Electronic medical record

An electronic medical record (EMR) is a medical record in digital format.

In health informatics an EMR is considered by some to be one of several types of EHR (electronic health record)s, but in general usage EMR and EHR are synonymous.

Definition

The term has sometimes included other (HIT, or Health Information Technology) systems which keep track of medical information, such as the practice management system which supports the electronic medical record.

Issues

As of 2006, adoption of EMRs and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States. Less than 10% of American hospitals have implemented health information technology, while a mere 16% of primary care physicians use EHRs. The vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s. The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%. The following issues are behind the slow rate of adoption:

Burnout among healthcare workforce due to EHRs

Whie in general, EHRs are concerns for causing burnout, when EHR are optimized they may improve the well-being of the healthcare workforce in a systematic review that cited two examples with one more recent example.

The American Academy of Family Physicians (AAFP) has sponsored proposed changes for improving EHRs in small practices.

Documentation burden

This has been addressed and best practices described by the 25x5 Symposium The goal of the 25x5 is to reduce the documentation burden on U.S. physicians byo 75% by the year 2025.

The American Nursing Informatics Association (ANIA) has created Six Domains of Documentation Burden:

Domain	Definition
Reimbursement	Documentation, coding and administrative charting required for reimbursement, by payors such as: CMS, Blue Cross/Blue Shield, United Healthcare, Aetna, Anthem, Cigna, Humana.
Regulatory	Accreditation agency documentation requirements such as: The Joint Commission, Healthcare Facilities Accreditation Program and State Regulatory Agencies.
Quality	Documentation required to demonstrate that quality patient care has been provided. This includes documentation requirements by the healthcare organization itself, as well as by governmental and regulatory agencies.
Usability	Insufficient use of human factors engineering and human-computer interface principles. EHRs are not following evidence-based usability/human factors design principles.
Interoperability	Insufficient standards requiring duplication and re-entry of data even though it resides elsewhere, either internal to the organization or in an external system.
Self-Imposed: “We’ve done it to ourselves”	Organizational culture’s influence on what should be documented can exceed what is needed for patient care, including fear of litigation, ‘we’ve always done it this way,’ and misinterpretation of regulatory standards. Includes insufficient education on system use.

Scribes

Human scrivbes have been proposed to reduce the burden of documentation. Scribes may contribute to "note bloat".

Note format

Alternatives' to the traditional SOAP format include:

• APSO (Assessment, Plan, Subjective, Objective) was recommended by the Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation

• ESOAP (Events, Assessment, Plan, Subjective, Objective)
• SOAPS (Assessment, Plan, Subjective, Objective, Safety)

The 'Subjective" component of the note has been criticized for unnecessary length due to each notes HPI copying forward the last HPI and appending with new events.

Interoperability

In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged.

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[2] Without interoperable EMRs, practicing physicians, pharmacies and hospitals cannot share patient information, which is necessary for timely, patient-centered and portable care. There are currently multiple competing vendors of EHR systems, each selling a software suite that in many cases is not compatible with those of their competitors. Only counting the outpatient vendors, there are more than 25 major brands currently on the market. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. Congress is currently working on legislation to increase funding to these and similar programs.

The Center for Information Technology Leadership described four different categories (“levels”) of data structuring at which health care data exchange can take place. While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are:

Level	Data Type	Example
1	Non-electronic data	Paper, mail, and phone call.
2	Machine transportable data	Fax, email, and unindexed documents.
3	Machine organizable data (structured messages, unstructured content)	HL7 messages and indexed (labeled) documents, images, and objects.
4	Machine interpretable data (structured messages, standardized content)	Automated transfer from an external lab of coded results into a provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.

Usability

EHR companies have a range from well-developed to basic UCD to misconceptions of user-centered design processes (UCD)

EHRs are sometimes associated with *reduced* clinical outcomes:

• After a new EHR is implemented

• Before a new EHR has matured
• Variable quality of EHR brands

Hospital computerized physician order entry (CPOE) may induce errors by

• Preventing a coherent view of patients' medications
• Inflexible ordering formats generating wrong orders

Social and organizational barriers

According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EMR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, dealing with physicians' resistance to change (or, alternatively, software engineers' evolving research in deep modeling of the physician's knowledge and workflow domains), and creating a collaborative environment that fosters communication between physicians and information technology project managers. A framework for barriers and solutions to social issues has been proposed.

Exemplifying these needs are several highly publicized HIT implementation fiascos, including one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system. There are, however, several successful examples of EMR implementations in large hospitals. The Animal Medical Center (AMC) has successfully implemented a veterinary EMR solution developed by CureMD Corporationof [New York].

Governance

Arrangements for governance have been addressed.

Technology limitations

Limitations in software, hardware and networking technologies has made EMR difficult to affordably implement in small, budget conscious, multiple location healthcare organizations. Until recently most EMR systems were developed using older programming languages such as Visual Basic and C++; however with many systems now being developed using Microsoft .NET Framework and Java technology EMRs can be securely implemented across multiple locations with greater performance and interoperability. Prior to the recent introduction of IEEE 802.11 g and n wireless technology access to large files such as MRI and X-Ray images was slow. With these new wireless technologies data can be securely transferred at speeds of up to 108 Mbit/s, across extended distances and in older buildings built with brick or concrete walls. Tablet PC technology has significantly improved over the recent years with the introduction of Windows XP Tablet PC Edition, Li-Ion/polymer batteries for battery life of up to 8 hours, biometric security, low-voltage processors and lighter weight solutions.

Older record incorporation

To attain the wide accessibility, efficiency, patient safety and cost savings promised by EMR, older paper medical records ideally should be incorporated into the patient's record. The digital scanning process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by different healthcare professionals over the life span of the patient, some of the content is illegible following conversion. The material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. In addition, the destruction of original healthcare records must be done in a way that ensures that they are completely and confidentially destroyed. Results of scanned records are not always usable; medical surveys found that 22-25% of physicians are much less satisfied with the use of scanned document images than that of regular electronic data.

Privacy

A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA 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 600,000 payers, providers and other entities that handle providers' billing data have some access. Multiple access points over an open network like the internet increases possible patient data interception. 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. 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. The organizations and individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. The growth of EHR creates new issues, since electronic data may be physically much more difficult to secure, as lapses in data security are increasingly being reported. Information security practices have been established for computer networks, but technologies like wireless computer networks offer new challenges as well.

Preservation

Under data protection legislation and the law generally 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, owns the information contained within the record and has a right to view the originals, and to obtain copies under law. Additionally, those responsible for the management of the EMR are responsible to see the hardware, software and media used to manage the information remain usable and not degraded. This requires backup of the data and protection being provided to copies. It will also require the planned periodic migration of information to address concerns of media degradation from use.

Problem lists

Culture can help improve problem list maintenance.

Most items are generator by primary care physicians.

Based on an earlier trial, a trial to study the role of problem lists to improve care foudn that intervetions could improve the quality of problem lists, but not the quality of care.

Problem Oriented View

A "problem-oriented view on clinical data" may help.

A demonstration of the POV is online at http://povuw.com/.

Legal status

Medical records, such as physician orders, exam and test reports are legal documents, which must be kept in unaltered form and authenticated by the creator.

• Digital signatures Most national and international standards accept electronic signatures. According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer." With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will continue to be prudent when using EMR.
• Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006, national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM).

Standards

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

• ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate enities.
• ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
• CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
• CEN - EHRcom (EN 13606), the European standard for the communication of information from EHR systems.
• CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• DICOM - a heavily used standard for representing and communicating radiology images and reporting
• HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
• ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
• openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.

Various factors involving the timing, the right players, market history, utility, governance play a key role in the overall enrichment of the standard and certification development. The standardization and certification even though seem to bring uniformity in the EMR development, do not guarantee their acceptability and sustainability in the long run. In 2005 the US Federal Government awarded a contract to CCHIT - Certification Commission for Healthcare Information Technology to develop certification criteria for EMR. Starting in early 2007 vendors began to utilize these certification criteria for their EMR systems.

Public implementations

As of 2005, one of the largest projects for a national EMR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic medical record by 2010.

The Canadian province of Alberta's Alberta Netcare project is a large-scale operational Electronic Health Record (EHR)system.

File:EHRadoption.gif

US medical groups' adoption of EHR (2005)

Adoption of electronic medical records by US doctors is slowly increasing. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially electronic medical record systems (EMR) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey. However, the survey also states that just 9.3% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. Barriers to adopting an EMR system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options. Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. On July 18 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products. and then on July 31 2006, additionally announced that two further EMR and EHR products had achieved certification.

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows healthcare providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests.

Monitoring quality

Surveys of users have been developed.

The AMA StepsForwards survey includes questions:

• "My proficiency with EHR use is:"
• "The amount of time I spend on the electronic health record (EHR) at home is"
• "Sufficiency of time for documentation is"

The proposed HealthIT.gov EHR Reporting Program, "Voluntary User-Reported Criteria Questionnaire" prepared by the Urban Institute contains:

2. "How would you rate your overall satisfaction with [autofill product name based on Q1]?"
3. "How likely is it that you would recommend [autofill product name based on Q1] to a colleague in a setting similar to yours?"
4. "Indicate your satisfaction with the ability to access, exchange, and use electronic health information with the following exchange partners using [autofill product name based on Q1]."
5. "How would you rate the overall usability of [autofill product name based on Q1]?"

• • "Integrates with practice workflow"
  • "Allows users to document patient care efficiently"
  • "Enables clinicians to efficiently deliver high-quality care"
  • "Supports clinician interaction with patients"
  • "Protects patient information confidentiality effectively"
  • "Saves users time, overall"
  • "Has advantages that outweigh its disadvantages, overall"

Another tool is teh System Usability Scale form usability.gov

See also

• Continuity of Care Record
• Electronic health record
• European Institute for Health Records (EuroRec)
• MUMPS
• Veterans Health Information Systems and Technology Architecture (VistA)

External links

• Active Semantic Documents project (LSDIS, University of Georgia)]
• OpenClinical - Electronic Medical Records
• US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC)
• US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology
• The ICMCC portal on access to electronic medical records. The portal includes a blog to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature.