electronic medical records

An electronic medical record (EMR) is a computer-based patient medical record. An EMR facilitates

• access of patient data by clinical staff at any given location
• accurate and complete claims processing by insurance companies
• building automated checks for drug and allergy interactions
• clinical notes
• prescriptions
• scheduling
• sending to and viewing by labs

The term has become expanded to include systems which keep track of other relevant medical information. The practice management system is the medical office functions which support and surround the electronic medical record.

Although an EMR system has the potential to permit invasion of medical privacy, if security policies are monitored effectively EMRs are as secure as banking records, for example.

Electronic records in health fall under the purview of health informatics, a combination of computation and computer science and medical record keeping.

According to the Medical Records Institute ^[1], five levels of an Electronic HealthCare Record (EHCR) can be distinguished:

• The Automated Medical Record is a paper-based record with some computer-generated documents.
• The Computerized Medical Record (CMR) makes the documents of level 1 electronically available.
• The Electronic Medical Record (EMR) restructures and optimizes the documents of the previous levels ensuring inter-operability of all documentation systems.
• The Electronic Patient Record (EPR) is a patient-centered record with information from multiple institutions.
• The Electronic Health Record (EHR) adds general health-related information to the EPR that is not necessarily related to a disease.

EMR issues

As of 2006, adoption of EMRs and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States. Less than 10% of American hospitals have implemented health information technology, ^[2] while a mere 16% of primary care physicians use EHRs. ^[3] The vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s. The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%. ^[4] The following issues are behind the slow rate of adoption:

Interoperability

In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda. Without interoperable EMRs, practicing physicians, pharmacies and hospitals cannot share patient information, which is necessary for timely, patient-centered and portable care. There are currently multiple competing vendors of EHR systems, each selling a software suite that in many cases is not compatible with those of their competitors. Only counting the outpatient vendors, there are more than 25 major brands currently on the market. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been estabilshed in many states in order to promote the sharing of health information. Congress is currently working on legislation to increase funding to these and similar programs. ^[5]

Adding older records to EMR

To attain the wide accessibility, efficiency, patient safety and cost savings promised by EMR, older paper medical records ideally should be incorporated into the patient's record. The digital scanning process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by different healthcare professionals over the life span of the patient, some of the content is illegible following conversion. The material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. In addition, the destruction of original healthcare records must be done in a way that ensures that they are completely and confidentially destroyed. Results of scanned records are not always useable; medical surveys found that 22-25% of physicians much less satisfied with the use of scanned document images than that of regular electronic data. ^[6]

Privacy

A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also. ^[7] Multiple access points over an open network like the internet increases possible patient data interception. In the United States, this class of information is referred to as Personal Healthcare Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws. ^[8] In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care. ^[9] The organizations and individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. The growth of EHR creates new issues, since electronic data may be physically much more difficult to secure, as lapses in data security are increasingly being reported. ^[10] Information security practices have been established for computer networks, but technologies like wireless computer networks offer new challenges as well.

Social and organizational barriers

According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EMR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, dealing with physicians' resistance to change (or, alternatively, software engineers' evolving research in deep modeling of the physician's knowledge and workflow domains), and creating a collaborative environment that fosters communication between physicians and information technology project managers. Exemplifying this need are several highly publicized HIT implementation fiascos, including one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system. ^[11]

Preserving electronic records

Under data protection legislation and the law generally responsibilty for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as x-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, owns the information contained within the record and has a right to view the originals, and to obtain copies under law. ^[12] Additionally, those responsible for the management of the EMR are responsible to see the hardware, software and media used to manage the information remain usable and not degraded. This requires backup of the data and protection being provided to copies. It will also require the planned periodic migration of information to address concerns of media degradation from use. ^[13]

Legal status of EMR

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

• Digital signatures Most national and international standards accept electronic signatures. ^[14] According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer." ^[15] With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will contiue to be prudent when using EMR.
• Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006, national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM). ^[16]

Standards

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

• ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate enities. ^[17]
• ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
• CEN - EN13606, the European standard for the communication of information from EHR systems, and HISA, a services standard for inter-system communication in a clinical information environment.
• DICOM - a heavily used standard for representing and communicating radiology images and reporting
• HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
• ISO - ISO TC215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
• openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.

Customization

Pricing for EMR systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit a medical specialty, environment or other specified needs. There are also EMR systems available that do not use templates and therefore can be easily personalized by each individual user, for example those based on Concept Processing technology.^[18]

Caveats and concerns

There are issues surrounding the generation and management of electronic medical records (EMRs), sometimes known as electronic health records (EHRs).

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

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

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

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

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

Another major concern is adequate protection of privacy of the individuals whose records are being managed electronically. This class of information (in the US) is referred to as Personal Healthcare Information (PHI) and its management is addressed under the Healthcare Insurance Portability and Accountability Act (HIPAA) as well as many State-specific privacy laws. The organization/individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties.

Public implementations

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

The Canadian province of Alberta's Alberta Netcare project is a large-scale operational EMR system.

Adoption of electronic medical records by US doctors is increasing slowly. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially electronic medical record systems (EMR) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey. ^[19] However, the survey also states that just 9.3% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. ^[20] Barriers to adopting an EMR system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options. ^[21] Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. On July 18 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products. ^[22] and then on July 31 2006, additionally announced that two further EMR and EHR products had achieved certification. ^[23]

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

See also

• Continuity of Care Record
• Electronic health record
• MUMPS
• Veterans Health Information Systems and Technology Architecture

References

External links

• Active Semantic Documents project (LSDIS, University of Georgia)]
• OpenClinical - Electronic Medical Records
• US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC)
• US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology
• The ICMCC portal on access to electronic medical records. The portal includes a blog to share and discuss experiences for both patients and clinicians as well as an extended overview of relevant literature.