The cost of healthcare is a serious concern for many governments. The health burden seems to be on the rise despite advances in medical technologies. There are newer disease strains, increased virulence of some diseases, issues like drug resistance, and increased people mobility increasing the rate of spread of diseases.
This is not to say that healthcare has not improved. Rather, it is the recognition that while there is improvement in healthcare standards, the cost is also on the increase. Cost management measure in healthcare includes expanding access to medical insurance such as Medicare and Medicaid.
The long-term efficacy of public healthcare systems depends on increasing efficiency to keep the cost of healthcare affordable. IT is proving useful as a means of increasing efficiencies in most industries. IT is already in use in health facilities. In conventional health facilities, IT finds use in areas such as billing, procurement, pharmaceutical services, and patient registration.
However, most conventional IT systems in Health institutions are not integrated. Even where integration exists, usually its aim is to streamline the business process. As such, there was a move to spread the benefits of IT in the management of health information retrieved from patients.
This brought about the concept of Electronic Medical Records (EMR). The role of EMR is to make patient information available across the medical value chain to increase the efficiency of medical care. The term Electronic Health Record (EHR) sometimes replaces EMR in literature.
Therefore, this paper uses them interchangeably. While EMR refers to the whole system comprising the hardware, software and the medical information in it, the information relating to a specific patient comprises the Personal Health Information (PHI) component of the system. The law protects PHI to deter breaches of patient privacy by parties with access to the information.
Structure of the Paper
The goal of this paper is to explore the contemporary issues surrounding the implementation of an EMR system. Specifically, the paper examines the stakeholders in the EMR system and their impact on the system. Secondly, the paper looks at the benefits associated with the use of an EMR system.
In addition, the paper examines some of the challenges and controversies EMR systems present. There is a brief look at the legal framework covering the use of EMR systems in America under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. This discussion gives way to a look at the future of EMR.
Stakeholders in the EMR System
It takes the effort and cooperation of a number of stakeholders to ensure the proper operation of the EMR system. As an IT-based platform, EMR relies on the expertise of IT professionals to operate. This category of stakeholders includes software designers, software vendors, IT administrators, and Hardware suppliers.
Their role is to avail and manage the IT infrastructure on which the system operates. There are several classes of stakeholder under each category. For instance, there are commercial software developers and open source developers.
The second category of stakeholders is those in the medical fraternity. They include the medical institutions using the EMR system. They also include the medical professionals who feed information into the system, or access the available information in order to provide care for the patients in the system.
In addition, there are support professionals such as laboratory technicians, pharmacists, radiographers and others who provide specialized services in the medical institutions. This category of stakeholder represents the primary users of EMR systems and it is responsible for entering data into the EMR system.
Patients form a very important category of stakeholders. They are the primary beneficiaries of the systems. They are also the source of information stored in the EMR systems.
Apart from the benefits, patients stand to suffer from risks associated with the operations of the EMR such as wrong records leading to erroneous diagnosis, or breach of their privacy based on wrongful use of the information help in the EMR systems. Patients stand to suffer the most, or benefit the most from EMR systems. Their main concern is the privacy of the information they provide. This is the basis of the HIPAA and HITECH laws.
Other stakeholders include regulators such as health agencies, and researchers who use aggregated information from the EMR to improve the services offered. Researchers who take an interest in EMR systems come from the IT industry and those involved in epidemiology and public health.
The federal government also forms part of this group of stakeholders considering it creates the rules that all other players live by. Insurance companies also are important stakeholders in the EMR industry because the operation of the industry affects their businesses. These stakeholders have legitimate claims to access data stored in the EMR systems.
Justification of EMR Systems
The justification for using EMR revolves around the efficiency of these systems and potential uses of electronic records as compared to paper records. Paper records still feature prominently in medical institutions as the means for gathering patient data. The transition to EMR is still underway, with a legal deadline set at 2015.
Paper records are very easy and convenient to handle during data entry. However, information storage and retrieval of paper-based systems is very expensive and inefficient. Paper records create serious logistical challenges that compromise the quality of healthcare. The difficulties of information sharing between institutions make paper records almost useless when it comes to determining a patient’s medical history. EMR on the other hand makes storage and retrieval easy, and reduces duplication of effort.
From the level of providing national healthcare, EMR promises to help cut the overall cost associated with health records. By using IT based systems, the need for warehouses to hold patient records disappears. Instead, medical institutions can use general IT silos, constructed for the storage and retrieval of digital information.
The health facility does not need to build its own data warehouse because of the availability of space in commercial data warehouses at competitive rates. In addition to these, the availability of information about a patient from multiple points eliminates the need for duplicate tests because each medical caregiver can refer to test results and treatment history indicated in the PHR of a patient. These records are available with the EMR infrastructure.
EMR also assists in increasing the efficiency of the entire healthcare value chain. Within the health facilities, the trend is to integrate the EMR system in use with the business systems such as medical supply order processing systems, and billing systems to increase the efficiency of the medical value chain.
Secondly, financiers such as insurance companies, can access better information regarding healthcare. This makes it possible for them to offer competitive premium rates based on the data. This is simply another benefit to the medical care value chain. All the stakeholders experience certain advantages derived from the benefits of EMR.
Benefits of EMR
Apart from the fundamental justification of EMR, there is a need to explore the specific benefits of the EMR systems in more detail. This section discusses the benefits of the EMR to various stakeholders.
Patients
Patients are the primary beneficiaries of EMR. Most of the advantages stemming from the use of EMR lead to better care for patients. The first advantage that patients get from EMR is that they have more control over their medical information. By using PHR access portals, a patient can add supplementary information to their health record thereby making a permanent entry to the EMR.
This control assures the patient that a physician taking care of him or her has access to all the important information. EMR systems trace the source of information in it. This enables physicians and other medical professionals to separate information provided by medical professionals, from that given by the patient.
The second benefit patients derive from EMR is that they are at a lower risk of wrong diagnosis. This means that a patient can get accurate treatment of ailments simply because the caregiver has access to the patient’s full medical history. Better care means that the patient can recover faster and resume a productive life quicker.
The costs of care also diminish because a patient does not have to spend their health cover on repeat tests after moving from one jurisdiction to another. All healthcare providers with access to the EMR have the same record to work from regarding a specific patient. There is no need to create duplicate files about the same patient.
EMR also provides physicians and other healthcare providers with several benefits. First, post-entry data management tasks reduce dramatically for the medical professionals. There is no need to spend time classifying paper records and sending them to warehouses. In addition, the process of retrieving information does not involve lengthy searches in a warehouse. Electronic systems make it very easy to access the records of a specific patient.
A healthcare professional can view all the tests undertaken and results posted from the comfort of a consultation room, and without waiting for them to come from a warehouse. They can also determine the best course of medical action to take very fast because there is no need to generate a new medical history.
Secondly, healthcare providers also enjoy the benefit of reduced risk of making the wrong diagnosis because of the availability of the medical history of any patient they are treating. It also eases referrals to specialists who can then determine treatment and other medical interventions necessary for a given patient based on the physicians entry on the EMR.
The specialist can view the full history of a patient’s condition without necessarily consulting with all the medical caregivers who have previously attended to the patient. The overall work rate of a physician working with EMR increases because of the ease with which patient records are available.
To healthcare institutions, EMR also posts several benefits. The entire institution stands the chance of increasing its overall efficiency by using EMR. In a healthcare facility, paperwork constitutes a critical component of service provision. A healthcare institution can eliminate a layer of overheads related to managing paper records simply by installing an EMR system. This cuts costs and increases the workflow rate in the entire medical institution.
For smaller practices, using EMR can increase patient confidence because of the integration with the overall healthcare system. A patient can enjoy personalized service with the assurance that their medical records will be accessible at any other health facility they will visit in the future.
Secondly, fewer medical errors by caregivers mean fewer cases of legal action or loss of practice license. This advantage reduces further the overheads a health facility incurs related to legal suits arising from negligence or medical errors caused by poor information. This also creates the added benefit of increasing patient confidence in the institution.
Another benefit health a facility derives from an EMR is that it can do away with warehouses used to store medical records in paper format. These warehouses can be quite large because of the amount of paperwork medical records tend to generate. There is a legal requirement to store paper records for at least seven years after their creation. The warehouses also need staff to maintain them. By eliminating paper records, health facilities no longer need to pay salaries of the staff involved in managing paper records.
Regulators derive several benefits from EMR. For the purposes of this paper, regulators refer to state and federal authorities active in the health sector. One area where regulators find benefits from the EMR is in the matter of epidemiology. Through the data provided from the EMR, agencies involved in the protection of public health can detect the spread of diseases and other health conditions. This enables them to develop responses that inform the quality of healthcare in their jurisdiction.
Similarly, the federal government is in a position to make better healthcare choices based on the data collected through the EMR. Reduction in healthcare costs makes it possible for the federal government to improve the quality and range of services offered to the public based on the benefits derived from EMR systems.
In total, EMR leads to a reduced health burden because of efficient care and lower cost of care. This advantage increases the overall productivity of the workforce, and frees resources for use in other areas of the economy.
Researchers are very critical in healthcare delivery. Within healthcare, there are several categories of researchers tackling various components of healthcare research. Researchers involved in healthcare issues do not only include medical researchers. There are other categories such as IT researchers and workflow research specialists.
The most significant benefit researchers derive from EMR is that it makes available high quality data. Researchers with access to EMR can use very clear data in standard formats to pursue their research needs. Unlike in the past when they had to collect data from various repositories, EMR is one large data pool where researchers can collect data quickly and in highly usable formats. The integrity of the data is also very high.
Researchers also enjoy the ease and speed of access to the data. They no longer need to deal with multiple authorities in order to access data. Since it is possible to aggregate electronic data, manipulating it is also very easy, which increases the range and quality of information researchers derive from EMR. It was almost impossible to remove identifying details in paper records to make it easy to use in research.
However, with EMR, it is possible to get the information relating to medical histories and treatment regimes without including the personally identifiable patient information. This also reduces the anxiety patients previously felt when researchers perused their data.
The final categories of stakeholders who benefit from EMR are other providers of healthcare support services such as insurance agencies and software vendors. Insurance companies are very important partners in healthcare financing. These companies use the data from EMR to calculate premiums. EMR reduces the cost of healthcare by reducing duplicate costs such as repeated medical tests when previous records are not available.
In addition, EMR eliminates the time and effort previously used to collect, store and retrieve medical records. This translates to reduced cost of medical insurance and increased quality of the services offered. Other stakeholders who provide support for healthcare also glean many benefits from EMR. For instance, software vendors and hardware providers in the health sector are in business because of the need to install and maintain EMR systems in health facilities.
Secondly, better records make it possible for pharmaceutical companies to determine the efficacy of drugs they provide. This is important when carrying out research regarding drug resistance, and when examining potential side effects of recently introduced drugs. These records provide all round benefits for anyone who needs information to provide better services in the healthcare setting.
Controversy Surrounding EMR
While there are glowing benefits of using an EMR, a number of practical problems accompany the use of EMR. Physicians suffer the brunt of these problems because they are the primary data entry professionals in the EMR systems. The first category of problems they encounter relate to usability.
Secondly, there are concerns about the overall effectiveness of EMR systems in cost savings for medical institutions. Thirdly, data security is of great concern to patients and finally, there are a number of hardware and software challenges dogging the use of EMR systems.
Usability
EMR systems have several documented usability problems. These problems come from the fact that there is no general standard when it comes to EMR design. Different software development firms adopt different system design standards for their systems. This results in a situation where there are numerous interfaces for EMR software developed by different companies. The difference in interface layout design is reducing the efficiency of physicians.
Physicians have to learn to use different EMR systems in the different facilities where they work. For instance, a physician based in one medical facility uses the EMR system in that facility to enter patient data. However, when that physician goes to another medical facility either as a consultant or as a supporting physician, chances are that the second facility uses a different EMR system.
This makes it necessary for this physician to learn how to use several EMR systems in order to be effective in each health facility that they visit. It is normal for physicians to use several EMR systems depending on the number of healthcare facilities that they work in. This situation is reducing the quality of user experience with EMR systems from the physician’s point of view.
In addition to reducing the quality of their experience, it obviously takes a lot of learning to become proficient in the use of several distinct EMR systems. Learning to use different EMR systems is making it very difficult for physicians to operate the systems as efficiently as expected. The systems tend to be complicated with different layout design, menu arrangement, naming protocols, and different data entry procedures.
Another well-documented problem is system access. Physicians are suffering from “password fatigue”. In each facility a physician visits, he needs a password to access the EMR system there.
In addition, each time a physician moves from the consultation room to the examination room, he must log out from the previous location and login in the new location. As if this is not enough, many facilities require physicians to change their passwords on a regular basis. Worse still, the passwords settings of some EMR systems require a combination of letters in both upper and lower case, and numbers. This makes access very difficult for physicians.
Cost Savings
In theory, IT increases operational efficiency, which should result in decreased overheads. Many sectors report gains in efficiency due to the adoption of IT based systems. In fact, even health facilities have seen savings and gains in efficiency because of the adoption of IT in the procurement of medical supplies and billing.
However, IT also comes with costs, which may wipe out any gain in efficiency. There is a lively debate relating to the potential of EMR to cut down healthcare costs. In large facilities, it seems that IT brings in large gains because of the historical operational inefficiencies associated with large medical facilities.
Large institutions benefit from the economies of scale, which IT harnesses. However, for smaller practices, the use of EMR systems creates an additional layer of overheads. The cost of installation and maintenance of EMR for small practices can wipe out the benefits it promises. In fact, some researchers have shown that adoption of EMR by small practices can result in increased overheads . It does not always bring about a reduction in operating costs.
While EMR systems bring about cost savings that accrued from management of paper records such as warehousing costs, the EMR systems also come with an additional layer of costs. There are hardware and software costs, and the cost associated with maintaining IT staff in the organization. Therefore, it is not always true for every organization that introduces EMR will see savings in their overall costs.
On another front, IT systems work at their optimum once there is widespread adoption and use of the systems. The barriers physicians face while using EMR systems is reducing the overall benefits of the systems. For instance, the time it takes to enter data into the EMR is longer than the time it takes for a physician to create a paper record. The experience of a patient getting attention from a physician who is not fluent in the use of EMR systems may be worse than their experience when using the physician uses paper.
Security Concerns
With the expansion of interconnection of IT based communication platforms in the last two decades, information security has taken center stage as the most significant threat to IT. Individuals and corporations alike need constant assurance that their information will be safe in the long term. With EMR systems, a very large network of people can access the information stored in the system. Any physician with access to the EMR can access data relating to any patient.
In addition, there are IT specialists, regulators, and insurance service providers with access to these systems. The numbers of potential people who can access the health records of an individual makes patients feel unsafe to have their PHR stored in EMR systems. That said, there is another layer of threat from cyber criminals. The motive of cyber criminals may by terrorism, criminal intent, or mischief. Whatever the case, patients are wary of the potential outcome of unauthorized access to their health records.
Privacy is also a matter of concern for many patients. Different people have different views on privacy, with some regarding privacy as something very important. Other people may not attach a lot of weight to the privacy of the information they provide as long as no one uses it to harm them. EMR complicates the arrangements that previously existed, which assured patients of confidentiality of their personal information under client-doctor privilege. EMR allows anyone with access to the system to access this information.
To increase information security, database management technology is advancing. Information silos are taking on data encryption to deter unauthorized access. Such a measure works well for unauthorized users, but it does not prevent leaks from those with authorization to access the EMR. Other data protection measures include the use of passwords, and tracking the users who access data in the EMR.
Tracking users do not work in situations where unauthorized persons use the accounts of authorized persons to access patient information in the EMR. Password based systems lack authentication capabilities. Therefore, it is possible to gain access to a physician’s account in the EMR after obtaining the physician’s password through phising. This demonstrates that there are still serious concerns relating to privacy and information security plaguing the use of EMR systems.
Software and Hardware Issues
EMR software comes in various forms. The most common form of EMR software is commercial software where the medical facility buys EMR software from a vendor under a license allowing for institution-wide use. Commercial software comes with technical support and at times, the software development company provides training for staff and other EMR users to improve uptake.
EMR software is useful only if the users are competent in its operations. Depending on their needs, medical institutions can choose from several commercial EMR software options. Each institution chooses the software that it feels meets its needs in the best way.
Apart from commercial software, open source software is also available for facilities that cannot afford commercial software, or are not ready or willing to pay for commercial software. Open source software depends on volunteer software developers who keep improving the quality of the software. Usually, a central committee moderates the development of the software and releases improvements over time.
Open source software can be a great place to start from because of the lower upfront obligations. That said, open source software frequently lacks dedicated support. The most common type of support available for open source software is through user forums. Through these online forums, users share experiences and potential fixes to glitches in the software.
The third type of EMR software is available under the arrangement called Software as a Service (SaaS). This version refers to a system where the software development company retains all rights to the software and does not sell the software as a product to users. Rather they give users a license to use the software for a period. The software remains in the provider’s server and the users access the software on demand.
The advantage of SaaS is that the developers can keep adding to the functionality of the service without the need to send copies of updates to the users. This makes SaaS a very reliable way of providing services. Difficulties associated with the use of SaaS include data management and transition to new platforms. Data storage is easier for the institution because the software development company invests in storage hence client health facilities do not need their own data silos.
It also protects the medical institutions from local threats such as the crushing of servers, destruction of data silos, and local sabotage. The software development companies can afford to implement higher-level security protocols for the data in their silos. However, the issue of access is still very thorny. Storing patient data in a third-party information warehouse exposes the data to information security threats. It is also very difficult to move data to a new data warehouse if the storage facility is not under the control of the health institution.
Other software related issues affecting the operation of EMR is data entry capabilities. The latest technologies supporting data query are still insufficient for Natural Language Processing (NLP). NLP refers to the capacity of software to aggregate data related to the same subject but expressed in different phrases.
The most developed technologies in this regard utilize keyword search algorithms. Keyword based systems cannot decode contextual meanings when aggregating data. Different physicians use different expressions to refer to the similar conditions. In addition, the medical vocabulary used for similar medical conditions tend to be diverse. The main limitation that this brings about is that it makes data aggregation very difficult.
It limits the usability of the data collected in the EMR. One of the ways of overcoming this challenge is by using electronic data collection forms with standardized vocabulary. This option is useful for medical services such as laboratory tests, and for diagnosis. However, the conclusions from these processes cannot fit on a form-based system.
A minor issue with huge consequence that also fits in this category of problems is the use of different spellings to refer to the same conditions. The spelling problems arise because of the differences in regional spelling standards, or simply wrong spelling of medical terms based on subjective mistakes. This also complicates the usefulness of EMR systems.
Legal Framework for EMR
The two main laws surrounding the use of an EMR is the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. These laws define the legally accepted use of medical information and address the rights and liabilities of various stakeholders.
In particular, these laws look at the parties involved in conveying health Information and seek to deter the misuse of health information. HIPAA sought to establish limits surrounding the transmission of “individually identifiable health information”. HIPAA served to reduce the risk of unauthorized information sharing by determining parties with a legal right to access medical records and the penalties for disclosing medical information.
Parties with access to personalized medical information include healthcare providers, healthcare funders, and regulatory agencies. Information meant for wider audiences such as researchers, by law, cannot include individually identifiable information. The law requires the removal of all information such as names of patients and the identity of their employers before transmission.
Some reviewers of the implementation of these laws felt that medical practitioners were more cautious about sharing information than these laws required . The explanation for this phenomenon is that there is an increase in the number of cases against medical practitioners. The professionals in the field feel that it is better to be stricter than required instead of dealing with a case in court.
The Future of EMR
It is difficult to imagine a future without EMR systems. While EMR is responsible for a new set of issues, its benefits, and potential, make EMR a necessary part of the future of medical services. The implementation of EMR led to the realization of other potential benefits that a medical facility could derive from it. These benefits outline the future of EMR.
The first element is that there will be increasing pressure from healthcare institutions to have EMR systems that improve a physician’s workflow. This is indeed the first advantage that EMR promised in addition to availing the information needed to treat a patient on-demand.
A physician’s workflow is a very important business element in the provision of health services. Reducing the work processes a physician undertakes to deliver healthcare, or improving the turnaround, makes physicians more efficient. In terms of resource commitment, a physician who concentrates on the highest value work makes more money for the healthcare facility than the one who handles other mundane tasks that reduce the effective high value time the physician spends waiting for the completion of processes.
Future EMR will strive towards improving physician workflow. The essential element of the workflow is the need to have faster, yet safer means of accessing data from different points in the healthcare value chain. There are movements towards e-medicine where a physician is able to treat a patient using virtual contact.
In the conceptualization of these systems, an experienced surgeon can supervise a surgery remotely, while specialists can render views on MRI scans and other tests from remote locations. The ability to do this without incurring travel costs will improve physician workflow leading to increased profitability for healthcare institutions.
Secondly, EMR systems will tend towards greater integration with other electronic systems to improve efficiency. This will take place at various levels. One of the major problems bedeviling EMR is information security. The use of complex passwords is cumbersome especially if there is need to log in at different locations within the same facility. The simplicity of a password based security system explains its current widespread use, not just in EMR, but also across the entire IT industry.
The problem with passwords is that there are no means of authenticating a login if a user gives a correct password, even if they are not the ones authorized to use that password. Already, there are many options available for better authentication based on biometrics. The options here include fingerprint scanning, iris scanning, facial recognition, speech pattern recognition, and hand dimension recognition (CITE).
These technologies require an additional investment in IT infrastructure. In addition, they can only provide security if they are available at all possible access points. It is possible to implement such systems within a closed facility, but it would be very difficult to support remote login.
However, with improving technologies, the standardization of security systems will make it possible for EMR systems to implement these security measures. For instance, most of the latest laptops come with a camera as a standard feature. This hardware can form the basis of a face recognition based security option for EHR.
There will be an increase in the standardization of EMR systems based on consumer needs. As software developers understand user needs better, they will be a convergence of systems to make it easier for physicians to interact with different EMR systems.
In part, this will reduce the current problems physicians face when they move from one facility another with different EMR systems. It is also likely that there will be an increasing degree of compatibility between EMR systems to reduce the problems associated with the use of different EMR systems.
In the last few years, mobile web is proving to be a serious competitor to traditional computer-based access to the internet. With the advent of smart phones, EMR systems will find their way to mobile devices . Physicians will have the option of accessing EMR systems using applications on their mobile devices.
EMR for mobile devices will require different software platforms from those used for computer based access. Its benefits will include round-the-clock access. Physicians will be able to attend to emergencies faster because they will not need to have access to a computer to attend to a patient remotely. Their phones will be sufficient for this role.
One of the benefits some healthcare facilities are enjoying from EMR is integration with billing systems and even drug supply. This kind of integration will increase. In the near future, EMR will have full integration with e-commerce systems such that after treatment, a patient will be able to pay for services automatically. EMR systems will also include communication integration options reminding a patient of their annual checkups and upcoming appointments either by email or via short messaging to their phones.
Patients with electronic health devices such as pace setters, electric wheelchairs, hearing aids, blood sugar monitors among others, will have real time data relating to their health status fed into the EMR automatically. Such devices, in conjunction with mobile communication devices can collect and relay data directly to the EMR. Such systems can then alert a patient to see a physician, and in cases of managed care, the caregivers would have alerts sent to them to check on their patients.
These technological possibilities point to multiple futures in the use of EMR. Some of these ideas are already past the research stage, and are simply awaiting commercialization. They will improve the functionality of EMR and will improve the quality of healthcare.
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