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

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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]
 
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]
 
=== EMR and Providers’ Productivity  ===
 
 
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. As with all new systems, there will be a temporary reduction in productivity as the healthcare staff become familiar with the new system. A study by Menachemi and Brooks (2006) estimated a 20% loss of productivity for the first month, 10% loss in the second month, and 5% loss in the third month and finally productivity returning to baseline in the subsequent months. <ref name="Brooks 2006">Menachemi, N. & Brooksm R. (2006). Reviewing the Benefits and Costs of Electronic Health Records and Associated Patient Safety Technologies.http://download.springer.com.ezproxyhost.library.tmc.edu/static/pdf/470/art%253A10.1007%252Fs10916-005-7988-x.pdf?auth66=1411967145_1fbceb4fa2c5cea1c67867e88dd78695&ext=.pdf</ref>. 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]
 
 
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]
 
  
 
== Return on Investment (ROI) Estimates ==
 
== Return on Investment (ROI) Estimates ==

Revision as of 07:28, 21 February 2015

The Electronic Medical Record may consist of computer order entry, decision support, electronic medication administration, documentation, and so much more. [1]

The sections below detail the benefits, costs, and barriers in evaluating EMR implementations. Selecting, financing, and launching an EHR system is difficult. Product certification seeks to make the first step a little easier. [2]


Informational

EMR Benefits: Informational

Security

EMR Benefits: Security

Environmental

EMR Benefits: Environmental

Medical Education

EMR Benefits: Medical education

Financial

EMR Benefits: Financial

Improving patient care

EMR Benefits: Healthcare quality

Research

EMR Benefits: Research

Health Information Exchange (HIE)

EMR Benefits: HIE

Personal Health Records

EMR Benefits: PHR

Telehealth

EMR Benefits: Telehealth

Mobile EMRs

EMR_Benefits: mHealth

Physicians

EMR Benefits: Physicians


Improve Legal and Regulatory Compliance

EMRs can facilitate and improve legal and regulatory compliance in terms of increased security of data and enhanced patient confidentiality through controlled and auditable provider access [3]. In a study by Bhattacherjee et al, Florida hospitals with a greater adoption of health information technology had higher operational performance, as measured by outcomes of Joint Commission on Accreditation of Healthcare Organizations (JCAHO) site visits [3]


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]


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. [4] Also, integrating sign off notes into EHR was found to improve physician workflow and improve physician satisfaction. [5]


Improve efficiency and patient throughput

The Institute of Medicine estimates that $17-29 billion is spent annually on unnecessary or inaccurate patient care due to misdiagnosis. If clinicians can rapidly determine the correct dose, calculation or diagnosis, they can order relevant tests and make appropriate referrals, saving time and eliminating unnecessary costs for the patients and the ED. Of course, CDS is most effective when it is built into the clinician’s workflow, which minimizes interruptions and dangerous distractions. It is also important for CDS to be incorporated into providers’ workflow in such a way that minimizes alert fatigue.[6].




Barriers to EMR Implementation

System Selection

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

ONE CONSISTENT THEME emerges from EHR implementations in physician practices: almost everyone underestimates the complexity, time, and effort required. [7]

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] The most frequent adoption factors common to all user groups were design and technical concerns, ease of use, interoperability, privacy and security, costs, productivity, familiarity and ability with EHR, motivation to use EHR, patient and health professional interaction, and lack of time and workload. Each user group also identified factors specific to their professional and individual priorities [30].

  • In order for an EMR to be truly successful, proper and timely training must be administered to all who will interact with the system.
  • Conflicting research findings on the cost and efficiency benefits of EMR implementations will make it difficult, if not impossible, for administration staff to be confident in choosing an EMR for their facility. Until there is adequate research on multitudes of EMR systems that shows causal relationships between facility characteristics and the related EMR components there will not be a sufficient method of EMR selection and implantation.
  • If it is true that implementations of EMRs cause a decrease in efficiency and an increase in quality of medical care then further research must take both of these repercussions into account and determine if there is an overall net benefit of EMR implementation.
  • The use of EMR and the afforded efficiencies may not provide immediate cost savings to some office-based physicians. These physicians may not be able to reduce their office expenses sufficiently to offset the revenue decreases they may see as a result of increasing efficiency. For example, a physician who is paid, as many laboratory or treatment centers are, per service rendered would see a direct decrease in revenue were they to reduce the number of duplicated diagnostic tests.[1]
  • 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. [2]
  • The variability of results of similar studies on the monetary and efficiency benefits of EHRs indicates that there is no single approach to EMR implementation that will fit all settings. Variables such as hospital size, setting, specialty, prior computer integration, etc will determine the effectiveness of an EMR dramatically and must be considered in all cases.
  • The high cost of basic infrastructure of clinical information technology is a substantial hurdle for many health care organizations, many of whose income margins have deteriorated after years of decreasing reimbursement (from Medicare and other sources) and whose access to capital for new medical technology is extremely scarce. Financial instability and scarce capital resources for IT infrastructure similarly affect small to mid-sized independent practice associations (IPAs) and independent physician offices, the practice venues for most physicians in the United States.
  • Diversity of products as well as lack of standards for common architecture of basic infrastructure of clinical information technology constitutes a barrier and further complicates EMR Implementation.

Costs

Cost benefit analysis is categorized into 3 fields [70]:

  1. Direct, one-time costs
    1. Hardware & Peripherals
    2. Packaged and customized software
    3. Network, peripherals, supplies, equipment
    4. Initial data collection and conversion of archival data
    5. Facilities upgrades, including site preparation and renovation
    6. End-user project management
    7. Project planning, contract negotiation, procurement
    8. Application development and deployment
    9. Configuration management
    10. Office accommodations, furniture, related items
    11. Initial user training
    12. Workforce adjustment for affected employees
    13. Transition costs (parallel systems, converting legacy systems)
    14. Quality assurance and post implementation reviews
  1. Direct, ongoing costs
    1. Salaries for IT and assigned end user staff
    2. Software maintenance, subscriptions, upgrades,
    3. Equipment leases
    4. Facilities rental and utilities
    5. Professional services, Ongoing training and
    6. Reviews and audits
  1. Indirect, ongoing costs.
    1. Data integrity
    2. Security
    3. Privacy
    4. IT policy management
    5. Help Desk

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.

For more information, see EMR Cost Categories.

Challenges to Identifying a Return on Investment (ROI)

Evidence of a strong ROI business case for EHR implementation is confounded by anecdotal evidence in peer reviewed research and trade journals. Furthermore, environmental differences across provider settings make it challenging to replicate information system strategies and dependence on disparate legacy applications [48]. For organizational stakeholders to embrace EHR adoption, they need assurance that adopting an EHR system would positively impact business performance [58].

Additional barriers include:

  • Vendor supplied benefits data may not be objective
  • Few vendors maintain a structured database of benefits information
  • Peer reviewed studies are difficult to compare due to the complexity of health services delivery and variety of provider settings.
  • Differences in system architecture
  • Trade journals tend to focus on anecdotal evidence rather then empirical evidence
  • No standardized domain method exists to measure the ROI of electronic health records
  • Lack of information regarding maintenance and optimization costs [48]

Consequently, providers frequently lack the necessary information to make sound financial decisions regarding Health IT capital investments. Uncovering the true cost and benefit of EHR adoption will require a national effort to standardize and centralize evidence in a national database. [48]

Return on Investment (ROI) Estimates

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] There are 2 main postulates for ROI which KOSH’s postulate and Sir Austin Bradford Hill’s criteria for Causation. Kosh’s postulate for CIS is i. The system or feature must be present in every case in which the benefit is observed. ii. The system must be isolated from the organization. iii. The benefit must be reproduced when the system is implemented in a new organization. iv. We must demonstrate that the system was used in the new organization. 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.

(a) Strength of Association tells us that the greater the change observed, the more likely the association is to be causal (e.g. If a EHR system is implemented and the CPOE feature greatly reduces medication errors, we could say that the implementation of the system had a causal effect on the reduction of medication errors and the strength of association is great).

(b) Consistency of Findings explains that if a change has been observed by different groups in different places with different circumstances and systems, the change is valid, so to speak. For example, if Company A (London, England, UK) implements System A , Company B (Houston, TX, USA) implements System B, and Company C (Guadalajara, Jalisco, Mexico) implements System C, and all three companies reduce medication errors using their respective systems, we can, again say that the CPOE feature of EHR systems can help reduce medication errors. It is important to note that the more consistent findings amongst different groups in different places, the better.

(c) Specificity of Association requires us to ask if there are any other factors which may have affected the change that we've observed. In regards to medication errors being reduced, one would have to ask if CPOE was the only factor involved. If errors could have been reduced due to other mechanisms in place besides CPOE alerts (e.g. better workflow in departments, new policies, etc.), the specificity of association could be considered weak. Weak does not imply wrong, but it does mean that more research has to be initiated.

(d) Temporality addresses the evaluation after an EHR system is implemented. Temporality asks us "were there any changes AFTER the system was implemented?" Usually this is harder to prove due to lack of data prior to EHR implementation, however, Sittig rates temporality as "strong."

(e) Dose-Response asks if the size of changes are directly correlated with the increase of system use (e.g. were medication errors greatly reduced due to the use of many medication alerts in the EHR system?). Usually, there is a strong and direct correlation between system use and the reduction of medication errors, as one example of a dose response in an EHR system.

(f) Plausibility must be shown; There must be some way to demonstrate that the EHR system was used the way it was intended to deliver certain results (e.g. Physicians must have used clinical support decisions the way the EHR system intended to reduce medication errors, in order to demonstrate plausibility.)

(g) Coherence simply states that changes caused by EHR systems should be caused by other EHR systems elsewhere. So, if medication errors are reduced by the use of one EHR system and that happens with the use of many other EHR systems, coherence exists.

(h) Experimental Evidence and Analogy is proving that when the system is not used properly or at all, that certain changes stop. So, if an EHR system is not being used properly or at all (after initial proper use), does a rise in medication errors resume? Experimental evidence is hard to obtain after EHR implementation because it requires not using the system for quite some time (which many would view as wasted money).


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: [8]

  • 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)[9] 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).

Misc, to sort later

  • E-prescribing will reduce number of physician office visit and phone call. phone calls and visits, Test results and appointments alert will be implemented and patients are automatically notified of test results and appointment times. [3] [4] [5]
  • Updates are done faster and files can be synchronized.
  • Duplicate orders and illegible handwriting will no longer be an issue is less of a problem [10]
  • Hard drives take up less space. Shared databases reduces the need for paper [6]
  • Billing is easier as the formatted documentation may improve the accuracy of charge capture.
  • Billing edits, including National and Local Coverage Determinations, can be alerted in real-time.
  • Patients arecan be informed of generic drugs, doctors can know if insurances do not cover patients, and formulary requirements can be identified.
  • Insurance and malpractice premiums can also be lowered. [7]) [8]
  • Different drugs can save hospitals money Hospitals will save money over various drugs [9].
  • Dictation is automatic
  • HIM staff may be reduced or staffing requirements changed [10]
  • Nurses will be more productive and more efficient [11]
  • Reduces medication errors and checks for drug-drug interactionsAdverse drug event (ADE), drug-drug interactions(DDI)will be detected thereby reducing errors in medication. [12] [13] [14] [15]
  • Reduces redundant lab tests [16] [17]
  • Reminders increase underused preventative measures [18]
  • deduce infections from a list of symptoms and help make doctors make good clinical decisions. [19] [20] [21] [22] The patient internet portal allows patients to know the most up to date information about healthcare. [23]
  • Telemedicine
  • Large scale data exchange and information integration [24] [25]
  • Surveillance and reporting of diseases [26]
  • Research information in the database [27]

Academic EHRs are functional systems that makes training for nursing staff more efficient. Student nurses apply their learnt skills to plan patient care in a simulated setup. This allows student nurses to develop their acquired knowledge in a practical setting and transition into a familiar working environment after their academic careers.([11].

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
60. Interviews with John Kansky, Laura Adams (2014, 8) by Mark Braunstein, GA Tech.
61. What is the DIRECT project (2010, 10) by The Direct Project. http://wiki.directproject.org/file/view/DirectProjectOverview.pdf

References (old, to edit)

  1. What Is an Electronic Medical Record (EMR)? http://www.healthit.gov/providers-professionals/electronic-medical-records-emr
  2. Heubusch, K. (2008). Certified EHRs. Journal of AHIMA, 79(8), 34-36. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/212569443?accountid=7034
  3. Cite error: Invalid <ref> tag; no text was provided for refs named benefits_.26_drawbacks
  4. Implementation of a Standardized, Electronic Patient Hand Off Communication Tool in a Level III NICU. Source: OJNI Volume 18, Number 2 June 1, 2014
  5. 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)
  6. Top 5 Benefits of Clinical Decision Support in the ED http://www.govhealthit.com/blog/top-5-benefits-clinical-decision-support-ed
  7. Gaudreau, E., & Palermo, D. (2009). EHR fast track. Journal of AHIMA, 80(8), 40-43. Retrieved from http://ezproxyhost.library.tmc.edu/login?url=http://search.proquest.com/docview/212610540?accountid=703
  8. 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
  9. Health Level 7, http://www.hl7.org/about/index.cfm?ref=nav
  10. IOM Key Capabilities of an Electronic Health Record System http://www.providersedge.com/ehdocs/ehr_articles/Key_Capabilities_of_an_EHR_System.pdf
  11. Gardner, C. and Jones, S. (June 2012). Utilization of academic electronic medical records in undergraduate nursing education. Online Journal of Nursing Informatics (OJNI), vol. 16 (2)


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

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