Healthcare organizations today at many different stages of information system adoption and implementation. They have already invested considerably in implementing administrative information systems and a handful of clinical applications. Examples of clinical information system expansion include everything from computerized provider order entry (CPOE) systems to medication administration systems to fully electronic medical record (EMR) systems.
Implementing healthcare information systems in an organization does not happen overnight. It is a process that occurs over a number of years.
Electronic Medical Record
The desire to improve patient safety, reduce medical errors, reduce duplicate services, improve organizational efficiency, optimize reimbursement, and compete locally and regionally are just a few of many factors healthcare organizations and providers to take steps toward implementing Electronic Medical Record systems. Electronic medical record (EMR) is “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one healthcare organization”. Healthcare leaders are becoming increasingly aware of the potential value of EMR systems to the patient, the provider, the organization, and the healthcare community at
large in improving quality, addressing patient safety concerns, and decreasing administrative costs. EMR system features that health information technology experts consider to be the minimal requirements for a complete EMR include computerized orders for prescriptions, orders for tests, reporting of tests results, and physician notes. Rates of EMR adoption tend to be higher in larger facilities than in a smaller one.
Electronic Health Record
Electronic health record (EHR) is “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization”. According to Institute of medicine (IOM), EHR system functions include health information and data, results from management, decision support, electronic
communication and connectivity, patient support, administrative processes, and reporting and population health management.
Personal Health Record
Personal health record (PHR) is “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards that can be drawn from multiple sources while being managed, shared, and controlled by the individual”. PHR would enable individuals to keep their own health records, and they could share information electronically with their physicians or other healthcare professionals and receive advice, reminders, test results, and alerts from them. PHRs may be particularly helpful to patients with chronic illnesses in enabling them to track their diseases in conjunction with their providers, prompting earlier intervention when they encounter a deviation or problem. PHRs can take one of several different types, they can be as simple as
a form created by an individual to record important health information (for example, medications, surgeries, vaccinations, and allergies) or as complex as a Web-based system accessed and populated by individuals, healthcare providers, insurers, pharmacies, employers, and companies providing health-related content.
Value of Electronic Medical Record Systems
Several studies over the past thirty years have demonstrated the value of using EMR systems and other types of clinical information systems. The benefits fall into three major categories:
Improved Quality, Outcomes, and Safety
EMRs can have a significant impact on patient quality, outcomes, and safety. Three major effects on quality are increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. EMR systems can improve communication, make knowledge more readily available, require key pieces of information (such as the dose of the drug), assist with calculations, perform checks in real time, assist with monitoring, and
provide decision support. EMR-related systems have also been shown to improve drug prescribing and administration by providing clinicians with information on the appropriate use of antibiotics at the point of care.
Improved Efficiency, Productivity, and Cost Reduction
It is not uncommon for clinicians who do not have EMR access to order a second set of tests because the results from the first set are unavailable, so one-way EMR systems improve efficiency is by making tests results readily available to clinicians. EMR features such as computerized reminders and alerts can reduce pharmaceutical costs by prompting physicians to use generic and formulary drugs. EMR can also provide the infrastructure necessary to measure care processes and aid in continuous quality improvement efforts. Several studies also reported that an EMR system has led to higher quality documentation, resulting in improved coding practices and subsequently higher reimbursement, and also in savings from lower drug expenditures, improved utilization of radiology tests, and decreased billing errors.
Improved Service and Satisfaction
Patients whose physicians use EMR systems like the fact that their health information (health history, allergies, medications, and test results) is readily available when and where it is needed. Patients in practices that use an EMR system view their physicians as being innovative and progressive. Physicians who have successfully implemented and EMR systems in their practices have reported that it has improved the quality of documentation, improved efficiency, and had a positive impact on their job satisfaction and stress levels.
Also, EMR users such as nurses and support staff have reported that the EMR has enhanced their ability to respond to patient questions promptly, which in return will be reflected on a higher patient satisfaction.
Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Telemedicine may be as simple as two healthcare providers discussing a case over the telephone or as sophisticated as using satellite technology and videoconferencing equipment to broadcast a consultation between providers at facilities in two countries. It is a tool that enables providers to deliver healthcare services to patients at distant locations, and it is often promoted as a means of addressing the imbalances in the distribution of healthcare resources. Telemedicine and telehealth terms are used interchangeably. Telehealth is referred to a broader view of remote healthcare, one that does not always involve the provision of clinical services, which is the
province of telemedicine. Telehealth includes the use of technology to access remote health information, diagnostic images and education.