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					                            IMR 655 : Management of Medical Records 2012

                   ISSUES IN ELECTRONIC MEDICAL RECORD (EMR)



1.0 Introduction

       Due to the new advances in computer and development of communications
technology, we are now living in information age which technology has continued to move
forward at a rapid pace and many organizational “going paperless” and slowed the pace of
implementation of automated systems for an electronic documentation record (Young, 2000).
Furthermore, technology holds great promise for improving the speed and ease of access to
various type of information, even for information that are distributed digitally. Nowadays,
most organization found that the use of modern computers have provide them with good level
of services and well manage of record keeping. Paper medical record easily can cause harm
due to loss, incomplete, and damaged compared to electronic medical record that are often
seen as a way to improve care and reduce cost as well as to improved clinical outcomes and
data security.


Generally, medical record always refer to document with detail information about patient
health along with their family medical history created by medical profession which usually
include current medicine, immunization, allergies, health history and lab result or test. This
definition fit with definition given by Current Law in State of Ohio that “medical record is
document or compilation of document related to patients medical history, diagnosis,
prognosis or medical condition that is create and retained in the process of patients health
care treatment”. Meanwhile, according to Legal Medical Record Standard (2008, p.1)
medical record is “collection of information on patient and her healthcare which designed and
maintained at regular of UC and accordance with UC policies”.




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                                 Figure 1: Evolution of EMR

Over the past 20 years, medical institutions have increasingly turned to computerization for
help managing patient information whereby government have plans to implement electronic
medical records or known as EMR in every hospital and clinic (Franklin, 2011). A
computerized medical record or electronic medical record (EMR) is paperless and digital
version of the paper charts created in an organization that delivers care such as clinician
office. Garet and Davis (2006) stated that electronic medical record are “an application
environment composed of the clinical data repository, clinical decision support, controlled
medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical
documentation applications. This environment supports the patient’s electronic medical
record across inpatient and outpatient environments, and is used by healthcare practitioners to
document, monitor, and manage health care delivery within a care delivery organization.
However in the simple word, EMR are those records about patient that are kept on a
computer rather than on paper (Heflin, 2012).



On the other hand, EMR may contain medical and treatment history of patient which includes
patient general health, current and past medical conditions, test result and medications
prescribed. Similar to Boulus (2012) who agreed that EMR is a way to store patient record on
computer which are pertinent for a treatment and nursing of patient that includes clinical
information such as diagnosis, medicine, allergies and patient demographic information. For
instance, EMR tends to be stand-alone health information system that allows storage,
retrieval and modification of patient records. Electronic medical records and the internet
provide a technical infrastructure on which to build longitudinal medical records that can be
integrated across sites of care (Mandl, 2001). EMR were designed to help healthcare
providers to have quick access to patient medical information whenever patient present for

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care as well as to reduce documentation errors by streamlining the process. By introducing
EMR, healthcare providers it will be able to better coordinate and enhance health care service
toward their patient (Boulus, 2012). However, some issues will be discussed regarding on the
implementation automated electronic medical record.




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2.0 Issues of Electronic Medical Record (EMR)

However, EMR systems still have problems that would prevent it from accepted by
healthcare professionals whereby some physician feels reluctant to use the system. There
were some issues being discuss includes privacy and patient confidentiality, usability, cost,
hardware and software, physician resistant.

        2.1 Privacy and patient confidentiality


As we know electronic medical record technology already transforming health care system
and been applied in most health care centre. Through EMR system it allows better
coordination between from one health care provider to another by sharing of patient record.
Besides, it improves and promises efficiency in service delivery to the new provider
especially for transferred patient whereby it gives benefit to both doctors and patient (Carey.
et al, 2012). She explains that sharing electronic record might be risk to patient privacy since
technology seen as threat to privacy. Electronic medical record sharing perceived as greatest
threat that bring to new ethical problems that related with issues regarding on the right of
access to information and the right to privacy of the individual. Further, shareable EMR may
lead to breaches of patient confidentiality. Patient confidentiality represent that personal
medical detail information given to a health care provider will not be disclosed to others
unless with the patient permission. In other terms patient confidentiality means disclosure of
patient private information that the physician has learned within the patient-physician
relationship to a third party, without a patient consent or other relevant reason for that action
(AMA, 2012). Privacy and patient confidentiality issues still remain unresolved whereby it is
has long been concerned of the health industry and government.




                    Figure 2: Person who can get access to medical record


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Patient medical information is shared by a wide range of people both in and out of the health
care industry. Through figure 2, generally patient had the ability to control which provider
had access to their medical history even when they agreed to let new providers to access and
see their medical record. Any information went into those records are depend on what the
patient want to tell her doctor and doctor chose to send to the new provider. However, in
reality patient have no choice but they have agreed to share their health information
especially if they want to obtain care and quality for insurance. Unless exchange networks are
carefully designed, electronic health records that can be shared at the click of a mouse can
threaten patient control over sensitive health information.


Each state and government has enacted laws which known as HIPAA1, in order to protect the
confidentiality of health care information which. For instance, HIPAA were designed to
protect patient’s identifiable health information to healthcare providers, health plans, doctors,
hospitals. According to HHS, "These new standards provide patients with access to their
medical records and more control over how their personal health information is used and
disclosed. But HIPAA leaves too many loopholes and it doesn't succeed in protecting
patients' privacy or confidentiality because secondary user such as (insurers, researchers,
court, etc) still can access information (Dudley, 2004). Besides, patient must also remember
that records have to be accessible to the professional who use the record to provide medical
care.


Following are those examples:

    a) Insurance companies

It is obvious that an insurance company need to know some pertinent information with such a
waiver they can access and routinely reviewed to the entire medical record in order to
processing claims for payment under an existing policy. Insurance companies require
releasing patient record if patient apply for individual health insurance as opposed to a group
health plan available through their company policies.




1
  The U.S. Department of Health and Human Services (HHS) has enacted a Privacy Rule under the Health
Insurance Portability and Accountability Act (HIPAA).

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   b) Employer

Employers usually obtain medical information about their employees by asking employees to
authorize disclosure of medical records. Unfortunately, the laws in only a few states require
employers to establish procedures to keep employee medical records confidential. Besides,
this can become even more troubling if the patient works for a self-insured company whereby
the employer has access to the patient's entire confidential medical record.

   c) Court


Patient medical record also could be disclosure for court case especially if patients involved
in administrative hearing or worker’s compensation hearing. Patient’s medical condition will
become an issue where the relevance parts of their medical record may be copied and
presented in court. In addition according to Privacy Rule, law enforcement officials may
obtain protected health information in other situations such as an instance of abuse, a death, a
gunshot, violent injures or murder.


Moreover, patients also worry that computer hackers can access their personal information if
it is stored electronically. If someone hacks into a computer system, thousands of patients'
records can be compromised.




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       2.2 Usability

Besides, usability can be a major obstacle affecting the implementation of an EHR. The
National Institute of Standards and Technology (NIST) defines usability as the
“…effectiveness, efficiency and satisfaction with which the intended users can achieve their
tasks in the intended context of product use.” As known, an ideal EMR system should be able
to provide timely data, alerts, reminders, clinical decision support and other aids which help
healthcare professional at all times. EMR system should provide useful function that
overcome problem of paper-based records as well as it should not cause problems for
physician that associated with electronic medium (Cimino, et al.). There were some usability
problems of EMR will be discussed. Even though, physicians have learnt on how to use EMR
system but there are some problems that cause they to be less productive. Healthcare
professional found that EMR system too cumbersome because they took longer time in order
to complete simple task since system failed to recognized word even with slightly
misspelling. Meanwhile, searching for a procedure or diagnosis can produce useless result
since physicians speak one language, but the procedures and diagnoses are sometimes based
on a different set of codes. Through perspective from Jiajie Zhang, user interface design
would be one of those problems since many interfaces in EMR system become barriers
between the user and task because it is not user friendly and hard to use.



       2. 3 Cost of EMR system implementation

Even though, system helps organization to save cost on storage space but cost involved in
implementation of EMR system can be expensive especially start-up cost and staff training.
On the other hand, total implementation costs also include cost for hardware and software,
licensing fees, technical assistance to install the system as well as ongoing maintainers
support. It has been estimated that the total cost for implementing the EMR system at
Belleville Family Medical Clinic and one year of technical support was about $220,800 to
$260,800 (Smith, 2003). According to American Health Information Management
Association conference panellists estimated “purchasing and installing EHR will cost over
$32,000 per physician, and maintenance about $1,200 per month.” Software usually cost up
to $1600 per provider per year depend on internal developed system, however it constant
with license fees which been estimated between $2500 and $3500 per provider for the initial
software purchase (Wang, et al. 2003). Return on investment has greatly influenced many

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health care providers in the investment of system because most of them did not confident
whether implementation of EMR will provide them with a return on their investment
especially system crash and technical difficulties will costly to repair. Moreover, training cost
involved in implementation of EMR system whereby extensive staffs training required assist
and teaching them in using EMR system. New employees, permanent or temporary, will also
require training as they are hired. Besides, Cedars Sinai Medical Center in LA spent almost
$34 million for developing and deploying physician order entry system for medications, labs
and procedures (Smelcer, 2009).




Figure 3: Example of estimating the total cost of an EMR at Belleville Family Medical Clinic




       2.4 Hardware and software barrier


Hardware and software is often offer significant barrier to the implementation of EMR
system. Placement of hardware and decisions regarding the portability of the equipment
should be considered. In order to run EMR system, computer access and network are also
required, so the number of workstation, laptops and other mobile computers must be
available to accommodate the number of healthcare providers at any one facility. I agreed
that the basic facilities or hardware are needed to support the EMR implementation.
According to Keshavjee, when organization decides to adopt EMR system, they need to
choose types of software carefully. He added that hardware must fit into clinician workflow,
speed processing and work process, while software must be able to support it. Moreover,
software technology advances at a rapid pace and most software systems require frequent
update. On the other hand, ever-changing software and operating system allow ongoing re

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implementation which might disrupt the workflow. Selection of inappropriate software can
allow mismatch between software and hardware whereby software was unable to achieve
stated performance goals on the stated hardware requirements (Tonnesen). This was because
EMR vendors might use different hardware platforms, databases, and operating systems
(Keshavjee) and inadequacy of software and hardware also affect system performance which
causing the system to operate slowly.


       2.4 Physician resistance


Physician resistance to EMR adoption also barrier to successful EMR implementation
Moving from paper records to electronic health records (EMRs) become challenges for
certain physician such as changes in workflow and process requires much time, effort and
training. Some of them are computer illiteracy whereby they not comfortable with the
technology especially senior clinician because they lived up with the paper system. On the
other hand, medical staff member might not be able to learn new technology because most of
their time focused on patient care. I believe that the exhausting daily routine is just enough to
make them unwilling to take time to attend training sessions and learn to competence with
new technology. Based from other scholar, system will takes more time to complete a task
whereby it is somewhat agreed by other researcher that electronically inputting information
may take practitioners more time than writing (iHealth Beat, 2004). It is also supported by
Brown, 2005, “EMRs that have been over-engineered and are not intuitive, forcing
physicians to spend more time clicking through screens and menus to get their work done.” In
addition, it is also possible that lack of availability IT trained staff and skill lead to EMR
implementation. Some of them uncertainty about what are types training and skills are needed
in to order to adopt EMR system.




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3.0 Solutions

Through the issues being discussed, there are some solution can in order to overcome the
barrier in implementation of EMR before it can be successful

It is very vital for healthcare providers in ensuring and protecting privacy of patient record
we need to protect our patient’s information from being disclose to the secondary users. This
has been agreed by the author Dudley, he explain that “there should be an amendment to
HIPAA to abolish the ability of secondary user in accessing patient record.” The legal action
must shift from time to time and regulation must tighten to prevent security of breaches,
besides it would improve the quality of care and allow forbidding access by secondary user
who might misuse patient record. However, any disclosure of patient record must received
patient consent. As we can look at in New York policy, it requires patient consent before
released record to third party exception to the law. Meanwhile, several technologies were
developed to help organization to protect their system from being access by unauthorized
individual. Physician can use encryption technology which is often used to provide integrity
and ensure the security of data. Shields explain in his article that the better way in protecting
patient confidentiality by implement two security protocols in the system which are Secure
Sockets Layer (SSL) and Secure Shell (SSH), whereby it can ‘enhance the security and
reliability of file transfer by using encryption to protect against unauthorized viewing and
modification of information’. Authentication mechanism such as password and audit trail also
can be use to ensure only authorized person can access to the system and to detect
unauthorized access to confidential information.


Furthermore, system design must be user friendly and easy to use or otherwise the system
will not accepted by healthcare providers. According Simmons, system design includes
workflow, navigation, screen layout, interaction and visual design, and ease of connectivity
with other parts of the system. Due to poor system design, it’s slowed down physician
efficiency in locating important patient record and it might affect the adoption of EMR
systems as said by Guerra, 2011. In order to design successful EMR system, designers should
consider the user’s need. Human factors should be considered in designing EMR system at
earlier stage (Cimino). Designer must appropriately design the system by considering user
needs in mind and designing proper user interface might help to minimize workload and
improve task performance and optimize decision making. Moreover, in terms of complexity


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and usability problem, physician also needs to allocate some time and effort in order to
master them.


In overcoming the technical issues, Keshavjee stated when organization decides to adopt
EMR system they need to choose types of software and hardware carefully by start. He added
that hardware must fit into clinician workflow, speed processing and work process, while
software must be able to support it. Organization can start with research in order to help them
in decision making to decide which software and hardware product can best meet their goal.
In addition, according to HIT exchange (2011), “analysis from the previous research it helps
provider to analyze the capabilities of existing hardware and what are the latest hardware
needed that meet medical standard”. Besides, hardware must be tested before software is
installed to ensure whether both software and hardware match well to one another to support
the system perform much better. The ability of different information technology system and
software application is able to communicate to exchange data accurately, effectively and
consistently to use information that has changed.
(Phillips, 2010).


In addition, implementation of an electronic medical record system in primary care can result
in a positive financial return on investment to the health care organization. Many health care
professionals claim that the financial cost is not worth the gain because implementation of
EMR cost big amount per year. However, I believe that the benefits of EMRs outweigh the
costs by reviewing several research studies. From recent studies by Wang, he obtained
figures to show cost benefit by comparing average annual expenditures per provider at
Partners HealthCare EMR System (Boston) before the implementation of EMR and expected
percentage cost savings after implementation. The average cost of a chart pull is about $5
while chart pulls reduced by 600 charts after implementation of EMR system. He added that
EMR system with its “ Clinical decision support alerts and reminders can decrease utilization
by reducing adverse drug events, offering alternatives to expensive medications, and reducing
the use of laboratory and radiology tests” and result found that after conversion to EMR
system its reduced billing error by 78%. Based on information from other studies, “one clinic
was able to reduce chart pulls by 60% to 70% and its medical records staff by 50%, for an
annual savings of about $4000 per provider “(Renner, 1996). Although providers are
concerned with return on investment, but not all EMR benefit are measurable in financial


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term, we should realize that the gains from implementation of EMR system includes helps
more in efficient decision making, increases patient safety, reduce billing error, improve
efficiency, reduce drug expenditures, reduce medical costs, improve utilization of radiology
test and so forth.




 Figure 4: annual expenditures before implementation of EMR and expected percentage cost
    savings after implementation of EMR at Partners HealthCare EMR System (Boston).



However, excessive trainings are required to assist physicians to familiarize and comfortable
using the EMR system. Although, some physician reported that they need 6 to 12 months to
comfort with EMR system but even after training they often less productive because EMR
slows them down (Smelcer, 2009). However, Kushinka said training is often most intense in
weeks and days before the transition and it is believe that without continuous and structured
follow-up training the benefits of EMR system will never fully utilized. Meanwhile
organizations should realize what benefits the EMR transformation can bring to them rather
than they have too much concern on budget incurred for staff training which as it was agreed
by Kushinka that “the cost of training for EMR adoption should be regard as investment
rather than as an expenses”. Organization should provide sometime for training staff and
clinician by hiring temporary staff to support nursing staff during the initial training or paying
overtime so that they can catch up their work in evening. Moreover, training sessions helps
clinician to know why EMR adoption is necessary by explaining benefits of EMR and how it
has impact on the entire data flow. The implementation of EMR system will assist in


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providing better patient care, complete day to day activities, reducing documentation time
and improved quality of care.


4.0 Conclusion


EMR gives the opportunity for healthcare organizations to improve quality of care and
patient safety. Integrated healthcare system provides comprehensive, reliable, relevant,
accessible, and timely patient information from multiple computer and location beyond office
to each healthcare provider without physically retrieving a paper chart. However, there are
also issues associated with EMR implementation. In order to support the barrier in EMR
implementation, government and providers should involved in investigating, motivating and
provide some encouragement to accelerate the development of solutions. Before the
implementation of EMR, organization should gather much information regarding the issues in
EMR and the information then must be reviewed and analyze to identify its pro and cons in
order to develop successful EMR.




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5.0 References

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Armijo, D, McDonnell, C. & Werner, K. (2009). Electronic Health Record Usability
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Horowitz, B. T. (2010). EHR Adoption Costs Medical Practices $120,000 Per Physician:
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Tonnesen, A. S., Tucker, D. & LeMaistre, A. (1999). Electronic Medical Record
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