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| 08/23/2007 11:17 PM, Tim Armstrong. |
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| 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.
EMR 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:
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. 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.
Adding older records to EMRs
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.
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. Exemplifying this need 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].
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.
Preserving electronic records
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. |
| 08/24/2007 06:23 PM, Tim Armstrong. |
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