EMR Benefits: Healthcare quality

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Quality Care

One could approach the ROI from the perspective of the Institute of Medicine Report, Crossing the Quality Chasm

  1. Safe: Reducing adverse drug events, inappropriate testing
  2. Effective: Reducing drug costs through appropriate prescribing
  3. Efficient: Reducing drug, laborotory, or radiologic utilization
  4. Timely: Reducing wait times
  5. Patient-centered: Reducing length-of-stay while hospitalized
  6. Equitable: Provides data to demonstrate equal delivery

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.

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.

Healthcare quality is plagued by overuse, underuse, and misuse of Healthcare services. Reducing these plagues will invariably improve the quality of care. Kuperman and Gibson indicate that EMR such as Computer Physician Order Entry have been found to: i)reduce overuse of health care services ii)reduce underuse of health care services iii)reduce misuse of health care services [17] Furthermore, CPOE has been continuously shown to reduce the overuse of diagnostic procedures and antibiotics.[1]

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.

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]

Improved quality and convenience of patient care

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:

  • 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.
  • Human memory is unreliable: so much research is being published that clinicians do not have time to read it all and the unaided mind is hard-pressed to recall all the detailed knowledge that current studies can impart. Computer based alerts, reminders and similar tools are needed!
  • Capturing clinical data is a new business imperative - clinically based information needs to be utilized for better responsiveness to unaffordable high costs of care and for use in disease management; EHRs are better adapted at these tasks than are paper based processes.
  • Rising consumer expectations - increasing numbers of consumers have high expectations of IT in various facets of their lives and this includes healthcare where they are increasingly responsible for managing their care [39]. Paper charts controlled by the provider do not meet consumer expectations for control of their information and convenient access.
  • EMR and EHR use enables health care facilities align the quality of their practice with the six aims of the Institute of Medicine (IOM) to provide patient care that is safe, effective, patient centered, timely, efficient and equitable[2]
  • EHR use can facilitate the collection and reporting of Quality informatics metrics / measures not only for compliance within a healthcare institution but also for external regulatory purposes. Ultimately the quality of patient care is enhanced as a result.
  • EMR use to support Patient Centered Care can be accomplished by the use of portable devices or accessing patient data via a portal at the patient bedside or in the exam room.

Enhanced Decision Support

Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and better health care. CDS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include:

  • Computerized alerts and reminders to care providers and patients based on patient specific data elements, including diagnosis, medication, and gender/age information as well as lab test results
  • Clinical guidelines/established best practices for managing patients with specific disease states
  • Condition-specific order sets
  • Focused patient data reports and summaries
  • Documentation templates
  • Diagnostic support

[3]


Preventing Adverse Events

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]

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]

This is an important benefit, since medication related adverse events, will not only cause patients harm but will increase the cost [4] 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].EHRs act as a multilevel feedback system to report adverse events. Reporting can be facilitated at multiple levels such as physicians, nursing staff, patients , thus capturing adverse event related data more quickly and efficiently

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. [5] 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.

Pharmacy order entry

EHRs with alerts at the point of pharmacy order entry can help reduce medication errors and prevent potential clinical hazards.

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. [1]

Care Coordination

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.

Improved Coordination of Care

The Need for Better Improved Care Coordination As medical practices and technologies have advanced, the delivery of sophisticated, high-quality medical care has come to require teams of health care providers—primary care physicians, specialists, nurses, technicians, and other clinicians.

Each member of the team tends to have specific, limited interactions with the patient and, depending on the team member's area of expertise, a somewhat different view of the patient. In effect, the health care team's view of the patient can become fragmented into disconnected facts and clusters of symptoms. Health care providers need less fragmented views of patients.

[6]

Tolomeo et al reported that the implementation of an EMR in a pediatric respiratory medicine practice has improved coordination of care with regard to asthma education. The article noted a 54% improvement in providing asthma action plan up on discharge to children who were treated for exacerbation of asthma. [7]

EMRs Help Manage Transactions

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]

Improved Medication Prescription

EMR systems allow for improved methods of prescription for patients and result in several benefits for patients, physicians and pharmacies alike. EMR provides a network by which prescriptions may be prescribed bypassing the traditional paper route, but instead utilizing facsimile or emailing prescription with digital signature. The electronic method allows for a record of any medications sent, while maintaining legibility. With this implementation, an accurate and up to date record is always on file, there is an increased ease of prescribing refills along with greater convenience to patients who may otherwise be handling paper prescriptions. [8]

Patient Handoff

Patients can be safely handed off from one caregiver to the other. Especially CPOE reduces errors due to bad handwriting, verbal miscommunication etc. Implementing standardized, electronic patient hand off communication tools is known to have a positive effect on provider satisfaction and potentially patient safety. [9] Also, integrating sign off notes into EHR was found to improve physician workflow and improve physician satisfaction. [10]

More effective urgent care

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]

Increased patient participation in their care

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.

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.

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].

Health outcomes

Improved accuracy of diagnoses and health outcomes

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. [5] 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.

More effective preventive care

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].

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. 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]

The use of EMRs has been shown to reduce ED visits and hospitalizations among diabetic patients in an integrated delivery network [37].

Healthcare quality

[[CDS|Clinical Decision Support (CDS)] can be used as an additional tool for performing potentially more accurate diagnoses in challenging situations, thus improving the quality of provided care. It 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.

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.

Improved patient safety

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.).

Furthermore, the system can reduce unnecessary prescription of antibiotics. There has been an increased prevalence of antibiotic resistant bacteria due to the widespread abuse of broad spectrum antibiotics. A study reported 73% of adults received antibiotic therapy from their primary care physicians when in reality only 5-17% of the cases warranted antibiotics.[11]. CDSS can help prevent the unnecessary use of antibiotics in addition to providing support regarding prescription medication. [11]

Reduce Diagnostic Errors

Diagnostic errors are defined as missed, delayed, or wrong diagnosis can lead to missed opportunity in patient care and increased cost [6].Example includes Failure to use an indicated diagnostic test, misinterpretation of test results pr failure to act on abnormal imaging results. Extensive adaptation of EHR along with clinical decision support tools will helps to reduce diagnostic errors and its percussion on patients, healthcare providers and healthcare organizations. Electronic clinical decision support alerts, red flags or triggers in the EHR will help providers to improve quality of patient care by reducing diagnostic and medication errors. For instance, for patients with abnormal test results, alerts in EHR will send notifications to providers to recommended follow up and appropriate management.[12].Medication alerts will send notifications to providers about possible drug interactions.For example, for patients with congestive heart failure that take the prescription medication Lasix, the EHR prompts providers to check potassium levels. Before the clinic used EHRs it was difficult to monitor for drug interactions. Now, the EHR alerts provide a safety net that helps reduce medication errors, improving overall patient care.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]

Patient Safety Outcomes

EMRs increase patient safety and improve patient quality care by:

  1. Insuring practice of better evidence-based medicine
  2. Allowing flawless health information exchange between health care providers
  3. Decreasing cost due to changes in drug frequency, dose or route administration [13]
  4. Improving communication and engagement with patients and their health care providers
  5. Increasing patient medication compliance leading to improved overall health outcomes
  6. Promoting higher rates of reporting incidents and near incidents, ensuring greater numbers of completed reports and resulting in a more diverse pool of healthcare staff who report. [14]

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.

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.

The impact of computerized provider order entry (CPOE) on medication errors with the use of a basic CPOE system in an ambulatory setting was associated with a significant reduction in medication errors of most types and severity levels. [15]

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]

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.

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]

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%). This type of notification is a clinical decision support tool that many hospitals and providers use in their EHR. Clinical Decision Support is not limited to just alerts but can also inform a physician of immunizations needed for a certain age group or clinical guidelines. [16]

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). [15].


Qualitative Benefits

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.

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.

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].

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

Universal Protocol

Universal protocols are developed by various disease monitoring agencies for accurate diagnosis, management and prevention of health related problems.For instance the universal protocol created by the joint commission to prevent wrong site, wrong procedure, and wrong surgery. [17].This ensures the same standard of care everywhere.

Up To Date Information About Patient at Point of Care

EMR can provide health information that is up-to-date with clinical information [18]. With an EMR, lab or radiology results can be retrieved much more rapidly. Test results and medical history are recorded directly into the EMR [19].

Increased Accuracy in Medication Administration

EMAR can help increase accuracy in Medication Administration. There are about 700,000 reasons annually—the estimated U.S. number of adverse drug events—for the increasing use of the electronic medication administration record (EMAR) to support inpatient care. With paper and other non-digital records prone to being incomplete, misread, or even misplaced, nurses need a way to help ensure that medications are properly administered and tracked. With the help of EMAR functionality and bar coding/electronic verification during medication administration along with real-time alerts, there is very little room for errors thus accuracy in Medication Administration most like happen at all times.

[20]


Financial

Medical Practice Efficiencies & Cost Savings

Many health care providers have found that electronic health records (EHRs) help improve medical practice management by increasing practice efficiencies and cost savings.

A national survey of doctors1 who are ready for meaningful use offers important evidence:

  • 79% of providers report that with an EHR, their practice functions more efficiently
  • 82% report that sending prescriptions electronically (e-prescribing) saves time
  • 68% of providers see their EHR as an asset with recruiting physicians
  • 75% receive lab results faster
  • 70% report enhances in data confidentiality

Based on the size of a health system and the scope of their implementation, benefits for large hospitals can range from $37M to $59M over a five-year period in addition to incentive payments.

[21]


Reference Laboratories

Reference Labs benefit greatly from interfacing with the various EMR's of the Hospitals, Clinics, and Physician Practices which utilize their services. Benefits include, but are not limited to: [22]

  • Decreased costs as a result of transitioning to a paperless system.
  • Decreased order entry time.
  • Decreased lab result response time.

Through the use of EMRs a physician is able to place a lab order for their patients in their EMR and have that information be conveyed electronically through the use of Health Level 7 (HL7)[23] messages to the system utilized by the reference lab. This saves time as the order will automatically populate within the reference lab's system and will not have to be manually entered.

Once the lab work is complete the results can be transmitted in a similar manner as the initial order to have the results populate in the ordering provider's EMR. This increases the precision of the results, and decreases the time required for the patient and physician to receive the results as the result would no longer require to wait until someone in the physician's office manually enters the results into the EMR (risking the possibility of errors).


References

  1. Cite error: Invalid <ref> tag; no text was provided for refs named Kuperman_CPOE
  2. Hoyt, R., & Yoshihashi, A. (2014). Health Informatics: Practical guide for healthcare and information technology professionals.(6th ed.). Informatics Education.
  3. Enhanced Decision Support http://www.healthit.gov/providers-professionals/frequently-asked-questions/455#id124
  4. 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. http://www.ncbi.nlm.nih.gov/pubmed/9002493
  5. 5.0 5.1 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
  6. Improved Care Coordination http://www.healthit.gov/providers-professionals/improved-care-coordination
  7. Tolomeo et al. Electronic medical records in a sub-specialty practice: One asthma center’s experience http://www-ncbi-nlm-nih-gov.ezproxyhost.library.tmc.edu/pubmed/18972308
  8. The more you use EMR, the more you benefit. http://www.aaos.org/news/aaosnow/feb09/managing6.asp
  9. Implementation of a Standardized, Electronic Patient Hand Off Communication Tool in a Level III NICU. Source: OJNI Volume 18, Number 2 June 1, 2014
  10. Bernstein, Jonathan A.; Imler, Daniel L.; Sharek, Paul; Longhurst, Christopher A. Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record Source: Joint Commission Journal on Quality and Patient Safety, Volume 36, Number 2, February 2010, pp. 72-78(7)
  11. Cite error: Invalid <ref> tag; no text was provided for refs named Hoffman_Cure
  12. Singh H, Naik AD, Rao R, Petersen LA. Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology.Journal of General Internal Medicine 2008;23(4):489-494. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359508
  13. 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
  14. Elliott, P., Martin, D. & Neville, D. (2014). Electronic Clinical Safety Reporting System: A Benefits Evaluation. JMIR MEDICAL INFORMATICS; 2(1):e12. http://www.ncbi.nlm.nih.gov/pubmed/25600569
  15. 15.0 15.1 The impact of computerized provider order entry on medication errors in a multispecialty group practice. http://www.ncbi.nlm.nih.gov/pubmed/20064806/
  16. Clinical Decision Support more than just alerts tipsheet. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/ClinicalDecisionSupport_Tipsheet-.pdf
  17. Chapter 4. Determining the Target Patient Safety Practices.http://archive.ahrq.gov/research/findings/finalreports/contextsensitive/context4.html
  18. The Era of Electronic Medical Records. http://health.usnews.com/health-news/most-connected-hospitals/articles/2011/07/18/most-connected-hospitals
  19. Cite error: Invalid <ref> tag; no text was provided for refs named practical_guide
  20. Electronic Mediation Administration. http://www.fdbhealth.com/solutions/emar/
  21. Medical Practice Efficiencies and Cost Savings http://www.healthit.gov/providers-professionals/medical-practice-efficiencies-cost-savings
  22. Making Reference Labs More Competitive and Profitable with an HL7 Interface Engine, http://www.corepointhealth.com/sites/default/files/whitepapers/reference-labs-hl7-engine-advantages.pdf
  23. Health Level 7, http://www.hl7.org/about/index.cfm?ref=nav