EMR

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An electronic medical record (EMR) is an electronic chart versus a paper medical record. This record can be accessed by multiple providers within the same institution, using the same software. This allows a better continuation of care as the patient moves to different locations throughout the hospital. It will allow access to multiple healthcare providers at the same time in different locations to see a more complete view of the patient’s medical record.

EMR components

Problem list

A problem list is a list of medical problems that patient has. Problems can be put on the problem list in two ways:

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

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

However, while problems from the problem list may be copied to/from the diagnosis list associated with an encounter, the two lists are not interchangeable. Other issues regarding problem lists.

Medication List

A list of medications that a given patient is currently taken. Medications are active prescription or are affirmed to be over the counter. All historically prescribed medications are also included. This makes it easier to see if medications are prescribed for the same problem (hypertension, analgesia, asthma, etc).

Clinician Sign-out applications

Clinician sign-out systems (also sign-outs, handoff communications, transfer-of-care communications) provide a provider with enough relevant clinical information about a given patient that they can make decisions about that patient’s care. Sign-outs are becoming more important as inpatient medicine is becoming more reliant on hospitalists, who typically work in shifts and care transitions. [1] [2]

Biometrics

Biometricsis the study of automated methods for uniquely recognizing [authenticating]humans based upon physical or physiological characteristics of the individual to provide access to sensitive data. This is a replacement for the traditional login-password combination. Biometrics can be used as a single-factor authentication or combined authentication with other features. The primary goal of this technology is to provide more secure and reliable authentication process based on unique biological characteristics. Examples of Biometrics is Fingerprints, retina scans, and voice patterns.

EMR benefits

Electronic Medical Records (EMRs) have many benefits over its analogous paper record.

Privacy and security

Privacy is required by the federal law, Health Insurance Portability and Accountability Act (HIPAA). Electronic software enhances privacy by providing different levels of security access to different governmental groups and individuals. However, it also lends itself to some false sense of security in that sense it doesn’t always prevent humans from errors,mislabeling, incorrectly granting access, or malicious tampering. A digital data trail is very durable and more difficult to erase than a paper. trail. However, privacy breaches are possible.

See Terms related to privacy, confidentiality, and security

Clinical

Electronic Medical Records (EMRs) have many clinical benefits. Although initially implementing EMRs can be expensive, computerized provider order entry (CPOE) systems are faster, efficient, and time-saving. In the long run, the return of investment (ROI) is beneficial. [3]

See also: more in-depth discussion of EMR benefits

EMR regulation and certification

Medical devices

As of early 2012, EMRs are not regulated by US law because not classified as medical devices. [4] This means that anyone can develop a computerized health record system and attempt to sell it to a medical practice or institution without any prerequisites for testing. Even a male fertility test kit classified as a Class II Medical Device [1] is subject to greater regulatory scrutiny than is an EMR used by clinicians to assist in making treatment decisions.

In practice, the boundary between computer systems and medical devices is rapidly disappearing. If an EMR has the capability to interface with a device and automatically capture data, than the device has become ancillary to the EMR. As medical devices run on increasingly complex embedded (and upgradeable) software instructions, and they are more commonly interfaced with the EMR, the distinction between the two fades further. Modern enterprise EMRs consist of multiple (optional) modules interfacing with each other. Medical devices are approaching similar modularity.

The FDA 510(k) program for medical devices may not be a good model for EMR regulation. Chief criticisms revolve around the "substantially equivalent" status granted to Class II devices. Using the equivalence test, regulatory applications refer to prior devices that perform primarily the same functions. If the agency finds that the new device does substantially the same things as a prior device, more extensive review is not necessary. Therefore, the argument follows, a disadvantage would be given to the first EMR to satisfy the regulatory hurdle, because all following EMR's would be substantially equivalent.

Certification

There is an existing voluntary certification for health care systems - the Certification Commission for Health Information Technology (CCHIT). Along with testing for functions such as usability and interoperability, CCHIT certification is used to establish meaningful use eligibility. With the advent of Meaningful Use, CCHIT certification has become a defacto standard for Medicare providers wishing to purchase an EMR.

The sociopoliticoeconomic model of the evolving standardization of health information technology (HIT) is a funded legislative mandate, with funding granted to a sanctioned non-profit enterprise formed by mainstream health information technology interests, and administrative (US Department of Health and Human Services) certification via standards published in the Federal Register, claiming "alignment with...test procedures published by the National Institute of Standards and Technology". [2]

A potential problem with the HIT system certification approach is that it treats the implementing healthcare delivery organization separately from the technology itself. A sociotechnological view of an EMR in a healthcare delivery enterprise considers operators (clinicians and ancillary staff) and technology (the EMR inclusive of back end and interfaces) together to be the system. Certifying the technology separately from the operating organization does not evaluate the ability of the holistic system to function properly. Patient health outcomes, including safety and quality, are the fundamental metrics, and only by testing individual organizational ability to operate complex systems can we truly certify the complete system. This concept can be scaled up to the regional service agency level.


Vendor selection criteria

Selection of a vendor product is certainly important and potentially problematic. Physician resistance is one of the major barriers to adoption of electronic medical records. Although some elements, such as diagnoses and medication lists, are relatively easy to implement, others are very difficult. [3] It is important to look at demonstrations or do trial runs before deciding on an EMR.

Security

The vendor's EMR must meet some minimum requirements. Its source code must comply with regulatory laws, such as

Functionality

The EMR software must have essential features that fulfill meaningful use. These include

Implementation cost

Although the total cost of ownership (TCO) is initially expensive, a good EMR system should pay for itself in time. Good EMRs should

  • have a track record for successful system implementations
  • detailed plan for implementation and training
  • clearly identified costs: hardware, software, interfaces, text conversions, maintenance, human resources, networks, peripherals such as computers and printers, training, technical support, and facility renovation to accommodate EMR system changes
  • specific software considerations: licenses fees, software upgrade and development timelines, and data integration from legacy systems.

Hardware and technical requirements

It is important to identify all hardware and software requirements to implement a full-scale EMR system.

  • Meet the technical requirements of OS platforms, language, and databases
  • Have system to meet future technological standards in hardware and software
  • Efficient debugging process
  • Scalable to a large number of users
  • Efficient information extraction

It is up to the buyer to decided whether to go with non-proprietary system or an established industry system, whether to have on-site or remote hosting; there are advantages and disadvantages to each. A hosted server requires the vendor to have adequate computing facilities. A remote server needs to have alternative plans for outages. Mobile and wireless clients also need consideration.

Long term vendor partnership

The software company itself should be stable, growing, and profitable over a long time period. A vendor should have:

  • A history of other successful contracts to similar health systems
  • A reputation for frequent check-ups and few uninstalls
  • Eegular and periodic updates
  • Sufficient, long-term, on-site customer support
  • Quick response during emergencies and backup in case the system malfunctions
  • Legal agreements should that specifications and quantifiable measures of support, with appropriate penalties if evaluated negatively.

For an in-depth discussion of vendor selection criteria

Request for Proposal

Comparing Vendors

The process of an EMR system selection incorporates several factors: [5]

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

Notable Electronic Medical Record Systems

Many EMRs have already been installed around the world.

Historically Important Electronic Medical Record Systems

For a list of important EMRs from around the world, see Historically Important Electronic Medical Record Systems.

Free and Open Source EMRs

For a list of free and open source EMRs, see Free and Open Source EMRs.

List of EMR companies

EMR models for small and medium sized practices

EMR Implementation

Training staff

Training clinicians to effectively utilize all the features of an EMR is difficult. The Health Resources and Services administration offers steps for healthcare organizations seeking to successfully implement an EHR, which includes planning, recruitment, budgeting, installation, and optimization. [4]




Changing the Training Experience Now that EHRs have become almost ubiquitous (at least a 90% adoption rate 1), it is time to re-think the way training is offered. For the most part, current EHR training is instructor-led, classroom-based training on the basic functionality of the EHR. As the majority of clinicians now have access to some form of an EHR, either during graduate work, an internship, or previous work at a hospital or clinic with an EHR, the role of training must change.

Most medical students, residents, incoming providers and nursing staff are already computer savvy, and need a more patient-focused simulation training style to effectively integrate the EHR as a tool into their workflows. Although there is not a lot of research on this topic, anecdotally, current training feedback is “fair” at best. Some simulations and competencies in the research world are being performed by several physicians, and they indicate the need for a shift in the training paradigm 2,3. There is also some research showing continued frustration and inefficiency with EHR use. 4


The Path Forward In addition to keeping in mind adult learning styles, it is recommended that revised EHR training include specific case-based scenarios for the clinicians to document, followed by active feedback and competencies. Students can work on scenarios in dyads or small groups, which mimics how clinicians function on a daily basis. Ideally, since providers have privileges at various institutions, it would be very efficient to be able to provide scenarios from different vendors during their time in school or during training.

As an example of current EHR training, workflows are generally introduced, but simply as a method to describe a menu or navigator within the application.

A more realistic method of training would be to incorporate simulation, or at the very least scenario-based training. If resources permit, simulate an office visit, or admitted patient utilizing a simulation lab. A low-tech model would include an exemplar case handout. And when computers are down, cardboard boxes and finger puppets will do. Colleagues in the human factors realm should be included in further development.


The Details For new users, a brief orientation to the EHR can be learned via an eLearning module. Vendors usually have stock modules available. In the classroom, the users can then be given scenarios based on their role. For instance, a cardiologist might be given a scenario that includes an office visit, then that patient is admitted, then a post-hospital follow up.

Clinical support staff (nurses, CMAs, etc.) duties are truly delineated between outpatient and inpatient services, so those roles would likely need to be separated in a training environment. However, by also including scenario-based instruction for these roles, the training experience can more closely represent reality in the practice, or floors.

Of great need is a library of standardized cases. These cases can then be used for training, simulations, research and beta-testing of new applications/modules. For now, the cases are created manually in each EHR. One ultimate goal of having a library of cases is that a “case stuffer” tool be formatted to allow import of fake patient data directly into any training environment. For example, create patient data on a spreadsheet, turn the spreadsheet into a flat file, and import into the environment. Assimilate. Another option is to create a thorough enough “scrubber” that a real patient file could be used, but all PHI eliminated. Until we are there, fake patient files can be shared between institutions using the same release of identical EHRs.



References

1. Quick Stats – HealthIT. [5] 2. Participation in EHR based simulation improves recognition of patient safety issues.

       Stephenson et al. BMC Medical Education 2014, 14:224
       [6]

3. Use of Electronic Health Record Simulation to understand the Accuracy of Intern Progress Notes

       DOI: [7]

4. The EHR and building the patient's story: A qualitative investigation of how EHR use obstructs a vital clinical activity.

       Varpio L, Rashotte J, Day K, King J, Kuziemsky C, Parush A.
       Int J Med Inform. 2015 Dec;84(12):1019-28. doi: 10.1016/j.ijmedinf.2015.09.004. Epub 2015 Sep 14.  PMID:26432683

Submitted by (Gretchen Scholl)

Buy-in

EMR adoption is an important issue. A great deal of effort is made to increase physician acceptance, nurse acceptance, and staff acceptance of EMR implementation.

Considerations for Specialists and Special Situations

Specialists can have different EMR needs.

Considerations for developing countries

Electronic Health Record in developing countriespoor countries with low standards of living, industrialization and technology but trying to be more advanced in these capabilities. Implementation of Electronic Health Records in these countries is very important because of the low health status, but at the same time many challenges may face its implementation.

Reviews

Integrating Medical Devices into EMRs

Integrating Medical Devices into EMRs

Quantitative data from medical devices in EMRs

EMR (EHR) Available Solutions and How to Choose the Right One

Socio-technical Issues

Liability

Genetic issues

Genetic Non-Discrimination

Privacy and security

Terms related to privacy, confidentiality, and security

A review of security of electronic health records

Privacy, Confidentiality, and Electronic Medical Records

Security and privacy in electronic health records: a systematic literature review.

Views on health information sharing and privacy from primary care practices using electronic medical records

Privacy policies for health social networking sites

Assuring the Privacy and Security of Transmitting Sensitive Electronic Health Information

Giving patients granular control of personal health information: Using an ethics ‘Points to Consider’ to inform informatics system designers

Reviews

The role of health care experience and consumer information efficacy in shaping privacy and security perceptions of medical records: national consumer survey results.

Business Case for Improving Usability

Business Case for Improving Usability

New Technologies

Strategies of Clinical Data Entry

Strategies of Clinical Data Entry

Natural language processing (NLP)

Coding Data

Reviews

EHR system selection

See more for what Marl Mench thinks of EHR system selections

Productivity

see Physician productivity

Document Imaging and Scanning into the EHR

see Considerations when using Document Imaging in an EHR

Related article

References

  1. Horwitz LI1, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. http://www.ncbi.nlm.nih.gov/pubmed/16772243
  2. R. Ram and B. Signing out patients for off-hours coverage: comparison of manual and computer-aided methods. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2248075/
  3. Use of Electronic Health Records in U.S. Hospitals. Jha, A. K., DesRoches, C. M., Campbell, E. G., Donelan, K., Rao, S. R., Ferris, T. G., … Blumenthal, D. (2009). New England Journal of Medicine, 360(16), 1628–1638. http://www.nejm.org/doi/pdf/10.1056/NEJMsa0900592
  4. Sharona Hoffman, Andy Podgurski. Finding a Cure: The Case for Regulation and Oversight of Electronic Health Record Systems. 2008. http://jolt.law.harvard.edu/articles/pdf/v22/22HarvJLTech103.pdf
  5. 5.0 5.1 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