Abstract The healthcare industry is one of the few industries today that is still paper-based.

Within recent years there has been a widespread computerization in healthcare. Computerization and technology is proven to lessen the margin of error in healthcare and overall improve patient care. Even though computerization improves patient care and decreases medication errors, healthcare is still plagued by fragmentation, insufficient care coordination. This paper examines the solution of computerization and care coordination, by discusses the implementation of an electronic medical record. If patient medical records were on a universal network accessible to sanctioned practitioners there would be an improvement of patient and the fragmentation in healthcare would be remedied. Despite the apparent positives to an electronic health record, there are some counter arguments to its adoption. Issues such as HIPPA violations and costs plague EMRs. The estimated costs of EMR adoption could run physicians $16,000 to $36,000 per physician, which is an expense that not all physicians might be willing to pay (Wang, 2003). Being that physicians are a key piece to EMR adoption incentives must be put into place to dampen the expenses. The security issues with an EMR could be remedied by the creation of a monitoring/troubleshooting center.

Introduction Improvement of patient care should always be the prime priority regardless of where in the healthcare system a provider lies. A bastion of medication errors occur in the pharmacy due to the hands-on nature of the workload. Pharmacy computer software help keep things organized

by arranging and holding various patient files, and keeping the inventory of the pharmacy. Computers help the pharmacist fill prescriptions quicker, and also they help keep patient profiles organized and readily accessible. The advantages of computers are countless, but the benefits of pharmacy computer software may be hindered due to the plethora of different pharmacy computer software on the market. Each big chain, independent, and hospital pharmacy has their own software in which the pharmacist and technicians need to learn. Idealistically one universal health system is a stretch; the first step towards this goal is to transition the largely paper-based healthcare industry onto an electronic medical record. It is unusual that in the technological age we live in today, where nearly almost all aspects of our lives is influenced by technology, that health-care remains one of the few remaining paper based industry. Would it not be easier and more productive to have a widely used electronic medical record or system that an aspiring healthcare professional could learn before even entering the job force? On the surface it seems the introduction of electronic health records would garner unanimous support, but there are opponents and various disadvantages to moving towards such a unified electronic health system.

Increased efficacy of Electronic Records over paper-based Physical space is the first major issue with paper records over electronic records. Different states have different guidelines that require healthcare offices to hold patients records for several years. This could prove troublesome to healthcare facilities due to added storage costs. In the United States there are many different providing sites such as hospitals, nursing homes, pharmacies, laboratories, physician offices, and home care agencies to name a few. Each

of these sites maintains their own patient records and medical files. For the health-care system to be truly efficient care coordination must be seamless, however paper-based records makes the transportation of medical records from provider to provider much more difficult. Handwritten paper records can sometimes be illegible to another reader which contributes to medical errors. An electronic medical record would not have that same issue due to standardization of abbreviations and terminology. The Department of Medicine at Case Western Reserve University conducted a study on 27,207 adults with diabetes at various locations. The results stated that patients that were treated at sites that utilized electronic health records received 35.1% more positive diabetes care (Cebul, 2011), this expresses the notion that electronic records in fact results in tangible improvements in patient care over paper based records. According to a composite annual review by the Annual Review non-profit scientific publisher, when physicians transferred from a paper based system to a computerized CPOE there was an approximate 70% decrease in adverse drug effects within primary care (Pham, 2012). Much like how computerized physician order entry appears central to generating benefits in hospital settings, electronic documentation by physicians and other healthcare providers appears central to creating benefits in ambulatory care settings. Based on a study performed by Health Affairs, a peer-reviewed healthcare journey, the basic use of the electronic medical records improved the legibility and accessibility of progress notes and increased the availability of electronic problem and allergy lists (Miller & Sim, 2004). According to the study prolonged usage of electronic medical records resulted in overall improved patient care (Miller & Sim, 2004).

Electronic Health Records improvement clinical outcomes Quality care can be defined as providing the patient with the appropriate services, and adequate evaluations in an effective and timely manner. Studies on electronic health records have been graded on whether or not EHRs improve on patient safety, efficacy, and efficiency of healthcare centers. EHR research has shown that the presence of electronic records correlates to improve clinical adherence to quality care standards. Researchers found that computerized physician reminders increased the use of influenza and pneumococcal vaccinations from practically 0% to 35% and 50% in hospitalized patients (Menachemi & Collum, 2011). Similar studies conducted in an outpatient setting saw an increase in flu vaccinations from 41% to 65%, and an increase in pneumococcal vaccinations from 19% to 41% (Menachemi & Collum, 2011). Research results like this hint at the fact that electronic medical records may in fact improve the quality of care in clinical settings as well as outpatient settings. Computerization in clinical settings results increased physician reminders incase the physician forgets to ask the patient certain questions. An accessible electronic patient record lets the physician past drug interactions and medical history, which results in an improved diagnosis. Redundancy is also a common aspect in health care today. In some instances redundancy is beneficial, because it results in thorough patient care by reinforcing past evaluations and tests. However redundancy can also be a negative factor due to decreasing the efficiency of health care. Efficiency is defined by avoiding the waste of resources and equipment (Cebul, 2011). Redundant diagnostic testing is a costly and wasteful aspect of health care that stymies efficiency. Researchers at New England Journal of Medicine conducted a study that showed that

the implementation of a computerized point of care system in a clinical setting resulted in 14.3% decrease in the number of diagnostic tests ordered per visit and a 12.9% decrease in diagnostic test costs per visit when using an electronic health records (with CPOE elements) (Cebul, 2011). A study, documented by the Journal of Emergency Medicine, conducted on data collected by an electronic computer system showed that patient care was improved by access to inpatient discharge summaries in 85 cases (Stair, 1998). Overall savings in tests, prescriptions, admissions, and errors were estimated at about five dollars per visit. Availability of previous laboratory results minimized the ordering of redundant studies. Computerized medical records also provided details of previous medications, treatments, and diagnosis (Stair, 1998).

Improvements on care coordination A universal electronic system could minimize the fragmentation of the health care system by improving care coordination. Universal electronic health records have the potential to organize and integrate pertinent health information for instant circulation amongst authorized health care providers involved in a patients care. CPOE and electronic health alerts can notify the practitioner on what stage a patient is in treatment, or if the patient recently checked into a hospital, allowing the provider to actively follow up with the patient. Universal electronic health records could provide every provider up to date patient information (Menachemi & Collum, 2011). Availability and accessibility of information among providers can also reduce the chance that one specialist will not know about a pertinent condition being managed by another specialist.

The risk of an adverse event is high when the continuity of care be transferred between providers is broken. If responsibility for the patient is not clearly transferred, the appropriate provider may not make decisions or receive information. In a Veterans Affairs study, an electronic medical record-based care coordination tool was associated with an increase in the accurate transfer of allergy lists (Accurate transfers went from 4.2% to 100% of the time), room numbers (Accurate relation of room numbers improved from 12.9% to 100%), and medication lists (Accuracy of transfer of medication lists improved from 14.7% to 98.5%) (Pham, 2012).

Privacy Implications of a Universal Electronic health records Privacy protection might inhibit adoption of a universal electronic record by hospitals if the benefits cannot substantially out shadow the potential for infringing on privacy protection. A study conducted on privacy protection by Amalia Miller (University of Virginia), and Catherine Tucker (Massachusetts Institute of Technology), show that privacy protection reduces the aggregate EMR adoption by hospitals by 24%. The establishment of an electronic medical record calls for an interoperable national network which raises many privacy concerns (Miller & Tucker, 2009). This is a significant barrier for the adoption of an EHR. Maintaining accountability among all the parties involved in the processing of electronic transactions including the patient, from physician office staff to the insurance companies that are involved, remains a tall order for computer informatics. What is preventing a noisy pharmacist from checking the health records of an unrelated patient out of spite? This is a counter argument made by NYU professor J.M. Appel. An electronic medical system can create security breaches that do not adhere to HIPPA regulations. (Appel, 2008) The Health Insurance Portability and

Accountability Act require certain privacy regulations when dealing with medical records that will be burdensome to implement (HITECH Act, 2013).

Uncertain financial benefits and high costs of implementation of Universal EMRs Electronic medical records would have high financial costs, a barrier to a universal EMR adoption. The financial costs are exacerbated by the uncertainty of any tangible financial benefits over time. Research shows that the upfront costs of implementing a universal EMR into the common physicians office ranged from $16,000 to $36,000 per physician (Wang, 2003). Some practices incurred additional costs by way of decrease revenue from seeing fewer patients during the universal EMR transition period. The financial benefits of transitioning to electronic medical records vary from none at all to over 20,000$ depending on the activity and infrastructure of the particular physicians office. Many studies have documented these costs in both the inpatient and outpatient settings (Wang, 2003). In a 2002 study conducted in a 280-bed acute care hospital, the projected total cost for a 7-year-long universal EMR adoption project was estimated to approximately US$19 million. In the outpatient setting, early researchers estimated an average initial cost of US$50,000 US$70,000 per physician for a three-physician office (Menachemi & Collum, 2011). Universal electronic medical records have become more ubiquitous in recent years, and therefore the initial cost of systems has decreased significantly. One industry group estimated the software services and maintenance to cost approximately US$14,000 per physician in the initial year of implementation for a six-physician practice and US$19,000 per physician at physician practice with fewer than four physicians (Menachemi & Collum, 2011).

Also being that an electronic medical record is associated with fewer redundancies, decrease medical errors, and shorter lengths of stay, it is must be noted that a given provider may avert certain billable transactions that, although excessive, may have generated reimbursements from third-party payers, especially in a fee-for-service payment system. The costs of electronic medical record adoption, implementation, and maintenance team are compounded by the fact that many financial benefits of a universal EMR generally dont accrue to the provider (who is required to make the initial investment), but rather to the financial benefits accrue to the consumers and insurance companies in the form of improved medical errors and efficiencies, which translate into reduced claims payments (Miller & Sim, 2004). The discrepancy of financial incentives for health care organizations, along with the high implementation costs of EMRs, creates an obstacle to adoption and implementation of an electronic medical record, especially for smaller practices with diminutive budgets.

Electronic medical record negative influence on workflow and data exchange Adoption of an EMR would prove to be troublesome and would also require a substantial learning curve. These complementary changes exact a great deal of time from physicians, especially health care providers in smaller settings. Studies predict that these changes to work flow and training could linger up months or even years after initial implementation of the electronic medical record (Miller & Sim, 2004). Health care providers had to patch together and deploy technical support from the various software, hardware, networking, and service vendors when technical glitches occurred. All these complementary changes stymied work flow.

There is also the issue of data exchange. A test done on early adopters of an EMR at certain health care facilities required physicians to work with their staffs to summarize and enter patient data from existing paper charts into the EMR. All physicians spent substantial time customizing their own visitor disease-specific electronic forms and documentation shortcuts to speed visit documentation. In some settings a providers notes stored in computers via dictation and transcription, and we can assume that all notes will eventually be via computer voice understanding. The difficulty lies in converting these free-text phrases into a computer understandable language (McDonald, 1997). Despite decades of investment, computers cannot accurately interpret unconstrained text, though some promising work continues. So we are left the option of the physician coding his / her own data as they enter it through selection menus and other techniques, which presents another obstacle to EMR implementation (McDonald, 1997). Adoption of an electronic medical health would not happen instantaneously and therefore the provider will be forced to switch between systems, thereby slowing workflow, requiring more time to manually enter data from external systems, and increasing physicians resistance to EMR use. Furthermore, with fewer data in the EMR, there was less opportunity for intervening electronically to improve quality, and reduced ability to perform internal analyses or to report performance externally for quality report cards or performance incentive programs (Miller & Sim, 2004).

Conclusion and possible routes of action There are several advantages and disadvantages to the implementation of an electronic medical record (EMR) in the United States. The positives of an electronic medical record accrue

to the efficiency of the healthcare system, and improved patient care. One of biggest issues with adoption of a universal EMR is the misappropriation of incentives for providers versus third party payers. A solution to this problem would be cooperation of providers with the government to mollify the initial financial burden of adopting and EMR. A step in this direction is the HITECH Act (Health Information Technology for Economic and Clinical Health) which hopes to provide financial incentives to health providers by defraying the costs associated with EMR, especially for smaller organizations that do not have access to a large budget (HITECH Act, 2013). Without ubiquitous use of EHR technologies, experts believe that much efficiency in the US health care system cannot be realized. Several risks may ensue by not pursuing EMR implementation. The technological obstacles of adopting an electronic medical record is one the barriers to universal EMR adoption. A solution to this could be a community wide data exchange center. A secure electronic exchange of clinical data among providers would help lessen the disruption from providers simultaneously switching between electronic and paper-based medical record systems. The federal government through the HITECH Act has offered $650 million USD to the establishment of a network of up to 70 computer informatics center to troubleshoot and train physicians on how to effectively utilize an electronic medical record (Miller, 2004). A major bane of the healthcare system in the United States is efficiency, and the widespread failure to computerize medical information leaves a plethora of gaps and leaves many margins of errors and redundancy. The population may benefit from new drugs and devices that depend on computerized information. Failure to computerize will lead to missed opportunities in quality care delivery and preventative services. The first step to solving this problem would be the widespread adoption of an EMR/EHR. If a majority of the top hospitals

take action and transition into an electronic health record that would be one step closer to universalizing health and improving patient care.

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