Electronic Medical Records

About
An electronic medical record (EMR) is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records.

Usage
Even though EMR systems with a computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 had a fully integrated system.

In the United States, the CDC reported that the EMR adoption rate had steadily risen to 48.3 percent at the end of 2009. This is an increase over 2008, when only 38.4% of office-based physicians reported using fully or partially electronic medical record systems (EMR) in 2008. However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical notes.

The cost of implementing an EMR system for smaller practices has also been criticized. Despite this, tighter regulations regarding meaningful use criteria have resulted in more physicians adopting EMR systems. Software, hardware and other services for EMR system implementation are provided for cost by various companies, including Dell. Open source EMR systems exist, but have not seen wide spread adoption of open-source EMR system software. Beyond financial concerns there are a number of legal and ethical dilemmas created by increasing EMR use.

Quality
Studies call into question whether, in real life, EMRs improve the quality of care. 2009 produced several articles raising doubts about EMR benefits. A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of checkboxes has led to fewer open-ended questions. 58% of users who can use their EHR on their tablet or smartphone reported being “very satisfied” with their software. Only 28% of users who couldn’t felt the same way.

Costs
The steep price of EMR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EMR adoption. In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EMR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product—and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EMR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." One CEO of an EMR company has argued if a physician performs tests in the office, it might reduce his or her income. "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."

Doubts have been raised about cost saving from EMRs by researchers at Harvard University, the Wharton School of the University of Pennsylvania, Stanford University, and others.

Software quality and usability deficiencies
The Healthcare Information and Management Systems Society (HIMSS), a very large U.S. healthcare IT industry trade group, observed that EMR adoption rates "have been slower than expected in the United States, especially in comparison to other industry sectors and other developed countries. A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available." The U.S. National Institute of Standards and Technology of the Department of Commerce studied usability in 2011 and lists a number of specific issues that have been reported by health care workers. The U.S. military's EMR "AHLTA" was reported to have significant usability issues.

Legal status
Electronic medical records, like medical records, must be kept in unaltered form and authenticated by the creator. Under data protection legislation, responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.

Technical features
Using an EMR to read and write a patient's record is not only possible through a workstation but, depending on the type of system and health care settings, may also be possible through mobile devices that are handwriting capable. Electronic Medical Records may include access to Personal Health Records (PHR) which makes individual notes from an EMR readily visible and accessible for consumers.

Event monitoring
Some EMR systems automatically monitor clinical events, by analyzing patient data from an electronic health record to predict, detect and potentially prevent adverse events. This can include discharge/transfer orders, pharmacy orders, radiology results, laboratory results and any other data from ancillary services or provider notes.

Role in an electronic research network
The Electronic Primary Care Research Network connects medical practitioners to researchers; promoting practice based research networks and facilitating clinical research. The internet-based infrastructure provides researchers with electronic medical records and standardized clinical report forms, shifting dependence away from paper based data collection tools that are not standardized. This mode of communication improves the quality of primary care and increases the number of clinical research opportunities. The information exchange between health care organizations encourages the translation of research into primary care practices.