Electronic medical record

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An electronic health record is a representation of all a patients’ data that would originally be found in the paper based record. It contains all information ranging from pathology, radiology and clinical information that has been combined and structured in a digital form.[1]


The system is designed to capture and re-present data that accurately capture the state of the patient at all times. It allows for an entire patient history to be viewed without the need to track down the patient’s previous medical record volume and assists in ensuring data is accurate, appropriate and legible. It reduces the chances of data replication as there is only one modifiable file, which means the file is constantly up to date when viewed at a later date and eliminates the issue of lost forms or paperwork. Due to all the information being in a single file, it makes it much more effective when extracting medical data for the examination of possible trends and long term changes in the patient.

Contents

Comparison with paper-based records[edit]

Paper-based records are still by far the most common method of recording patient information for most hospitals and practices in the U.S.[2] The majority of doctors still find their ease of data entry and low cost hard to part with.[citation needed] However, as easy as they are for the doctor to record medical data at the point of care, they require a significant amount of storage space compared to digital records. In the United States, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, collating them to a single location for review by a health care provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centered records, which are impractical to maintain if not electronic (thus difficult to centralize or federate). When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records.[citation needed] Because of these many "after-entry" benefits, federal and state governments, insurance companies and other large medical institutions are heavily promoting the adoption of electronic medical records. The US Congress included a formula of both incentives (up to $44,000 per physician under Medicare or up to $65,000 over six years, under Medicaid) and penalties (i.e. decreased Medicare and Medicaid reimbursements for covered patients to doctors who fail to use EMRs by 2015) for EMR/EHR adoption versus continued use of paper records as part of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009.[3]

One study estimates electronic medical records improve overall efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.[4][5] Jerome Groopman disputed these results, publicly asking "how such dramatic claims of cost-saving and quality improvement could be true".[6]

However, the increased portability and accessibility of electronic medical records may also increase the ease with which they can be accessed and stolen by unauthorized persons or unscrupulous users versus paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act and by large-scale breaches in confidential records reported by EMR users.[7][8] Concerns about security contribute to the resistance shown to their widespread adoption.

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.[10][11]

In contrast, EMRs can be continuously updated (within certain legal limitations – see below). The ability to exchange records between different EMR systems ("interoperability"[12]) would facilitate the co-ordination of health care delivery in non-affiliated health care facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[13]

Contribution under UN administration and accredited organizations[edit]

The United Nations World Health Organization (WHO) administration intentionally does not contribute to an internationally standardized view of medical records nor to personal health records. However, WHO contributes to minimum requirements definition for developing countries.[14]

The United Nations accredited standardisation body International Organization for Standardization (ISO) however has settled thorough word[clarification needed] for standards in the scope of the HL7 platform for health care informatics. Respective standards are available with ISO/HL7 10781:2009 Electronic Health Record-System Functional Model, Release 1.1[15] and subsequent set of detailing standards.[16]

In the United States[edit]

Usage[edit]

Even though EMR systems with a computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 had a fully integrated system.[17]

In the United States, the CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009.[18] This is an increase over 2008, when only 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008.[19] However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical progress notes. As of 2012, 72 percent of office physicians are using basic electronic medical records.

The usage of electronic medical records can vary depending on who the user is and how they are using it. Electronic medical records can help improve the quality of medical care given to patients. Many doctors and office-based physicians refuse to get rid of the traditional paper records. Harvard University has conducted a experiment in which they tested how doctors and nurses use electronic medical records to keep their patients' information up to date. The studies found that electronic medical records were very useful; a doctor or a nurse was able to find a patient's information fast and easy just by typing their name; even if it was misspelled. The usage of electronic medical records increases in some work places due to the ease of use of the system; whereas the president of the Canadian Family Practice Nurses Association says that using electronic medical records can be time consuming, and it isn't very helpful due to the complexity of the system.[20] Beth Israel Deaconess Medical Center reported that doctors and nurses prefer to use a much more friendly user software due to the difficulty and time it takes for a medical staff to input the information as well as to find a patients information. A study was done and the amount of information that was recorded in the EMRs was recorded; about 44% of the patients information was recorded in the EMRs. This shows that EMRs are not very efficient most of the time.[21]

The cost of implementing an EMR system for smaller practices has also been criticized.[by whom?] Despite this, tighter regulations regarding meaningful use criteria have resulted in more physicians adopting EMR systems. Software, hardware and other services for EMR system implementation are provided for cost by various companies, including Dell.[22] Open source EMR systems exist, but have not seen widespread adoption of open-source EMR system software. Beyond financial concerns there are a number of legal and ethical dilemmas created by increasing EMR use.[23]

Goals And Objectives[edit]

Quality and safety measurement
Clinical decision support (automated advice) for providers
Patient registries (e.g., “a directory of patients with diabetes”)
Electronic laboratory reporting for reportable conditions (hospitals)
Immunization reporting to immunization registries
Syndromic surveillance (health event awareness)

Quality[edit]

Studies call into question whether, in real life, EMRs improve the quality of care.[24][25] 2009 produced several articles raising doubts about EMR benefits.[26][27][28] A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of check-boxes has led to fewer open-ended questions.[29]

Costs[edit]

The steep[clarification needed] price of EMR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment have a significant influence on EMR adoption.[30] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EMR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[30]

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EMR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians."[31] One CEO of an EMR company has argued if a physician performs tests in the office, it might reduce his or her income.[32] "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."[31]

Doubts have been raised about cost saving from EMRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.[28][33][34]

Software quality and usability deficiencies[edit]

The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. health care IT industry trade group, observed that EMR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available."[35] The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers.[36] The U.S. military's EMR "AHLTA" was reported to have significant usability issues.[37]

Legal status[edit]

Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator.[38] Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.[39]

Technical features[edit]


Health Information Exchange[40]


Using an EMR to read and write a patient's record is not only possible through a workstation but, depending on the type of system and health care settings, may also be possible through mobile devices that are handwriting capable.[41] Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers.

Some EMR systems automatically monitor clinical events, by analyzing patient data from an electronic health record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.[42] This type of event monitoring has been implemented using the Louisiana Public health information exchange linking state wide public health with electronic medical records. This system alerted medical providers when a patient with HIV/AIDS had not received care in over twelve months. This system greatly reduced the number of missed critical opportunities.[43]

In ambulances[edit]

Ambulance services in Australia have introduced the use of EMR systems [44] The benefits of EMR in ambulances include the following: better training for paramedics, review of clinical standards, better research options for pre-hospital care and design of future treatment options [45]

Automated handwriting recognition of ambulance medical forms has also been successful. These systems allow paper-based medical documents to be converted to digital text with substantially less cost overhead. Patient identifying information would not be converted to comply with government privacy regulations. The data can then be efficiently used for epidemiological analysis.[46]

GP2GP project[edit]

GP2GP is an NHS Connecting for Health project in the United Kingdom. It enables GPs to transfer a patient's electronic medical record to another practice when the patient moves onto the list.[47]

Privacy concerns[edit]

A major concern is adequate confidentiality of the individual records being managed electronically.[who?] According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and over 600,000 payers, providers and other entities that handle providers' billing data have some access.[48]

In the United States, this class of information is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[49] The HIPAA protects a patient's information; the information that is protected under this act are: information doctors and nurses input into the electronic medical record, conversations between a doctor and a patient that may have been recorded, as well as billing information. Under this act there is a limit as to how much information can be disclosed, and as well as who can see a patients information. Patients also get to have a copy of their records if they desire, and get a notified if their information is ever to be shared with third parties.[50]

Medical and health care providers experienced 767 security breaches resulting in the compromised confidential health information of 23,625,933 patients during the period of 2006–2012.[51]

In the European Union (EU), several directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[52]

Technical standards[edit]

Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EMRs. These include:

Lack of semantic interoperability, a fundamental problem[edit]

In the United States, there are no standards for semantic interoperability of health care data; there are only syntactic standards. This means that while data may be packaged in a standard format (using the pipe notation of HL7, or the bracket notation of XML), it lacks definition, or linkage to a common shared dictionary. The addition of layers of complex information models (such as the HL7 v3 RIM) does not resolve this fundamental issue.

Regulatory compliance[edit]

In veterinary medicine[edit]

In UK veterinary practice, the replacement of paper recording systems with electronic methods of storing animal patient information escalated from the 1980s and the majority of clinics now use electronic medical records. In a sample of 129 veterinary practices, 89% used a Practice Management System (PMS) for data recording.[53] There are more than ten PMS providers currently in the UK. Collecting data directly from PMSs for epidemiological analysis abolishes the need for veterinarians to manually submit individual reports per animal visit and therefore increases the reporting rate.[54]

Veterinary electronic medical record data are being used to investigate antimicrobial efficacy; risk factors for canine cancer; and inherited diseases in dogs and cats, in the small animal disease surveillance project 'VetCOMPASS' (Veterinary Companion Animal Surveillance System) at the Royal Veterinary College, London, in collaboration with the University of Sydney and RxWorks (the VetCOMPASS project was formerly known as VEctAR).[55]

The Future of Electronic Health Records – Personally Controlled Electronic Health Records[edit]

A Personally Controlled Electronic Health Record (PCEHR) is a system that proposes to store admission or event summaries in an electronic format over a large network accessible by doctors, nurses, GPs and chemists without the need for written scripts or requesting medical files from another hospital. The system proposes to record and store any health information provided by a health care professional that has agreed to be a part of the system. This allows the storage and retrieval of a lifetimes worth of clinical and demographic information of a patient that can be viewed as event summaries and reports with the appropriate authorization[56]

See also[edit]

References[edit]

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  56. ^ http://www.ncbi.nlm.nih.gov/pubmed/15359551

External links[edit]