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Electronic medical records and hospital management systems for management of diabetes
Diabetes & Metabolic Syndrome: Clinical Research & Reviews 3 (2009) 55–59
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Review
Electronic medical records and hospital management systems for management of diabetes G.R. Sridhar a,*, Allam Appa Rao b, M.V. Muraleedharan c, R.V. Jaya Kumar d, Venkat Yarabati e a
Endocrine and Diabetes Centre, 15-12-15 Krishnanagar, Visakhapatnam 530002, India Vice Chancellor, JNTU, Kakinada, India c Jubilee Mission Medical College, Thrissur, India d Amrita Institute of Medical Sciences, Kochi, India e Agilisys, 26–28, Hammersmith, Grove, London, UK W67AW b
A R T I C L E I N F O
S U M M A R Y
Keywords: Information technology Point of care information Software Hand held devices Security Database Networks Quality of care
Computers are used for a variety of purposes in clinical management. They are used to store data of patients using electronic medical records (EMR): it requires a careful analysis and decision of the clinician along with the software personnel in designing, refining and maintaining electronic medical record system. Many kinds of data can be stored, retrieved and analysed, which helps in clinical care, communication as well as research. EMRs can be networked to hospital information system (HIS) in which data from different locations can be accessed and used as with EMRs. Security issues would become important for both EMRs and HISs. In addition, information technology and computers can be used to access scientific information from the Internet using PubMed and other sources. ß 2008 Diabetes India. Published by Elsevier Ltd. All rights reserved.
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Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Electronic medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Strengths and weaknesses of paper records . . . . . . . . . . . . . 2.2. Electronic medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Readymade programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. What information or data can be stored? . . . . . . . . . . . . . . . 2.5. Utilization of information . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Caveats in going for EMRs . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7. Legal aspects and ownership of information . . . . . . . . . . . . Linking electronic medical records to hospital information system 3.1. Hospital information system (HIS) . . . . . . . . . . . . . . . . . . . . 3.2. Why link EMR with HIS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Local area networking (LAN) and HIS . . . . . . . . . . . . . . . . . . 3.4. Advantages: EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Disadvantages: EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7. Clinical database networking. . . . . . . . . . . . . . . . . . . . . . . . . 3.8. Scope and limitations in a real world situation . . . . . . . . . .
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* Corresponding author. Tel.: +91 891 2566301/2706385. E-mail addresses: [email protected], [email protected] (G.R. Sridhar), [email protected] (A.A. Rao), [email protected] (M.V. Muraleedharan), [email protected] (R.V. Jaya Kumar), [email protected] (V. Yarabati). 1871-4021/$ – see front matter ß 2008 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2008.10.008
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Ethical issues in implementing EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scope and summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Background Information technology has a broad sweep [1]; it is defined in the Oxford Dictionary as ‘. . .technology involved in the recording, storage and dissemination of information, especially using computers, telecommunications, etc.’ Here we discuss the following areas: (a) electronic medical records (EMR) and (b) networking of EMR with hospital information systems. The EMR is defined as ‘the computerization of health record content and associated processes usually referring to an electronic medical health record in a physician office setting or a computerized system of files [American Health Information Management Association] [2]. 2. Electronic medical records Essentially, electronic medical records (EMRs) exist in electronic format instead of paper. The effort lies in transitioning conventional records to electronic format so that the known advantages and flexibility of EMRs can be harnessed: the main purpose of clinical care and research is to discern patterns and modify treatment according to changing parameters, be they weight, blood pressure, plasma glucose or serum lipids [1]. EMRs are ‘enabling technology’ although they are neither easy nor lowcost to implement [3]. Benefits include reduced errors, improved clinical care, universal access to records, besides administrative ease of scheduling and billing [4,5]. From an administrative and policy viewpoint, they result in improvement of quality, competitiveness, efficiency and in integration of medical care. 2.1. Strengths and weaknesses of paper records Records on paper have advantages of being familiar, mobile and are flexible, allowing the entry of subjective data [6]. Yet, they have substantial limitations: data may not be recorded in a uniform fashion, papers may be lost, misplaced or become complex and unmanageable; multiple problem assessment is difficult, sorting according to relevance is not easy, and they cannot be accessed across different locations. 2.2. Electronic medical records In an ideal situation there should be no reason for even waiting to consider a switch to EMRs: ‘they accurately record detailed and legible clinical notes; populate a comprehensive, lifetime digital record for every patient, which includes medication history, lab tests, and radiology images and can be secured and shared between multiple providers to improve quality of care; provide access to disease management and outcomes information to help medical practitioners make good clinical decisions; prevent medical errors by having complete patient histories on hand. . .’ Yet EMRs are not as commonly employed because not only are they expensive but also they did not fit with physician workflow. The ideal EMR should fit in the work habits of a physician so that it does not impede work flow, should improve quality of care by work audit and transparently accomplish tasks traditionally provided by other staff, besides being an aid in practice management tools [1,7]. Such as ideal has not yet been met. The most important practical difficulty in implementing EMRs is an inability to replicate the non-structured capture of data in the
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physician–patient interaction, which depends on face-to-face interview [8]. A structured database can incorporate a detailed symptoms or sign checklist; but it needs feedback from the clinician in dovetailing what and how much data to collect. The interaction between these two is the usual bottleneck. In addition one should revamp ones skills to not lose social and emotional contact with patients. Therefore physicians who plan to use EMRs must first carefully analyze and plan what can be captured: the kind of data, the order and the details, without losing focus of the patient in the interview. A discussion with the software developer must be followed by user feedback. If EMRs are linked to ‘knowledge-based reminders’ a robust process must be in place to maintain the quality of the knowledge base [9]. A variety of rules can be incorporated, including but not limited to lipid measurements (health maintenance), alternative less expensive medications (expensive medication reminders), annual eye examination (diabetes mellitus) and starting of ACE inhibitors in diabetes with hypertension (therapeutic recommendations) [9]. It needs coordination of medical domain experts, knowledge engineer and programmers. An analysis of workflow is critical, with most involvement coming from physicians themselves. The outcome should result in improved physician productivity, so that patients are seen faster, with easier access to relevant information. Despite drawbacks, EMRs have undeniable advantages: they are complete and comprehensive, flexible to store and retrieve data, which can be used for a variety of purposes. Computerized guidelines can provide evidence-based recommendations by allowing access to references, showing errors and sending reminders [10]. Interactive telemedicine support is possible. In a small confusion about patients’ medication regimens, electronic order entry and medication reconciliation are possible, particularly at the point of service care delivery when newer technology is employed such as personal digital assistants [11,12]. However practical questions must be answered before they can be put into real life use: how and when would the data be entered—self or assisted? What are the levels of computer skills and typing skills needed? Are there programmes available for the purpose? Solutions to these problems must be found for implementing EMRs. 2.3. Readymade programmes Readymade programmes (EMRs) employing a standard format for specific diseases are available in varying degrees of complexity. They are useful for a wide variety of uses besides EMR: pharmacy data, prescription generation, accounts and billing. Such a comprehensive, standardized and naturally expensive program may not be relevant to individual practitioners but may also be useful for group practice and for hospitals. In contrast, programmes developed by individual physicians may provide only the basic functions, without harnessing the full potential of programmes made by experts. However the leanness and flexibility may be all that is needed for individual practice where the focus is to store patient data. This is a situation where the clinician provides the software experts who then create the programme. It is tested initially in dummy record entry and trouble-shot prior to live operation of the programme. This often provides best of both worlds, provided the
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requirements can be decided and conveyed clearly and comprehensively [1]. The further assistance of a software professional is also needed to solve problem which are expected to occur when having live operation of the software in clinical setting.
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Privacy issues are rampant in the developed countries; we must be aware of such issues cropping up and must plan accordingly [1]. 3. Linking electronic medical records to hospital information system
2.4. What information or data can be stored? 3.1. Hospital information system (HIS) It is possible to record and store all patient information, laboratory details including X-rays and imaging data, as well as patient photographs when relevant. A regular and systematic backup of all data is imperative to guard against machine failure. 2.5. Utilization of information When one is interested in presentation or research, the programme should have capability of statistical operation, including facility for creation of graphs or ability to export the data to a programme when graphs can be created and imported back EMRs are helpful in adhering to recommendations for proper management of metabolic diseases such as diabetes where regular assessment of glycemia, blood pressure, lipid levels, foot and eye care are essential [13]. Simultaneously, improved performance measures must be associated with improved outcome measures [14,15]. 2.6. Caveats in going for EMRs Despite all the potential advantages, one should consider the problems that may crop up in terms of software and hardware support, the time as well as cost needed to familarise with software for routine data entry, and more importantly the possibility of data loss and how to avoid it, besides security and legal issues [5]. They must be balanced against the advantages of enhanced speed, efficiency, ease of data retrieval, applicability for purposes other than patient care including planning of services, and in the follow up programme for diabetes—when to call a patient back for check up. All these translate into improved patient care. One must assess how computer use in examination room affects clinician–patient communication. A qualitative study has shown that four aspects affected interactions: visit organization, verbal and nonverbal behaviour, mastery of computer navitation and spatial organization of the examining room [16]. Undoubtedly computers add complexity to computer-naı¨ve clinicians, who are however becoming uncommon these days. Those who could integrate data gathering with data recording into their interaction were able to use computer into their visits without significant barriers in communication. Verbal and nonverbal behaviours such as support, posture, gesture and toe of voice were helpful in integrating computers. Physical placement of computer also had a significant effect on clinician–patient communication, which could be the most easily modifiable aspect to improve computer use in examination room. Transition from paper records to EMRs must also be carefully planned, keeping in view different aspects such as ‘leadership, application functionality, speed, note writing time requirements, data availability, training needs’ [17]. 2.7. Legal aspects and ownership of information Information laws of the country can be expected to consider EMR as a legal document. They may be electronically signed and must be permanent. An identifier must be attached to any further modifications. Similarly the question of ownership may arise because electronic information is much more easily transferable.
Information technology and computerization have been in use for administrative purposes for a long time in medical organizations for a variety of purposes: e.g. financial information systems (FIS), management information systems (MIS), ward-related nursing information systems (NIS), radiology information systems (RIS) and pharmacy information systems (PIS). The HIS has traditionally included a broad sweep: in-patient administration, out-patient administration, patient care, tests and results, pharmacy control, purchase department, patient billing, financial accounting, human resources management and medical insurance policies. The online activities include the entering patient profile into database for subsequent retrieval/analysis, reservation for inpatients, transfer of patients from one bed to another, pending discharges, displaying specified physicians patients, displaying patient details by name inquiry and displaying bed availability by nursing station. In addition, offline activities can also be performed such as reservation list, daily in-patient report, list of patients admitted, transferred or discharged, bed census report indicating bed availability, and monthly maternity and death report. 3.2. Why link EMR with HIS? The purpose and strength of EMRs is to make available information independent of time and space. Therefore linking EMRs with HIS is a crucial if difficult decision. The key issue is the integration of digital data so that authorized personnel can retrieve the necessary information anywhere and at any time they need it. Data can be of different varieties. A physician may have to look into radiographic images, listen to voice, hear live signals from intensive care and read the notes of other physicians. Such integration is only possible by linking EMR to HIS. 3.3. Local area networking (LAN) and HIS Such linking of EMR and HIS is possible by local area networking, which is a data communication system interconnecting large mainframe system to peripheral computer terminals. It allows a large number of devises to share organizational resources like storage devices, printers, programs and data files. A server on the network provides a specific service like storage, access facility, printing, etc. for all terminals connected to LAN. 3.4. Advantages: EMR–HIS A confluence of EMR–HIS results in improved quality of care, boost in patient safety, reduced length of hospital stay, and increased efficiency and timeliness of care. In healthcare benefits are usually found in cost avoidance, rather than in revenue enhancement. Return of Investment analysis—add value to patient encounter rather than add revenue. Automation results in fewer preventable medical errors: misinterpretation of doctor’s orders resulting from poor physician hand writing, pharmacists trying to clarify prescription and medication doses—can all be overcome by HIS, besides cost reduction from decreased staffing, improved billing practices and charge capture. Besides, clinical outcomes can be improved by
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ensuring better adherence to clinical protocols. Real time alerts reduce medical errors, drug interaction prevention. There is also organization value: decreased waiting time, increased provider satisfaction, nurses’ time saved from documentation to caregiver role [18]. Coordinated and comprehensive management of chronic diseases is possible with the use of EMRs, even though it is not provided by a single clinician, which is the usual situation in large scale medical settings [18]. Similarly they also have a positive impact as educational tools for residents and medical students [19]. They assure assimilation of new knowledge when presented in context while the patient is being examined. Down the line, information systems that ‘pushed’ information to users could do better; it is advantageous for the system to be incorporated into workflow and automatically prompt users. However the user is offered the option of either using or discarding the suggestion given. Clinical decision support can span the spectrum of reference materials, diagnostic assistance systems, clinical alert systems, drug-dosing assistance and preventive care reminders [19].
3.8. Scope and limitations in a real world situation Alluring as the scope of information technology in clinical practice is, how does it translate in real life? A recent survey in USA has shown that adoption of information technology tools was slow; important barriers to use were cost to set up and lack of time to learn new skills [27]. One should not confuse knowledge with judgement in clinical interactions. A combination of new technology and human interaction is needed [28]. Development of interface is crucial, as a factor in being implemented to improve life [29]. One must also consider the effect on quality of life of physicians by the use of new technologies [30]. Ultimately change in practice management is likely to be the one stumbling blocks to implement a new system such as electronic medical records [31]. With advances in technology, hand held devices are being introduced to bring IT into clinical care [32]. One can identify drivers of EMR adoption among medical groups; in the US, larger medical groups with greater financial and human resources tended to adopt EMRs in hospital management systems [33].
3.5. Disadvantages: EMR–HIS 4. Ethical issues in implementing EMR–HIS As in implementing any new technology, in the first few months following implementation, the physician may find it difficult to learn new skills in the effort required to create the chart, cost may be high for some of these technologies, and privacy is an issue. Similarly lack of access to IT nodes and poorly designed user interface are initial barriers to computer use. The barriers may be summarized as high initial cost in the face of uncertain financial benefits and difficulty in implementing technology [3]. They can be overcome by multifaceted approaches by improving electronic data exchange, quality performance incentives and technical support.
Implementation of EMR–HIS brings with it ethical issues about confidentiality of information that is collected and stored. Theoretically the confidentiality of patient data is compromised because of the lack of physical records, although newer technologies with user security can improve confidentiality, preventing unauthorized access to health data [34]. The issue of using data for advertising or marketing arises. It is here that the physician must distinguish between clinical and business views of confidentiality. The physicians’ professionalism should serve as an important protection to patients [34].
3.6. Concerns Principal issues of concern relate to access of information, control, privacy and security [20]. Security can be controlled in a variety of ways; Authentication—verification of the identity of the person who is using the service: Username/password, Smart-card or token, fingerprint or retinal scan; Authorization—If the identified person is authorized to use the services requested-list of registered users and their access rights; and Privacy—Encrypt the message into mathematical formula, e.g. 128 bit encryption. User authentication processes can be developed [21]. 3.7. Clinical database networking Over time, clinical database networking across institutions offers advantages such as pattern recognition from a much larger database than a single institution or individual can possess; secondly patients may be allowed access to their health records [22,23]. Such access helps them to communicate with their physicians, in seeking appointments and other administrative matters. Eventually context-related information can be accessed or sent to individuals (e.g. to stop smoking or to start exercise). They can also develop a patient database of experiences, analogous to peer-reviewed medical journals (e.g. Database of Individual Patients’’ Experience of illness) [22]. Technical advances in computation and matched human–machine interaction should make this possible. There is now adequate evidence that regional registries for conditions such as diabetes and renal diseases can be set up that can help in audit and feedback functionality [24,25]. Such registry networks have been shown to be possible even in rural healthcare [26].
5. Scope and summary It is possible to scale the development of EMR and HIS from clinical documentation through display, workflow, decision support and knowledge management. Converge of clinical data, mathematics, statistics and computer sciences can use data to build models and then use the model to answer relevant questions [35]. References [1] Sridhar GR, Venkat Y. Information technology and endocrine sciences in the new millennium. Indian J Endocrinol Metab 2000;4:70–80. [2] Wu RC, Straus SE. Evidence for handheld electronic medical records in improving care: a systemic review. BMC Med Inform Decision Making 2006;6:26. [3] Hiller RH, Sim I. Physicians’ use of electronic medical records: barriers and solutions. Health Affairs 2004;23:116–26. [4] Harrison JP, Palacio C. The role of clinical information systems in health care quality improvement. Health Care Manag (Fredrick) 2006;25:206–12. [5] Helm S, Hansen HC. Information technology in the interventional pain practice: electronic medical records, practice management software, and document management. Pain Physician 2004;7:357–64. [6] Lusk R, Herrmann K. The computerized patient record. Otolaryngol Clin North Am 1998;31:289–300. [7] Brooks RJ, Kahn JA, Smith RL. Practice management, health maintenance, and the use of computers in today’s medical office. Medical Clin North Am 1996;80:279–97. [8] Sridhar GR, Venkat Y. Computers and information technology in diabetes mellitus. In: Shah S, editor. Diabetes Update. Guwahati: North Eastern Diabetes Society; 2001. p. 82–4. [9] Kupermann GJ, Fiskio JM, Karson A. A process to maintain the quality of a computerized knowledge base. Proc AMIA Symp 1999;p87–91. [10] Sullivan F, Wyatt JC. How decision support tools help define clinical problems. BMJ 2005;331:831–3. [11] Poon EG, Blumenfeld B, Hamann C, Turchin A, Baker GE, McCarthy PC, et al. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform Assoc 2006;13:581–92.
G.R. Sridhar et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 3 (2009) 55–59 [12] Alvornoz MA, Anderson RB. An overview of the use of computers in clinical rheumatology: models of care for the next millennium. J Clin Rheumatol 2003;9:15–24. [13] Ahmann AJ. Guideline and performance measures for diabetes. Am J Manag Care 2007;13:S41–6. [14] Haywad RA. Performance measurement in search of a path. N Engl J Med 2007;356:951–3. [15] Appa Rao A, Sridhar GR. Quality of care: assessment. Lipids Health Disease 2007;6:12. [16] Frankel R, Altschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of exam-room computing on clinician–patient communication. J Gen Intern Med 2005;20:677–82. [17] Payne TH, Perkins M, Kalus R, Reilly D. The Transition to Electronic Documentation on a Teaching Hospital Medical Service. AMIA Annu Symp Proc 2006;629–33. [18] Litaker D, Ober S, Aron D. Continuity of care and cardiovascular risk factor management: does care by a single clinician add to informational continuity provided by electronic medical records? Am J Manag Care 2005;11: 689–96. [19] Keenan CR, Nguyen HH, Srinivasan M. Electronic medical records and their impact on resident and medical student education. Acad Psychiatry 2006;30:522–7. [20] Ball MJ, Gold J. Banking on health. J Health Inf Manag 2006;20:71–83. [21] Chao HM, Twu SH, Hsu CM. A patient-identity security mechanism for electronic medical records during transit and at rest. Med Inform Inter med 2005;30:227–40. [22] Sridhar GR, Rao YSV. Clinical database network. Curr Sci 2000;79:549–50.
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[23] Sullivan F, Wyatt JC. How computers help make efficient use of consultations. BMJ 2005;331:1010–2. [24] Benedetti MM, Carinci F, Federici MO. The Umbria diabetes register. Diabetes Res Clin Pract 2006;74(Suppl 2):S200–4. [25] Zoccali C. Clinical databases in nephrology: research and clinical practice goas and challenges. J Nephrol 2006;19:551–5. [26] Skinner A, Maginn FR, Mueller KJ. Chronic disease management systems registries in rural health care. Rural Policy Brief 2006;11:1–8. [27] Audet AM, Doty M, Peugh J, Shamasdin J, Zapert K, Schoenbaum S. 2004. Medscape General Med 6(4) [www.medscape.com/viewarticle/493210]. [28] Klass DJ. Will e-learning improve clinical judgement? BMJ 2004;328:1147–8. [29] Gustafson DH. Evaluation of e-health systems and services. BMJ 2004;328:1150–1. [30] Jadad AR. What next for electronic communication and health care? BMJ 2004;328:1143–4. [31] Baron RJ, Fabens EL, Schiffman M, Wolf E. electronic health records: just around the corner? Or over the cliff? Ann Intern Med 2005;143:222–6. [32] Wu RC, Straus SE. Evidence for handheld electronic medical records in improving care: a systematic review. BMC Med Inform Decision Making 2006;6:26. [33] Simon JS, Rundall TG, Shortell SM. Drivers of electronic medical record adoption among medical groups. J Comm J Qual Patient Saf 2005;31:631–9. [34] Lo B. Professionalism in the age of computerized medical records. Singapore Med J 2006;47:1018–22. [35] Eddy DM. Linking electronic medical records to large-scale simulation models: can we put rapid learning on Turbo? Health Affairs; 2007, w125–36. doi:10.1377/hlthaff.26.2w125.
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Review
Electronic medical records and hospital management systems for management of diabetes G.R. Sridhar a,*, Allam Appa Rao b, M.V. Muraleedharan c, R.V. Jaya Kumar d, Venkat Yarabati e a
Endocrine and Diabetes Centre, 15-12-15 Krishnanagar, Visakhapatnam 530002, India Vice Chancellor, JNTU, Kakinada, India c Jubilee Mission Medical College, Thrissur, India d Amrita Institute of Medical Sciences, Kochi, India e Agilisys, 26–28, Hammersmith, Grove, London, UK W67AW b
A R T I C L E I N F O
S U M M A R Y
Keywords: Information technology Point of care information Software Hand held devices Security Database Networks Quality of care
Computers are used for a variety of purposes in clinical management. They are used to store data of patients using electronic medical records (EMR): it requires a careful analysis and decision of the clinician along with the software personnel in designing, refining and maintaining electronic medical record system. Many kinds of data can be stored, retrieved and analysed, which helps in clinical care, communication as well as research. EMRs can be networked to hospital information system (HIS) in which data from different locations can be accessed and used as with EMRs. Security issues would become important for both EMRs and HISs. In addition, information technology and computers can be used to access scientific information from the Internet using PubMed and other sources. ß 2008 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Contents 1. 2.
3.
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Electronic medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Strengths and weaknesses of paper records . . . . . . . . . . . . . 2.2. Electronic medical records . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Readymade programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. What information or data can be stored? . . . . . . . . . . . . . . . 2.5. Utilization of information . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Caveats in going for EMRs . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.7. Legal aspects and ownership of information . . . . . . . . . . . . Linking electronic medical records to hospital information system 3.1. Hospital information system (HIS) . . . . . . . . . . . . . . . . . . . . 3.2. Why link EMR with HIS? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Local area networking (LAN) and HIS . . . . . . . . . . . . . . . . . . 3.4. Advantages: EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5. Disadvantages: EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6. Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.7. Clinical database networking. . . . . . . . . . . . . . . . . . . . . . . . . 3.8. Scope and limitations in a real world situation . . . . . . . . . .
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* Corresponding author. Tel.: +91 891 2566301/2706385. E-mail addresses: [email protected], [email protected] (G.R. Sridhar), [email protected] (A.A. Rao), [email protected] (M.V. Muraleedharan), [email protected] (R.V. Jaya Kumar), [email protected] (V. Yarabati). 1871-4021/$ – see front matter ß 2008 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2008.10.008
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Ethical issues in implementing EMR–HIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scope and summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Background Information technology has a broad sweep [1]; it is defined in the Oxford Dictionary as ‘. . .technology involved in the recording, storage and dissemination of information, especially using computers, telecommunications, etc.’ Here we discuss the following areas: (a) electronic medical records (EMR) and (b) networking of EMR with hospital information systems. The EMR is defined as ‘the computerization of health record content and associated processes usually referring to an electronic medical health record in a physician office setting or a computerized system of files [American Health Information Management Association] [2]. 2. Electronic medical records Essentially, electronic medical records (EMRs) exist in electronic format instead of paper. The effort lies in transitioning conventional records to electronic format so that the known advantages and flexibility of EMRs can be harnessed: the main purpose of clinical care and research is to discern patterns and modify treatment according to changing parameters, be they weight, blood pressure, plasma glucose or serum lipids [1]. EMRs are ‘enabling technology’ although they are neither easy nor lowcost to implement [3]. Benefits include reduced errors, improved clinical care, universal access to records, besides administrative ease of scheduling and billing [4,5]. From an administrative and policy viewpoint, they result in improvement of quality, competitiveness, efficiency and in integration of medical care. 2.1. Strengths and weaknesses of paper records Records on paper have advantages of being familiar, mobile and are flexible, allowing the entry of subjective data [6]. Yet, they have substantial limitations: data may not be recorded in a uniform fashion, papers may be lost, misplaced or become complex and unmanageable; multiple problem assessment is difficult, sorting according to relevance is not easy, and they cannot be accessed across different locations. 2.2. Electronic medical records In an ideal situation there should be no reason for even waiting to consider a switch to EMRs: ‘they accurately record detailed and legible clinical notes; populate a comprehensive, lifetime digital record for every patient, which includes medication history, lab tests, and radiology images and can be secured and shared between multiple providers to improve quality of care; provide access to disease management and outcomes information to help medical practitioners make good clinical decisions; prevent medical errors by having complete patient histories on hand. . .’ Yet EMRs are not as commonly employed because not only are they expensive but also they did not fit with physician workflow. The ideal EMR should fit in the work habits of a physician so that it does not impede work flow, should improve quality of care by work audit and transparently accomplish tasks traditionally provided by other staff, besides being an aid in practice management tools [1,7]. Such as ideal has not yet been met. The most important practical difficulty in implementing EMRs is an inability to replicate the non-structured capture of data in the
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physician–patient interaction, which depends on face-to-face interview [8]. A structured database can incorporate a detailed symptoms or sign checklist; but it needs feedback from the clinician in dovetailing what and how much data to collect. The interaction between these two is the usual bottleneck. In addition one should revamp ones skills to not lose social and emotional contact with patients. Therefore physicians who plan to use EMRs must first carefully analyze and plan what can be captured: the kind of data, the order and the details, without losing focus of the patient in the interview. A discussion with the software developer must be followed by user feedback. If EMRs are linked to ‘knowledge-based reminders’ a robust process must be in place to maintain the quality of the knowledge base [9]. A variety of rules can be incorporated, including but not limited to lipid measurements (health maintenance), alternative less expensive medications (expensive medication reminders), annual eye examination (diabetes mellitus) and starting of ACE inhibitors in diabetes with hypertension (therapeutic recommendations) [9]. It needs coordination of medical domain experts, knowledge engineer and programmers. An analysis of workflow is critical, with most involvement coming from physicians themselves. The outcome should result in improved physician productivity, so that patients are seen faster, with easier access to relevant information. Despite drawbacks, EMRs have undeniable advantages: they are complete and comprehensive, flexible to store and retrieve data, which can be used for a variety of purposes. Computerized guidelines can provide evidence-based recommendations by allowing access to references, showing errors and sending reminders [10]. Interactive telemedicine support is possible. In a small confusion about patients’ medication regimens, electronic order entry and medication reconciliation are possible, particularly at the point of service care delivery when newer technology is employed such as personal digital assistants [11,12]. However practical questions must be answered before they can be put into real life use: how and when would the data be entered—self or assisted? What are the levels of computer skills and typing skills needed? Are there programmes available for the purpose? Solutions to these problems must be found for implementing EMRs. 2.3. Readymade programmes Readymade programmes (EMRs) employing a standard format for specific diseases are available in varying degrees of complexity. They are useful for a wide variety of uses besides EMR: pharmacy data, prescription generation, accounts and billing. Such a comprehensive, standardized and naturally expensive program may not be relevant to individual practitioners but may also be useful for group practice and for hospitals. In contrast, programmes developed by individual physicians may provide only the basic functions, without harnessing the full potential of programmes made by experts. However the leanness and flexibility may be all that is needed for individual practice where the focus is to store patient data. This is a situation where the clinician provides the software experts who then create the programme. It is tested initially in dummy record entry and trouble-shot prior to live operation of the programme. This often provides best of both worlds, provided the
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requirements can be decided and conveyed clearly and comprehensively [1]. The further assistance of a software professional is also needed to solve problem which are expected to occur when having live operation of the software in clinical setting.
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Privacy issues are rampant in the developed countries; we must be aware of such issues cropping up and must plan accordingly [1]. 3. Linking electronic medical records to hospital information system
2.4. What information or data can be stored? 3.1. Hospital information system (HIS) It is possible to record and store all patient information, laboratory details including X-rays and imaging data, as well as patient photographs when relevant. A regular and systematic backup of all data is imperative to guard against machine failure. 2.5. Utilization of information When one is interested in presentation or research, the programme should have capability of statistical operation, including facility for creation of graphs or ability to export the data to a programme when graphs can be created and imported back EMRs are helpful in adhering to recommendations for proper management of metabolic diseases such as diabetes where regular assessment of glycemia, blood pressure, lipid levels, foot and eye care are essential [13]. Simultaneously, improved performance measures must be associated with improved outcome measures [14,15]. 2.6. Caveats in going for EMRs Despite all the potential advantages, one should consider the problems that may crop up in terms of software and hardware support, the time as well as cost needed to familarise with software for routine data entry, and more importantly the possibility of data loss and how to avoid it, besides security and legal issues [5]. They must be balanced against the advantages of enhanced speed, efficiency, ease of data retrieval, applicability for purposes other than patient care including planning of services, and in the follow up programme for diabetes—when to call a patient back for check up. All these translate into improved patient care. One must assess how computer use in examination room affects clinician–patient communication. A qualitative study has shown that four aspects affected interactions: visit organization, verbal and nonverbal behaviour, mastery of computer navitation and spatial organization of the examining room [16]. Undoubtedly computers add complexity to computer-naı¨ve clinicians, who are however becoming uncommon these days. Those who could integrate data gathering with data recording into their interaction were able to use computer into their visits without significant barriers in communication. Verbal and nonverbal behaviours such as support, posture, gesture and toe of voice were helpful in integrating computers. Physical placement of computer also had a significant effect on clinician–patient communication, which could be the most easily modifiable aspect to improve computer use in examination room. Transition from paper records to EMRs must also be carefully planned, keeping in view different aspects such as ‘leadership, application functionality, speed, note writing time requirements, data availability, training needs’ [17]. 2.7. Legal aspects and ownership of information Information laws of the country can be expected to consider EMR as a legal document. They may be electronically signed and must be permanent. An identifier must be attached to any further modifications. Similarly the question of ownership may arise because electronic information is much more easily transferable.
Information technology and computerization have been in use for administrative purposes for a long time in medical organizations for a variety of purposes: e.g. financial information systems (FIS), management information systems (MIS), ward-related nursing information systems (NIS), radiology information systems (RIS) and pharmacy information systems (PIS). The HIS has traditionally included a broad sweep: in-patient administration, out-patient administration, patient care, tests and results, pharmacy control, purchase department, patient billing, financial accounting, human resources management and medical insurance policies. The online activities include the entering patient profile into database for subsequent retrieval/analysis, reservation for inpatients, transfer of patients from one bed to another, pending discharges, displaying specified physicians patients, displaying patient details by name inquiry and displaying bed availability by nursing station. In addition, offline activities can also be performed such as reservation list, daily in-patient report, list of patients admitted, transferred or discharged, bed census report indicating bed availability, and monthly maternity and death report. 3.2. Why link EMR with HIS? The purpose and strength of EMRs is to make available information independent of time and space. Therefore linking EMRs with HIS is a crucial if difficult decision. The key issue is the integration of digital data so that authorized personnel can retrieve the necessary information anywhere and at any time they need it. Data can be of different varieties. A physician may have to look into radiographic images, listen to voice, hear live signals from intensive care and read the notes of other physicians. Such integration is only possible by linking EMR to HIS. 3.3. Local area networking (LAN) and HIS Such linking of EMR and HIS is possible by local area networking, which is a data communication system interconnecting large mainframe system to peripheral computer terminals. It allows a large number of devises to share organizational resources like storage devices, printers, programs and data files. A server on the network provides a specific service like storage, access facility, printing, etc. for all terminals connected to LAN. 3.4. Advantages: EMR–HIS A confluence of EMR–HIS results in improved quality of care, boost in patient safety, reduced length of hospital stay, and increased efficiency and timeliness of care. In healthcare benefits are usually found in cost avoidance, rather than in revenue enhancement. Return of Investment analysis—add value to patient encounter rather than add revenue. Automation results in fewer preventable medical errors: misinterpretation of doctor’s orders resulting from poor physician hand writing, pharmacists trying to clarify prescription and medication doses—can all be overcome by HIS, besides cost reduction from decreased staffing, improved billing practices and charge capture. Besides, clinical outcomes can be improved by
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ensuring better adherence to clinical protocols. Real time alerts reduce medical errors, drug interaction prevention. There is also organization value: decreased waiting time, increased provider satisfaction, nurses’ time saved from documentation to caregiver role [18]. Coordinated and comprehensive management of chronic diseases is possible with the use of EMRs, even though it is not provided by a single clinician, which is the usual situation in large scale medical settings [18]. Similarly they also have a positive impact as educational tools for residents and medical students [19]. They assure assimilation of new knowledge when presented in context while the patient is being examined. Down the line, information systems that ‘pushed’ information to users could do better; it is advantageous for the system to be incorporated into workflow and automatically prompt users. However the user is offered the option of either using or discarding the suggestion given. Clinical decision support can span the spectrum of reference materials, diagnostic assistance systems, clinical alert systems, drug-dosing assistance and preventive care reminders [19].
3.8. Scope and limitations in a real world situation Alluring as the scope of information technology in clinical practice is, how does it translate in real life? A recent survey in USA has shown that adoption of information technology tools was slow; important barriers to use were cost to set up and lack of time to learn new skills [27]. One should not confuse knowledge with judgement in clinical interactions. A combination of new technology and human interaction is needed [28]. Development of interface is crucial, as a factor in being implemented to improve life [29]. One must also consider the effect on quality of life of physicians by the use of new technologies [30]. Ultimately change in practice management is likely to be the one stumbling blocks to implement a new system such as electronic medical records [31]. With advances in technology, hand held devices are being introduced to bring IT into clinical care [32]. One can identify drivers of EMR adoption among medical groups; in the US, larger medical groups with greater financial and human resources tended to adopt EMRs in hospital management systems [33].
3.5. Disadvantages: EMR–HIS 4. Ethical issues in implementing EMR–HIS As in implementing any new technology, in the first few months following implementation, the physician may find it difficult to learn new skills in the effort required to create the chart, cost may be high for some of these technologies, and privacy is an issue. Similarly lack of access to IT nodes and poorly designed user interface are initial barriers to computer use. The barriers may be summarized as high initial cost in the face of uncertain financial benefits and difficulty in implementing technology [3]. They can be overcome by multifaceted approaches by improving electronic data exchange, quality performance incentives and technical support.
Implementation of EMR–HIS brings with it ethical issues about confidentiality of information that is collected and stored. Theoretically the confidentiality of patient data is compromised because of the lack of physical records, although newer technologies with user security can improve confidentiality, preventing unauthorized access to health data [34]. The issue of using data for advertising or marketing arises. It is here that the physician must distinguish between clinical and business views of confidentiality. The physicians’ professionalism should serve as an important protection to patients [34].
3.6. Concerns Principal issues of concern relate to access of information, control, privacy and security [20]. Security can be controlled in a variety of ways; Authentication—verification of the identity of the person who is using the service: Username/password, Smart-card or token, fingerprint or retinal scan; Authorization—If the identified person is authorized to use the services requested-list of registered users and their access rights; and Privacy—Encrypt the message into mathematical formula, e.g. 128 bit encryption. User authentication processes can be developed [21]. 3.7. Clinical database networking Over time, clinical database networking across institutions offers advantages such as pattern recognition from a much larger database than a single institution or individual can possess; secondly patients may be allowed access to their health records [22,23]. Such access helps them to communicate with their physicians, in seeking appointments and other administrative matters. Eventually context-related information can be accessed or sent to individuals (e.g. to stop smoking or to start exercise). They can also develop a patient database of experiences, analogous to peer-reviewed medical journals (e.g. Database of Individual Patients’’ Experience of illness) [22]. Technical advances in computation and matched human–machine interaction should make this possible. There is now adequate evidence that regional registries for conditions such as diabetes and renal diseases can be set up that can help in audit and feedback functionality [24,25]. Such registry networks have been shown to be possible even in rural healthcare [26].
5. Scope and summary It is possible to scale the development of EMR and HIS from clinical documentation through display, workflow, decision support and knowledge management. Converge of clinical data, mathematics, statistics and computer sciences can use data to build models and then use the model to answer relevant questions [35]. References [1] Sridhar GR, Venkat Y. Information technology and endocrine sciences in the new millennium. Indian J Endocrinol Metab 2000;4:70–80. [2] Wu RC, Straus SE. Evidence for handheld electronic medical records in improving care: a systemic review. BMC Med Inform Decision Making 2006;6:26. [3] Hiller RH, Sim I. Physicians’ use of electronic medical records: barriers and solutions. Health Affairs 2004;23:116–26. [4] Harrison JP, Palacio C. The role of clinical information systems in health care quality improvement. Health Care Manag (Fredrick) 2006;25:206–12. [5] Helm S, Hansen HC. Information technology in the interventional pain practice: electronic medical records, practice management software, and document management. Pain Physician 2004;7:357–64. [6] Lusk R, Herrmann K. The computerized patient record. Otolaryngol Clin North Am 1998;31:289–300. [7] Brooks RJ, Kahn JA, Smith RL. Practice management, health maintenance, and the use of computers in today’s medical office. Medical Clin North Am 1996;80:279–97. [8] Sridhar GR, Venkat Y. Computers and information technology in diabetes mellitus. In: Shah S, editor. Diabetes Update. Guwahati: North Eastern Diabetes Society; 2001. p. 82–4. [9] Kupermann GJ, Fiskio JM, Karson A. A process to maintain the quality of a computerized knowledge base. Proc AMIA Symp 1999;p87–91. [10] Sullivan F, Wyatt JC. How decision support tools help define clinical problems. BMJ 2005;331:831–3. [11] Poon EG, Blumenfeld B, Hamann C, Turchin A, Baker GE, McCarthy PC, et al. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform Assoc 2006;13:581–92.
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