This is the fourth article in a series dedicated to uncovering the best practices for an EMR implementation. The information presented has been developed by the author as part of a research project.
Literature Review - Introduction
Opinions vary on widely on the benefits of EMR technology and whether providers should implement them. Christman suggests that the security issues alone is reason enough to seriously assess whether an EMR is right for a particular practice (Christman, 2006). However, government entities at both the state and federal level (Edwards, Lovelock, & Rose, 2006) along with third party payer groups (Wojcik, 2006) and corporate entities (Bit by bit, 2006) are driving health care providers ultimately to electronically accessible medical records.
Currently, about 25 percent of U.S physicians are using systems that facilitate electronic health records (Murdock, 2007). As EMR systems gain momentum due to private and public pressures, the number of implementations will continue to rise and subsequently lead to the rise in failures (The Standish Group, 1995). It is the purpose of this study to help reduce failures by providing a framework in which effective best practice within the field.
Many factors may influence the successful implementation of EMR systems. An understanding of an EMR system's purpose, function and intended benefits help determine in part what influences the success or failure of an EMR project along with awareness of mistakes in the past while leveraging integration best practices that may be unique to EMR implementations.
Electronic Medical Record Systems
The collection of personal health data is described to have many formats when speaking of systems that manage it. An Electronic Medical Record is the collection of data that is central to the patient (Rishel, Handler, & Edwards, 2005). An EMR system exists to facilitate the storage, retrieval and continuity of the record itself (Gans, Kralewski, Hammons, & Dowd, 2005). EMR systems vary in functionality. According to Gans et al., EMR systems typically have the following functions listed from most common to least common:
Patient Demographics
Visit/encounter notes
Patient medications/prescriptions
Presenting complaint
Physical exam/review of symptoms
Past medical history
Problem lists
Procedure/operative notes
Laboratory results
Drug interaction warnings
Radiology/imaging results
Consult/reports from specialists
Referrals to specialists
Drug reference information
Immunization tracking
Drug formularies
Clinical guidelines and protocols
Integration with practice billing system
Other functions may include a claims processing component that allows the coding and transmitting of clinical data to insurance companies to improve the time and cost involved in dealing with insurance carriers (Research Notes, 2006).
There are other names for EMR systems such as the Electronic Health Record (EHR), Personal Health Record (PHR), Electronic Patient Record (EPR) and Computerized Patient Record (CPR). Confusion around the many terms as well as what is represented by them impacts a provider's ability to strategically assess which system is best for them (Rishel et al., 2005). Still, there are some subtle differences between each of the terms. An EMR is typically generated by a physician's practice. An EPR or EHR is typically generated using multiple sources such as those shared between a physician and a hospital. Finally, a PHR is a collection of patient information that the patient themselves hold and share with providers (Barlow, 2007).
EMR systems can be a complex set of connected systems with significant data collection points or it can be a simple system that collects basic data needed to record and associate health information with a specific patient (Rishel, 2007). An EMR system is a collection of information technology that perform the functions noted above by leveraging databases for repositories of data or aggregation points for summary data from other systems (Rishel et al., 2005).
The result of multi-faceted interaction of patient and the health care system is a distributed health record that resides in as many locations as the patient has seen physicians (Ewing, 2007). No one provider has a consistent and full picture of the patient history or treatment. One of the primary benefits of the EMR system is to help eliminate the disconnect and attempt to aggregate patient data as well as make it easier to share the data with other participating providers.
The patient's complex interaction with the healthcare system (Ewing, 2007) further reveals a problematic approach to the purpose and the ultimate goals of implementing an EMR system. This complex interaction of both human and functional provider systems leads to the case for an EMR system. Ewing suggests that the complex interactions of a patient with the medical delivery system expose the patient to significant risk of adverse treatment. Risks identified include delivery of incorrect medication, prescription interactions and lack of medical history in emergency situations. EMR systems are designed to help improve patient medical care and the provider's ability to deliver accurate medical information (Kizer, 2007).
EMR systems may ultimately feed other systems such as an aggregation point for a PHR that a patient can access and carry with them from appointment to appointment (Shetty, 2007). Reversing the scenario, an EMR system can collect and aggregate information from other sources such as laboratory, x-ray and unstructured data like faxes or handwritten notes (Wojcik, 2006). Reduction of the storage necessary to keep paper charts is also a noted as a reason to leverage and EMR freeing up of space better used for revenue generation. Paper charts have their own risks associated with them in terms of getting lost, productivity impacts to maintain and retrieve paper records and the resulting negative patient care. (Carpenter, 2002). Effective access to medical records has become is another purpose of an EMR system. The ability to access a record from remote locations is important to ensure continuity of care (Research notes, 2006).
The intended effect of EMR systems on the healthcare landscape is wide-ranged depending on the type of system and the environment in which it is being implemented. A group practice implemented an EMR system to improve the accuracy of their claims and improve efficiency and information flow (Sonnenberg,
2007). Government entities such as the Department of Veteran Affairs and the Department of Defense have larger goals of integration and delivery of a common medical record and full digitization of clinical data that can be shared with branches of the military (Melvin, 2007).
The near term presents providers with realizing the digitization of the boxes of paper that is generated by patient encounters. These paper databases represent the clinical data that is ultimately needed to take EMR systems to the next level. Clinical data is the baseline in which all healthcare processes subscribe including decision support, health outcome analysis, billing and claims processing and health maintenance.
Correlation and access to this data is what EMR systems seek to facilitate (Handler & Hieb, 2007). With Clinical data as a basis, further utilization of EMR systems can occur. EMR systems, once materially implemented across the healthcare spectrum, will itself become the framework in which more overarching goals can be accomplished, such as the centralization of a person's health history.
Gartner (Handler & Hieb, 2007) break down EMR system into generational phases of maturity (summarized):
Phase 1 systems are designed to collect encounter based information such as prevalent in a physician provider environment.
Phase 2 systems are designed to allow the updating and entry of information at the point of care. For example, a physician is making rounds at a hospital and can update his EMR records remotely rather than just access it.
Phase 3 systems are designed to support clinical episodes where there are one or more encounters that provide complete information on a patient with system recommended treatment options provided by decisions support systems. Phase 3 attempts to provide basic level evidence based medicine implementation.
Phase 4 systems are designed to further enhance the integration of systems to provide all stakeholders (physicians, nurses, pharmacists, etc.) access to patient data and to help facilitate the care process rather than just document it.
Phase 5 are complex, fully integrated systems that provide solutions across the full spectrum of care. These systems provide both visual and data driven insight and suggested courses of action where appropriate. Knowledge management is fully integrated into phase 5 systems to facilitate a more partner based approach to care.
The iterative nature of EMR system provides a baseline in which each generation can grow. However, very few EMR implementations reviewed have been shown to reach much past the first generation. Even those that are utilizing a Phase 1 EMR system are about one in four (Murdock, 2007). As adoption continues to grow, so will opportunities to further integrate with disparate systems and the development of standards for access to EMR data in a format that can be shared with both the consumer of services and the providers of care.
The next article(s) will delve into additional reference material and case studies related to EMR Implementations.
All References can be found on my website at http://www.keithfulmer.com
Keith has been in information technology planning and project management for over 16 years and is a senior healthcare operations executive. He has a passion for project management best practices and healthcare and looks forward to the coming age of the EHR.
Having two children with allergies to peanuts, Keith is passionate about allergy awareness. Come visit his latest website over at http://www.allergyalertbracelet.com/ which helps people find the best allergy alert bracelet and information they are looking for when dealing with adult or child allergy awareness.
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