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

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The efficiency of increased information flow and documentation allow for measurable time and cost savings. The amount of time support staff save during patient encounters has been directly demonstrated in a clinical setting [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513660/pdf/261.pdf].
 
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].
 
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].
 
Furthermore, the integration of EMR systems enables for a more consistent application of medical protocols, such as those that provide guidance on the use of specific or expensive drugs.  As a result, the availability of information 24 hours a day, 7 days a week, helps to contribute significantly to reduced errors, better decision-making, improved outcomes, and lower malpractice risk. In a study done by Harvard researchers, 6.1% of physicians with electronic records had malpractice settlements, compared to 10.8% without electronic records [3].
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== Environmental Benefits ==
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# Decrease in paper consumption. [http://jamia.bmj.com/content/18/2/169.full.pdf+html].
  
 
== Better Sharing of integrated information ==
 
== Better Sharing of integrated information ==

Revision as of 02:23, 11 September 2013

The Electronic Medical Record may consist of computer order entry, decision support, electronic medication administration, documentation, and so much more. When compared to paper charts, Electronic Medical Records (EMRs) have many benefits and return on investments (ROIs). Following is a brief discussion of some of those benefits and ROIs.



Efficiency

EMRs improve clinical efficiency in multiple ways:

  1. It stores all the patient’s data, including but not limited to, patient medical history, medication history, vital signs, lab tests results, as well as other pertinent information in a single location, and is readily available to anyone directly involved in the patient’s care, regardless of location. It eliminates time and cost from paper chart pulls and transcription and re-file of paper charts (Wang at al, 2003).
  2. It reduces the likelihood that tests will be unnecessarily duplicated.
  3. Coordination of care is easier to achieve and eliminates steps that may lead to discrepancies in the sharing of data.
  4. 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).
  5. EMRs 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).
  6. EMRs reduce the number of lost or missing reports.
  7. They reduce variability of care.

Storage and Retrieval

EMRs improve the storage and retrieval in these ways:

  1. Reduces the amount of physical storage space required to house charts.
  2. Protected from fire, natural disaster, or theft.
  3. Records can be backed up to off-site facilities
  4. Instant access to records.
  5. More controlled access, including a record of who accessed the record.
  6. Eliminates “lost” or incomplete charts.
  7. More than one provider can access the record at one time. Ability to identify who modified the record.


Lower costs and better management of risks

By consolidating information across the entire spectrum of clinical operations, from admission to treatment to labs and beyond, EMR allows for:

  1. Increase in the pace of information flow including service delivery.
  2. Coding/billing accuracy.
  3. Better documentation of patient encounters.
  4. Reduction in overall administrative and maintenance costs of healthcare institutions.
  5. Reduction in costs for the patient.
  6. Reduction in transcription costs [1].
  7. Decrease in malpractice insurance premiums.

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 [2]. 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].

Environmental Benefits

  1. Decrease in paper consumption. [3].

Better Sharing of integrated information

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.

Facilitated referral for multidisciplinary care

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].

More timely application of preventive care measures

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].

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 local, regional, national EMR system [19]. In such a scenario, the emergency room or urgent care physician could consult the patient’s EMR file to view the patient’s current medications, diagnoses, recent surgeries or procedures, and medical history, allowing the emergency physician to be better informed about the patient’s status and urgent needs [19]. Information security and privacy concerns will have to be addressed, however, in order for shared EMRs to gain widespread public acceptance [19]

Patient Safety Outcomes

  1. Improve the quality of patient care.
  2. Insures practice of better evidence-based medicine.
  3. Allows flawless health information exchange between health care providers.
  4. Decreased cost due to change in drug frequency, dose or route (Wang at al, 2003).

EMRs help to increase patient safety in a number of ways. Evidence-based clinical reminders as well as reminders based on Good Clinical Practice guidelines can be prompted during the patient encounter . Also, medical errors due to illegible handwritings is drastically reduced. Alerts can be posted on the screen for the provider in instances where a drug that the patient is allergic to may be ordered, or in a situation where the drug(s) being ordered are incompatible with medications the patient is currently taking. Also, alerts may be posted for adverse effects for medications based on the patient’s profile and medical history.

EMRs have tremendous potential for improving medication safety by implementing computerized provider entry forms (CPOE). Medication errors are common and are mainly attributed to illegible handwritten orders, incomplete information about the patient or communication breakdowns between clinicians. EHRs can greatly reduce such errors when clinicians would enter medical orders directly into the system. While the clinicians are entering the orders, the system allows automated checks for allergies and other drug-to drug interaction.

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 (Wang at al, 2003). Interventions to switch the twice-daily dosing of ceftriaxone to once-daily dosing at Brigham and Women's Hospital (BWH)resulted in $320,000 in annual cost savings (Kaushal at al, 2006).


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).

Investment Flexibility

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).

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)

Management Risk Disposition

Willingness to invest in experimental efforts.

Provide users with real time knowledge

Reduce non-clinical time

Increase patient doctor time

Investment Motivation

To reduce cost, position for capitation/managed care, and gain market share.

To enable providers to take advantage of financial incentives under the HITECH Act related to "Meaningful Use". [4]

--Sfjafari 22:21, 10 September 2011 (CDT)

--Sfjafari 22:29, 10 September 2011 (CDT)

Administrative and Management Benefits

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.

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. Health care providers with busy practices and patients with busy lives can conveniently manage their health care transactions with EMRs.

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.

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.


Improved accuracy of diagnoses and health outcomes

EMR 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 and reduce, even prevent medical errors, improve patient safety, and support better patient outcomes. EMRs can also have beneficial effects on the public health by identifying and working with patients to manage specific risk factors or combinations of risk factors to improve patient outcomes.

Improved care coordination

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.

Increased practice efficiencies and cost savings

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. 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.

There is significant evidence to show that while initial costs remain an issue, switching from paper records to EHR systems will ultimately reduce overall health care expenses. Research indicates that Medicare and private payers could save tens of billions of dollars every year. To incentivize EMR adoption, the federal government has established a plan to provide $44.7 billion during 2010-2019 to financially assist health care providers in the EMR implementation process [4]. However according to Himmelstein, Wright & Woolhandler, as currently implemented, the use of Electronic Medical Records could moderately advance metrics related to quality measures, it does however not reduce the cost of administration of ‘overall’ costs. “Hospitals on the ‘Most Wired’ list performed no better than others on quality, costs, or administrative costs” (Himmelstein, Wright & Woolhandler, 2009). Forecasts of potential improvements in efficiency and cost-savings from implementation of computerized health care and the use of Electronic Medical Records seem premature at the time the authors published their data in 2009 [12].

Return on Investment (ROI)

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

Quantitative Benefits:

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.

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).


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.

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.

An overview of attempts 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


Strategic Benefits:

These offer substantial benefits to the organization, but at some future date. E.g. investments in networking and telecommunications offer significant future strategic benefits, positioning organizations to utilize enterprise-wide patient indexing and EMR or distributed case management technologies as they emerge.

--Sfjafari 22:29, 10 September 2011 (CDT)

Sources of Funding

  1. Organizational Reserves – provider organization make investments in affiliated organizations
  2. Bank and other financial service – short term loans
  3. Capital leases – used for large equipment acquisitions but can be negotiated for a major IT investment
  4. Vendor discounts and incentives – requires something in return
  5. Joint venture or partnership – tighter relationship
  6. Health plans and plan sponsors – contractual arrangement
  7. Private philanthropy – fellowships or university chairs
  8. Pharmaceutical companies – willing to conduct clinical trials
  9. Public grants – government initiatives
  10. State legislative initiatives – local and state initiatives


System Selection

Based on the application the type of system selected will vary based on current research, size of practice, institution, academic affiliation, vendors and their ability to demonstrate compliance with current research “by identifying funded and published research(Kannry Mukani& Myers , 2006)” and ultimately the assessment and analysis of the total cost of ownership.


According to Kannry Mukani& Myers in their 2006 article Using an Evidence-based Approach for System Selection at a Large Academic Medical Center: Lessons Learned in Selecting an Ambulatory EMR at Mount Sinai Hospital . The authors note the technology requirements of educational institutions vary greatly from the needs of the private sector. Although both the private sector and academia have concerns with accurate documentation, patient safety and patient care, educational institutions focus on “education, training and research, (Kannry Mukani& Myers, 2006). The need of residents and compliance with regulatory requirements is significant and cannot be minimized. [13}

Costs

The Medical Group Management Association (MGMA) says the average cost of an EMR per physician is $33,000. (http://www.physicianspractice.com/display/article/1462168/1591117)

Software License:: EMR license prices can easily range from $1,000 – $25,000. The average license for a FULL/TRUE EMR usually starts at $10,000, while a light/entry EMR usually starts at around $1,000, and these costs tend to recur. (http://www.phyaura.com/resources-2/open_source/)

Implementation: Implementation costs are usually billed hourly at a rate of $75-$150 per hour. Average implementation time per provider is 35 hours. Where 10 hours are used for customization, 25 hours for training and 10 hours for computer/network setup. This becomes exponentially lower as more physicians are added. (http://www.emrexperts.com/emr-roi/index.php)

Hardware: Network hardware and configuration, number and type of servers/workstations, hand-held devices, etc. is driven by the vendor's requirements and recommendations, as well as your organization's needs. Costs depend on quantity of equipment purchased or leased. For example, a tablet PC could cost $2,000, a workstation $1,500 and a server $5,000. (http://www.emrapproved.com/emr-hardware.php)

Support & Maintenance: Ongoing support costs will be incurred from both an annual support contract with the software vendor for updates and technical support and the increased need of hardware/network support through a local IT representative. (http://www.emrexperts.com/emr-roi/index.php)

Incentive Programs

In recent years, many providers have factored government incentive payments into the cost analysis and final decision to purchase an EHR. The Medicare EHR Incentive Program provides incentive payments of $44,000 over five years to eligible professionals, eligible hospitals, and CAHs that demonstrate meaningful use of certified EHR technology. There's an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HPSA). 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)


The American Reinvestment and Recovery Act law creates two key concepts to determine whether providers qualify for the health IT incentives: they must make "meaningful use" of IT and use a "qualified or certified EHR" (electronic health record). Besides incentives to providers and hospitals, the law also creates $2 billion in health IT funding administered by the Office of the National Coordinator for Health Information Technology (ONC). A significant amount of this $2 billion should lay important groundwork to help providers use health IT meaningfully toward the goals of improving the nation's health. (14)

Improving clinical decision support

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 (CDS) 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 CDS.

Improving workflow

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.

Improving patient care

In addition, 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.

Improving interpersonal and communication skills

EMR can reduce time of getting information and trainees can spend more time on synthesizing and demonstrating clinical reasoning in real time.

Enhancing professionalism

Detailed data provided by EMR can help doctors or other medical workers to convince patients more easily.

Establishing a learning chance to improve healthcare system

EMR can assist people to review the outcomes of populations under care. Mangers can find a more Meaningful Use criteria applied on quality improvement, research, outreach, and reduction of disparities.

Research

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.

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].

Barriers of EMR Implementation

  • In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system.
  • Conflicting research findings on the cost and efficiency benefits of EMR implementations will make it difficult, if not impossible, for administration staff to be confident in choosing an EMR for their facility. Until there is adequate research on multitudes of EMR systems that shows causal relationships between facility characteristics and the related EMR components there will not be a sufficient method of EMR selection and implantation.
  • If it is true that implementations of EMRs cause a decrease in efficiency and an increase in quality of medical care then further research must take both of these repercussions into account and determine if there is an overall net benefit of EMR implementation.
  • The use of EMR and the afforded efficiencies may not provide immediate cost savings to some office-based physicians. These physicians may not be able to reduce their office expenses sufficiently to offset the revenue decreases they may see as a result of increasing efficiency. For example, a physician who is paid, as many laboratory or treatment centers are, per service rendered would see a direct decrease in revenue were they to reduce the number of duplicated diagnostic tests.[5]
  • 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. [6]
  • 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.

EMR Cost Categories

References

Committee on Quality of Health Care in America, Institute of Medicine. "Front Matter." Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001. Full text

  1. http://www.msdc.com/EMR_Benefits.htm
  2. http://patients.about.com/od/electronicpatientrecords/a/EMRbenefits.htm
  3. http://www.eurekalert.org/pub_releases/2008-11/hms-ehr112508.php
  4. http://www.cdc.gov/about/grand-rounds/archives/2011/july2011.htm
  5. http://www.mayoclinic.org/emr/benefits.html
  6. http://www.philblock.info/hitkb/e/EMRs_and_EHRs.html
  7. 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.
  8. Crane, R. M., Raymond, B., (Winter 2003). Fulfilling the Potential of Clinical Information Systems. The Permanente Journal. 7 (1), pp.62-67
  9. Hersh, W. R., (2002). Medical Informatics: Improving Health Care Through Information. Journal of American Medical Association. 288 (16), pp.1955-1958
  10. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_046429.hcsp?dDocName=bok1_046429
  11. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/56_DataAndReports.asp
  12. http://www.ischool.drexel.edu/faculty/ssilverstein/AJM-Himmelstein-Hospital-Computing.pdf
  13. http://www.himss.org/content/files/jhim/20-2/16_original_evidence.pdf
  14. http://www.markle.org/publications/403-achieving-health-it-objectives-american-recovery-and-reinvestment-act
  15. http://www.cdc.gov/ehrmeaningfuluse/
  16. http://healthit.ahrq.gov/portal/server.pt/document/958478/barriers_to_meaningful_use_in_medicaid_final_report_pdf?qid=82968838&rank=5
  17. 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.
  18. Kuperman GJ, Gibson RF. Computer Physician Order Entry: Benefits, Costs and Issues. Ann Intern Med. 2003;139:31-39.
  19. 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.
  20. Wang, S. J., Middleton,, B., A. Prosser, L., G. Bardon, C., D. Spurr, C., J. Carchidi, P., … Bates, D. W. (2003). A Cost-Benefit Analysis of Electronic Medical Records in Primary Care. Excerpta Medica Inc, (114), 397–403. doi:10.1016/S0002-9343(03)00057-3
  21. 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.
  22. 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