file or document [2].<br />
** Provide direct decision support explanation link to [[EBM|evidence based knowledge]] (through such as "infobutton",etc) about needed test information, such as purpose and methods of conducting that test, normal range of that test, clinical indications when abnormal results occurred and suggestions what to do, etc.<br />
** Provide abnormal alerts to providers and/or patients through various ways, such as online display, cell phone text messages, etc if the patients/doctors register for this service.<br />
* The organization will need to strike a balance between displaying so many alerts that it causes clinical care to slow. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
*Does the EHR have an aspect of the CPOE that can manage patient protocols and treatment plans? <ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the software have “Clinical/Business Intelligence” capability based on local clinic medical trends, e.g. if there is above normal upper respiratory infection clinic visits, perhaps a flu season is imminent and may warrant stocking of flu vaccine in the clinic?<br />
<br />
=== Data storage and retrieval ===<br />
* EHR systems should be capable of capturing, storing, indexing, retrieving and displaying externally created documents [2]. Indexing of captured documents should include not only patient identifiers and descriptive information, but also date/time stamps and document type [2].<br />
* EHR systems should be capable of retaining all system data until such data is archived or intentionally purged from the system [2].<br />
* The system should load patient records in a timely manner to not interrupt workflow. <br />
* This system should present chronological data of patients like medicine history, progress of diseases. <br />
* Also, system provides gene information or drug allergies of patients to avoid [[Adverse drug event|ADE]].<br />
* System should be compatible with old system to reduce re-entry time.<br />
* System should update regularly.<br />
* system should be able to have Patient prescription plan eligibility, prescription product formulary and external medication history.<br />
* System should be able to have insurance retrieval capabilities (i.e. insurance firms, sum insured, premium dues, etc.).[11]<br />
* Capability to integrate with other products such as practice management software, billing systems and public health interfaces.<br />
<br />
=== Other Clinical Functionality ===<br />
<br />
* Does the system promote delivery of safe care?<br />
* The system shall require documentation of the audit support functionality in the vendor provided user guides and other support documentation, including how to identify and retrospectively reconstruct all data elements in the audit log including date, time. [1]<br />
* Can the system identify the chronic disease management subgroups?<br />
* Is the EHR scalable to different medical specialties and practice demographics (i.e., Neurology vs. Cardiology, small satellite practice vs. intensive care unit) <br />
* Can the system support future clinical models (i.e., Medical Home)?<br />
* Does the EHR system support accurate, consistent and effective clinical documentation by appropriately balancing data auto-population, structured data entry, and unrestricted physician entry of natural-language narrative?<br />
* Does the EMR have the capability to display data over time graphically, such as growth charts?<br />
* The system shall provide the ability to query for a patient by more than one form of identification<br />
* Can it integrate with external knowledge sources such as links to journal references or other knowledge base systems (such as [http://www.hopkinsguides.com/ John Hopkins Guidelines System]) to provide more academic information and update on particular patient problem?<br />
* Does the EHR store the identity of the user and associate the ID with the additions or changes made to the system?<br />
* Can the EHR system be used to capture clinical trial data? How the clinical trial specific data is managed?<br />
* Does the EHR system have the ability to import and export data (interact) in a standard format to EHR systems from other vendors?<br />
*In outpatient departments, does the EHR have a patient-to-physician email and/or web access abilities for the outpatient department to communicate directly with the patient in case more information is needed or the office needs the patient to take some action?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the vendor’s product provide the key functionality needed to achieve the organization vision?<br />
* Does the EHR provide outcomes data in terms of key metrics (cost savings, medication error reduction, disease management) in line with the vision of the organization?<br />
* How does the system import data from personal health devices?<br />
* Can patient data be directly imported from patient portals or [[PHR|personal health records]]?<br />
* Does the vendor provide an EHR system that can be integrated with and is interoperable with other systems?<br />
* Can the vendor provide an EHR system with standard terminology that is cross platform with other EHR systems?<br />
* Does the vendor provide safe log in for patients and clients?<br />
* Does the EMR could provide appropriate information on screen without cramming too much information?<br />
* If the EMR/EHR system allows users to access through mobile devices (through the web or an app), is the mobile version similar to the computer-based version? Is it user-friendly? Will mobile access require additional training, or will user feel comfortable with it after training on the computer-based version?<br />
<br />
=== Nursing Functionality ===<br />
# Supporting eMAR: supporting real-time electronic medication administration record and bar code medication administration technology [http://www.ncbi.nlm.nih.gov/pubmed/20445181[Link to reference]]<br />
# Supporting bedside automation in medication delivery: Support data interface and real-time monitoring of smart pumps and home infusion pumps [http://www.ncbi.nlm.nih.gov/pubmed/15753744[Link to reference]]<br />
=== Pharmacy operation ===<br />
====Formulary management====<br />
# Data repository for formulary information, maintain real time update of medication information with national drug information database<br />
# Support periodic update of formulary, restricted formulary, and nonformulary medications<br />
# Cross reference patient’s insurance formulary list to allow for generic medications to be selected when e-prescribing.<br />
<br />
====Drug dispense and delivery====<br />
# Support outpatient pharmacy operation functionality: <br />
## Maintain outpatient prescription data<br />
## Management of prescription fill, refill and dispense activities<br />
## Support billing protocols with governmental and private insurance<br />
# Support inpatient pharmacy operation functionality<br />
## Maintain inpatient medication ordering data<br />
## Real-time monitoring of IV and oral medication compounding and delivery<br />
## Support real-time data interface with automatic dispensing cabinet<br />
<br />
== Research Functionality ==<br />
<br />
* Does the vendor bid include the product's ability to be used as a tool for research. If "no", is an add-on solution for research capability needed and will it entail extra cost. <ref name="kannry 2006">Kannry J 2006: 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. http://www.ncbi.nlm.nih.gov/pubmed/16669592</ref><br />
* Does the EMR have informed consent alerts and documentation systems for clinical research?<br />
* If the proposed installation site is a research hospital, what are the research capabilities of the EMR?<br />
* How is research achieved?<br />
* How are reports produced?<br />
* How is data exported from the production system?<br />
* Which database is used for reporting? For research? Vendor or other?<br />
* Does the vendor provide [[Natural language processing (NLP)|natural language processing for entry data]] or document?<br />
* Support for research billing including research orders (6)<br />
* Does the EHR system provide data mining capabilities to support clinical research?<br />
** Are there limits on the fields that researchers can use?<br />
** How difficult is it to interface with the database?<br />
** Does the EMR have smart search abilities to search through physician notes for specific keywords while extracting research data.<br />
** Does the vendor assist in research endeavors, or is it left up to the institution?<br />
* Does the EMR have the flexibility to capture documents necessary for specific clinical trials like adverse events, enrollments, and etc? [9]<br />
* If research involves use of pathological/histological samples, does the EMR system tie into the laboratory management systems and database to allow for retrieval and processing of samples?<br />
* Does the EMR system provide functionality to identify clinical related concepts?<br />
* Does the EMR provide the flexibility to normalize the clinical concepts found in the document?<br />
* Does the EMR provide the assistance to automatically generate the de-identified document for research purpose? <br />
* Does EMR system provide functionality to implement study-screening parameter into patients’ registration, scheduling, medication lists, diagnostic codes (ICD) and clinical notes? <ref name="sixteen"> Integrating Electronic Health Records and Clinical Trials http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf <br />
.</ref><br />
<br />
* Does EMR system provide functionality to contact potential candidates and notify the patient’s providers of potential study eligibility? <ref name="sixteen"></ref><br />
* Does EMR system provide capability to systematically captured study specific data and electronically exports deidentified study data to clinical trial electronic data capture system? <ref name="sixteen"></ref><br />
<br />
=== Meaningful use gap analysis ===<br />
* The ONC’s Regional Extension Centers (RECs), located in every region of the country, serve as a support and resource center to assist providers in EHR implementation and HealthIT needs. As trusted advisors, RECs “bridge the technology gap” by helping providers navigate the EHR adoption process from vendor selection and workflow analysis to implementation and meaningful use. <ref name="regional extension center">Regional Extension Centers (RECs) http://www.healthit.gov/providers-professionals/regional-extension-centers-recs </ref><br />
* Does the system provide relevant reports for data for compliance with meaningful use of the EHR.[11]<br />
* Does the EHR vendor provide any guarantees regarding the ability of a practice to meet meaningful use requirements? (http://www.americanehr.com/Home.aspx)<br />
*Does the vendor support data documentation and capture of future government mandated measures such as Meaningful Use, ACO measures, CMS measures for Patient Quality, population health etc?<br />
* Make sure the vendor's product is able to document the [[meaningful use]] <ref name="factors selecting vendor"></ref><br />
* Is the EMR CCHIT Certified?<br />
* Is there a way for the organization to monitor the usage of EMR components?<br />
* Will the EMR user potentially qualify for the [[ARRA|American Recovery Health and Reinvestment Act]] or [[ARRA|Health Information Technology for Economic & Clinical Health Act]] funding opportunities?<br />
* Be certain that the organization has a way to transfer pertinent data from the current EMR to proposed EMR. Create a plan that is not only financially safe, but also allows the organization enough time for implementation.<br />
* Does the vendor provide training and resources specific to Meaningful Use compliance? <br />
* Does the vendor provide any consulting services to assist with workflow modifications and attestation for Meaningful Use?<br />
<br />
******Will the EHR help the hospital to meet the following requirement of Meaningful Use:<br />
1. Use CPOE for medication, laboratory, radiology ordering by licensed professionals<br />
2. Automatically track medications from order to administration using assistive technologies such as bar coding in conjunction with an electronic medication administration record (eMAR)<br />
3. Generate and transmit permissible prescriptions electronically (eRX)<br />
4. Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities.<br />
5. Implement drug-drug, drug-allergy checking. <br />
6. Maintain up-to-date problem/diagnosis list.<br />
7. E-Prescribing<br />
8. Maintain active medication list and medication allergy list<br />
9. Record demographics: Gender, Race, Date of Birth, Ethnicity, Preferred Language<br />
10. Record and chart changes in vital signs: Height, Weight, Blood Pressure, Calculate and Display, BMI, Plot and display growth charts for children 2-20 years, including BMI<br />
<br />
=== Patient quality improvement ===<br />
* Link to patient education materials database or service and the ability to load practice specific documents for patient handouts. Must be able to access and print these from visit encounter interface.<br />
* Does EHR system provide better integration among providers by improved information sharing, viewable and up-to-date medication and allergy lists and order entry at point of care or off-site ?<br />
* Will the EHR system provide standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine ?<br />
* Does EHR system provide access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine ?<br />
* Can EHR system manipulate and provide feedback on population management trended data and treatment and outcome studies for more convenient, faster, and simpler disease management?<br />
* Can the system pull from clinical documentation for billing, quality reporting and patient safety reporting?<br />
* How does the vendor use certified EHR technology in ways that can be measured significantly in quality and in quantity?<br />
* Will the system support utilization review with the Milliman and Interqual clinical criteria for Quality Management and discharge planning.<br />
* Does EMR system provide capability to aggregates data on the impact of specific evidence based/cost effectiveness intervention as compared to current population in management practice?<br />
<br />
=== Public Health research ===<br />
* Does the vendor support the ability to send de-identified bio-surveillance data to population health agencies to support epidemiologic research?<br />
* Does the vendor have the ability to send patient specific public health disease report(s) to a disease registry, as a part of a Public Health Information Network (PHIN)?<br />
* Does the vendor have the ability to report on Quality Improvement, such as infection control measures (i.e., Hospital Acquired Infection rates) or patient safety measures?<br />
* Does the vendor have the ability to report to the State, CDC Registry and external sources<br />
<br />
== IT and Technical Requirements ==<br />
<br />
* For already existing software functionality, does the vendor employ reliable and trustworthy software like an open-source MySQL or Apache server? Or do they develop their own system, or do we have to license a proprietary one (extra cost)?<br />
* How the vendor estimates the total amount of users and licenses needed? Will they be concurrent user licenses or asynchronic?<br />
* Will technical support remain active even if the Hospital is running a non-upgraded system? For how long?<br />
* Does the system use [http://medical.nema.org/ DICOM] standards for the transmission of image data?<br />
* Does the system provide an imaging database or allow customized program attachments of imaging needs of specific departments in the hospital?<br />
* What are the hardware requirements? [1]<br />
* How frequently does the vendor provide patch upgrades for the product?<br />
*Is the system using standards such as Snomed, [http://www.who.int/classifications/icd/en/ ICD 10]; [http://hl7book.net/index.php?title=HL7_version_2 HL7 Version 2] or [http://hl7book.net/index.php?title=HL7_version_3 3]; HL7 infobutton…)<br />
*How does the system handle multiple logins of the same user at different locations/instances?<br />
*How does the system handle user inactivity? (auto-logout, discarding\saving changes, draft creation)<br />
* Is the software capable of using biometric data for rapid login by providers who are mobile between patients/sites?<br />
* How does the system lend itself to automated back-ups? Does the vendor provide IT support team to implement specific back-up plans that will work with the hospital's IT team? <br />
* Can the system allow login remotely – off site transcription or home or other clinic?<br />
* Does the system provide the ability to identify all users who have accessed an individual's chart over a given time period, including date and time of access?<br />
* Does the vendor offer a Software as a Service (SaaS) solution, also know as an Application Service Provider (ASP), or a client-server solution?<br />
* With existing systems, how tightly integrated will the new EHR system be and what prep work is required to make the integration possible?<br />
* Does the system have modules for automatic update of knowledge sets at regular intervals, more like automatic update of antivirus definitions?<br />
* How often does the software need to be upgraded? [1]<br />
* Does the software allow generation of customized reports such that desired information can be extracted periodically for performance improvement projects or performance monitoring.<br />
* Does the vendor utilize the desired technology?<br />
* Is remote access available for mobile devices?<br />
** Is this web-access or a dedicated app?<br />
** In what way is this mobile access limited? Does it have access to all functionality?<br />
** What devices can access the mobile apps? (e.g. iPad, iPhone, Android, etc.)<br />
* Is remote access cross platform? The use of open standards (e.g. HTML5, [[Extensible Markup Language (XML)|XML)]] allows users on any platform, including smartphones and tablets, to have equivocal access to the system.<br />
* Does the system support web-based working environment?<br />
* Does the system provide extension package or software for IT engineers or users? <br />
* Does the system comply with HIMMS standard?<br />
* Can the system be installed on Windows or IOS operating systems?<br />
* How does the system’s IT infrastructure requirement align with the institution’s current infrastructure and the institution’s infrastructure five-year strategic road map?<br />
* What hardware technology (Server) does the database support? And does the supported hardware provide built-in high availability?<br />
* Does the system’s application (not database) support virtual environments? Will it run on a virtual server? <br />
* Is your ticketing system capable of interfacing with [name of ITSM software utilized by your institution]?<br />
* Negotiate the terms and prices of the interface system: to/from PM system, scanner, fax machine, laboratory, health information exchange partners such as hospitals, ambulatory surgical centers, radiology, ePrescribing.<br />
* Can the system be hosted and supported remotely by the vendor? <br />
* How scalable is the IT infrastructure? Is there a peak limit on the number of concurrent users utilizing the system? (this comes in handy during mergers & acquisitions in which you may exponentially increase in size of user base) <br />
* Does the system support dictation function?<br />
* Does the system support speech recognition?<br />
<br />
=== Legacy systems ===<br />
<br />
* How does the vendor compare in [http://www.klasresearch.com/ KLAS] rankings of similar systems and applications?<br />
* How will legacy patient record data be integrated into the new system?<br />
* Does the vendor provide services to convert and transfer data from legacy systems into the new system, and if so, what is the cost?<ref name="himss-ama-legacy">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* How does a legacy Practice Management System integrate with the EHR system? Is there a list of successful PM vendor integrations? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
*Make sure the vendors give accurate information for the Request for Proposal. So the stakeholders can make informed decisions on the comparison of vendors.<br />
-Zoker 9/17/2011<br />
* What is the legacy Practice Management System conversion process for legacy data import into the EHR system? Time/cost and loose-ends? What reference clients are there for particular legacy PM systems? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
* Does the vendor have a List of Lessons Learned from previous implementations?<br />
* Does the vendor have a legal license to essential code sets, such as the [http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page? AMA Current Procedural Terminology] (CPT®) file? Will the vendor maintain this license annually as part of your service or maintenance agreement?[http://www.ama-assn.org American Medical Association]<br />
* How does the vendor manage diagnosis documentation and coding? Does the system require specific coding terminology or does it allow provider synonyms for coding terms? How is that updated and maintained? <br />
* Does the vendor offer a “test environment” in which upgrades are loaded to allow you time to test and learn their functionality without affecting your live system? [http://www.ama-assn.org American Medical Association]<br />
* What is the vendor's rate for on time & under budget implementations?<br />
* Are other consulting firms certified to implent the vendor's product? If so will the vendor provide system updates and customer service if system issues (not related to implementation) arise?<br />
* Check whether the vendors EMR products are [http://www.cchit.org/ CCHIT] certified (http://www.cchit.org/products/cchit)<br />
* What services does the EHR vendor offers for post-implementation optimization of the system with respect to training and system customization? (http://www.americanehr.com/Home.aspx)<br />
* What is the company policy regarding data ownership for the ASP EHR? <br />
* The EHR product should be certified for the standards and certification criteria issued by the Office of the National Coordinator for Health Information Technology (ONC-HIT)? How many criteria does it satisfy?<br />
<br />
=== Troubleshooting ===<br />
<br />
* Immediate trouble shooting ability.<br />
* Regular connect with customers about their problems<br />
* The system shall include documentation that describes the patch (hot-fix) handling process the vendor will use for EHR, operating system and underlying tools (e.g. a specific web site for notification of new patches, an approved patch list, special instructions for installation, and post-installation test).[1]<br />
* The system shall include documented procedures for product installation, start-up and/or connection.[1]<br />
* What options does the EMR have for upfront abstraction and scanning? Are these costs included in the purchase of the EMR?<br />
* Can the vendor support the organization desired implementation strategy?<br />
* How can the EHR technology be useful for electronic exchange of clinical health information among providers and patient authorized entities? (http://en.wikipedia.org/wiki/Electronic_health_record#Quality)<br />
* Is implementation of the new EHR system going to be in stages or at once based on the size and complexity of the purchasing institution?<br />
<br />
=== EHR Disaster Recovery ===<br />
<br />
Either internal hardware problems or external sources (especially in EHR systems that store data in the cloud) may cause unexpected EHR system failures. The EHR may be unavailable for a few hours or for a week or more. Disaster recovery must always be considered when selecting a vendor to ensure that data is secure in these emergency situations. Questions to consider include:<br />
<br />
* Does the EHR use internal hosting or an ASP model? <ref name="himssdisaster">EHR and Disaster Recovery. http://www.himss.org/News/NewsDetail.aspx?ItemNumber=6469</ref><br />
* Is the EHR system adherent to the HIPAA Security Rule and provides both a contingency plan and secure data back-up reserves in case of system failure? <br />
* Has the EHR provided users with a detailed disaster plan during implementation of the EHR that includes how to cope with unexpected system failure?<br />
* Has the EHR provided training packets and educational materials for end users to study to prepare for unscheduled downtime of the EHR?<br />
* Will the EHR notify users immediately when system failure occurs and provide information about the breadth of the failure and the time anticipated before the EHR will be restored?<br />
<br />
**** Some of the criteria I will like to see in an EHR system in the event that it crashes or during downtime*****<br />
1. What backup system does it have in place during such an event so that patient care continues without reverting to a paper system? <br />
2. How is data updated into the system when it is back up and running again?<br />
3. Where is the data stored so that in the event of a catastrophic crash historical data is not lost?<br />
<br />
=== Health information exchange, connectivity, and standards ===<br />
<br />
* Does it meet the following connectivity standards: [[HL7]], HL7 CDA, CCR, HL7 CCD, ELINCS and Vendor software specifications? <ref name="whitepaper emr connectivity">What is Your EHR Connectivity Strategy? http://www.corepointhealth.com/sites/default/files/whitepapers/emr-connectivity-strategy-healthcare-interoperability.pdf </ref><br />
* How flexible is there connection framework? Can it negotiate multiple standards?<br />
* How quickly can you build and implement an interface within the interface engine?<br />
<br />
== Implementation ==<br />
<br />
* Implementation Project Manager – A project manager is necessary to bring vendor experience and guidance to the implementation process and should hand off the implementation to your internal team within 12 to 15 months.<br />
* Will the vendor be readily available to conduct training for all shift and service line?<br />
* Service Agreement - A service agreement identifies what the EMR vendor will do to maintain the software, including software maintenance, technical support, and upgrades. <br />
* IT Support Agreement - Hardware installations are your responsibility, not the EHR vendor. However, if you do not have onsite IT support, request an estimate for the following: <br />
** Installation charges for electrical requirements, cable and phone connections for the system<br />
** Monthly fees to provide access to patient data on a remote server<br />
** Networking design and administration charges related to the set-up and service of client's network<br />
** Hardware onsite installation and maintenance<br />
** Third-party software maintenance for products not provided by the vendor<br />
** Correcting errors that result from changes you or a third-party made to the software. This applies primarily to client-server agreements<br />
** Backup capabilities. This applies primarily to client-server agreements.<br />
* Terms and Conditions - Irrespective of the contract length, ask about penalties for withdrawing your data. Any vendor interested in preserving its reputation will provide you with data in a common format able to be transitioned to another system, but there is a withdrawal fee. [13]<br />
<br />
=== Configuration ===<br />
* Does the vendor factor the number of users as part of their implementation cost? <br />
* Does the vendor provide their own hardware or use a third-party company for their hardware needs? Based on the practice size and niche, is a well-established vendor with all software and hardware in-house preferable?<br />
* If you have an existing system, what kind of difficulties will the vendor encounter? Will it be possible to transfer existing data to the new system? <br />
*In calculating the Total Cost of Ownership (TCO), the break out costs should include who pays for the additional costs due to delays in implementation, especially those due to the Vendor. In fairness, the Vendor's rate for successful, on-time and under-budget implementation should be discussed as well.<br />
•Does the TCO include lifecycle costs that include milestone payment scheduling to back up promises made by EHR implementation? [8]<br />
* Does the system minimize or ease the data input, so that doctors spend more time with their patient?<br />
* Does the vendor qualify under the organization acquisition policies?<br />
* How will current policies and procedures change once implementation takes place?<br />
* Is there a dedicated support team?<br />
* If implementation of the system fails, what steps is the EHR willing to take to make it successful?<br />
* Will the license cost for updated versions of the EHR be borne solely by the purchasing institution or will there be cost sharing between the institution and the vendor for updates?<br />
* How often the possibility of system break out?<br />
* Does the fee include pre-training and post-training?<br />
* How long and including of the warranty of infrastructure and system? Do we pay for accident damage for system or hardware?<br />
* What system configurations are available? How does the vendor involve the client in the configuration of the system?<br />
<br />
=== Training of users ===<br />
* How many hours of initial training is provided for administrators? For users?<br />
* When is the initial training provided, during or after implementation?<br />
* How large a virtual environment will be required to provide training for staff, and how much time should be allocated. <br />
* What are the time requirements to train the trainers?<br />
* Is the initial training included in the costs of the tool?<br />
* If additional training is required post-implementation, how is it priced – lump sum or hourly rate?<br />
* How many hours of post-implementation support is included?* Will the vendor provide technical training to the IT Department of the purchasing institution to handle minor non-critical hardware problems?<br />
* How long is the training that is required for each subgroup to fully implement the system?<br />
* What are the training requirements for the vendor? For the clinic/hospital?<br />
* What is the vendor's track record for successfully training a new system for your clinic/hospital size?<br />
* What training manuals, user guides, on-line training assets, and any other training materials will be made available to the clinic/hospital?<br />
* What training mechanisms are used by the EHR Vendor? (http://www.americanehr.com/Home.aspx) <br />
* Does the vendor provides training instructors at beginning?<br />
* Are the training staff familiar with both the technical aspects of the product and the clinical needs of the department of interest? (i.e. subject matter specialist, clinical informatic specialist)<br />
* Does the vendor has well-organized and reliable training courses?<br />
* Training Contract - Training should be included in the licensing and service agreement, but some vendors provide separate online and onsite training contracts.<br />
* Does the EHR vendor provide a test version of EHR product for training and quality assurance (QA) purposes as well as the full production environment that is installed in the clinic? (The test version is a segmented area where users can make changes to templates or forms without it affecting the live environment) (http://www.americanehr.com/Home.aspx)<br />
* Are training materials provided by the vendor or is the organization responsible for producing in-house? If the training material will be developed in-house, does the vendor stipulate specific training requirements (i.e. classroom-based vs. web-based, mandatory competency examinations)?<br />
* What kind of on-going training and support will be provided after implementation? Is the cost of post-implementation training and support clearly specified?<br />
* If there are major updates to the system, will the vendor provide ample support and training for the users? And how much will this additional training cost?<br />
* Does the EHR/EMR vendor offer the option to have their staff available to be present at the hospital/clinic/facility during training and then "go-live" implementation? This would allow the EHR/EMR staff to offer hands-on support for any obstacles that come up during training and "go live" implementation. <br />
<br />
<br />
<br />
'''* Spell out pricing before selecting and Electronic Medical Record (EMR/Electronic Health Record (EHR) system such as hardware, software, maintenance, upgrade costs, lab and pharmacies interfaces, customized quality reports, expenditure to connect to health information exchange (HIE)Bold text'''== Future relationships: vendor partnership ==<br />
<br />
* Talk to vendor's existing customers, making sure to also contact some vendor customers independently, as the vendors tend to only provide contacts to their most satisfied customers.<br />
*Research available EMR systems and vendors: determine if your jurisdiction has a "pre-approved" vendor list; develop checklists & questionnaires to assist with product comparison; and prepare a Request for Proposals (RFP). <br />
*An important consideration is whether the vendor or any of its industry partners have done an analysis of processes in healthcare<br />
*Ensure there will be well-laid out contractual agreement regards the 'source code' that will satisfy/cover necessary conditions: "When does the company get the 'source code?, How does the company get the source code?"<br />
*If there are workflow changes within the organization, after the product is implemented, is the product flexible enough to allow for changes without major outages or disruptions to daily activity?<br />
*What are the vendors’ contingency plans if technical glitches occur, post implementation?<br />
*Is technical support offered by the vendor 24 hours per day/ 7 days a week?<br />
*In the event of need for support from the vendor, what is the approximate response time to calls that vendor the projects?<br />
* What is the cost of providing this technical support per hour?<br />
* What size, in terms of employees, is the EHR vendor? Do they have the staff to fully address the support needs of their current client base and, can they accommodate the added support load of your institution?<br />
*In terms of clinical decision support, how often are drug list and drug interaction list updated? Once updated, how long will it take for the changes to be accessible by the end users?<br />
* When code sets and medical vocabularies, ontologies, etc. are updated, how long after will the tool be updated?<br />
*In "EMR Vendor Selection" on Health Technology Review.com (http://www.healthtechnologyreview.com/emr-vendor-selection.php) it states an old adage in the Software industry that consumers will buy a product based on features, but will leave the vendor based on a lack of support. Therefore, it is important to check references for the vendor related to post-implementation technical support satisfaction.<br />
* Aside from providing source code in the event the company undergoes changes, how and when can the organization acquire the "raw" data?<br />
* Will the source code be placed in escrow so that the system could be maintained and modified by internal IT staff in the event that the vendor ceases operation.<br />
* Does the vendor have local support personnel or will all issues be handled by a distant team?<br />
* What is an average time for installing and testing upgrades to the system? If an upgrade is missed or skipped, does the subsequent upgrade(s) have all prior changes included or just the current fix or feature for that version?<br />
* Is there going to be a vendor-institution confidentiality agreement or can the vendor share institutional information and dealings with other establishments?<br />
<br />
'''* Does the vendor's produce meet our needs and goals for our practice? Carryout a test drive of our specific needs with the vendor's product and provide the vendor with patient and office scenarios or mock trial that they may use to customize their produce demonstration.Bold text'''=== Upgrades ===<br />
<br />
* Does the vendor share the organization's '''vision''' for the EHR?<br />
* Does the product provided by the vendor has all the '''key functions''' needed to fulfill the vision of the organization?<br />
* Is the vendor utilizing the desired technology?<br />
* Compare retail broker workstation alternatives, including proprietary and third party packages, based on user requirements and technology/operational considerations. Project included EMR development and response evaluation<br />
* Does the vendor plan to offer interoperability options in the event of a nationally implemented CIS?<br />
* Upon the termination of a license or agreement, is there an orderly process for you to extract your data? This is applicable if you access the vendor’s software within an application service provider (ASP) model.[http://www.ama-assn.org American Medical Association]<br />
* Ability to have HIE compatibility<br />
* Improved billing accuracy and charge capture<br />
* Electronic replacement for traditional reportable disease notifications to health departments, may become part of biosurveillance in the future.[1]<br />
* Is it possible to virtualize or [http://en.wikipedia.org/wiki/Sandbox_(software_development) sandbox] the system to test updates? This functionality would allow site specific testing of new features and systems with less risk of corruption of the current system. It would also allow testing of new features functionality and allow easy rollback if features end up being unwanted.<br />
* Does the system allow outreach/growth to affiliates as a "subset" of the existing clinical provider group? Does that outreach include full or limited functionality? How does that data interface with the existing clinical record?<br />
*How does the system scale? Is the vendor able to provide support and functionality as a practice grows or can they provide functionality to a small, regional branch?<br />
* Provision of EHR systems that support the capture of public health data from Clinical Information Systems.<br />
* Does the system can combine with EHR in long term health care area as a reminder of senior people?<br />
* Ensure that your vendor will be around when you need help. While specific vendor qualifications vary, generally information to be considered in the vendor vetting process, besides functional and technical details, includes vendor reputation, staff experience and qualifications, and financial solvency. (Chao, C., & Goldbort, J. (2012). Lessons Learned from Implementation of a Perinatal Documentation System. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), 599-608. doi:10.1111/j.1552-6909.2012.01378.x)<br />
*Does the vendor allow discrete data capture and easy reporting of critical data that needs to be submitted for reimbursement by the national and state policies on healthcare?<br />
*Is the vendor at the forefront of research in healthcare and does the software offer clinical dashboards and predictive models for easy tracking and analysis of patient data and efficient decision making by clinicians.<br />
*Does the vendor require hiring of outside consultants for training?<br />
<br />
== Contracts ==<br />
<br />
Contracts are as much a business tool as they are a purchasing agreement. <ref name="ehr contract">Carolyn Hartley - signing an EHR contract http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
<br />
* Project Payments<br />
* Contract Terms [http://calhipso.org/documents/ehr_contracting_terms_final_508_compliant.pdf]<br />
* All costs, current and future, associated with the implementation<br />
Details of the total cost incurred by the institution also called total cost of ownership (TCO) is an important consideration in the selection process. It helps to predict the longevity of the program. The request for proposal to vendors should include a request for information about vendor license and implementation costs. Vendors should deliniate the assumptions made when preparing the TCO so the decision committee is able to verify that they are parallel to the goals and objectives of the insitutions. If the same assumptions are encorporated in all request for proposals one can better compare the applications.(8)<br />
Institutions must also consider the intangible return on their investments such as reduced adverse events, decreased hospital stay, accurate and timely billing and improved management of supplies. <br />
* Time commitment from vendor with regard to implementation and training<br />
* Penalties for delays in implementation<br />
* Code escrow - be sure code will be available if vendor goes out of business<br />
* Indemnification and hold harmless clauses <br />
* Confidentiality and nondisclosure agreements <br />
* Warranties and disclaimers <br />
* Limits on liability <br />
* Dispute resolution <br />
* Termination and wind down<br />
* Intellectual property disputes <br />
* IT support agreement<br />
* Training Contract<br />
* Applied area contract<br />
* User and vender liability<br />
* Disputation judgment <br />
* Attorney of vender and clients<br />
* User License - The person who has access to data using a user ID and password. Pricing structures vary according to the definition of user.<br />
* Consider variation of user licenses according to the needs: one price per MD, tiered price (MD, nurse or administrator), site license (25+ providers in the same facility), and enterprise license (multiple users in multiple departments). <ref name="user license">Signing an EHR contract. Tips to control costs. http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
* Interface - The EHR vendor's contract includes the cost of interfaces. These include interfaces such as those with your scanner or fax machine; and more complex interfaces such <br />
* Hardware Contract - Review the EHR vendor's hardware quote, but research may lower costs. Check the vendor's website for hardware specifications the vendor supports. Hardware includes servers, high-speed scanners, computers, handhelds, computer on wheels (COW), wall mounts, etc. Hardware installation to a wholesaler means assembling the server and software to make it work at their location prior to delivering it to you. It usually does NOT mean the installation at your location, a difference that will create a significant budget surprise. Clarify the term "installation" with any hardware wholesaler before making the purchase.<br />
* Third Party Software Contracts – Software includes encryption, speech-recognition, password management, Microsoft™ suite, anti-virus, golden image, bar-coding or webcams.<br />
* Business Associate Agreement - To be HIPAA-compliant you will need a business associate agreement with the vendor, and must ensure the vendor meets HIPAA security and privacy requirements.<ref name="HIMSS-AMA-BAA">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Check Vendor References ===<br />
<br />
*Each vendor being considered should provide minimal of three (3) references, to include a) physician users, b) IT person, and c) senior manager of the facility or practice.<br />
* Vendor provided references may be considered 'happy customers' with biased viewpoints.<br />
* Ask supplied list of references how they acquired the EHR system, eg did they purchase the system or was it provided by the vendor?<br />
* Ask each reference to rate the vendor on a scale from 1 (very dissatisfied/strongly disagree) to 5 (very satisfied/strongly agree) for each criterion<br />
* Each vendor reference should provide reference on background information such as version of system currently being used, duration using current system, length of implementation, number of interfaces practice currently installed and estimated time to install, training provided on-site or remote.<br />
* Each vendor reference should provide reference on current system overview such as system reliability, satisfaction with vendor, and overall satisfaction with system.<br />
* Research references the vendor did not mention, visit facility to get an unbiased viewpoint<br />
* Must use list serves, internet searches and networking to identify other users to interview to get more objective viewpoint.<br />
* All interviewers should utilize the same questionnaire approved by the project manager or steering team.<br />
* Notes must be recorded by each interviewer for each customer interviewed.<br />
* These notes should be made part of the overall evaluation process, ideally kept by the project manager [7].<br />
* Is the vendor currently involved in or have a history of any litigation with customers?<ref name="himss-ama-litigation">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Transparency ===<br />
<br />
EHR vendors may enter contracts with confidentiality or non-disclosure terms that can prevent transparency. Examples include:<br />
<br />
* Disclosures required by law or regulation, sometimes with an obligation to give the other party advance notice and the opportunity to oppose the disclosure or seek confidential treatment.<br />
<br />
*Disclosure of information that has been independently developed by the disclosing party<br />
<br />
*Disclosure of information that is available to the general public or has been provided separately to the disclosing party without violation of an agreement. <br />
<br />
The definition of confidential information may be broad and could restrict your ability to share access to the EHR technology developer’s software in order to compare different EHR technology developer systems, provide access to researchers, or even address possible patient safety concerns. You should review the confidentiality and non-disclosure language carefully to make certain it does not inhibit your ability to conduct activities you value. <ref name="westatterms">EHR Contracts: Key Contract Terms for Users to Understand. http://www.healthit.gov/sites/default/files/ehr_contracting_terms_final_508_compliant.pdf </ref><br />
<br />
== Misc considerations ==<br />
<br />
* It is not uncommon for developers or implementers to impose lock-in features in order to protect their IP rights. How mature is the support community for the particular vendor and is there a marketplace for support and services to their product or is support limited to their own team?<br />
* A multidisciplinary team, usually a subset of the decision team consisting of a physician, IT personnel and a senior management must conduct a site visit to one of the vendor customer sites and vendor headquarters. Informal discussions at this level were quite informative as they bridged the gap between theory and practice for actual software implementation and usage.<br />
* An unstructured “drive-by” demonstration of the system must be arranged for, wherein the vendors conduct product demos, demonstrate product futures and distribute promotional materials for a majority of the employees to get the feel of the new systems. It facilitates building a comfort level and relationship with the vendor and the product offered.<br />
* Can the company demonstrate tangible ways that use of the product can increase hospital revenue? If yes, can you validate this/these claims?<br />
* Is the vendor willing to contract to go "at risk" for any part(s) of the contract?<br />
* What other services does the company offer (especially useful for rural or small hospitals or practices)? e.g. consultants to do special projects, data transmission/claims, billing<br />
*Can the record be accessed at home by clinicians and patients, or do they have to be on-site at the facility?<br />
* Is the vendor capable of adapting to emerging technology such as open source programming, cloud computing, "tablet" PCs/Macs, demand for smartphones (e.g. iPhone), and Web 2.0 technology?<br />
* Is the vendor capable of integrating its system with a personal health record and allowing more patient control?<br />
* Can the company provide return on investment analysis?<br />
* Vendors may not be chosen if the current managers have been convicted of or have had a civil judgment for the following: fraud, antitrust violations, embezzlement, theft, etc.<br />
* Reduced pharmaceutical costs derived from having information available at the time it is needed<br />
* How can this EHR be an asset for the solo practitioner who sees this technology primarily as a financial drain?<br />
* How much extra financial cost will it be to train outpatient clinics that are a subset of the system?<br />
* Does the vender return loss money if their system can not complete established goal in scheduled time?<br />
* Can the company provide a multi-background consult team from doctors, nurses, IT engineer, to attorney?<br />
* Does the vendor qualify the organization's acquisition policies? Is the vendor '''CCHIT certified'''?<br />
* Certification can be verified at the Certified Health IT Product List (CHPL) <ref name="onc ehrcert">Certified Health IT Product List (CHPL) list of EMRs. http://oncchpl.force.com/ehrcert </ref><br />
* Is the vendor active in national EMR leadership task forces, such as the Electronic Health Records Vendors Association <ref name="HIMSSEHRA">HIMSS Electronic Health Record Association http://www.himssehra.org/ASP/index.asp </ref><br />
* Will the vendor be supporting the organization's desired implementation strategy?<br />
* Check the track record of vendor for operations and maintenance support?<br />
* Will the vendor sell or monetize of our clinical data for research or any other purposes? <br />
* Is Application Support provided by on-shore resources? <br />
* Clarify the roles, responsibilities and costs for data migration if desired. <ref name="factors selecting vendor"></ref><br />
* Does the Vendor demonstrate financial and management stability?<br />
* Does the vendor have experience with implementing the product in a similar type of organizations? How many?<br />
* Conduct a site visit <ref name="factors selecting vendor">What factors should I consider when selecting a vendor? http://www.healthit.gov/providers-professionals/faqs/what-factors-should-i-consider-when-selecting-vendor </ref><br />
* Ensure that the site is similar to you - similar number of beds, acuity, rural/urban setting<br />
*'''Flexibility that allows for significant changes in product or order lines'''. Thus, this enables for businesses to modify orders, if necessary, without having to face a penalty from the vendor. Not always do things go as planned and if any modifications are needed, there should not be any consequences that inhibit this from occurring. <br />
* '''The ability to provide all the products/services required and/or the complete solution.''' This in turn can provide the whole picture in allowing for the consumer more transparency in terms of being able to distinguish between the products/services that a particular vendor is offering. As a result, this can save time and money in terms of a consumer being able to choose a certain business that can provide everything that is needed instead of wasting time and effort in purchasing products/services from individual vendors that have a small selection available.<br />
* '''The ability to have a consistent supply of products or services readily available for the business to purchase at all times.''' There is always a need for products and services to be provided on a regular basis; thus a business does not want to have a vendor that has supply issues. If a vendor is not reliable, then it can affect the business’s ability to in turn supply and provide for its customers, which can have a dramatic effect on the reputation and finances of the business.<br />
* Does vendor volunteering disclose adverse events or near misses data involving vendor’s EMR system to potential buyers? Are there protocol designed to notify federally designated patient safety organizations of IT related adverse events or near misses? <ref name="seventeen"> Better Patient Safety is Goal of Confidential EHR Error Reports http://www.amednews.com/article/20130724/profession/130729986/8/ .</ref><br />
<br />
== EHR Evaluation Resources ==<br />
<br />
* American Academy of Family Physicians [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrvendorrating.Par.0001.File.tmp/ehrvendorrating.pdf Vendor Rating Tool]<br />
* American Academy Of Family Physicians HR Demonstration Rating Form EHR Demonstration Rating Form [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrdemorateform.Par.0001.File.tmp/ehrdemorating.pdf<br />
* American Academy of Family Physicians vendor's references verification form [http://www.aafp.org/fpm/2005/0200/p55.html#fpm20050200p55-bt4]<br />
* American College of Physicians [http://www.acponline.org/acp_press/electronic_health_records/checklist.pdf EHR Feature Checklist]<br />
* Bureau of Primary Health Care. BPHC Electronic Medical Record Resources page. [http://bphc.hrsa.gov/chc/CHCInitiatives/emr.htm]<br />
* Doctor's Office Quality - Information Technology [http://www.healthinsight.org/Internal/REC_Event_Resources/MU_Boot_Camp_Materials_Resources/Guidelines%20for%20Evaluating%20Systems.pdf Guidelines for Evaluating EHR Vendors]<br />
* www.purchasing-procurement-center.com/selecting-a-vendor.html<br />
* The National Learning Consortium Vendor Evaluation Matrix Tool. <ref name="NLCmatrix">The National Learning Consortium Vendor Evaluation Matrix Tool. http://www.healthit.gov/providers-professionals/implementation-resources/vendor-evaluation-matrix-tool</ref><br />
<br />
<br />
*California Health Care Foundation, EMR Evaluation Tool and User Guide - A Guide for Small Physician Practices: [http://www.chcf.org/publications/2003/10/emr-evaluation-tool-and-user-guide]<br />
*American Medical Association - 15 questions to ask before signing an EMR/EHR agreement<ref name"AMA-HIMSS-15Questions">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
'''Select/upgrade to a certified electronic health record vendor<br />
Retrieved from http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr<br />
text'''==References (old, to edit) ==<br />
<br />
# RI Regional Extension Center. 2011. Vendor members and applicants. Retrieved from http://www.docehrtalk.org/selecting-ehr/for-vendors<br />
# The Certification Commission for Healthcare Information Technology (CCHIT). CCHIT Certified 2011 Ambulatory EHR Certification Criteria. May 17, 2011. Available at: https://www.cchit.org/documents/18/158304/CCHIT+Certified+2011+Ambulatory+EHR+Criteria.pdf.<br />
#http://mhcc.dhmh.maryland.gov/hit/ehr/Documents/sp.mhcc.maryland.gov/ehr/cmsdemo/februarycmsehrdemonstrationarticle.pdf<br />
#McDowell SW, Wahl R, Michelson J. Herding Cats: The Challenges of EMR Vendor Selection. Journal of Healthcare Information Management. 2003; 17(3):17.<br />
# Weber, M. (January 2008). "Selecting an EHR, Now What????" wwww.healthconsultingstrategies.com<br />
# Eastaugh, S. R. (2013). Electronic Health Records Lifecycle Cost. J Health Care Finance, 39(4), 36-43.<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361387/<br />
# Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23(42), 1-4.<br />
# Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24<br />
# Hoyt, R. (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals. Informatics Education<br />
<br />
== References ==<br />
<references/></div>Adlaihttp://clinfowiki.org/wiki/index.php/Vendor_Selection_CriteriaVendor Selection Criteria2014-09-17T22:27:21Z<p>Adlai: /* Formulary management */</p>
<hr />
<div>Choosing an [[EMR|electronic medical record (EMR)]] vendor is an important task, with many aspects to consider. An EMR can completely redesign a hospital's practice, but can also optimize it in ways a [[Removing Paper|paper-based system]] could not. With over 400 EMR vendors in the market, selecting the best option could be overwhelming. After clearly defining the needs of the company, the next step is to evaluate which vendors more closely match your list of priorities.<ref name="Selecting a vendor">Selecting the right EMR vendor. http://www.himss.org/files/HIMSSorg/content/files/selectingemr_flyer2.pdf </ref><br />
Here is a list of some of the important considerations when choosing, installing, implementing and upgrading an EMR system. <ref name="factors selecting vendor"></ref><br />
<br />
== Core Clinical Features ==<br />
<br />
In 2003, the DHHS asked the IOM to provide guidance on the basic functionalities of electronic health records systems. The committee concluded that the core functionalities should address the following areas:<br />
* Improvement of patient safety<br />
* Support delivery of effective patient care<br />
* Facilitate management of chronic conditions<br />
* Improve efficiency<br />
* Feasibility of implementation and <br />
* Integration of hospital services<br />
In the Journal of Healthcare Information Management Kranny et. al discussed the importance of an application in the EHR which will promote continuity of care. During the selection of a vendor it is imperative for the decision committee to find out if there is an integration of inpatient, clinical and outpatient interface systems. (8) The patient's progress in house and discharge summary should be accessible by his primary care provider upon discharge. Medications that were discontinued during hospitalization should be updated in the patient's outpatient medication profile so worng medications are not refilled by the patient. IN addition, when new medications are added to the patient medication regimen it should be accessible by the primary care provider and outpatient pharmacist.<br />
<br />
Based on these areas, the IOM committee identified eight categories of core functionalities, including: <ref name="johnson 2006">Johnson 2006: Selecting an electronic medical record system for the physician practice. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_035390.hcsp?dDocName=bok1_035390g</ref><br />
* Health information and data<br />
* Results management<br />
* [[CPOE|Order entry/management]]<br />
* [[CDS|Decision support]]<br />
* Electronic communication and connectivity<br />
* Patient support; administrative processes<br />
* Reporting and population health management<br />
<br />
== Analyzing Business(EHR) requirements ==<br />
* Assemble an Evaluation Team<br />
The Evaluation team or decision Team should consist of clinicl healthcare professionals including house staff, tech support professionals, administrators, and financers from all areas of the institution. Each person brings to the table a differnt perspective of usage from their daily job responsibilites. Insitution-wide involvement creates awareness and knowledge of EMRs and their benefits. AS well as, an understanding of the upcoming modifications in work flows. <br />
* Define the Product, Material or Service<br />
* Define the Technical and Business Requirements<br />
* Define the Vendor Requirements<br />
* Publish a Requirements Document for Approval<br />
<br />
=== EMR software ===<br />
<br />
* Health Information & Data Management (Demographics, Problem list [CC, Conditions, Acute/Chronic, Worsening/Resolving, Injuries, Present Illness] with [[ICD|ICD-9 or ICD-10 numbering]], Procedures, Diagnoses, Medications, Allergies, Family medical history, Consultations, Signs & Symptoms and Vitals, Progress Notes and Discharge Summaries, Appointments/Admissions/Visits, Advance Directives, Clinical Reminders [Immunizations, Screenings, Risks])<br />
** EHR that allows for the creation and maintenance of patient specific problem lists that are dated and organized by diagnosis, problem, and problem type and associates encounters, orders, medications and notes to one or more problems. Once a problem is resolved, the EHR provides an automated algorithm that closes that problem.<br />
* Is the Software configuration flexible to customize for future needs.<br />
* Result Management (lab, imaging, other diagnostic measurements, pictures, multimedia)<br />
** Review and search results easily by sorting test types, test time, test administers, test results and so on<br />
** Choose one or several test types, such as HGB, and/or WBC, and/or blood sugar and chart on their results for showing trends.<br />
* The proposed EMR software should bring minimal to no new limitations to the institution. Selectors must be certain that the EMR system meets all required operational tasks.<br />
* How much customization to the EMR can the vendor offer to meet the institution’s needs? Will there be a surplus of unusable or insufficient components to the EMR?<br />
* Ensure that the EMR software is tested prior to finalizing the vendor contract.<br />
* Proposed EHR should allow for expandability to mobile devices, mobile medical applications and upcoming mobile technology.<br />
* Does the EHR have integrated practice management to avoid having to interface with a 3rd part practice management system?<ref name"himss-ama-pms">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* Does the software provide a tool for workflow mapping/charting? <br />
* Can the software be easily configured/adapted to changing workflows?<br />
* Does the EHR/EMR system allow multiple terminals (physician, nurses' station, X-ray, labs, etc.) to log in to the same patient's record simultaneously? Certain systems only allow one terminal to access a patient record at a time - they must log out before any other terminal can access patient EHR/EMR. (For example, if a nurse forgets to log out at their station, the lab cannot access that patient's record.)<br />
<br />
=== Privacy and Security ===<br />
<br />
* Does the system provide roadmaps for adherence to organizational policies (such as HIPAA)?<br />
* The system shall allow an authorized administrator to enable or disable auditing for events or groups of related events to properly collect evidence of compliance with implementation-specific policies. Note: In response to a [[Health Insurance Portability and Accountability Act (HIPAA)|HIPAA-mandated risk analysis]] and management, there will be a variety of implementation- specific organizational policies and operational limits.[1]<br />
* Internet Connectivity and Redundancy Contract - There are three main types of connections for clinical data connections: business class digital subscriber line (DSL), business class cable, and T1 connection. Redundant back up systems and procedures to ensure your data will be backed up in multiple locations and securely stored off-site. <br />
* Will the system allow staff administrators to create and manage users and [[Data security|user security profiles]]?<br />
* The system restore functionality shall result in a fully operational and secure state. This state shall include the restoration of the application data, [[Security|security credentials]], and log/audit files to their previous state. [1]<br />
* If the system includes hardware, the system shall include documentation that covers the expected physical environment necessary for proper secure and reliable operation of the system including: electrical, HVAC, sterilization, and work area.<br />
* How well does the EMR work with antivirus, antispyware and other security software?<br />
* What is the vendor’s history with cyber attacks? <ref name="mit cybersecurity">MIT Geospactial Data Center: Protecting EMR Data (1 of 2) http://cybersecurity.mit.edu/2012/11/protecting-emr-data-1-of-2/</ref><br />
* Does the system allow for off-site access to files/data and how does the technology protect against external breech or diversion of patient information?<br />
<br />
=== CPOE ===<br />
<br />
* [[CPOE| Computerized Physician Order Entry (CPOE)]], [[Electronic prescribing| e-Prescribing]]<br />
* Computerized Physician Order Entry system that integrates and provides for two-way communication with the Pharmacy, Laboratory, Registration systems, and that allows for scanning and downloading of health information as needed. The EHR system should have a completely understood interface and provide for [[HIE|interoperability]] with all current and future systems and between clinics and providers.<br />
* CPOE will generally allow for the organization to specify a default dose for a medication order. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* The CPOE team will need to review what happens when non-formulary items are entered. The workflow for non-formulary items will also need to be determined. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
* Does the EHR have a referral management system so that within large organizations, specialty and primary care departments can easily communication with each other and have similar information on a patient that is using both offices to treat their illness?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
<br />
=== Clinical decision support (CDS) ===<br />
<br />
* [[CDS|Decision Support]] (Drug Interaction, Drug information and other Prescription Supports, Clinical Guidelines [Plans & Protocols] and disease information, Diagnosis and differential diagnosis Support, Risk Assessments, Clinical Checklists, Medical References, etc)<br />
* Formulary Database Support<br />
* Electronic Communication (Provider-Provider & Patient-Provider Direct Communication, Health Data Exchange, Interface to Medical Devices, Notifications, Clinical Documentation such as Nursing Notes)<br />
* Patient Administration (ADT [Admit, Transfer, Discharge], Reservation & Scheduling, Billing, Waiting List Management, Records of Patient Activity, Master Patient Index across the Healthcare Organization)<br />
* Querying & Reporting (Research & Analysis, Statistics [Vital Statistics, National Statistics], External Accountability Reporting)<br />
* Telecare, Telehealth, and Telemedicine functionality. Home Monitoring device input/linking.<br />
* [[PHR|Patient Portal for online personal health record access]]<br />
* Clinical policies and procedures guidelines<br />
* Produce visit summary and complete medical record printout and data export on demand for patient use.<br />
* Electronic Health Record (EHR) systems should be capable of accommodating multiple users working concurrently within the system and within the same patient file or document [2]. EHR systems should also be capable of protecting the integrity of data in the system so that no data loss occurs when multiple users are working concurrently with the same patient file or document [2].<br />
** Provide direct decision support explanation link to [[EBM|evidence based knowledge]] (through such as "infobutton",etc) about needed test information, such as purpose and methods of conducting that test, normal range of that test, clinical indications when abnormal results occurred and suggestions what to do, etc.<br />
** Provide abnormal alerts to providers and/or patients through various ways, such as online display, cell phone text messages, etc if the patients/doctors register for this service.<br />
* The organization will need to strike a balance between displaying so many alerts that it causes clinical care to slow. <ref name="HIMSS CPOE Wiki">HIMSS Computerized Provider Order Entry (CPOE) Wiki. https://himsscpoewiki.pbworks.com/w/page/26349065/Clinical%20Content </ref>.<br />
*Does the EHR have an aspect of the CPOE that can manage patient protocols and treatment plans? <ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the software have “Clinical/Business Intelligence” capability based on local clinic medical trends, e.g. if there is above normal upper respiratory infection clinic visits, perhaps a flu season is imminent and may warrant stocking of flu vaccine in the clinic?<br />
<br />
=== Data storage and retrieval ===<br />
* EHR systems should be capable of capturing, storing, indexing, retrieving and displaying externally created documents [2]. Indexing of captured documents should include not only patient identifiers and descriptive information, but also date/time stamps and document type [2].<br />
* EHR systems should be capable of retaining all system data until such data is archived or intentionally purged from the system [2].<br />
* The system should load patient records in a timely manner to not interrupt workflow. <br />
* This system should present chronological data of patients like medicine history, progress of diseases. <br />
* Also, system provides gene information or drug allergies of patients to avoid [[Adverse drug event|ADE]].<br />
* System should be compatible with old system to reduce re-entry time.<br />
* System should update regularly.<br />
* system should be able to have Patient prescription plan eligibility, prescription product formulary and external medication history.<br />
* System should be able to have insurance retrieval capabilities (i.e. insurance firms, sum insured, premium dues, etc.).[11]<br />
* Capability to integrate with other products such as practice management software, billing systems and public health interfaces.<br />
<br />
=== Other Clinical Functionality ===<br />
<br />
* Does the system promote delivery of safe care?<br />
* The system shall require documentation of the audit support functionality in the vendor provided user guides and other support documentation, including how to identify and retrospectively reconstruct all data elements in the audit log including date, time. [1]<br />
* Can the system identify the chronic disease management subgroups?<br />
* Is the EHR scalable to different medical specialties and practice demographics (i.e., Neurology vs. Cardiology, small satellite practice vs. intensive care unit) <br />
* Can the system support future clinical models (i.e., Medical Home)?<br />
* Does the EHR system support accurate, consistent and effective clinical documentation by appropriately balancing data auto-population, structured data entry, and unrestricted physician entry of natural-language narrative?<br />
* Does the EMR have the capability to display data over time graphically, such as growth charts?<br />
* The system shall provide the ability to query for a patient by more than one form of identification<br />
* Can it integrate with external knowledge sources such as links to journal references or other knowledge base systems (such as [http://www.hopkinsguides.com/ John Hopkins Guidelines System]) to provide more academic information and update on particular patient problem?<br />
* Does the EHR store the identity of the user and associate the ID with the additions or changes made to the system?<br />
* Can the EHR system be used to capture clinical trial data? How the clinical trial specific data is managed?<br />
* Does the EHR system have the ability to import and export data (interact) in a standard format to EHR systems from other vendors?<br />
*In outpatient departments, does the EHR have a patient-to-physician email and/or web access abilities for the outpatient department to communicate directly with the patient in case more information is needed or the office needs the patient to take some action?<ref name="KDHE 2008">Kansas Department of Health and Environment 2008: Selecting an EHR, Now What??? http://krhis.kdhe.state.ks.us/olrh/Notices.nsf/bf25ab0f47ba5dd785256499006b15a4/720f6f7bfa876f0a862573c600595a2f/$FILE/EHR%20System%20Selection%20Process.pdf</ref>.<br />
* Does the vendor’s product provide the key functionality needed to achieve the organization vision?<br />
* Does the EHR provide outcomes data in terms of key metrics (cost savings, medication error reduction, disease management) in line with the vision of the organization?<br />
* How does the system import data from personal health devices?<br />
* Can patient data be directly imported from patient portals or [[PHR|personal health records]]?<br />
* Does the vendor provide an EHR system that can be integrated with and is interoperable with other systems?<br />
* Can the vendor provide an EHR system with standard terminology that is cross platform with other EHR systems?<br />
* Does the vendor provide safe log in for patients and clients?<br />
* Does the EMR could provide appropriate information on screen without cramming too much information?<br />
* If the EMR/EHR system allows users to access through mobile devices (through the web or an app), is the mobile version similar to the computer-based version? Is it user-friendly? Will mobile access require additional training, or will user feel comfortable with it after training on the computer-based version?<br />
<br />
=== Nursing Functionality ===<br />
# Supporting eMAR: supporting real-time electronic medication administration record and bar code medication administration technology [http://www.ncbi.nlm.nih.gov/pubmed/20445181[Link to reference]]<br />
# Supporting bedside automation in medication delivery: Support data interface and real-time monitoring of smart pumps and home infusion pumps [http://www.ncbi.nlm.nih.gov/pubmed/15753744[Link to reference]]<br />
=== Pharmacy operation ===<br />
====Formulary management====<br />
# Data repository for formulary information, maintain real time update of medication information with national drug information database<br />
# Support periodic update of formulary, restricted formulary, and nonformulary medications<br />
# Cross reference patient’s insurance formulary list to allow for generic medications to be selected when e-prescribing.<br />
<br />
====Drug dispense and delivery====<br />
# Support outpatient pharmacy operation functionality: <br />
## Maintain outpatient prescription data<br />
## Management of prescription fill, refill and dispense activities<br />
## Support billing protocols with governmental and private insurance<br />
# Support inpatient pharmacy operation functionality<br />
## Maintain inpatient medication ordering data<br />
## Real-time monitoring of IV and oral medication compounding and delivery<br />
## Support real-time data interface with automatic dispensing cabinet<br />
<br />
== Research Functionality ==<br />
<br />
* Does the vendor bid include the product's ability to be used as a tool for research. If "no", is an add-on solution for research capability needed and will it entail extra cost. <ref name="kannry 2006">Kannry J 2006: 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. http://www.ncbi.nlm.nih.gov/pubmed/16669592</ref><br />
* Does the EMR have informed consent alerts and documentation systems for clinical research?<br />
* If the proposed installation site is a research hospital, what are the research capabilities of the EMR?<br />
* How is research achieved?<br />
* How are reports produced?<br />
* How is data exported from the production system?<br />
* Which database is used for reporting? For research? Vendor or other?<br />
* Does the vendor provide [[Natural language processing (NLP)|natural language processing for entry data]] or document?<br />
* Support for research billing including research orders (6)<br />
* Does the EHR system provide data mining capabilities to support clinical research?<br />
** Are there limits on the fields that researchers can use?<br />
** How difficult is it to interface with the database?<br />
** Does the EMR have smart search abilities to search through physician notes for specific keywords while extracting research data.<br />
** Does the vendor assist in research endeavors, or is it left up to the institution?<br />
* Does the EMR have the flexibility to capture documents necessary for specific clinical trials like adverse events, enrollments, and etc? [9]<br />
* If research involves use of pathological/histological samples, does the EMR system tie into the laboratory management systems and database to allow for retrieval and processing of samples?<br />
* Does the EMR system provide functionality to identify clinical related concepts?<br />
* Does the EMR provide the flexibility to normalize the clinical concepts found in the document?<br />
* Does the EMR provide the assistance to automatically generate the de-identified document for research purpose? <br />
* Does EMR system provide functionality to implement study-screening parameter into patients’ registration, scheduling, medication lists, diagnostic codes (ICD) and clinical notes? <ref name="sixteen"> Integrating Electronic Health Records and Clinical Trials http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf <br />
.</ref><br />
<br />
* Does EMR system provide functionality to contact potential candidates and notify the patient’s providers of potential study eligibility? <ref name="sixteen"></ref><br />
* Does EMR system provide capability to systematically captured study specific data and electronically exports deidentified study data to clinical trial electronic data capture system? <ref name="sixteen"></ref><br />
<br />
=== Meaningful use gap analysis ===<br />
* The ONC’s Regional Extension Centers (RECs), located in every region of the country, serve as a support and resource center to assist providers in EHR implementation and HealthIT needs. As trusted advisors, RECs “bridge the technology gap” by helping providers navigate the EHR adoption process from vendor selection and workflow analysis to implementation and meaningful use. <ref name="regional extension center">Regional Extension Centers (RECs) http://www.healthit.gov/providers-professionals/regional-extension-centers-recs </ref><br />
* Does the system provide relevant reports for data for compliance with meaningful use of the EHR.[11]<br />
* Does the EHR vendor provide any guarantees regarding the ability of a practice to meet meaningful use requirements? (http://www.americanehr.com/Home.aspx)<br />
*Does the vendor support data documentation and capture of future government mandated measures such as Meaningful Use, ACO measures, CMS measures for Patient Quality, population health etc?<br />
* Make sure the vendor's product is able to document the [[meaningful use]] <ref name="factors selecting vendor"></ref><br />
* Is the EMR CCHIT Certified?<br />
* Is there a way for the organization to monitor the usage of EMR components?<br />
* Will the EMR user potentially qualify for the [[ARRA|American Recovery Health and Reinvestment Act]] or [[ARRA|Health Information Technology for Economic & Clinical Health Act]] funding opportunities?<br />
* Be certain that the organization has a way to transfer pertinent data from the current EMR to proposed EMR. Create a plan that is not only financially safe, but also allows the organization enough time for implementation.<br />
* Does the vendor provide training and resources specific to Meaningful Use compliance? <br />
* Does the vendor provide any consulting services to assist with workflow modifications and attestation for Meaningful Use?<br />
<br />
******Will the EHR help the hospital to meet the following requirement of Meaningful Use:<br />
1. Use CPOE for medication, laboratory, radiology ordering by licensed professionals<br />
2. Automatically track medications from order to administration using assistive technologies such as bar coding in conjunction with an electronic medication administration record (eMAR)<br />
3. Generate and transmit permissible prescriptions electronically (eRX)<br />
4. Protect electronic health information created or maintained by the CEHRT through the implementation of appropriate technical capabilities.<br />
5. Implement drug-drug, drug-allergy checking. <br />
6. Maintain up-to-date problem/diagnosis list.<br />
7. E-Prescribing<br />
8. Maintain active medication list and medication allergy list<br />
9. Record demographics: Gender, Race, Date of Birth, Ethnicity, Preferred Language<br />
10. Record and chart changes in vital signs: Height, Weight, Blood Pressure, Calculate and Display, BMI, Plot and display growth charts for children 2-20 years, including BMI<br />
<br />
=== Patient quality improvement ===<br />
* Link to patient education materials database or service and the ability to load practice specific documents for patient handouts. Must be able to access and print these from visit encounter interface.<br />
* Does EHR system provide better integration among providers by improved information sharing, viewable and up-to-date medication and allergy lists and order entry at point of care or off-site ?<br />
* Will the EHR system provide standardization of data, order sets, and care plans helping to implement common treatment of patients using evidence-based medicine ?<br />
* Does EHR system provide access to experts for rural health care providers by sharing best practices and allowing for specialized care through telemedicine ?<br />
* Can EHR system manipulate and provide feedback on population management trended data and treatment and outcome studies for more convenient, faster, and simpler disease management?<br />
* Can the system pull from clinical documentation for billing, quality reporting and patient safety reporting?<br />
* How does the vendor use certified EHR technology in ways that can be measured significantly in quality and in quantity?<br />
* Will the system support utilization review with the Milliman and Interqual clinical criteria for Quality Management and discharge planning.<br />
* Does EMR system provide capability to aggregates data on the impact of specific evidence based/cost effectiveness intervention as compared to current population in management practice?<br />
<br />
=== Public Health research ===<br />
* Does the vendor support the ability to send de-identified bio-surveillance data to population health agencies to support epidemiologic research?<br />
* Does the vendor have the ability to send patient specific public health disease report(s) to a disease registry, as a part of a Public Health Information Network (PHIN)?<br />
* Does the vendor have the ability to report on Quality Improvement, such as infection control measures (i.e., Hospital Acquired Infection rates) or patient safety measures?<br />
* Does the vendor have the ability to report to the State, CDC Registry and external sources<br />
<br />
== IT and Technical Requirements ==<br />
<br />
* For already existing software functionality, does the vendor employ reliable and trustworthy software like an open-source MySQL or Apache server? Or do they develop their own system, or do we have to license a proprietary one (extra cost)?<br />
* How the vendor estimates the total amount of users and licenses needed? Will they be concurrent user licenses or asynchronic?<br />
* Will technical support remain active even if the Hospital is running a non-upgraded system? For how long?<br />
* Does the system use [http://medical.nema.org/ DICOM] standards for the transmission of image data?<br />
* Does the system provide an imaging database or allow customized program attachments of imaging needs of specific departments in the hospital?<br />
* What are the hardware requirements? [1]<br />
* How frequently does the vendor provide patch upgrades for the product?<br />
*Is the system using standards such as Snomed, [http://www.who.int/classifications/icd/en/ ICD 10]; [http://hl7book.net/index.php?title=HL7_version_2 HL7 Version 2] or [http://hl7book.net/index.php?title=HL7_version_3 3]; HL7 infobutton…)<br />
*How does the system handle multiple logins of the same user at different locations/instances?<br />
*How does the system handle user inactivity? (auto-logout, discarding\saving changes, draft creation)<br />
* Is the software capable of using biometric data for rapid login by providers who are mobile between patients/sites?<br />
* How does the system lend itself to automated back-ups? Does the vendor provide IT support team to implement specific back-up plans that will work with the hospital's IT team? <br />
* Can the system allow login remotely – off site transcription or home or other clinic?<br />
* Does the system provide the ability to identify all users who have accessed an individual's chart over a given time period, including date and time of access?<br />
* Does the vendor offer a Software as a Service (SaaS) solution, also know as an Application Service Provider (ASP), or a client-server solution?<br />
* With existing systems, how tightly integrated will the new EHR system be and what prep work is required to make the integration possible?<br />
* Does the system have modules for automatic update of knowledge sets at regular intervals, more like automatic update of antivirus definitions?<br />
* How often does the software need to be upgraded? [1]<br />
* Does the software allow generation of customized reports such that desired information can be extracted periodically for performance improvement projects or performance monitoring.<br />
* Does the vendor utilize the desired technology?<br />
* Is remote access available for mobile devices?<br />
** Is this web-access or a dedicated app?<br />
** In what way is this mobile access limited? Does it have access to all functionality?<br />
** What devices can access the mobile apps? (e.g. iPad, iPhone, Android, etc.)<br />
* Is remote access cross platform? The use of open standards (e.g. HTML5, [[Extensible Markup Language (XML)|XML)]] allows users on any platform, including smartphones and tablets, to have equivocal access to the system.<br />
* Does the system support web-based working environment?<br />
* Does the system provide extension package or software for IT engineers or users? <br />
* Does the system comply with HIMMS standard?<br />
* Can the system be installed on Windows or IOS operating systems?<br />
* How does the system’s IT infrastructure requirement align with the institution’s current infrastructure and the institution’s infrastructure five-year strategic road map?<br />
* What hardware technology (Server) does the database support? And does the supported hardware provide built-in high availability?<br />
* Does the system’s application (not database) support virtual environments? Will it run on a virtual server? <br />
* Is your ticketing system capable of interfacing with [name of ITSM software utilized by your institution]?<br />
* Negotiate the terms and prices of the interface system: to/from PM system, scanner, fax machine, laboratory, health information exchange partners such as hospitals, ambulatory surgical centers, radiology, ePrescribing.<br />
* Can the system be hosted and supported remotely by the vendor? <br />
* How scalable is the IT infrastructure? Is there a peak limit on the number of concurrent users utilizing the system? (this comes in handy during mergers & acquisitions in which you may exponentially increase in size of user base) <br />
* Does the system support dictation function?<br />
* Does the system support speech recognition?<br />
<br />
=== Legacy systems ===<br />
<br />
* How does the vendor compare in [http://www.klasresearch.com/ KLAS] rankings of similar systems and applications?<br />
* How will legacy patient record data be integrated into the new system?<br />
* Does the vendor provide services to convert and transfer data from legacy systems into the new system, and if so, what is the cost?<ref name="himss-ama-legacy">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
* How does a legacy Practice Management System integrate with the EHR system? Is there a list of successful PM vendor integrations? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
*Make sure the vendors give accurate information for the Request for Proposal. So the stakeholders can make informed decisions on the comparison of vendors.<br />
-Zoker 9/17/2011<br />
* What is the legacy Practice Management System conversion process for legacy data import into the EHR system? Time/cost and loose-ends? What reference clients are there for particular legacy PM systems? [[User:MikeField|MikeField]] 20:47, 29 January 2010 (CST)<br />
* Does the vendor have a List of Lessons Learned from previous implementations?<br />
* Does the vendor have a legal license to essential code sets, such as the [http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page? AMA Current Procedural Terminology] (CPT®) file? Will the vendor maintain this license annually as part of your service or maintenance agreement?[http://www.ama-assn.org American Medical Association]<br />
* How does the vendor manage diagnosis documentation and coding? Does the system require specific coding terminology or does it allow provider synonyms for coding terms? How is that updated and maintained? <br />
* Does the vendor offer a “test environment” in which upgrades are loaded to allow you time to test and learn their functionality without affecting your live system? [http://www.ama-assn.org American Medical Association]<br />
* What is the vendor's rate for on time & under budget implementations?<br />
* Are other consulting firms certified to implent the vendor's product? If so will the vendor provide system updates and customer service if system issues (not related to implementation) arise?<br />
* Check whether the vendors EMR products are [http://www.cchit.org/ CCHIT] certified (http://www.cchit.org/products/cchit)<br />
* What services does the EHR vendor offers for post-implementation optimization of the system with respect to training and system customization? (http://www.americanehr.com/Home.aspx)<br />
* What is the company policy regarding data ownership for the ASP EHR? <br />
* The EHR product should be certified for the standards and certification criteria issued by the Office of the National Coordinator for Health Information Technology (ONC-HIT)? How many criteria does it satisfy?<br />
<br />
=== Troubleshooting ===<br />
<br />
* Immediate trouble shooting ability.<br />
* Regular connect with customers about their problems<br />
* The system shall include documentation that describes the patch (hot-fix) handling process the vendor will use for EHR, operating system and underlying tools (e.g. a specific web site for notification of new patches, an approved patch list, special instructions for installation, and post-installation test).[1]<br />
* The system shall include documented procedures for product installation, start-up and/or connection.[1]<br />
* What options does the EMR have for upfront abstraction and scanning? Are these costs included in the purchase of the EMR?<br />
* Can the vendor support the organization desired implementation strategy?<br />
* How can the EHR technology be useful for electronic exchange of clinical health information among providers and patient authorized entities? (http://en.wikipedia.org/wiki/Electronic_health_record#Quality)<br />
* Is implementation of the new EHR system going to be in stages or at once based on the size and complexity of the purchasing institution?<br />
<br />
=== EHR Disaster Recovery ===<br />
<br />
Either internal hardware problems or external sources (especially in EHR systems that store data in the cloud) may cause unexpected EHR system failures. The EHR may be unavailable for a few hours or for a week or more. Disaster recovery must always be considered when selecting a vendor to ensure that data is secure in these emergency situations. Questions to consider include:<br />
<br />
* Does the EHR use internal hosting or an ASP model? <ref name="himssdisaster">EHR and Disaster Recovery. http://www.himss.org/News/NewsDetail.aspx?ItemNumber=6469</ref><br />
* Is the EHR system adherent to the HIPAA Security Rule and provides both a contingency plan and secure data back-up reserves in case of system failure? <br />
* Has the EHR provided users with a detailed disaster plan during implementation of the EHR that includes how to cope with unexpected system failure?<br />
* Has the EHR provided training packets and educational materials for end users to study to prepare for unscheduled downtime of the EHR?<br />
* Will the EHR notify users immediately when system failure occurs and provide information about the breadth of the failure and the time anticipated before the EHR will be restored?<br />
<br />
**** Some of the criteria I will like to see in an EHR system in the event that it crashes or during downtime*****<br />
1. What backup system does it have in place during such an event so that patient care continues without reverting to a paper system? <br />
2. How is data updated into the system when it is back up and running again?<br />
3. Where is the data stored so that in the event of a catastrophic crash historical data is not lost?<br />
<br />
=== Health information exchange, connectivity, and standards ===<br />
<br />
* Does it meet the following connectivity standards: [[HL7]], HL7 CDA, CCR, HL7 CCD, ELINCS and Vendor software specifications? <ref name="whitepaper emr connectivity">What is Your EHR Connectivity Strategy? http://www.corepointhealth.com/sites/default/files/whitepapers/emr-connectivity-strategy-healthcare-interoperability.pdf </ref><br />
* How flexible is there connection framework? Can it negotiate multiple standards?<br />
* How quickly can you build and implement an interface within the interface engine?<br />
<br />
== Implementation ==<br />
<br />
* Implementation Project Manager – A project manager is necessary to bring vendor experience and guidance to the implementation process and should hand off the implementation to your internal team within 12 to 15 months.<br />
* Will the vendor be readily available to conduct training for all shift and service line?<br />
* Service Agreement - A service agreement identifies what the EMR vendor will do to maintain the software, including software maintenance, technical support, and upgrades. <br />
* IT Support Agreement - Hardware installations are your responsibility, not the EHR vendor. However, if you do not have onsite IT support, request an estimate for the following: <br />
** Installation charges for electrical requirements, cable and phone connections for the system<br />
** Monthly fees to provide access to patient data on a remote server<br />
** Networking design and administration charges related to the set-up and service of client's network<br />
** Hardware onsite installation and maintenance<br />
** Third-party software maintenance for products not provided by the vendor<br />
** Correcting errors that result from changes you or a third-party made to the software. This applies primarily to client-server agreements<br />
** Backup capabilities. This applies primarily to client-server agreements.<br />
* Terms and Conditions - Irrespective of the contract length, ask about penalties for withdrawing your data. Any vendor interested in preserving its reputation will provide you with data in a common format able to be transitioned to another system, but there is a withdrawal fee. [13]<br />
<br />
=== Configuration ===<br />
* Does the vendor factor the number of users as part of their implementation cost? <br />
* Does the vendor provide their own hardware or use a third-party company for their hardware needs? Based on the practice size and niche, is a well-established vendor with all software and hardware in-house preferable?<br />
* If you have an existing system, what kind of difficulties will the vendor encounter? Will it be possible to transfer existing data to the new system? <br />
*In calculating the Total Cost of Ownership (TCO), the break out costs should include who pays for the additional costs due to delays in implementation, especially those due to the Vendor. In fairness, the Vendor's rate for successful, on-time and under-budget implementation should be discussed as well.<br />
•Does the TCO include lifecycle costs that include milestone payment scheduling to back up promises made by EHR implementation? [8]<br />
* Does the system minimize or ease the data input, so that doctors spend more time with their patient?<br />
* Does the vendor qualify under the organization acquisition policies?<br />
* How will current policies and procedures change once implementation takes place?<br />
* Is there a dedicated support team?<br />
* If implementation of the system fails, what steps is the EHR willing to take to make it successful?<br />
* Will the license cost for updated versions of the EHR be borne solely by the purchasing institution or will there be cost sharing between the institution and the vendor for updates?<br />
* How often the possibility of system break out?<br />
* Does the fee include pre-training and post-training?<br />
* How long and including of the warranty of infrastructure and system? Do we pay for accident damage for system or hardware?<br />
* What system configurations are available? How does the vendor involve the client in the configuration of the system?<br />
<br />
=== Training of users ===<br />
* How many hours of initial training is provided for administrators? For users?<br />
* When is the initial training provided, during or after implementation?<br />
* How large a virtual environment will be required to provide training for staff, and how much time should be allocated. <br />
* What are the time requirements to train the trainers?<br />
* Is the initial training included in the costs of the tool?<br />
* If additional training is required post-implementation, how is it priced – lump sum or hourly rate?<br />
* How many hours of post-implementation support is included?* Will the vendor provide technical training to the IT Department of the purchasing institution to handle minor non-critical hardware problems?<br />
* How long is the training that is required for each subgroup to fully implement the system?<br />
* What are the training requirements for the vendor? For the clinic/hospital?<br />
* What is the vendor's track record for successfully training a new system for your clinic/hospital size?<br />
* What training manuals, user guides, on-line training assets, and any other training materials will be made available to the clinic/hospital?<br />
* What training mechanisms are used by the EHR Vendor? (http://www.americanehr.com/Home.aspx) <br />
* Does the vendor provides training instructors at beginning?<br />
* Are the training staff familiar with both the technical aspects of the product and the clinical needs of the department of interest? (i.e. subject matter specialist, clinical informatic specialist)<br />
* Does the vendor has well-organized and reliable training courses?<br />
* Training Contract - Training should be included in the licensing and service agreement, but some vendors provide separate online and onsite training contracts.<br />
* Does the EHR vendor provide a test version of EHR product for training and quality assurance (QA) purposes as well as the full production environment that is installed in the clinic? (The test version is a segmented area where users can make changes to templates or forms without it affecting the live environment) (http://www.americanehr.com/Home.aspx)<br />
* Are training materials provided by the vendor or is the organization responsible for producing in-house? If the training material will be developed in-house, does the vendor stipulate specific training requirements (i.e. classroom-based vs. web-based, mandatory competency examinations)?<br />
* What kind of on-going training and support will be provided after implementation? Is the cost of post-implementation training and support clearly specified?<br />
* If there are major updates to the system, will the vendor provide ample support and training for the users? And how much will this additional training cost?<br />
* Does the EHR/EMR vendor offer the option to have their staff available to be present at the hospital/clinic/facility during training and then "go-live" implementation? This would allow the EHR/EMR staff to offer hands-on support for any obstacles that come up during training and "go live" implementation. <br />
<br />
<br />
<br />
'''* Spell out pricing before selecting and Electronic Medical Record (EMR/Electronic Health Record (EHR) system such as hardware, software, maintenance, upgrade costs, lab and pharmacies interfaces, customized quality reports, expenditure to connect to health information exchange (HIE)Bold text'''== Future relationships: vendor partnership ==<br />
<br />
* Talk to vendor's existing customers, making sure to also contact some vendor customers independently, as the vendors tend to only provide contacts to their most satisfied customers.<br />
*Research available EMR systems and vendors: determine if your jurisdiction has a "pre-approved" vendor list; develop checklists & questionnaires to assist with product comparison; and prepare a Request for Proposals (RFP). <br />
*An important consideration is whether the vendor or any of its industry partners have done an analysis of processes in healthcare<br />
*Ensure there will be well-laid out contractual agreement regards the 'source code' that will satisfy/cover necessary conditions: "When does the company get the 'source code?, How does the company get the source code?"<br />
*If there are workflow changes within the organization, after the product is implemented, is the product flexible enough to allow for changes without major outages or disruptions to daily activity?<br />
*What are the vendors’ contingency plans if technical glitches occur, post implementation?<br />
*Is technical support offered by the vendor 24 hours per day/ 7 days a week?<br />
*In the event of need for support from the vendor, what is the approximate response time to calls that vendor the projects?<br />
* What is the cost of providing this technical support per hour?<br />
* What size, in terms of employees, is the EHR vendor? Do they have the staff to fully address the support needs of their current client base and, can they accommodate the added support load of your institution?<br />
*In terms of clinical decision support, how often are drug list and drug interaction list updated? Once updated, how long will it take for the changes to be accessible by the end users?<br />
* When code sets and medical vocabularies, ontologies, etc. are updated, how long after will the tool be updated?<br />
*In "EMR Vendor Selection" on Health Technology Review.com (http://www.healthtechnologyreview.com/emr-vendor-selection.php) it states an old adage in the Software industry that consumers will buy a product based on features, but will leave the vendor based on a lack of support. Therefore, it is important to check references for the vendor related to post-implementation technical support satisfaction.<br />
* Aside from providing source code in the event the company undergoes changes, how and when can the organization acquire the "raw" data?<br />
* Will the source code be placed in escrow so that the system could be maintained and modified by internal IT staff in the event that the vendor ceases operation.<br />
* Does the vendor have local support personnel or will all issues be handled by a distant team?<br />
* What is an average time for installing and testing upgrades to the system? If an upgrade is missed or skipped, does the subsequent upgrade(s) have all prior changes included or just the current fix or feature for that version?<br />
* Is there going to be a vendor-institution confidentiality agreement or can the vendor share institutional information and dealings with other establishments?<br />
<br />
'''* Does the vendor's produce meet our needs and goals for our practice? Carryout a test drive of our specific needs with the vendor's product and provide the vendor with patient and office scenarios or mock trial that they may use to customize their produce demonstration.Bold text'''=== Upgrades ===<br />
<br />
* Does the vendor share the organization's '''vision''' for the EHR?<br />
* Does the product provided by the vendor has all the '''key functions''' needed to fulfill the vision of the organization?<br />
* Is the vendor utilizing the desired technology?<br />
* Compare retail broker workstation alternatives, including proprietary and third party packages, based on user requirements and technology/operational considerations. Project included EMR development and response evaluation<br />
* Does the vendor plan to offer interoperability options in the event of a nationally implemented CIS?<br />
* Upon the termination of a license or agreement, is there an orderly process for you to extract your data? This is applicable if you access the vendor’s software within an application service provider (ASP) model.[http://www.ama-assn.org American Medical Association]<br />
* Ability to have HIE compatibility<br />
* Improved billing accuracy and charge capture<br />
* Electronic replacement for traditional reportable disease notifications to health departments, may become part of biosurveillance in the future.[1]<br />
* Is it possible to virtualize or [http://en.wikipedia.org/wiki/Sandbox_(software_development) sandbox] the system to test updates? This functionality would allow site specific testing of new features and systems with less risk of corruption of the current system. It would also allow testing of new features functionality and allow easy rollback if features end up being unwanted.<br />
* Does the system allow outreach/growth to affiliates as a "subset" of the existing clinical provider group? Does that outreach include full or limited functionality? How does that data interface with the existing clinical record?<br />
*How does the system scale? Is the vendor able to provide support and functionality as a practice grows or can they provide functionality to a small, regional branch?<br />
* Provision of EHR systems that support the capture of public health data from Clinical Information Systems.<br />
* Does the system can combine with EHR in long term health care area as a reminder of senior people?<br />
* Ensure that your vendor will be around when you need help. While specific vendor qualifications vary, generally information to be considered in the vendor vetting process, besides functional and technical details, includes vendor reputation, staff experience and qualifications, and financial solvency. (Chao, C., & Goldbort, J. (2012). Lessons Learned from Implementation of a Perinatal Documentation System. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), 599-608. doi:10.1111/j.1552-6909.2012.01378.x)<br />
*Does the vendor allow discrete data capture and easy reporting of critical data that needs to be submitted for reimbursement by the national and state policies on healthcare?<br />
*Is the vendor at the forefront of research in healthcare and does the software offer clinical dashboards and predictive models for easy tracking and analysis of patient data and efficient decision making by clinicians.<br />
*Does the vendor require hiring of outside consultants for training?<br />
<br />
== Contracts ==<br />
<br />
Contracts are as much a business tool as they are a purchasing agreement. <ref name="ehr contract">Carolyn Hartley - signing an EHR contract http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
<br />
* Project Payments<br />
* Contract Terms [http://calhipso.org/documents/ehr_contracting_terms_final_508_compliant.pdf]<br />
* All costs, current and future, associated with the implementation<br />
Details of the total cost incurred by the institution also called total cost of ownership (TCO) is an important consideration in the selection process. It helps to predict the longevity of the program. The request for proposal to vendors should include a request for information about vendor license and implementation costs. Vendors should deliniate the assumptions made when preparing the TCO so the decision committee is able to verify that they are parallel to the goals and objectives of the insitutions. If the same assumptions are encorporated in all request for proposals one can better compare the applications.(8)<br />
Institutions must also consider the intangible return on their investments such as reduced adverse events, decreased hospital stay, accurate and timely billing and improved management of supplies. <br />
* Time commitment from vendor with regard to implementation and training<br />
* Penalties for delays in implementation<br />
* Code escrow - be sure code will be available if vendor goes out of business<br />
* Indemnification and hold harmless clauses <br />
* Confidentiality and nondisclosure agreements <br />
* Warranties and disclaimers <br />
* Limits on liability <br />
* Dispute resolution <br />
* Termination and wind down<br />
* Intellectual property disputes <br />
* IT support agreement<br />
* Training Contract<br />
* Applied area contract<br />
* User and vender liability<br />
* Disputation judgment <br />
* Attorney of vender and clients<br />
* User License - The person who has access to data using a user ID and password. Pricing structures vary according to the definition of user.<br />
* Consider variation of user licenses according to the needs: one price per MD, tiered price (MD, nurse or administrator), site license (25+ providers in the same facility), and enterprise license (multiple users in multiple departments). <ref name="user license">Signing an EHR contract. Tips to control costs. http://physiciansehr.org/signing-an-ehr-contract-25-tips-to-control-costs.aspx </ref><br />
* Interface - The EHR vendor's contract includes the cost of interfaces. These include interfaces such as those with your scanner or fax machine; and more complex interfaces such <br />
* Hardware Contract - Review the EHR vendor's hardware quote, but research may lower costs. Check the vendor's website for hardware specifications the vendor supports. Hardware includes servers, high-speed scanners, computers, handhelds, computer on wheels (COW), wall mounts, etc. Hardware installation to a wholesaler means assembling the server and software to make it work at their location prior to delivering it to you. It usually does NOT mean the installation at your location, a difference that will create a significant budget surprise. Clarify the term "installation" with any hardware wholesaler before making the purchase.<br />
* Third Party Software Contracts – Software includes encryption, speech-recognition, password management, Microsoft™ suite, anti-virus, golden image, bar-coding or webcams.<br />
* Business Associate Agreement - To be HIPAA-compliant you will need a business associate agreement with the vendor, and must ensure the vendor meets HIPAA security and privacy requirements.<ref name="HIMSS-AMA-BAA">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Check Vendor References ===<br />
<br />
*Each vendor being considered should provide minimal of three (3) references, to include a) physician users, b) IT person, and c) senior manager of the facility or practice.<br />
* Vendor provided references may be considered 'happy customers' with biased viewpoints.<br />
* Ask supplied list of references how they acquired the EHR system, eg did they purchase the system or was it provided by the vendor?<br />
* Ask each reference to rate the vendor on a scale from 1 (very dissatisfied/strongly disagree) to 5 (very satisfied/strongly agree) for each criterion<br />
* Each vendor reference should provide reference on background information such as version of system currently being used, duration using current system, length of implementation, number of interfaces practice currently installed and estimated time to install, training provided on-site or remote.<br />
* Each vendor reference should provide reference on current system overview such as system reliability, satisfaction with vendor, and overall satisfaction with system.<br />
* Research references the vendor did not mention, visit facility to get an unbiased viewpoint<br />
* Must use list serves, internet searches and networking to identify other users to interview to get more objective viewpoint.<br />
* All interviewers should utilize the same questionnaire approved by the project manager or steering team.<br />
* Notes must be recorded by each interviewer for each customer interviewed.<br />
* These notes should be made part of the overall evaluation process, ideally kept by the project manager [7].<br />
* Is the vendor currently involved in or have a history of any litigation with customers?<ref name="himss-ama-litigation">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
=== Transparency ===<br />
<br />
EHR vendors may enter contracts with confidentiality or non-disclosure terms that can prevent transparency. Examples include:<br />
<br />
* Disclosures required by law or regulation, sometimes with an obligation to give the other party advance notice and the opportunity to oppose the disclosure or seek confidential treatment.<br />
<br />
*Disclosure of information that has been independently developed by the disclosing party<br />
<br />
*Disclosure of information that is available to the general public or has been provided separately to the disclosing party without violation of an agreement. <br />
<br />
The definition of confidential information may be broad and could restrict your ability to share access to the EHR technology developer’s software in order to compare different EHR technology developer systems, provide access to researchers, or even address possible patient safety concerns. You should review the confidentiality and non-disclosure language carefully to make certain it does not inhibit your ability to conduct activities you value. <ref name="westatterms">EHR Contracts: Key Contract Terms for Users to Understand. http://www.healthit.gov/sites/default/files/ehr_contracting_terms_final_508_compliant.pdf </ref><br />
<br />
== Misc considerations ==<br />
<br />
* It is not uncommon for developers or implementers to impose lock-in features in order to protect their IP rights. How mature is the support community for the particular vendor and is there a marketplace for support and services to their product or is support limited to their own team?<br />
* A multidisciplinary team, usually a subset of the decision team consisting of a physician, IT personnel and a senior management must conduct a site visit to one of the vendor customer sites and vendor headquarters. Informal discussions at this level were quite informative as they bridged the gap between theory and practice for actual software implementation and usage.<br />
* An unstructured “drive-by” demonstration of the system must be arranged for, wherein the vendors conduct product demos, demonstrate product futures and distribute promotional materials for a majority of the employees to get the feel of the new systems. It facilitates building a comfort level and relationship with the vendor and the product offered.<br />
* Can the company demonstrate tangible ways that use of the product can increase hospital revenue? If yes, can you validate this/these claims?<br />
* Is the vendor willing to contract to go "at risk" for any part(s) of the contract?<br />
* What other services does the company offer (especially useful for rural or small hospitals or practices)? e.g. consultants to do special projects, data transmission/claims, billing<br />
*Can the record be accessed at home by clinicians and patients, or do they have to be on-site at the facility?<br />
* Is the vendor capable of adapting to emerging technology such as open source programming, cloud computing, "tablet" PCs/Macs, demand for smartphones (e.g. iPhone), and Web 2.0 technology?<br />
* Is the vendor capable of integrating its system with a personal health record and allowing more patient control?<br />
* Can the company provide return on investment analysis?<br />
* Vendors may not be chosen if the current managers have been convicted of or have had a civil judgment for the following: fraud, antitrust violations, embezzlement, theft, etc.<br />
* Reduced pharmaceutical costs derived from having information available at the time it is needed<br />
* How can this EHR be an asset for the solo practitioner who sees this technology primarily as a financial drain?<br />
* How much extra financial cost will it be to train outpatient clinics that are a subset of the system?<br />
* Does the vender return loss money if their system can not complete established goal in scheduled time?<br />
* Can the company provide a multi-background consult team from doctors, nurses, IT engineer, to attorney?<br />
* Does the vendor qualify the organization's acquisition policies? Is the vendor '''CCHIT certified'''?<br />
* Certification can be verified at the Certified Health IT Product List (CHPL) <ref name="onc ehrcert">Certified Health IT Product List (CHPL) list of EMRs. http://oncchpl.force.com/ehrcert </ref><br />
* Is the vendor active in national EMR leadership task forces, such as the Electronic Health Records Vendors Association <ref name="HIMSSEHRA">HIMSS Electronic Health Record Association http://www.himssehra.org/ASP/index.asp </ref><br />
* Will the vendor be supporting the organization's desired implementation strategy?<br />
* Check the track record of vendor for operations and maintenance support?<br />
* Will the vendor sell or monetize of our clinical data for research or any other purposes? <br />
* Is Application Support provided by on-shore resources? <br />
* Clarify the roles, responsibilities and costs for data migration if desired. <ref name="factors selecting vendor"></ref><br />
* Does the Vendor demonstrate financial and management stability?<br />
* Does the vendor have experience with implementing the product in a similar type of organizations? How many?<br />
* Conduct a site visit <ref name="factors selecting vendor">What factors should I consider when selecting a vendor? http://www.healthit.gov/providers-professionals/faqs/what-factors-should-i-consider-when-selecting-vendor </ref><br />
* Ensure that the site is similar to you - similar number of beds, acuity, rural/urban setting<br />
*'''Flexibility that allows for significant changes in product or order lines'''. Thus, this enables for businesses to modify orders, if necessary, without having to face a penalty from the vendor. Not always do things go as planned and if any modifications are needed, there should not be any consequences that inhibit this from occurring. <br />
* '''The ability to provide all the products/services required and/or the complete solution.''' This in turn can provide the whole picture in allowing for the consumer more transparency in terms of being able to distinguish between the products/services that a particular vendor is offering. As a result, this can save time and money in terms of a consumer being able to choose a certain business that can provide everything that is needed instead of wasting time and effort in purchasing products/services from individual vendors that have a small selection available.<br />
* '''The ability to have a consistent supply of products or services readily available for the business to purchase at all times.''' There is always a need for products and services to be provided on a regular basis; thus a business does not want to have a vendor that has supply issues. If a vendor is not reliable, then it can affect the business’s ability to in turn supply and provide for its customers, which can have a dramatic effect on the reputation and finances of the business.<br />
* Does vendor volunteering disclose adverse events or near misses data involving vendor’s EMR system to potential buyers? Are there protocol designed to notify federally designated patient safety organizations of IT related adverse events or near misses? <ref name="seventeen"> Better Patient Safety is Goal of Confidential EHR Error Reports http://www.amednews.com/article/20130724/profession/130729986/8/ .</ref><br />
<br />
== EHR Evaluation Resources ==<br />
<br />
* American Academy of Family Physicians [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrvendorrating.Par.0001.File.tmp/ehrvendorrating.pdf Vendor Rating Tool]<br />
* American Academy Of Family Physicians HR Demonstration Rating Form EHR Demonstration Rating Form [http://www.aafp.org/online/etc/medialib/aafp_org/documents/news_pubs/fpm/pcmhtools/ehrdemorateform.Par.0001.File.tmp/ehrdemorating.pdf<br />
* American Academy of Family Physicians vendor's references verification form [http://www.aafp.org/fpm/2005/0200/p55.html#fpm20050200p55-bt4]<br />
* American College of Physicians [http://www.acponline.org/acp_press/electronic_health_records/checklist.pdf EHR Feature Checklist]<br />
* Bureau of Primary Health Care. BPHC Electronic Medical Record Resources page. [http://bphc.hrsa.gov/chc/CHCInitiatives/emr.htm]<br />
* Doctor's Office Quality - Information Technology [http://www.healthinsight.org/Internal/REC_Event_Resources/MU_Boot_Camp_Materials_Resources/Guidelines%20for%20Evaluating%20Systems.pdf Guidelines for Evaluating EHR Vendors]<br />
* www.purchasing-procurement-center.com/selecting-a-vendor.html<br />
* The National Learning Consortium Vendor Evaluation Matrix Tool. <ref name="NLCmatrix">The National Learning Consortium Vendor Evaluation Matrix Tool. http://www.healthit.gov/providers-professionals/implementation-resources/vendor-evaluation-matrix-tool</ref><br />
<br />
<br />
*California Health Care Foundation, EMR Evaluation Tool and User Guide - A Guide for Small Physician Practices: [http://www.chcf.org/publications/2003/10/emr-evaluation-tool-and-user-guide]<br />
*American Medical Association - 15 questions to ask before signing an EMR/EHR agreement<ref name"AMA-HIMSS-15Questions">http://www.himss.org/files/HIMSSorg/content/files/Code%2093_15%20questions%20to%20ask%20before%20signing%20an%20EMR-EHR%20agreement_AMA.pdf</ref><br />
<br />
'''Select/upgrade to a certified electronic health record vendor<br />
Retrieved from http://www.healthit.gov/providers-professionals/ehr-implementation-steps/step-3-select-or-upgrade-certified-ehr<br />
text'''==References (old, to edit) ==<br />
<br />
# RI Regional Extension Center. 2011. Vendor members and applicants. Retrieved from http://www.docehrtalk.org/selecting-ehr/for-vendors<br />
# The Certification Commission for Healthcare Information Technology (CCHIT). CCHIT Certified 2011 Ambulatory EHR Certification Criteria. May 17, 2011. Available at: https://www.cchit.org/documents/18/158304/CCHIT+Certified+2011+Ambulatory+EHR+Criteria.pdf.<br />
#http://mhcc.dhmh.maryland.gov/hit/ehr/Documents/sp.mhcc.maryland.gov/ehr/cmsdemo/februarycmsehrdemonstrationarticle.pdf<br />
#McDowell SW, Wahl R, Michelson J. Herding Cats: The Challenges of EMR Vendor Selection. Journal of Healthcare Information Management. 2003; 17(3):17.<br />
# Weber, M. (January 2008). "Selecting an EHR, Now What????" wwww.healthconsultingstrategies.com<br />
# Eastaugh, S. R. (2013). Electronic Health Records Lifecycle Cost. J Health Care Finance, 39(4), 36-43.<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2361387/<br />
# Finding an EHR vendor: Mistakes are costly, and questions about confidentiality linger. (2011). Alcoholism & Drug Abuse Weekly, 23(42), 1-4.<br />
# Jain, V. (2010). Evaluating EHR systems. Health Management Technology, 31(8), 22-24<br />
# Hoyt, R. (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals. Informatics Education<br />
<br />
== References ==<br />
<references/></div>Adlaihttp://clinfowiki.org/wiki/index.php/EMR_Benefits_and_Return_on_Investment_CategoriesEMR Benefits and Return on Investment Categories2014-09-13T21:20:59Z<p>Adlai: /* More effective preventive care */</p>
<hr />
<div>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:<br />
<br />
* Lower number of doctor visits (from the payer's perspective)<br />
* Communication, coding, efficiency, safety improvements<br />
* Transformation of healthcare delivery<br />
* Better Coordination of care<br />
* Improved management of chronic conditions<br />
<br />
However, quantifying these benefits is not a simple task. Issues that have hampered Return on Investment (ROI) studies and affected their validity include:<br />
<br />
* Pressure to justify expense<br />
* Shoddy collection of "before" comparison data after the implementation<br />
* Application of multiple simple statistical tests (the more statistical tests you run, the more likely you are to find something significant)<br />
<br />
The sections below detail the benefits, costs, and barriers in evaluating EMR implementations.<br />
<br />
== Informational ==<br />
<br />
=== Storage and retrieval ===<br />
<br />
EMRs improve the storage and retrieval of patient information in the following ways:<br />
<br />
# Reduces the amount of physical storage space required to house charts.<br />
# Protected from fire, natural disaster, or theft.<br />
# Records can be backed up to off-site facilities<br />
# Instant access to records.<br />
# More controlled access, including a record of who accessed the record.<br />
# Eliminates “lost” or incomplete charts.<br />
# More than one provider can access the record at one time. Ability to identify who modified the record.<br />
# Ensures business continuity and uninterrupted medical service.<br />
<br />
# 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 <ref name="wang 2003"></ref> <br />
# They reduce the likelihood that tests will be unnecessarily duplicated. <br />
# Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data. <br />
# 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). <br />
# 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). <br />
# EMRs reduce the number of lost or missing reports. <br />
# They reduce variability of care.<br />
# Timely delivery of critical services <br />
# Ensures business continuity and uninterrupted medical service.<br />
# Facilitates patient self-service and increases patient's engagement with the help of Patient portal which is a secure online website that patients can access anywhere and anytime to view their medications, immunizations, lab reports, request prescription refills, schedule appointments, make payments and much more.<br />
# Enforces data confidentiality and improves compliance.<br />
<br />
Respondents from the 2011 U.S. Physician Workflow study of office-based physicians reported that the EHR helped them access patient records remotely (81%) and enhanced patient care overall (78%).<br />
<br />
=== Increased Security of Patient Information ===<br />
<br />
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. Installing and enabling encryption is another way to protect and secure patient health information. Encryption is the conversion of data into a form that cannot be read without the decryption key or password. This method is paramount to secure information saved in mobile devices. There are several different ways to encrypt data in motion, such as a virtual private network (VPN) or a secure browser connection [56].<br />
<br />
=== Mobile EMRs ===<br />
<br />
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 presents the following advantages in addition to those observed for EMRs in general (29).<br />
<br />
# Enhanced patient education and satisfaction<br />
# Increased mobility of the device provides a better fit of technology to the application setting <br />
# The iPad touch screen enables easy use even without excessive knowledge of computers<br />
# Mobile devices was similar to paper charts in that they are extremely portable allowing physicians to carry it around in EDs easily<br />
# Remote patient monitoring and diagnosis<br />
# Ability to cross-reference medical terminology and provide multi language support.<br />
# Supports globalization of medical care.<br />
# Ability to send health data directly from wearable devices to medical records [1]<br />
# Link daily activities of living (e.g. fitness, nutrition data) to health data [1]<br />
# Dictate on the iOS device, e-Prescribe, and perform real-time eligibility checks [74]. <br />
<br />
<br />
The March 16, 2012, Letter to Us at Kaiser Permanente reported that Kaiser Permanente members can use mobile smartphones (Android, iPhones, or Blackberrys) to access their medical records, lab results, and all other aspects of kp.org. Kaiser Permanente members accessed the smartphone application over 1,000,000 times during the first month of use. In 2011, KP patients participated in more than 12,000,000 e-visits with their health care providers.<br />
<br />
[http://www.advisory.com/daily-briefing/blog/2014/09/will-apple-iwatch-revolutionize-health-care]<br />
<br />
=== Architecture of Mobile EMRs ===<br />
<br />
Severence Hospital started developing mobile EMR applications in 2005. In 2010, a mobile solutions for healthcare professionals for IOS based iPhones. In 2012, this application was redesinged to be platform independent, encryption policy was added to ensure data security and provided integrated management of Legacy EMR and a mobile solution. The patient list was organized by themes and its main feature was EMR history retrieval. The new architecture design process had four steps: Server and its architecture, Screen layout and story board making, Screen UI design and development, Pilot test and step by step by step deployment.<br />
The Mobile architecture: consists of Mobile server and Mobile device.The server receives information from the EMR system matched with search parameters which is then converted into information to be displayed on specific mobile device.<br />
This mobiles solution was first pilot tested for two month and later deployed in four Severence Hospitals[69]<br />
<br />
=== Improving workflow ===<br />
<br />
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.<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
An EMR service that fully analyzes and streamlines the patient workflow, and works to support a lean practice operation, can actually improve efficiency, such as integrated billing. Providers can be more productive, spend more time with patients, and even enjoy increased patient visits.<br />
<br />
=== Improved care coordination ===<br />
<br />
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.<br />
<br />
=== Integrated View of Patient Data ===<br />
EHR systems can provide integrated access to all data about a patient from many visits and facilities such as laboratory tests, problems, diagnoses, medications, etc. from the database. This retrieval is made easy by data standards like HL7, LOINC, and SNOMED. Practitioners can also have multiple views of data through links provided in the user interfaces.<br />
<br />
=== Tracking Patients’ Medical Data ===<br />
By having the electronic medical record (EMR) save patient data (such as heart rate, blood pressure, eating habits, etc.) over, healthcare providers – or even the patients – can check parameters during a specific time frame when certain symptoms occur and correlate any relation. Having the constant patient data, allows the healthcare professional to go back in time and see any relationship to specific parameters and patient illness symptoms. [5]<br />
<br />
== Health Information Exchange (HIE) ==<br />
<br />
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.<br />
<br />
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.<br />
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.<br />
<br />
=== Facilitated referral for multidisciplinary care ===<br />
<br />
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]. <br />
<br />
=== Better Integrated Care by Hospitals and Long-Term Facilities/Rehabilitation Centers ===<br />
<br />
EHR plays an important role in improving the health care quality and safety; thus reducing the costs of providing care in long-term care facilities. <ref name="ford e 2010">Ford E. Electronic Health Records Hold Great Promise for Long-Term Care Facilities. http://www.ihealthbeat.org/perspectives/2010/electronic-health-records-hold-great-promise-for-longterm-care-facilities </ref> 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. <br />
<br />
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]<br />
<br />
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]<br />
<br />
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].<br />
<br />
=== Minimize Repeating Diagnostic Imaging Studies ===<br />
<br />
HIE can potentially eliminate unnecessary repetition of diagnostic testing, especially in the Emergency Department. Indeed as study found that HIE reduced imaging studies order by Emergency Department physicians for patients presenting with back pain, this is not only decrease the cost of expensive imaging studies but also decrease risk of unnecessary patients exposure to radiation[1]. This illustrate the importance of HIE and the potentially huge impact it will have on reducing cost and delivery an optimal health care. <br />
<br />
=== Facilitate Health Information Exchange ===<br />
<br />
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. HIEs also assist with provider/patient interactions regarding chronic disease management. One example of this looks at Western New York (WNY) Beacon Community and the regional health information exchange (HIE) HealtheLink. The two organizations teamed up to help diabetic patients in upstate New York with disease management. The cost of diabetes management has risen from $174 billion in 2007 to $245 billion in 2012; that is a 41% increase over five years (American Diabetes Association, 2014). These figures address an increased in financial burden, use of health resources and lost productivity associated with diabetes (American Diabetes Association, 2014). In response to this rise in cost, WNY Beacon has shared strategies not only improving the health of diabetic patients, but cutting costs for such management as well. Their strategies cover three primary topics: 1) expanding research for better analytics, 2) improving real-time care coordination and communication and 3) patient education, telehealth and population management. <br />
<br />
==== The Direct Project ====<br />
<br />
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.<br />
<br />
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]<br />
<br />
== Environmental ==<br />
<br />
Using EHRs can greatly reduce the need for paper in an office setting. Instead of throwing away and shredding old paper records or documents and destroying trees, digital documents can be erased without another tree being cut down to make another sheet of paper. http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/ As an eco-friendly software application, it reduces need for reams of paper and the environmental costs associated with it. http://www.healthynumbers.co.za/index.php?page=electronic_medical_records_environment<br />
<br />
== Medical Education ==<br />
<br />
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:<br />
# Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR<br />
# Training the students to follow accepted clinical guidelines (best practices) using CDS<br />
# 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.<br />
# 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].<br />
<br />
The disadvantages of EMRs to education were noted by the following issues:<br />
# Problems with student access into the facilities systems such as obtaining log-ins and passwords<br />
# 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.<br />
# 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.<br />
# Trainees overly attentive to patient’s EMR data versus gaining information from physical examination and patient interactions<br />
# Focus on engagement with computer terminal disrupts patient-physician relationship in exam room<br />
# Automation bias - too much trust in decision support systems without consideration of their limitations<br />
<br />
As EMR use becomes standard fare in medical practice, the benefits of using EMR need to be harnessed by adapting the training curriculum of medical students and graduate medical education trainees to incorporate EMR-related sub- competencies (5).<br />
<br />
[http://jama.jamanetwork.com/article.aspx?articleid=1787416]<br />
<br />
=== Improving interpersonal and communication skills ===<br />
<br />
EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.<br />
<br />
=== Enhancing professionalism ===<br />
Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.<br />
<br />
=== Access to knowledge resource ===<br />
Today, clinicians can get access to medical literature on the internet while making clinical decisions or reviewing patient charts. EHRs can provide links in a patient record to internet resources like PubMed, NLM, and OVID to show clinicians the most up-to-dated information and knowledge in medicine.<br />
<br />
== Financial ==<br />
<br />
By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for: <br />
<br />
# Increase in the pace of information flow including service delivery.<br />
# Coding/billing accuracy.<br />
# Better documentation of patient encounters.<br />
# Reduction in overall administrative and maintenance costs of healthcare institutions.<br />
# Reduction in costs for the patient. <br />
# Reduction in transcription costs [http://jamia.bmj.com/content/18/2/169.full.pdf+html].<br />
# Decrease in malpractice insurance premiums.<br />
# 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].<br />
# Reduction in overtime expenses.<br />
<br />
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].<br />
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].<br />
<br />
Another feature of EMR is the capability to eliminate paper-based informed consents. Paper consents get lost or misplaced very easily and this problem contributes $3.3 billion to the cost of health care in the U.S. due to resulting operating room delays for example. Electronic informed consents also help better reducing liability risk [57]. <br />
<br />
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<br />
<br />
Financial benefits include averted costs and increased revenues, which can be divided into three categories: payer-independent benefits, benefits under capitated reimbursement, and benefits under fee-for-service reimbursement [58].<br />
<br />
=== Quantitative Benefits === <br />
<br />
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.<br />
<br />
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]<br />
<br />
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).<br />
<br />
=== Reducing cost ===<br />
<br />
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]. <br />
<br />
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.<br />
<br />
Kuperman et al. (2003) upon reviewing the benefits of CPOE said that a reduction in medication errors would increase hospital savings. They found two studies showing that half of all of medication errors were due to ordering of a drug for which the patient had an allergy and the other half were because of incorrect drug and incorrect dose. (11) During physician order entries standardized computer order sets can assist physicians to select disease-sensitive drug and patient-specific dosing. Computer applications can also send alerts about patient allergies, drug interactions and monitoring of drug levels.<br />
<br />
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 <ref name="wang 2003"></ref>Interventions to switch the twice-daily dosing of ceftriaxone to once-d<br />
*Provide users with real time knowledge<br />
*Reduce non-clinical time<br />
*Increase patient doctor time<br />
*Investment Motivationaily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).<br />
<br />
Over a 5-year period and determined by the overall size of the particular health system and scope of the EMR implementation, large hospitals can potentially save between $37M and $59M. <ref>Bell, B, Thornton, K. (2011). From promise to reality achieving the value of an EHR. Healthcare Financial Management, 65(2),51-56.</ref><br />
<br />
=== Investment Flexibility ===<br />
<br />
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).<br />
<br />
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)<br />
<br />
=== Management Risk Disposition ===<br />
<br />
The following tenets are the willingness to invest in experimental efforts.<br />
• Provide users with real time knowledge<br />
• Reduce non-clinical time<br />
• Increase patient doctor time<br />
• Investment Motivation<br />
To reduce cost, position for capitation/managed care, and gain market share.<br />
To enable providers to take advantage of financial incentives, the Health Information Technology for Economic and Clinical Health Act (HITECH) lists related criteria related to "Meaningful Use of EHR technology". [8] In addition, the Centers for Medicare & Medicaid Services, along with the Office of the National Coordinator for Health IT requires that an EHR technology are constituted of the following five pillars as health outcome policy priorities (67):<br />
* Improving quality, safety, efficiency, and reducing health disparities.<br />
* Engaging patients and families in their health.<br />
* Improving care coordination.<br />
* Improving population and public health.<br />
* Ensuring adequate privacy and security protection for personal health information.<br />
<br />
== Patient Safety Outcomes ==<br />
<br />
Electronic Medical Records (EMRs) increase patient safety and improve patient quality care by:<br />
<br />
# Insuring practice of better evidence-based medicine<br />
# Allowing flawless health information exchange between health care providers<br />
# Decreasing cost due to changes in drug frequency, dose or route administration <ref name="wang 2003">Wang, S. J., Middleton, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P. A cost-benefit analysis of electronic medical records in primary care. http://www.ncbi.nlm.nih.gov/pubmed/12714130 </ref><br />
# Improving communication and engagement with patients and their health care providers<br />
# Increasing patient medication compliance leading to improved overall health outcomes<br />
<br />
EMRs insure the practice of better evidence-based medicine by developing evidence-based clinical and Good Clinical Practice guideline reminders that are prompted to health care providers during patient encounters. <br />
<br />
The exchange of health information is greatly improved with EMRs because it can be delivered instantly and securely. Since the health care provider is entering the data into an EMR, medical errors are reduced from illegible handwriting. <br />
<br />
EMRs help health care providers by alerting them to potential adverse drug events when entering new prescribed medications in the computerized provider entry forms (CPOE) for patients with allergies, incompatible medication interactions, and delivering medications to verified patients. CPOE systems address these problems, ensure patient safety and save associated costs and injuries. CPOE features that help to achieve this are patient-specific dosage suggestions, reminder to monitor drug levels, reminders to choose an appropriate drugs, checking for drug allergy and drug-drug interactions, standardized order sets, increased legibility, automated communication to ancillary departments and ease of access to patient data.[17] <br />
<br />
EMRs allow pharmacists access to patient histories, past medication therapies, and current lab values. Clinical pharmacists have the responsibility of medication reconciliation, medication dose adjustments due to changes in liver/kidney function, transition of IV to oral therapies (in order to discharge the patient) and establishment of outpatient therapies. These areas of focus have shown to dramatically decrease length of hospital stay, increase beneficial patient outcomes, and decrease overall healthcare cost.<br />
<br />
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]<br />
<br />
Participants in the U.S. 2011 Physician Workflow study of office-based physicians responded that use of the EHR alerted them to potential medication errors (65%) and critical lab values (75%). <br />
<br />
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).<br />
<br />
<ref name="wang 2003"></ref><br />
<br />
=== Improving patient care ===<br />
<br />
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. <br />
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.<br />
<br />
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.<br />
<br />
In the 2014 HIMSS study, "EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates", it was noted that a relationship exists between the level of EMR adoption as measured by the EMRAM score, and a hospital’s performance as measured by predicted, actual rates of mortality and associated z-scores. This study implications include that hospitals with advanced EMR capabilities are able to capture more information about the patient. This improved data capture involving the patient’s co-morbidities and other risks allow clinicians to better manage patients seen in the hospital, resulting in more positive predicted clinical outcomes. [63]<br />
<br />
=== Improved quality and convenience of patient care ===<br />
<br />
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. In addition, it serves in achieving a higher form of personalized medicine and continuity of care, which are really important in the quality of patient 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:<br />
* 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.<br />
* 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! <br />
* 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.<br />
* 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.<br />
<br />
=== Data Legibility ===<br />
Legibility is very important to reduce medical errors. For instance, patient information presented as typed text is much easier to read compared to human writings. They are also unified in structures and standards to prevent confusion. Misspelled words can be corrected with spell checks or autocorrect function. Clinicians will be required by computers to enter complete patient notes to avoid missing information.<br />
<br />
=== Data Legibility Regarding Medications ===<br />
When physicians use Computer Provider Order Entry (CPOE) systems within the EMR, fewer medication errors also occur because there are fewer legibility issues. Proper dosages are clearly entered into the computer by the ordering physician, thus reducing the need for nurses or other staff to “second guess” or question the order. [7]<br />
<br />
<br />
In addition, with the use of electronic prescribing, the hand-written prescription is no longer applicable as a physician can electronically send a prescription directly to the pharmacy of the patient’s choice. This means there’s no question regarding which medication/dosage the provider prescribed and there are no complications with the physical prescription potentially being lost in transition [73].<br />
<br />
=== Engage and improve communication with patients ===<br />
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].<br />
<br />
<br />
With the increase in use of patient portals, more patients and physicians are communicating via secure online messaging. Patients can request appointments, refills, review lab results, pay bills or ask general questions about their health via online portals. Online appointment scheduling is one of the most desired features of the patient portal followed by reviewing test results. In fact, Kaiser Permanente experienced a jump from 9% to 27% in patient registration once they added the feature to review test results [72]. <br />
<br />
<br />
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].<br />
<br />
=== More effective preventive care ===<br />
<br />
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 wellness/follow up visits are recommended [18].<br />
<br />
Kuperman et al. (2003) conducted a review of studies discussing the benefits of CPOE. A randomized control trial of 6731 patients and 200 physicians in a General Medicine teaching institution where the computer application sent a reminder that the patient was eligible for preventive care yielded an increase number of orders for the flu and pneumococcal vaccine as well as aspirin for coronary artery disease.<br />
Another 4 week study conducted in medical and surgical units showed increased number of orders for H2 blockers and prophylactic Heparin when the EHR prompted physicians during CPOE. [11]<br />
<br />
The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].<br />
<br />
=== More effective urgent care ===<br />
<br />
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 ilocal, 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]<br />
<br />
=== Improved Coordination of Care ===<br />
<br />
The use of electronic medical records has allowed multiple healthcare providers across different specialties to access the patient's complete medical record. This more complete picture into the patient's medical history allows better collaborative medical treatment.<br />
<br />
=== Increased patient participation in their care === <br />
<br />
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. Patients are able to obtain medication refill reminders, insert lab values (i.e. glucose levels or warfarin levels) for review by a clinician, and request refills. The pharmacist at a distant location is able to review this information and make the appropriate changes in therapy. This electronic process allows patients to be more involved in their medication therapies and this involvement may increase compliance and overall outcomes.<br />
<br />
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.<br />
<br />
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].<br />
<br />
=== Improved accuracy of diagnoses and health outcomes === <br />
<br />
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]. One study showed a 48% decrease in the likelihood of medication errors in an inpatient hospital setting. <ref name="Radley"></ref> Although it is unclear that CPOE can reduce the harm for patients from medication, the increasing amounts of data acquired such as particular medication for certain diseases and outcomes, may play a vital role in the efforts for improving public health.<br />
<br />
===Preventing Adverse Events===<br />
Physician surveys have attributed EMRs to alerting to allergic drug reactions and drug interactions that might have been missed. In addition, they reported more timely reporting of critical laboratory values.[60] <br />
A systematic review of the effectiveness of safety alerts in EMRs showed a reduction in medication errors in patients with renal insufficiency, pregnant women, elderly patients, drug-drug interactions and ADEs related to hyperkalemia.[61]<br />
<br />
This is an important benefit, since medication related adverse events, will not only cause patients harm but will increase the cost.[2] and the use CPOE will eventually help to reduce the cost of medication related adverse events [3]. Although, some study suggested that is less likely to occur during the early implantation phase[4].<br />
<br />
Although many studies have shown CPOE can reduce the frequency of medication errors, there is no distinct association between CPOE and reduced harm for patients from medication. <ref name="Radley"> Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6 </ref> For instance, there are certain antibiotics that work well with certain disease pathways, and selecting the wrong one may have null effects that may cause further harm for the patient. Developing EHR systems will provide additional data on the usage of certain medications with diseases and outcomes, which will expand our knowledge on selecting efficient medication for improving quality in patient care.<br />
<br />
=== Improve patient safety at the point of pharmacy order entry ===<br />
EHRs with alerts at the point of pharmacy order entry can help reduce medication errors and prevent potential clinical hazards. <br />
<br />
EHR alerts has been beneficialin reduce medication errors in elder patient, pregenant patient and patient with compromised renal or liver functions. EHR alerts can help reduce drug-drug interactions and allergic and adverse events. [http://www.ncbi.nlm.nih.gov/pubmed/23816138]<br />
<br />
=== Qualitative Benefits === <br />
<br />
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. The EMR can help the provider deliver the best quality of care because the EMR contains the complete patient‘s health history. In a crisis, the EMR provides immediate access to a patient's medical history, allergies, and medications. The retrieved information enables providers to make decisions sooner which otherwise they would have to wait for, like information from test results or other resources. This feature is very critical when a patient has a serious or chronic medical condition, such as diabetes. Also, the EMR information can be shared with patients and their family, so they can more fully take part in decisions about their health care. In addition, using decision support tools in EMRs help the provider to make efficient and effective decisions about patient care through clinical alerts and reminders.<br />
<br />
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.<br />
<br />
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].<br />
<br />
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<br />
<br />
== Personalizing Healthcare ==<br />
<br />
===After Visit summaries (AVS)===<br />
<br />
Stage 3 meaningful use recommends that patients or their authorized representative receive a clinical summary after each visit that is not just an abstract from the medical records, Most EHRs enable clinicians to supply patients with such information in the form of an After Visit Summary (AVS) that is generated from data entered into their medical records. The AVS should have relevant clinical information and instructions pertinent to the office visit. It should also be provided in a language other than English, when needed, within 3 business days of the clinic visit, and should contain more than 50% of the office visit clinical summary. Provision of the AVS is important, as physicians usually overestimate patient understanding of the treatment plan. Therefore, the AVS has the potential to improve patient engagement in their care and contribute to more personalized healthcare and share medical decisions.<br />
<br />
===Improved Documentation of Advanced Care Planning=== <br />
EMR can be utilized to screen patients in an outpatient setting and prompt the physician to have a discussion about Advanced Directives. A study conducted as a QI improvement project showed that EMR-based reminders on counseling were effective in improving documentation rates of Advanced Directives.[59]<br />
=== Targeted cancer therapy ===<br />
EHR with clinical decision support help process the genomic data in the context of individual patient and provide dosing recommendation in a timely manner. <br />
EHR when intergrated into work flow can help realize personalized cancer treatment at the point of care. [www.ncbi.nlm.nih.gov/pubmed/21568680]<br />
=== Enhanced Patient Access ===<br />
Some EHR systems provide functionality e.g. MyChart [10] for patients to access portions of their medical record, view test results, renew prescriptions, schedule appointments etc. These convenience features enable patients to engage in and take ownership of their own health care.<br />
<br />
[http://my.clevelandclinic.org/online-services/mychart.aspx]<br />
<br />
== Administrative and Management Benefits ==<br />
<br />
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 interoperable, EMRs can provide far more benefits than paper records such as "help providers improve productivity and work life balance." [68] At a higher level of EMR implementation and functionality, Computerized Provider Order Entry (CPOE) can help standardize the clinical practice and eliminate variation. Some benefits of CPOE are:<br />
<br />
* Help improve communication amongst care givers<br />
* Expedite patient transfer to other levels of care<br />
* Capture data for quality assurance and administrative purposes<br />
* Aid practice and care in a complex care environment through the use of alerts and reminders<br />
* Provides some level of assurance to patients that technology is being applied to their safety [38].<br />
* 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.<br />
<br />
=== Establishing a learning chance to improve healthcare system === <br />
<br />
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.<br />
<br />
=== Customer Support ===<br />
<br />
Some EHR provide help and support in the form of a medical billing specialist. This specialist gives both practices and patients customer support. The specialist also has access to medical codes (ICD-9), CPT code books and practice-related HIPAA information. Other EHRs provide onsite training and on-the-phone consulting for software and billing questions. http://www.advancedmd.com/medical-billing-services <br />
<br />
===Increased practice efficiencies, cost savings, and reimbursement===<br />
<br />
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]. <br />
<br />
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. Historically, it has been difficult to identify and achieve a solid, measurable Return on Investment (ROI) following Electronic Health Records (EHR) or other clinical system implementation initiatives. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has motivated system implementations, and the associated incentive dollars have offered a simple measure of ROI on the revenue side of the ledger, but this represents only one aspect of the substantial benefits clinical systems can yield. A proper optimization program, with broader consideration for the projects comprising it, can bring a truly positive ROI to healthcare organizations over a 10-15 year period if properly considered and executed. (Cumberland Consulting Group, 2013) 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]. According to DRCRHONO, physicians qualify to get $24,000 or more as part of the economic stimulus incentive offered by the HITECH act if they adopt a certified EMR. Incentives are given to providers who qualify. The stimulus includes $24,000 in Medicare Incentives or $63,750 in Medicaid Incentives. The government is putting in $19.2 billion dollars to help move all doctors off paper records onto electronic systems [62].<br />
<br />
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.<br />
<br />
=== EMRs Help Manage Transactions ===<br />
EMRs help better manage the “large number of transactions and handoffs” which can include: billing, physicians’ orders, prescriptions, nurses’ orders insurance information, and more. Having this information all in one place makes it easier for any staff member – from administrators/front office to pharmacists to physical therapists – to gain access to the patient’s records and read and notes that may apply to them. [6]<br />
<br />
== Clinical Decision Support ==<br />
<br />
[[CDS|Clinical Decision Support (CDS)]] has been shown to increase healthcare quality and patient safety, improve adherence to guidelines for prevention and treatment, avoid medication errors and reduce cost of care.<br />
<br />
=== Improved healthcare quality ===<br />
CDS can be used as an additional tool for performing potentially more accurate diagnoses in challenging situations, thus improving the quality of provided care.<br />
Monitors attached to the patient in a hospital bed emit a plethora of real-time physiological data, i.e. EKG signals, blood-oxygen saturation, etc. A CDSS driven by computer algorithms capable of pattern recognition by interpreting the data, ideally in real-time, will aid the physician in providing prompt, better quality care.<br />
<br />
=== Improved patient safety ===<br />
CDSS affect patient safety by substantially reducing medication error rates, reducing risk of overdose or medication abuse, decreasing the occurrence of adverse drug reactions, and increasing adequate follow-up of critical test results such as abnormal biopsies, radiological studies, and laboratory tests Further, these systems utilize a variety of tools to enhance decision-making in clinical workflow, including computerized alerting systems, reminders, advice, critiques, and suggestions which can notify physicians about problems occurring asynchronously (clinical guidelines, condition-specific order sets, focused patient data report, summaries, etc.). <br />
<br />
=== Improved Reporting Capabilities ===<br />
An EMR has the capability of providing a more robust reporting environment with integrated clinical and administrative data, standardized clinical assessments and calculation of outcome measures[http://ptjournal.apta.org/content/86/3/434.full.pdf+html].<br />
<br />
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.<br />
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. Researchers from King Saud University in Saudi Arabia also found the usefulness of incorporating EHR techniques in their clinical decision support systems. The team created a four-module knowledge-based system that incorporated algorithmic guidelines and EHR data mining (66). Guidelines used in the proposed system are the International Classification of Disease (IDC), SNOMED CT, LOINIC, and the Unified Medical Language System (UMLS). The sophisticated system is projected to not only increase workflow, but also serve as a system for various entities to use as a consulting tool.<br />
<br />
===Reduce Diagnostic Errors===<br />
Diagnostic errors are defined as missed, delayed, or wrong diagnosis can lead to missed opportunity in patient care and increased cost [6]. CDS have the potential to improve the diagnostic process[7]. Moreover, systematic reviews found that CDS can improve health care professional performance [8]. Therefore, there is increase evidence that CDS can be helpful in many ways. It is clear that CDSS will have significant effect on improving patient safety strategies [9] <br />
<br />
===Reduced Cost ===<br />
Incorporating decision support within a CPOE not only assists a physician in practicing evidence-based medicine, it has also been demonstrated to reduce cost. Specifically, renal dosing guidance, specific drug guidance and adverse drug prevention have contributed to a net operating budget savings of $9.5 million at Brigham and Women's Hospital [21]. The average savings computed from the study indicated a 6-month savings of $3,450 per clinician. This is just one example of a study result measuring the impact of a specific CDSS in a specific EHR system in a singular clinic setting.<br />
<br />
== Research ==<br />
<br />
=== Informatics ===<br />
<br />
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.<br />
<br />
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].<br />
<br />
* 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. <br />
* 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). <br />
*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. <br />
* 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]<br />
<br />
=== Bioinformatics ===<br />
<br />
* 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.]<br />
<br />
=== Enhance public health surveillance ===<br />
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. According to The Advisory Board Company, there are three key elements for successful population health management (The Advisory Board Company, 2014):<br />
1. Information-powered clinical decision making (e.g. robust patient data sets and integrated data networks)<br />
2. Primary care-led clinical workforce (e.g. PCP care team leaders and mobilization of community workforces)<br />
3. Patient engagement and community integration (e.g. map services to population need and overcoming non-clinical barriers to maximize health outcomes).<br />
<br />
EHRs in conjunction with organizational improvement practices can help to address all three of these key elements. Incorporating electronic health records into public health practice not only improves public health surveillance, but also expands the communication between health care providers and public health professionals. In addition, organizations will be better able to track and prevent disease before an epidemic occurs. Through current government legislation, EHRs will assist public health research in achieving meaningful use(68). Many programs have already been implemented to begin this integration. <br />
<br />
An example of successful EMR surveillance is displayed in a 2012 article of the American Journal of Preventive Medicine, where the study focused on a model EMR-based public health surveillance platform, Electronic Medical Record Support for Public Health (ESP). It was noted to enable clinicians to provide high-quality surveillance data on notifiable diseases, influenza-like illness, and diabetes to public health agencies. This surveillance data can help health departments acquire rich and timely data on broader populations and wider sets of health indicators than is routinely possible with current surveillance systems. [64]<br />
<br />
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.<br />
<br />
=== Tracking Epidemics ===<br />
<br />
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 [[Centers for Disease Control and Prevention (CDC)|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. <ref name="emr cdc outbreak">http://www.gereports.com/using-emrs-to-help-the-cdc-track-outbreaks-faster/ </ref><br />
<br />
=== Better Evidence Based Practices ===<br />
<br />
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]<br />
<br />
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]<br />
<br />
=== Pharmacogenetic Research ===<br />
Patients' responses to drug treatment differ due to their genetic backgrounds. Such information is important to provide patient with optimized drug treatment. <br />
<br />
EHR can improve the quality and efficiency of pharmacogenetic research works by providing the link between pharmacoepidemiology and pharmacogenetics. EHR also supporting the pharmacogenetic research with access to health record database. [http://www.ncbi.nlm.nih.gov/pubmed/24581153]<br />
<br />
=== Clinical Research ===<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Front-end)''' [69]<br />
<br />
#Study setup<br />
##Query EMR database to establish number of potential study candidates.<br />
##Incorporate study manual or special instructions into EMR “clinical content” for study encounters.<br />
#Study enrollment<br />
#Implement study screening parameters into patient registration and scheduling. <br />
##Query EHR database to contact/recruit potential candidates and notify the patient’s providers of potential study eligibility.<br />
#Study execution<br />
##Incorporate study specific data capture as part of routine clinical care/documentation workflows. <br />
##Auto-populate study data elements into care report forms from other parts of the EMR database.<br />
##Embed study specific data requirement as special tabs/documentation templates using structured data entry.<br />
##Implement rules/alerts to ensure compliance with study data collection requirements.<br />
##Create range checks and structured documentation checks to ensure valid data entry.<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Back-end)''' [69]<br />
<br />
# Submission & Reporting<br />
##Provide data extraction formats that support data exchange standards<br />
##Document and report adverse events<br />
#Evidence-based review<br />
##Assess congruence of new findings and existing evidence with current practice and outcomes (incorporate into meta-analyses)<br />
##Submit findings to electronic trial banks using published standards.<br />
#Evidence-based clinical care<br />
##Implement study findings as clinical documentation, order sets, point of care rules/alerts<br />
##Monitor changes in care and outcomes in response to evidence base clinical decision support.<br />
##Provide easy access to detailed clinical care data for motivating new clinical trial hypotheses.<br />
<br />
=== The n-of-1 Clinical Trial ===<br />
<br />
N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. The availability of electronically accessible data provides opportunities for learning from experience in clinical care; this can also referred to as evidence farming or using evidence macrosystem. Evidence farming can be characterized as a “bottom up” paradigm for clinical practices to incorporate practice data systematically as source of evidence, or and articulated form of clinical experience. <ref name="n-of-1">Lillie, Elizabeth O., et al. "The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?" http://www.ncbi.nlm.nih.gov/pubmed/21695041 </ref><br />
<br />
=== Clinical Data Research Networks ===<br />
<br />
Since electronic medical records systems allow for the capture and storage of records in a discrete data format many secondary uses of the data is made possible. By utilizing health information exchange communities can share and aggregate their data for research to improve population health. The compiled data can be used to improve patient engagement, improve regulatory oversight, share the results of studies across health systems, and increase the use of research to improve outcomes at member institutions. In New York City this very concept has been proven successful through a project funded by the Patient-Centered Outcomes Research Institute (PCORI), and with the future adoption and utilization of HIEs more populations will be able to take advantage of these benefits. <ref name="CDRN">Kaushal, R., Hripcsak, G., Ascheim, DD., et al. (2014, March 25). Changing the research landscape: the New York City Clinical Data Research Network. J Am Med Inform Assoc. doi:10.1136/amiajnl-2014-002764</ref><br />
<br />
== National and international effects ==<br />
<br />
=== Growth, Job creation, and enhancement in the Commercial Clinical IT sector ===<br />
<br />
The commercial marketplace for clinical IT products has evolved dramatically<br />
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.<br />
<br />
=== Adapt to governmental regulatory changes and requirements ===<br />
<br />
HIPAA and other legislative bodies often require specific requirements. Compiling information from thousands of documents could be needed to complete the government’s requirements, a feat that would be inefficiently labor and time intensive if done with paper records. Digital patient records helps administration and upper management to meet requirements and regulatory changes to satisfy legislative demands. With digital records, auditors can quickly see if physicians and hospital systems are government compliant and can easily point out if they are not, allowing the non-compliant party to correct their inadequacy. http://www.msdc.com/EMR_Benefits.htm<br />
<br />
== Barriers to EMR Implementation ==<br />
<br />
=== System Selection ===<br />
<br />
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.<br />
<br />
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] According to Ajami and Chadegani, despite of the potential benefits of electronic health records, implement of this project facing with barriers and restriction, that the most of these limitations are cost constraints, technical limitations, standardization limits, attitudinal constraints–behavior of individuals and organizational constraints.[71]<br />
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].<br />
<br />
* In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system. <br />
* 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. <br />
* 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. <br />
*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 ]<br />
* 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]<br />
* 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. <br />
*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.<br />
*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.<br />
<br />
=== Costs ===<br />
Cost benefit analysis is categorized into 3 fields [70]:<br />
# Direct, one-time costs<br />
## Hardware & Peripherals<br />
## Packaged and customized software<br />
## Network, peripherals, supplies, equipment<br />
## Initial data collection and conversion of archival data<br />
## Facilities upgrades, including site preparation and renovation<br />
## End-user project management<br />
## Project planning, contract negotiation, procurement<br />
## Application development and deployment<br />
## Configuration management<br />
## Office accommodations, furniture, related items<br />
## Initial user training<br />
## Workforce adjustment for affected employees<br />
## Transition costs (parallel systems, converting legacy systems)<br />
## Quality assurance and post implementation reviews<br />
<br />
# Direct, ongoing costs<br />
## Salaries for IT and assigned end user staff<br />
## Software maintenance, subscriptions, upgrades,<br />
## Equipment leases<br />
## Facilities rental and utilities<br />
## Professional services, Ongoing training and<br />
## Reviews and audits<br />
<br />
# Indirect, ongoing costs. <br />
## Data integrity<br />
## Security<br />
## Privacy<br />
## IT policy management<br />
## Help Desk<br />
<br />
The financial commitment of implementing a CPOE system varies amongst facilities and depends on the facility's current hardware and software systems. The institution's current system needs to have a strong infrastructure in order to be able to enhance it's capabilities. The license for the software is but a small portion of the total cost. The larger expenses incurred will be a result of training healthcare professionals and support activities. Customer service and technical support should be available everyday 24 hours a day. <br />
<br />
For more information, see [[EMR Cost Categories]].<br />
<br />
=== Challenges to Identifying a Return on Investment (ROI) ===<br />
<br />
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]. For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance [58]. <br />
<br />
Additional barriers include:<br />
<br />
*Vendor supplied benefits data may not be objective <br />
*Few vendors maintain a structured database of benefits information<br />
*Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings. <br />
*Differences in system architecture <br />
*Trade journals tend to focus on anecdotal evidence rather then empirical evidence<br />
*No standardized domain method exists to measure the ROI of electronic health records <br />
*Lack of information regarding maintenance and optimization costs [48]<br />
<br />
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]<br />
<br />
=== EMR and Providers’ Productivity ===<br />
<br />
Health care providers are adopting electronic medical records, but some doctors report a disturbing side effect. Instead of becoming more efficient, some practices, especially smaller ones are becoming less. Several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday. [70] <br />
<br />
In a study by Bhargava et al. which examines productivity impacts of electronic medical records (EMR) implementation in a large academic hospital in California. Bhargava et al. also investigate the dynamics through which EMRs may impact productivity. The study employ random effects model on panel data comprising 3,189 physician-month observations for productivity data collected on 87 physicians specializing in internal medicine, pediatrics and family practice. The total duration of data collection was 39 months. Bhargava et al. find that the productivity of physicians dropped immediately after EMR implementation, but began to recover in a few months and finally leveled-off. Additionally, Bhargava et al. find that productivity impacts of EMR are contingent upon physician specialty. Bhargava et al postulate that the fit provided by an EMR to the task requirements of physicians of various specialties is key to entangling the productivity dynamics. [71]<br />
<br />
== Return on Investment (ROI) Estimates ==<br />
<br />
While barriers of determining actual ROI for EMR implementations exist, companies such as Dr. Cloud EMR are providing EMR and EHR ROI estimates based on each practice's details. This however does not suggest that it is entirely accurate and is only an estimate. DrCloudEMR is built by DrCloud Healthcare Solutions Inc, a wholly owned EnSoftek, Inc. subsidiary. [65]<br />
There are 2 main postulates for ROI which KOSH’s postulate and Sir Austin Bradford Hill’s criteria for Causation. <br />
Kosh’s postulate for CIS is <br />
i. The system or feature must be present in every case in which the benefit is observed.<br />
ii. The system must be isolated from the organization. <br />
iii. The benefit must be reproduced when the system is implemented in a new organization.<br />
iv. We must demonstrate that the system was used in the new organization.<br />
Hill’s Criteria for Causation includes (a) Strength of Association (b) Consistency of findings (c) Specificity of Association (d) Temporality (e) Dose-response (f) Plausibility (g) Coherence (h) Experimental Evidence and Analogy.<br />
<br />
=== Sittig's Postulates ===<br />
<br />
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.<br />
<br />
* Must have the hardware and software available before the effect is identified.<br />
** Need to at least estimate state of affairs before system is implemented…manual review<br />
* Show that clinicians are actually using the system that could produce the effect.<br />
* Show that the effect increases with increasing availability and usage of the system.<br />
* Show that all obvious “alternative explanations” for the effect are false.<br />
* Show the effect goes away when the system goes away.<br />
* Show that a similar effect occurs when a similar system is installed and used at a similar facility.<br />
<br />
=== Quality Care ===<br />
<br />
One could approach the ROI from the perspective of the Institute of Medicine Report, ''Crossing the Quality Chasm''<br />
# Safe: Reducing adverse drug events, inappropriate testing<br />
# Effective: Reducing drug costs through appropriate prescribing<br />
# Efficient: Reducing drug, laborotory, or radiologic utilization<br />
# Timely: Reducing wait times<br />
# Patient-centered: Reducing length-of-stay while hospitalized<br />
# Equitable: Provides data to demonstrate equal delivery<br />
<br />
=== Strategic Benefits === <br />
<br />
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.<br />
<br />
<br />
<br />
If EMR is fully implemented and functional, the benefits they offer are substantially than a paper records. Some of these benefits are:<br />
* Improvement in quality of patient care<br />
* An increase patient participation in their care (making appoints, refill of prescriptions, limited access to their records.<br />
* There will be an improvement in the accuracy of diagnoses and health outcomes-decrease of some types of medical errors<br />
* Improve care coordination<br />
* Increase practice efficiencies and cost savings <ref name="healthIT.gov"> http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs </ref><br />
<br />
Arlotto (2014) defends the right that EHRs are able to provide organizations the greatest value in the future of healthcare. She argues that this can be accomplished through the involvement of business, clinical, and financial platforms within an organization. As the healthcare industry is transitioning from volume to value based payment, organizations are increasingly depending on IT applications to facilitate the progress. She explains that our current healthcare practices use EHRs as an entity that simply automates the paper record and measure value based on direct cost-benefit analysis, rather than ensuring value realized over the lifetime of the investment.<ref name="ArlottoAccelROI"></ref> Five commonly mistaken truths are further discussed in order to facilitate the transition for more efficient use of EHR. <ref name="ArlottoAccelROI"> Arlotto, P. (2014). Accelerating the ROI of EHRs. Healthcare Financial Management : Journal of the Healthcare Financial Management Association, 68, 2, 72-9. </ref><br />
<br />
<br />
=== Achieving a Positive ROI ===<br />
<br />
A key to achieving a positive return on investment (ROI) when implementing an EHR system is using it for more than meeting meaningful use requirements. A 2013 study conducted by Harvard University researchers showed that many practices that implemented EHRs showed a negative 5 year ROI. Citing only 27 percent of practices which adopted EHRs would show a positive ROI. The reason for this according to their research was that many practices were not using their EHR systems effectively. The practices which showed a positive ROI were able to use their EHR in a way that increased the number of patients they were able to see in a day as well as improving their billing to reduce rejected claims. The practices which showed a negative ROI were mostly still using paper charts heavily even after implementing the EHR system. This resulted in decreased productivity on top of the expense of the system. The most important step practices must take to see a positive ROI on EHRs is to take the time to optimize their use so they can improve efficiency and reduce costs.<ref name="posroi">Harvard University Reports Findings in Electronic Medical Records. (2013, June 7). Health & Medicine Week, 1809. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA332414959&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&asid=f6372a5c3f33b3956c1739aae9c7d466</ref><br />
<br />
== Incentive Programs ==<br />
<br />
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)<br />
<br />
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)<br />
<br />
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)<br />
<br />
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 [[Office of the National Coordinator for Health Information Technology (ONC)|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)<br />
<br />
=== Sources of Funding === <br />
<br />
# Organizational Reserves – provider organization make investments in affiliated organizations<br />
# Bank and other financial service – short term loans<br />
# Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment<br />
# Vendor discounts and incentives – requires something in return<br />
# Joint venture or partnership – tighter relationship <br />
# Health plans and plan sponsors – contractual arrangement<br />
# Private philanthropy – fellowships or university chairs<br />
# Pharmaceutical companies – willing to conduct clinical trials<br />
# Public grants – government initiatives<br />
# State legislative initiatives – local and state initiatives<br />
<br />
== References (old, to edit) ==<br />
<br />
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]<br />
<br />
# http://www.msdc.com/EMR_Benefits.htm<br />
# http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm<br />
# http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php<br />
# http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm<br />
# http://www.mayoclinic.org/emr/benefits.html<br />
# 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.<br />
# Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67<br />
# Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429 <br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp<br />
# http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf<br />
# http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf<br />
# http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act<br />
# http://www.cdc.gov/ehrmeaningfuluse/<br />
# http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5<br />
# 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.<br />
# Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.<br />
# 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.<br />
#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.<br />
#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.<br />
# http://www.hhs.gov/news/press/2013pres/08/20130805a.html<br />
# http://www.fierceemr.com/story/new-york-looks-ehrs-enhance-public-health-surveillance/2013-08-27<br />
# http://ehrintelligence.com/2012/12/10/engaging-patients-through-ehr-access-open-notes/<br />
# 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,<br />
# Driessen J,CioffiM, Alide N,et al. J Am Med Inform Assoc 2013;20:743–748.<br />
# Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study Sameer Kumar, Krista Aldrich<br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html<br />
# http://www.ncbi.nlm.nih.gov/pubmed/9576410<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# http://www.practicefusion.com/ehrbloggers/2010/10/return-on-investment-for-emrs.html<br />
# http://jama.jamanetwork.com/article.aspx?articleid=1737043#ArticleInformation<br />
# Kuperman, G.J. and Gibson, R.F. (2003) “Computer Physician Order Entry: Benefits, Costs & Issues” Am Intern Med 2003; 139:31-39<br />
# Crane, R.M. and Raymond, B. (2003) “Fulfilling the Potential of Clinical Information Systems: The Permanente Journal Winter/2003/Vol.7No1<br />
# Kaushal, R.; Jha, A.K.; Franz, C. et al. (2006) J Am Med Inform Assoc 2006;13:261-266 doi 10.1197/jamia.J1984<br />
# http://www.nejm.org/doi/full/10.1056/NEJMp1211315#t=article<br />
# Menachemi N, Collum H.T. Benefits and drawbacks of electronic health record systems.Risk Manag Healthc Policy. 2011; 4: 47–55.<br />
# http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide-chapter-2.pdf<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978883/<br />
# 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.<br />
# Butcher L. Hospitals strengthen bonds with post-acute providers. http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG<br />
# Voigt, C. & Torzewski, S. (2011). Direct results: An HIE simple information exchange using the direct project. Journal of AHIMA, 38-41.<br />
# Kohn, L. T., Corrigan, J. M., & Donaldson, M. S., eds. (2000). To err is human. ''Institute of Medicine Committee on Quality of Health Care in America''. Washington, DC: National Academic Press.<br />
# McGeath, J. (2012). The Team Dynamics of Connecting Medical Devices with EMR Systems. 24X7, 17(10), 34-41<br />
# Mulherin, D. P., Zimmerman, C. R., & Chaffee, B. W. (2013). National standards for computerized prescriber order entry and clinical decision support: The case of drug interactions. American Journal Of Health-System Pharmacy, 70(1), 59-64. doi:10.2146/ajhp120217<br />
# Otte-Trojel, T., de Bont, A., Rundall, T. G., & van de Klundert, J. (2014). How outcomes are achieved through patient portals: a realist review. Journal of the American Medical Informatics Association, amiajnl-2013.<br />
# http://www.healthit.gov/providers-professionals/2-install-and-enable-encryption<br />
# http://www.dialogmedical.com/informed-consent-2-3/<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047866.hcsp?dDocName=bok1_047866<br />
# Hayek S1 et al. End-of-Life Care Planning: Improving Documentation of Advance Directives in the Outpatient Clinic using Electronic Medical Records. J Palliat Med. 2014 Jul 2.<br />
# Gummadi S1. Electronic medical record: a balancing act of patient safety, privacy and health care delivery. Am J Med Sci. 2014 Sep;348(3):238-43.<br />
# Ojeleye O1 et al. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013 Jul 1;13:69.<br />
# https://www.drchrono.com/meaningful-use-ehr/<br />
# EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates. http://apps.himss.org/content/files/HAHealthgradesEMRStudyWhitePaper.pdf<br />
# Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. http://www.ajpmonline.org/article/S0749-3797(12)00249-8/fulltext<br />
# EMR ROI / EHR ROI Calculator. http://www.drcloudemr.com/roi/<br />
# http://www.academia.edu/4083826/An_Adaptive_Evidence_Based_Medicine_System_Based_on_a_Clinical_Decision_Support_System<br />
# http://www.cdc.gov/ehrmeaningfuluse/introduction.html<br />
# http://www.healthit.gov/providers-professionals/faqs/how-can-electronic-health-records-improve-public-and-population-health-<br />
# http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf<br />
# http://www.forbes.com/sites/hbsworkingknowledge/2014/03/26/how-electronic-patient-records-can-slow-doctor-productivity/ <br />
# Bhargava, Hemant K., and Abhay Mishra. "Electronic Medical Records and Physicians Productivity: Insights from Panel Data Analysis and Design Implications." 2nd round at Management Science (2011).<br />
# http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1855&pageaction=displayproduct<br />
# Shortliffe, E. H., & Cimino, J. J. (2006). ''Biomedical informatics''. Springer Science+ Business Media, LLC.<br />
# http://www.healthit.gov/providers-professionals/faqs/what-are-advantages-electronic-health-records<br />
# Kim, Y., Kim, S. S., Kang, S., Kim, K., & Jun Kim. (2014). Development of Mobile Platform Integrated with Existing Electronic Medical Records. Health Infrormatics Research.<br />
# Zaroukian, M. (n.d.). EMR Cost-Benefit Analysis: Managing ROI into Reality. Retrieved from http://www.himss.org/files/HIMSSorg/content/files/EMRCost-BenefitReality.pdf<br />
# Ajami, S., & Arabchadegani, R. (n.d.). Barriers to implement Electronic Health Records (EHRs). Materia Socio Medica, 213-213. Retrieved September 10, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804410/<br />
# http://hitconsultant.net/2014/08/19/patient-portal-features-which-is-the-most-beneficial-frustrating/<br />
# http://www.cms.gov/Medicare/E-Health/Eprescribing/index.html?redirect=/EPrescribing<br />
# https://www.drchrono.com<br />
<br />
== References ==<br />
<references/><br />
<br />
5. What Is an Electronic Medical Record (EMR)? http://www.healthit.gov/providers-professionals/electronic-medical-records-emr <br />
<br />
6. Harrington, L., Porch, L., Acosta, K., & Wilkens, K. (2011). Realizing electronic medical record benefits: an easy-to-do usability study. The Journal of Nursing Administration, 41(7-8), 331–5. doi:10.1097/NNA.0b013e3182250b23<br />
<br />
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 (Project Hope), 24(5), 1103–17. doi:10.1377/hlthaff.24.5.1103<br />
<br />
== References ==<br />
# Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health Information Exchange Reduces Repeated Diagnostic Imaging for Back Pain. Annals of Emergency Medicine 2013 Jul;62(1):16-24.<br />
# Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997 Jan 22;277(4):307-11.<br />
# Johnston D, Pan E, Walker J. The value of CPOE in ambulatory settings. J Healthc Inf Manag 2004;18(1):5-8.<br />
# Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 Mar;11(2):100-3.<br />
# Stage DRMU. 3; Meaningful Use Work Group; Paul Tang, chair and George Hripcsak, co-chair. 2013. August. <br />
# Singh H. Editorial: Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis. Joint Commission Journal on Quality and Patient Safety 2014 Mar;40(3):99-101.<br />
# Bogua¡eviaius A, Maleckas A, Pundzius J, Skaudickas D. Prospective randomised trial of computerâ€aided diagnosis and contrast radiography in acute small bowel obstruction. European Journal of Surgery 2002;168(2):78-83.<br />
# Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293(10):1223-38.<br />
# McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):381-9.<br />
# Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. ( 2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6.<br />
11. Kuperman,G.J.,Gibson,R.F. (2003)Computer Order Physician Entry: Benefits, Costs, and Issues. ''Annals of Internal Medicine,139,31-19'' <br />
<br />
[[Category:EMR]]</div>Adlaihttp://clinfowiki.org/wiki/index.php/EMR_Benefits_and_Return_on_Investment_CategoriesEMR Benefits and Return on Investment Categories2014-09-13T21:15:36Z<p>Adlai: /* Administrative and Management Benefits */</p>
<hr />
<div>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:<br />
<br />
* Lower number of doctor visits (from the payer's perspective)<br />
* Communication, coding, efficiency, safety improvements<br />
* Transformation of healthcare delivery<br />
* Better Coordination of care<br />
* Improved management of chronic conditions<br />
<br />
However, quantifying these benefits is not a simple task. Issues that have hampered Return on Investment (ROI) studies and affected their validity include:<br />
<br />
* Pressure to justify expense<br />
* Shoddy collection of "before" comparison data after the implementation<br />
* Application of multiple simple statistical tests (the more statistical tests you run, the more likely you are to find something significant)<br />
<br />
The sections below detail the benefits, costs, and barriers in evaluating EMR implementations.<br />
<br />
== Informational ==<br />
<br />
=== Storage and retrieval ===<br />
<br />
EMRs improve the storage and retrieval of patient information in the following ways:<br />
<br />
# Reduces the amount of physical storage space required to house charts.<br />
# Protected from fire, natural disaster, or theft.<br />
# Records can be backed up to off-site facilities<br />
# Instant access to records.<br />
# More controlled access, including a record of who accessed the record.<br />
# Eliminates “lost” or incomplete charts.<br />
# More than one provider can access the record at one time. Ability to identify who modified the record.<br />
# Ensures business continuity and uninterrupted medical service.<br />
<br />
# 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 <ref name="wang 2003"></ref> <br />
# They reduce the likelihood that tests will be unnecessarily duplicated. <br />
# Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data. <br />
# 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). <br />
# 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). <br />
# EMRs reduce the number of lost or missing reports. <br />
# They reduce variability of care.<br />
# Timely delivery of critical services <br />
# Ensures business continuity and uninterrupted medical service.<br />
# Facilitates patient self-service and increases patient's engagement with the help of Patient portal which is a secure online website that patients can access anywhere and anytime to view their medications, immunizations, lab reports, request prescription refills, schedule appointments, make payments and much more.<br />
# Enforces data confidentiality and improves compliance.<br />
<br />
Respondents from the 2011 U.S. Physician Workflow study of office-based physicians reported that the EHR helped them access patient records remotely (81%) and enhanced patient care overall (78%).<br />
<br />
=== Increased Security of Patient Information ===<br />
<br />
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. Installing and enabling encryption is another way to protect and secure patient health information. Encryption is the conversion of data into a form that cannot be read without the decryption key or password. This method is paramount to secure information saved in mobile devices. There are several different ways to encrypt data in motion, such as a virtual private network (VPN) or a secure browser connection [56].<br />
<br />
=== Mobile EMRs ===<br />
<br />
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 presents the following advantages in addition to those observed for EMRs in general (29).<br />
<br />
# Enhanced patient education and satisfaction<br />
# Increased mobility of the device provides a better fit of technology to the application setting <br />
# The iPad touch screen enables easy use even without excessive knowledge of computers<br />
# Mobile devices was similar to paper charts in that they are extremely portable allowing physicians to carry it around in EDs easily<br />
# Remote patient monitoring and diagnosis<br />
# Ability to cross-reference medical terminology and provide multi language support.<br />
# Supports globalization of medical care.<br />
# Ability to send health data directly from wearable devices to medical records [1]<br />
# Link daily activities of living (e.g. fitness, nutrition data) to health data [1]<br />
# Dictate on the iOS device, e-Prescribe, and perform real-time eligibility checks [74]. <br />
<br />
<br />
The March 16, 2012, Letter to Us at Kaiser Permanente reported that Kaiser Permanente members can use mobile smartphones (Android, iPhones, or Blackberrys) to access their medical records, lab results, and all other aspects of kp.org. Kaiser Permanente members accessed the smartphone application over 1,000,000 times during the first month of use. In 2011, KP patients participated in more than 12,000,000 e-visits with their health care providers.<br />
<br />
[http://www.advisory.com/daily-briefing/blog/2014/09/will-apple-iwatch-revolutionize-health-care]<br />
<br />
=== Architecture of Mobile EMRs ===<br />
<br />
Severence Hospital started developing mobile EMR applications in 2005. In 2010, a mobile solutions for healthcare professionals for IOS based iPhones. In 2012, this application was redesinged to be platform independent, encryption policy was added to ensure data security and provided integrated management of Legacy EMR and a mobile solution. The patient list was organized by themes and its main feature was EMR history retrieval. The new architecture design process had four steps: Server and its architecture, Screen layout and story board making, Screen UI design and development, Pilot test and step by step by step deployment.<br />
The Mobile architecture: consists of Mobile server and Mobile device.The server receives information from the EMR system matched with search parameters which is then converted into information to be displayed on specific mobile device.<br />
This mobiles solution was first pilot tested for two month and later deployed in four Severence Hospitals[69]<br />
<br />
=== Improving workflow ===<br />
<br />
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.<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
An EMR service that fully analyzes and streamlines the patient workflow, and works to support a lean practice operation, can actually improve efficiency, such as integrated billing. Providers can be more productive, spend more time with patients, and even enjoy increased patient visits.<br />
<br />
=== Improved care coordination ===<br />
<br />
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.<br />
<br />
=== Integrated View of Patient Data ===<br />
EHR systems can provide integrated access to all data about a patient from many visits and facilities such as laboratory tests, problems, diagnoses, medications, etc. from the database. This retrieval is made easy by data standards like HL7, LOINC, and SNOMED. Practitioners can also have multiple views of data through links provided in the user interfaces.<br />
<br />
=== Tracking Patients’ Medical Data ===<br />
By having the electronic medical record (EMR) save patient data (such as heart rate, blood pressure, eating habits, etc.) over, healthcare providers – or even the patients – can check parameters during a specific time frame when certain symptoms occur and correlate any relation. Having the constant patient data, allows the healthcare professional to go back in time and see any relationship to specific parameters and patient illness symptoms. [5]<br />
<br />
== Health Information Exchange (HIE) ==<br />
<br />
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.<br />
<br />
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.<br />
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.<br />
<br />
=== Facilitated referral for multidisciplinary care ===<br />
<br />
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]. <br />
<br />
=== Better Integrated Care by Hospitals and Long-Term Facilities/Rehabilitation Centers ===<br />
<br />
EHR plays an important role in improving the health care quality and safety; thus reducing the costs of providing care in long-term care facilities. <ref name="ford e 2010">Ford E. Electronic Health Records Hold Great Promise for Long-Term Care Facilities. http://www.ihealthbeat.org/perspectives/2010/electronic-health-records-hold-great-promise-for-longterm-care-facilities </ref> 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. <br />
<br />
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]<br />
<br />
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]<br />
<br />
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].<br />
<br />
=== Minimize Repeating Diagnostic Imaging Studies ===<br />
<br />
HIE can potentially eliminate unnecessary repetition of diagnostic testing, especially in the Emergency Department. Indeed as study found that HIE reduced imaging studies order by Emergency Department physicians for patients presenting with back pain, this is not only decrease the cost of expensive imaging studies but also decrease risk of unnecessary patients exposure to radiation[1]. This illustrate the importance of HIE and the potentially huge impact it will have on reducing cost and delivery an optimal health care. <br />
<br />
=== Facilitate Health Information Exchange ===<br />
<br />
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. HIEs also assist with provider/patient interactions regarding chronic disease management. One example of this looks at Western New York (WNY) Beacon Community and the regional health information exchange (HIE) HealtheLink. The two organizations teamed up to help diabetic patients in upstate New York with disease management. The cost of diabetes management has risen from $174 billion in 2007 to $245 billion in 2012; that is a 41% increase over five years (American Diabetes Association, 2014). These figures address an increased in financial burden, use of health resources and lost productivity associated with diabetes (American Diabetes Association, 2014). In response to this rise in cost, WNY Beacon has shared strategies not only improving the health of diabetic patients, but cutting costs for such management as well. Their strategies cover three primary topics: 1) expanding research for better analytics, 2) improving real-time care coordination and communication and 3) patient education, telehealth and population management. <br />
<br />
==== The Direct Project ====<br />
<br />
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.<br />
<br />
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]<br />
<br />
== Environmental ==<br />
<br />
Using EHRs can greatly reduce the need for paper in an office setting. Instead of throwing away and shredding old paper records or documents and destroying trees, digital documents can be erased without another tree being cut down to make another sheet of paper. http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/ As an eco-friendly software application, it reduces need for reams of paper and the environmental costs associated with it. http://www.healthynumbers.co.za/index.php?page=electronic_medical_records_environment<br />
<br />
== Medical Education ==<br />
<br />
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:<br />
# Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR<br />
# Training the students to follow accepted clinical guidelines (best practices) using CDS<br />
# 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.<br />
# 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].<br />
<br />
The disadvantages of EMRs to education were noted by the following issues:<br />
# Problems with student access into the facilities systems such as obtaining log-ins and passwords<br />
# 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.<br />
# 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.<br />
# Trainees overly attentive to patient’s EMR data versus gaining information from physical examination and patient interactions<br />
# Focus on engagement with computer terminal disrupts patient-physician relationship in exam room<br />
# Automation bias - too much trust in decision support systems without consideration of their limitations<br />
<br />
As EMR use becomes standard fare in medical practice, the benefits of using EMR need to be harnessed by adapting the training curriculum of medical students and graduate medical education trainees to incorporate EMR-related sub- competencies (5).<br />
<br />
[http://jama.jamanetwork.com/article.aspx?articleid=1787416]<br />
<br />
=== Improving interpersonal and communication skills ===<br />
<br />
EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.<br />
<br />
=== Enhancing professionalism ===<br />
Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.<br />
<br />
=== Access to knowledge resource ===<br />
Today, clinicians can get access to medical literature on the internet while making clinical decisions or reviewing patient charts. EHRs can provide links in a patient record to internet resources like PubMed, NLM, and OVID to show clinicians the most up-to-dated information and knowledge in medicine.<br />
<br />
== Financial ==<br />
<br />
By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for: <br />
<br />
# Increase in the pace of information flow including service delivery.<br />
# Coding/billing accuracy.<br />
# Better documentation of patient encounters.<br />
# Reduction in overall administrative and maintenance costs of healthcare institutions.<br />
# Reduction in costs for the patient. <br />
# Reduction in transcription costs [http://jamia.bmj.com/content/18/2/169.full.pdf+html].<br />
# Decrease in malpractice insurance premiums.<br />
# 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].<br />
# Reduction in overtime expenses.<br />
<br />
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].<br />
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].<br />
<br />
Another feature of EMR is the capability to eliminate paper-based informed consents. Paper consents get lost or misplaced very easily and this problem contributes $3.3 billion to the cost of health care in the U.S. due to resulting operating room delays for example. Electronic informed consents also help better reducing liability risk [57]. <br />
<br />
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<br />
<br />
Financial benefits include averted costs and increased revenues, which can be divided into three categories: payer-independent benefits, benefits under capitated reimbursement, and benefits under fee-for-service reimbursement [58].<br />
<br />
=== Quantitative Benefits === <br />
<br />
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.<br />
<br />
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]<br />
<br />
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).<br />
<br />
=== Reducing cost ===<br />
<br />
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]. <br />
<br />
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.<br />
<br />
Kuperman et al. (2003) upon reviewing the benefits of CPOE said that a reduction in medication errors would increase hospital savings. They found two studies showing that half of all of medication errors were due to ordering of a drug for which the patient had an allergy and the other half were because of incorrect drug and incorrect dose. (11) During physician order entries standardized computer order sets can assist physicians to select disease-sensitive drug and patient-specific dosing. Computer applications can also send alerts about patient allergies, drug interactions and monitoring of drug levels.<br />
<br />
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 <ref name="wang 2003"></ref>Interventions to switch the twice-daily dosing of ceftriaxone to once-d<br />
*Provide users with real time knowledge<br />
*Reduce non-clinical time<br />
*Increase patient doctor time<br />
*Investment Motivationaily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).<br />
<br />
Over a 5-year period and determined by the overall size of the particular health system and scope of the EMR implementation, large hospitals can potentially save between $37M and $59M. <ref>Bell, B, Thornton, K. (2011). From promise to reality achieving the value of an EHR. Healthcare Financial Management, 65(2),51-56.</ref><br />
<br />
=== Investment Flexibility ===<br />
<br />
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).<br />
<br />
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)<br />
<br />
=== Management Risk Disposition ===<br />
<br />
The following tenets are the willingness to invest in experimental efforts.<br />
• Provide users with real time knowledge<br />
• Reduce non-clinical time<br />
• Increase patient doctor time<br />
• Investment Motivation<br />
To reduce cost, position for capitation/managed care, and gain market share.<br />
To enable providers to take advantage of financial incentives, the Health Information Technology for Economic and Clinical Health Act (HITECH) lists related criteria related to "Meaningful Use of EHR technology". [8] In addition, the Centers for Medicare & Medicaid Services, along with the Office of the National Coordinator for Health IT requires that an EHR technology are constituted of the following five pillars as health outcome policy priorities (67):<br />
* Improving quality, safety, efficiency, and reducing health disparities.<br />
* Engaging patients and families in their health.<br />
* Improving care coordination.<br />
* Improving population and public health.<br />
* Ensuring adequate privacy and security protection for personal health information.<br />
<br />
== Patient Safety Outcomes ==<br />
<br />
Electronic Medical Records (EMRs) increase patient safety and improve patient quality care by:<br />
<br />
# Insuring practice of better evidence-based medicine<br />
# Allowing flawless health information exchange between health care providers<br />
# Decreasing cost due to changes in drug frequency, dose or route administration <ref name="wang 2003">Wang, S. J., Middleton, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P. A cost-benefit analysis of electronic medical records in primary care. http://www.ncbi.nlm.nih.gov/pubmed/12714130 </ref><br />
# Improving communication and engagement with patients and their health care providers<br />
# Increasing patient medication compliance leading to improved overall health outcomes<br />
<br />
EMRs insure the practice of better evidence-based medicine by developing evidence-based clinical and Good Clinical Practice guideline reminders that are prompted to health care providers during patient encounters. <br />
<br />
The exchange of health information is greatly improved with EMRs because it can be delivered instantly and securely. Since the health care provider is entering the data into an EMR, medical errors are reduced from illegible handwriting. <br />
<br />
EMRs help health care providers by alerting them to potential adverse drug events when entering new prescribed medications in the computerized provider entry forms (CPOE) for patients with allergies, incompatible medication interactions, and delivering medications to verified patients. CPOE systems address these problems, ensure patient safety and save associated costs and injuries. CPOE features that help to achieve this are patient-specific dosage suggestions, reminder to monitor drug levels, reminders to choose an appropriate drugs, checking for drug allergy and drug-drug interactions, standardized order sets, increased legibility, automated communication to ancillary departments and ease of access to patient data.[17] <br />
<br />
EMRs allow pharmacists access to patient histories, past medication therapies, and current lab values. Clinical pharmacists have the responsibility of medication reconciliation, medication dose adjustments due to changes in liver/kidney function, transition of IV to oral therapies (in order to discharge the patient) and establishment of outpatient therapies. These areas of focus have shown to dramatically decrease length of hospital stay, increase beneficial patient outcomes, and decrease overall healthcare cost.<br />
<br />
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]<br />
<br />
Participants in the U.S. 2011 Physician Workflow study of office-based physicians responded that use of the EHR alerted them to potential medication errors (65%) and critical lab values (75%). <br />
<br />
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).<br />
<br />
<ref name="wang 2003"></ref><br />
<br />
=== Improving patient care ===<br />
<br />
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. <br />
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.<br />
<br />
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.<br />
<br />
In the 2014 HIMSS study, "EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates", it was noted that a relationship exists between the level of EMR adoption as measured by the EMRAM score, and a hospital’s performance as measured by predicted, actual rates of mortality and associated z-scores. This study implications include that hospitals with advanced EMR capabilities are able to capture more information about the patient. This improved data capture involving the patient’s co-morbidities and other risks allow clinicians to better manage patients seen in the hospital, resulting in more positive predicted clinical outcomes. [63]<br />
<br />
=== Improved quality and convenience of patient care ===<br />
<br />
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. In addition, it serves in achieving a higher form of personalized medicine and continuity of care, which are really important in the quality of patient 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:<br />
* 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.<br />
* 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! <br />
* 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.<br />
* 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.<br />
<br />
=== Data Legibility ===<br />
Legibility is very important to reduce medical errors. For instance, patient information presented as typed text is much easier to read compared to human writings. They are also unified in structures and standards to prevent confusion. Misspelled words can be corrected with spell checks or autocorrect function. Clinicians will be required by computers to enter complete patient notes to avoid missing information.<br />
<br />
=== Data Legibility Regarding Medications ===<br />
When physicians use Computer Provider Order Entry (CPOE) systems within the EMR, fewer medication errors also occur because there are fewer legibility issues. Proper dosages are clearly entered into the computer by the ordering physician, thus reducing the need for nurses or other staff to “second guess” or question the order. [7]<br />
<br />
<br />
In addition, with the use of electronic prescribing, the hand-written prescription is no longer applicable as a physician can electronically send a prescription directly to the pharmacy of the patient’s choice. This means there’s no question regarding which medication/dosage the provider prescribed and there are no complications with the physical prescription potentially being lost in transition [73].<br />
<br />
=== Engage and improve communication with patients ===<br />
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].<br />
<br />
<br />
With the increase in use of patient portals, more patients and physicians are communicating via secure online messaging. Patients can request appointments, refills, review lab results, pay bills or ask general questions about their health via online portals. Online appointment scheduling is one of the most desired features of the patient portal followed by reviewing test results. In fact, Kaiser Permanente experienced a jump from 9% to 27% in patient registration once they added the feature to review test results [72]. <br />
<br />
<br />
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].<br />
<br />
=== More effective preventive care ===<br />
<br />
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].<br />
<br />
Kuperman et al. (2003)conducted a review of studies discussing the benefits of CPOE. A randomized control trial of 6731 patients and 200 physicians in a General Medicine teaching institution where the computer application sent a reminder that the patient was eligible for preventive care yielded in increase number of orders for the flu and pneumococcal vaccine as well as aspirin for coronary artery disease.<br />
Another 4week study conducted in medical and surgical units showed increased number of orders for H2 blockers and prophylactic Heparin when the computer prompted physicians during CPOE.(11)<br />
<br />
The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].<br />
<br />
=== More effective urgent care ===<br />
<br />
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 ilocal, 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]<br />
<br />
=== Improved Coordination of Care ===<br />
<br />
The use of electronic medical records has allowed multiple healthcare providers across different specialties to access the patient's complete medical record. This more complete picture into the patient's medical history allows better collaborative medical treatment.<br />
<br />
=== Increased patient participation in their care === <br />
<br />
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. Patients are able to obtain medication refill reminders, insert lab values (i.e. glucose levels or warfarin levels) for review by a clinician, and request refills. The pharmacist at a distant location is able to review this information and make the appropriate changes in therapy. This electronic process allows patients to be more involved in their medication therapies and this involvement may increase compliance and overall outcomes.<br />
<br />
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.<br />
<br />
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].<br />
<br />
=== Improved accuracy of diagnoses and health outcomes === <br />
<br />
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]. One study showed a 48% decrease in the likelihood of medication errors in an inpatient hospital setting. <ref name="Radley"></ref> Although it is unclear that CPOE can reduce the harm for patients from medication, the increasing amounts of data acquired such as particular medication for certain diseases and outcomes, may play a vital role in the efforts for improving public health.<br />
<br />
===Preventing Adverse Events===<br />
Physician surveys have attributed EMRs to alerting to allergic drug reactions and drug interactions that might have been missed. In addition, they reported more timely reporting of critical laboratory values.[60] <br />
A systematic review of the effectiveness of safety alerts in EMRs showed a reduction in medication errors in patients with renal insufficiency, pregnant women, elderly patients, drug-drug interactions and ADEs related to hyperkalemia.[61]<br />
<br />
This is an important benefit, since medication related adverse events, will not only cause patients harm but will increase the cost.[2] and the use CPOE will eventually help to reduce the cost of medication related adverse events [3]. Although, some study suggested that is less likely to occur during the early implantation phase[4].<br />
<br />
Although many studies have shown CPOE can reduce the frequency of medication errors, there is no distinct association between CPOE and reduced harm for patients from medication. <ref name="Radley"> Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6 </ref> For instance, there are certain antibiotics that work well with certain disease pathways, and selecting the wrong one may have null effects that may cause further harm for the patient. Developing EHR systems will provide additional data on the usage of certain medications with diseases and outcomes, which will expand our knowledge on selecting efficient medication for improving quality in patient care.<br />
<br />
=== Improve patient safety at the point of pharmacy order entry ===<br />
EHRs with alerts at the point of pharmacy order entry can help reduce medication errors and prevent potential clinical hazards. <br />
<br />
EHR alerts has been beneficialin reduce medication errors in elder patient, pregenant patient and patient with compromised renal or liver functions. EHR alerts can help reduce drug-drug interactions and allergic and adverse events. [http://www.ncbi.nlm.nih.gov/pubmed/23816138]<br />
<br />
=== Qualitative Benefits === <br />
<br />
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. The EMR can help the provider deliver the best quality of care because the EMR contains the complete patient‘s health history. In a crisis, the EMR provides immediate access to a patient's medical history, allergies, and medications. The retrieved information enables providers to make decisions sooner which otherwise they would have to wait for, like information from test results or other resources. This feature is very critical when a patient has a serious or chronic medical condition, such as diabetes. Also, the EMR information can be shared with patients and their family, so they can more fully take part in decisions about their health care. In addition, using decision support tools in EMRs help the provider to make efficient and effective decisions about patient care through clinical alerts and reminders.<br />
<br />
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.<br />
<br />
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].<br />
<br />
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<br />
<br />
== Personalizing Healthcare ==<br />
<br />
===After Visit summaries (AVS)===<br />
<br />
Stage 3 meaningful use recommends that patients or their authorized representative receive a clinical summary after each visit that is not just an abstract from the medical records, Most EHRs enable clinicians to supply patients with such information in the form of an After Visit Summary (AVS) that is generated from data entered into their medical records. The AVS should have relevant clinical information and instructions pertinent to the office visit. It should also be provided in a language other than English, when needed, within 3 business days of the clinic visit, and should contain more than 50% of the office visit clinical summary. Provision of the AVS is important, as physicians usually overestimate patient understanding of the treatment plan. Therefore, the AVS has the potential to improve patient engagement in their care and contribute to more personalized healthcare and share medical decisions.<br />
<br />
===Improved Documentation of Advanced Care Planning=== <br />
EMR can be utilized to screen patients in an outpatient setting and prompt the physician to have a discussion about Advanced Directives. A study conducted as a QI improvement project showed that EMR-based reminders on counseling were effective in improving documentation rates of Advanced Directives.[59]<br />
=== Targeted cancer therapy ===<br />
EHR with clinical decision support help process the genomic data in the context of individual patient and provide dosing recommendation in a timely manner. <br />
EHR when intergrated into work flow can help realize personalized cancer treatment at the point of care. [www.ncbi.nlm.nih.gov/pubmed/21568680]<br />
=== Enhanced Patient Access ===<br />
Some EHR systems provide functionality e.g. MyChart [10] for patients to access portions of their medical record, view test results, renew prescriptions, schedule appointments etc. These convenience features enable patients to engage in and take ownership of their own health care.<br />
<br />
[http://my.clevelandclinic.org/online-services/mychart.aspx]<br />
<br />
== Administrative and Management Benefits ==<br />
<br />
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 interoperable, EMRs can provide far more benefits than paper records such as "help providers improve productivity and work life balance." [68] At a higher level of EMR implementation and functionality, Computerized Provider Order Entry (CPOE) can help standardize the clinical practice and eliminate variation. Some benefits of CPOE are:<br />
<br />
* Help improve communication amongst care givers<br />
* Expedite patient transfer to other levels of care<br />
* Capture data for quality assurance and administrative purposes<br />
* Aid practice and care in a complex care environment through the use of alerts and reminders<br />
* Provides some level of assurance to patients that technology is being applied to their safety [38].<br />
* 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.<br />
<br />
=== Establishing a learning chance to improve healthcare system === <br />
<br />
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.<br />
<br />
=== Customer Support ===<br />
<br />
Some EHR provide help and support in the form of a medical billing specialist. This specialist gives both practices and patients customer support. The specialist also has access to medical codes (ICD-9), CPT code books and practice-related HIPAA information. Other EHRs provide onsite training and on-the-phone consulting for software and billing questions. http://www.advancedmd.com/medical-billing-services <br />
<br />
===Increased practice efficiencies, cost savings, and reimbursement===<br />
<br />
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]. <br />
<br />
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. Historically, it has been difficult to identify and achieve a solid, measurable Return on Investment (ROI) following Electronic Health Records (EHR) or other clinical system implementation initiatives. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has motivated system implementations, and the associated incentive dollars have offered a simple measure of ROI on the revenue side of the ledger, but this represents only one aspect of the substantial benefits clinical systems can yield. A proper optimization program, with broader consideration for the projects comprising it, can bring a truly positive ROI to healthcare organizations over a 10-15 year period if properly considered and executed. (Cumberland Consulting Group, 2013) 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]. According to DRCRHONO, physicians qualify to get $24,000 or more as part of the economic stimulus incentive offered by the HITECH act if they adopt a certified EMR. Incentives are given to providers who qualify. The stimulus includes $24,000 in Medicare Incentives or $63,750 in Medicaid Incentives. The government is putting in $19.2 billion dollars to help move all doctors off paper records onto electronic systems [62].<br />
<br />
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.<br />
<br />
=== EMRs Help Manage Transactions ===<br />
EMRs help better manage the “large number of transactions and handoffs” which can include: billing, physicians’ orders, prescriptions, nurses’ orders insurance information, and more. Having this information all in one place makes it easier for any staff member – from administrators/front office to pharmacists to physical therapists – to gain access to the patient’s records and read and notes that may apply to them. [6]<br />
<br />
== Clinical Decision Support ==<br />
<br />
[[CDS|Clinical Decision Support (CDS)]] has been shown to increase healthcare quality and patient safety, improve adherence to guidelines for prevention and treatment, avoid medication errors and reduce cost of care.<br />
<br />
=== Improved healthcare quality ===<br />
CDS can be used as an additional tool for performing potentially more accurate diagnoses in challenging situations, thus improving the quality of provided care.<br />
Monitors attached to the patient in a hospital bed emit a plethora of real-time physiological data, i.e. EKG signals, blood-oxygen saturation, etc. A CDSS driven by computer algorithms capable of pattern recognition by interpreting the data, ideally in real-time, will aid the physician in providing prompt, better quality care.<br />
<br />
=== Improved patient safety ===<br />
CDSS affect patient safety by substantially reducing medication error rates, reducing risk of overdose or medication abuse, decreasing the occurrence of adverse drug reactions, and increasing adequate follow-up of critical test results such as abnormal biopsies, radiological studies, and laboratory tests Further, these systems utilize a variety of tools to enhance decision-making in clinical workflow, including computerized alerting systems, reminders, advice, critiques, and suggestions which can notify physicians about problems occurring asynchronously (clinical guidelines, condition-specific order sets, focused patient data report, summaries, etc.). <br />
<br />
=== Improved Reporting Capabilities ===<br />
An EMR has the capability of providing a more robust reporting environment with integrated clinical and administrative data, standardized clinical assessments and calculation of outcome measures[http://ptjournal.apta.org/content/86/3/434.full.pdf+html].<br />
<br />
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.<br />
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. Researchers from King Saud University in Saudi Arabia also found the usefulness of incorporating EHR techniques in their clinical decision support systems. The team created a four-module knowledge-based system that incorporated algorithmic guidelines and EHR data mining (66). Guidelines used in the proposed system are the International Classification of Disease (IDC), SNOMED CT, LOINIC, and the Unified Medical Language System (UMLS). The sophisticated system is projected to not only increase workflow, but also serve as a system for various entities to use as a consulting tool.<br />
<br />
===Reduce Diagnostic Errors===<br />
Diagnostic errors are defined as missed, delayed, or wrong diagnosis can lead to missed opportunity in patient care and increased cost [6]. CDS have the potential to improve the diagnostic process[7]. Moreover, systematic reviews found that CDS can improve health care professional performance [8]. Therefore, there is increase evidence that CDS can be helpful in many ways. It is clear that CDSS will have significant effect on improving patient safety strategies [9] <br />
<br />
===Reduced Cost ===<br />
Incorporating decision support within a CPOE not only assists a physician in practicing evidence-based medicine, it has also been demonstrated to reduce cost. Specifically, renal dosing guidance, specific drug guidance and adverse drug prevention have contributed to a net operating budget savings of $9.5 million at Brigham and Women's Hospital [21]. The average savings computed from the study indicated a 6-month savings of $3,450 per clinician. This is just one example of a study result measuring the impact of a specific CDSS in a specific EHR system in a singular clinic setting.<br />
<br />
== Research ==<br />
<br />
=== Informatics ===<br />
<br />
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.<br />
<br />
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].<br />
<br />
* 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. <br />
* 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). <br />
*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. <br />
* 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]<br />
<br />
=== Bioinformatics ===<br />
<br />
* 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.]<br />
<br />
=== Enhance public health surveillance ===<br />
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. According to The Advisory Board Company, there are three key elements for successful population health management (The Advisory Board Company, 2014):<br />
1. Information-powered clinical decision making (e.g. robust patient data sets and integrated data networks)<br />
2. Primary care-led clinical workforce (e.g. PCP care team leaders and mobilization of community workforces)<br />
3. Patient engagement and community integration (e.g. map services to population need and overcoming non-clinical barriers to maximize health outcomes).<br />
<br />
EHRs in conjunction with organizational improvement practices can help to address all three of these key elements. Incorporating electronic health records into public health practice not only improves public health surveillance, but also expands the communication between health care providers and public health professionals. In addition, organizations will be better able to track and prevent disease before an epidemic occurs. Through current government legislation, EHRs will assist public health research in achieving meaningful use(68). Many programs have already been implemented to begin this integration. <br />
<br />
An example of successful EMR surveillance is displayed in a 2012 article of the American Journal of Preventive Medicine, where the study focused on a model EMR-based public health surveillance platform, Electronic Medical Record Support for Public Health (ESP). It was noted to enable clinicians to provide high-quality surveillance data on notifiable diseases, influenza-like illness, and diabetes to public health agencies. This surveillance data can help health departments acquire rich and timely data on broader populations and wider sets of health indicators than is routinely possible with current surveillance systems. [64]<br />
<br />
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.<br />
<br />
=== Tracking Epidemics ===<br />
<br />
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 [[Centers for Disease Control and Prevention (CDC)|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. <ref name="emr cdc outbreak">http://www.gereports.com/using-emrs-to-help-the-cdc-track-outbreaks-faster/ </ref><br />
<br />
=== Better Evidence Based Practices ===<br />
<br />
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]<br />
<br />
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]<br />
<br />
=== Pharmacogenetic Research ===<br />
Patients' responses to drug treatment differ due to their genetic backgrounds. Such information is important to provide patient with optimized drug treatment. <br />
<br />
EHR can improve the quality and efficiency of pharmacogenetic research works by providing the link between pharmacoepidemiology and pharmacogenetics. EHR also supporting the pharmacogenetic research with access to health record database. [http://www.ncbi.nlm.nih.gov/pubmed/24581153]<br />
<br />
=== Clinical Research ===<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Front-end)''' [69]<br />
<br />
#Study setup<br />
##Query EMR database to establish number of potential study candidates.<br />
##Incorporate study manual or special instructions into EMR “clinical content” for study encounters.<br />
#Study enrollment<br />
#Implement study screening parameters into patient registration and scheduling. <br />
##Query EHR database to contact/recruit potential candidates and notify the patient’s providers of potential study eligibility.<br />
#Study execution<br />
##Incorporate study specific data capture as part of routine clinical care/documentation workflows. <br />
##Auto-populate study data elements into care report forms from other parts of the EMR database.<br />
##Embed study specific data requirement as special tabs/documentation templates using structured data entry.<br />
##Implement rules/alerts to ensure compliance with study data collection requirements.<br />
##Create range checks and structured documentation checks to ensure valid data entry.<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Back-end)''' [69]<br />
<br />
# Submission & Reporting<br />
##Provide data extraction formats that support data exchange standards<br />
##Document and report adverse events<br />
#Evidence-based review<br />
##Assess congruence of new findings and existing evidence with current practice and outcomes (incorporate into meta-analyses)<br />
##Submit findings to electronic trial banks using published standards.<br />
#Evidence-based clinical care<br />
##Implement study findings as clinical documentation, order sets, point of care rules/alerts<br />
##Monitor changes in care and outcomes in response to evidence base clinical decision support.<br />
##Provide easy access to detailed clinical care data for motivating new clinical trial hypotheses.<br />
<br />
=== The n-of-1 Clinical Trial ===<br />
<br />
N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. The availability of electronically accessible data provides opportunities for learning from experience in clinical care; this can also referred to as evidence farming or using evidence macrosystem. Evidence farming can be characterized as a “bottom up” paradigm for clinical practices to incorporate practice data systematically as source of evidence, or and articulated form of clinical experience. <ref name="n-of-1">Lillie, Elizabeth O., et al. "The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?" http://www.ncbi.nlm.nih.gov/pubmed/21695041 </ref><br />
<br />
=== Clinical Data Research Networks ===<br />
<br />
Since electronic medical records systems allow for the capture and storage of records in a discrete data format many secondary uses of the data is made possible. By utilizing health information exchange communities can share and aggregate their data for research to improve population health. The compiled data can be used to improve patient engagement, improve regulatory oversight, share the results of studies across health systems, and increase the use of research to improve outcomes at member institutions. In New York City this very concept has been proven successful through a project funded by the Patient-Centered Outcomes Research Institute (PCORI), and with the future adoption and utilization of HIEs more populations will be able to take advantage of these benefits. <ref name="CDRN">Kaushal, R., Hripcsak, G., Ascheim, DD., et al. (2014, March 25). Changing the research landscape: the New York City Clinical Data Research Network. J Am Med Inform Assoc. doi:10.1136/amiajnl-2014-002764</ref><br />
<br />
== National and international effects ==<br />
<br />
=== Growth, Job creation, and enhancement in the Commercial Clinical IT sector ===<br />
<br />
The commercial marketplace for clinical IT products has evolved dramatically<br />
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.<br />
<br />
=== Adapt to governmental regulatory changes and requirements ===<br />
<br />
HIPAA and other legislative bodies often require specific requirements. Compiling information from thousands of documents could be needed to complete the government’s requirements, a feat that would be inefficiently labor and time intensive if done with paper records. Digital patient records helps administration and upper management to meet requirements and regulatory changes to satisfy legislative demands. With digital records, auditors can quickly see if physicians and hospital systems are government compliant and can easily point out if they are not, allowing the non-compliant party to correct their inadequacy. http://www.msdc.com/EMR_Benefits.htm<br />
<br />
== Barriers to EMR Implementation ==<br />
<br />
=== System Selection ===<br />
<br />
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.<br />
<br />
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] According to Ajami and Chadegani, despite of the potential benefits of electronic health records, implement of this project facing with barriers and restriction, that the most of these limitations are cost constraints, technical limitations, standardization limits, attitudinal constraints–behavior of individuals and organizational constraints.[71]<br />
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].<br />
<br />
* In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system. <br />
* 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. <br />
* 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. <br />
*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 ]<br />
* 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]<br />
* 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. <br />
*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.<br />
*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.<br />
<br />
=== Costs ===<br />
Cost benefit analysis is categorized into 3 fields [70]:<br />
# Direct, one-time costs<br />
## Hardware & Peripherals<br />
## Packaged and customized software<br />
## Network, peripherals, supplies, equipment<br />
## Initial data collection and conversion of archival data<br />
## Facilities upgrades, including site preparation and renovation<br />
## End-user project management<br />
## Project planning, contract negotiation, procurement<br />
## Application development and deployment<br />
## Configuration management<br />
## Office accommodations, furniture, related items<br />
## Initial user training<br />
## Workforce adjustment for affected employees<br />
## Transition costs (parallel systems, converting legacy systems)<br />
## Quality assurance and post implementation reviews<br />
<br />
# Direct, ongoing costs<br />
## Salaries for IT and assigned end user staff<br />
## Software maintenance, subscriptions, upgrades,<br />
## Equipment leases<br />
## Facilities rental and utilities<br />
## Professional services, Ongoing training and<br />
## Reviews and audits<br />
<br />
# Indirect, ongoing costs. <br />
## Data integrity<br />
## Security<br />
## Privacy<br />
## IT policy management<br />
## Help Desk<br />
<br />
The financial commitment of implementing a CPOE system varies amongst facilities and depends on the facility's current hardware and software systems. The institution's current system needs to have a strong infrastructure in order to be able to enhance it's capabilities. The license for the software is but a small portion of the total cost. The larger expenses incurred will be a result of training healthcare professionals and support activities. Customer service and technical support should be available everyday 24 hours a day. <br />
<br />
For more information, see [[EMR Cost Categories]].<br />
<br />
=== Challenges to Identifying a Return on Investment (ROI) ===<br />
<br />
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]. For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance [58]. <br />
<br />
Additional barriers include:<br />
<br />
*Vendor supplied benefits data may not be objective <br />
*Few vendors maintain a structured database of benefits information<br />
*Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings. <br />
*Differences in system architecture <br />
*Trade journals tend to focus on anecdotal evidence rather then empirical evidence<br />
*No standardized domain method exists to measure the ROI of electronic health records <br />
*Lack of information regarding maintenance and optimization costs [48]<br />
<br />
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]<br />
<br />
=== EMR and Providers’ Productivity ===<br />
<br />
Health care providers are adopting electronic medical records, but some doctors report a disturbing side effect. Instead of becoming more efficient, some practices, especially smaller ones are becoming less. Several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday. [70] <br />
<br />
In a study by Bhargava et al. which examines productivity impacts of electronic medical records (EMR) implementation in a large academic hospital in California. Bhargava et al. also investigate the dynamics through which EMRs may impact productivity. The study employ random effects model on panel data comprising 3,189 physician-month observations for productivity data collected on 87 physicians specializing in internal medicine, pediatrics and family practice. The total duration of data collection was 39 months. Bhargava et al. find that the productivity of physicians dropped immediately after EMR implementation, but began to recover in a few months and finally leveled-off. Additionally, Bhargava et al. find that productivity impacts of EMR are contingent upon physician specialty. Bhargava et al postulate that the fit provided by an EMR to the task requirements of physicians of various specialties is key to entangling the productivity dynamics. [71]<br />
<br />
== Return on Investment (ROI) Estimates ==<br />
<br />
While barriers of determining actual ROI for EMR implementations exist, companies such as Dr. Cloud EMR are providing EMR and EHR ROI estimates based on each practice's details. This however does not suggest that it is entirely accurate and is only an estimate. DrCloudEMR is built by DrCloud Healthcare Solutions Inc, a wholly owned EnSoftek, Inc. subsidiary. [65]<br />
There are 2 main postulates for ROI which KOSH’s postulate and Sir Austin Bradford Hill’s criteria for Causation. <br />
Kosh’s postulate for CIS is <br />
i. The system or feature must be present in every case in which the benefit is observed.<br />
ii. The system must be isolated from the organization. <br />
iii. The benefit must be reproduced when the system is implemented in a new organization.<br />
iv. We must demonstrate that the system was used in the new organization.<br />
Hill’s Criteria for Causation includes (a) Strength of Association (b) Consistency of findings (c) Specificity of Association (d) Temporality (e) Dose-response (f) Plausibility (g) Coherence (h) Experimental Evidence and Analogy.<br />
<br />
=== Sittig's Postulates ===<br />
<br />
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.<br />
<br />
* Must have the hardware and software available before the effect is identified.<br />
** Need to at least estimate state of affairs before system is implemented…manual review<br />
* Show that clinicians are actually using the system that could produce the effect.<br />
* Show that the effect increases with increasing availability and usage of the system.<br />
* Show that all obvious “alternative explanations” for the effect are false.<br />
* Show the effect goes away when the system goes away.<br />
* Show that a similar effect occurs when a similar system is installed and used at a similar facility.<br />
<br />
=== Quality Care ===<br />
<br />
One could approach the ROI from the perspective of the Institute of Medicine Report, ''Crossing the Quality Chasm''<br />
# Safe: Reducing adverse drug events, inappropriate testing<br />
# Effective: Reducing drug costs through appropriate prescribing<br />
# Efficient: Reducing drug, laborotory, or radiologic utilization<br />
# Timely: Reducing wait times<br />
# Patient-centered: Reducing length-of-stay while hospitalized<br />
# Equitable: Provides data to demonstrate equal delivery<br />
<br />
=== Strategic Benefits === <br />
<br />
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.<br />
<br />
<br />
<br />
If EMR is fully implemented and functional, the benefits they offer are substantially than a paper records. Some of these benefits are:<br />
* Improvement in quality of patient care<br />
* An increase patient participation in their care (making appoints, refill of prescriptions, limited access to their records.<br />
* There will be an improvement in the accuracy of diagnoses and health outcomes-decrease of some types of medical errors<br />
* Improve care coordination<br />
* Increase practice efficiencies and cost savings <ref name="healthIT.gov"> http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs </ref><br />
<br />
Arlotto (2014) defends the right that EHRs are able to provide organizations the greatest value in the future of healthcare. She argues that this can be accomplished through the involvement of business, clinical, and financial platforms within an organization. As the healthcare industry is transitioning from volume to value based payment, organizations are increasingly depending on IT applications to facilitate the progress. She explains that our current healthcare practices use EHRs as an entity that simply automates the paper record and measure value based on direct cost-benefit analysis, rather than ensuring value realized over the lifetime of the investment.<ref name="ArlottoAccelROI"></ref> Five commonly mistaken truths are further discussed in order to facilitate the transition for more efficient use of EHR. <ref name="ArlottoAccelROI"> Arlotto, P. (2014). Accelerating the ROI of EHRs. Healthcare Financial Management : Journal of the Healthcare Financial Management Association, 68, 2, 72-9. </ref><br />
<br />
<br />
=== Achieving a Positive ROI ===<br />
<br />
A key to achieving a positive return on investment (ROI) when implementing an EHR system is using it for more than meeting meaningful use requirements. A 2013 study conducted by Harvard University researchers showed that many practices that implemented EHRs showed a negative 5 year ROI. Citing only 27 percent of practices which adopted EHRs would show a positive ROI. The reason for this according to their research was that many practices were not using their EHR systems effectively. The practices which showed a positive ROI were able to use their EHR in a way that increased the number of patients they were able to see in a day as well as improving their billing to reduce rejected claims. The practices which showed a negative ROI were mostly still using paper charts heavily even after implementing the EHR system. This resulted in decreased productivity on top of the expense of the system. The most important step practices must take to see a positive ROI on EHRs is to take the time to optimize their use so they can improve efficiency and reduce costs.<ref name="posroi">Harvard University Reports Findings in Electronic Medical Records. (2013, June 7). Health & Medicine Week, 1809. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA332414959&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&asid=f6372a5c3f33b3956c1739aae9c7d466</ref><br />
<br />
== Incentive Programs ==<br />
<br />
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)<br />
<br />
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)<br />
<br />
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)<br />
<br />
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 [[Office of the National Coordinator for Health Information Technology (ONC)|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)<br />
<br />
=== Sources of Funding === <br />
<br />
# Organizational Reserves – provider organization make investments in affiliated organizations<br />
# Bank and other financial service – short term loans<br />
# Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment<br />
# Vendor discounts and incentives – requires something in return<br />
# Joint venture or partnership – tighter relationship <br />
# Health plans and plan sponsors – contractual arrangement<br />
# Private philanthropy – fellowships or university chairs<br />
# Pharmaceutical companies – willing to conduct clinical trials<br />
# Public grants – government initiatives<br />
# State legislative initiatives – local and state initiatives<br />
<br />
== References (old, to edit) ==<br />
<br />
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]<br />
<br />
# http://www.msdc.com/EMR_Benefits.htm<br />
# http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm<br />
# http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php<br />
# http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm<br />
# http://www.mayoclinic.org/emr/benefits.html<br />
# 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.<br />
# Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67<br />
# Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429 <br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp<br />
# http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf<br />
# http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf<br />
# http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act<br />
# http://www.cdc.gov/ehrmeaningfuluse/<br />
# http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5<br />
# 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.<br />
# Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.<br />
# 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.<br />
#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.<br />
#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.<br />
# http://www.hhs.gov/news/press/2013pres/08/20130805a.html<br />
# http://www.fierceemr.com/story/new-york-looks-ehrs-enhance-public-health-surveillance/2013-08-27<br />
# http://ehrintelligence.com/2012/12/10/engaging-patients-through-ehr-access-open-notes/<br />
# 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,<br />
# Driessen J,CioffiM, Alide N,et al. J Am Med Inform Assoc 2013;20:743–748.<br />
# Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study Sameer Kumar, Krista Aldrich<br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html<br />
# http://www.ncbi.nlm.nih.gov/pubmed/9576410<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# http://www.practicefusion.com/ehrbloggers/2010/10/return-on-investment-for-emrs.html<br />
# http://jama.jamanetwork.com/article.aspx?articleid=1737043#ArticleInformation<br />
# Kuperman, G.J. and Gibson, R.F. (2003) “Computer Physician Order Entry: Benefits, Costs & Issues” Am Intern Med 2003; 139:31-39<br />
# Crane, R.M. and Raymond, B. (2003) “Fulfilling the Potential of Clinical Information Systems: The Permanente Journal Winter/2003/Vol.7No1<br />
# Kaushal, R.; Jha, A.K.; Franz, C. et al. (2006) J Am Med Inform Assoc 2006;13:261-266 doi 10.1197/jamia.J1984<br />
# http://www.nejm.org/doi/full/10.1056/NEJMp1211315#t=article<br />
# Menachemi N, Collum H.T. Benefits and drawbacks of electronic health record systems.Risk Manag Healthc Policy. 2011; 4: 47–55.<br />
# http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide-chapter-2.pdf<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978883/<br />
# 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.<br />
# Butcher L. Hospitals strengthen bonds with post-acute providers. http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG<br />
# Voigt, C. & Torzewski, S. (2011). Direct results: An HIE simple information exchange using the direct project. Journal of AHIMA, 38-41.<br />
# Kohn, L. T., Corrigan, J. M., & Donaldson, M. S., eds. (2000). To err is human. ''Institute of Medicine Committee on Quality of Health Care in America''. Washington, DC: National Academic Press.<br />
# McGeath, J. (2012). The Team Dynamics of Connecting Medical Devices with EMR Systems. 24X7, 17(10), 34-41<br />
# Mulherin, D. P., Zimmerman, C. R., & Chaffee, B. W. (2013). National standards for computerized prescriber order entry and clinical decision support: The case of drug interactions. American Journal Of Health-System Pharmacy, 70(1), 59-64. doi:10.2146/ajhp120217<br />
# Otte-Trojel, T., de Bont, A., Rundall, T. G., & van de Klundert, J. (2014). How outcomes are achieved through patient portals: a realist review. Journal of the American Medical Informatics Association, amiajnl-2013.<br />
# http://www.healthit.gov/providers-professionals/2-install-and-enable-encryption<br />
# http://www.dialogmedical.com/informed-consent-2-3/<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047866.hcsp?dDocName=bok1_047866<br />
# Hayek S1 et al. End-of-Life Care Planning: Improving Documentation of Advance Directives in the Outpatient Clinic using Electronic Medical Records. J Palliat Med. 2014 Jul 2.<br />
# Gummadi S1. Electronic medical record: a balancing act of patient safety, privacy and health care delivery. Am J Med Sci. 2014 Sep;348(3):238-43.<br />
# Ojeleye O1 et al. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013 Jul 1;13:69.<br />
# https://www.drchrono.com/meaningful-use-ehr/<br />
# EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates. http://apps.himss.org/content/files/HAHealthgradesEMRStudyWhitePaper.pdf<br />
# Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. http://www.ajpmonline.org/article/S0749-3797(12)00249-8/fulltext<br />
# EMR ROI / EHR ROI Calculator. http://www.drcloudemr.com/roi/<br />
# http://www.academia.edu/4083826/An_Adaptive_Evidence_Based_Medicine_System_Based_on_a_Clinical_Decision_Support_System<br />
# http://www.cdc.gov/ehrmeaningfuluse/introduction.html<br />
# http://www.healthit.gov/providers-professionals/faqs/how-can-electronic-health-records-improve-public-and-population-health-<br />
# http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf<br />
# http://www.forbes.com/sites/hbsworkingknowledge/2014/03/26/how-electronic-patient-records-can-slow-doctor-productivity/ <br />
# Bhargava, Hemant K., and Abhay Mishra. "Electronic Medical Records and Physicians Productivity: Insights from Panel Data Analysis and Design Implications." 2nd round at Management Science (2011).<br />
# http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1855&pageaction=displayproduct<br />
# Shortliffe, E. H., & Cimino, J. J. (2006). ''Biomedical informatics''. Springer Science+ Business Media, LLC.<br />
# http://www.healthit.gov/providers-professionals/faqs/what-are-advantages-electronic-health-records<br />
# Kim, Y., Kim, S. S., Kang, S., Kim, K., & Jun Kim. (2014). Development of Mobile Platform Integrated with Existing Electronic Medical Records. Health Infrormatics Research.<br />
# Zaroukian, M. (n.d.). EMR Cost-Benefit Analysis: Managing ROI into Reality. Retrieved from http://www.himss.org/files/HIMSSorg/content/files/EMRCost-BenefitReality.pdf<br />
# Ajami, S., & Arabchadegani, R. (n.d.). Barriers to implement Electronic Health Records (EHRs). Materia Socio Medica, 213-213. Retrieved September 10, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804410/<br />
# http://hitconsultant.net/2014/08/19/patient-portal-features-which-is-the-most-beneficial-frustrating/<br />
# http://www.cms.gov/Medicare/E-Health/Eprescribing/index.html?redirect=/EPrescribing<br />
# https://www.drchrono.com<br />
<br />
== References ==<br />
<references/><br />
<br />
5. What Is an Electronic Medical Record (EMR)? http://www.healthit.gov/providers-professionals/electronic-medical-records-emr <br />
<br />
6. Harrington, L., Porch, L., Acosta, K., & Wilkens, K. (2011). Realizing electronic medical record benefits: an easy-to-do usability study. The Journal of Nursing Administration, 41(7-8), 331–5. doi:10.1097/NNA.0b013e3182250b23<br />
<br />
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 (Project Hope), 24(5), 1103–17. doi:10.1377/hlthaff.24.5.1103<br />
<br />
== References ==<br />
# Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health Information Exchange Reduces Repeated Diagnostic Imaging for Back Pain. Annals of Emergency Medicine 2013 Jul;62(1):16-24.<br />
# Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997 Jan 22;277(4):307-11.<br />
# Johnston D, Pan E, Walker J. The value of CPOE in ambulatory settings. J Healthc Inf Manag 2004;18(1):5-8.<br />
# Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 Mar;11(2):100-3.<br />
# Stage DRMU. 3; Meaningful Use Work Group; Paul Tang, chair and George Hripcsak, co-chair. 2013. August. <br />
# Singh H. Editorial: Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis. Joint Commission Journal on Quality and Patient Safety 2014 Mar;40(3):99-101.<br />
# Bogua¡eviaius A, Maleckas A, Pundzius J, Skaudickas D. Prospective randomised trial of computerâ€aided diagnosis and contrast radiography in acute small bowel obstruction. European Journal of Surgery 2002;168(2):78-83.<br />
# Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293(10):1223-38.<br />
# McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):381-9.<br />
# Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. ( 2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6.<br />
11. Kuperman,G.J.,Gibson,R.F. (2003)Computer Order Physician Entry: Benefits, Costs, and Issues. ''Annals of Internal Medicine,139,31-19'' <br />
<br />
[[Category:EMR]]</div>Adlaihttp://clinfowiki.org/wiki/index.php/EMR_Benefits_and_Return_on_Investment_CategoriesEMR Benefits and Return on Investment Categories2014-09-13T21:15:13Z<p>Adlai: /* Administrative and Management Benefits */</p>
<hr />
<div>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:<br />
<br />
* Lower number of doctor visits (from the payer's perspective)<br />
* Communication, coding, efficiency, safety improvements<br />
* Transformation of healthcare delivery<br />
* Better Coordination of care<br />
* Improved management of chronic conditions<br />
<br />
However, quantifying these benefits is not a simple task. Issues that have hampered Return on Investment (ROI) studies and affected their validity include:<br />
<br />
* Pressure to justify expense<br />
* Shoddy collection of "before" comparison data after the implementation<br />
* Application of multiple simple statistical tests (the more statistical tests you run, the more likely you are to find something significant)<br />
<br />
The sections below detail the benefits, costs, and barriers in evaluating EMR implementations.<br />
<br />
== Informational ==<br />
<br />
=== Storage and retrieval ===<br />
<br />
EMRs improve the storage and retrieval of patient information in the following ways:<br />
<br />
# Reduces the amount of physical storage space required to house charts.<br />
# Protected from fire, natural disaster, or theft.<br />
# Records can be backed up to off-site facilities<br />
# Instant access to records.<br />
# More controlled access, including a record of who accessed the record.<br />
# Eliminates “lost” or incomplete charts.<br />
# More than one provider can access the record at one time. Ability to identify who modified the record.<br />
# Ensures business continuity and uninterrupted medical service.<br />
<br />
# 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 <ref name="wang 2003"></ref> <br />
# They reduce the likelihood that tests will be unnecessarily duplicated. <br />
# Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data. <br />
# 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). <br />
# 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). <br />
# EMRs reduce the number of lost or missing reports. <br />
# They reduce variability of care.<br />
# Timely delivery of critical services <br />
# Ensures business continuity and uninterrupted medical service.<br />
# Facilitates patient self-service and increases patient's engagement with the help of Patient portal which is a secure online website that patients can access anywhere and anytime to view their medications, immunizations, lab reports, request prescription refills, schedule appointments, make payments and much more.<br />
# Enforces data confidentiality and improves compliance.<br />
<br />
Respondents from the 2011 U.S. Physician Workflow study of office-based physicians reported that the EHR helped them access patient records remotely (81%) and enhanced patient care overall (78%).<br />
<br />
=== Increased Security of Patient Information ===<br />
<br />
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. Installing and enabling encryption is another way to protect and secure patient health information. Encryption is the conversion of data into a form that cannot be read without the decryption key or password. This method is paramount to secure information saved in mobile devices. There are several different ways to encrypt data in motion, such as a virtual private network (VPN) or a secure browser connection [56].<br />
<br />
=== Mobile EMRs ===<br />
<br />
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 presents the following advantages in addition to those observed for EMRs in general (29).<br />
<br />
# Enhanced patient education and satisfaction<br />
# Increased mobility of the device provides a better fit of technology to the application setting <br />
# The iPad touch screen enables easy use even without excessive knowledge of computers<br />
# Mobile devices was similar to paper charts in that they are extremely portable allowing physicians to carry it around in EDs easily<br />
# Remote patient monitoring and diagnosis<br />
# Ability to cross-reference medical terminology and provide multi language support.<br />
# Supports globalization of medical care.<br />
# Ability to send health data directly from wearable devices to medical records [1]<br />
# Link daily activities of living (e.g. fitness, nutrition data) to health data [1]<br />
# Dictate on the iOS device, e-Prescribe, and perform real-time eligibility checks [74]. <br />
<br />
<br />
The March 16, 2012, Letter to Us at Kaiser Permanente reported that Kaiser Permanente members can use mobile smartphones (Android, iPhones, or Blackberrys) to access their medical records, lab results, and all other aspects of kp.org. Kaiser Permanente members accessed the smartphone application over 1,000,000 times during the first month of use. In 2011, KP patients participated in more than 12,000,000 e-visits with their health care providers.<br />
<br />
[http://www.advisory.com/daily-briefing/blog/2014/09/will-apple-iwatch-revolutionize-health-care]<br />
<br />
=== Architecture of Mobile EMRs ===<br />
<br />
Severence Hospital started developing mobile EMR applications in 2005. In 2010, a mobile solutions for healthcare professionals for IOS based iPhones. In 2012, this application was redesinged to be platform independent, encryption policy was added to ensure data security and provided integrated management of Legacy EMR and a mobile solution. The patient list was organized by themes and its main feature was EMR history retrieval. The new architecture design process had four steps: Server and its architecture, Screen layout and story board making, Screen UI design and development, Pilot test and step by step by step deployment.<br />
The Mobile architecture: consists of Mobile server and Mobile device.The server receives information from the EMR system matched with search parameters which is then converted into information to be displayed on specific mobile device.<br />
This mobiles solution was first pilot tested for two month and later deployed in four Severence Hospitals[69]<br />
<br />
=== Improving workflow ===<br />
<br />
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.<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
An EMR service that fully analyzes and streamlines the patient workflow, and works to support a lean practice operation, can actually improve efficiency, such as integrated billing. Providers can be more productive, spend more time with patients, and even enjoy increased patient visits.<br />
<br />
=== Improved care coordination ===<br />
<br />
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.<br />
<br />
=== Integrated View of Patient Data ===<br />
EHR systems can provide integrated access to all data about a patient from many visits and facilities such as laboratory tests, problems, diagnoses, medications, etc. from the database. This retrieval is made easy by data standards like HL7, LOINC, and SNOMED. Practitioners can also have multiple views of data through links provided in the user interfaces.<br />
<br />
=== Tracking Patients’ Medical Data ===<br />
By having the electronic medical record (EMR) save patient data (such as heart rate, blood pressure, eating habits, etc.) over, healthcare providers – or even the patients – can check parameters during a specific time frame when certain symptoms occur and correlate any relation. Having the constant patient data, allows the healthcare professional to go back in time and see any relationship to specific parameters and patient illness symptoms. [5]<br />
<br />
== Health Information Exchange (HIE) ==<br />
<br />
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.<br />
<br />
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.<br />
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.<br />
<br />
=== Facilitated referral for multidisciplinary care ===<br />
<br />
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]. <br />
<br />
=== Better Integrated Care by Hospitals and Long-Term Facilities/Rehabilitation Centers ===<br />
<br />
EHR plays an important role in improving the health care quality and safety; thus reducing the costs of providing care in long-term care facilities. <ref name="ford e 2010">Ford E. Electronic Health Records Hold Great Promise for Long-Term Care Facilities. http://www.ihealthbeat.org/perspectives/2010/electronic-health-records-hold-great-promise-for-longterm-care-facilities </ref> 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. <br />
<br />
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]<br />
<br />
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]<br />
<br />
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].<br />
<br />
=== Minimize Repeating Diagnostic Imaging Studies ===<br />
<br />
HIE can potentially eliminate unnecessary repetition of diagnostic testing, especially in the Emergency Department. Indeed as study found that HIE reduced imaging studies order by Emergency Department physicians for patients presenting with back pain, this is not only decrease the cost of expensive imaging studies but also decrease risk of unnecessary patients exposure to radiation[1]. This illustrate the importance of HIE and the potentially huge impact it will have on reducing cost and delivery an optimal health care. <br />
<br />
=== Facilitate Health Information Exchange ===<br />
<br />
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. HIEs also assist with provider/patient interactions regarding chronic disease management. One example of this looks at Western New York (WNY) Beacon Community and the regional health information exchange (HIE) HealtheLink. The two organizations teamed up to help diabetic patients in upstate New York with disease management. The cost of diabetes management has risen from $174 billion in 2007 to $245 billion in 2012; that is a 41% increase over five years (American Diabetes Association, 2014). These figures address an increased in financial burden, use of health resources and lost productivity associated with diabetes (American Diabetes Association, 2014). In response to this rise in cost, WNY Beacon has shared strategies not only improving the health of diabetic patients, but cutting costs for such management as well. Their strategies cover three primary topics: 1) expanding research for better analytics, 2) improving real-time care coordination and communication and 3) patient education, telehealth and population management. <br />
<br />
==== The Direct Project ====<br />
<br />
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.<br />
<br />
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]<br />
<br />
== Environmental ==<br />
<br />
Using EHRs can greatly reduce the need for paper in an office setting. Instead of throwing away and shredding old paper records or documents and destroying trees, digital documents can be erased without another tree being cut down to make another sheet of paper. http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/ As an eco-friendly software application, it reduces need for reams of paper and the environmental costs associated with it. http://www.healthynumbers.co.za/index.php?page=electronic_medical_records_environment<br />
<br />
== Medical Education ==<br />
<br />
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:<br />
# Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR<br />
# Training the students to follow accepted clinical guidelines (best practices) using CDS<br />
# 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.<br />
# 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].<br />
<br />
The disadvantages of EMRs to education were noted by the following issues:<br />
# Problems with student access into the facilities systems such as obtaining log-ins and passwords<br />
# 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.<br />
# 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.<br />
# Trainees overly attentive to patient’s EMR data versus gaining information from physical examination and patient interactions<br />
# Focus on engagement with computer terminal disrupts patient-physician relationship in exam room<br />
# Automation bias - too much trust in decision support systems without consideration of their limitations<br />
<br />
As EMR use becomes standard fare in medical practice, the benefits of using EMR need to be harnessed by adapting the training curriculum of medical students and graduate medical education trainees to incorporate EMR-related sub- competencies (5).<br />
<br />
[http://jama.jamanetwork.com/article.aspx?articleid=1787416]<br />
<br />
=== Improving interpersonal and communication skills ===<br />
<br />
EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.<br />
<br />
=== Enhancing professionalism ===<br />
Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.<br />
<br />
=== Access to knowledge resource ===<br />
Today, clinicians can get access to medical literature on the internet while making clinical decisions or reviewing patient charts. EHRs can provide links in a patient record to internet resources like PubMed, NLM, and OVID to show clinicians the most up-to-dated information and knowledge in medicine.<br />
<br />
== Financial ==<br />
<br />
By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for: <br />
<br />
# Increase in the pace of information flow including service delivery.<br />
# Coding/billing accuracy.<br />
# Better documentation of patient encounters.<br />
# Reduction in overall administrative and maintenance costs of healthcare institutions.<br />
# Reduction in costs for the patient. <br />
# Reduction in transcription costs [http://jamia.bmj.com/content/18/2/169.full.pdf+html].<br />
# Decrease in malpractice insurance premiums.<br />
# 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].<br />
# Reduction in overtime expenses.<br />
<br />
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].<br />
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].<br />
<br />
Another feature of EMR is the capability to eliminate paper-based informed consents. Paper consents get lost or misplaced very easily and this problem contributes $3.3 billion to the cost of health care in the U.S. due to resulting operating room delays for example. Electronic informed consents also help better reducing liability risk [57]. <br />
<br />
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<br />
<br />
Financial benefits include averted costs and increased revenues, which can be divided into three categories: payer-independent benefits, benefits under capitated reimbursement, and benefits under fee-for-service reimbursement [58].<br />
<br />
=== Quantitative Benefits === <br />
<br />
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.<br />
<br />
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]<br />
<br />
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).<br />
<br />
=== Reducing cost ===<br />
<br />
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]. <br />
<br />
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.<br />
<br />
Kuperman et al. (2003) upon reviewing the benefits of CPOE said that a reduction in medication errors would increase hospital savings. They found two studies showing that half of all of medication errors were due to ordering of a drug for which the patient had an allergy and the other half were because of incorrect drug and incorrect dose. (11) During physician order entries standardized computer order sets can assist physicians to select disease-sensitive drug and patient-specific dosing. Computer applications can also send alerts about patient allergies, drug interactions and monitoring of drug levels.<br />
<br />
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 <ref name="wang 2003"></ref>Interventions to switch the twice-daily dosing of ceftriaxone to once-d<br />
*Provide users with real time knowledge<br />
*Reduce non-clinical time<br />
*Increase patient doctor time<br />
*Investment Motivationaily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).<br />
<br />
Over a 5-year period and determined by the overall size of the particular health system and scope of the EMR implementation, large hospitals can potentially save between $37M and $59M. <ref>Bell, B, Thornton, K. (2011). From promise to reality achieving the value of an EHR. Healthcare Financial Management, 65(2),51-56.</ref><br />
<br />
=== Investment Flexibility ===<br />
<br />
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).<br />
<br />
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)<br />
<br />
=== Management Risk Disposition ===<br />
<br />
The following tenets are the willingness to invest in experimental efforts.<br />
• Provide users with real time knowledge<br />
• Reduce non-clinical time<br />
• Increase patient doctor time<br />
• Investment Motivation<br />
To reduce cost, position for capitation/managed care, and gain market share.<br />
To enable providers to take advantage of financial incentives, the Health Information Technology for Economic and Clinical Health Act (HITECH) lists related criteria related to "Meaningful Use of EHR technology". [8] In addition, the Centers for Medicare & Medicaid Services, along with the Office of the National Coordinator for Health IT requires that an EHR technology are constituted of the following five pillars as health outcome policy priorities (67):<br />
* Improving quality, safety, efficiency, and reducing health disparities.<br />
* Engaging patients and families in their health.<br />
* Improving care coordination.<br />
* Improving population and public health.<br />
* Ensuring adequate privacy and security protection for personal health information.<br />
<br />
== Patient Safety Outcomes ==<br />
<br />
Electronic Medical Records (EMRs) increase patient safety and improve patient quality care by:<br />
<br />
# Insuring practice of better evidence-based medicine<br />
# Allowing flawless health information exchange between health care providers<br />
# Decreasing cost due to changes in drug frequency, dose or route administration <ref name="wang 2003">Wang, S. J., Middleton, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P. A cost-benefit analysis of electronic medical records in primary care. http://www.ncbi.nlm.nih.gov/pubmed/12714130 </ref><br />
# Improving communication and engagement with patients and their health care providers<br />
# Increasing patient medication compliance leading to improved overall health outcomes<br />
<br />
EMRs insure the practice of better evidence-based medicine by developing evidence-based clinical and Good Clinical Practice guideline reminders that are prompted to health care providers during patient encounters. <br />
<br />
The exchange of health information is greatly improved with EMRs because it can be delivered instantly and securely. Since the health care provider is entering the data into an EMR, medical errors are reduced from illegible handwriting. <br />
<br />
EMRs help health care providers by alerting them to potential adverse drug events when entering new prescribed medications in the computerized provider entry forms (CPOE) for patients with allergies, incompatible medication interactions, and delivering medications to verified patients. CPOE systems address these problems, ensure patient safety and save associated costs and injuries. CPOE features that help to achieve this are patient-specific dosage suggestions, reminder to monitor drug levels, reminders to choose an appropriate drugs, checking for drug allergy and drug-drug interactions, standardized order sets, increased legibility, automated communication to ancillary departments and ease of access to patient data.[17] <br />
<br />
EMRs allow pharmacists access to patient histories, past medication therapies, and current lab values. Clinical pharmacists have the responsibility of medication reconciliation, medication dose adjustments due to changes in liver/kidney function, transition of IV to oral therapies (in order to discharge the patient) and establishment of outpatient therapies. These areas of focus have shown to dramatically decrease length of hospital stay, increase beneficial patient outcomes, and decrease overall healthcare cost.<br />
<br />
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]<br />
<br />
Participants in the U.S. 2011 Physician Workflow study of office-based physicians responded that use of the EHR alerted them to potential medication errors (65%) and critical lab values (75%). <br />
<br />
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).<br />
<br />
<ref name="wang 2003"></ref><br />
<br />
=== Improving patient care ===<br />
<br />
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. <br />
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.<br />
<br />
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.<br />
<br />
In the 2014 HIMSS study, "EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates", it was noted that a relationship exists between the level of EMR adoption as measured by the EMRAM score, and a hospital’s performance as measured by predicted, actual rates of mortality and associated z-scores. This study implications include that hospitals with advanced EMR capabilities are able to capture more information about the patient. This improved data capture involving the patient’s co-morbidities and other risks allow clinicians to better manage patients seen in the hospital, resulting in more positive predicted clinical outcomes. [63]<br />
<br />
=== Improved quality and convenience of patient care ===<br />
<br />
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. In addition, it serves in achieving a higher form of personalized medicine and continuity of care, which are really important in the quality of patient 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:<br />
* 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.<br />
* 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! <br />
* 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.<br />
* 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.<br />
<br />
=== Data Legibility ===<br />
Legibility is very important to reduce medical errors. For instance, patient information presented as typed text is much easier to read compared to human writings. They are also unified in structures and standards to prevent confusion. Misspelled words can be corrected with spell checks or autocorrect function. Clinicians will be required by computers to enter complete patient notes to avoid missing information.<br />
<br />
=== Data Legibility Regarding Medications ===<br />
When physicians use Computer Provider Order Entry (CPOE) systems within the EMR, fewer medication errors also occur because there are fewer legibility issues. Proper dosages are clearly entered into the computer by the ordering physician, thus reducing the need for nurses or other staff to “second guess” or question the order. [7]<br />
<br />
<br />
In addition, with the use of electronic prescribing, the hand-written prescription is no longer applicable as a physician can electronically send a prescription directly to the pharmacy of the patient’s choice. This means there’s no question regarding which medication/dosage the provider prescribed and there are no complications with the physical prescription potentially being lost in transition [73].<br />
<br />
=== Engage and improve communication with patients ===<br />
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].<br />
<br />
<br />
With the increase in use of patient portals, more patients and physicians are communicating via secure online messaging. Patients can request appointments, refills, review lab results, pay bills or ask general questions about their health via online portals. Online appointment scheduling is one of the most desired features of the patient portal followed by reviewing test results. In fact, Kaiser Permanente experienced a jump from 9% to 27% in patient registration once they added the feature to review test results [72]. <br />
<br />
<br />
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].<br />
<br />
=== More effective preventive care ===<br />
<br />
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].<br />
<br />
Kuperman et al. (2003)conducted a review of studies discussing the benefits of CPOE. A randomized control trial of 6731 patients and 200 physicians in a General Medicine teaching institution where the computer application sent a reminder that the patient was eligible for preventive care yielded in increase number of orders for the flu and pneumococcal vaccine as well as aspirin for coronary artery disease.<br />
Another 4week study conducted in medical and surgical units showed increased number of orders for H2 blockers and prophylactic Heparin when the computer prompted physicians during CPOE.(11)<br />
<br />
The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].<br />
<br />
=== More effective urgent care ===<br />
<br />
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 ilocal, 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]<br />
<br />
=== Improved Coordination of Care ===<br />
<br />
The use of electronic medical records has allowed multiple healthcare providers across different specialties to access the patient's complete medical record. This more complete picture into the patient's medical history allows better collaborative medical treatment.<br />
<br />
=== Increased patient participation in their care === <br />
<br />
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. Patients are able to obtain medication refill reminders, insert lab values (i.e. glucose levels or warfarin levels) for review by a clinician, and request refills. The pharmacist at a distant location is able to review this information and make the appropriate changes in therapy. This electronic process allows patients to be more involved in their medication therapies and this involvement may increase compliance and overall outcomes.<br />
<br />
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.<br />
<br />
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].<br />
<br />
=== Improved accuracy of diagnoses and health outcomes === <br />
<br />
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]. One study showed a 48% decrease in the likelihood of medication errors in an inpatient hospital setting. <ref name="Radley"></ref> Although it is unclear that CPOE can reduce the harm for patients from medication, the increasing amounts of data acquired such as particular medication for certain diseases and outcomes, may play a vital role in the efforts for improving public health.<br />
<br />
===Preventing Adverse Events===<br />
Physician surveys have attributed EMRs to alerting to allergic drug reactions and drug interactions that might have been missed. In addition, they reported more timely reporting of critical laboratory values.[60] <br />
A systematic review of the effectiveness of safety alerts in EMRs showed a reduction in medication errors in patients with renal insufficiency, pregnant women, elderly patients, drug-drug interactions and ADEs related to hyperkalemia.[61]<br />
<br />
This is an important benefit, since medication related adverse events, will not only cause patients harm but will increase the cost.[2] and the use CPOE will eventually help to reduce the cost of medication related adverse events [3]. Although, some study suggested that is less likely to occur during the early implantation phase[4].<br />
<br />
Although many studies have shown CPOE can reduce the frequency of medication errors, there is no distinct association between CPOE and reduced harm for patients from medication. <ref name="Radley"> Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6 </ref> For instance, there are certain antibiotics that work well with certain disease pathways, and selecting the wrong one may have null effects that may cause further harm for the patient. Developing EHR systems will provide additional data on the usage of certain medications with diseases and outcomes, which will expand our knowledge on selecting efficient medication for improving quality in patient care.<br />
<br />
=== Improve patient safety at the point of pharmacy order entry ===<br />
EHRs with alerts at the point of pharmacy order entry can help reduce medication errors and prevent potential clinical hazards. <br />
<br />
EHR alerts has been beneficialin reduce medication errors in elder patient, pregenant patient and patient with compromised renal or liver functions. EHR alerts can help reduce drug-drug interactions and allergic and adverse events. [http://www.ncbi.nlm.nih.gov/pubmed/23816138]<br />
<br />
=== Qualitative Benefits === <br />
<br />
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. The EMR can help the provider deliver the best quality of care because the EMR contains the complete patient‘s health history. In a crisis, the EMR provides immediate access to a patient's medical history, allergies, and medications. The retrieved information enables providers to make decisions sooner which otherwise they would have to wait for, like information from test results or other resources. This feature is very critical when a patient has a serious or chronic medical condition, such as diabetes. Also, the EMR information can be shared with patients and their family, so they can more fully take part in decisions about their health care. In addition, using decision support tools in EMRs help the provider to make efficient and effective decisions about patient care through clinical alerts and reminders.<br />
<br />
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.<br />
<br />
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].<br />
<br />
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<br />
<br />
== Personalizing Healthcare ==<br />
<br />
===After Visit summaries (AVS)===<br />
<br />
Stage 3 meaningful use recommends that patients or their authorized representative receive a clinical summary after each visit that is not just an abstract from the medical records, Most EHRs enable clinicians to supply patients with such information in the form of an After Visit Summary (AVS) that is generated from data entered into their medical records. The AVS should have relevant clinical information and instructions pertinent to the office visit. It should also be provided in a language other than English, when needed, within 3 business days of the clinic visit, and should contain more than 50% of the office visit clinical summary. Provision of the AVS is important, as physicians usually overestimate patient understanding of the treatment plan. Therefore, the AVS has the potential to improve patient engagement in their care and contribute to more personalized healthcare and share medical decisions.<br />
<br />
===Improved Documentation of Advanced Care Planning=== <br />
EMR can be utilized to screen patients in an outpatient setting and prompt the physician to have a discussion about Advanced Directives. A study conducted as a QI improvement project showed that EMR-based reminders on counseling were effective in improving documentation rates of Advanced Directives.[59]<br />
=== Targeted cancer therapy ===<br />
EHR with clinical decision support help process the genomic data in the context of individual patient and provide dosing recommendation in a timely manner. <br />
EHR when intergrated into work flow can help realize personalized cancer treatment at the point of care. [www.ncbi.nlm.nih.gov/pubmed/21568680]<br />
=== Enhanced Patient Access ===<br />
Some EHR systems provide functionality e.g. MyChart [10] for patients to access portions of their medical record, view test results, renew prescriptions, schedule appointments etc. These convenience features enable patients to engage in and take ownership of their own health care.<br />
<br />
[http://my.clevelandclinic.org/online-services/mychart.aspx]<br />
<br />
== Administrative and Management Benefits ==<br />
<br />
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 interoperable, EMRs can provide far more benefits than paper records such as "help providers improve productivity and work life balance." [68] At a higher level of EMR implementation and functionality, Computerized Provider Order Entry (CPOE) can help standardize the clinical practice and eliminate variation. Some benefits of CPOE are:<br />
<br />
* Help improve communication amongst care givers<br />
* Expedite patient transfer to other levels of care<br />
* Capture data for quality assurance and administrative purposes<br />
* Aid practice and care in a complex care environment through the use of alerts and reminders<br />
* Provides some level of assurance to patients that technology is being applied to their safety [38].<br />
* 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.<br />
<br />
<br />
=== Establishing a learning chance to improve healthcare system === <br />
<br />
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.<br />
<br />
=== Customer Support ===<br />
<br />
Some EHR provide help and support in the form of a medical billing specialist. This specialist gives both practices and patients customer support. The specialist also has access to medical codes (ICD-9), CPT code books and practice-related HIPAA information. Other EHRs provide onsite training and on-the-phone consulting for software and billing questions. http://www.advancedmd.com/medical-billing-services <br />
<br />
===Increased practice efficiencies, cost savings, and reimbursement===<br />
<br />
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]. <br />
<br />
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. Historically, it has been difficult to identify and achieve a solid, measurable Return on Investment (ROI) following Electronic Health Records (EHR) or other clinical system implementation initiatives. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has motivated system implementations, and the associated incentive dollars have offered a simple measure of ROI on the revenue side of the ledger, but this represents only one aspect of the substantial benefits clinical systems can yield. A proper optimization program, with broader consideration for the projects comprising it, can bring a truly positive ROI to healthcare organizations over a 10-15 year period if properly considered and executed. (Cumberland Consulting Group, 2013) 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]. According to DRCRHONO, physicians qualify to get $24,000 or more as part of the economic stimulus incentive offered by the HITECH act if they adopt a certified EMR. Incentives are given to providers who qualify. The stimulus includes $24,000 in Medicare Incentives or $63,750 in Medicaid Incentives. The government is putting in $19.2 billion dollars to help move all doctors off paper records onto electronic systems [62].<br />
<br />
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.<br />
<br />
=== EMRs Help Manage Transactions ===<br />
EMRs help better manage the “large number of transactions and handoffs” which can include: billing, physicians’ orders, prescriptions, nurses’ orders insurance information, and more. Having this information all in one place makes it easier for any staff member – from administrators/front office to pharmacists to physical therapists – to gain access to the patient’s records and read and notes that may apply to them. [6]<br />
<br />
== Clinical Decision Support ==<br />
<br />
[[CDS|Clinical Decision Support (CDS)]] has been shown to increase healthcare quality and patient safety, improve adherence to guidelines for prevention and treatment, avoid medication errors and reduce cost of care.<br />
<br />
=== Improved healthcare quality ===<br />
CDS can be used as an additional tool for performing potentially more accurate diagnoses in challenging situations, thus improving the quality of provided care.<br />
Monitors attached to the patient in a hospital bed emit a plethora of real-time physiological data, i.e. EKG signals, blood-oxygen saturation, etc. A CDSS driven by computer algorithms capable of pattern recognition by interpreting the data, ideally in real-time, will aid the physician in providing prompt, better quality care.<br />
<br />
=== Improved patient safety ===<br />
CDSS affect patient safety by substantially reducing medication error rates, reducing risk of overdose or medication abuse, decreasing the occurrence of adverse drug reactions, and increasing adequate follow-up of critical test results such as abnormal biopsies, radiological studies, and laboratory tests Further, these systems utilize a variety of tools to enhance decision-making in clinical workflow, including computerized alerting systems, reminders, advice, critiques, and suggestions which can notify physicians about problems occurring asynchronously (clinical guidelines, condition-specific order sets, focused patient data report, summaries, etc.). <br />
<br />
=== Improved Reporting Capabilities ===<br />
An EMR has the capability of providing a more robust reporting environment with integrated clinical and administrative data, standardized clinical assessments and calculation of outcome measures[http://ptjournal.apta.org/content/86/3/434.full.pdf+html].<br />
<br />
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.<br />
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. Researchers from King Saud University in Saudi Arabia also found the usefulness of incorporating EHR techniques in their clinical decision support systems. The team created a four-module knowledge-based system that incorporated algorithmic guidelines and EHR data mining (66). Guidelines used in the proposed system are the International Classification of Disease (IDC), SNOMED CT, LOINIC, and the Unified Medical Language System (UMLS). The sophisticated system is projected to not only increase workflow, but also serve as a system for various entities to use as a consulting tool.<br />
<br />
===Reduce Diagnostic Errors===<br />
Diagnostic errors are defined as missed, delayed, or wrong diagnosis can lead to missed opportunity in patient care and increased cost [6]. CDS have the potential to improve the diagnostic process[7]. Moreover, systematic reviews found that CDS can improve health care professional performance [8]. Therefore, there is increase evidence that CDS can be helpful in many ways. It is clear that CDSS will have significant effect on improving patient safety strategies [9] <br />
<br />
===Reduced Cost ===<br />
Incorporating decision support within a CPOE not only assists a physician in practicing evidence-based medicine, it has also been demonstrated to reduce cost. Specifically, renal dosing guidance, specific drug guidance and adverse drug prevention have contributed to a net operating budget savings of $9.5 million at Brigham and Women's Hospital [21]. The average savings computed from the study indicated a 6-month savings of $3,450 per clinician. This is just one example of a study result measuring the impact of a specific CDSS in a specific EHR system in a singular clinic setting.<br />
<br />
== Research ==<br />
<br />
=== Informatics ===<br />
<br />
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.<br />
<br />
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].<br />
<br />
* 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. <br />
* 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). <br />
*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. <br />
* 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]<br />
<br />
=== Bioinformatics ===<br />
<br />
* 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.]<br />
<br />
=== Enhance public health surveillance ===<br />
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. According to The Advisory Board Company, there are three key elements for successful population health management (The Advisory Board Company, 2014):<br />
1. Information-powered clinical decision making (e.g. robust patient data sets and integrated data networks)<br />
2. Primary care-led clinical workforce (e.g. PCP care team leaders and mobilization of community workforces)<br />
3. Patient engagement and community integration (e.g. map services to population need and overcoming non-clinical barriers to maximize health outcomes).<br />
<br />
EHRs in conjunction with organizational improvement practices can help to address all three of these key elements. Incorporating electronic health records into public health practice not only improves public health surveillance, but also expands the communication between health care providers and public health professionals. In addition, organizations will be better able to track and prevent disease before an epidemic occurs. Through current government legislation, EHRs will assist public health research in achieving meaningful use(68). Many programs have already been implemented to begin this integration. <br />
<br />
An example of successful EMR surveillance is displayed in a 2012 article of the American Journal of Preventive Medicine, where the study focused on a model EMR-based public health surveillance platform, Electronic Medical Record Support for Public Health (ESP). It was noted to enable clinicians to provide high-quality surveillance data on notifiable diseases, influenza-like illness, and diabetes to public health agencies. This surveillance data can help health departments acquire rich and timely data on broader populations and wider sets of health indicators than is routinely possible with current surveillance systems. [64]<br />
<br />
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.<br />
<br />
=== Tracking Epidemics ===<br />
<br />
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 [[Centers for Disease Control and Prevention (CDC)|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. <ref name="emr cdc outbreak">http://www.gereports.com/using-emrs-to-help-the-cdc-track-outbreaks-faster/ </ref><br />
<br />
=== Better Evidence Based Practices ===<br />
<br />
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]<br />
<br />
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]<br />
<br />
=== Pharmacogenetic Research ===<br />
Patients' responses to drug treatment differ due to their genetic backgrounds. Such information is important to provide patient with optimized drug treatment. <br />
<br />
EHR can improve the quality and efficiency of pharmacogenetic research works by providing the link between pharmacoepidemiology and pharmacogenetics. EHR also supporting the pharmacogenetic research with access to health record database. [http://www.ncbi.nlm.nih.gov/pubmed/24581153]<br />
<br />
=== Clinical Research ===<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Front-end)''' [69]<br />
<br />
#Study setup<br />
##Query EMR database to establish number of potential study candidates.<br />
##Incorporate study manual or special instructions into EMR “clinical content” for study encounters.<br />
#Study enrollment<br />
#Implement study screening parameters into patient registration and scheduling. <br />
##Query EHR database to contact/recruit potential candidates and notify the patient’s providers of potential study eligibility.<br />
#Study execution<br />
##Incorporate study specific data capture as part of routine clinical care/documentation workflows. <br />
##Auto-populate study data elements into care report forms from other parts of the EMR database.<br />
##Embed study specific data requirement as special tabs/documentation templates using structured data entry.<br />
##Implement rules/alerts to ensure compliance with study data collection requirements.<br />
##Create range checks and structured documentation checks to ensure valid data entry.<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Back-end)''' [69]<br />
<br />
# Submission & Reporting<br />
##Provide data extraction formats that support data exchange standards<br />
##Document and report adverse events<br />
#Evidence-based review<br />
##Assess congruence of new findings and existing evidence with current practice and outcomes (incorporate into meta-analyses)<br />
##Submit findings to electronic trial banks using published standards.<br />
#Evidence-based clinical care<br />
##Implement study findings as clinical documentation, order sets, point of care rules/alerts<br />
##Monitor changes in care and outcomes in response to evidence base clinical decision support.<br />
##Provide easy access to detailed clinical care data for motivating new clinical trial hypotheses.<br />
<br />
=== The n-of-1 Clinical Trial ===<br />
<br />
N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. The availability of electronically accessible data provides opportunities for learning from experience in clinical care; this can also referred to as evidence farming or using evidence macrosystem. Evidence farming can be characterized as a “bottom up” paradigm for clinical practices to incorporate practice data systematically as source of evidence, or and articulated form of clinical experience. <ref name="n-of-1">Lillie, Elizabeth O., et al. "The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?" http://www.ncbi.nlm.nih.gov/pubmed/21695041 </ref><br />
<br />
=== Clinical Data Research Networks ===<br />
<br />
Since electronic medical records systems allow for the capture and storage of records in a discrete data format many secondary uses of the data is made possible. By utilizing health information exchange communities can share and aggregate their data for research to improve population health. The compiled data can be used to improve patient engagement, improve regulatory oversight, share the results of studies across health systems, and increase the use of research to improve outcomes at member institutions. In New York City this very concept has been proven successful through a project funded by the Patient-Centered Outcomes Research Institute (PCORI), and with the future adoption and utilization of HIEs more populations will be able to take advantage of these benefits. <ref name="CDRN">Kaushal, R., Hripcsak, G., Ascheim, DD., et al. (2014, March 25). Changing the research landscape: the New York City Clinical Data Research Network. J Am Med Inform Assoc. doi:10.1136/amiajnl-2014-002764</ref><br />
<br />
== National and international effects ==<br />
<br />
=== Growth, Job creation, and enhancement in the Commercial Clinical IT sector ===<br />
<br />
The commercial marketplace for clinical IT products has evolved dramatically<br />
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.<br />
<br />
=== Adapt to governmental regulatory changes and requirements ===<br />
<br />
HIPAA and other legislative bodies often require specific requirements. Compiling information from thousands of documents could be needed to complete the government’s requirements, a feat that would be inefficiently labor and time intensive if done with paper records. Digital patient records helps administration and upper management to meet requirements and regulatory changes to satisfy legislative demands. With digital records, auditors can quickly see if physicians and hospital systems are government compliant and can easily point out if they are not, allowing the non-compliant party to correct their inadequacy. http://www.msdc.com/EMR_Benefits.htm<br />
<br />
== Barriers to EMR Implementation ==<br />
<br />
=== System Selection ===<br />
<br />
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.<br />
<br />
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] According to Ajami and Chadegani, despite of the potential benefits of electronic health records, implement of this project facing with barriers and restriction, that the most of these limitations are cost constraints, technical limitations, standardization limits, attitudinal constraints–behavior of individuals and organizational constraints.[71]<br />
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].<br />
<br />
* In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system. <br />
* 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. <br />
* 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. <br />
*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 ]<br />
* 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]<br />
* 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. <br />
*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.<br />
*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.<br />
<br />
=== Costs ===<br />
Cost benefit analysis is categorized into 3 fields [70]:<br />
# Direct, one-time costs<br />
## Hardware & Peripherals<br />
## Packaged and customized software<br />
## Network, peripherals, supplies, equipment<br />
## Initial data collection and conversion of archival data<br />
## Facilities upgrades, including site preparation and renovation<br />
## End-user project management<br />
## Project planning, contract negotiation, procurement<br />
## Application development and deployment<br />
## Configuration management<br />
## Office accommodations, furniture, related items<br />
## Initial user training<br />
## Workforce adjustment for affected employees<br />
## Transition costs (parallel systems, converting legacy systems)<br />
## Quality assurance and post implementation reviews<br />
<br />
# Direct, ongoing costs<br />
## Salaries for IT and assigned end user staff<br />
## Software maintenance, subscriptions, upgrades,<br />
## Equipment leases<br />
## Facilities rental and utilities<br />
## Professional services, Ongoing training and<br />
## Reviews and audits<br />
<br />
# Indirect, ongoing costs. <br />
## Data integrity<br />
## Security<br />
## Privacy<br />
## IT policy management<br />
## Help Desk<br />
<br />
The financial commitment of implementing a CPOE system varies amongst facilities and depends on the facility's current hardware and software systems. The institution's current system needs to have a strong infrastructure in order to be able to enhance it's capabilities. The license for the software is but a small portion of the total cost. The larger expenses incurred will be a result of training healthcare professionals and support activities. Customer service and technical support should be available everyday 24 hours a day. <br />
<br />
For more information, see [[EMR Cost Categories]].<br />
<br />
=== Challenges to Identifying a Return on Investment (ROI) ===<br />
<br />
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]. For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance [58]. <br />
<br />
Additional barriers include:<br />
<br />
*Vendor supplied benefits data may not be objective <br />
*Few vendors maintain a structured database of benefits information<br />
*Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings. <br />
*Differences in system architecture <br />
*Trade journals tend to focus on anecdotal evidence rather then empirical evidence<br />
*No standardized domain method exists to measure the ROI of electronic health records <br />
*Lack of information regarding maintenance and optimization costs [48]<br />
<br />
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]<br />
<br />
=== EMR and Providers’ Productivity ===<br />
<br />
Health care providers are adopting electronic medical records, but some doctors report a disturbing side effect. Instead of becoming more efficient, some practices, especially smaller ones are becoming less. Several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday. [70] <br />
<br />
In a study by Bhargava et al. which examines productivity impacts of electronic medical records (EMR) implementation in a large academic hospital in California. Bhargava et al. also investigate the dynamics through which EMRs may impact productivity. The study employ random effects model on panel data comprising 3,189 physician-month observations for productivity data collected on 87 physicians specializing in internal medicine, pediatrics and family practice. The total duration of data collection was 39 months. Bhargava et al. find that the productivity of physicians dropped immediately after EMR implementation, but began to recover in a few months and finally leveled-off. Additionally, Bhargava et al. find that productivity impacts of EMR are contingent upon physician specialty. Bhargava et al postulate that the fit provided by an EMR to the task requirements of physicians of various specialties is key to entangling the productivity dynamics. [71]<br />
<br />
== Return on Investment (ROI) Estimates ==<br />
<br />
While barriers of determining actual ROI for EMR implementations exist, companies such as Dr. Cloud EMR are providing EMR and EHR ROI estimates based on each practice's details. This however does not suggest that it is entirely accurate and is only an estimate. DrCloudEMR is built by DrCloud Healthcare Solutions Inc, a wholly owned EnSoftek, Inc. subsidiary. [65]<br />
There are 2 main postulates for ROI which KOSH’s postulate and Sir Austin Bradford Hill’s criteria for Causation. <br />
Kosh’s postulate for CIS is <br />
i. The system or feature must be present in every case in which the benefit is observed.<br />
ii. The system must be isolated from the organization. <br />
iii. The benefit must be reproduced when the system is implemented in a new organization.<br />
iv. We must demonstrate that the system was used in the new organization.<br />
Hill’s Criteria for Causation includes (a) Strength of Association (b) Consistency of findings (c) Specificity of Association (d) Temporality (e) Dose-response (f) Plausibility (g) Coherence (h) Experimental Evidence and Analogy.<br />
<br />
=== Sittig's Postulates ===<br />
<br />
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.<br />
<br />
* Must have the hardware and software available before the effect is identified.<br />
** Need to at least estimate state of affairs before system is implemented…manual review<br />
* Show that clinicians are actually using the system that could produce the effect.<br />
* Show that the effect increases with increasing availability and usage of the system.<br />
* Show that all obvious “alternative explanations” for the effect are false.<br />
* Show the effect goes away when the system goes away.<br />
* Show that a similar effect occurs when a similar system is installed and used at a similar facility.<br />
<br />
=== Quality Care ===<br />
<br />
One could approach the ROI from the perspective of the Institute of Medicine Report, ''Crossing the Quality Chasm''<br />
# Safe: Reducing adverse drug events, inappropriate testing<br />
# Effective: Reducing drug costs through appropriate prescribing<br />
# Efficient: Reducing drug, laborotory, or radiologic utilization<br />
# Timely: Reducing wait times<br />
# Patient-centered: Reducing length-of-stay while hospitalized<br />
# Equitable: Provides data to demonstrate equal delivery<br />
<br />
=== Strategic Benefits === <br />
<br />
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.<br />
<br />
<br />
<br />
If EMR is fully implemented and functional, the benefits they offer are substantially than a paper records. Some of these benefits are:<br />
* Improvement in quality of patient care<br />
* An increase patient participation in their care (making appoints, refill of prescriptions, limited access to their records.<br />
* There will be an improvement in the accuracy of diagnoses and health outcomes-decrease of some types of medical errors<br />
* Improve care coordination<br />
* Increase practice efficiencies and cost savings <ref name="healthIT.gov"> http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs </ref><br />
<br />
Arlotto (2014) defends the right that EHRs are able to provide organizations the greatest value in the future of healthcare. She argues that this can be accomplished through the involvement of business, clinical, and financial platforms within an organization. As the healthcare industry is transitioning from volume to value based payment, organizations are increasingly depending on IT applications to facilitate the progress. She explains that our current healthcare practices use EHRs as an entity that simply automates the paper record and measure value based on direct cost-benefit analysis, rather than ensuring value realized over the lifetime of the investment.<ref name="ArlottoAccelROI"></ref> Five commonly mistaken truths are further discussed in order to facilitate the transition for more efficient use of EHR. <ref name="ArlottoAccelROI"> Arlotto, P. (2014). Accelerating the ROI of EHRs. Healthcare Financial Management : Journal of the Healthcare Financial Management Association, 68, 2, 72-9. </ref><br />
<br />
<br />
=== Achieving a Positive ROI ===<br />
<br />
A key to achieving a positive return on investment (ROI) when implementing an EHR system is using it for more than meeting meaningful use requirements. A 2013 study conducted by Harvard University researchers showed that many practices that implemented EHRs showed a negative 5 year ROI. Citing only 27 percent of practices which adopted EHRs would show a positive ROI. The reason for this according to their research was that many practices were not using their EHR systems effectively. The practices which showed a positive ROI were able to use their EHR in a way that increased the number of patients they were able to see in a day as well as improving their billing to reduce rejected claims. The practices which showed a negative ROI were mostly still using paper charts heavily even after implementing the EHR system. This resulted in decreased productivity on top of the expense of the system. The most important step practices must take to see a positive ROI on EHRs is to take the time to optimize their use so they can improve efficiency and reduce costs.<ref name="posroi">Harvard University Reports Findings in Electronic Medical Records. (2013, June 7). Health & Medicine Week, 1809. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA332414959&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&asid=f6372a5c3f33b3956c1739aae9c7d466</ref><br />
<br />
== Incentive Programs ==<br />
<br />
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)<br />
<br />
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)<br />
<br />
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)<br />
<br />
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 [[Office of the National Coordinator for Health Information Technology (ONC)|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)<br />
<br />
=== Sources of Funding === <br />
<br />
# Organizational Reserves – provider organization make investments in affiliated organizations<br />
# Bank and other financial service – short term loans<br />
# Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment<br />
# Vendor discounts and incentives – requires something in return<br />
# Joint venture or partnership – tighter relationship <br />
# Health plans and plan sponsors – contractual arrangement<br />
# Private philanthropy – fellowships or university chairs<br />
# Pharmaceutical companies – willing to conduct clinical trials<br />
# Public grants – government initiatives<br />
# State legislative initiatives – local and state initiatives<br />
<br />
== References (old, to edit) ==<br />
<br />
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]<br />
<br />
# http://www.msdc.com/EMR_Benefits.htm<br />
# http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm<br />
# http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php<br />
# http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm<br />
# http://www.mayoclinic.org/emr/benefits.html<br />
# 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.<br />
# Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67<br />
# Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429 <br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp<br />
# http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf<br />
# http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf<br />
# http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act<br />
# http://www.cdc.gov/ehrmeaningfuluse/<br />
# http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5<br />
# 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.<br />
# Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.<br />
# 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.<br />
#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.<br />
#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.<br />
# http://www.hhs.gov/news/press/2013pres/08/20130805a.html<br />
# http://www.fierceemr.com/story/new-york-looks-ehrs-enhance-public-health-surveillance/2013-08-27<br />
# http://ehrintelligence.com/2012/12/10/engaging-patients-through-ehr-access-open-notes/<br />
# 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,<br />
# Driessen J,CioffiM, Alide N,et al. J Am Med Inform Assoc 2013;20:743–748.<br />
# Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study Sameer Kumar, Krista Aldrich<br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html<br />
# http://www.ncbi.nlm.nih.gov/pubmed/9576410<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# http://www.practicefusion.com/ehrbloggers/2010/10/return-on-investment-for-emrs.html<br />
# http://jama.jamanetwork.com/article.aspx?articleid=1737043#ArticleInformation<br />
# Kuperman, G.J. and Gibson, R.F. (2003) “Computer Physician Order Entry: Benefits, Costs & Issues” Am Intern Med 2003; 139:31-39<br />
# Crane, R.M. and Raymond, B. (2003) “Fulfilling the Potential of Clinical Information Systems: The Permanente Journal Winter/2003/Vol.7No1<br />
# Kaushal, R.; Jha, A.K.; Franz, C. et al. (2006) J Am Med Inform Assoc 2006;13:261-266 doi 10.1197/jamia.J1984<br />
# http://www.nejm.org/doi/full/10.1056/NEJMp1211315#t=article<br />
# Menachemi N, Collum H.T. Benefits and drawbacks of electronic health record systems.Risk Manag Healthc Policy. 2011; 4: 47–55.<br />
# http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide-chapter-2.pdf<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978883/<br />
# 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.<br />
# Butcher L. Hospitals strengthen bonds with post-acute providers. http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG<br />
# Voigt, C. & Torzewski, S. (2011). Direct results: An HIE simple information exchange using the direct project. Journal of AHIMA, 38-41.<br />
# Kohn, L. T., Corrigan, J. M., & Donaldson, M. S., eds. (2000). To err is human. ''Institute of Medicine Committee on Quality of Health Care in America''. Washington, DC: National Academic Press.<br />
# McGeath, J. (2012). The Team Dynamics of Connecting Medical Devices with EMR Systems. 24X7, 17(10), 34-41<br />
# Mulherin, D. P., Zimmerman, C. R., & Chaffee, B. W. (2013). National standards for computerized prescriber order entry and clinical decision support: The case of drug interactions. American Journal Of Health-System Pharmacy, 70(1), 59-64. doi:10.2146/ajhp120217<br />
# Otte-Trojel, T., de Bont, A., Rundall, T. G., & van de Klundert, J. (2014). How outcomes are achieved through patient portals: a realist review. Journal of the American Medical Informatics Association, amiajnl-2013.<br />
# http://www.healthit.gov/providers-professionals/2-install-and-enable-encryption<br />
# http://www.dialogmedical.com/informed-consent-2-3/<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047866.hcsp?dDocName=bok1_047866<br />
# Hayek S1 et al. End-of-Life Care Planning: Improving Documentation of Advance Directives in the Outpatient Clinic using Electronic Medical Records. J Palliat Med. 2014 Jul 2.<br />
# Gummadi S1. Electronic medical record: a balancing act of patient safety, privacy and health care delivery. Am J Med Sci. 2014 Sep;348(3):238-43.<br />
# Ojeleye O1 et al. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013 Jul 1;13:69.<br />
# https://www.drchrono.com/meaningful-use-ehr/<br />
# EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates. http://apps.himss.org/content/files/HAHealthgradesEMRStudyWhitePaper.pdf<br />
# Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. http://www.ajpmonline.org/article/S0749-3797(12)00249-8/fulltext<br />
# EMR ROI / EHR ROI Calculator. http://www.drcloudemr.com/roi/<br />
# http://www.academia.edu/4083826/An_Adaptive_Evidence_Based_Medicine_System_Based_on_a_Clinical_Decision_Support_System<br />
# http://www.cdc.gov/ehrmeaningfuluse/introduction.html<br />
# http://www.healthit.gov/providers-professionals/faqs/how-can-electronic-health-records-improve-public-and-population-health-<br />
# http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf<br />
# http://www.forbes.com/sites/hbsworkingknowledge/2014/03/26/how-electronic-patient-records-can-slow-doctor-productivity/ <br />
# Bhargava, Hemant K., and Abhay Mishra. "Electronic Medical Records and Physicians Productivity: Insights from Panel Data Analysis and Design Implications." 2nd round at Management Science (2011).<br />
# http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1855&pageaction=displayproduct<br />
# Shortliffe, E. H., & Cimino, J. J. (2006). ''Biomedical informatics''. Springer Science+ Business Media, LLC.<br />
# http://www.healthit.gov/providers-professionals/faqs/what-are-advantages-electronic-health-records<br />
# Kim, Y., Kim, S. S., Kang, S., Kim, K., & Jun Kim. (2014). Development of Mobile Platform Integrated with Existing Electronic Medical Records. Health Infrormatics Research.<br />
# Zaroukian, M. (n.d.). EMR Cost-Benefit Analysis: Managing ROI into Reality. Retrieved from http://www.himss.org/files/HIMSSorg/content/files/EMRCost-BenefitReality.pdf<br />
# Ajami, S., & Arabchadegani, R. (n.d.). Barriers to implement Electronic Health Records (EHRs). Materia Socio Medica, 213-213. Retrieved September 10, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804410/<br />
# http://hitconsultant.net/2014/08/19/patient-portal-features-which-is-the-most-beneficial-frustrating/<br />
# http://www.cms.gov/Medicare/E-Health/Eprescribing/index.html?redirect=/EPrescribing<br />
# https://www.drchrono.com<br />
<br />
== References ==<br />
<references/><br />
<br />
5. What Is an Electronic Medical Record (EMR)? http://www.healthit.gov/providers-professionals/electronic-medical-records-emr <br />
<br />
6. Harrington, L., Porch, L., Acosta, K., & Wilkens, K. (2011). Realizing electronic medical record benefits: an easy-to-do usability study. The Journal of Nursing Administration, 41(7-8), 331–5. doi:10.1097/NNA.0b013e3182250b23<br />
<br />
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 (Project Hope), 24(5), 1103–17. doi:10.1377/hlthaff.24.5.1103<br />
<br />
== References ==<br />
# Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health Information Exchange Reduces Repeated Diagnostic Imaging for Back Pain. Annals of Emergency Medicine 2013 Jul;62(1):16-24.<br />
# Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997 Jan 22;277(4):307-11.<br />
# Johnston D, Pan E, Walker J. The value of CPOE in ambulatory settings. J Healthc Inf Manag 2004;18(1):5-8.<br />
# Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 Mar;11(2):100-3.<br />
# Stage DRMU. 3; Meaningful Use Work Group; Paul Tang, chair and George Hripcsak, co-chair. 2013. August. <br />
# Singh H. Editorial: Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis. Joint Commission Journal on Quality and Patient Safety 2014 Mar;40(3):99-101.<br />
# Bogua¡eviaius A, Maleckas A, Pundzius J, Skaudickas D. Prospective randomised trial of computerâ€aided diagnosis and contrast radiography in acute small bowel obstruction. European Journal of Surgery 2002;168(2):78-83.<br />
# Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293(10):1223-38.<br />
# McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):381-9.<br />
# Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. ( 2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6.<br />
11. Kuperman,G.J.,Gibson,R.F. (2003)Computer Order Physician Entry: Benefits, Costs, and Issues. ''Annals of Internal Medicine,139,31-19'' <br />
<br />
[[Category:EMR]]</div>Adlaihttp://clinfowiki.org/wiki/index.php/EMR_Benefits_and_Return_on_Investment_CategoriesEMR Benefits and Return on Investment Categories2014-09-13T20:57:24Z<p>Adlai: /* Costs */</p>
<hr />
<div>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:<br />
<br />
* Lower number of doctor visits (from the payer's perspective)<br />
* Communication, coding, efficiency, safety improvements<br />
* Transformation of healthcare delivery<br />
* Better Coordination of care<br />
* Improved management of chronic conditions<br />
<br />
However, quantifying these benefits is not a simple task. Issues that have hampered Return on Investment (ROI) studies and affected their validity include:<br />
<br />
* Pressure to justify expense<br />
* Shoddy collection of "before" comparison data after the implementation<br />
* Application of multiple simple statistical tests (the more statistical tests you run, the more likely you are to find something significant)<br />
<br />
The sections below detail the benefits, costs, and barriers in evaluating EMR implementations.<br />
<br />
== Informational ==<br />
<br />
=== Storage and retrieval ===<br />
<br />
EMRs improve the storage and retrieval of patient information in the following ways:<br />
<br />
# Reduces the amount of physical storage space required to house charts.<br />
# Protected from fire, natural disaster, or theft.<br />
# Records can be backed up to off-site facilities<br />
# Instant access to records.<br />
# More controlled access, including a record of who accessed the record.<br />
# Eliminates “lost” or incomplete charts.<br />
# More than one provider can access the record at one time. Ability to identify who modified the record.<br />
# Ensures business continuity and uninterrupted medical service.<br />
<br />
# 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 <ref name="wang 2003"></ref> <br />
# They reduce the likelihood that tests will be unnecessarily duplicated. <br />
# Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data. <br />
# 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). <br />
# 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). <br />
# EMRs reduce the number of lost or missing reports. <br />
# They reduce variability of care.<br />
# Timely delivery of critical services <br />
# Ensures business continuity and uninterrupted medical service.<br />
# Facilitates patient self-service and increases patient's engagement with the help of Patient portal which is a secure online website that patients can access anywhere and anytime to view their medications, immunizations, lab reports, request prescription refills, schedule appointments, make payments and much more.<br />
# Enforces data confidentiality and improves compliance.<br />
<br />
Respondents from the 2011 U.S. Physician Workflow study of office-based physicians reported that the EHR helped them access patient records remotely (81%) and enhanced patient care overall (78%).<br />
<br />
=== Increased Security of Patient Information ===<br />
<br />
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. Installing and enabling encryption is another way to protect and secure patient health information. Encryption is the conversion of data into a form that cannot be read without the decryption key or password. This method is paramount to secure information saved in mobile devices. There are several different ways to encrypt data in motion, such as a virtual private network (VPN) or a secure browser connection [56].<br />
<br />
=== Mobile EMRs ===<br />
<br />
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 presents the following advantages in addition to those observed for EMRs in general (29).<br />
<br />
# Enhanced patient education and satisfaction<br />
# Increased mobility of the device provides a better fit of technology to the application setting <br />
# The iPad touch screen enables easy use even without excessive knowledge of computers<br />
# Mobile devices was similar to paper charts in that they are extremely portable allowing physicians to carry it around in EDs easily<br />
# Remote patient monitoring and diagnosis<br />
# Ability to cross-reference medical terminology and provide multi language support.<br />
# Supports globalization of medical care.<br />
# Ability to send health data directly from wearable devices to medical records [1]<br />
# Link daily activities of living (e.g. fitness, nutrition data) to health data [1]<br />
# Dictate on the iOS device, e-Prescribe, and perform real-time eligibility checks [74]. <br />
<br />
<br />
The March 16, 2012, Letter to Us at Kaiser Permanente reported that Kaiser Permanente members can use mobile smartphones (Android, iPhones, or Blackberrys) to access their medical records, lab results, and all other aspects of kp.org. Kaiser Permanente members accessed the smartphone application over 1,000,000 times during the first month of use. In 2011, KP patients participated in more than 12,000,000 e-visits with their health care providers.<br />
<br />
[http://www.advisory.com/daily-briefing/blog/2014/09/will-apple-iwatch-revolutionize-health-care]<br />
<br />
=== Architecture of Mobile EMRs ===<br />
<br />
Severence Hospital started developing mobile EMR applications in 2005. In 2010, a mobile solutions for healthcare professionals for IOS based iPhones. In 2012, this application was redesinged to be platform independent, encryption policy was added to ensure data security and provided integrated management of Legacy EMR and a mobile solution. The patient list was organized by themes and its main feature was EMR history retrieval. The new architecture design process had four steps: Server and its architecture, Screen layout and story board making, Screen UI design and development, Pilot test and step by step by step deployment.<br />
The Mobile architecture: consists of Mobile server and Mobile device.The server receives information from the EMR system matched with search parameters which is then converted into information to be displayed on specific mobile device.<br />
This mobiles solution was first pilot tested for two month and later deployed in four Severence Hospitals[69]<br />
<br />
=== Improving workflow ===<br />
<br />
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.<br />
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.<br />
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.<br />
<br />
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.<br />
<br />
An EMR service that fully analyzes and streamlines the patient workflow, and works to support a lean practice operation, can actually improve efficiency, such as integrated billing. Providers can be more productive, spend more time with patients, and even enjoy increased patient visits.<br />
<br />
=== Improved care coordination ===<br />
<br />
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.<br />
<br />
=== Integrated View of Patient Data ===<br />
EHR systems can provide integrated access to all data about a patient from many visits and facilities such as laboratory tests, problems, diagnoses, medications, etc. from the database. This retrieval is made easy by data standards like HL7, LOINC, and SNOMED. Practitioners can also have multiple views of data through links provided in the user interfaces.<br />
<br />
=== Tracking Patients’ Medical Data ===<br />
By having the electronic medical record (EMR) save patient data (such as heart rate, blood pressure, eating habits, etc.) over, healthcare providers – or even the patients – can check parameters during a specific time frame when certain symptoms occur and correlate any relation. Having the constant patient data, allows the healthcare professional to go back in time and see any relationship to specific parameters and patient illness symptoms. [5]<br />
<br />
== Health Information Exchange (HIE) ==<br />
<br />
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.<br />
<br />
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.<br />
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.<br />
<br />
=== Facilitated referral for multidisciplinary care ===<br />
<br />
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]. <br />
<br />
=== Better Integrated Care by Hospitals and Long-Term Facilities/Rehabilitation Centers ===<br />
<br />
EHR plays an important role in improving the health care quality and safety; thus reducing the costs of providing care in long-term care facilities. <ref name="ford e 2010">Ford E. Electronic Health Records Hold Great Promise for Long-Term Care Facilities. http://www.ihealthbeat.org/perspectives/2010/electronic-health-records-hold-great-promise-for-longterm-care-facilities </ref> 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. <br />
<br />
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]<br />
<br />
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]<br />
<br />
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].<br />
<br />
=== Minimize Repeating Diagnostic Imaging Studies ===<br />
<br />
HIE can potentially eliminate unnecessary repetition of diagnostic testing, especially in the Emergency Department. Indeed as study found that HIE reduced imaging studies order by Emergency Department physicians for patients presenting with back pain, this is not only decrease the cost of expensive imaging studies but also decrease risk of unnecessary patients exposure to radiation[1]. This illustrate the importance of HIE and the potentially huge impact it will have on reducing cost and delivery an optimal health care. <br />
<br />
=== Facilitate Health Information Exchange ===<br />
<br />
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. HIEs also assist with provider/patient interactions regarding chronic disease management. One example of this looks at Western New York (WNY) Beacon Community and the regional health information exchange (HIE) HealtheLink. The two organizations teamed up to help diabetic patients in upstate New York with disease management. The cost of diabetes management has risen from $174 billion in 2007 to $245 billion in 2012; that is a 41% increase over five years (American Diabetes Association, 2014). These figures address an increased in financial burden, use of health resources and lost productivity associated with diabetes (American Diabetes Association, 2014). In response to this rise in cost, WNY Beacon has shared strategies not only improving the health of diabetic patients, but cutting costs for such management as well. Their strategies cover three primary topics: 1) expanding research for better analytics, 2) improving real-time care coordination and communication and 3) patient education, telehealth and population management. <br />
<br />
==== The Direct Project ====<br />
<br />
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.<br />
<br />
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]<br />
<br />
== Environmental ==<br />
<br />
Using EHRs can greatly reduce the need for paper in an office setting. Instead of throwing away and shredding old paper records or documents and destroying trees, digital documents can be erased without another tree being cut down to make another sheet of paper. http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/ As an eco-friendly software application, it reduces need for reams of paper and the environmental costs associated with it. http://www.healthynumbers.co.za/index.php?page=electronic_medical_records_environment<br />
<br />
== Medical Education ==<br />
<br />
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:<br />
# Increased accessibility to relevant and up-to-date literature for diagnosis and management plans via clinical decision support (CDS) systems within the EMR<br />
# Training the students to follow accepted clinical guidelines (best practices) using CDS<br />
# 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.<br />
# 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].<br />
<br />
The disadvantages of EMRs to education were noted by the following issues:<br />
# Problems with student access into the facilities systems such as obtaining log-ins and passwords<br />
# 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.<br />
# 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.<br />
# Trainees overly attentive to patient’s EMR data versus gaining information from physical examination and patient interactions<br />
# Focus on engagement with computer terminal disrupts patient-physician relationship in exam room<br />
# Automation bias - too much trust in decision support systems without consideration of their limitations<br />
<br />
As EMR use becomes standard fare in medical practice, the benefits of using EMR need to be harnessed by adapting the training curriculum of medical students and graduate medical education trainees to incorporate EMR-related sub- competencies (5).<br />
<br />
[http://jama.jamanetwork.com/article.aspx?articleid=1787416]<br />
<br />
=== Improving interpersonal and communication skills ===<br />
<br />
EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.<br />
<br />
=== Enhancing professionalism ===<br />
Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.<br />
<br />
=== Access to knowledge resource ===<br />
Today, clinicians can get access to medical literature on the internet while making clinical decisions or reviewing patient charts. EHRs can provide links in a patient record to internet resources like PubMed, NLM, and OVID to show clinicians the most up-to-dated information and knowledge in medicine.<br />
<br />
== Financial ==<br />
<br />
By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for: <br />
<br />
# Increase in the pace of information flow including service delivery.<br />
# Coding/billing accuracy.<br />
# Better documentation of patient encounters.<br />
# Reduction in overall administrative and maintenance costs of healthcare institutions.<br />
# Reduction in costs for the patient. <br />
# Reduction in transcription costs [http://jamia.bmj.com/content/18/2/169.full.pdf+html].<br />
# Decrease in malpractice insurance premiums.<br />
# 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].<br />
# Reduction in overtime expenses.<br />
<br />
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].<br />
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].<br />
<br />
Another feature of EMR is the capability to eliminate paper-based informed consents. Paper consents get lost or misplaced very easily and this problem contributes $3.3 billion to the cost of health care in the U.S. due to resulting operating room delays for example. Electronic informed consents also help better reducing liability risk [57]. <br />
<br />
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<br />
<br />
Financial benefits include averted costs and increased revenues, which can be divided into three categories: payer-independent benefits, benefits under capitated reimbursement, and benefits under fee-for-service reimbursement [58].<br />
<br />
=== Quantitative Benefits === <br />
<br />
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.<br />
<br />
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]<br />
<br />
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).<br />
<br />
=== Reducing cost ===<br />
<br />
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]. <br />
<br />
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.<br />
<br />
Kuperman et al. (2003) upon reviewing the benefits of CPOE said that a reduction in medication errors would increase hospital savings. They found two studies showing that half of all of medication errors were due to ordering of a drug for which the patient had an allergy and the other half were because of incorrect drug and incorrect dose. (11) During physician order entries standardized computer order sets can assist physicians to select disease-sensitive drug and patient-specific dosing. Computer applications can also send alerts about patient allergies, drug interactions and monitoring of drug levels.<br />
<br />
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 <ref name="wang 2003"></ref>Interventions to switch the twice-daily dosing of ceftriaxone to once-d<br />
*Provide users with real time knowledge<br />
*Reduce non-clinical time<br />
*Increase patient doctor time<br />
*Investment Motivationaily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).<br />
<br />
=== Investment Flexibility ===<br />
<br />
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).<br />
<br />
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)<br />
<br />
=== Management Risk Disposition ===<br />
<br />
The following tenets are the willingness to invest in experimental efforts.<br />
• Provide users with real time knowledge<br />
• Reduce non-clinical time<br />
• Increase patient doctor time<br />
• Investment Motivation<br />
To reduce cost, position for capitation/managed care, and gain market share.<br />
To enable providers to take advantage of financial incentives, the Health Information Technology for Economic and Clinical Health Act (HITECH) lists related criteria related to "Meaningful Use of EHR technology". [8] In addition, the Centers for Medicare & Medicaid Services, along with the Office of the National Coordinator for Health IT requires that an EHR technology are constituted of the following five pillars as health outcome policy priorities (67):<br />
* Improving quality, safety, efficiency, and reducing health disparities.<br />
* Engaging patients and families in their health.<br />
* Improving care coordination.<br />
* Improving population and public health.<br />
* Ensuring adequate privacy and security protection for personal health information.<br />
<br />
== Patient Safety Outcomes ==<br />
<br />
Electronic Medical Records (EMRs) increase patient safety and improve patient quality care by:<br />
<br />
# Insuring practice of better evidence-based medicine<br />
# Allowing flawless health information exchange between health care providers<br />
# Decreasing cost due to changes in drug frequency, dose or route administration <ref name="wang 2003">Wang, S. J., Middleton, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P. A cost-benefit analysis of electronic medical records in primary care. http://www.ncbi.nlm.nih.gov/pubmed/12714130 </ref><br />
# Improving communication and engagement with patients and their health care providers<br />
# Increasing patient medication compliance leading to improved overall health outcomes<br />
<br />
EMRs insure the practice of better evidence-based medicine by developing evidence-based clinical and Good Clinical Practice guideline reminders that are prompted to health care providers during patient encounters. <br />
<br />
The exchange of health information is greatly improved with EMRs because it can be delivered instantly and securely. Since the health care provider is entering the data into an EMR, medical errors are reduced from illegible handwriting. <br />
<br />
EMRs help health care providers by alerting them to potential adverse drug events when entering new prescribed medications in the computerized provider entry forms (CPOE) for patients with allergies, incompatible medication interactions, and delivering medications to verified patients. CPOE systems address these problems, ensure patient safety and save associated costs and injuries. CPOE features that help to achieve this are patient-specific dosage suggestions, reminder to monitor drug levels, reminders to choose an appropriate drugs, checking for drug allergy and drug-drug interactions, standardized order sets, increased legibility, automated communication to ancillary departments and ease of access to patient data.[17] <br />
<br />
EMRs allow pharmacists access to patient histories, past medication therapies, and current lab values. Clinical pharmacists have the responsibility of medication reconciliation, medication dose adjustments due to changes in liver/kidney function, transition of IV to oral therapies (in order to discharge the patient) and establishment of outpatient therapies. These areas of focus have shown to dramatically decrease length of hospital stay, increase beneficial patient outcomes, and decrease overall healthcare cost.<br />
<br />
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]<br />
<br />
Participants in the U.S. 2011 Physician Workflow study of office-based physicians responded that use of the EHR alerted them to potential medication errors (65%) and critical lab values (75%). <br />
<br />
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).<br />
<br />
<ref name="wang 2003"></ref><br />
<br />
=== Improving patient care ===<br />
<br />
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. <br />
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.<br />
<br />
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.<br />
<br />
In the 2014 HIMSS study, "EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates", it was noted that a relationship exists between the level of EMR adoption as measured by the EMRAM score, and a hospital’s performance as measured by predicted, actual rates of mortality and associated z-scores. This study implications include that hospitals with advanced EMR capabilities are able to capture more information about the patient. This improved data capture involving the patient’s co-morbidities and other risks allow clinicians to better manage patients seen in the hospital, resulting in more positive predicted clinical outcomes. [63]<br />
<br />
=== Improved quality and convenience of patient care ===<br />
<br />
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. In addition, it serves in achieving a higher form of personalized medicine and continuity of care, which are really important in the quality of patient 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:<br />
* 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.<br />
* 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! <br />
* 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.<br />
* 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.<br />
<br />
=== Data Legibility ===<br />
Legibility is very important to reduce medical errors. For instance, patient information presented as typed text is much easier to read compared to human writings. They are also unified in structures and standards to prevent confusion. Misspelled words can be corrected with spell checks or autocorrect function. Clinicians will be required by computers to enter complete patient notes to avoid missing information.<br />
<br />
=== Data Legibility Regarding Medications ===<br />
When physicians use Computer Provider Order Entry (CPOE) systems within the EMR, fewer medication errors also occur because there are fewer legibility issues. Proper dosages are clearly entered into the computer by the ordering physician, thus reducing the need for nurses or other staff to “second guess” or question the order. [7]<br />
<br />
<br />
In addition, with the use of electronic prescribing, the hand-written prescription is no longer applicable as a physician can electronically send a prescription directly to the pharmacy of the patient’s choice. This means there’s no question regarding which medication/dosage the provider prescribed and there are no complications with the physical prescription potentially being lost in transition [73].<br />
<br />
=== Engage and improve communication with patients ===<br />
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].<br />
<br />
<br />
With the increase in use of patient portals, more patients and physicians are communicating via secure online messaging. Patients can request appointments, refills, review lab results, pay bills or ask general questions about their health via online portals. Online appointment scheduling is one of the most desired features of the patient portal followed by reviewing test results. In fact, Kaiser Permanente experienced a jump from 9% to 27% in patient registration once they added the feature to review test results [72]. <br />
<br />
<br />
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].<br />
<br />
=== More effective preventive care ===<br />
<br />
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].<br />
<br />
Kuperman et al. (2003)conducted a review of studies discussing the benefits of CPOE. A randomized control trial of 6731 patients and 200 physicians in a General Medicine teaching institution where the computer application sent a reminder that the patient was eligible for preventive care yielded in increase number of orders for the flu and pneumococcal vaccine as well as aspirin for coronary artery disease.<br />
Another 4week study conducted in medical and surgical units showed increased number of orders for H2 blockers and prophylactic Heparin when the computer prompted physicians during CPOE.(11)<br />
<br />
The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].<br />
<br />
=== More effective urgent care ===<br />
<br />
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 ilocal, 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]<br />
<br />
=== Improved Coordination of Care ===<br />
<br />
The use of electronic medical records has allowed multiple healthcare providers across different specialties to access the patient's complete medical record. This more complete picture into the patient's medical history allows better collaborative medical treatment.<br />
<br />
=== Increased patient participation in their care === <br />
<br />
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. Patients are able to obtain medication refill reminders, insert lab values (i.e. glucose levels or warfarin levels) for review by a clinician, and request refills. The pharmacist at a distant location is able to review this information and make the appropriate changes in therapy. This electronic process allows patients to be more involved in their medication therapies and this involvement may increase compliance and overall outcomes.<br />
<br />
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.<br />
<br />
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].<br />
<br />
=== Improved accuracy of diagnoses and health outcomes === <br />
<br />
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]. One study showed a 48% decrease in the likelihood of medication errors in an inpatient hospital setting. <ref name="Radley"></ref> Although it is unclear that CPOE can reduce the harm for patients from medication, the increasing amounts of data acquired such as particular medication for certain diseases and outcomes, may play a vital role in the efforts for improving public health.<br />
<br />
===Preventing Adverse Events===<br />
Physician surveys have attributed EMRs to alerting to allergic drug reactions and drug interactions that might have been missed. In addition, they reported more timely reporting of critical laboratory values.[60] <br />
A systematic review of the effectiveness of safety alerts in EMRs showed a reduction in medication errors in patients with renal insufficiency, pregnant women, elderly patients, drug-drug interactions and ADEs related to hyperkalemia.[61]<br />
<br />
This is an important benefit, since medication related adverse events, will not only cause patients harm but will increase the cost.[2] and the use CPOE will eventually help to reduce the cost of medication related adverse events [3]. Although, some study suggested that is less likely to occur during the early implantation phase[4].<br />
<br />
Although many studies have shown CPOE can reduce the frequency of medication errors, there is no distinct association between CPOE and reduced harm for patients from medication. <ref name="Radley"> Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. (2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6 </ref> For instance, there are certain antibiotics that work well with certain disease pathways, and selecting the wrong one may have null effects that may cause further harm for the patient. Developing EHR systems will provide additional data on the usage of certain medications with diseases and outcomes, which will expand our knowledge on selecting efficient medication for improving quality in patient care.<br />
<br />
=== Improve patient safety at the point of pharmacy order entry ===<br />
EHRs with alerts at the point of pharmacy order entry can help reduce medication errors and prevent potential clinical hazards. <br />
<br />
EHR alerts has been beneficialin reduce medication errors in elder patient, pregenant patient and patient with compromised renal or liver functions. EHR alerts can help reduce drug-drug interactions and allergic and adverse events. [http://www.ncbi.nlm.nih.gov/pubmed/23816138]<br />
<br />
=== Qualitative Benefits === <br />
<br />
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. The EMR can help the provider deliver the best quality of care because the EMR contains the complete patient‘s health history. In a crisis, the EMR provides immediate access to a patient's medical history, allergies, and medications. The retrieved information enables providers to make decisions sooner which otherwise they would have to wait for, like information from test results or other resources. This feature is very critical when a patient has a serious or chronic medical condition, such as diabetes. Also, the EMR information can be shared with patients and their family, so they can more fully take part in decisions about their health care. In addition, using decision support tools in EMRs help the provider to make efficient and effective decisions about patient care through clinical alerts and reminders.<br />
<br />
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.<br />
<br />
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].<br />
<br />
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<br />
<br />
== Personalizing Healthcare ==<br />
<br />
===After Visit summaries (AVS)===<br />
<br />
Stage 3 meaningful use recommends that patients or their authorized representative receive a clinical summary after each visit that is not just an abstract from the medical records, Most EHRs enable clinicians to supply patients with such information in the form of an After Visit Summary (AVS) that is generated from data entered into their medical records. The AVS should have relevant clinical information and instructions pertinent to the office visit. It should also be provided in a language other than English, when needed, within 3 business days of the clinic visit, and should contain more than 50% of the office visit clinical summary. Provision of the AVS is important, as physicians usually overestimate patient understanding of the treatment plan. Therefore, the AVS has the potential to improve patient engagement in their care and contribute to more personalized healthcare and share medical decisions.<br />
<br />
===Improved Documentation of Advanced Care Planning=== <br />
EMR can be utilized to screen patients in an outpatient setting and prompt the physician to have a discussion about Advanced Directives. A study conducted as a QI improvement project showed that EMR-based reminders on counseling were effective in improving documentation rates of Advanced Directives.[59]<br />
=== Targeted cancer therapy ===<br />
EHR with clinical decision support help process the genomic data in the context of individual patient and provide dosing recommendation in a timely manner. <br />
EHR when intergrated into work flow can help realize personalized cancer treatment at the point of care. [www.ncbi.nlm.nih.gov/pubmed/21568680]<br />
=== Enhanced Patient Access ===<br />
Some EHR systems provide functionality e.g. MyChart [10] for patients to access portions of their medical record, view test results, renew prescriptions, schedule appointments etc. These convenience features enable patients to engage in and take ownership of their own health care.<br />
<br />
[http://my.clevelandclinic.org/online-services/mychart.aspx]<br />
<br />
== Administrative and Management Benefits ==<br />
<br />
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. They can, "help providers improve productivity and work life balance." [68] 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:<br />
* help improve communication amongst care givers<br />
* expedite patient transfer to other levels of care<br />
* capture data for quality assurance and administrative purposes<br />
* aid practice and care in a complex care environment through the use of alerts and reminders<br />
* provides some level of assurance to patients that technology is being applied to their safety [38].<br />
* 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.<br />
<br />
=== Establishing a learning chance to improve healthcare system === <br />
<br />
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.<br />
<br />
=== Customer Support ===<br />
<br />
Some EHR provide help and support in the form of a medical billing specialist. This specialist gives both practices and patients customer support. The specialist also has access to medical codes (ICD-9), CPT code books and practice-related HIPAA information. Other EHRs provide onsite training and on-the-phone consulting for software and billing questions. http://www.advancedmd.com/medical-billing-services <br />
<br />
===Increased practice efficiencies, cost savings, and reimbursement===<br />
<br />
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]. <br />
<br />
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. Historically, it has been difficult to identify and achieve a solid, measurable Return on Investment (ROI) following Electronic Health Records (EHR) or other clinical system implementation initiatives. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 has motivated system implementations, and the associated incentive dollars have offered a simple measure of ROI on the revenue side of the ledger, but this represents only one aspect of the substantial benefits clinical systems can yield. A proper optimization program, with broader consideration for the projects comprising it, can bring a truly positive ROI to healthcare organizations over a 10-15 year period if properly considered and executed. (Cumberland Consulting Group, 2013) 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]. According to DRCRHONO, physicians qualify to get $24,000 or more as part of the economic stimulus incentive offered by the HITECH act if they adopt a certified EMR. Incentives are given to providers who qualify. The stimulus includes $24,000 in Medicare Incentives or $63,750 in Medicaid Incentives. The government is putting in $19.2 billion dollars to help move all doctors off paper records onto electronic systems [62].<br />
<br />
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.<br />
<br />
=== EMRs Help Manage Transactions ===<br />
EMRs help better manage the “large number of transactions and handoffs” which can include: billing, physicians’ orders, prescriptions, nurses’ orders insurance information, and more. Having this information all in one place makes it easier for any staff member – from administrators/front office to pharmacists to physical therapists – to gain access to the patient’s records and read and notes that may apply to them. [6]<br />
<br />
== Clinical Decision Support ==<br />
<br />
[[CDS|Clinical Decision Support (CDS)]] has been shown to increase healthcare quality and patient safety, improve adherence to guidelines for prevention and treatment, avoid medication errors and reduce cost of care.<br />
<br />
=== Improved healthcare quality ===<br />
CDS can be used as an additional tool for performing potentially more accurate diagnoses in challenging situations, thus improving the quality of provided care.<br />
Monitors attached to the patient in a hospital bed emit a plethora of real-time physiological data, i.e. EKG signals, blood-oxygen saturation, etc. A CDSS driven by computer algorithms capable of pattern recognition by interpreting the data, ideally in real-time, will aid the physician in providing prompt, better quality care.<br />
<br />
=== Improved patient safety ===<br />
CDSS affect patient safety by substantially reducing medication error rates, reducing risk of overdose or medication abuse, decreasing the occurrence of adverse drug reactions, and increasing adequate follow-up of critical test results such as abnormal biopsies, radiological studies, and laboratory tests Further, these systems utilize a variety of tools to enhance decision-making in clinical workflow, including computerized alerting systems, reminders, advice, critiques, and suggestions which can notify physicians about problems occurring asynchronously (clinical guidelines, condition-specific order sets, focused patient data report, summaries, etc.). <br />
<br />
=== Improved Reporting Capabilities ===<br />
An EMR has the capability of providing a more robust reporting environment with integrated clinical and administrative data, standardized clinical assessments and calculation of outcome measures[http://ptjournal.apta.org/content/86/3/434.full.pdf+html].<br />
<br />
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.<br />
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. Researchers from King Saud University in Saudi Arabia also found the usefulness of incorporating EHR techniques in their clinical decision support systems. The team created a four-module knowledge-based system that incorporated algorithmic guidelines and EHR data mining (66). Guidelines used in the proposed system are the International Classification of Disease (IDC), SNOMED CT, LOINIC, and the Unified Medical Language System (UMLS). The sophisticated system is projected to not only increase workflow, but also serve as a system for various entities to use as a consulting tool.<br />
<br />
===Reduce Diagnostic Errors===<br />
Diagnostic errors are defined as missed, delayed, or wrong diagnosis can lead to missed opportunity in patient care and increased cost [6]. CDS have the potential to improve the diagnostic process[7]. Moreover, systematic reviews found that CDS can improve health care professional performance [8]. Therefore, there is increase evidence that CDS can be helpful in many ways. It is clear that CDSS will have significant effect on improving patient safety strategies [9] <br />
<br />
===Reduced Cost ===<br />
Incorporating decision support within a CPOE not only assists a physician in practicing evidence-based medicine, it has also been demonstrated to reduce cost. Specifically, renal dosing guidance, specific drug guidance and adverse drug prevention have contributed to a net operating budget savings of $9.5 million at Brigham and Women's Hospital [21]. The average savings computed from the study indicated a 6-month savings of $3,450 per clinician. This is just one example of a study result measuring the impact of a specific CDSS in a specific EHR system in a singular clinic setting.<br />
<br />
== Research ==<br />
<br />
=== Informatics ===<br />
<br />
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.<br />
<br />
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].<br />
<br />
* 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. <br />
* 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). <br />
*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. <br />
* 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]<br />
<br />
=== Bioinformatics ===<br />
<br />
* 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.]<br />
<br />
=== Enhance public health surveillance ===<br />
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. According to The Advisory Board Company, there are three key elements for successful population health management (The Advisory Board Company, 2014):<br />
1. Information-powered clinical decision making (e.g. robust patient data sets and integrated data networks)<br />
2. Primary care-led clinical workforce (e.g. PCP care team leaders and mobilization of community workforces)<br />
3. Patient engagement and community integration (e.g. map services to population need and overcoming non-clinical barriers to maximize health outcomes).<br />
<br />
EHRs in conjunction with organizational improvement practices can help to address all three of these key elements. Incorporating electronic health records into public health practice not only improves public health surveillance, but also expands the communication between health care providers and public health professionals. In addition, organizations will be better able to track and prevent disease before an epidemic occurs. Through current government legislation, EHRs will assist public health research in achieving meaningful use(68). Many programs have already been implemented to begin this integration. <br />
<br />
An example of successful EMR surveillance is displayed in a 2012 article of the American Journal of Preventive Medicine, where the study focused on a model EMR-based public health surveillance platform, Electronic Medical Record Support for Public Health (ESP). It was noted to enable clinicians to provide high-quality surveillance data on notifiable diseases, influenza-like illness, and diabetes to public health agencies. This surveillance data can help health departments acquire rich and timely data on broader populations and wider sets of health indicators than is routinely possible with current surveillance systems. [64]<br />
<br />
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.<br />
<br />
=== Tracking Epidemics ===<br />
<br />
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 [[Centers for Disease Control and Prevention (CDC)|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. <ref name="emr cdc outbreak">http://www.gereports.com/using-emrs-to-help-the-cdc-track-outbreaks-faster/ </ref><br />
<br />
=== Better Evidence Based Practices ===<br />
<br />
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]<br />
<br />
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]<br />
<br />
=== Pharmacogenetic Research ===<br />
Patients' responses to drug treatment differ due to their genetic backgrounds. Such information is important to provide patient with optimized drug treatment. <br />
<br />
EHR can improve the quality and efficiency of pharmacogenetic research works by providing the link between pharmacoepidemiology and pharmacogenetics. EHR also supporting the pharmacogenetic research with access to health record database. [http://www.ncbi.nlm.nih.gov/pubmed/24581153]<br />
<br />
=== Clinical Research ===<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Front-end)''' [69]<br />
<br />
#Study setup<br />
##Query EMR database to establish number of potential study candidates.<br />
##Incorporate study manual or special instructions into EMR “clinical content” for study encounters.<br />
#Study enrollment<br />
#Implement study screening parameters into patient registration and scheduling. <br />
##Query EHR database to contact/recruit potential candidates and notify the patient’s providers of potential study eligibility.<br />
#Study execution<br />
##Incorporate study specific data capture as part of routine clinical care/documentation workflows. <br />
##Auto-populate study data elements into care report forms from other parts of the EMR database.<br />
##Embed study specific data requirement as special tabs/documentation templates using structured data entry.<br />
##Implement rules/alerts to ensure compliance with study data collection requirements.<br />
##Create range checks and structured documentation checks to ensure valid data entry.<br />
<br />
'''How EMR’s Could Accelerate Clinical Trials (Back-end)''' [69]<br />
<br />
# Submission & Reporting<br />
##Provide data extraction formats that support data exchange standards<br />
##Document and report adverse events<br />
#Evidence-based review<br />
##Assess congruence of new findings and existing evidence with current practice and outcomes (incorporate into meta-analyses)<br />
##Submit findings to electronic trial banks using published standards.<br />
#Evidence-based clinical care<br />
##Implement study findings as clinical documentation, order sets, point of care rules/alerts<br />
##Monitor changes in care and outcomes in response to evidence base clinical decision support.<br />
##Provide easy access to detailed clinical care data for motivating new clinical trial hypotheses.<br />
<br />
=== The n-of-1 Clinical Trial ===<br />
<br />
N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. The availability of electronically accessible data provides opportunities for learning from experience in clinical care; this can also referred to as evidence farming or using evidence macrosystem. Evidence farming can be characterized as a “bottom up” paradigm for clinical practices to incorporate practice data systematically as source of evidence, or and articulated form of clinical experience. <ref name="n-of-1">Lillie, Elizabeth O., et al. "The n-of-1 clinical trial: the ultimate strategy for individualizing medicine?" http://www.ncbi.nlm.nih.gov/pubmed/21695041 </ref><br />
<br />
=== Clinical Data Research Networks ===<br />
<br />
Since electronic medical records systems allow for the capture and storage of records in a discrete data format many secondary uses of the data is made possible. By utilizing health information exchange communities can share and aggregate their data for research to improve population health. The compiled data can be used to improve patient engagement, improve regulatory oversight, share the results of studies across health systems, and increase the use of research to improve outcomes at member institutions. In New York City this very concept has been proven successful through a project funded by the Patient-Centered Outcomes Research Institute (PCORI), and with the future adoption and utilization of HIEs more populations will be able to take advantage of these benefits. <ref name="CDRN">Kaushal, R., Hripcsak, G., Ascheim, DD., et al. (2014, March 25). Changing the research landscape: the New York City Clinical Data Research Network. J Am Med Inform Assoc. doi:10.1136/amiajnl-2014-002764</ref><br />
<br />
== National and international effects ==<br />
<br />
=== Growth, Job creation, and enhancement in the Commercial Clinical IT sector ===<br />
<br />
The commercial marketplace for clinical IT products has evolved dramatically<br />
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.<br />
<br />
=== Adapt to governmental regulatory changes and requirements ===<br />
<br />
HIPAA and other legislative bodies often require specific requirements. Compiling information from thousands of documents could be needed to complete the government’s requirements, a feat that would be inefficiently labor and time intensive if done with paper records. Digital patient records helps administration and upper management to meet requirements and regulatory changes to satisfy legislative demands. With digital records, auditors can quickly see if physicians and hospital systems are government compliant and can easily point out if they are not, allowing the non-compliant party to correct their inadequacy. http://www.msdc.com/EMR_Benefits.htm<br />
<br />
== Barriers to EMR Implementation ==<br />
<br />
=== System Selection ===<br />
<br />
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.<br />
<br />
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] According to Ajami and Chadegani, despite of the potential benefits of electronic health records, implement of this project facing with barriers and restriction, that the most of these limitations are cost constraints, technical limitations, standardization limits, attitudinal constraints–behavior of individuals and organizational constraints.[71]<br />
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].<br />
<br />
* In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system. <br />
* 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. <br />
* 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. <br />
*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 ]<br />
* 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]<br />
* 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. <br />
*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.<br />
*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.<br />
<br />
=== Costs ===<br />
Cost benefit analysis is categorized into 3 fields [70]:<br />
# Direct, one-time costs<br />
## Hardware & Peripherals<br />
## Packaged and customized software<br />
## Network, peripherals, supplies, equipment<br />
## Initial data collection and conversion of archival data<br />
## Facilities upgrades, including site preparation and renovation<br />
## End-user project management<br />
## Project planning, contract negotiation, procurement<br />
## Application development and deployment<br />
## Configuration management<br />
## Office accommodations, furniture, related items<br />
## Initial user training<br />
## Workforce adjustment for affected employees<br />
## Transition costs (parallel systems, converting legacy systems)<br />
## Quality assurance and post implementation reviews<br />
<br />
# Direct, ongoing costs<br />
## Salaries for IT and assigned end user staff<br />
## Software maintenance, subscriptions, upgrades,<br />
## Equipment leases<br />
## Facilities rental and utilities<br />
## Professional services, Ongoing training and<br />
## Reviews and audits<br />
<br />
# Indirect, ongoing costs. <br />
## Data integrity<br />
## Security<br />
## Privacy<br />
## IT policy management<br />
## Help Desk<br />
<br />
The financial commitment of implementing a CPOE system varies amongst facilities and depends on the facility's current hardware and software systems. The institution's current system needs to have a strong infrastructure in order to be able to enhance it's capabilities. The license for the software is but a small portion of the total cost. The larger expenses incurred will be a result of training healthcare professionals and support activities. Customer service and technical support should be available everyday 24 hours a day. <br />
<br />
For more information, see [[EMR Cost Categories]].<br />
<br />
=== Challenges to Identifying a Return on Investment (ROI) ===<br />
<br />
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]. For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance [58]. <br />
<br />
Additional barriers include:<br />
<br />
*Vendor supplied benefits data may not be objective <br />
*Few vendors maintain a structured database of benefits information<br />
*Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings. <br />
*Differences in system architecture <br />
*Trade journals tend to focus on anecdotal evidence rather then empirical evidence<br />
*No standardized domain method exists to measure the ROI of electronic health records <br />
*Lack of information regarding maintenance and optimization costs [48]<br />
<br />
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]<br />
<br />
=== EMR and Providers’ Productivity ===<br />
<br />
Health care providers are adopting electronic medical records, but some doctors report a disturbing side effect. Instead of becoming more efficient, some practices, especially smaller ones are becoming less. Several studies indicated that when physicians spent extra time entering data themselves, it cut down time spent with patients and stretched out their workday. [70] <br />
<br />
In a study by Bhargava et al. which examines productivity impacts of electronic medical records (EMR) implementation in a large academic hospital in California. Bhargava et al. also investigate the dynamics through which EMRs may impact productivity. The study employ random effects model on panel data comprising 3,189 physician-month observations for productivity data collected on 87 physicians specializing in internal medicine, pediatrics and family practice. The total duration of data collection was 39 months. Bhargava et al. find that the productivity of physicians dropped immediately after EMR implementation, but began to recover in a few months and finally leveled-off. Additionally, Bhargava et al. find that productivity impacts of EMR are contingent upon physician specialty. Bhargava et al postulate that the fit provided by an EMR to the task requirements of physicians of various specialties is key to entangling the productivity dynamics. [71]<br />
<br />
== Return on Investment (ROI) Estimates ==<br />
<br />
While barriers of determining actual ROI for EMR implementations exist, companies such as Dr. Cloud EMR are providing EMR and EHR ROI estimates based on each practice's details. This however does not suggest that it is entirely accurate and is only an estimate. DrCloudEMR is built by DrCloud Healthcare Solutions Inc, a wholly owned EnSoftek, Inc. subsidiary. [65]<br />
There are 2 main postulates for ROI which KOSH’s postulate and Sir Austin Bradford Hill’s criteria for Causation. <br />
Kosh’s postulate for CIS is <br />
i. The system or feature must be present in every case in which the benefit is observed.<br />
ii. The system must be isolated from the organization. <br />
iii. The benefit must be reproduced when the system is implemented in a new organization.<br />
iv. We must demonstrate that the system was used in the new organization.<br />
Hill’s Criteria for Causation includes (a) Strength of Association (b) Consistency of findings (c) Specificity of Association (d) Temporality (e) Dose-response (f) Plausibility (g) Coherence (h) Experimental Evidence and Analogy.<br />
<br />
=== Sittig's Postulates ===<br />
<br />
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.<br />
<br />
* Must have the hardware and software available before the effect is identified.<br />
** Need to at least estimate state of affairs before system is implemented…manual review<br />
* Show that clinicians are actually using the system that could produce the effect.<br />
* Show that the effect increases with increasing availability and usage of the system.<br />
* Show that all obvious “alternative explanations” for the effect are false.<br />
* Show the effect goes away when the system goes away.<br />
* Show that a similar effect occurs when a similar system is installed and used at a similar facility.<br />
<br />
=== Quality Care ===<br />
<br />
One could approach the ROI from the perspective of the Institute of Medicine Report, ''Crossing the Quality Chasm''<br />
# Safe: Reducing adverse drug events, inappropriate testing<br />
# Effective: Reducing drug costs through appropriate prescribing<br />
# Efficient: Reducing drug, laborotory, or radiologic utilization<br />
# Timely: Reducing wait times<br />
# Patient-centered: Reducing length-of-stay while hospitalized<br />
# Equitable: Provides data to demonstrate equal delivery<br />
<br />
=== Strategic Benefits === <br />
<br />
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.<br />
<br />
<br />
<br />
If EMR is fully implemented and functional, the benefits they offer are substantially than a paper records. Some of these benefits are:<br />
* Improvement in quality of patient care<br />
* An increase patient participation in their care (making appoints, refill of prescriptions, limited access to their records.<br />
* There will be an improvement in the accuracy of diagnoses and health outcomes-decrease of some types of medical errors<br />
* Improve care coordination<br />
* Increase practice efficiencies and cost savings <ref name="healthIT.gov"> http://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs </ref><br />
<br />
Arlotto (2014) defends the right that EHRs are able to provide organizations the greatest value in the future of healthcare. She argues that this can be accomplished through the involvement of business, clinical, and financial platforms within an organization. As the healthcare industry is transitioning from volume to value based payment, organizations are increasingly depending on IT applications to facilitate the progress. She explains that our current healthcare practices use EHRs as an entity that simply automates the paper record and measure value based on direct cost-benefit analysis, rather than ensuring value realized over the lifetime of the investment.<ref name="ArlottoAccelROI"></ref> Five commonly mistaken truths are further discussed in order to facilitate the transition for more efficient use of EHR. <ref name="ArlottoAccelROI"> Arlotto, P. (2014). Accelerating the ROI of EHRs. Healthcare Financial Management : Journal of the Healthcare Financial Management Association, 68, 2, 72-9. </ref><br />
<br />
<br />
=== Achieving a Positive ROI ===<br />
<br />
A key to achieving a positive return on investment (ROI) when implementing an EHR system is using it for more than meeting meaningful use requirements. A 2013 study conducted by Harvard University researchers showed that many practices that implemented EHRs showed a negative 5 year ROI. Citing only 27 percent of practices which adopted EHRs would show a positive ROI. The reason for this according to their research was that many practices were not using their EHR systems effectively. The practices which showed a positive ROI were able to use their EHR in a way that increased the number of patients they were able to see in a day as well as improving their billing to reduce rejected claims. The practices which showed a negative ROI were mostly still using paper charts heavily even after implementing the EHR system. This resulted in decreased productivity on top of the expense of the system. The most important step practices must take to see a positive ROI on EHRs is to take the time to optimize their use so they can improve efficiency and reduce costs.<ref name="posroi">Harvard University Reports Findings in Electronic Medical Records. (2013, June 7). Health & Medicine Week, 1809. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA332414959&v=2.1&u=txshracd2509&it=r&p=HRCA&sw=w&asid=f6372a5c3f33b3956c1739aae9c7d466</ref><br />
<br />
== Incentive Programs ==<br />
<br />
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)<br />
<br />
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)<br />
<br />
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)<br />
<br />
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 [[Office of the National Coordinator for Health Information Technology (ONC)|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)<br />
<br />
=== Sources of Funding === <br />
<br />
# Organizational Reserves – provider organization make investments in affiliated organizations<br />
# Bank and other financial service – short term loans<br />
# Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment<br />
# Vendor discounts and incentives – requires something in return<br />
# Joint venture or partnership – tighter relationship <br />
# Health plans and plan sponsors – contractual arrangement<br />
# Private philanthropy – fellowships or university chairs<br />
# Pharmaceutical companies – willing to conduct clinical trials<br />
# Public grants – government initiatives<br />
# State legislative initiatives – local and state initiatives<br />
<br />
== References (old, to edit) ==<br />
<br />
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]<br />
<br />
# http://www.msdc.com/EMR_Benefits.htm<br />
# http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm<br />
# http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php<br />
# http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm<br />
# http://www.mayoclinic.org/emr/benefits.html<br />
# 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.<br />
# Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67<br />
# Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429 <br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp<br />
# http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf<br />
# http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf<br />
# http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act<br />
# http://www.cdc.gov/ehrmeaningfuluse/<br />
# http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5<br />
# 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.<br />
# Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.<br />
# 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.<br />
#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.<br />
#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.<br />
# http://www.hhs.gov/news/press/2013pres/08/20130805a.html<br />
# http://www.fierceemr.com/story/new-york-looks-ehrs-enhance-public-health-surveillance/2013-08-27<br />
# http://ehrintelligence.com/2012/12/10/engaging-patients-through-ehr-access-open-notes/<br />
# 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,<br />
# Driessen J,CioffiM, Alide N,et al. J Am Med Inform Assoc 2013;20:743–748.<br />
# Overcoming barriers to electronic medical record (EMR) implementation in the US healthcare system: A comparative study Sameer Kumar, Krista Aldrich<br />
# http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Basics.html<br />
# http://www.ncbi.nlm.nih.gov/pubmed/9576410<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# 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.<br />
# http://www.practicefusion.com/ehrbloggers/2010/10/return-on-investment-for-emrs.html<br />
# http://jama.jamanetwork.com/article.aspx?articleid=1737043#ArticleInformation<br />
# Kuperman, G.J. and Gibson, R.F. (2003) “Computer Physician Order Entry: Benefits, Costs & Issues” Am Intern Med 2003; 139:31-39<br />
# Crane, R.M. and Raymond, B. (2003) “Fulfilling the Potential of Clinical Information Systems: The Permanente Journal Winter/2003/Vol.7No1<br />
# Kaushal, R.; Jha, A.K.; Franz, C. et al. (2006) J Am Med Inform Assoc 2006;13:261-266 doi 10.1197/jamia.J1984<br />
# http://www.nejm.org/doi/full/10.1056/NEJMp1211315#t=article<br />
# Menachemi N, Collum H.T. Benefits and drawbacks of electronic health record systems.Risk Manag Healthc Policy. 2011; 4: 47–55.<br />
# http://www.healthit.gov/sites/default/files/pdf/privacy/privacy-and-security-guide-chapter-2.pdf<br />
# http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978883/<br />
# 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.<br />
# Butcher L. Hospitals strengthen bonds with post-acute providers. http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/01JAN2013/0113HHN_Feature_strategy&domain=HHNMAG<br />
# Voigt, C. & Torzewski, S. (2011). Direct results: An HIE simple information exchange using the direct project. Journal of AHIMA, 38-41.<br />
# Kohn, L. T., Corrigan, J. M., & Donaldson, M. S., eds. (2000). To err is human. ''Institute of Medicine Committee on Quality of Health Care in America''. Washington, DC: National Academic Press.<br />
# McGeath, J. (2012). The Team Dynamics of Connecting Medical Devices with EMR Systems. 24X7, 17(10), 34-41<br />
# Mulherin, D. P., Zimmerman, C. R., & Chaffee, B. W. (2013). National standards for computerized prescriber order entry and clinical decision support: The case of drug interactions. American Journal Of Health-System Pharmacy, 70(1), 59-64. doi:10.2146/ajhp120217<br />
# Otte-Trojel, T., de Bont, A., Rundall, T. G., & van de Klundert, J. (2014). How outcomes are achieved through patient portals: a realist review. Journal of the American Medical Informatics Association, amiajnl-2013.<br />
# http://www.healthit.gov/providers-professionals/2-install-and-enable-encryption<br />
# http://www.dialogmedical.com/informed-consent-2-3/<br />
# http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047866.hcsp?dDocName=bok1_047866<br />
# Hayek S1 et al. End-of-Life Care Planning: Improving Documentation of Advance Directives in the Outpatient Clinic using Electronic Medical Records. J Palliat Med. 2014 Jul 2.<br />
# Gummadi S1. Electronic medical record: a balancing act of patient safety, privacy and health care delivery. Am J Med Sci. 2014 Sep;348(3):238-43.<br />
# Ojeleye O1 et al. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013 Jul 1;13:69.<br />
# https://www.drchrono.com/meaningful-use-ehr/<br />
# EMR Effectiveness: The Positive Benefit Electronic Medical Record Adoption has on Mortality Rates. http://apps.himss.org/content/files/HAHealthgradesEMRStudyWhitePaper.pdf<br />
# Integrating Clinical Practice and Public Health Surveillance Using Electronic Medical Record Systems. http://www.ajpmonline.org/article/S0749-3797(12)00249-8/fulltext<br />
# EMR ROI / EHR ROI Calculator. http://www.drcloudemr.com/roi/<br />
# http://www.academia.edu/4083826/An_Adaptive_Evidence_Based_Medicine_System_Based_on_a_Clinical_Decision_Support_System<br />
# http://www.cdc.gov/ehrmeaningfuluse/introduction.html<br />
# http://www.healthit.gov/providers-professionals/faqs/how-can-electronic-health-records-improve-public-and-population-health-<br />
# http://www.esi-bethesda.com/ncrrworkshops/clinicalresearch/pdf/MichaelKahnPaper.pdf<br />
# http://www.forbes.com/sites/hbsworkingknowledge/2014/03/26/how-electronic-patient-records-can-slow-doctor-productivity/ <br />
# Bhargava, Hemant K., and Abhay Mishra. "Electronic Medical Records and Physicians Productivity: Insights from Panel Data Analysis and Design Implications." 2nd round at Management Science (2011).<br />
# http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1855&pageaction=displayproduct<br />
# Shortliffe, E. H., & Cimino, J. J. (2006). ''Biomedical informatics''. Springer Science+ Business Media, LLC.<br />
# http://www.healthit.gov/providers-professionals/faqs/what-are-advantages-electronic-health-records<br />
# Kim, Y., Kim, S. S., Kang, S., Kim, K., & Jun Kim. (2014). Development of Mobile Platform Integrated with Existing Electronic Medical Records. Health Infrormatics Research.<br />
# Zaroukian, M. (n.d.). EMR Cost-Benefit Analysis: Managing ROI into Reality. Retrieved from http://www.himss.org/files/HIMSSorg/content/files/EMRCost-BenefitReality.pdf<br />
# Ajami, S., & Arabchadegani, R. (n.d.). Barriers to implement Electronic Health Records (EHRs). Materia Socio Medica, 213-213. Retrieved September 10, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3804410/<br />
# http://hitconsultant.net/2014/08/19/patient-portal-features-which-is-the-most-beneficial-frustrating/<br />
# http://www.cms.gov/Medicare/E-Health/Eprescribing/index.html?redirect=/EPrescribing<br />
# https://www.drchrono.com<br />
<br />
== References ==<br />
<references/><br />
<br />
5. What Is an Electronic Medical Record (EMR)? http://www.healthit.gov/providers-professionals/electronic-medical-records-emr <br />
<br />
6. Harrington, L., Porch, L., Acosta, K., & Wilkens, K. (2011). Realizing electronic medical record benefits: an easy-to-do usability study. The Journal of Nursing Administration, 41(7-8), 331–5. doi:10.1097/NNA.0b013e3182250b23<br />
<br />
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 (Project Hope), 24(5), 1103–17. doi:10.1377/hlthaff.24.5.1103<br />
<br />
== References ==<br />
# Bailey JE, Pope RA, Elliott EC, Wan JY, Waters TM, Frisse ME. Health Information Exchange Reduces Repeated Diagnostic Imaging for Back Pain. Annals of Emergency Medicine 2013 Jul;62(1):16-24.<br />
# Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA 1997 Jan 22;277(4):307-11.<br />
# Johnston D, Pan E, Walker J. The value of CPOE in ambulatory settings. J Healthc Inf Manag 2004;18(1):5-8.<br />
# Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 Mar;11(2):100-3.<br />
# Stage DRMU. 3; Meaningful Use Work Group; Paul Tang, chair and George Hripcsak, co-chair. 2013. August. <br />
# Singh H. Editorial: Helping Health Care Organizations to Define Diagnostic Errors as Missed Opportunities in Diagnosis. Joint Commission Journal on Quality and Patient Safety 2014 Mar;40(3):99-101.<br />
# Bogua¡eviaius A, Maleckas A, Pundzius J, Skaudickas D. Prospective randomised trial of computerâ€aided diagnosis and contrast radiography in acute small bowel obstruction. European Journal of Surgery 2002;168(2):78-83.<br />
# Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005;293(10):1223-38.<br />
# McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):381-9.<br />
# Radley, D. C., Wasserman, M. R., Olsho, L. E., Shoemaker, S. J., Spranca, M. D., & Bradshaw, B. ( 2013). Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems. Journal of the American Medical Informatics Association : Jamia, 20, 3, 470-6.<br />
11. Kuperman,G.J.,Gibson,R.F. (2003)Computer Order Physician Entry: Benefits, Costs, and Issues. ''Annals of Internal Medicine,139,31-19'' <br />
<br />
[[Category:EMR]]</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T17:01:51Z<p>Adlai: /* Certification */</p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. Skycare EHR was first introduced into the market in January of 2011. The following year, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. Accessed through a secured web portal, Skycare allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.[2]<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
* Electronic Health Records<br />
* Practice Management<br />
* Electronic Prescribing<br />
* Electronic Billing<br />
* Revenue Cycle Management<br />
* Documents and Data<br />
<br />
==Certification==<br />
<br />
As of July 28, 2014, Skycare is 2014 certified to be a complete EHR under the "ambulatory practice" type. The certifying body that performed the overview is InfoGard and utilized the certification criteria 170.314.[3]<br />
<br />
==References==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php<br />
# http://skycareehr.com/html/index.php<br />
# http://oncchpl.force.com/ehrcert/ehrproductdetail?allClassification=BothEHR&attestationYear=None&browseBy=vendorName&completeOnly=false&counter=0&cqmCriteriaIds=&criteriaIds=&criteriaSearchByMeasures=false&doLastSearch=false&id=a0A130000108MzTEAU&lastSearch=searchByField&modularOnly=false&pageNumber=1&pageSize=25&practiceRadio2014=Both&searchByType=productName&searchByValue=skycare&selectedTab=settingName1&showSeachOption=BothEHR&sortAsc=true&sortBy=3&viewCertYear=2014&viewPracticeSetting=Ambulatory</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T17:00:52Z<p>Adlai: </p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. Skycare EHR was first introduced into the market in January of 2011. The following year, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. Accessed through a secured web portal, Skycare allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.[2]<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
* Electronic Health Records<br />
* Practice Management<br />
* Electronic Prescribing<br />
* Electronic Billing<br />
* Revenue Cycle Management<br />
* Documents and Data<br />
<br />
==Certification==<br />
<br />
As of July 28, 2014, Skycare is 2014 certified to be a classified as a complete EHR under "ambulatory practice" type. The certifying body that performed the overview is InfoGard and utilized the certification criteria 170.314.[3]<br />
<br />
==References==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php<br />
# http://skycareehr.com/html/index.php<br />
# http://oncchpl.force.com/ehrcert/ehrproductdetail?allClassification=BothEHR&attestationYear=None&browseBy=vendorName&completeOnly=false&counter=0&cqmCriteriaIds=&criteriaIds=&criteriaSearchByMeasures=false&doLastSearch=false&id=a0A130000108MzTEAU&lastSearch=searchByField&modularOnly=false&pageNumber=1&pageSize=25&practiceRadio2014=Both&searchByType=productName&searchByValue=skycare&selectedTab=settingName1&showSeachOption=BothEHR&sortAsc=true&sortBy=3&viewCertYear=2014&viewPracticeSetting=Ambulatory</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T16:30:04Z<p>Adlai: /* REFERENCES */</p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. Skycare EHR was first introduced into the market in January of 2011. The following year, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. Accessed through a secured web portal, Skycare allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.[2]<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
* Electronic Health Records<br />
* Practice Management<br />
* Electronic Prescribing<br />
* Electronic Billing<br />
* Revenue Cycle Management<br />
* Documents and Data<br />
<br />
==References==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php<br />
# http://skycareehr.com/html/index.php</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T16:29:33Z<p>Adlai: /* Products and Services Offered by Skycare */</p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. Skycare EHR was first introduced into the market in January of 2011. The following year, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. Accessed through a secured web portal, Skycare allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.[2]<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
* Electronic Health Records<br />
* Practice Management<br />
* Electronic Prescribing<br />
* Electronic Billing<br />
* Revenue Cycle Management<br />
* Documents and Data<br />
<br />
==REFERENCES==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php<br />
# http://skycareehr.com/html/index.php</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T16:25:16Z<p>Adlai: </p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. Skycare EHR was first introduced into the market in January of 2011. The following year, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. Accessed through a secured web portal, Skycare allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.[2]<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
* Electronic Health Records<br />
* Practice Management<br />
* Electronic Prescribing<br />
* Electronic Billing<br />
* Revenue Cycle Management<br />
* Documents and Data<br />
<br />
==<br />
<br />
==REFERENCES==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php<br />
# http://skycareehr.com/html/index.php</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T16:07:59Z<p>Adlai: </p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
==History==<br />
<br />
Skycare was founded in 2007 under the name of PlatinumMD. Since then, Skycare has grown in size and relocated to larger facilities. In addition, Skycare joined with UBcare of South Korea in 2012 which they believe may lead to innovative and important advancements in their software development and understanding of the healthcare business. UBcare has 20 years of experience and knowledge in the healthcare sector and currently owns about 50% of the Korean EHR market. Both UBcare and Skycare is committed to recreate the success of UBcare both in the US and internationally.[1] <br />
<br />
==Software==<br />
<br />
Skycare is a web-based EHR that promotes high accessibility through complete access with any device capable of internet access. A secured web framework allows for patient information and medical records to be safely stored on servers that meet 100% of the HIPAA regulations and standards.<br />
<br />
==Products and Services Offered by Skycare==<br />
<br />
<br />
<br />
<br />
==REFERENCES==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php</div>Adlaihttp://clinfowiki.org/wiki/index.php/SkycareSkycare2014-09-08T15:42:44Z<p>Adlai: Created page with "'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and val..."</p>
<hr />
<div>'''Skycare''' is a self-financed, debt free, privately held company using the latest technologies and positioned to offer the best financing, sales, concierge services and value to physicians for their investment in an [[EMR|electronic health records systems]] for medical practices. Skycare is currently based in Santa Ana, California.[1]<br />
<br />
<br />
==REFERENCES==<br />
<br />
# http://www.platinummd.com/our_company/about_platinummd.php</div>Adlaihttp://clinfowiki.org/wiki/index.php/Historically_Important_Electronic_Medical_Record_SystemsHistorically Important Electronic Medical Record Systems2014-09-08T15:35:55Z<p>Adlai: </p>
<hr />
<div>The following [[EMR|electronic medical record (EMR)]] systems are among the first kind ever developed. Each of the following systems added key information to our current understanding of how EMRs can improve the cost, quality, and efficiency of the care delivered within the modern health care system.<br />
<br />
{| border="1" cellpadding="2" class="wikitable sortable"<br />
!width = "10%" | Year<br />
!width = "30%" | System<br />
!width = "50% | Summary<br />
!width = "10% | Country<br />
|-<br />
|1999||[[ADP AdvancedMD]]||An all-in-one medical software for private practices that unifies EHR, billing and scheduling software. EHR software ensures accuracy of health and medical records.||United States<br />
|-<br />
|1966||[[Akron General Hospital and IBM]]||Developed with aim of eliminating paperwork. Key Features include system to remind nursing staff of drug orders.||United States<br />
|-<br />
|2009||[[American Reinvestment Act of 2009]]||Mandating policy change both investment and implementation of EMR technology. To provide financial incentives to instigate societal movement towards EMR technology.||United States<br />
|-<br />
|2003||[[Alberta Netcare]]||Canada's first Province wide EMR||Canada<br />
|-<br />
|1982||[[Allscripts]]||Practice management System, mainly for private practices, Developed by Medic Computing Systems (later acquired by Allscripts)||United States<br />
|-<br />
|2006||[[athenaClinicals]]||It was launched by AthenaHealth as the "first economically sustainable, service-based" EMR. It is web-based/ cloud-based.||United States<br />
|-<br />
|1995||[[Rayavaran Dynamic Medical Objects and Documents (DMOD)]]||Iran's first windows-based EMR||Iran<br />
|-<br />
|1999||[[Amazing Charts]]||Developed by Jonathan Bertman for his private practice, later adopted by many others due to easy usability||United States<br />
|-<br />
|2001||[[AMPATH medical record system (AMRS)]]||Sub-Saharan Africa's first electronic medical record system for the comprehensive management of the clinical care of patients infected with HIV. Implemented at primary care level||Kenya<br />
|-<br />
|2001||[[OSCAR McMaster]]||open source browser-based EMR system developed by McMaster University||Canada<br />
|-<br />
|2001||[[Hospital OS]]||Hospital Management Software to support small rural hospitals in Thailand||Thailand<br />
|-<br />
|||[[T SystemEV]]||Emergency Department Information System based on T-Sheet charting||United States<br />
|-<br />
|2006||[[ART-EMR]]||Touchscreen input with Direct 48V DC powered systems with unique patient ID system.||Malawi<br />
|-<br />
|||[[Armed Forces Health Longitudinal Technology Application (AHLTA)]]||US Department of Defense (DoD)||United States<br />
|-<br />
|1975||[[Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) ]]||Stanford University Department of Medicine, Stanford, California.||United States<br />
|-<br />
|||[[Brigham Integrated Computing System (BICS)]]||Brigham & Women's Hospital, Boston, MA||United States<br />
|-<br />
|||[[Buenos Aires Hospital Network EHR System]]||||Argentina<br />
|-<br />
|||[[Care2x Integrated Healthcare Open Source Environment]]||||<br />
|-<br />
|||[[Center for Clinical Computing (CCC)]]||Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA||United states<br />
|-<br />
|||[[Centricity EMR]]||GE Healthcare||United States<br />
|-<br />
|1979||[[Cerner Millennium]]||Cerner Corporation, Kansas City, MO||United States<br />
|-<br />
|||[[Certification Commission for Health Information Technology (CCHIT)]]||200 S Wacker Drive in Chicago||United States<br />
|-<br />
|1994||[[ChartLogic EHR]]||Chartlogic mission is to make doctor’s job easier. They create tools that mimic doctor's work but now they will be able to work faster and more efficiently. Chartlogic Corporate office in Salt Lake City, Utah.||United States<br />
|-<br />
|||[[ClearPractice]]||||<br />
|-<br />
|1999||[[ClinicStation]]||M. D. Anderson Cancer Center, Houston, TX||United States<br />
|-<br />
|||[[Composite Health Care System (CHCS)]]||Original DoD EHR||<br />
|-<br />
|1987||[[Comprehensive Health Enhancement Support System - CHESS]]||Developed at the University of Wisconsin-Madison||United states<br />
|-<br />
|1991||[[Comchart EMR]]||Comchart EMR - is designed to minimize the amount of time a physician spends “documenting,” while giving them the tools they need to understand the medical needs of their patients and practice.North Chelmsford, MA||United States<br />
|-<br />
|1968||[[Computer Stored Ambulatory Record (COSTAR)]]||Harvard Pilgrim Health Plan, Boston, MA||United States<br />
|-<br />
||1971||[[Computer Aids in the Physician's Office]]||Project by Bolt Beranek and Newman (BBN) aimed at automated patient-history taking at private physicians' offices || United States<br />
|-<br />
|1997||[[CureMD]]||||<br />
|-<br />
|1978||[[Diogene]]||University Hospital, Geneva ||Switzerland<br />
|-<br />
|1983||[[Distributed Hospital Computer Program (DHCP)]]||Veterans Health Administration||United States<br />
|-<br />
|||[[DSS Inc.]]||"The VistA Experts"||<br />
|-<br />
|1999||[[eClinicalWorks]]||Comprehensive electronic health record solution and unified practice management.||United States<br />
|-<br />
|||[[eMAR]]||||<br />
|-<br />
|1996||[[e-MDs]]||It was started by a group of Family Practice physicians (Dr. David Winn and colleagues) in Austin, Texas||United States<br />
|-<br />
|||[[eCHN]]||Toronto, Ontario Canada, The Hospital for Sick Children||Canada<br />
|-<br />
|||[[Eclipsys]]||"The Outcomes Company" - Atlanta Georgia. In 2010, the company had merged into [[Allscripts]]||United States<br />
|-<br />
|||[[EcMR]]||||<br />
|-<br />
|||[[ELIAS]]||||<br />
|-<br />
|1979||[[Epic Systems]]||Judith Faulkner launched Human Services Computing Inc., which later became Epic Systems, at Madison, WI.||United States<br />
|-<br />
|1992||[[EpicCare]]||EPIC released the first Windows-based EMR called EpicCare.||United States<br />
|-<br />
|2003||[[e-Sushrut]]||First Hospital Management System developed by the Center for Advance Computing (CDAC), Govt of India.||India<br />
|-<br />
|||[[First DataBank]]||||<br />
|-<br />
|||[[Follow-Up Care of Clinical HIV infection and AIDS (FUCHIA)]]||||<br />
|-<br />
|1999||[[FreeMED]]||It is an open source EMR based on LAMP||United States<br />
|-<br />
|1998||[[Greenway Medical technologies, Inc – PrimeSUITE]]||Carrollton, GA||United States<br />
|-<br />
|||[[Health Evaluation through Logical Programming (HELP)]]||LDS Hospital, Salt Lake City, UT||United States<br />
|-<br />
|||[[Hospital Italiano EHR System]]|| - Buenos Aires||Argentina<br />
|-<br />
||1961||[[Hospital Computer Project]]||The initial project at the MGH developed by Bolt Beranek and Newman(BBN). Which later let to development of MUMPS.||United States<br />
|-<br />
|2001||[[Isabel]]|| - Paddington, London||United Kingdom<br />
|-<br />
|||[[Integrating Patient Generated Family Health History From Varied EHR Entry Portals]]||Brigham and Women's Hospital||<br />
|-<br />
|||[[Intuitive Medical Software - UroChartEHR]]||||<br />
|-<br />
|||[[Itoiz Clinic EMR]]||||<br />
|-<br />
|||[[Janus Health - JanusOSSM]]||- San Diego, CA||United States<br />
|-<br />
|||[[Junzi No.1 Hospital Information System]]||- PLA General Hospital, Beijing,||China<br />
|-<br />
|||[[Liang Zhang Han Expert System]]||||<br />
|-<br />
|||[[Lockheed-Martin / Technicon Data Systems (TDS)]]||- El Camino Hospital, Mountain View, CA||United States<br />
|-<br />
|2005||[[Lorenzo patient record systems]]||Lorenzo was an EMR provided as part of the United Kingdom government’s National Program for IT (NHS Connecting for Health) in the NHS. Ultimately, the program was dismantled, and is considered one of the most expensive healthcare IT failures||United Kingdom<br />
|-<br />
|||[[Maine General Health (MGH) EMR]]||One Patient, one chart to achieve interoperability standard||<br />
|-<br />
|||[[McKesson Practice Partner]]||||<br />
|-<br />
|1997||[[MEDHOST EDIS]]||||<br />
|-<br />
|1968||[[Meditech]]||A comprehensive electronic medical record that encompasses all aspects of healthcare related technologies and provides a total solution to meet the demands of Meaningful Use||United States<br />
|-<br />
|1978||[[Medicomp Systems ]]||||<br />
|-<br />
|||[[MedicsDocAssistant Electronic Health Records System]]||||<br />
|-<br />
|1995||[[MediNotes ]]|| Des Moines, IA|| United States<br />
|-<br />
|||[[MOSORIOT Medical Record System (MMRS)]]||||<br />
|-<br />
|||[[Novella EMR System]]|| Mumbai|| India<br />
|-<br />
|2001||[[NextGen]]||Horsham, Pennsylvania|| United States<br />
|-<br />
|||[[OpenEHR]]||Future-proof and flexible||<br />
|-<br />
|||[[OpenEMR]]||||<br />
|-<br />
|2004||[[OpenMRS]]||||<br />
|-<br />
|2003||[[OpenSDE]]||||<br />
|-<br />
|2002||[[OpenVista]]||California||United States<br />
|-<br />
|||[[Optum Physician EMR]]||web-based||United States<br />
|-<br />
|1989||[[Out-patient Medical Record (OMR)]]||Beth Israel Deaconess Medical Center, Boston, MA||United States<br />
|-<br />
|2002||[[Palm-based Clinical Information System (PalmCIS)]]||||<br />
|-<br />
|||[[PalmSecure]]||||<br />
|-<br />
|1969||[[Patient Care Information System (PCIS)]]||Indian Health Service CIS system||<br />
|-<br />
|2007||[[Practice Fusion]]||Free, cloud based EHR system for Private Physicians and Medical Peofessionals||United States<br />
|-<br />
|||[[Problem-Knowledge Couplers]]||||<br />
|-<br />
|1976||[[Problem-Oriented Medical Information System (PROMIS)]]||Burlington, VT||United States<br />
|-<br />
|1972||[[Regenstrief Medical Record System (RMRS)]]||Reginstrief Foundation, Wishard Memorial Hospital, Indianapolis, IN||United States<br />
|-<br />
|||[[Risk Analysis and Security]]||||<br />
|-<br />
|||[[Three-layer Graph-based Model]]||(3LGM) - University of Heidelberg/University of Leipzig||Germany<br />
|-<br />
|2003||[[Satellife]]||PDA based EMR used in Uganada||Uganda<br />
|-<br />
|1994||[[SOAPware]]||||<br />
|-<br />
|||[[Structured Data Entry]]||||<br />
|-<br />
|1965||[[Technicon Medical Information System (TMIS)]]||Eclipsys Corporatons, Atlanta, GA||United States<br />
|-<br />
|1969||[[The Medical Record (TMR)]]||- Duke University, Durham, NC||<br />
|-<br />
|1983||[[THERESA CPR]]||Computer-based patient record system at Emory University||<br />
|-<br />
|1982||[[Veterans Health Information Systems and Technology Architecture (VistA)]]|| - Department of Veterans Affairs (VA)||<br />
|-<br />
|1988||[[Wellsoft Corporation - Wellsoft EDIS]]|| Somerset, New Jersey|| United States<br />
|-<br />
|2002||[[WorldVistA]]||open source||<br />
|-<br />
|1997||[[SRS Soft]]||- Montvale NJ||United States<br />
|-<br />
|||[[Sage Intergy EHR]]|| – Tampa, FL||United States<br />
|-<br />
|2012||[[Skycare]]|||Santa Ana, CA|| United States<br />
|-<br />
|1993||[[NueMD By Nuesoft]]||||<br />
|-<br />
|||[[mmfEMR]]||||<br />
|-<br />
||2008||[[GNU Health]]||opensource EMR and HIS ||<br />
|-<br />
||1997||[[Athenahealth]]||cloud-based||United States<br />
|-<br />
|2003||[[MMF EMR- Newyork, NY]]|||Free, Web-based EMR allowing doctors to submit pre-op data to the facility via cloud-based forms, existing servers or simply fax. Founded by MMF Systems.|| United States<br />
|-<br />
|2011||[[FollowMyHealth]]|| Patient Access Portal. Founded by Jardogs in Springfield, Illinois.||United States<br />
|-<br />
|1980||[[Healthland ]]||Nationwide provider of comprehensive healthcare information systems for rural and critical access hospitals. Founded in Glenwood, Minnesota.||United States<br />
|-<br />
||2010||[[Vitera healthcare solutions]]||||<br />
|-<br />
||||[[3M Helath informatic systems]]||||<br />
|-<br />
|2000||[[DocuTAP]]|||Urgent Care EMR|| United States<br />
|-<br />
|2012||[[E-Health Record International]]||| “Advancing Global Health Through Mobile Cloud Computing.”|| United States<br />
|-<br />
|2014||[[Computer Provider Order Entry (CPOE)]]||| || United States<br />
|-<br />
[[Category: EHR]]<br />
[[Category: UT-SHIS SP09]]</div>Adlai