Introduction: Electronic Medical Records
Overview of Electronic Medical Records
Electronic Medical Records (EMRs) can be described as a digitized version of a patient’s medical history, prescribed type of care to be implemented as well as other health related information that a doctor or medical practitioner might need to efficiently and effectively diagnose and treat a patient’s current symptoms (What a Difference an EMR Makes, 2002).
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EMRs have been described as “the wave of the future” for the various advocates of their use due to the supposed advantages that come with their implementation in hospitals and medical institutions alike (What a Difference an EMR Makes, 2002).
Such advantages come in the form of a considerable reduction in human error, greater safety for medical records due to the possibility of a natural disaster or human negligence as well as supposedly providing hospitals with significant cost savings in the long term.
EMRs also come with considerable drawbacks such as the significant cost that comes with their implementation, the lack of EMR standardization across hospitals in the U.S. as well as privacy concerns involving the access of private medical histories to unscrupulous individuals.
The Role of Electronic Medical Records
In theory, the supposed role of electronic medical records at the present is that they should act as a replacement for the current manual filing and recording system utilized by hospitals and medical institutions. They would enable doctors and medical practitioners alike to immediately pull up a patient’s medical history and treatment procedures in a way that results in a more rapid and efficient method of medical treatment.
EMRs would act as the modern day version of the traditional patient history file yet is easier to update, store and locate. In practice, EMRs have been noted by doctors and hospitals alike as being costly, burdensome to update and are a basically a bad investment.
Evidence of this can be seen in a recent survey released by Julia Adler-Milstein, Carol Green and David W. Bates in the academic journal “Health Affairs” which showed that medical institutions and doctors should expect to lose $44,000 on their initial investment into EMRs despite the presence of government subsidies to encourage their use.
The problem originates from the disparity between the image the government has of EMRs and the actual product that doctors and hospitals have to deal with. The current image of the government involving EMRs is a quick and intuitive system that allows doctors and nurses alike to easily input and retrieve information through iPhone or iPad like devices in a manner that quick, clean and seamless (Solimeo et al., 2013).
There would be no extensive digging through file cabinets, no need to go from one end of the hospital to another and patients would not have to wait as long to be attended to. Unfortunately, present day EMR systems are counter-intuitive and have a considerable degree of repetition with medical practitioners often finding them aggravating to use (Financial Worries Curb Efforts To Employ EMRs, 2003).
Solimeo et al., (2013) in their interview of various doctors even showed in their study that the use of EMRs actually increased the time that doctors had to work in order to fill out the laborious details required in EMRs which often resulted in fewer patients seen and longer wait times to see doctors, all of which affected the efficiency and effectiveness of hospital services.
Further examination of the issue reveals that the problem with EMRs is that the various software designs currently in use, despite the various certifications attributed to them, have yet to reach a point of adaptiveness to the needs of doctors and the manner in which they work. As a result, instead of facilitating more efficient practices they actually impede them which is the exact opposite of what medical institutions desire.
The current issue of whether to implement EMRs or not, has its origins in both the desire of medical institutions to implement a quick and easy method of updating patient medical records as well as has its roots in the Affordable Care Act (Obamacare).
Basically, hospitals perceive the use of EMRs as a means of cutting down their labor costs while in the case of the ACA (Affordable Care Act) the government has set a deadline for the implementation of EMRs in various clinics and hospitals with a reimbursement incentive encouraging their implementation Solimeo et al., (2013).
While the concept of a reimbursement may seem appealing, what must be understood is that at the same time the government has also similarly implemented a series of penalties for non-compliance to what it perceives as a “necessary service” for patient care.
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Thus, for doctors and hospitals alike, it becomes immediately clear that they need to implement some form of EMR within their institution due to the current perception of the government that EMRs are a necessary medical standard.
In practice however, there are many within the field of medicine that consider the use of EMRs as a “necessary standard” for patient care as a reflection of the lack of knowledge of the government involving the current method of operations of most clinics and hospitals. What must be understood is that there is a difference between theory and application when it comes to utilizing electronic medical records.
The reason why examining such an issue is imperative is due to fact that the penalties associated with noncompliance to the ACA will start to be imposed. Numerous proponents both for and against “Obamacare” will correctly argue that EMRs as they are now at the present will increase costs without sufficient justification for their use yet they will also incorrectly argue that EMRs should not be utilized at all.
Other potential correct/incorrect arguments take the form of correct arguments stating that in the future EMRs do have the potential to save costs yet there will also be incorrect arguments stating that it is necessary to continuing moving on with the same flawed system despite its inadequacies.
What is necessary is to present both the advantages and disadvantages of EMRs in a way that can help to clarify future arguments regarding the potential use of such a system as a standardized practice.
Pros of Electronic Medical Records
Sharing of Patient Information
Electronic medicals records are an effective means of efficiently and effectively sharing patient data with doctors and medical practitioners (i.e. nurses, EMTs etc.). Williams and Boren (2008) explains that one of the main benefits associated with EMR is the use of a networked system which is comprised of a database, local area network, and methods of display such as tablet PCs.
Through such a system, patient data can be stored in a localized server and retrieved through either a desktop computer at a doctor’s desk or through a tablet PC that allows nurses to review a patient’s case prior to escalating their case to a medical practitioner.
Such a method of open access reduces the amount of time it would normally take for a doctor to track down the patient’s data via a closed file cabinet as well as supposedly helps to increase the efficiency of updating patient information.
Other apparent benefits of such a system is that it would save on storage space, studies such as those by Groves (2005) which explored office management solutions in ophthalmology practices and other specialties reveals that medical practices (i.e. clinics, private practice and hospitals) in general often seek to improve their operational efficiency and reduce their overhead cost through a reduction of “paper shuffling” (i.e. the amount of printed paper and paperwork) as well as the integration of functions in the office.
One way in which this has been achieved through EMRs is via the integration of patient history, content updates and billing for prescriptions and other medical procedures.
Previously, patients had to sign and fill out extensive forms for their insurance, doctors had to write out prescriptions for medications, and other such forms had to be filled out to indicate what practices had been done and what future doctors and nurses had to expect from the patient.
This often resulted in a considerable amount of paperwork that had to be shuffled from one department to another as well as had to be brought to the billing section as well as other such requirements as determined by operational procedure for that particular medical institution.
Delays in such a system often entailed the individual behind the operations desk (i.e. billing or other such departments) having to evaluate the various files that were given which can often take a extensive period of time leading to longer lines and waiting periods at hospitals.
EMRs resolve such an issue by accomplishing all the necessary filing via an online system that can instantly send information from one department to another enabling them to expect when patients will get to them, what had been done and how the billing will be accomplished.
Such a system would, in theory, greatly expedite the issue of discharging a patient leading to a more efficient process that patients would not find tiring due to the sheer amount of paperwork and the different departments they would have to visit in order to be properly discharged.
Necessity for better maintenance of records and patient discharge procedures
EMRs help to reduce hospital overhead costs through improved operational efficiency and less expenditure on paper and storage. Through the work of Ruffin (2002), an analysis of the L.A. County Department of Health Services (LACDHS) was conducted.
Based on the examination, it was noted that the main financial problems of the LACDHS stemmed from fixed or decreasing funding for the uninsured and inadequate information systems that they continued to utilize.
Such costs were the result of increased staffing requirements, storage costs for the medical records as well as an assortment of miscellaneous costs and expenditures associated within maintaining a primarily hardcopy system of records. To resolve the issue, the head of the LACDHS, Tom Garthwaite, proposed the implementation of an EMR system due the following identified problems:
a.) Since health care records are owned and organized by institutions, hospitals and medical groups, most Americans have many medical records. Ruffin (2002) states that the sheer amount of medical records per patient for a variety of medical procedures and checkups (dental, mental, cardiology etc.) often result in patient records reaching an inch thick or greater.
Combined with haphazard filing methods, hundreds of patients within a given week and limited storage space within hospitals, it is not surprising that hospitals and various medical centers would experience problems in storing and archiving such records.
Another factor that should also be taken into consideration that was identified by the article “Automated ER Triage Process Saves Money, Speeds Patient Care (1999)” is that the haphazard method of storing hardcopy records is one of the primary reasons behind improper medical procedures being performed on patients.
Various studies such as those by Lachman (2012) have revealed through interviews with hospital staff that it is actually a common occurrence for various parts of a patient’s hardcopy medical records to go missing.
As a result, various prescriptions, medical procedures and other types of tests that were already performed tend to go unrecorded resulting in the need to undergo such testing procedures once more. This can result in unneeded medical prescriptions or tests being performed which have the potential for adversely affecting the health of the patient.
b.) Most medical records are written by hand and illegible to everyone but their authors. An analysis of the Kinonen et al. (2012) which examined the degree of medical errors for outpatient and patient discharge procedures showed that a vast majority of the problems seen in this cases were caused by misunderstanding the instructions of the doctor.
As a result, a form of “guess work” was implemented by nurses and patients alike which led to either using higher than or lower than normal doses of the prescribed medication (Kinonen et al., 2012).
The end result was the implementation of improper treatment procedures which caused the patient to go back to the doctor with either the same problem that the medication failed to resolve due to the lower dose or an entirely new set of problems due to the higher than normal dose that they ingested.
Other studies which have examined the current state of patient medical records are actually in support of the implementation of EMRs given the standardization and legibility of the text implemented.
Li & Korniewicz (2013) states that if a standardized text that is clearly legible is implemented in the case of patient medical records through the use of EMRs, then it would be likely that instances of medical records due to illegible handwriting can be entirely avoided leading to better outpatient results for hospitals
c.) Paper medical records cannot be searched for keywords and do not have indices. One of the inherent limitations of hardcopy medical records is that they lack the ease of use found in many of today’s online search engines. For example, a quick search for “Crohn’s Disease” through Google can bring up a variety of articles and posts on the subject.
Similar search engines can be found in smaller networkers such as Pubmed (an online medical article repository) and EBSCO (the world’s largest academic article database). The purpose of a search engine is to utilize a series of keywords and tags found in specific articles or pieces of information in order for a user to easily find what they are looking for.
In the case of hardcopy medical records an assistant would need to go through several file cabinets and files to find the necessary documents pertaining to the patient. Given the sheer amount of patients that a hospital encounters on weekly basis, finding the right file could take 20 minutes or more which, as explained by Romanow, Sunyoung, & Straub (2012), is one of the reasons behind the long waits in many hospitals.
Romanow, Sunyoung, & Straub (2012) indicates that research and development into new ways of producing and utilizing technology is one of best practices most often seen in some of the most efficient medical centers in the world. This is due to the fact that technology has as of late been under a constantly accelerating level development and, as a result, has enabled better medical practices to be implemented.
As such, failure to sufficiently innovate along with new technological trends and products can be thought of as a failure on the part of the administrative practices at a hospital since being able to anticipate trends and use them to either increase hospital efficiency or create a better means of patient care is a necessity in today’s technology intensive medical industry.
It is based on arguments such as this that proponents for the implementation of EMRs such as Romanow, Sunyoung, & Straub (2012) state that their use is a necessary endeavor in order to resolve the current problem with paper records that many hospitals have to put up with which result in slower operations and longer wait times for patients.
EMRs and Hospital Services
Utilizing EMRs actually enables hospitals to provide better services by streamlining the process by which a patient’s information is accessed, shared and updated thus making the process less labor intensive and allows nurses to take better care of their patients.
Through the work of Altmann (2007), it was shown that hospital staff in general are overworked, exhausted and have to deal with stressful situations on a weekly basis. It is not surprising to see staff members undergo 12 to 16 hour shifts due to the sheer amount of patients as well as problems regarding staffing requirements. The end result is mistakes are made either during normal operations or outpatient procedures.
This can take the form of wrong dosages being written, improper procedures being listed down as well as an assortment of other potential problems that may occur.
Based on these problems, the implementation of EMR systems help to create a better work environment for hospital staff by streamlining the procedure for documentation as well as enables them to the necessary procedures and medicines from a set list of categories and dosages which helps to minimize the potential for problems to occur.
It should be noted though that there have been arguments that EMRs, as they are at the present, would create problems with hospital services since nurses and other medical practitioners will be unable to properly adapt to the use of EMRs given the sheer amount of complications seen in their use.
The main premise behind Benner’s theory of development involving the transition of a nurse from novice to expert involves the assumption that all individuals develop skills over time through the use of a sound educational base as well as a multitude of experiences in order to develop a certain degree of expertise within their particular field of nursing (Benner, 2011).
It is based on this that it can be stated that nurses and other medical practitioners could eventually get used to EMRs and eventually develop a certain level of expertise in them. In a way, expertise can be categorized as a movement away from reliance on distinct abstract principles that are presented in classroom lessons to the utilization of concrete experience in order to handle particular situations (Altmann, 2007) (Johnson, 2005).
As such, from the perspective of Benner, theory and practice intertwine in the development process of a nurse with theory being the starting point from which all successive actions are based upon with practice being the means by which such actions are improved upon resulting in a greater degree of efficiency, proficiency, improved decision making capacity and intuition regarding appropriate actions for particular cases (McNiesh, Benner & Chesla, 2011).
This means that while hospital staff may initially find it difficult to adapt to the new EMR system, they will be able to adapt in time.
EMR assists patients to better manage their data
It should be noted that aside from EMRs being available within hospitals, there has been an ongoing development wherein a patient can have an EMR located on their very body via an RFID chip that has been injected underneath their skin. An RFID (Radio-frequency identification) chip can considered an ingenious device due to its overall simplicity yet wide applicability in a variety of fields and applications.
The chip, no bigger than a grain of rice, works via system of query and transmission wherein the chip releases a coded identification number when it is queried by a reader device that produces the necessary type of signal.
The result is a method of tracking and identification which enables companies, medical institutions and even government agencies to immediately identify and track a particular object or person based on the RFID signal transmitted by an embedded chip.
For example, the Verichip, a small innocuous device no bigger than a grain of rice, was debuted in the latter half of 2004 as being a safe and efficient way for hospitals to access the medical history of a patient so as to speed up treatment and recovery via an embedded RFID chip in their arm.
In a way the advent of this particular type of technology could be thought of as a medical milestone, the future of medicine so to speak; wherein doctors, EMTs, nurses and various other medical personnel can quickly and accurately diagnose a patient’s current condition based on their medical history should the patient be unconscious, unable to speak or is relatively unaware of their own history of medical care.
From the point of view of medical practitioners the use of medical “chips” is a positive facilitator of medical care since not only can doctors respond quickly and efficiently to a patient’s condition but they can avoid utilizing particular medicines, procedures or methods of treatment should the patient’s medical record reveal a possible adverse reaction to the intended procedure.
Despite these apparent advantages, privacy concerns are at the forefront of the debate against their usage by the general public due to the potential for disreputable individuals to gain access to an individual’s private records via an appropriated RFID reader.
The case of Weis (2011) reveals that while the technology itself makes it easier to track, locate and facilitate the transfer of people, goods and services it has also made it that much easier for unscrupulous individuals to abuse the technology for their own ends Weiss (2011). This took the form of people who “stole” RFID identification data via a reader and embedding it in their own customized chips.
By doing so this in effect allowed them to access services without having to pay for them or even pretend to be someone else based on embedded RFID telemetry data. As noted by studies such as Weiss (2011) which examined the prevalence of hacking and hacking related crimes, any form of personally identifiable information that can be easily and openly accessed can be used by hackers as a form of identity theft.
Weiss (2011) pointed to the case of implanted RFID medical chips wherein people may not even realize that their medical information could be accessed, copied and used as way to for others to pose as them in order to receive free medical treatment (Weiss, 2011).
With the increasing prevalence of RFID usage also comes with it criticisms in the way in which it supposedly enables the government and private corporations to in effect track the movement of any individual broadcasting an RFID frequency.
For example, one of the current plans of the U.S. government is to implant an RFID medical chip in every U.S. citizen so as to facilitate easy identification of certain individuals leading to faster medical care.
Unfortunately, one of the consequences of having an RFID chip embedded within your body is that should there be RFID readers placed in certain public locations a person can in effect be tracked wherever they go which many consider to be a massive violation of privacy.
It must also be noted that studies such as those by Reza & Geok (2009) indicate that despite the increasingly sophisticated methods of ensuring that information within RFID chips can only be read by appropriate readers with the right type of authentication key, hackers and a variety of other unscrupulous individuals have also “stepped up their game” so to speak creating increasingly clever ways to circumvent the protective measures meant to ensure the safety of private data contained within the chips (Reza & Geok,2009).
Reza & Geok (2009) even notes that the problem lies in the broadcasting of information itself which is the main problem behind RFID chip technologies since it practically invites unscrupulous individuals to attempt to access this broadcast for their own aims (Reza & Geok, 2009).
Taking the factors that have been mentioned into consideration, it can be seen that be seen that the implementation of EMRs in hospitals help to control overhead costs by creating a method of increased efficiency by way of a centralized database that utilizes search engines in order to easily find and update the information of patients.
Through such a process this helps to resolve complaints involving hospital waiting times and results in better operational procedures for the hospital as a whole.
Cons of Electronic Medical Records
Resistance to change from local physicians who prefer physical rather than digital records
Through the work of Martinez (2005) which examined the utilization of EMRs in Detroit, it was noted that doctors ranging from ophthalmologists, cardiologists, pediatrics, OB-GYN etc. preferred the use of physical medical records over their electronic counterparts.
An analysis of other studies which noted such a predilection such as those by Klimek et al. (2011), Thrall (2007) and Merisalo (2002) revealed that the primary reason behind the preference for physical records was the manner in which information was placed in digital records.
The Groves (2005) study on the use of EMRs showed that usability was one of the main problems in California wherein many doctors and support staff found the menus, options, and the “necessary data field” selections confusing and often put in any random data in order to push the data through and into the system.
In fact, it was seen in several instances within the California medical system that the use of particular data entries that had no relevance whatsoever to what was actually done to a patient became a common place practice given the difficulty that the hospital staff had in utilizing the software.
While various training programs and guides have been implemented throughout several medical institutions utilizing EMR software, it was seen that the use of random data entries within data records continued to be a persistent practice.
Further investigation into this issue was done in the Furukawa et al. (2010) study which showed that time constraints combined with the sheer amount of patients that they had to deal with on a daily basis resulted in the use of such practices.
Unfortunately, while such practices may have made the input of data that much easier for hospital staff, it resulted in inaccurate estimates regarding the types of procedures being done within the hospital resulting in the allocation of resources towards trends in treatments that were never there to begin with.
Another way of looking at the resistance to change is from the concept of preference as seen in the study of Boonstra & Broekhuis (2010) who explained that doctors, nurses and hospital staff simply found it easier to utilize the current paper forms that the hospital utilizes in order to jot down a patient’s data.
Interviews conducted by Boonstra & Broekhuis (2010) showed that the lack of restrictions, the ability to add as little or as much information as necessary as well as the fact that there are not as many fields to place data in made the process easier resulting in a greater degree of preference for the “old way” of doing things.
Other studies that have analyzed this issue revealed that private practices (i.e. small family clinic etc.) simply preferred the use of paper records since they normally serviced smaller communities and had relatively fewer patients per day as compared to large hospitals.
Boonstra & Broekhuis (2010) elaborates more on this issue by explaining that one of the problems with the affordable care act is that it neglected to take into consideration its potential impact on small private practices wherein such clinics may be required to implement expensive EMRs when it is not necessary.
Chou et al., (2011) even explains that the resistance to change towards the use of EMRs was simply because physicians believed that they had no need for the software given their limited amount of patients.
This is an aspect of EMR standardization that should be looked into in the future when it comes to standardization of medical practices across the U.S. It creates the question: if a small family clinic or medical practice does not require EMRs given the small amount of patients it services on a daily basis, does it still need to implement an expensive EMR system due to the need for medical standardization?
Developers who create medical record programs do not think in the same manner as doctors and, as such, this creates problems in the way in which information is presented and shared between medical institutions and patient care facilities.
Through the work of Nowottny (2007) which investigated the use of EMRs in medical centers around the U.S., it was seen that one of the primary complaints involving the use of such technology was from a user operation standpoint.
Ilie et al. (2009) explains that despite the numerous certifications attached to a variety of commercial EMR programs that indicate that they can be used in medical centers, the fact remains that hospital staff (even with training) continue to find aspects of the software to be unwieldy and results in operational inefficiency rather than operational efficiency.
Common complaints range from the layout of the data fields, the numerous data requirements that prevent a file from being sent without them being filled out, as well as the numerous categories, drop down menus and checklists that have to be selected which cause a considerable degree of confusion for the hospital staff.
Based on the work of Zaccagnini (2010), it can be stated that the issue behind the development of commercially available EMRs is that they were created with insufficient input from the very users who are to utilize the program on a daily basis. As a result, there is a significant level of disparity between the theoretical application of EMRs as increasing work efficiency as compared to their actual performance in the field.
The main issue originates from the manner in which program developers simply do not think in the same way as actual medical practitioners. This is reflected in the sheer amount of fields and categories that program developers believed would help in categorizing patient records but in the end actually resulted in an increased workload for hospital staff due to the sheer amount of data that they have to input into the system.
Valdes et al. (2004) explains that hardcopy medical records gave staff the advantage of inputting data on an “as needed basis” in that they could place as little or as much information as they desired based on their current workload. This enabled them to handle multiple cases at the same time while enabling them to concurrently update patient records “on the go” so to speak.
The multiple field and category requirements in present day EMR systems prevents medical staff and doctors alike from their former practice of data entry wherein it requires them to input an extensive amount of information on the patient in order for the data to be sent to the main server.
Doctors and hospital staff alike state that such an unwieldy system has caused them to work slower and has increased the amount of time they spend merely inputting information on the patient instead of actually treating them. This is a major concern given that EMRs were meant to increase operational efficiency and not decrease it.
Transferring Medical Records
Lack of sufficient interoperability and sharing between different medical institutions that have their own methods of storing and sharing patient data creates an issue when it comes to knowing patient histories.
Through the analysis of Ilie et al. (2009), it was seen that there are numerous types of EMR software currently in the market today such as MediTouch, Waiting Room, Kareo, Medios, Vitera and Greenway. While the diverse nature of the software ensures the creation of a competitive market environment, the sheer amount creates issues when it comes to inter-center transferability of patient data.
For example, MediTouch which is a cloud based (i.e. online software) EMR has a different method of file formatting and data storage as compared to Medio, Kareo and Vitera which are primarily LAN based server software which operate only within a particular network.
As a result, should a patient transfer from one hospital that utilizes MediTouch to one that utilizes Medio, Vitera or Greenway, their EMR cannot be transferred along with them due to software compatibility issues.
Of course one way around this problem would be to simply print out the records and take a physical copy to their new hospital and create new records, however, such a process would not be any different than original hardcopy medical records that are currently being utilized.
What is needed in the case of EMR software within the U.S. is the capacity for sufficient interoperability and sharing between different medical institutions. Angst & Agarwal (2009) points out that while the idea of interoperability and sharing is the best solution to such an endeavor, it is unlikely to be implemented at the present due to the sheer amount of different EMR software that currently exists.
There is no specific type of software that has a significant enough market share to be utilized as the “go to” software for hospitals and medical institutions. Not only that, the AMA has not created a set prescribed any set format when it comes to file formatting differences among medical institutions.
This is another of the problems that the ACA (Affordable Care Act) has glossed over wherein it requires hospitals and private practices to implement EMRs set has not determined what sort of interoperable formatting should be implemented.
In effect, the ACA actually promotes divisiveness of medical care within the U.S. since hospitals cannot transfer electronic records with each other and have to rely on hardcopies which defeats the purpose of having EMRs in the first place.
Another point of view on the issue is from Carlson et al. (2010) who explains that while multiple studies such as those by Angst & Agarwal (2009) and Nicholson (2011) lament problems on interoperability and sharing, they neglect to examine how this could potentially impact patients on a local and regional level.
The fact that EMRs cannot be transferred digitally could result in numerous complications should a medical emergency happen to a patient in another hospital and their medical records are needed in order to properly treat them.
On the other end of the spectrum are studies such as those by Letrilliart (2009) who point to the lack of standardization of EMR formatting as consumer issue wherein the sheer amount of difficulty in transferring and updating digital records from one medical institution to another actually causes them to stay in one hospital despite more affordable treatment being available elsewhere.
It is based on such issues that a solution must be devised to create better interoperability and sharing between different medical institutions despite the proliferation of numerous varieties of EMR software currently within the market today.
Possible data lose or corruption could result in wrong dosages being prescribed or patient medical histories being corrupted to the extent that a misdiagnosis can occur. Through the work of Abraham, Watson & Bcudreau (2008) examining hospital medical errors and various forms of malpractice, it was seen that EMRs cannot be considered an infallible system.
Various cases in the U.S. presented by Abraham, Watson & Bcudreau (2008) show that an assortment of errors related to hardware malfunction, viruses, software corruption and an assortment of other problems that can impact the functionality of EMR software can result in damage to the EMR data which could result in problems in indicated procedures as well as the type of dosages prescribed.
In one case presented by Jones et al. (2010), an error in the EMR system resulted in 50 times the dosage of heart medication being indicated for daily use which could have potentially lead to a fatal overdose if it was not caught in time.
The problem with data corruption when it comes to EMR systems is that the general perception regarding the infallibility of a digital record often results in errors being pushed through when they normally would not be in the case of hardcopy records.
Jones et al. (2010) points to the fact that procedures and medicine dosages in hardcopy records often under human scrutiny prior to approval, this is due to the problems mentioned earlier involving issues with the ineligible nature of the handwriting of some doctors. A second or third party is often needed in order to ensure that what is interpreted from the doctor’s handwriting is accurate.
In the case of digital records Price & Robinson (2011) explains that hospital staff have a habit of complacency wherein they immediately believe in the accuracy of what is stated.
This creates the potential for complications during patient discharge procedures since it is expected that patients follow the instructions that they are given yet due to data corruption the instructions may in fact be erroneous leading to possible medical complications down the line.
Before proceeding, it is important to note that data corruption is not limited to software or hardware glitches but also encompasses human error in the software whether intentional or not.
The reason why the concept of intentional human error is being brought up is due to the study of ( ) which examined EMR usage in several U.S. based hospitals and how the perceived difficulty in the software’s use lead to the staff inputting random fields and categories just to push the information through.
While this is not a glitch due to the fact that it is an intentional action on the part of their user, the fact remains that it is still a form of corruption brought about by the digital nature of the system due to the sheer amount of categories and fields that have to be filled out which leads many hospital staff to just choose random fields just to get their work done.
Cost and EMR Implementation
When deceiving to implement an EMR system, the significant financial cost related to purchasing the necessary hardware and software need to be taken into consideration. An EMR system has two parts, hardware and software, each has its own inherent cost depending on the type of hardware utilized and the type of software that is compatible with the needs of the hospital or clinic.
An examination of the work of Lloyd (2011) reveals that one of the current trends in EMR implementation has been the use of computer tablets, such as the iPad, which act as mobile check boards and terminals for nurses and doctors alike so that they can seamlessly connect to the hospital’s network in order to access a patient’s medical records.
Epstein (2010) does not disparage the use of iPads and other tablet like devices due to their portability and proven effectiveness, the main argument of Epstein (2010) is that the cost effectiveness of such devices are rarely taken into consideration given that 1 tablet can cost $250 or more with a hospital requiring 100 to 200 tablets depending on its size and the amount of medical personnel it has.
This equates into an outright significant financial cost for the hospital which has yet to take into consideration the upfront costs necessary for its LAN servers and the EMR software that it will utilize.
Current estimates show that installing an EMR package (i.e. hardware and software included) for even a moderately sized clinic can equate to an average of $44,000. Such a price does not take into consideration the potential that the hardware may become obsolete in the near future given the rapid development of technology.
Going back to the issue of price, if a moderately sized clinic could cost $44,000 then what would be the cost of an EMR systems for a hospital. In most cases, the server architecture, the hardware and software combined could reach a combined cost of 5 to 10 million dollars or more depending on the needs of the hospital.
Combined with the necessity of system maintenance and yearly upgrades, an EMR system could wind up costing nearly a $500,000 a year in maintenance and system upgrade fees alone.
While it can be argued that given the increase in productivity that an EMR system could provide, the increased cost would be worth it in the end since it would enable the hospital to provision better services and take off the burden of continuously filing paper work by the medical staff.
However, what has been shown so far is that putting into place an EMR system has no guarantee of increased staff performance, instead what is more likely is a considerable decrease in performance combined with the possibility of more medical errors appearing in files due to the problems related to categories and data fields that were mentioned earlier.
Based on this, it can be seen that implementing an expensive EMR system with no outright guarantee of the increased performance such systems are supposed to deliver would be a bad long term investment.
Patient Privacy and Data Security
Considering the ease of access of sharing of private records, patient privacy concerns are an aspect of EMRs that should be taken into consideration. Mir (2011) elaborates more on this issue by explaining that the safety and security of patient medical records should be at the forefront of any development that aims to improve the ease of access of these files to hospital personnel.
Mir (2011) points to the potential dangers surrounding ease of access, especially when it comes to individuals with malicious content. Studies have shown that between 2001 and 2012, there has been an estimated $500 billion lost on issues involving fraudulent medical practices involving identity theft and false claims made on medical records.
For example, an investigation on several local hospitals and clinics in Texas, Florida and California utilizing Medicare claims for services provided to their patients revealed extensive fraudulent activity.
Billing related to procedures that were never performed, excessive use of expensive and unneeded tests for routine procedures, prescribing more medicine than was needed and other such practices that were meant to inflate the insurance claims that such facilities could make.
The inherent problem with this is that not only is it a violation of a the medical code of ethics but it is also a violation of the patient’s trust and privacy since they are in effect being utilized as “cash cows” with their data being used as a means of gaining money instead of actually helping doctors make a diagnosis.
Other potential problems related to patient privacy is the potential for hackers to simply access the database of the hospital and steal patient medical records in order to perform the aforementioned malicious acts.
While it may be true that hospitals would employ a variety of firewalls and other means of protection to ensure the integrity of their systems. Unfortunately, no system is truly safe and, as a result, there is a legitimate concern over the potential for malicious data access without even the hospital realizing.
Another potential problem with patient privacy comes in the form of malicious access by hospital staff. It is true that in most cases the code of medical ethics would prevent unethical actions on the part of the local staff; however, history has shown that there have been instances in the past where hospital staff has acted in a malicious manner for personal gain.
It is due to instances such as this that the ease of access that EMRs provide is worrisome given that it would enable someone to discreetly access patient data from a terminal without anyone realizing it. In the case of hardcopy records, accessing them can be considered far more difficult as compared to digital records since in most cases hospitals have a filing department where the records are stored with limited access.
Digital records on the other hand can be opened through a computer terminal anywhere within the hospital and, as a result, the limitations that were previously in place are no long present.
While there are instances where terminals and tablets have passwords in order to prevent access by anybody walking by, Etzioni (2010) explains that hospital staff have a habit of sharing passwords among terminals since it makes things easier for them. Despite the fact that this defeats the purpose of putting passwords in the first place it is tolerated due to the need for worker efficiency.
Taking all the factors that have been mentioned into consideration, what emerges is a situation where implementing an EMR system in a hospital creates a considerable level of doubt as to whether patient privacy can truly be safeguarded when confronted with the problems digitization presents.
“The percentage of medical institutions with the same EHR/EMR software is 0.4%. The number of AAFP members with unique EHR/EMR software is very large. Fragmentation, caused by the use of hundreds of unique systems, is a major barrier to proliferation of these systems” (Valdes, Kibbe, Tolleson, Kunik, Petersen, 2004).
While the case of EMR proliferation has already been discussed so far, another aspect of the topic that should also be taken into consideration is the system fragmentation caused by the proliferation of numerous EMR systems which prevents any form of consolidation from taking place.
Lamont (2013) states that consolidation of medical practices is an important facet of any national medical system since consolidation creates the concept of “best practices” which eventually leads to set standards within particular medical systems.
The inherent problem with fragmentation in the case of EMR systems is that this prevents any form of consolidation from taking place with multiple hospitals utilizing different variations of EMR software in different ways and methods. While it may be true that no two hospitals or medical practice are alike in terms of their needs, there still should be some standardization through their operational procedures.
Through a lack of consolidation and standardization, complacency sets in resulting in the possibility of inferior if not outright reckless and dangerous practices being implemented when it comes to the protection of patient data. For example, one potential practice that could be put in play through a lack of consolidation is partnerships with corporations in exchange for patient data.
Corporations would in effect give discounts to hospitals for medical equipment and prescription drugs in exchange for patient data. This would enable them to create better marketing strategies to target these specific individuals leading to higher profits in the long term.
Technically, this use of patient data is not harmful due to the non-malicious nature of most corporations, however, from an ethical perspective it is an abuse of the trust of patients who put faith in hospital to not reveal their medical conditions to random corporations for the sake of money.
Other potential manifestations of fragmentation is the potential for current problems in EMR design and use to continue. Lamont (2013) elaborates more on this issue by explaining that consolidation of medical practices leads to a better identification of problems within a particular system or medical practice which enables solutions to be devised in order to resolve them.
However, when fragmentation occurs, this creates problems when it comes to properly identifying problems which results in problems continuing to exist. For example, an analysis of medical procedures in South American hospitals showed that there was an endemic problem related to the use of imported anesthetics instead of local anesthetics for simple procedures.
Imported anesthetics were more potent, more expensive and were unnecessarily strong for the procedures that were done (i.e. broken wrists, dentistry, etc.). It was revealed that local anesthetics would have been a much better alternative yet due to the lack of inter-hospital communication only a few hospitals relied on such a practice.
This shows how fragmentation in medical practices can occur and how it can result in more expensive procedures which adversely impact both the patient and the hospital. For Lamont (2013), what is needed in the case of EMRs within the U.S. is a greater level of involvement of the AMA and the government in their implementation.
However, such implementation should not be done for the sake of implementation; instead, what is necessary is the creation of better levels of standardization so as to avoid the various pitfalls associated with medical practice fragmentation.
Necessity of staff training, which can be expensive, in acclimatizing them towards the use of EMR systems
The implementation of an EMR system also requires the use of staff training programs in order to get them used to the various systems and hardware that will be utilized.
What must be understood is that aside from implementing changes in a hospital in the form of an EMR in order to improve performance, it is also important to ensure that there are proper methods in place to make sure that there is a smooth transition from doing one form of documentation to another in order to minimize the possible problems that may occur (Hart, Newton, & Boone, 2010).
The problem though with staff training involving the use of new technology is that it often takes a considerable level of time and expense to do so. With a city hospital averaging 200 to 300 staff members, doctors, nurses, support staff etc., this can create a considerable expense for the hospital since training sessions for the use of the new hardware and software could cost up to $100 per person.
Not only that there processes involving transitioning employees from one type of operations structure to another which could also cost the hospital in terms of operational efficiency as employees adjust to the change.
Transitioning hospital staff often involves the following
Changing Staff Mindsets
One of the first techniques necessary in managing change is to change the way in which employees think about the way in which they work. It is often the case that employees develop a certain mindset regarding work which makes them far less apt to change when the need arises. In the case of hospital staff this comes in the form of utilizing a terminal or tablet PC instead of the hardcopy paper records that they utilized before.
The problem though with this method is there would of course be a considerable level of initial resistance to change since the staff has already gotten used to and prefer the old system.
It is based on this that what is needed is to slowly change internal hospital policies and workplace culture so as to make it more amenable to the desired change rather than implement it all at once. This conforms with the first principle of change in which a person is adjusted via a change in the system that they work.
Implementing a workplace culture of open communication
Earlier it was stated that people tend to resist change, while this is true the fact remains that there are actually method of mitigating this.
One of them is implementing a workplace culture of open communication, by doing so not only can employee fears be addressed and taking into account when implementing change within the organization but it can be used as way in which to dampen the unforeseen and adverse effects the might happen should change be implemented.
Establish Goals/Purpose driven work
In their study examining record performance, it was discovered by Hart, Newton, & Boone (2010) that it is often the case that employees work better and adapt to change faster if there is a given goal or rather their work is driven by a specific purpose.
Taking the third principle chosen into consideration it can be assumed that by creating a defined vision by which employees can work towards not only would this result in a smooth transition during change but can actually result in improved employee performance as well.
Taking all these factors into consideration, it can be seen that the necessity of staff training for EMRs can be a costly and extensive venture which will be met with an initial level of resistance from employees. However, there is no guarantee that this resistance will disappear should the EMR system that the hospital employs result in a greater rather than lesser workload.
Web Based EMR Systems
Web based implementation of medical records is considered “dangerous’ given the potential for unlawful access. An examination of the various problems that have been elaborated on in this paper so far have shown that the issue of multiple systems, information transferring and ease of access could all be potentially resolved through the use of an online cloud based infrastructure that all medical institutions in the U.S. could utilize.
This would resolve multiple issues and allow EMR systems to be integrated in a low cost and easily implemented manner since all that would be needed would be a web log in order to access the necessary patient information via a computer terminal or tablet PC.
The main issue though with this particular method of EMR implementation is connected to patient privacy concerns and the potential for hackers to infiltrate online systems (Web-based personal health records raise privacy concerns, 2008).
This could lead to malicious use of private patient information which could result in identity theft or even millions of dollars in false claims being paid by third parties through the use of such information.
The term “hacker” has been connected by popular culture to mean someone who infiltrates into secure systems for the purpose of sowing chaos and mayhem for their own purposes. They have been described as individuals who steal credit card numbers, create computer viruses, attempt identity theft and all other manner of illegal behavior.
For hackers, their pursuit of hacking into databases is based on their desire to be able analyze the way such systems are constructed, learn their fundamental aspects and build upon them to either enhance or reinvent the systems in a way that is better in terms of functionality and usability.
It has been shown that open access to information often times leads to greater levels of creativity resulting in the development of better and more efficient information systems and programs. On the other hand, corporations argue their right to maintain the integrity of their proprietary systems due to the sheer amount of expense and investment they devoted towards their creation.
These corporations do have a point, the amount of work and money that went into the development of various programs and systems constitutes a multi-billion dollar international industry that provides jobs to thousands of people. They are able to make money due to their possession of a particular system or program that is a necessity to a large consumer market.
In the case of EMR systems, the information provided within often contains extensive information on their medical condition, their insurance information and other such details which can be utilized by third parties to pose as them and get free treatment at other medical centers (Web-based personal health records raise privacy concerns, 2008).
This is one of the main issues when it comes to cloud based systems since previously “impenetrable systems” that were lauded by various corporations were then subsequently hacked with private information stolen. This was seen in the case of the Sony Playstation network wherein potentially thousands of credit card numbers were stolen as a result of hackers cracking into their proprietary system.
Considering the fact that Sony is a multibillion dollar company and was still hacked, this shows the vulnerability of online systems and why a cloud based EMR system may not be the best method of securing patient data given the potential for the data to be hacked and then subsequently used for malicious purposes.
Studies such as those by Rind & Kohane (1997) on data security show that the best method of securing digital data is through the use of closed LAN (Local Area Network) systems that have no internet access. This prevents instances of outside infiltration and reduces possible malicious system intrusion to users within the hospital.
Through the work of Etzioni (2010), it was noted that standards within any profession are important to ensure that proper and effective services can be provided to clients, however, before such standards can be implemented, it is important to take note of whether the profession itself is ready to adopt such standards.
Based on the information that has been presented in this study, it is the recommendation of the researcher that the use of EMRs should not be implemented as a standardized practice across all medical institutions and facilities within the U.S. Aside from issues related to cost and preference, there is a considerably high degree of fragmentation among medical institutions regarding the type of EMR software they are utilizing.
“As stated earlier, the percentage of medical institutions with the same EHR/EMR software is 0.4% while the number of AAFP members with unique EHR/EMR software is very large”(Valdes, Kibbe, Tolleson, Kunik, Petersen, 2004). This creates a significant issue involving patients being able to transfer their medical records from one medical institution to the next.
Such a problem does not exist when it comes to hardcopy medical records which follow a standardized transcription format as per the guidelines set by the AMA (American Medical Institution). Such a process enables patients to easily transfer from one medical center to another on an “as needed basis” since they can always request a copy of their medical records.
While theoretically the use of EMRs “should” result in an easier and more seamless process of transferring patient medical records due to their digitized nature, the lack of a standardized platform across multiple institutions creates compatibility issues that cannot be easily remedied.
Differences in file formatting, methods of storage, areas where the information is displayed as well as an assortment of other problems prevents information from being transferred from one medical institution to another without the possibility of file corruption or it being unreadable.
Such a problem stems from the fact that unlike standardized hardcopy medical records which can be printed from an assortment of printing suppliers, there is no set standard that EMR programmers follow when it comes to developing their individual software. Each software is configured in such a way as to conform to the budget and needs of that particular institution resulting in different variations across the country.
What is necessary in this particular case is for the AMA to create a set standard that current EMR developers need to follow in terms of file formatting, inputting information as well as the means by which such records can be accessed. This would enable EMRs to be seamlessly transferred from one medical center to another without the aforementioned issues that were stated.
At the present, there are variety of EMR software types such as MediTouch, Waiting Room, Kareo, Medios, Vitera and Greenway, all of which have a variety of ONC-ATCB, ARRA/HITECH and CCHIT 2011 certifications.
However, further analysis of these software types shows little in the way of inter-functionality, transferability of information as well as having the capacity to share information in between institutions that utilize different EMR software.
While there are cloud based services such as MediTouch that enable a seamless transition from one institution to another that similarly utilizes MediTouch software, the fact remains that the 0.4% similarity ratio within the U.S. ensures that it is unlikely that another medical practice, even one next door, would utilize the same type of software.
One possible solution would be to appoint a single developer for all EMR software that will be utilized in the U.S. Unfortunately such a tactic would be in violation of the Federal government’s fair practices act which focuses on allowing “the market” to determine the prices and the providers of particular services.
Based on this, the researcher has shown that due to the proliferation of multiple types of EMR software, the lack of inter-institution transferability of digital data, and the non-existence of a set standard, EMRs should not be considered as a necessary and obligatory standard that all medical institutions within the U.S. must practice.
Just as there are standard medical practices that allow for no deviation, there similarly must be a set method of compliance that has no deviation when it comes to keeping patient records in such a way that they can be accessed and secured in a manner that is practiced across all medical institutions within the U.S. Until such a time that this can become a reality, it is inadvisable and reckless to implement such a system at the present.
Another recommendation that this study proposes is that aside from creating a set standard to be applied across all medical institutions involving the implementation of EMR programs, their development should be either supervised or assessed by medical professionals.
Based on the information that has been provided within the study, one of the problems with present day EMR technology is that it is based on what the programmer thinks would be the most effective means of inputting data instead of what is considered standard practices in medical record transcription.
This results in medical practitioners who have been trained to transcribe or input information in a particular fashion to have to get used to an entirely new method of data input which has the possibility of creating mistakes.
While ONC-ATCB, ARRA/HITECH and CCHIT 2011 certifications have become a standard among many of today’s EMR providers, which has led to methods of information input that is closer to the standard written input found in present day hardcopy medical records, there are still numerous issues that need to be tackled.
For example, studies such as those by Etzioni (2010) mention that instead of improving work flow and productivity, EMRs supposedly increase them due to the increased need for documentation.
Combined with the point and click system of some EMRs (i.e. drop down menus, categorical selections etc.) which require information to be placed in a particular order before it can be submitted to the database, this often results in many physicians simply putting in erroneous data in order to “get it over with” as Etzioni (2010) explains.
This has lead to the propagation of erroneous data being inputted into records simply because physicians find it easier to do it this way which helps to cut back on their enormous workload. This has resulted in various procedures, medications and processes finding their way into medical records that have not been performed at all which could lead to a fatal misdiagnosis down the line.
It is true that the program developers of EMR systems have created an efficient and effective method of categorizing and classifying a wide variety of procedures and medical prescriptions, however, in doing so they have neglected the “human element” so to speak wherein in their desire to make things more systematic they have made it less user friendly.
It is based on these observations that the researcher recommends that program developers focus less on creating a systematic method of information input and one that is more in line with what doctors want, namely a method of recording patient information that is not “fussy”, can easily be used, and does not have the same level of restrictions seen in present day systems.
One of the recommendations of Nicholas Carr on how organizations can get the most out of IT infrastructures such as EMRs is to delay in investing into particular IT products and services (Carr, 2007). This notion is actually supported by the fact that with the current rate of technological innovation products bought at the start of new wave of innovative equipment are usually obsolete within 6 months to a year of buying them.
Based on projections from Asus, one of the largest manufacturers of computer components in the world, specific types of technological innovations usually reach their zenith within 2 – 3 years of their inception before new innovations enter into the market.
This is actually not a coincidence but a planned marketing strategy by various companies in order to better capitalize on the irrational exuberance of consumers to constantly upgrade their equipment into the latest standards with various multinational companies spearheading the foray into such endeavors.
As such, after evaluating the various pros and cons of implementing EMRs at the present, it is the recommendation of the researcher that it would be more advisable to wait until a set standard has been developed which would enable secure requests for patient medical records across any medical institution or facility within the U.S.
Such a system, despite having different program developers, would have an integrated internet based backend cloud operated system that would enable information to be seamlessly transferred upon a patient checking into a new medical institution.
In this particular case it is recommended that medical institutions and health clinics focus on conservative buying behaviors and focus on buying equipment that can last the 2 year time period until certain new innovations reach a point at which they are at their best before being replaced by new products.
By doing so, such institutions are able to get equipment that will be of the highest quality, be viable for 2 more years and will actually be cheaper and more stable than earlier creations. Irrational buying behaviors where yearly purchases of new equipment are done in order to remain “competitive” and “up-to-date” are not only costly to hospitals in general but are inherently useless due to the fast progression of technology.
It is due to this that conservative buying behaviors and timing purchases to coincide with technological zenith of the 2 – 3 year period would thus result in better buying behaviors and savings for hospitals in the U.S. instead of focusing on purchasing an EMR system which may be obsolete in the years to come.
The last recommendation involves the current problems surrounding patient privacy concerns and the use of EMR systems. In order to make EMR systems easily transferable and updatable, it is necessary to implement some means of limiting the ability for them to be accessed.
It is based on this that the researcher recommends that EMR records should be tied to the Medicard serial number located on each patient’s medical insurance card.
To open a particular electronic medical record, it would be necessary to implement the series of numbers on the back of the card. By utilizing such a method of security, this would help to reduce patient privacy concerns regarding their records being unilaterally opened by an individual with malicious intent.
Overall, it can be concluded that the current predilection among members of the medical academe as well as medical organizations alike to consider EMRs as a required technology for hospitals and medical institutions is erroneous and should be reconsidered.
The researcher does not disparage the use of EMRs given the advantages in efficiency and effectiveness in patient care that they bring, the implementation of such a technology should not be considered a requirement. Instead, they should be considered a process that hospitals and other practices should transition into based on their own discretion and patient healthcare goals.
Connoting EMRs as a required technology for hospitals and medical institutions alike would be equivalent to considering it as part of the standardized practices and policies in healthcare that all medical institutions in the U.S. have to adhere to.
Given that the current variances in the way in which healthcare is applied in different states as well as the fact that some medical centers at the present simply do not have the funding necessary to implement medical record digitization, considering the use of such a technology as a standard would result in numerous institutions being found at fault for not following industry standards.
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