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Electronic Medical Records

Electronic Medical Records, Electronic Health Records ...
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Paper-based records have been in existence for centuries* and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems. Computerised information systems have not achieved the same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail industries. Further, deployment has varied greatly from country to country and from speciality to specialty and in may cases has revolved around local systems designed for local use. National penetration of EMRs may have reached over 90% in primary care practices in Norway, Sweden and Denmark (2003), but has been limited to 17% of physician office practices in the USA (2001-2003) [HHS, 2005]. Those EMR systems that have been implemented however have been used mainly for administrative rather than clinical purposes.

Electronic medical record systems lie at the center of any computerised health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless, interoperable, multi-provider, multi-specialty, multi-discipline computerised medical record, which has been a goal for many researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in many western countries.

Over the past decade, the political impetus for change in almost all western countries has become stronger and stronger. Incontrovertible evidence has increasingly shown that current systems are not delivering sufficiently safe, high quality, efficient and cost effective healthcare (see Public Reports section on OpenClinical), and that computerisation, with the EMR at the centre, is effectively the only way forward. As Tony Abott (Australian Minister for Heath and Ageing) said in August 2005: "Better use of IT is no panacea, but there's scarcely a problem in the health system it can't improve". For the first time, the responses have been national and co-ordinated. Governments in Australia, Canada, Denmark, Finland, France, New Zealand, the UK, the USA and other countries have announced - and are implementing - plans to build integrated computer-based national healthcare infrastructures based around the deployment of interoperable electronic medical record systems. And many of these countries aim to have EMR systems deployed for their populations within the next 10 years.


(* See Coiera's chapter on the EMR for a discussion and comparison of paper-based and electronic records which highlights the effectiveness of modern paper-based records for certain tasks.)

Terms used in the field include electronic medical record (EMR), electronic patient record (EPR), electronic health record (EHR), computer-based patient record (CPR) etc. These terms can be used interchangeably or generically but some specific differences have been identified. For example, an Electronic Patient Record has been defined as encapsulating a record of care provided by a single site, in contrast to an Electronic Health Record which provides a longitudinal record of a patient’s care carried out across different institutions and sectors. But such differentiations are not consistently observed.

C. Peter Waegemann in his Medical Record Institute EHR Status Report provides, within a historical context, a summary of the different functions and visions implied by the various terms used to refer to EMRs.


The 2003 IOM Patient Safety Report describes an EMR as encompassing :

  1. "a longitudinal collection of electronic health information for and about persons
  2. [immediate] electronic access to person- and population-level information by authorized users;
  3. provision of knowledge and decision-support sysems [that enhance the quality, safety, and efficiency of patient care] and
  4. support for efficient processes for health care delivery." [IOM, 2003, P4 (footnote)]

The 1997 Institute of Medicine report: The Computer-Based Patient Record: An Essential Technology for Health Care, provides the following more extensive definition:

"A patient record system is a type of clinical information system, which is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems)." [IOM, 1997]

The HIMSS EHR definitional model document [HIMSS, 2003] includes "a working definition of an EHR, attributes, key requirements to meet attributes, and measures or "evidence" to assess the degree to which essential requirements have been met once EHR is implemented".

Key Capabilities of an Electronic Health Record System

Linda Kloss, executive vice president and CEO of the American Health Information Management Association (AHIMA), defines the three essential capabilities of an electronic health record as follows:

  • To capture data at the point of care
  • To integrate data from multiple internal and external sources
  • To support caregiver decision making.
  • spacer

    The US IOM report, Key Capabilities of an Electronic Health Record System [Tang, 2003], identified a set of 8 core care delivery functions that electronic health records systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery:

    "The eight core capabilities that EHRs should possess are:

    • Health information and data. Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner.
    • Result management. The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase patient safety and the effectiveness of care.
    • Order management. The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed.
    • Decision support. Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments.
    • Electronic communication and connectivity. Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
    • Patient support. Tools that give patients access to their health records, provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes.
    • Administrative processes. Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide more timely service to patients.
    • Reporting. Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease surveillance."


    The report also specified how some of its conclusions and recommendations were to be implemented: "This list of key capabilities will be used by Health Level Seven (HL7) ... to devise a common industry standard for EHR functionality that will guide the efforts of software developers...".

    Note: The above report forms a part of a public and private collaborative effort in the USA to advance the adoption of EHR systems. It was sponsored by the U.S. Department of Health and Human Services and formed part of the third phase of the IOM’s Quality Initiative, started in 1996.)

    benefits of EMRs

    • Replace paper-based medical records which can be incomplete, fragmented (different parts in different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up to date, accurate, rapidly retrieveable source of information, potentially available anywhere at any time. Require less space and administrative resources.
    • Potential for automating, structuring and streamlining clinical workflow.
    • Provide integrated support for a wide range of discrete care activities including decision support, monitoring, electronic prescribing, electronic referrals radiology, laboratory ordering and results display.
    • Maintain a data and information trail that can be readily analysed for medical audit, research and quality assurance, epidemiological monitoring, disease surveillance ....
    • Support for continuing medical education.
    Widespread implementation of EMRs has been hampered by many perceived barriers including:
    • Technical matters (uncertain quality, functionality, ease of use, lack of integration with other applications,
    • Financial matters - particularly applicable to non-publicly funded health service systems (initial costs for hardware and software, maintenance, upgrades, replacement, ROI ...)
    • Resources issues, training and re-training; resistance by potential users; implied changes in working practices.
    • Certification, security, ethical matters; privacy and confidentiality issues
    • Doubts on clinical usefulness
    • Incompatibility between systems (user interface, system architecture and functionality can vary significantly between suppliers' products).

  • Integrated systems require consistent use of standards in e.g. medical terminologies and high quality data to support information sharing across wide networks
  • Ethical, legal and technical issues linked to accuracy, security confidentiality and access rights are set to increase as national EMR systems come online. These issues become more pressing with the current movement to promoting consumer empowerment and information ownership, championed by the European Commission for example, which is leading towards patient records accessible by patients (Personal Health Records).
  • Common record architectures, structures
  • Clinical information standards and communications protocols
  • Security and confidentiality of information
  • Patient data quality; data sets, data dictionaries.
  • interoperability
    Interoperability aims to support :
    • Data transfer and sharing on much more than a local or enterprise-wide scale
    • Knowledge transfer and integration
    • Medical terminology transfer, mapping and integration
    • Image transfer
    • Integration with clinical and non-clinical applications
    Walker et al 2005 define four levels for interoperability between health information systems:
    • Level 1: Non-electronic data (eg mail, telephone)
    • Level 2: Machine-transportable data (eg faxed or scanned documents)
    • Level 3: Machine-organisable data (eg e-mail, proprietary file formats)
    • Level 4: Machine-interpretable data (eg structured data within standardised messages).

    The US National Committee on Vital and Health Statistics describes three levels of interoperability:

    • Basic interoperability—allowing a message from one computer to be received by another, but not requiring the receiving computer to be able to interpret the data.
    • Functional interoperability—an intermediate level defining the format of messages. This ensures messages between computers can be interpreted at the level of data fields, so that data can pass from a structured field in one system to a comparably structured field in another. Neither system, however, has understanding of the meaning of the data within the field(s).
    • Semantic interoperability—provides common interpretability, that is, information within the data fields can be used intelligently.
    National Committee on Vital and Health Statistics, Uniform Data Standards for Patient Medical Record Information: Report to the Secretary of the US Department of Health and Human Services. US Department of Health and Human Services, July 2000.

    EMR / EHR-related standards and work in progress
    ISO 18308 Clinical and technical requirements for an Electronic Health Record Reference Architecture "that supports using, sharing, and exchanging electronic health records across different health sectors, different countries, and different models of healthcare delivery". (2004)
    ASTM Committee E31.19 Standards on Electronic Health Record Content and Structure
    CEN 13606 The European electronic healthcare record interoperability standard (2004). Includes: EHR reference model, archetype interchange specification, reference archetypes and term lists, security functions, exchange models to support communication.
    HL7 v3 Messaging standard to support communications "between hospital and physician record systems and between EMR systems and practice management systems" (2003).
    HL7 Clinical Document Architecture (CDA) [OC] An XML-based generic model for the representation and transfer of clinical documents.

    "CDA is being used also in electronic health records projects to provide a standard format for entry, retrieval and storage of health information." The CDA release 2.0 was approved as an ANSI standard in May 2005.

    ASTM Continuity of Care Record (CCR) [OC] XML-based document standard for a summary of personal health information (data set) to help achieve interoperability between medical records and to ensure "a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider."
    Work in progress  
    e-MS: Electronic Medical Summary A projected standard for the Canadian province of British Columbia for an e-MS minimum dataset, messaging standards and technical architecture to support integrated health information management.
    HL7 RIM Reference information model: "a single, all-encompassing model of the data structures that healthcare applications can exchange" (University of Manchester). "The RIM is an essential part of the HL7 Version 3 development methodology, as it provides an explicit representation of the semantic and lexical connections that exist between the information carried in the fields of HL7 messages" [HL7}.
    references: general
    E. Coiera. The Guide to Health Informatics (2nd Edition). Arnold, London, October 2003.

    [Chapter 10: The electronic medical record, p111-123]

    [See also: Chapter 9: Information management systems p101-110]

    Coiera, 2nd Edition, 2003 This chapter discusses the benefits and limitations of traditional paper-based medical records and "the major functions that could ... be replaced or enhanced by" electronic medical record systems.

    HIMSS Electronic Health Record Committee. HIMSS Electronic Health Record Definitional Model, 2003. Version 1.1

    []   [HIMSS v1.1]   [HIMSS v1.0]

    EHR Definition, Attributes and Essential Requirements Version 1.1

    " Purpose: To develop a definitional model of a fully functional Electronic Health Record (EHR) that includes: EHR definition, Key attributes and essential requirements, Evidence for each attribute that will demonstrate the essential requirements have been met. Mandatory evidence is bolded. This definitional model will be the basis of assessing the extent to which an organization is using an EHR by 2010. "

    Tang P. Key Capabilities of an Electronic Health Record System. Letter Report. Institute of Medicine Committee on Data Standards for Patient Safety. Board on Health Care Services. Washington D.C.: National Academies Press. July 31, 2003

    []   [NAP]

    (This report is also published as Appendix E of: Philip Aspden, Janet M. Corrigan, Julie Wolcott, Shari M. Erickson (Editors) (Committee on Data Standards for Patient Safety). Patient Safety: Achieving a New Standard for Care. Board on Health Care Services, Institute of Medicine, p430-467, November 2003.)

    Häyrinen K, Saranto K, Nykänen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform. 2008 May;77(5):291-304.

    [PubMed]   []

    " PURPOSE: This paper reviews the research literature on electronic health record (EHR) systems. The aim is to find out (1) how electronic health records are defined, (2) how the structure of these records is described, (3) in what contexts EHRs are used, (4) who has access to EHRs, (5) which data components of the EHRs are used and studied, (6) what is the purpose of research in this field, (7) what methods of data collection have been used in the studies reviewed and (8) what are the results of these studies. METHODS: A systematic review was carried out of the research dealing with the content of EHRs. A literature search was conducted on four electronic databases: Pubmed/Medline, Cinalh, Eval and Cochrane. RESULTS: The concept of EHR comprised a wide range of information systems, from files compiled in single departments to longitudinal collections of patient data. Only very few papers offered descriptions of the structure of EHRs or the terminologies used. EHRs were used in primary, secondary and tertiary care. Data were recorded in EHRs by different groups of health care professionals. Secretarial staff also recorded data from dictation or nurses' or physicians' manual notes. Some information was also recorded by patients themselves; this information is validated by physicians. It is important that the needs and requirements of different users are taken into account in the future development of information systems. Several data components were documented in EHRs: daily charting, medication administration, physical assessment, admission nursing note, nursing care plan, referral, present complaint (e.g. symptoms), past medical history, life style, physical examination, diagnoses, tests, procedures, treatment, medication, discharge, history, diaries, problems, findings and immunization. In the future it will be necessary to incorporate different kinds of standardized instruments, electronic interviews and nursing documentation systems in EHR systems. The aspects of information quality most often explored in the studies reviewed were the completeness and accuracy of different data components. It has been shown in several studies that the use of an information system was conducive to more complete and accurate documentation by health care professionals. The quality of information is particularly important in patient care, but EHRs also provide important information for secondary purposes, such as health policy planning. CONCLUSION: Studies focusing on the content of EHRs are needed, especially studies of nursing documentation or patient self-documentation. One future research area is to compare the documentation of different health care professionals with the core information about EHRs which has been determined in national health projects. The challenge for ongoing national health record projects around the world is to take into account all the different types of EHRs and the needs and requirements of different health care professionals and consumers in the development of EHRs. A further challenge is the use of international terminologies in order to achieve semantic interoperability. "

    C. Peter Waegemann. Status Report 2002: Electronic Health Records. Medical Record Institute

    []   [Med Rec Inst]

    " This report deals with the following: Why EHRs? - Understanding Various Concepts - CPR - Patient-carried Medical Record - Computerized Medical Record - Electronic Patient Record - Electronic Medical Record - Digital Medical Record - Patient Medical Record Information - Personal Health Record - Electronic Health Record - Current Hurdles Facing EHRs - The Survey on EHR Trends and Usages - Functions of the EHR - Dimensions of the EHR - Applications, not Records - Small Steps toward EHR Adoption. "

    Garets D, Davis M (HIMSS Analytics, Chicago). Electronic Patient Records : EMRs and EHRs Healthcare Informatics, October 2005.

    [Healthcare Informatics Online]   []

    A short documents that differrentiates the concepts EMR and EHR.

    " ... EMRs are computerized legal clinical records created in CDOs, such as hospitals and physician offices. EHRs represent the ability to easily share medical information among stakeholders and to allow it to follow the patient through various modalities of care from different CDOs. ... "

    Beale T. The Health Record – why is it so hard? IMIA Yearbook of Medical Informatics 2005: Ubiquitous Health Care Systems. Haux R, Kulikowski C, editors. Stuttgart: Schattauer; 2004. p. 301-304.

    []   [paper on]

    The paper introduces the Yearbook's section on EHRs.

    " It is often asked: what is the difference between health IT and IT in other domains? One well-known answer is “the patient”. Systems in other domains such as banking and airline reservation have “customers” or “travellers” but these are grossly simplified abstract versions of a person. “Patients” in clinical systems are anything but: their biological and social complexity is manifested directly in clinical information, posing a far greater challenge than in other domains. ... "

    Lloyd D, Kalra D. EHR requirements. Stud Health Technol Inform. 2003;96:231-7.

    [PubMed]   []

    " Published requirements for the EHR are principally available via ISO 18308. They are statements defining the generic features necessary in any Electronic Health Record for it to be communicable and complete, retain integrity across systems, countries and time, and be a useful and effective ethico-legal record of care. Examples of requirements are provided in four themes: EHR functional requirements; Ethical, legal, and security requirements; Clinical requirements; Technical requirements. The main logical building blocks of an EHR are described using the terminology of CEN TC251 ENV13606. Examples are given of the placement of attributes to satisfy contextual and other requirements at the level of specific building blocks. A worked example of the use of the building blocks is given for the request-report cycle for an imaging investigation. "

    Kalra D, Beale T, Heard S. The openEHR Foundation. Stud Health Technol Inform. 2005;115:153-73.

    [PubMed]   []

    " The openEHR Foundation is an independent, not-for-profit organisation and community, facilitating the creation and sharing of health records by consumers and clinicians via open-source, standards-based implementations. It was formed as a union of ten-year international R&D efforts in specifying the requirements, information models and implementation of comprehensive and ethico-legally sound electronic health record systems. Between 2000 and 2004 it has grown to having an on-line membership of over 300, published a wide range of EHR information viewpoint specifications. Several groups have now begun collaborative software development, within an open source framework. This chapter summarises the formation of openEHR, its research underpinning, practical demonstrators, the principle design concepts, and the roles openEHR members are playing in international standards. "

    References: issues

    Sujansky WV. The benefits and challenges of an electronic medical record: much more than a "word-processed" patient chart. West J Med. 1998 Sep;169(3):176-83.

    [PubMed]   []

    " The electronic medical record (EMR) will constitute the core of a computerized health care system in the near future. The electronic storage of clinical information will create the potential for computer-based tools to help clinicians significantly enhance the quality of medical care and increase the efficiency of medical practice. These tools may include reminder systems that identify patients who are due for preventative care interventions, alerting systems that detect contraindications among prescribed medications, and coding systems that facilitate the selection of correct billing codes for patient encounters. Numerous other "decision-support" tools have been developed and may soon facilitate the practice of clinical medicine. The potential of such tools will not be realized, however, if the EMR is just a set of textual documents stored in a computer, i.e. a "word-processed" patient chart. To support intelligent and useful tools, the EMR must have a systematic internal model of the information it contains and must support the efficient capture of clinical information in a manner consistent with this model. Although commercially available EMR systems that have such features are appearing, the builders and the buyers of EMR systems must continue to focus on the proper design of these systems if the benefits of computerization are to be fully realized. "

    McDonald CJ. The barriers to electronic medical record systems and how to overcome them. J Am Med Inform Assoc. 1997 May-Jun;4(3):213-21.

    [PubMed]   [PubMed Central]

    " Institutions all want electronic medical record (EMR) systems. They want them to solve their record movement problems, to improve the quality and coherence of the care process, to automate guidelines and care pathways to assist clinical research, outcomes management, and process improvement. EMRs are very difficult to construct because the existing electronic data sources, e.g., laboratory systems, pharmacy systems, and physician dictation systems, reside on many isolated islands with differing structures, differing levels of granularity, and different code systems. To accelerate EMR deployment we need to focus on the interfaces instead of the EMR system. We have the interface solutions in the form of standards: IP, HL7/ASTM, DICOM, LOINC, SNOMED, and others developed by the medical informatics community. We just have to embrace them. One remaining problem is the efficient capture of physician information in a coded form. Research is still needed to solve this last problem. "

    Walker J, Pan E, Johnston D et al. The Value Of Health Care Information Exchange And Interoperability. Health Aff (Millwood). 2005

    [PubMed]   [Health Aff]

    " In this paper we assess the value of electronic health care information exchange and interoperability (HIEI) between providers (hospitals and medical group practices) and independent laboratories, radiology centers, pharmacies, payers, public health departments, and other providers. We have created an HIEI taxonomy and combined published evidence with expert opinion in a cost-benefit model. Fully standardized HIEI could yield a net value of $77.8 billion per year once fully implemented. Nonstandardized HIEI offers smaller positive financial returns. The clinical impact of HIEI for which quantitative estimates cannot yet be made would likely add further value. A compelling business case exists for national implementation of fully standardized HIEI. "

    Poissant L, Pereira J, Tamblyn R, Kawasumi Y. The impact of electronic health records on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005 Sep-Oct;12(5):505-16.

    [PubMed]   []

    " A systematic review of the literature was performed to examine the impact of electronic health records (EHRs) on documentation time of physicians and nurses and to identify factors that may explain efficiency differences across studies. In total, 23 papers met our inclusion criteria; five were randomized controlled trials, six were posttest control studies, and 12 were one-group pretest-posttest designs. Most studies (58%) collected data using a time and motion methodology in comparison to work sampling (33%) and self-report/survey methods (8%). A weighted average approach was used to combine results from the studies. The use of bedside terminals and central station desktops saved nurses, respectively, 24.5% and 23.5% of their overall time spent documenting during a shift. Using bedside or point-of-care systems increased documentation time of physicians by 17.5%. In comparison, the use of central station desktops for computerized provider order entry (CPOE) was found to be inefficient, increasing the work time from 98.1% to 328.6% of physician's time per working shift (weighted average of CPOE-oriented studies, 238.4%). Studies that conducted their evaluation process relatively soon after implementation of the EHR tended to demonstrate a reduction in documentation time in comparison to the increases observed with those that had a longer time period between implementation and the evaluation process. This review highlighted that a goal of decreased documentation time in an EHR project is not likely to be realized. It also identified how the selection of bedside or central station desktop EHRs may influence documentation time for the two main user groups, physicians and nurses. "

    Levy B. Evolving to clinical terminology. J Healthc Inf Manag. 2004 Summer;18(3):37-43.

    [PubMed]   []

    " The electronic medical record (EMR) is slowly replacing the paper chart for documenting patient details. As the adoption curve for EMRs rapidly increases, so will the need for clinical terminologies. Currently, administrative classifications such as ICD-9-CM, CPT and HCPCS serve not only billing and reporting purposes, but also are used by healthcare providers for documentation and capturing patient procedures and problem lists. But the use of clinical terminologies, such as SNOMED CT, will assume the interface role in EMRs and thus replace these administrative classifications at the point of care. These billing terminologies will then be relegated back to the coders and payers for use, enabling the clinicians to document using richer and more granular terminologies. During this transition phase to the clinical terminology, training will likely be required as healthcare providers adjust to using terminologies in more robust ways. Clinical informaticists and early adopters will play a role in this training and help to demonstrate the many advantages of richer documentation. The use of clinical standards in EMRs is one of the key evolutions in informatics. "

    references: EMR/EHR adoption

    Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009 Apr 16;360(16):1628-1638.

    [PubMed]   [NEJM]

    " BACKGROUND: Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals. METHODS: We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption. RESULTS: On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems. CONCLUSIONS: The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals. "

    references: EMR/EHR and quality of care

    Poon EG, Wright A, Simon SR, Jenter CA, Kaushal R, Volk LA, Cleary PD, Singer JA, Tumolo AZ, Bates DW. Relationship between use of electronic health record features and health care quality: results of a statewide survey. Med Care. 2010 Mar;48(3):203-9.

    [PubMed]   []

    "BACKGROUND: Electronic health records (EHRs) are widely viewed as useful tools for supporting the provision of high quality healthcare. However, evidence regarding their effectiveness for this purpose is mixed, and existing studies have generally considered EHR usage a binary factor and have not considered the availability and use of specific EHR features. OBJECTIVE: To assess the relationship between the use of an EHR and the use of specific EHR features with quality of care. RESEARCH DESIGN: A statewide mail survey of physicians in Massachusetts conducted in 2005. The results of the survey were linked with Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, and generalized linear regression models were estimated to examine the associations between the use of EHRs and specific EHR features with quality measures, adjusting for physician practice characteristics. SUBJECTS: A stratified random sample of 1884 licensed physicians in Massachusetts, 1345 of whom responded. Of these, 507 had HEDIS measures available and were included in the analysis (measures are only available for primary care providers). MEASURE: Performance on HEDIS quality measures. RESULTS: The survey had a response rate of 71%. There was no statistically significant association between use of an EHR as a binary factor and performance on any of the HEDIS measure groups. However, there were statistically significant associations between the use of many, but not all, specific EHR features and HEDIS measure group scores. The associations were strongest for the problem list, visit note and radiology test result EHR features and for quality measures relating to women's health, colon cancer screening, and cancer prevention. For example, users of problem list functionality performed better on women's health, depression, colon cancer screening, and cancer prevention measures, with problem list users outperforming nonusers by 3.3% to 9.6% points on HEDIS measure group scores (all significant at the P < 0.05 level). However, these associations were not universal. CONCLUSIONS: Consistent with past studies, there was no significant relationship between use of EHR as a binary factor and performance on quality measures. However, availability and use of specific EHR features by primary care physicians was associated with higher performance on certain quality measures. These results suggest that, to maximize health care quality, developers, implementers and certifiers of EHRs should focus on increasing the adoption of robust EHR systems and increasing the use of specific features rather than simply aiming to deploy an EHR regardless of functionality. "

    Keyhani S, Hebert PL, Ross JS, Federman A, Zhu CW, Siu AL. Electronic health record components and the quality of care. Med Care. 2008 Dec;46(12):1267-72.

    [PubMed]   []

    " BACKGROUND: Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care. METHODS: Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of all visits with an established primary care provider and examined the association between presence of EHR components and: (1) blood pressure control; and (2) receipt of appropriate therapy for chronic conditions. We examined similar associations for complete EHRs which we defined as one that includes physician and nursing notes, electronic reminder system, computerized prescription order entry, test results, and computerized test order entry. We constructed multivariate models to examine the association between EHR components and each outcome controlling for patient sociodemographic, health, physician practice, and geographic factors. RESULTS: We found no association between electronic physician notes and blood pressure control or receipt of appropriate therapies, with the exception of inhaled steroids among asthmatics (adjusted odds ratio 2.86; 95% confidence interval, 1.12-7.32). We found no association between electronic reminder systems and blood pressure control or receipt of appropriate therapies, with the exception of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients with diabetes with hypertension (odds ratio 2.58; 95% confidence interval, 1.22-5.42). We found no association between electronic physician notes and any measure of quality. We found no relationship between having a complete EHR and any of the quality measures investigated. CONCLUSIONS: We found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. Future research focusing on how an EHR is implemented and used and how care is integrated through an EHR will improve our understanding of the impact of EHRs on the quality of care. "

    references: EMR/EHR and decision support

    Ohno-Machado L. Electronic health records and computer-based clinical decision support: are we there yet? J Am Med Inform Assoc. 2011 Mar 1;18(2):109.

    []   []

    " "

    Romano MJ, Stafford RS. Arch Intern Med. 2011 Jan 24. Electronic Health Records and Clinical Decision Support Systems: Impact on National Ambulatory Care Quality. [Epub ahead of print]

    [PubMed]   []

    Should be read in conjunction with invited comment: McDonald C, Abhyankar S. Clinical Decision Support and Rich Clinical Repositories: A Symbiotic Relationship. Arch Intern Med. 2011 Jan 24.

    [PubMed]   [Arch Intern Med]

    " BACKGROUND: Electronic health records (EHRs) are increasingly used by US outpatient physicians. They could improve clinical care via clinical decision support (CDS) and electronic guideline-based reminders and alerts. Using nationally representative data, we tested the hypothesis that a higher quality of care would be associated with EHRs and CDS. METHODS: We analyzed physician survey data on 255 402 ambulatory patient visits in nonfederal offices and hospitals from the 2005-2007 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Based on 20 previously developed quality indicators, we assessed the relationship of EHRs and CDS to the provision of guideline-concordant care using multivariable logistic regression. RESULTS: Electronic health records were used in 30% of an estimated 1.1 billion annual US patient visits. Clinical decision support was present in 57% of these EHR visits (17% of all visits). The use of EHRs and CDS was more likely in the West and in multiphysician settings than in solo practices. In only 1 of 20 indicators was quality greater in EHR visits than in non-EHR visits (diet counseling in high-risk adults, adjusted odds ratio, 1.65; 95% confidence interval, 1.21-2.26). Among the EHR visits, only 1 of 20 quality indicators showed significantly better performance in visits with CDS compared with EHR visits without CDS (lack of routine electrocardiographic ordering in low-risk patients, adjusted odds ratio, 2.88; 95% confidence interval, 1.69-4.90). There were no other significant quality differences. CONCLUSIONS: Our findings indicate no consistent association between EHRs and CDS and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality. "

    references: electronic summary care record

    Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J, Potts HW. Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study. BMJ. 2010 Jun 16;340.

    [PubMed]   []

    " OBJECTIVE: To evaluate a national programme to develop and implement centrally stored electronic summaries of patients' medical records. DESIGN: Mixed-method, multilevel case study. SETTING: English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively. RESULTS: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme's fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. CONCLUSIONS: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale. "

    Coiera E. Do we need a national electronic summary care record? Med J Aust. 2011 Jan 17;194(2):90-2.

    [PubMed]   []

    " Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them. "


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