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Barriers for Implementation of Electronic Medical Record (EMR)

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Barriers for Implementation of Electronic Medical Record

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									Barriers for Implementation of Electronic Medical Record (EMR)

                  Bilal Ali Yaseen AL-nassar , Mohd Syazwan Abdullah,
                                Wan Rozaini Sheik Osman
              Department of Computer Sciences, College of Arts and Sciences
              Universiti Utara Malaysia, 06010 UUM-Sintok, Kedah, Malaysia
                bllnssr75@yahoo.com, {syazwan, rozai174}@uum.edu.my

                                      ABSTRACT
Electronic Medical Record system (EMRs) plays vital role in improving the quality of
Healthcare. This paper discusses the factors which are recognized to be the barriers for
implementations EMR in hospitals. The paper also describes the general implementation of
the workflow as well as the potential benefits of EMR. The current implementation of EMRs
in Jordan Hospitals and usage are also presented.

Key words: Electronic Medical Record (EMR), Information Communication Technology (ITC)
Healthcare Information System (HIS).

1. Introduction

Information       and       Communication         EMR is available in many countries
Technology (ICT) is very important                nowadays, nevertheless there are still many
nowadays because it has many potential            obstacles to overcome before it can be
which makes our life easier. The effects of       successful implemented.
ICT technology on our daily life cannot be
refuted. It is impacting on every facet of        Several technological impacts and social
human activities and the health industry is       issues have slowed the pace of
no exception. Electronic Medical Record           implementation or the widespread plan to
(EMR) is one type of Healthcare                   EMR implementation. Users of EMR
Information System (HIS) like Electronic          include administrative staff, medical staff,
Health Record (EHR), Computerized                 and patients. The main users are the
Physician Order Entries (CPOE) and                medical staffs who are physicians and
Electronic Patients Record (EPR). There           nurses who have used EMR to have
are many advantages for using EMR such            electronic access to patient health
as; playing a major role to improve patient       information. They have found EMR to be
safety, quality of care, and medical              very helpful and resourceful. The next
records. EMR implementation benefits              section will focus on technology that can
healthcare related organizations such as          be used in EMR.
hospitals and clinics in reducing medical
errors, facilitating access, supporting           The paper is organized as follows: Section
clinical decisions and others. On the other       1 presents the introduction of the paper,
hand there are disadvantages for EMR              while section 2 discusses the electronic
such as high cost, security, privacy and          medical record in detail. Section 3
others.                                           describes the benefits of using EMR, while
Although there many benefits of EMR,              section 4 shows the analysis of the
many studies are conducted to see the             implementation barriers of EMR. Section 5
challenges or barriers in implementing            shows the EMR implementation in Jordan,
EMR as people do tend to resist any new           while section 6 concludes the paper and
technology.                                       presents the future work.


                                              1
2. Electronic Medical Record                       billing information. Therefore, the users
                                                   (hospital administrative staffs) can retrieve
EMR is the software that enables medical           the information that is needed at anytime
data to be digitally processed, stored and         and anywhere. EMR also enable the
communicated. It can also be used to               patients to access their data by themselves.
access, process, manage and present                The workflow of EMR shown in Figure 1
medical information of the patients, to            are based on the main functions of EMR
doctors, administrative staffs and other           [3-7].
users. EMR play a major role in activating
the communication between the users and            These functions are:
patients, and between users themselves. It         -Medical history: describe as detail or
can also be applied for different medical          longitudinal record of what happened to
issues, and business areas especially in           the patient since birth or visit to the
hospitals.                                         physicians. It show chronic diseases, major
                                                   and minor illnesses, as well as growth
EMR enable the retrieval of the medical            details and what happened to the patient
information, storage of data for longer            over the years. Medical history also
period and availability of data at anytime         includes surgical history, medications,
and anywhere. EMR can be defined as an             medical allergies and medications.
electronic middleman, which allows the
users to retrieve the patient data such as
history for patients, diagnosis, treatments,
radiology, laboratory and booking for
patient in wards [1]. According to Pike [2]
and Wald [3], EMR is an electronic
record of patient health information such
as: medical history, medical encounters,
booking, immunizations, diagnosis data,
treatment, laboratory data, radiology, as
well as administrative issues. The next
sub-section 2.1 will explain the workflow
of EMR system, to show how EMR works.

2.1Workflow of EMRs

Workflows of EMR have no fixed criterion
(standards), as different organizations have
different understanding of EMRs. Since,
there are multiple interpretations of what
                                                                    Storage
exactly EMR is, and what the EMR                                    element
                                                                   (Database)
                                                                                   Storage
                                                                                   element
                                                                                  (Database)

requirements are, therefore, organizations
are unable to identify their current and
future needs from it [4]. Figure 1 shows               Figure 1 Workflow of an EMR System
the workflow of EMR and how the users
can capture, store, process, communicants,         -Medical encounter: This includes
and security all data for each patent.             complaint, history of the present illness,
EMR helps administrative staff in order to         assessment, plan (diagnosis, treatment),
access and retrieve information, and by            and progress notes. Within the medical
activating communication with each                 record, individual medical encounters are
others, users and medical researchers.             marked by discrete summations of a
EMR can be used in human resource                  patient's medical history by a physician,
departments, and in obtaining the patient
                                               2
nurse, practitioner, or physician assistant          events. The cost of these errors is about
and can take several forms.                          $38 billion per year [8].
-Radiology: This allows physicians or                There are many causes of medical errors,
other users make booking and get results             and one of these is different physicians
of CT scan, magnetic resonance (MR),                 treating the same patient. Not all or only a
nuclear medicine, X-Ray and ultra sound              few physicians can access to all the
easily and fast.                                     patient’s medical records. Some of them
-Laboratories: Allows users to make                  do not know anything about the history of
booking during interviews with patients              their patients [8] and these can have
and get result which include blood test,             damaging consequences if the wrong drugs
urine test, semen test and stool test.               or treatments are given to the patients.
-Booking in the wards: Allows physicians
to make booking for patients in the wards
if there is an emergency case.
-Billing information: Via EMR, care
users can access to the billing information
of the patients, and conduct instant bill
calculation for paying cases.
-Pharmacy: EMR is able to offer the
electronic medical prescription which is
easier than paper medical prescription.
Thus, it is able to reduce the medical
errors.
-Demographics:          Include        patient
information that it is not medical
information in particular. This information
will include      the location of patients,
identifying numbers, addresses, and
contact numbers. And contain information
about race and religion as well as
workplace and type of occupational
information. It may also contain
information regarding the patient's health
insurance.
Through the implementation of EMR,
                                                         Figure 2: Potential and benefits (Deutsch, 2006)
users can access these functions that enable
them to perform their job function                   Another important cause of medical errors
efficiently.                                         is in prescriptions, as writing them on
                                                     paper is not clear and is too difficult to
                                                     read it. Thus, electronic prescription would
3. Benefits of EMR                                   greatly reduce the prescription errors.
Figure 2 shows the most important benefits           Medical errors could be reduced by the use
EMR, and how EMR can improve                         of decision support tools that would check
healthcare in general and patient care in            for drug interactions as well as dosage
particular.                                          levels and allergies. EMR could receive
According to the Institute of Medicine               alert reminders for preventative care
(IOM) 44,000 to 98,000 deaths occur each             treatments, testing, and alert about various
year in USA hospitals due to preventable             treatment procedures, guidelines associated
medical errors and over 770,000                      with the diagnosis [9].
individuals are either injured or die each           Moreover, electronic records improve
year in hospitals due to adverse drug                record      keeping,      recording      and
                                                     documentation of medical examination.
                                                 3
EMR usage in hospitals generally reduces              information over and over again. They
cost, improves clarity of documentation,              may even forget about it. Therefore, there
clinical decision support, and enables                is a general consensus that the widespread
better communication of information about             use of electronic medical records improves
patient referred for consultation, potential          the coordination and quality of healthcare
availability of the record anywhere,                  for patients. However, there are still many
anytime as well as increased storage                  barriers in implementing EMR in hospital
capabilities for longer periods of time.              around the world. The next section will
The EMR also enhance the patient                      section there barriers.
provider communication. EMRs can
remove the communication barrier                      4. Implementation Barriers of
between users and patients. EMR can help                 EMR
public health officials easily detect an              Table 1 in the last page shows the results
outbreak of illness and determine what                of analyzing the EMR implementation
measures are needed to protect the                    barriers conducted in this research. This
community [10]. Another advantage of                  was done by analyzing previous studies by
using EMR is the patient privacy and                  researchers in the area of EMR
security. Electronic files play a significant         implementation over the years. This paper
role in maintaining patient information and           will discuss these barriers in order of
confidentiality, as unauthorized access can           importance.
reveal history of drug abuse, venereal
disease, or life-threatening illness,                 1. High Cost of Implementations for
psychiatric notes reveal inner fantasies,             EMR:
sexual activities, crimes, or the crimes and          Costs        significantly     affect      the
abuses of family members.                             implementation of EMRs. For example,
Therefore, if anyone could have easy                  the cost of installation, and maintenance
access to these private information without           of EMRs, will increase during the use of
any security, will caused a lot of problems           EMRs [12, 13].When discussing about cost
for patients that can affect their daily lives.       it is not only covering the software cost
EMR also make it easier for medical                   because the implementation           of EMR
researchers to ask questions or query about           includes the costs of                hardware,
diseases that were previously been                    networking (including Internet service
impossible to ask of it, and it may well              providers), infrastructure, installation
lead to the discovery of tens or even                 operating system and training. Therefore,
hundreds of new diseases and allow                    this will increased the costs that may be
reclassifications of existing ones [11].              unaffordable for sector hospitals [12-14].
The EMR have some functions associated                2. Training Issues: Training is the
with patients different than the medical              sessions these organizations teach the
functions such as financial, legal                    skills to improve their practice during
information,      research     and      quality       work. Thus, training is one factor which
improvement purposes. Due to some                     increases the costs of implementation for
reasons, this information must not be                 EMRs. This is because training on
shared among many professionals who are               electronic medical records software will
not related to the healthcare team.                   add additional expense as if involves
On the financial side, EMR allows the                 paying people to take training and paying
accounting staff to provide more accurate             the trainers to teach practitioners.
billing information and allow users to                Training helps to enhance the works of
submit     their     claims     electronically.       users to enter the data faster and get some
Therefore, receiving payment will be                  background of using computer; also
quicker, and the information for any                  training is important for users [15, 16].
patient will available. Thus, there is no             After proper training, there is no guarantee
need for the patient to provide the same              that all users will feel comfortable using
                                                  4
the computer [17]. Therefore, training will           medical record because it needs high costs
cost organizations time and money.                    [9, 23].
3. Resistance to New Technologies:                    The lack of limited access to health
Technology is changing rapidly every day              information from external sources and the
in our life and this is reflected adversely on        lack of data sharing with users is already
the technology systems that we use.                   causing major barrier in the widespread
Physician resistance is one of the barriers           implementation of the electronic medical
in EMR implementation [18-20]. Every                  record systems. Thus, the lack of sharing
time new EMR technology appears, users                data between the users to access
will resist these new technologies. This is           information for patients will make their
because it will make them take more time              work limited.
to learn on how to use the new software,              5. Ease of Use: User friendly programs:
and they become reluctant to adopt the                systems should make users comfortable
new ways of working. Thus it will interfere           using it. EMR helps to improve the quality
their workflow and will slow their work               of healthcare and help users to accomplish
[21].                                                 their work short period time and
New technologies force the physicians to              efficiently. Thus, to provide a good EMR
work on the same way together, although               software, it should not be complex to its
almost of them had practiced medicine in              users to understand and use [24, 25]. User
different ways. This causes frustration and           friendly programs will help users to enter
impatience amongst them because EMR                   data easily, and the results of training will
take time from them. Therefore, they are              be positive. Therefore, this will encourage
unable to see the same number of patients             the user to accept EMR [18, 26].
as when they were under a paper chart                 Furthermore, continued vendor support
system [12, 22].                                      will encourage the users to accepts EMR
EMR is closely tied to the computer                   through the as they can give provide
industry, whose obsolescence is another               technical assistance this is important as it
concern. EMR technology is changing                   make it easy for users to use [27].
rapidly, and just as the PC that someone              6. Resident Background: The resident
bought three or four years ago is made                background is the knowledge (experience)
obsolete by today’s PCs, today’s EMRs                 of using computers, which is acquired
will also be obsolete in a short period of            during study or during work.
time. This means that the EMR that took a             The users who do not have any computer
lot of time and money on implementing                 background will not accept to use IT in
may be obsolete by the time that the                  their work. Therefore, they will not accept
practice is fully implemented and used                to use EMR or even to take the training,
[22].                                                 especially older individuals who have
                                                      never used computers in their lives [28,
4. Limited Ability to Access External                 29].
Data:                                                 The users who have a computer
Exchange of data between EMRs and the                 background will accept training, and use
users and other clinical data systems is              EMR. The reason is because they already
important to reduce the medical errors.               know how to use computers and they will
One of the medical errors is that different           not face problems like those who have no
physicians treating the same patient, do              computer background.
not have access to all the patient’s medical          Moreover, there are very strong relation
records or they do not have all data about            between health care professionals and
the history of their patients, such as lab test       computer skills, when the medical users
results and others. The EMR does not                  have experience or computer skills the
cover all application areas, and all                  users will accept working using the EMRs
information types that constitute the                 and will not affect the implementation of
                                                      EMRs [12, 30].
                                                  5
EMR has been implemented in many                    nevertheless these are seldom or never
countries and we will discuss the current           utilized.
implementation in Jordan in the next                Furthermore, some medical organizations
section.                                            want to implement EMRs but they are
5. EMR Implementation in                            unable to make the bold step in
  Jordan                                            implementing Electronic Medical Record
Jordan has one of the highest population            System (EMRs) at their hospitals.
growths in the world. The Jordanian                 There are other reasons that contributes to
government plans to implement EMR for               the limited EMR implementation in Jordan
its hospitals via the Medsphere Systems             such as effective training program for
Corporation of USA. Jordan is at the centre         health care users, high implementation
of the middle-east healthcare, where a              cost, lack of computer background
fairly high level of medical care standards         amongst users, delay in data entry,
is found. However, this good reputation             software immaturity, lack of standards,
started to face some threats due to the lack        security, privacy, limited access, patient
of medical technology [31]. The number              confidentiality and others. We strongly
the hospitals which have implementation             believe that understanding these barriers
of EMRs is very little compared to the total        and having the right strategy to deal with
number of hospitals in Jordan.                      these will ensure the success of EMR
All hospitals in Jordan are under the               implementation in Jordan.
administration of one of the following
entities: government hospitals, ministry of         6. Conclusion and Future work
defense, universities and private sector.           This paper shows how implementation of
Most hospitals are using manual paper               EMRs can be affected by organizational,
work or on very basic software tools. Most          technological and social issues and the
of the hospitals that have implemented              barriers that affect the implementation of
EMRs are in the private sector. Many                EMRs. Future research in these areas such
researches have already been conducted in           as investigating the effects of EMR
the field of Electronic Medical Records in          implementations on the total quality of
many countries. However, they are no                care as perceived by the medical users
research conducted in Jordan to identify            such as physicians, pharmacists, nurses,
and investigate the main barriers in                lab technicians, administration staff and
implementing EMR systems.                           medical records staff at medical
Few Jordan hospitals have implemented               organizations in Jordan will be undertaken.
EMR system, which is often different than           A comprehensive research on finding the
other highly developed countries such as            successful factors that contributes to EMR
Sweden, United Kingdom, Netherlands,                implementation can also be beneficial.
and Australia whose more than half of
their primary care physicians are using the
EMR [21, 32]. This indicates that Jordan is
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                                                6
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Table 1: Analysis of EMR Implementation Barriers




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