Electronic Medical Record (EMR) Systems - Research Paper Example

Electronic medical record (EMR) systems Introduction Various evidence-based reviews aimed at improving the quality of health care provided conclude that some kinds of health information technology (HIT) systems, more so electronic medical records (EMRs) are essential in reducing medication errors, improving adherence to guideline recommendations for various illnesses, and patient satisfaction. Although there are substantial benefits that may be enjoyed by a health care center that adopts and implements the digital records, there are various aspects and challenges that slow the adoption of the technological system. The purpose of this paper is to present a report on the experiences of adopting and implementing EMRs in a hospital setting. Background and the Objectives Though there are systematic reviews concluding that EMRs have the potential to reduce medication errors, save clinicians’ time, promote adherence to evidence-based guidelines in management of various health conditions, and improve patient safety; adoption of EMR systems is still low in health care setting (Jones, & Blavin, 2013; King, Patel, Jamoom, & Furukawa, 2014). According to Jones, and Blavin (2013), only 1.5% of the non-federal acute care facilities had a comprehensive electronic health record system in 2008 while only 7.6% had installed basic EMR. To facilitate widespread adoption and utilization of HITs, the Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009, with an overarching aim of enhancing the efficiency, quality as well as safety of the American health care system (Silow-Carroll, Edwards, & Rodin, 2012). Through Medicaid and Medicare EHR programs, HITECH avails financial incentives to eligible health care providers and hospitals that adopt and demonstrate meaningful use of the health information technology. The meaningful use legislation seems to be associated with increased adoption and implementation of EHR systems in various health care settings. For instance, in the year 2012, about 17% of non-federal acute care health care centers reported to be using a comprehensive EHR system while 27.6% reported to have adopted a basic EHR system. This was a 15% and 20% rise in the adoption and implementation of EHR systems in non-federal acute care settings from 2008, respectively (Jones, & Blavin, 2013). Likewise, about 40% of the office-based physicians claimed to be using some type of EHRs that satisfied the criteria for the basic systems in 2012, representing more than a two-fold increase in the proportion of US physicians with a basic EHR system from 2008 (Silow-Carroll, Edwards, & Rodin, 2012). To accomplish the ultimate goals of meaningful use legislation, hospitals must not only implement the system, but must also meaningfully and optimally make use of EMRs. Adoption and implementation of EHR, according to Edwards, Silow-Carroll, and Lashbrook (2011), is a process that is marked by significant changes in workflow, technical complexities, and heavy investment among other challenges that a health care organization has to overcome to achieve meaningful use. The purpose of this report is to describe the experiences of adopting and implementing EMR system in one of non-federal acute care hospital. Specifically, the paper presents information on the background of the health care organization, the process of adopting and implementing the system, and how the organization strives to achieve meaningful use. Interviews were conducted with key informatics involved throughout the adoption and implementation of the system. The key informants included the head of the quality assurance department, the chief information officer, and other staff members involved in the process. Though the results may not be generalized to all other non-federal hospitals, the findings may provide valuable insights into the barriers, challenges, and benefits of adopting the technological system from a practical perspective, particularly to those hospitals considering adopting EMR. Organization Information Description of the hospital and technology The health care organization selected is a Medicare and Medicaid certified acute care hospital located in the US. The hospital has a bed capacity of 400 patients and is affiliated to one medical school and has three home health and hospice facilities with a total of 612 care providers. The hospital provides skilled social and medical care to both adults and children with different types of health insurance programs. The hospital is a not-for profit care center with a mission of providing care to all people regardless of their ethnicity, age, gender, and ability to pay. The hospital has adopted Eclipsys EMR system which was traded by Eclipsys Corporation, an American company that is recognized as global leader in providing hospitals and other care organizations with knowledge-driven and process improving software services to improve patient safety and quality of care provided. The company was established in 1995 and merged with Allscripts in the year 2010 to promote sharing and interoperability of HIT (Eclipsys, 2016). According to the interviewees, the EMR system has increased revenues for the hospital by improving the ability to produce documented evidence on improved quality of care, enhanced compliance with existing regulatory policies, improved both the quality and quantity of documentation as a result of improved efficiency, improved patient safety by identifying key patient safety indicators, and has increased patient and care providers’ satisfaction with the quality of services provided. The health information system has also been used to support health care related research. The electronic system has improved accessibility to clinical and patient data necessary for research. The hospital has developed real-time notifications to assist in the identification of patients qualifying for certain studies, thus making it easy to select potential participants for various types of studies. The digital record system has also been used in quality improvement initiatives. This is because the system makes it possible for the hospital to capture clinical and patient data which is used to determine the quality of care provided. For instance, the hospital has educational interventions aimed at providing heart failure patients with education at discharge to reduce the hospital readmission rates. In essence, the system integrates clinical and administrative data over various departments to improve the quality of health care provided. Reasons for adoption of the system The need for adoption and implementation of the technological system was identified from the practice problem experienced at the care facility. Before the adoption of the system, there were high rates of medication errors, poor access to patient records, lots of paperwork, poor communication between care practitioners working with the organization, and lengthy data preparation and collection time which all served as a catalyst for the implementation of the EMR system. The need for EHR has been confirmed by several systematic reviews noting that adoption and implementation of the digital record systems contributes to reduced medication errors, less paper work, and improved documentation (Jones, & Blavin, 2013; Lau et al., 2012). The need for the system was also confirmed during an internal meeting that was held prior to the implementation of the system. The meeting was aimed at discussing various ways the hospital could improve the quality of care provided, improve patient safety while improving on financial revenues. After lengthy discussions, the stakeholders unanimously endorsed the decision to adopt an EMR system and provide training to staff members to smoothen the transition from paper based to electronic health record system. The decision to implement a comprehensive EMR system was part of a strategic plan to incorporate outpatient and inpatient care so as to offer a continuum of coordinated medical services. A literature search through key health databases such as Pubmed confirmed that implementation of the EHR system could be effective in fulfilling the identified organizational needs. Management of the EMR system The health information system is managed by the head of health information technology department in the hospital. The department offers efficient, steady, and responsive health information services to all the hospital departments. The goal of the department is to assist health care practitioners in providing excellent care to patients by facilitating access to patient and medical information whenever needed at the hospital. The Chief information Officer (the head of the information technology department) is an executive officer working with the hospital. Information System Application Design and Development Decision-making process The hospital top leadership closely participated in the decision-making process relating to the type of EMR system most suitable for the needs of the organization. The decision to implement the EMR system was made at the corporate level, though nursing leaders and other senior clinicians were closely involved in the system selection process. The selection criteria was a system that has huge potential for integration of inpatient and outpatient care, vendor’s reputation in provision of effective and timely technical support prior, during, and upon implementation of the system, updates that would assist the organization in satisfying the meaningful use requirements, and customization options. Registered nurses and other end-users were involved in the selection of the type of EMR. The top-leadership narrowed down to two main EMR vendors, then recorded the vendor demonstration of their EMRs and their features. Sections of the recorded videos were sent to various hospital departments for review by the end-users. About 500 people took part in the selection of the EHR system. Involvement of the end-users led to successful implementation of the electronic system. Training and user support Existing literature on adoption and implementation of EHRs describes training as an essential strategy in promoting effective use of the systems. There are studies providing evidence of the importance of investing in training programs involving end-users to avoid productivity loses and costly setbacks that are associated with poor use of HER systems (Edwards, Silow-Carroll, and Lashbrook, 2011; Jones, & Blavin, 2013). Though the commercial vendor selected to install EMR provided training to the end-users, the health care organization had to extend training to all clinical and administrative staff members. A key training policy at the organization was that training is compulsory: all staff members had to take part in the training and pass all the proficiency tests to be allowed to use the system and go round various units. Besides the training provided by the vendor, individualized post-implementation training support was provided by the IT department to optimize EHR use. Expert EHR users are also encouraged to assist in training their colleagues who may have inadequate skills to perform various tasks using the system. Security issues Though there has been increased use of EHRs due to the various benefits, there are concerns that some physicians are reluctant to implement the systems due to security and legal risks associated with the digital health records (Sittig & Singh, 2011). Security breaches jeopardize the privacy of patients when confidential medical record information is accessed by unauthorized individuals (Kopala & Mitchell, 2011). The hospital has a number of security policies in place. All computers are password protected and the staff members have to use their own passwords to login and must always log off when leaving a station. Leaving computers with sensitive data unattended and sharing of passwords with non-authorized persons is prohibited. The same policies apply to all students taking their internship at the care center. To guarantee compliance with the organization security policies, random audits are regularly carried out. The health information system identifies high risk access to hospital or patient data. The technological system has the ability to capture essential details of the person accessing the health records in an inappropriate manner. Some of the details that can be captured include the time, date, name of the person, location, the length of the review, and the records reviewed. These data is essential in establishing whether the access was intentional or accidental. Disciplinary actions including termination of work contract are taken depending on the magnitude of the offence. The hospital policies help in upholding patient privacy and enhancing security by preventing unauthorized access or sharing of patient data. Funding and budget The process of adopting and maintaining the digital records requires adequate capital and input by various stakeholders including consultants, information technologists and health care providers. Selection of a technological system that has the potential to meet organization needs is crucial to the cost of investment and returns on investment (Silow-Carroll, Edwards, & Rodin, 2012). According to Kopala and Mitchell (2011), the initial financial cost in the adoption and implementation of EHR system by a hospital runs in million dollars. Training and system maintenance constitutes additional costs. The initial funds for the project for the hospital came from grants and donations from charitable foundations and individuals. Another source of funds for the adoption of the technological system was fee for services provided by the hospital. The budget for the health information technology is managed by the healthcare chief information officer. The officer determines the resources required to purchase and install new technological systems or software based on their return to investment (ROI). The officer advises the hospital on the cost and how long the training program should take place taking into consideration the learning process and disruption of workflow as well as other considerations essential for effective implementation of a technological system. In essence, the chief information officer plays a huge role in influencing buying decisions for the hospital by determining where and how the budget for health information technology should be spent. Organization issues A number of organization issues impacted on the continuing funding of the organization. One of the main issues was varying level of support for the project by leaders in various departments. Managerial and clinical leadership support is essential in ensuring adequate financial support for adoption of HIT (Jones, & Blavin, 2013). There were concerns over return on investment on the new system. Hospital top executives expressed concerns in that the health care organization recorded a four to five per cent annual growth rate, while the information technology department demanded higher and higher rates of investments which were 15% of the organization budget. Organization politics in light of competing priorities made it hard for the budget estimates to be approved by the hospital executive committee. The chief information officer had to review the budget and provide credible and specific ROI estimates. Unexpected financial spending upon the implementation of the technological system increased organizational issues affecting funding of the project. There were additional expenses associated with post-implementation planning, maintenance, and acquisition of hardware, just to mention a few. However, the hospital satisfied the meaningful use policy, thus most of the additional expenses were addressed by meaningful use legislation. Innovative Aspects of the system Technological innovations Interviewees emphasized that one of the main features of the specialized EMR system adopted by the hospital was the ability to add new functions or modules over time. The organization has acquired extra components to support workflow needs. For instance, the hospital has switched from scanning of patient consent forms and signatures into EHR to the use of digital pens to insert signatures into digital patient consent forms. Patients can now sign in the signature pads and their signatures are immediately recorded in their health records. In addition to that, the organization is using real-time medical dictation technology to incorporate notes directly into the EMR. Another way the hospital is making innovative use of EMR is using the technological system in the decision making process. The system has made it easier to adopt and make use of evidence-based guidelines in the management of various health conditions. With real-time evidence-based information, physicians no longer face difficulties in making treatment decisions. One clinician claimed that “…any medical assistant or student can come here and do things in the right way”. This is because the clinical guidelines are embedded in the EMR system. The hospital has also automated its surgical workflow which has improved operational efficiency and annual savings. Patient portals have been incorporated into the existing EMR records promoting online access to medical records by patients at the comfort of their homes. The hospital also has plans in place to give copies of patient records in flash drives when requested. The online patient portals enables the patients to communicate with their physicians, book appointments, view radiography or laboratory diagnosis results, and order prescription refills with the pharmacy department. The hospital also offers e-visits which are commonly used to address health issues that do not necessitate office care. The interviewees reported that the use of electronic patient portals has been increasing at a high rate and has been associated with increased patient satisfaction with the system. Recommendable technologies Though the hospital has been using the electronic system to prevent medication errors by ensuring that the right medication is provided to the right patient, there are still unexploited potential as far as improving patient quality is concerned. The HIT system can be used to reduce rates of nosocomial infections by prompting all care providers to follow the recommended guidelines. For instance, the hospital can prompt all care providers to provide an explanation on why a catheter is needed and send a reminder to remove it at the right time. Such an approach would reduce catheter associated urinary tract infection rates. The hospital can also develop a module for confirmation of patient to avoid having clinicians erroneously enter wrong orders on the patient- a problem that has been discussed in the existing literature as an undesirable effect of EHR (Silow-Carroll, Edwards, & Rodin, 2012). Such kinds of error are common when physicians are working with lengthy electronic lists of patients considering that selection of a patient from the list is an easy process. The use of patient identification module would reduce such errors by generating a big patient verification screen displaying the date of birth of the patient, the names of the patient, and the health record number. The module can have other triggers that can be used to make sure that the care provider has selected the right patient. Examples of these triggers are the diagnosis of the patient at admission, name of the clinician attending to the patient, recent medications, and the gender of the patient (Silow-Carroll, Edwards, & Rodin, 2012). Furthering EBP As highlighted earlier, the hospital has embraced innovations in EHR system to streamline and improve provision of health care services. More effective and efficient guidelines have been embedded in the EMR software. Existing literature suggests that there concerns over the possibility of using the guideline recommendations as “cookbook medicine” (Silow-Carroll, Edwards, & Rodin, 2012). To avoid such situations, the hospital can allow the order sets to be modified. For instance, the medication ordering process can be guided with questions and prompts to assist health care practitioners in selecting the right drug or treatment regimen for a the right patient. Pharmacists can identify those patients whose care is does not meet certain standards, and reach out to the clinicians to find out why. The hospital can also integrate automated alerts with the EMR system to alert clinicians when they administer medication or treatment that conflicts with evidence-based practice. The alerts should also have the capability to notify physicians when they fail to administer the right care. However, the alerts should be designed carefully to avoid interrupting the care process. Such approaches would assist the hospital in meeting its quality goals. References Eclipsys. (2016). Home | eclipsys.com. Retrieved from http://www.eclipsys.com/ Edwards, J. N., Silow-Carroll, S.,& Lashbrook, A. (2011). Achieving efficiency: Lessons from four top-performing hospitals. Commonwealth Fund. Jones, E., & Blavin, F. (2013). Lessons from the Literature on Electronic Health Record Implementation. Retrieved from: http://healthitgov-stage.ahrqstg.org/sites/default/files/hit_lessons_learned_lit_review_final_08-01-2013.pdf King, J., Patel, V., Jamoom, E. W., & Furukawa, M. F. (2014). Clinical benefits of electronic health record use: national findings. Health services research, 49(1pt2), 392-404. Kopala, B., & Mitchell, M. E. (2011). Use of digital health records raises ethics concerns. JONA'S healthcare law, ethics and regulation, 13(3), 84-89. Lau, F., Price, M., Boyd, J., Partridge, C., Bell, H., & Raworth, R. (2012). Impact of electronic medical record on physician practice in office settings: a systematic review. BMC medical informatics and decision making, 12(1), 1. Silow-Carroll, S., Edwards, J. N., & Rodin, D. (2012). Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Commonwealth Fund pub. Sittig, D. F., & Singh, H. (2011). Legal, ethical, and financial dilemmas in electronic health record adoption and use. Pediatrics, 127(4), e1042-e1047. Read More