Electronic Medical Record Utilization on Improving Care, and Proposals for an Integrated Electronic Medical Record System in the

United States

Mark Dimski Soc 4353: Sociology of Medicine Dr. Diana Kendall 20 April 2011

Abstract: Electronic Medical Records (EMR) utilization has been identified as one avenue to improve healthcare in the United States. Through a literature search of several databases, studies examining the efficacy of improving care were found and reviewed. Also goals of the United States Federal governments recent pushes for forming an integrated network of EMR was evaluated and compared to existing nationwide EMR networks, and suggestions for and key implications of a successful EMR system are discussed. While many studies disagree about impact of EMR systems impacts on patient care, medical efficiency, and cost-benefits, the United States are proceeding down the path to EMRs. However an effective system would improve on current models, and allow for better health outcomes and ease of access to medical information for patients.

Introduction Electronic medical records (EMR) have become one of the hotbeds of investment, innovation, debate, and implementation over the past decade in hospitals, clinics, professional organizations, and governing bodies around the world. Electronic medical record systems (EMRs) are a system that integrated electronically originated and maintained patient-level clinical information, derived form multiple sources into one point of access, and replaces the paper record as the primary source of patient information (Kazley and Ozcan 209-216). The current interest in establishing EMRs is to determine if these networks can reduce costs, increase patient safety, increase medical staff efficiency, and allow greater portability of medical information. The system of pen and paper charts and orders that exists without EMRs is wrought with difficulties and flaws: the time requirement of manually recording information and reviewing old records to discern pertinent information, the often illegible writing on pen and paper charts, missing and lost pages and charts, difficulty (and often impossibility) of transferring paper charts to another location quickly, and the possibility of duplicate testing at different sites (Joan Solomon Zolot pp. 64+66+68-69). Also, with paper and pen charts, old treatment information is legally authorized for destruction after ten years, so valuable information previously available to a provider may become destroyed. A 2000 Institute of Medicine report estimated that medical errors annually cause 44,000 to 94,000 deaths, mainly involving prescription errors 29% of which were due to lack of patient information (Wu and Straus 26-5). It is estimated that more than $1.2 trillion healthcare dollars in the United States is wasted, about half of the total healthcare spending, much of it as a result of disorganization and lack of accurate information (Ali 8-10). Advocates for EMRs believe that by

implementing these systems, physicians will have access to much more medical history information about their patients, in a quick and searchable format. Improving Medical Care The scope of impact that EMRs have on the medical field is not easily quantifiable, and many studies disagree about whether EMRs aid in patient care, or if they actually put patients at risk. Karsh, Beasley and Hagenauer (2004) examine the perception of the quality of medical records kept by users of EMRs (Karsh, Beasley and Hagenauer 327335). This cross-sectional survey of 1482 family physicians in a Midwestern state in the US investigated a possible relationship between EMR usage with working conditions and quality of life. First, this study looked at the physicians beliefs about their own records up-to-datedness, accessibility, the record keeping systems adaptability to suit the physicians needs and the overall quality of the record keeping system, whether they used an EMRs or pen and paper charts. Then, the Karsch, Beasly, and Hagenauer inquired about the physicians sense of freedom to spend time with patients, freedom to control ones work schedule, satisfaction with ones ability to provide continuity of care, satisfaction with patient relationships, satisfaction with the ability of the primary clinical assistant to support the physician appropriately, how often the physician worked under time pressure, and to what extent the physician felt the amount of paperwork typically processed was reasonable. Third, the researchers asked about the physicians perceptions about their own quality of life, measured with a 1-5, ranging Not Satisfied to Very Satisfied, in response to their perceived: satisfaction with their work group, satisfaction with their parent organization, to what extent one is able to achieve overall professional goals within the current practice situation. And finally on 1-5, from Poor to Excellent, to the question

Given your work situation in total, how would you rate the overall quality of medical care you are able to provide?(Karsh, Beasley and Hagenauer 327-335). One hundred and forty-three physicians (23.6%) responded that they do use an EMRs at their clinic. The researchers looked for possible confounders between EMR and gender, age, minority status, and practice location, and found none. However, they did find a relationship between EMRs usage and belonging to a larger health care system or hospital that used EMR, with 26% of respondents using EMRs, while only 6.8% of respondents in independent clinics used EMR, and adjusted all of the results for this difference. What the results then found was that use of an EMRs predicted all four medical record outcome variables. However upon both univariate and multivariate analysis, EMRs usage did not predict any of the seven working condition questions. When EMRs usage was placed against the quality of life questions, EMRs users were actually found to be less satisfied with being a physician than non-EMRs users, but more likely to report being able to achieve their own professional goals. Although when adjusted for membership in a larger health care organization or any other working condition variables that were related to the outcome, there was no relation between the quality of life measures and EMR usage. In a 2005 study by Garrido et al. organizational structure changes including implementation of an EMRs showed a decrease in office rate visits at ambulatory care clinics in two markets (Garrido et al. pp. 581-584). The researchers looked at the Colorado and the Northwest regions of the Kaiser Permanente medical system. These regions separately implemented comprehensive EMRs, and Garrido et al. performed a retrospective, serial, cross-sectional study on selected measures of use and quality of ambulatory care. Previous to the EMRs, paper records were delivered to multiple sites

throughout the Kaiser Permanente system, and records for same day or unscheduled care was unreliable. While the Colorado and the Northwest regions used different systems, both EMRs had several features in common: 1. integrated documentation and reporting of clinical results reporting, including comprehensive recording of use of primary and specialty care, telephone contact, urgent care, and emergency departments 2. computerized prescription, physician orders, and test orders 3. 24 hour availability of medial records at the point of care, 4. immediate availability for all potential users for example, staff in telephone advice centers, pharmacists, and staff reporting clinical results and 5. easy search features throughout the system (Garrido et al. pp. 581-584). At the time of analysis, Colorados EMRs was only two years old, and the Northwest region had been utilizing their system for four years. However, both regions exhibited significant decreases of 9% in the total office visits, and a decrease of 11% of primary care visits, both adjusted by age, by two years after implementation. In the Northwest region, with EMRs, telephone contacts by the physician with the patient increased from 1.26 per member per year to 2.09 by year two. During the EMRs implementation in Colorado, call center staffing shifted from primarily nurses to include physicians for a brief period, and during that time, office visits after phone consultations decreased by 7%, and rose again when staffing went back to nurses. The EMRs creation decreased the office visit rates for both primary and specialty care services, partially due to the substitution for telephone consultations to traditional office visits, while quality of care measures remained stable or increased. The physicians and researchers attribute the decrease in office visits to the availability of comprehensive clinical information, so physicians were able to identify and resolve patients health issues in the first contact or with fewer contacts (Garrido et al. pp. 581-

584). However, after further analysis of quality of care measures, contrary to the perception of increasing measures, EMR did not affect the quality of care. These levels remained relatively stable, with only occasional improvements on select measures. However, from this study, the authors conclude that electronic health records and the resulting effects on usage do not reduce the quality of care and may in fact increase appropriate use of healthcare services (Garrido et al. pp. 581-584). In The Electronic Patient Record in Primary Care Regression or Progression? A Cross-Sectional Study, Hippisley-Cox et al. examine the amount and quality of medical information contained within traditional paper charts and new computerized charts (Hippisley-Cox et al. 1439-1443). Their sample pool was of 25 general practices in Trent region of England, where 53 British general practitioners, 25 using EMR and 28 using paper charts, each provided the records of ten consultations. The records from these 53 physicians were then scored using the terms legible, for records which the words or characters could be read in full, in part, or not at all by another physician, medically understandable, whether the clinical content of the record could be understood or followed in full, in part, or not at all by another physician, and medically appropriate, referring to whether the clinical decision was deemed appropriate based on the information in the record. Diagnosis, chief complaint, symptoms, family history, medical history, social history, lifestyle, patient beliefs/views, physical exam vital signs, issuance of a sick note, referrals, investigations, referrals (and their specialty), and prescription information (drug name, dose, and frequency) were all collected on each consultation, as well as the number of words, abbreviations, symbols, numbers, and values that were present in the record. All of the EMR were qualified as fully legible, whereas 6% of the paper charts were ruled as

completely illegible, and 30% as only partially legible. The EMR contained more words, abbreviations and symbols than the paper charts, but unsurprisingly the paper charts contained seven diagrams. EMR were shown to be more likely to be fully understandable (89% v 69%), contain at least one diagnosis (48% v 34%) to record that advice had been given (24% v 11%), to contain details of the specialty of a referral when made (77% v 60%), and to have drug dosage details when a prescription had been given (87% v 66%) (Hippisley-Cox et al. 1439-1443). Family history was more likely to be included in the EMR versus the paper chart, however the vast majority of both types of charts omitted family history (4% v 2%). EMR were demonstrated to be easier to understand, and contain more specific information about a consultation. Hippisley-Cox et al. concluded that there is likely then no detriment to continuity of care as a result of the usage of EMRs in general practice. Existing Integrated EMR Systems Integrated EMRs is a system of electronic medical records that is maintained by the central government and has the capability of being accessed nationally. There have been several attempts by other developed nations to establish an integrated EMR network. Norway is an example of a country that is struggling with their integrated EMRs, whereas Denmark is the gold standard for integrated EMR. Lrum, Ellingsen, and Faxvaag performed a cross-sectional survey of Doctors usage of EMR in three of the largest hospitals in Norway (Lrum, Ellingsen and Faxvaag pp. 1344-1348). By January 2001, 53 of the 72 hospitals in Norway have purchased licenses for EMR software, representing 77% of all hospital beds in Norway. However, none of the largest hospitals had completed their implementation of EMRs in all

departments. The authors developed a questionnaire of twenty-three clinical tasks that could be accomplished on EMRs, asking physicians how often they utilized the EMRs to accomplish the tasks. These ranged from reviewing patient problems, to ordering x-rays, to writing prescriptions and sick leave notes. There are three main EMRs in use in Norway, DocuLive, DIPS, and Infomedix. None of these systems are capable of performing all twenty-three clinical tasks, DocuLive, the system in the five largest hospitals, supports only eleven tasks, while Infomedix and DIPS support sixteen and nineteen tasks, respectively. Only two tasks, reviewing a patients problems and seeking out specific information from patient records, were performed with the EMRs by at least half of the respondents. On user satisfaction data, based on content, accuracy, format, ease of use, and timeliness, none of the systems were well rated, with DocuLive receiving the worst rating, a 61.4. Norwegian physicians mainly used the EMRs for reading patient data, and doctor used the systems for less than half of the tasks that the systems were functional. Some of the most underutilized functions were repetitive tasks such as writing prescriptions and sick leave notes. Some of the barriers to the full utilization of EMRs in these hospitals include the concurrent operation of a paper system. Physicians can choose whether to use the EMRs or paper charts. The DocuLive system was mainly used solely for checking and signing medical records, which could be explained by the lack of integration with other components in hospital departments. DocuLive is in the largest hospitals, and thus the infrastructure of the hospital is more complex, and more likely to be fragmented. Denmark is a success story of EMRs implementation. 98% of primary care physicians, all hospital physicians, and all pharmacists are part of the integrated EMRs (Harrell, Crumley and Kirchner 36-39). This EMRs also has a web-based component,

where patients can actually have access to their health records with detailed records back to 2000 and basic records back to 1977. The system also alerts the patient by email if a doctor, pharmacist or nurse views their records, and allows patients to make appointments, make end-of-life decisions, and even email their physician for advice for an illness not requiring an appointment. The implementation of the Danish integrated EMRs was not a seamless transition however; there was an early system established in 1999 of a common coding system that required physicians and health care providers to input all information in alphanumeric form. However, by 2006, the system had been discarded after complaints from physicians and nurses. Now, instead of a single record keeping system, there are multiple systems, which are all inter-compatible, and linked by regional health agencies. HER adoption must be done by evolution rather than revolution, says Jens Andersen of sunded.dk, the state run web portal. You have to work with the systems already in place (Harrell, Crumley and Kirchner 36-39). While Denmarks system has achieved many goals, it does not mean that this system could directly cross over to a United States system, Denmark only has a population of 5 million people, roughly the population of Chicago, Illinois and Houston, Texas, and these 5 million people are well educated, and technology savvy. Secondly, the citizens have high trust in the government, and, most importantly, the entire healthcare system is public run. Denmark also has had a long-term history with centralized medical information centralization; in 1977 the countrys health service began a patient registry, where physicians were required to file information about each visit with the government health service in order to be reimbursed. The EMRs in Denmark has greatly improved efficiency, saving physicians an average of 50 minutes a day on administrative work.

An American Integrated EMR System Several medical systems in the United States have already instituted EMRs that comply with these federal guidelines: Kaiser Permanente (Scott et al. pp. 1313-1316), The Veterans Administration (VA)(Ali 8-10), and members of The Premier Health Care Alliance (DeVore and Figlioli 664). In 1999, Kaiser Permanente (Kaiser), the largest non-profit healthcare system in the United States, began looking at two different EMRs: EpiCare and Clinical Information System (CIS). CIS was a joint project between Kaiser and IBM computers, and was eventually selected as the software to be rolled out in October 2000. However, due to problems with the software, the rollout did not begin until October 2001. However by 2003, Kaiser decided that CIS did not meet their needs, and halted the nationwide implementation of CIS and began the process to utilize EpiCare. Scott, Rundall, Voight, and Hsu conducted a qualitative study on the implementation of EMRs in Kaisers Hawaii region (Scott et al. pp. 1313-1316). The authors interviewed twenty-six senior clinicians, managers, and project team members about their attitudes on the implementation processes of EMR systems, and the brief, twenty-eight month, use of CIS. At the time of the 2003 announced switch from CIS to EpiCare, a third of Kaisers Hawaiian sites had fully implemented CIS, and the rest had read-only access, some with order entry functionality. The authors focused on four themes that came up in the interviews: Critical processes in the implementation of CIS, Roles played by organizational leadership during implementation, Organizational culture changes, and Conflict over the selection and implementation process. From these themes, seven key findings were identified: 1. Users believed that the CIS selection was not made with the local environment (the clinics and

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hospitals) in mind, instead it was made by some corporate head thinking of profits. 2. Software design and development issues increased local resistance 3. CIS reduced clinicians productivity 4. CIS initially clarified job roles and then changed roles and responsibilities 5. Culture had varying effects: corporate values minimized resistance to change early on but also inhibited feedback during implementation 6. Leadership had varying effects: participatory leadership was valued for selection decision, but hierarchical leadership was valued for implementation. 7. An overall effect was a counter-climate of conflict in the company, which the withdrawal of CIS resolved (Scott et al. pp. 1313-1316). Scott et al. drew several conclusions from these findings that could be applied to other organizations implementing EMRs, that a participatory, grassroots process in selection and fine tuning of the EMR software is important, considering local needs. While a corporate culture of support for the EMR implementation is important, there must also be a channel for feedback and criticism of the EMRs. Creating this culture requires different styles of leadership at different times: participatory leadership at selection, but decisive hierarchical leadership during the implementation. Clear regular communication from the top levels of management is important to drive the adoption of the new system and workflows, however there should also be horizontal communication from clinical champions physicians, nurses, and other providers and involve these team members in the process of design, implementation, and improvement (DeVore and Figlioli 664). Implementing a EMRs represents a sweeping change away from business as usual to an entirely new approach in health care one that will require process and behavior changes from nearly all health care workers (DeVore and Figlioli 664). In 1995 the VA, launched a major re-engineering of its healthcare system that

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included better use of information technology, measurement and reporting of performance, integration of services, and realigned payment policies(Ali 8-10). This restructuring resulted in 1999 with the VA Computerized Patient Record System (CPRS) being implemented nationwide. The CPRS allows clinicians nationwide to log into a secure network and access complete patient records from inpatient visits, specialty consults, primary care and emergency room visits, laboratory results, radiology reports, medication history since the 1980s, surgical notes, and discharge summaries. This creates a single EMR, which every physician that interacts with the patient uses to manage the patients care. This allows communication among care providers, makes data collection more efficient, and because of the digital format, removes the possibility of illegible handwriting. The CPRS can provide the physician with clinical guidelines, patient data, clinical reminders, and makes relevant information accessible in real time. The system keeps track of when veterans are due for preventative care, as well as tracking their history. It alerts providers when a patient is due for vaccinations, diagnostic screenings, or laboratory tests. In 2000, the quality of care provided by Veterans Health Administration was measured, and compared to 1994 (pre-restructuring) levels, the quality of care had greatly improved in every measured area. In fact, compared to quality of care data from Medicares fee-forservice program, from 1997 to 1999 the VA was significantly better Medicare on all eleven similar health quality indicators. In 2000, the VA outperformed Medicare on 12 of 13 indicators, and other health systems in the community on standard measures of health care quality (Ali 8-10). The EMR has supported this performance improvement throughout the system. Two strategies tied across all performance indicators and impacted patient care most were clinical reminders and computer based standing orders. Which are proven

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interventions to enhance preventative care like immunizations and cancer screenings. By re-engineering the way the VA System practiced medicine, and implementing an system wide EMR network, they drastically improved the quality of care provided to veterans. The Institute of Medicine now recommends many of the principles adopted by the VA in order to improve quality of care, especially emphasis on use of health information technology and performance measurement and reporting. With the passage of the new American Recovery and Reinvestment Act (ARRA), and the Health Information Technology and Clinical Health Act (HITECH Act) began a federally funded push for adoption of EMRs in hospitals and clinics across America. Since January 2011, physicians who begin to implement and have meaningful use of certified EMRs are eligible for up to $44,000 in bonus payments over the years 2011-2014 (JONES and KESSLER 39-68). In order for a physician to qualify for meaningful use they must meet three criteria, which stem from the VAs system: 1. Be able and utilize electronic prescriptions 2. Use a certified EMRs with the ability to exchange health information with other healthcare providers and hospitals. 3. Provide statistical data on quality of care to the government. The Certification Commission for Healthcare Information Technology is responsible for EMR management software certification. In order for an EMRs to be certified it must include patient demographic and clinical health information, have clinical decision-making support built in that includes physician order capture, and be able to exchange information with, and integrate into itself from, other sources. Strategy for a Successful Integrated EMR System in the Untied States From the experiences from closed networks, like Kaiser and the VA, and foreign nations, there is a plan to create a meaningful, effective integrated EMR system in the

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United States. However, there are obstacles that must be overcome. Both healthcare workers and the public have different hesitations about the creation of an American integrated EMRs. Bronstra and Broekhuis identify eight key barriers to the acceptance of EMR by physicians: Financial, Technical, Time, Psychological, Social, Legal, Organizational and Change Process (Boonstra and Broekhuis 231-247). An EMRs is an investment, and many times physicians are unable to see past the costs of implementing a system. There are high start up costs, high ongoing costs to maintain the EMRs, uncertainty of return on investment, and lack of financial resources. However, with the new federal incentives to implement EMRs, much of the costs can be repaid back from the Federal Government. Technical concerns include lack of computer skills, lack of technical training and support, complexity of use of the system, limitations of the system, lack of customizability, lack of reliability, interconnectivity and standardization, and lack of computers and hardware. Time to select, purchase, learn, set up, and implement systems often deters potential EMR users, along with fear of loss of efficiency. Psychological barriers include lack of faith in EMR, and a need for control. Social barriers include uncertainty of the EMR software vendor, lack of support from external parties, interference with the doctor-patient relationship, lack of support from colleagues, and lack of support from management. Legal barriers consist of privacy or security concerns. Patients have trusted their physician with confidential information, and the physician could be held legally liable for a breach of information. Organizational barriers include organization size, and organization type. Finally the change process is the final barrier. The process be deterred by lack of support from the organizational culture, lack of incentives, lack of participation, and lack of leadership. The two types barriers that pose the greatest obstacles

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are the organizational and change process barriers. Organizational category barriers determine the relative importance of the other barriers even before implementation has started, as characteristics of a practice can affect the height of certain barriers. Barriers in the change process category can mediate other identified barriers during the implementation process by restricting the ability to overcome them and achieve successful EMR adoption. Dixon proposes a roadmap to EMR adoption; first there must be a foundation, a strong business case for providing evidence for justification of investing money in EMR technology (Dixon pp. 3-13). Then there are three parallel avenues that must be developed: Best Practices, Workforce Development, and Sustainability. Sharing best practices represents a constant commitment to providing quality care, and constantly looking for opportunities for improvement. It is imperative to develop a skilled workforce, who is able to use the EMRs technology to deliver quality, safe, and effective care. Finally, the growth and use of EMR technology relies on the sustainability of the momentum and adaptability of EMR technology. Then and only then, will there be widespread adoption and use. Dixon models this roadmap into a house: the foundation is the business case, best practices and workforce development are three pillars, supporting the roof of widespread EMR use and adoption. Currently, the role of the medical profession is changing. Physicians are becoming interconnected, no longer operating as a single practitioner with a patient. By utilizing EMR technologies, and helping create a integrated EMRs in the United States, physicians can better help their patients, by helping ensure a safe, ever improving, and efficient medical system.

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Works Cited Ali, Tanya. "Electronic Medical Record and Quality of Patient Care in the VA." Medicine & Health Rhode Island 93.1 (2010): 8-10. Web. Boonstra, Albert, and Manda Broekhuis. "Barriers to the Acceptance of Electronic Medical Records by Physicians from Systematic Review to Taxonomy and Interventions." BMC Health Services Research 10 (2010): 231-47. Web. DeVore, S. D., and K. Figlioli. "Lessons Premier Hospitals Learned about Implementing Electronic Health Records." Health affairs 29.4 (2010): 664. Web. Dixon, Brian E. "A Roadmap for the Adoption of e-Health." e-Service Journal 5.3, Special Issue: Practices and Outcomes in e-Health (2007): pp. 3-13. Web. Garrido, Terhilda, et al. "Effect of Electronic Health Records in Ambulatory Care: Retrospective, Serial, Cross Sectional Study." BMJ: British Medical Journal 330.7491 (2005): pp. 581-584. Web. Harrell, Eben, Bruce Crumley, and Stephanie Kirchner. "Health Lessons from Europe." Time International (Atlantic Edition) 173.22 (2009): 36-9. Web. Hippisley-Cox, J., et al. "The Electronic Patient Record in Primary Care--Regression Or Progression? A Cross Sectional Study." BMJ (Clinical research ed.) 326.7404 (2003): 1439-43. Web. Joan Solomon Zolot. "Computer-Based Patient Records." The American Journal of Nursing 99.12 (1999): pp. 64+66+68-69. Web. JONES, D. SCOTT, and HOWARD B. KESSLER. "Can Electronic Medical Records really Improve Quality? the Obama Administration Bets Yes." Journal of Health Care Compliance 12.1 (2010): 39-68. Web.

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Karsh, Ben-Tzion, John W. Beasley, and Mary Ellen Hagenauer. "Are Electronic Medical Records Associated with Improved Perceptions of the Quality of Medical Records, Working Conditions, Or Quality of Working Life?" Behaviour & Information Technology 23.5 (2004): 327-35. Web. Kazley, Abby Swanson, and Yasar A. Ozcan. "Electronic Medical Record use and Efficiency: A DEA and Windows Analysis of Hospitals." Socio-economic planning sciences 43.3 (2009): 209-16. Web. Lrum, Hallvard, Gunnar Ellingsen, and Arild Faxvaag. "Doctors' use of Electronic Medical Records Systems in Hospitals: Cross Sectional Survey." BMJ: British Medical Journal 323.7325 (2001): pp. 1344-1348. Web. Scott, J. Tim, et al. "Kaiser Permanente's Experience of Implementing an Electronic Medical Record: A Qualitative Study." BMJ: British Medical Journal 331.7528 (2005): pp. 1313-1316. Web. Wu, Robert C., and Sharon E. Straus. "Evidence for Handheld Electronic Medical Records in Improving Care: A Systematic Review." BMC Medical Informatics & Decision Making 6 (2006): 26-5. Web.

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