EMR

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An electronic medical record (EMR) (also electronic healthcare record (EHR) or clinical information system (CIS)) is a data repository that digitally collects the medical reports of patients, exchanges such information with other healthcare provides, and makes a personal health record (PHR) for the patient to share with their doctor and other providers.

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 be 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.

Medication List

The medication list is a single list of all medications. 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). Sorting the list by "reason for prescription" will be helpful.

An alert for medications changes, such as dose or prescription changes, should be made to the prescribing clinician or primary care physician (PCP) and the listed supervisor of non MD clinician.

EMR benefits

Electronic Medical Records have many benefits over an analogous paper record. Updates are done faster and files can be synchronized. Duplicate orders and illegible handwriting is less of a problem. [1]

Privacy and security

Privacy is required by the federal law, Health Insurance Portability and Accountability Act (HIPAA). Electronic objects enhance 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 it doesn’t prevent humans from 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.

Financial

Although initially implementing EMRs can be expensive [2], computer systems are more efficient and can save time and money.

  • Eliminate the paper chart by typing orders directly into the computer . [3]
  • Hard drives take up less space. Shared databases reduces the need for paper [4]
  • Billing is easier. Patients can be informed of generic drugs and doctors can know if insurances do not cover patients.
  • Insurance and malpractice premiums can also be lowered. [5]) [6]
  • Different drugs can save hospitals money [7].
  • Dictation is automatic
  • E-prescribing reduces number of phone calls and visits, and patients are automatically notified of test results and appointment times. [8] [9] [10]

Clinical

EMRs have many clinical benefits.

See also: more in-depth discussion of EMR benefits

EMR (EHR) regulation and certification

As of early 2012, EHRs are not regulated by US law. 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. EHRs are not classified as medical devices [28]. A male fertility test kit classified as a Class II Medical Device [29] is subject to greater regulatory scrutiny than is an EHR used by clinicians to assist in making treatment decisions.

In practice, the boundary between computer systems and medical devices is rapidly disappearing. If an EHR has the capability to interface with a device and automatically capture data, than the device has become ancillary to the EHR. As medical devices run on increasingly complex embedded (and upgradeable) software instructions, and they are more commonly interfaced with the EHR, the distinction between the two fades further. Modern enterprise EHRs 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 EHR 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. This is commonly used under the 510(k) process. If the agency finds that the new device does substantially the same thing(s) as a prior device, more extensive review is not necessary. Therefore, the argument follows, a disadvantage would be given to the first EHR to satisfy the regulatory hurdle, because all following EHR's would be substantially equivalent.

There is an existing voluntary certification for health care systems - the Certification Commission for Health Information Technology [30]. 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 EHR.

CCHIT is "an independent, 501(c)3 nonprofit organization with the public mission of accelerating the adoption of robust, interoperable health information technology" [31]. CCHIT was founded by a consortium of academic and professional health information technology organizations [32]. CCHIT received extensive funding from the US Department of Health and Human Services to "develop and evaluate the certification criteria and inspection process for EHRs and the networks through which they operate". [33]

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". [34]

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 EHR in a healthcare delivery enterprise considers operators (clinicians and ancillary staff) and technology (the EHR 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.

Submitted by (Dan Slater)

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. [35] 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: [36]

  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.

Historically Important Electronic Medical Record Systems

Many EMRs have already been installed around the world. For a list of EMRs, see Historically Important Electronic Medical Record Systems.

EMR Training

Training clinicians to effectively utilize all the features of an EMR is difficult.

EMR adoption

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

Clinician Sign-out applications

sign-out

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. [37] [38]

Free and Open Source EMRs

Free and Open Source EMRs

OpenEHR

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

Considerations for Specialists

Specialists can have different EMR needs.

EMR and Biometrics

Biometrics

Socio-technical Issues

Genetic Non-Discrimination

Terms related to privacy, confidentiality, and security

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

EHR system selection

See more for what Marl Mench thinks of EHR system selections

List of EMR companies

EMR models for small and medium sized practices

Productivity

see Physician productivity and Electronic Medical Record (EMR)