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Electronic Medical Records Adoption Model

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(EMRAM) Electronic Medical Records Adoption Model

In health informatics an Electronic Medical Records Adoption Model (EMRAM) is considered by some to be one of several types of EHRs (electronic health records), but in general usage EMRAM and EHR are synonymous.[1]

Definition

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

Issues

As of 2006, adoption of EMRAM and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States, in spite of studies (such as Development of a Module for Point-of-care Charge Capture and Submission Using an Anesthesia Information Management System,[3] by David L. Reich, Ronald A. Kahn and David Wax, et al) showing revenue gains after implementation. Fewer than 10% of American hospitals have implemented health information technology,[2] while a mere 16% of primary care physicians use EHRs.[3] 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%.[4] 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. [5]

In the United States, the development of standards for EMRAM interoperability is at the forefront of the national health care agenda.[4] EMRAM, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with health information exchange (HIE), allowing for first steps in sharing share patient information(lab results, public health reporting) which are 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. [6] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are[7]:

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.

Older record incorporation

To attain the wide accessibility, efficiency, patient safety and cost savings promised by EMRAM, older paper medical records ideally should be incorporated into the patient's record. The digital scanning >

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.[8] 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.[9] 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.[10] 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.[11] 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, Electronic Medical Records Adoption Models (EMRAMs) 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), as well as IT personnels' resistance to design and implementation flexibility needed in the complex healthcare environment, and creating a collaborative environment that fosters communication between physicians and information technology project managers. Exemplifying this need are several highly publicized HIT implementation failures, such as one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system [12] as well as others compiled at a collection of cases of health IT difficulties by medical informatics specialists.[13] There are, however, several successful examples of EMRAM implementations in large hospitals, usually hospital systems that have had years of experience developing custom EMRAMs, for example the Veterans Administration hospital system, Kaiser Permanente's HealthConnect and the VistA EMRAM.

Technology limitations

Limitations in software, hardware and networking technologies has made EMRAM difficult to affordably implement in small, budget conscious, multiple location healthcare organizations. Until recently most EMRAM 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 EMRAMs can be securely implemented across multiple locations with greater performance and interoperability.[14] 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, Li-Ion/polymer batteries for battery life of up to 8 hours, biometric security, low-voltage processors and lighter weight solutions. For the new generation of Tablet PC, there are now EMRAMs that are fully handwriting capable[15]

Preservation

Under data protection legislation and the law generally responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, owns the information contained within the record and has a right to view the originals, and to obtain copies under law.[16] Additionally, those responsible for the management of the EMRAM 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.[17]

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

  • Digital signatures Most national and international standards accept electronic signatures.[18] According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer."[19] With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will continue to be prudent when using EMRAM.
  • Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006, national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM).[20]

Standards

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

  • ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMRAM systems, allowing easy interoperability between otherwise disparate enities.[21]
  • ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
  • CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
  • CEN - EHRcom (EN 13606), the European standard for the communication of information from EHR systems.
  • CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
  • DICOM - a heavily used standard for representing and communicating radiology images and reporting
  • HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMRAM systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
  • ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
  • openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.

Various factors involving the timing, the right players, market history, utility, and governance play a key role in the overall enrichment of the standard and certification development. The standardization and certification even though seem to bring uniformity in the EMRAM development, do not guarantee their acceptability and sustainability in the long run. [22] In 2005 the US Federal Government awarded a contract to CCHIT - Certification Commission for Healthcare Information Technology to develop certification criteria for EMRAM. Starting in early 2007 vendors began to utilize these certification criteria for their EMRAM systems.

Customization

Pricing for EMRAM systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMRAM systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit data entry based on a medical specialty, environment or other specified needs. There are also EMRAM systems available that do not use templates for data entry and therefore can be easily personalized by each individual user. Alternative data entry methods include concept processing, voice recognition, and transcription.

Caveats and concerns

There are issues surrounding the generation and management of the Electronic Medical Records Adoption Model (EMRAM), sometimes known as electronic health records (EHRs).

There are a two primary categories of the EMRAM; the "born digital" record and the scanned/imaged record.

The "born digital" record, which is information captured in a native electronic format originally is information that may be entered into a database, transcribed from an electronic tablet or notebook PC, or in some other manner captured from its inception electronically. The information is then transferred to a server or other host environment, where it is stored electronically.

The second category are records originally produced in a paper or other hardcopy form (X-ray film, photographs, etc.) that have been scanned or imaged and converted to a digital form. These records are best described as "digital format records", as their content is not able to be modified or altered (with the exception of the use of a third party software to make "overlay notations") as electronic records are. Most medical records generated preceding the year 2000 are of this category.

The process involved in conversion of these physical records to EMRAM is an expensive, time-consuming process, which must be done to exacting standards to ensure exact and accurate capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by any number of healthcare professionals over the life span of the patient, there exists a high probability of some of the content being illegible following conversion. In addition, the material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. Consideration should be given to developing a procedure to sample and verify images at a high ratio to determine the accuracy and usability of the scanned images prior to disposal of the physical records, if they are disposed of at all.

Further, all electronic repositories of information are subject to the need for periodic conversion and migration to ensure the formats they were captured in remain accessible over the life of the patient, and in some cases beyond, to the expected life of their heirs. Additionally, those responsible for the management of the EMRAM are responsible to see the hardware, software (applications) and media used to manage the information remain viable and are not subject to obsolescence or degradation. This will require generation of backup copies of the data and protection being provided to these copies in the event of damage to the primary repository. It will also require the planned periodic migration of information to address concerns of media degradation from use. These are all costly, time consuming processes that must be planned and budgeted for when making decisions to convert physical medical records to digital formats.

Another major concern is adequate protection of privacy of the individuals whose records are being managed electronically. This class of information (in the US) is referred to as Protected Healthcare Information (PHI) and its management is addressed under the Healthcare Insurance Portability and Accountability Act (HIPAA) as well as many State-specific privacy laws. The organization/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. Few EMRAM companies are truly secure and this remains a serious concern. Patientprivacyrights.org is a patient 'privacy' advocacy group that audits EMRAM companies and rates them for security policies and how well they safeguard patient information. Microsoft Healthvault is one of the first applications to be certified.

Lastly, EMRAM technology is a new frontier. It has attracted some notoriously unsavory individuals. Some of these companies have been shut down or 'disappeared', but not before extracting a high price from trusting physicians. DrNotes is an infamous example of the worst kind with a very colorful history. Doctorsinperil.org is an organization that helps doctors avoid unscrupulous companies. This organization aggregates complaints against EMRAM companies, verifies the authenticity and posts the results. Companies with brilliant marketing and polished demos don't necessarily fare well here where endusers speak up and the 'rubber meets the road', so to speak.

Comparison of EMRAM software solutions

Basic general information about major software solutions: creator/company, license/price etc., focusing on small-scale practice systems.

Creator Preferred Vendor Latest stable version Cost (USD) Software license
eClinicalWorks eClinicalWorks 8.0 ? Proprietary
e-MDs Razor EMRAM e-MDs 6.3 from $2,995 Proprietary
Praxis EMRAM Infor-Med ? 4 ?
CureMD EMRAM CureMD Corporation 10 (custom pricing) Proprietary
Medscribbler Scriptnetics Inc. 5 from $2,899.99 (custom pricing) Proprietary
MedicWare EMRAM MedicWare ? ? ? Proprietary
SOAPware SOAPware EMRAM Systems AutoMED Software 516.369.7091, Medisys 304-204-3400 5.x from $1,999.99 (custom pricing) Proprietary
NextGen EMRAM NextGen ? ? ? Proprietary
MediNotes e EHR MediNotes AutoMED Software 516.369.7091, Medisys 304-204-3400 5.2 from 5,000.00 Proprietary
JonokeMed Jonoke Software Development Inc. 4.05.01 ? Proprietary
HealthHighway EMRAM HealthHighway Inc. ? 3.1 ? Proprietary
HARMONY MedTec 5.21 ? Proprietary
OmniMD EMRAM OmniMD ? ? from $325/month (custom pricing) Proprietary
Creator Preferred Reseller Latest stable version Cost (USD) Software license

Operating system compatibility:

Client Windows Mac OS X Linux BSD Unix AmigaOS
eClinicalWorks EMRAM Yes No Yes No ? No
e-MDs 'Razor' EMRAM Yes Yes Yes Yes Yes Yes
Praxis EMRAM Yes No No No No No
CureMD EMRAM Yes No No No No No
Medscribbler Yes No No No No No
MedicWare EMRAM Yes No No No No No
SOAPware Yes No No No No No
NextGen EMRAM Yes No No No No No
MediNotes e EMRAM Yes No No No No No
JonokeMed Yes Yes No No No No
HealthHighway EMRAM Yes Yes Yes No Yes No
HARMONY Yes No Yes No Yes No
OmniMD EMRAM Yes No No No No No
Client Windows Mac OS X Linux BSD Unix AmigaOS

Public implementations

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

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

US medical groups' adoption of EHR (2005)

Adoption of electronic medical records by US doctors is increasing slowly. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially Electronic Medical Records Adoption Models (EMRAM) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey.[23] However, the survey also states that just 9.3% of these physicians actually have a "complete EMRAM system", with all four basic functions deemed minimally necessary for a full EMRAM: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.[24] Barriers to adopting an EMRAM system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options.[25] Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. On July 18 2006, CCHIT released its first list of 20 certified ambulatory EMRAM and EHR products.[26] and then on July 31 2006, additionally announced that two further EMRAM and EHR products had achieved certification.[27]

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

See also

References

  1. ^ "A State Policy Approach: Promoting Health Information Technology in California". California Legislative Analyst Office. 2007. {{cite web}}: Unknown parameter |month= ignored (help)
  2. ^ DJ Ringold, JP Santell, and PJ Schneider (2000). "ASHP national survey of pharmacy practice in acute care settings: dispensing and administration—1999". American Journal of Health-System Pharmacy. 57 (19): 1759–75. PMID 11030028. Retrieved 2006-08-04.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  3. ^ Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." WEllesley, MA: Center for Information Technology Leadership, 2003
  4. ^ Raymond, B. and C. Dold. "Clinical Information Systems: Achieving the Vision. Prepared for the Meeting "The Benefits of Clinical Information Systems" Sponsored by the Kaiser Permanent Institute for Health Policy, 2001.
  5. ^ Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601)
  6. ^ Walker J, Pan E, Johnston D, Adler-Milstein J, Bates D, Middleton B. The Value Of Health Care Information Exchange And Interoperability. Health Affairs. Web Exclusive, January 19, 2005.
  7. ^ NAHIT Levels of EHR Interoperbility [1] Retrieved April 4, 2007
  8. ^ Health & Medicine (2006-06-26). "At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded". Los Angeles Times. Retrieved 2006-08-08. {{cite news}}: Check date values in: |date= (help)
  9. ^ US Code of Federal Regulations, Title45, Volume 1 (Revised October 1, 2005): of Individually Identifiable Health Information (45CFR164.501) Retrieved July 30, 2006
  10. ^ European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive Retrieved July 30, 2006
  11. ^ CNN.com (May 23, 2006): FBI seeks stolen personal data on 26 million vets Retrieved July 30, 2006
  12. ^ Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper". The Washington Post. Retrieved 2006-08-03. {{cite news}}: Check date values in: |date= (help)
  13. ^ Sliverstein, Scot. "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties". Drexel University. Retrieved 2007-11-15.
  14. ^ EMRAM Experts: State of the Industry - Electronic Medical Records eBook Retrieved January 14, 2007
  15. ^ Handwriting and mobile computing experts: [2] Retrieved August 20, 2008
  16. ^ Medical Board of California: Medical Records - Frequently Asked Questions Retrieved July 30, 2006
  17. ^ National Archives and Records Administration (NARA): Long-Term Usability of Optical Media Retrieved July 30, 2006
  18. ^ American Bar [[Association, Section of Science and Technology, Information Security Committee: Jurisdictions with legislation regarding electronic signatures Retrieved July 31, 2006
  19. ^ American Bar Association, Section of Science and Technology, Information Security Committee: Digital Signature Guidelines] Retrieved July 31, 2006
  20. ^ The National Archives: Electronic Records Management Initiative retrieved July 31, 2006
  21. ^ Nainil C. Chheda, MS (2005). "Electronic Medical Records Adoption Model and Continuity of Care Records - The Utility Theory" (PDF). Application of Information Technology and Economics. Retrieved 2006-07-25. {{cite journal}}: Unknown parameter |month= ignored (help)
  22. ^ Nainil C. Chheda, MS (2007). "Standardization & Certification: The truth just sounds different" (PDF). Application of Healthcare Governance. Retrieved 2007-01-16. {{cite journal}}: Unknown parameter |month= ignored (help)
  23. ^ National Center for Health Statistics: Electronic Medical Record Use by Office-Based Physicians:, United States, 2005 Retrieved July 24, 2006
  24. ^ CDC's National Center for Health Statistics: More Physicians Using Electronic Medical Records Adoption Models Retrieved July 27, 2006
  25. ^ Gans D, Kralewski J, Hammons T, Dowd B (2005). "Medical groups' adoption of electronic health records and information systems". Health affairs (Project Hope). 24 (5): 1323–1333. doi:10.1377/hlthaff.24.5.1323. PMID 16162580. {{cite journal}}: |access-date= requires |url= (help)CS1 maint: multiple names: authors list (link)
  26. ^ Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products Retrieved July 26, 2006
  27. ^ Certification Commission for Healthcare Information Technology (July 31, 2006):CCHIT Announces Additional Certified Electronic Health Record Products Retrieved July 31, 2006
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