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Madison, Michele Person. "Electronic Medical Record and Regulatory Implications." Journal of Medical Regulation 93, no. 4 (December 1, 2007): 7–15. http://dx.doi.org/10.30770/2572-1852-93.4.7.
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ABSTRACT Health care practices increasingly rely upon Electronic Medical Records (EMR). EMR systems impact the daily operations and generate additional legal obligations. Effectively implementing an EMR system requires review of the state and federal regulations. EMR access, automation and aggregation of a comprehensive medical record benefit providers. However, each benefit poses substantial risk to the privacy and security of patient information. Vulnerable wireless or internet access, quick unsecured transferability and improper access of the patient’s entire record are implicit within an EMR system. Therefore, providers should perform a risk assessment and implement legally directed safeguards. The national implementation of an “electronic national health record” emphasizes the numerous risks and practical considerations arising through expansive access, automation and aggregation. The government is currently attempting to resolve such risks to ensure the effective use of EMR systems for all providers and patients. Protecting patient’s privacy and security is a daily challenge.
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Malhotra, Naveen, and Marlieta Lassiter. "The Coming Age Of Electronic Medical Records: From Paper To Electronic." International Journal of Management & Information Systems (IJMIS) 18, no. 2 (March 28, 2014): 117. http://dx.doi.org/10.19030/ijmis.v18i2.8493.
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Medical records, first developed in the fifth century, have remained virtually unchanged until the explosion of new technology in the mid-1960s. The National Space and Aeronautics Administrations development of computerized patient record (CPR) brought life to the electronic medical record (EMR) industry. Preventable deaths due to medical errors drew the attention of public and health care professionals to the need for increased patient safety and improved quality measures in medicine. With health care costs compromising 16-17% of the U.S. Gross Domestic Product, Congress passed legislation to financially support providers to adopt electronic medical record (EMR). As a result, future efforts will focus on the sharing of information among all health care stakeholders. Across the world, governments, technology companies, and care providers are collaborating efforts to make the EMR a reality.
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Olson, DaiWai M., Michael S. Rogers, and Sonja E. Stutzman. "Electronic Medical Record Validation: Exploring the Reliability of Intracranial Pressure Data Abstracted From the Electronic Medical Record–Pilot." Journal of Nursing Measurement 23, no. 3 (2015): 532–40. http://dx.doi.org/10.1891/1061-3749.23.3.532.
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Background and Purpose: Intracranial pressure (ICP) monitoring is crucial to decision making for neurologically injured patients, yet measurement of ICP varies greatly among practitioners. Methods: Unblinded, nonrandomized, observational pilot study comparing ICP values collected using pen and paper (P&P), electronic medical record (EMR), and video data with continuous data acquisition (CDA) technology. Results: ICP values did not significantly differ between EMR and P&P records, despite an average of 16 minutes difference in reporting times. ICP values varied significantly when comparing CDA data to EMR or paper. Conclusion: The results of this pilot study put in to question the validity of ICP values that are recorded in the medical record, which has implications for patient care and research.
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Yu, Bo, Duminda Wijesekera, and Paulo Costa. "Informed Consent in Electronic Medical Record Systems." International Journal of Reliable and Quality E-Healthcare 4, no. 1 (January 2015): 25–44. http://dx.doi.org/10.4018/ijrqeh.2015010103.
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Informed consents, either for treatment or use/disclosure, that protect the privacy of patient information subject to law that in certain circumstances may override patient wishes, are mandatory practice in healthcare. Although the healthcare industry has widely adopted Electronic Medical Record (EMR) systems, consents are still obtained and stored primarily on paper or scanned electronic documents. Integrating a consent management system into an EMR system involves various implementation challenges. The authors show how consents can be electronically obtained and enforced using a system that combines medical workflows and ontologically motivated rule enforcement. Finally, the authors describe an implementation that uses open-source software based addition of these components to an open-source EMR system, so that existing systems needn't be scrapped or otherwise rendered obsolete.
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Gajra, Ajeet, Dewilka Simons, Yolaine Jeune-Smith, Amy W. Valley, and Bruce A. Feinberg. "Physician satisfaction with electronic medical records (EMRs): Time for an intelligent health record?" Journal of Clinical Oncology 39, no. 28_suppl (October 1, 2021): 318. http://dx.doi.org/10.1200/jco.2020.39.28_suppl.318.
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318 Background: EMRs are devised to improve the quality and efficiency of healthcare delivery and to reduce medical errors. Despite the widespread use of EMRs, various factors can limit their effectiveness in improving healthcare quality. General EMR use has been cited as a factor contributing to increased workload and clinician burnout in oncology and other specialties. The objective of this qualitative research study was to identify barriers perceived by medical oncologists and hematologists (mO/H) in utilizing EMR software and factors associated with levels of satisfaction. Methods: Between January and April 2021, mO/H from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 369 mO/H completed the survey: 72% practice in a community setting; 47% identified as a hospital employee; they have an average of 19 years of clinical experience and spend on average 86% of their working time in direct patient care, seeing 17 patients per day on average on clinic days. Most (99%) of mO/H surveyed use an EMR software at their practice, with Epic (45%) and OncoEMR (16%) being the most common. Regarding satisfaction, 16% and 50% reported feeling highly satisfied and satisfied, respectively, with their current EMR, and 3% and 11% reported feeling very dissatisfied or dissatisfied, respectively. Some (19%) stated that they have considered changing their EMR, and 68% are unsure how EMR licensing fees for their practice are paid. EMR pain points most commonly experienced were: time-consuming, e.g., too many steps/click (70%); interoperability, e.g., difficulty sharing information across institutions or other EMR software (45%); data entry issues, e.g., difficulty entering clinical information, scheduling patient visits and reminders, or ordering multiple labs (38%); and poor workflow support (31%). The most useful aspects/features of their EMR software reported were availability of information, e.g., preloaded protocols, chemotherapy regimens and pathways (64%); data access (64%); and multiple access points, including remote access (37%). Conclusions: Satisfaction with EMR were generally positive among the mO/H surveyed. However, there are multiple deterrents to the efficient use of current EMR systems. This information is essential in the design of next-generation EMR (an Intelligent Medical Records system) to allow for incorporation of aspects most useful to the end-users, such as pathway access, preloaded information on cancer management as well as ease of access and portability, and a user experience that minimizes clicks and reduces physician time with EMR.
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Masyfufah, Lilis, Mrs Sriwati, Amir Ali, and Bambang Nudji. "Readiness of Application of Electronic Medical Records in Health Services (Literature Study)." Proceeding International Conference on Medical Record 2, no. 1 (January 10, 2022): 1–12. http://dx.doi.org/10.47387/icmr.v2i1.148.
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Background: Information and Communication Technology is advancing rapidly and has a major impact on all life, especially in the health sector, especially medical records. This is manifested in the Electronic Medical Record (EMR), which has now been further developed into an Electronic Health Record (EHR). This technology is used to replace or complement paper medical records. The purpose of this literature study is to determine the readiness to apply electronic medical records in health services.Methods: This study uses a literature study obtained from searching scientific research articles from the 2010–2020 range. Keywords used in this study is readiness and DOQ-IT. The database used comes from Google Sholar, Garuda, Neliti, and One Search. The search found 130 articles, then a critical appraisal process was carried out to produce 10 suitable manuscripts.Results: Various literatures found that the readiness to apply electronic medical records using the DOQ-IT method was influencedby 4 factors including the readiness of human resources, orgnizational culture, insfrastructure, and leadership governance. It can be concluded that the readiness for the application of electronic medical recors in health services with the very ready category is 30%, the moderately ready category is 50%, then the unready category is 20%.Conclusions: From the discussion above, it can be concluded that EMR readiness in health services is categorized as quite ready (50%), very ready (30%), and not ready (20%).
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Childress, Susan B., Tyler Buckley, Andrew Badke, Amy Horyna, Julie Howell, Lisa Gren, and Anna Catherine Beck. "Hardwiring advance directives into an electronic medical record." Journal of Clinical Oncology 34, no. 7_suppl (March 1, 2016): 146. http://dx.doi.org/10.1200/jco.2016.34.7_suppl.146.
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146 Background: Patient preference at the end of life has been extensively researched and documented. Advance Directives (AD) have been shown to make a difference for patients in the areas of quality, cost, and patient satisfaction. Organizations struggle with meeting federal laws and accreditation expectations due to our complex systems. Literature supports “hardwiring” AD documentation into the EMR and providing “one click” accessibility to AD’s. Changing EMR vendors provides a unique opportunity to optimize access to AD’s, both through patient education /endorsement, review of providers’ role, and engagement of IT. Methods: Huntsman Cancer Institute at the University of Utah identified an opportunity to improve the process of obtaining AD's during a change to Epic as an EMR. MD/RN champions brought a team together that included pastoral care, social work, medical records, and IT. The group used national "Decision Day" efforts as a platform for kicking off the project. Notable barriers to implementation included AD’s from previous EMR not migrating, inadequate systems for RN and SW consultation, lack of triggers to engage provider support, and MD order sets requiring major revisions Accessibility on the banner from any view was deemed best practice. Audits were created to give feedback to hospital staff and the quality department. This effort was also identified as a priority quality goal for the entire institution. Results: There have been significant improvements in assessing patients, obtaining AD's, and providing easy access to these records. Conclusions: EMR systems do not always come with processes in place to address the need to obtain AD's, scan or enter them into the EMR, and provide easy access during critical decision points in patient care. Collaboration with the IT team in identifying institutional requirements and workflow is critical as an organization identifies the need to improve AD system flow or begins planning for transition to a new EMR.
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Corbett, Mary, Ariel Deardorff, and Iris Kovar-Gough. "Emerging Data Management Roles for Health Librarians in Electronic Medical Records." Journal of the Canadian Health Libraries Association / Journal de l'Association des bibliothèques de la santé du Canada 35, no. 2 (August 1, 2014): 55. http://dx.doi.org/10.5596/c14-022.
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<p>Objective: To examine current and developing data management roles and opportunities for health librarians<br />to become involved in electronic medical record (EMR) initiatives. This paper focuses on the Canadian context but has implications farther afield. Methods: To accomplish a state-of-the-art review, searches were conducted in the library and information science databases (LISTA, LISA), biomedical databases (MEDLINE, CINAHL, EMBASE), and on the web for grey literature. Keywords included: clinical librarian, health science librarian, medical librarian, hospital librarian, medical informationist, electronic medical record, EMR, electronic health record, EHR, data management, data curation, health informatics, e-science, and e-science librarianship. MeSH subject headings used were: Medical Records Systems, Computerized/, Electronic Health Records/, and libraries/. Results: There is little evidence of Canadian health librarians’ current involvement in EMR initiatives, but examples from the United States indicate that health librarians’ participation is primarily in system implementation, creating links to the medical literature, and using EMRs to provide patient health information. Further roles for health librarians are emerging in this area as health librarians draw on their core competencies and learn from e-science librarianship to create new opportunities. Data management examples from e-science librarianship, such as building data dictionaries and data management plans and infrastructure, give further direction to health librarians’ involvement in EMRs. Conclusion: As EMRs gradually become more popular in Canada, Canadian health librarians should seek further opportunities for education and outreach to become more involved with these EMR initiatives.</p>
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Carpeggiani, Clara, Alberto Macerata, and Maria Aurora Morales. "Electronic medical record in cardiology: a 10-year Italian experience." Revista da Associação Médica Brasileira 61, no. 4 (August 2015): 317–23. http://dx.doi.org/10.1590/1806-9282.61.04.317.
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SummaryObjectives:the aim of this study was to report a ten years experience in the electronic medical record (EMR) use. An estimated 80% of healthcare transactions are still paper-based.Methods:an EMR system was built at the end of 1998 in an Italian tertiary care center to achieve total integration among different human and instrumental sources, eliminating paper-based medical records. Physicians and nurses who used EMR system reported their opinions. In particular the hospital activity supported electronically, regarding 4,911 adult patients hospitalized in the 2004- 2008 period, was examined.Results:the final EMR product integrated multimedia document (text, images, signals). EMR presented for the most part advantages and was well adopted by the personnel. Appropriateness evaluation was also possible for some procedures. Some disadvantages were encountered, such as start-up costs, long time required to learn how to use the tool, little to no standardization between systems and the EMR technology.Conclusion:the EMR is a strategic goal for clinical system integration to allow a better health care quality. The advantages of the EMR overcome the disadvantages, yielding a positive return on investment to health care organization.
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Kusriyanti, Diana, Budi Matuwi, and Supriyantoro. "Readiness Analysis of Electronic Medical Record Implementation at Dinda Tangerang Hospital Using Correlational Method." European Journal of Business and Management Research 6, no. 4 (July 2, 2021): 19–25. http://dx.doi.org/10.24018/ejbmr.2021.6.4.915.
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The electronic medical record (EMR) known today is not a new system in the documentation of patient medical records. Electronic Medical Record is a system that contains the patient's health and disease history, diagnostic test results, other medical data, and treatment cost information. In Indonesia it is known as Rekam Medis Elektronik (RME).
In accordance with the vision of Dinda Tangerang Hospital to be a quality hospital and trusted by all levels of society, it is appropriate to use technology in its medical record services. Where currently the medical record unit of Dinda Tangerang Hospital still uses Paper Based Medical Record. So, a readiness analysis is required to switch to EMR. This research uses quantitative research method with correlational research design that aims to know the readiness of Dinda Tangerang Hospital in applying EMR. The departments studied are the medical department, the medical support department, and the medical records unit. The most powerful relationship between a variable with an R value is 0.632. The value is in the criteria of correlation coefficient value of 0.51–0.75 which means there is a strong relationship between the organization and monitoring and collaboration. while the readiness analysis of Dinda Tangerang Hospital to apply electronic medical records is in range IV and can be said to be ready.
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Tierney, Michael J., Natalie M. Pageler, Madelyn Kahana, Julie L. Pantaleoni, and Christopher A. Longhurst. "Medical Education in the Electronic Medical Record (EMR) Era." Academic Medicine 88, no. 6 (June 2013): 748–52. http://dx.doi.org/10.1097/acm.0b013e3182905ceb.
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Ana Katukia, Ana Katukia, and Ekaterine Sanikidze Ekaterine Sanikidze. "PERSPECTIVES OF E-HEALTH FOREIGN ACHIEVEMENTS INTRODUCING IN GEORGIA." Economics 105, no. 03 (April 15, 2022): 214–20. http://dx.doi.org/10.36962/ecs105/3/2022-214.
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The article discusses current issues in e-Health and Health Information Technology (IT), which aims to provide access to patient health information at the right time and place, thereby ensuring the continuity and quality of medical services to improve health outcomes. The paper identifies the interrelationships and relevance of the economic aspects of medical treatment, where the introduction of information technology highlights the importance of quality management in medical treatment, as well as new ways of providing e-health services that facilitate collaboration between different health care institutions The new forms based on electronic medical record (EMR), which play an important role in gathering information from different healthcare providers, provide a single, unique record for each person that will be available through the Electronic Health Record System (EHR). Key words: e-Health (Digital Healthcare, TeleHealth), COVID-19 pandemic, Electronic Health Record (EHR), Electronic Medical Record (EMR), Health Information Systems (HIS).
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Witkowski, Chris, Lara Kimmel, Elton Edwards, and Filip Cosic. "Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients." Australian Health Review 46, no. 2 (November 9, 2021): 204–9. http://dx.doi.org/10.1071/ah21112.
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Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032). Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record. What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record. What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement. What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.
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Kadish, Sarah, Arik Senderovich, Ryan Leib, Avishai Mandelbaum, Petar Momcilovic Momcilovic, Nikos Trichakis, and Craig A. Bunnell. "Quantifying the electronic medical record implementation to stabilization curve." Journal of Clinical Oncology 35, no. 8_suppl (March 10, 2017): 140. http://dx.doi.org/10.1200/jco.2017.35.8_suppl.140.
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140 Background: The implementation of electronic medical records (EMR) has been noted to disrupt clinical workflows as providers acclimate to a new EMR. On May 30, 2015, Dana-Farber Cancer Institute (DFCI) implemented a new EMR. Using our Real Time Location System (RTLS), we sought to identify the time required to stabilize the experience for providers. We identified factors that may speed the stabilization rate to guide EMR implementations elsewhere. Methods: DFCI uses an RTLS to timestamp patient and provider locations throughout the day. To adjust for variation in appointment types, we measured the ratio of the actual exam duration (recorded by the RTLS) to the scheduled exam duration. We compared to a 3-month baseline average to quantify the immediate impact of implementation. We tracked the ratio over time to identify when stabilization occurred and compare to baseline performance. To infer influential factors, we performed a regression analysis based on RTLS data from the first 6 months post implementation. Results: The stabilization curve fits the “classical” power function model. Rapid improvement over the first ten days of clinical practice was followed by a gradual period of ongoing stabilization. The EMR impact on exam duration required approximately 30 clinical days for each provider to reach the baseline value with continued improvement over the next 30 clinical days. Factors with a potential to improve the rate of stabilization were provider type (MD, NP or PA), provider gender and provider age. Conclusions: The first ten clinical days experience a fast rate of improvement. Thus, while the initial impact is disruptive, operations improve rapidly. Initial improvement may be attributed to fixing “bugs” in the EMR and rapid learning by providers. Our presentation will explore factors that impact the rate of improvement. Understanding the stabilization rate and factors can aid organizations in training, implementation, and ongoing improvement to minimize the impact of EMR disruption. [Table: see text]
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Gabehart, Kari, Sara Tuvell, Christina L. Cook, David Roggy, and Rajiv Sood. "36 Developing Burn Specific Documents in the Electronic Medical Record." Journal of Burn Care & Research 41, Supplement_1 (March 2020): S25. http://dx.doi.org/10.1093/jbcr/iraa024.040.
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Abstract Introduction The challenge with burn documentation needs in electronic medical record systems is recognized and often limited in the foundation of commercial electronic systems. In October 2016, our institution transitioned to a new all-inclusive electronic medical record. The transition to this new Electronic Medical Record (EMR) afforded us the opportunity to develop and build burn specific documentation needs in the new EMR system. In this paper, we share our experiences and the keys to our successful builds to streamline burn patients’ documentation and information. Methods In January 2013, the EMR build team was composed of corporate contractors, dedicated clinical staff from all areas of the hospital that transitioned to the build team, and private contractors experienced in the EMR build process. To our great fortune, our burn team was provided access to four dedicated build team members that worked specifically on meeting our burn team documentation needs. With high level collaboration our team was able to assess foundation abilities of the new system, identify gaps to burn care and collaboratively create and build automated documents to meet our burn needs. In October 2016, the EMR system was implemented with our burn specific documents, flowsheets, and reports. Results Through working with our dedicated build team, we were able to create an electronic Lund-Browder Chart with an avatar that is completed with each admission by our medical team. We developed a fluid resuscitation flowsheet that is documented in real-time; displays fluid resuscitation goals; displays urine output goals. The creation of a standardized wound care note template was necessary as the wound template within the existing EMR system was too cumbersome. Burn wound photo-documentation to include inpatient, outpatient, intra-operative and emergency department needs automatically uploads into the patient’s medical record from an encrypted portable handheld device connected to the EMR. Burn specific reports were developed to meet the specific needs of inquiry whether it is for performance improvement or research. Additionally, the same EMR is used in all phases of care to include the burn clinic which allows for ease and continuity of care. Conclusions An EMR that is all-inclusive has benefitted our team and patient safety by streamlining the review and documentation of information. Having specific and dedicated EMR build specialist allocated to focusing on the needs of the burn unit was invaluable in the build, implementation, and maintenance phases. We continue to work with our EMR specialist to improve processes and documentation practices that impact patient outcomes. Our burn EMR specialist meets with the burn team on a monthly basis to evaluate and assess ongoing needs to further outcomes. Applicability of Research to Practice Within this presentation, we will share our journey, challenges, and successes.
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Hesita, E. L. "Electronic medical record (EMR) in the oncology setting tested: A first hand experience." Journal of Clinical Oncology 24, no. 18_suppl (June 20, 2006): 16043. http://dx.doi.org/10.1200/jco.2006.24.18_suppl.16043.
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16043 Background: Current data indicate that America’s medical system has been slow to embrace technology in relation to the use of the electronic medical record (EMR). The disruption caused by hurricane Katrina in the lives of cancer patients living in the city of New Orleans may prove to be an eye-opening experience that will persuade healthcare providers to change the traditional way of storing medical records. This study focuses on the experience of displaced New Orleans cancer patients. Methods: An anonymous validated questionnaire was completed by a random group of returning patients six weeks after the hurricane. This random group of patients evacuated to various states across the country. The focal questions asked were: the degree of difficulty in obtaining records, whether the alternate oncologist had to order further test(s), and whether the patients agree to having their medical records in an electronic format. Results: Of the total of 75 respondents, 93% are served by an institution in the New Orleans area that utilizes EMR while 7% are served by various institutions within the New Orleans area that do not have EMR. Overall, 81% stated ease in obtaining their records (within 1–4 days) while 19% stated difficulty (7 days or greater). Only 3% of the patients with EMR indicated difficulty while 100% of the non-EMR patients stated difficulty. For patients with EMR, 83% of the alternate oncologists did not order further tests, while 100% of the alternate oncologists ordered further testing for patients without EMR. In terms of patients’ sentiments regarding EMR, 76% agree to have EMR while 24% disagree. Conclusions: EMR in the oncology setting may prove to be an essential component in the delivery of quality patient care in terms of safety, cost effectiveness, and preservation of privacy. The majority of the patients surveyed agree to a form of electronic record-keeping based on their first-hand experience. No significant financial relationships to disclose.
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Naeem, Muhammad, and Ibrahim Alqasimi. "Unfolding and Addressing the Issues of Electronic Medical Record Implementation." Information Resources Management Journal 33, no. 3 (July 2020): 59–80. http://dx.doi.org/10.4018/irmj.2020070103.
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The social influence and competitive pressure for health technology adoption has increased among developed, developing, and emerging countries. The present study aimed to uncover and address the issues of electronic medical record (EMR) implementation in public sector hospitals in the Kingdom of Saudi Arabia (KSA). It used the social constructivism approach to understand employee attitudes, behaviors, and motivations within the local culture, structure, political forces of the KSA. Data was gathered from 40 participants. These individuals and institutional factors influence the EMR adoption and implementation efforts in public sector hospitals in the KSA. Key EMR implementation issues identified included limited IT skills, low professional qualifications, work-overload, and lack of sufficient planning for the integration of EMR with other systems. The study used a mixture of three theories, institutional, Diffusion of Innovation (DOI), and ability, motivation, and opportunity (AMO), to understand the role of these factors and to propose strategies able to increase the rate of successful EMR implementations in public hospitals in the KSA.
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Romero, Mary Rachel, Michelle Ballou, Deanna Rinehart, and Catherine Kleiner. "Effective Strategies for Electronic Medical Record (EMR) Implementation." Journal of PeriAnesthesia Nursing 28, no. 3 (June 2013): e1. http://dx.doi.org/10.1016/j.jopan.2013.04.002.
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Weber-Jahnke, Jens H., and Fieran Mason-Blakley. "The safety of Electronic Medical Record (EMR) systems." ACM SIGHIT Record 1, no. 2 (September 2011): 13–22. http://dx.doi.org/10.1145/2047478.2047480.
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DeMers, Gerard, Christopher Kahn, Per Johansson, Colleen Buono, Octav Chipara, William Griswold, and Theodore Chan. "Secure Scalable Disaster Electronic Medical Record and Tracking System." Prehospital and Disaster Medicine 28, no. 5 (June 26, 2013): 498–501. http://dx.doi.org/10.1017/s1049023x13008686.
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AbstractIntroductionElectronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability.ReportAs the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures.ConclusionA secure prehospital triage EMR improves documentation quality during disaster drills.DeMersG, KahnC, JohanssonP, BuonoC, ChiparaO, GriswoldW, ChanT. Secure scalable disaster electronic medical record and tracking system. Prehosp Disaster Med. 2013;28(5):1-4.
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McMurtrey, Josie, Paul Driver, Pam Reed, Thomas Thrower, and Binay Kumar Shah. "Selection of medical oncology electronic medical record (EMR): A case study." Journal of Clinical Oncology 30, no. 34_suppl (December 1, 2012): 327. http://dx.doi.org/10.1200/jco.2012.30.34_suppl.327.
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327 Background: Selection of an ideal EMR is an important but a complicated process, especially because there are few established guidelines available. We describe a case study on the process of selection of medical oncology EMR from our experience at St. Joseph Regional Cancer Center, Lewiston ID. Methods: A multidisciplinary team was developed, including a medical oncologist to develop workflow diagrams capturing tasks completed for patient care. This allowed the team to identify requirements and functionality important to have within an EMR. Requirements rating as high, medium or low. The scoring methodology was based on a rating scale (0-5, where 0 does not meet the fundamental requirement and 5 fully meets the fundamental requirement; 0-2, where 0 does not meet the differentiator requirement and 2 fully meets the differentiator requirement) to capture if system met fundamental and differentiator requirements. The team developed a list of the ten most important needs within a system to focus on while viewing vendor demos. The top 10 requirements focused on lab result integration, other facility integration, alerts, billing flow of information, electronic prescriptions, local assessments, electronic consent forms, flexibility in chemo calculations, sign-offs of treatments throughout the patient flow process, and the ability to order cycles of treatment in a multi-visit treatment plan. Finally, use case scenarios were developed and vendors were given the opportunity to demo their product using workflow scenarios. Results: Out of 10 medical oncology systems in consideration, the evaluation included four 3rd party vendor systems and one EMR platform system. Four systems were chosen for evaluation based on rankings from the 2011 Oncology IS KLAS report. Complete evaluation of the systems and the scorings were based on vendor demo webinars and multidisciplinary input. This methodical approach allowed the team to gain a broad, balanced approach in narrowing the search down to the top three finalists. Conclusions: A systematic approach that includes an objective scoring system and research by interviewing other sites is useful in selection of a medical oncology EMR.
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Tange, H. J. "Consultation of Medical Narratives in the Electronic Medical Record." Methods of Information in Medicine 38, no. 04/05 (1999): 289–93. http://dx.doi.org/10.1055/s-0038-1634417.
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AbstractThis article presents an overview of a research project concerning the consultation of medical narratives in the electronic medical record (EMR). It describes an analysis of user needs, the design and implementation of a prototype EMR system, and the evaluation of the ease of consultation of medical narratives when using this system. In a questionnaire survey, 85 hospital physicians judged the quality of their paper-based medical record with respect to data entry, information retrieval and some other aspects. Participants were more positive about the paper medical record than the literature suggests. They wished to maintain the flexibility of data entry but indicated the need to improve the retrieval of information. A prototype EMR system was developed to facilitate the consultation of medical narratives. These parts were divided into labeled segments that could be arranged source-oriented and problem-oriented. This system was used to evaluate the ease of information retrieval of 24 internists and 12 residents at a teaching hospital when using free-text medical narratives divided at different levels of detail. They solved, without time pressure, some predefined problems concerning three voluminous, inpatient case records. The participants were randomly allocated to a sequence that was balanced by patient case and learning effect. The division of medical narratives affected speed, but not completeness of information retrieval. Progress notes divided into problem-related segments could be consulted 22% faster than when undivided. Medical history and physical examination divided into segments at organ-system level could be consulted 13% faster than when divided into separate questions and observations. These differences were statistically significant. The fastest divisions were also appreciated as the best combination of easy searching and best insight in the patient case. The results of our evaluation study suggest a trade-off between searching and reading: too much detailed segments will delay the consultation of medical narratives. Validation of the results in daily practice is recommended.
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Ajayi, Stephen Adekunle, Peter Wamae, and Daniel Wambiri Muthee. "Assessing Electronic Medical Records Readiness for Service Delivery in State Hospitals in Southwest Nigeria." International Journal of Current Aspects 5, no. 3 (July 5, 2021): 1–17. http://dx.doi.org/10.35942/ijcab.v5i3.175.
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Electronic Medical Records (EMR) is an important communications channel relating to patient health conditions. Unfortunately, many hospitals in Africa, including Nigeria, have not implemented EMR. The few Hospitals that have some level of EMR continues are still struggling with the use of paper and hybrid medical records, which has led to inadequate medical follow-up, medical error, and long waiting time for patients. A sample size of three hundred and ninety-seven (397) was determined using krejcie and morgan models, comprising of strategic managers, and the operational staff drawn from a population of 2889 in the selected hospitals. At the hospital level, purposive sampling was applied in picking strategic managers, while stratified random sampling was method was used to select operational health workers. Questionnaires were used for data collection. The study adopted a descriptive statistical analysis method to describe the existing medical records systems. The finding indicated that the systems in the hospitals are mainly paper-based. The hospitals are also using hybrid system with a few treatment areas having fully electronic medical records systems. In the area where EMR has been implemented, the finding indicates poor penetration of the EMR system, limited modules, staff readiness and poor performance in the treatment area, among others. The study concluded that hospitals that have implemented, EMR is not serving the classical purpose of medical record of supporting treatment and follow up. The study recommended that the selected hospitals should ensure there is the availability of fund, staff training, and technical infrastructures like electronic record managers, ICT support staff, and computer compatible medical devices, among others.
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MOROS, DANIEL A. "The Electronic Medical Record and the Loss of Narrative." Cambridge Quarterly of Healthcare Ethics 26, no. 2 (March 31, 2017): 328–31. http://dx.doi.org/10.1017/s0963180116000918.
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Abstract:The use of the electronic medical record (EMR) facilitates many aspects of patient care as well as clinical and outcomes research. However, our thought processes are directed differently when collecting data to be entered into a structured database compared with when collecting data to construct a narrative of the patient and his or her complaints. While recognizing that the EMR will improve overall patient care, it is worthwhile examining aspects of patient–doctor interaction that may be sacrificed.
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Ajayi, Stephen Adekunle, Peter Wamae, and Daniel Wambiri Muthee. "Implementation of Electronic Medical Records for Service Delivery in Selected State Hospitals in Southwest Nigeria." International Journal of Current Aspects 5, no. 2 (June 30, 2021): 75–94. http://dx.doi.org/10.35942/ijcab.v5i2.174.
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Electronic Medical Records (EMR) is an important communications channel relating to patient health conditions. Unfortunately, many hospitals in Africa, including Nigeria, have not implemented EMR. The few Hospitals that have some level of EMR continues are still struggling with the use of paper and hybrid medical records, which has led to inadequate medical follow-up, medical error, and long waiting time for patients. A sample size of three hundred and ninety-seven (397) was determined using krejcie and morgan models, comprising of strategic managers, and the operational staff drawn from a population of 2889 in the selected hospitals. At the hospital level, purposive sampling was applied in picking strategic managers, while stratified random sampling was method was used to select operational health workers. Questionnaires were used for data collection. The study adopted a descriptive statistical analysis method to describe the existing medical records systems. The finding indicated that the systems in the hospitals are mainly paper-based. The hospitals are also using hybrid system with a few treatment areas having fully electronic medical records systems. In the area where EMR has been implemented, the finding indicates poor penetration of the EMR system, limited modules, staff readiness and poor performance in the treatment area, among others. The study concluded that hospitals that have implemented, EMR is not serving the classical purpose of medical record of supporting treatment and follow up. The study recommended that the selected hospitals should ensure there is the availability of fund, staff training, and technical infrastructures like electronic record managers, ICT support staff, and computer compatible medical devices, among others.
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Zhang, Ziqi, Chao Yan, Diego A. Mesa, Jimeng Sun, and Bradley A. Malin. "Ensuring electronic medical record simulation through better training, modeling, and evaluation." Journal of the American Medical Informatics Association 27, no. 1 (October 8, 2019): 99–108. http://dx.doi.org/10.1093/jamia/ocz161.
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Abstract Objective Electronic medical records (EMRs) can support medical research and discovery, but privacy risks limit the sharing of such data on a wide scale. Various approaches have been developed to mitigate risk, including record simulation via generative adversarial networks (GANs). While showing promise in certain application domains, GANs lack a principled approach for EMR data that induces subpar simulation. In this article, we improve EMR simulation through a novel pipeline that (1) enhances the learning model, (2) incorporates evaluation criteria for data utility that informs learning, and (3) refines the training process. Materials and Methods We propose a new electronic health record generator using a GAN with a Wasserstein divergence and layer normalization techniques. We designed 2 utility measures to characterize similarity in the structural properties of real and simulated EMRs in the original and latent space, respectively. We applied a filtering strategy to enhance GAN training for low-prevalence clinical concepts. We evaluated the new and existing GANs with utility and privacy measures (membership and disclosure attacks) using billing codes from over 1 million EMRs at Vanderbilt University Medical Center. Results The proposed model outperformed the state-of-the-art approaches with significant improvement in retaining the nature of real records, including prediction performance and structural properties, without sacrificing privacy. Additionally, the filtering strategy achieved higher utility when the EMR training dataset was small. Conclusions These findings illustrate that EMR simulation through GANs can be substantially improved through more appropriate training, modeling, and evaluation criteria.
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Sarfraz, Muhammad, Anwar F. Al-Hussainan, Farah Mohammad, and Hanouf Al-Azmi. "An Electronic Medical Record System." International Journal of Extreme Automation and Connectivity in Healthcare 2, no. 1 (January 2020): 68–102. http://dx.doi.org/10.4018/ijeach.2020010105.
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This research proposes, designs, and implements a new online system for electronic medical records (EMR) for assisting the current processes of labs and hospitals. Specific consideration is given to the records of blood donors. It provides an online automated alternate to the traditional manual processes adopted for various medical labs. The proposed system provides an easy way to communicate with the world. The article presents use case diagrams that model the logics of the system. It also proposes schema for supporting databases in the system. The system is prototyped, and ready to be used. To achieve the targeted system, in addition to investigating the latest studies in this area, the needed data was collected through a questionnaire survey with the community. The system, as a special case, has been oriented for the communities of the state of Kuwait to improve its healthcare sector. However, this design can be easily ported to other countries platforms due to its generic formulation.
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Febrianti, Eka Cintiya, Ida Nurmawati, and Indah Muflihatin. "Evaluasi Rekam Medis Elektronik di Tempat Pendaftaran Pasien Gawat Darurat dan Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang." J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan 1, no. 4 (October 15, 2020): 537–44. http://dx.doi.org/10.25047/j-remi.v1i4.2145.
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Each hospital is required to hold records or records of all services provided to patients called medical records. Increasing the effectiveness of recording medical data that is accurate, fast, can take advantage of current technological advances through the implementation of the Electronic Medical Record (EMR) system in hospitals. RSUD K.R.M.T Wongsonegoro is one of the hospitals that has implemented an electronic medical record (EMR) especially in the inpatient and emergency department registration units. The application of this electronic medical record still has some flaws that must be evaluated. This study aims to evaluate the implementation of electronic medical records at the emergency and inpatient registrations of Wongsonegoro Hospital. Data collection in this study consisted of observations and interviews. Identification of problems using the TAM (Technology Acceptance Model) method by reviewing from 3 aspects namely perceived usefulness, perceived ease of use, and behavioral intention to use. This type of research is descriptive qualitative by narrating the results of research based on the data obtained. The results obtained from this study are based on the aspect of usefulness (perceived usefulness), namely the use of electronic medical records in TPPGD and TPPRI, making the registration officer work faster and more effective.The aspect of ease (perceived ease of use) obtained from the interview results is that it is able to make it easier to accelerate the registration process in the TPPGD and TPPRI. The behavioral intention to use obtained is that the users of this system really need this electronic medical record and the registration officer at TPPGD and TPPRI plans to use the EMR in the future.
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Randhawa, Gurprit K., Aviv Shachak, Karen L. Courtney, and Andre Kushniruk. "Effective Design, Development, and Evaluation of Video Tutorials for Electronic Medical Record Training." ACI Open 04, no. 01 (January 2020): e69-e82. http://dx.doi.org/10.1055/s-0040-1708036.
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Abstract Background Electronic medical record (EMR) use by primary care physicians (PCP) in the United States and Canada is suboptimal, especially for supporting chronic diseases like diabetes. PCPs need postimplementation training to achieve value-adding EMR use. Video tutorials demonstrate how to accomplish tasks using software. However, there is a dearth of research on the use of video tutorials for EMR training. Objective The purpose of the study was to design, develop, and evaluate video tutorials for training PCPs in using EMR advanced features for diabetes care. This study addressed three research questions related to PCP's views of video tutorials as an EMR training method/approach, barriers, and facilitators to applying the EMR video tutorials to PCPs' practice, and how the design of EMR video tutorials can be improved. Methods The overall research study employed a QUAN (qual) mixed methods approach with an embedded design. This article focuses on the qualitative phase of the mixed methods study. A series of four theory-informed and evidence-based video tutorials for diabetes care was developed with a physician champion. Qualitative data were collected at four time points: 1 month before (O1), immediately before (O2), 3 months after (O3), and 6 months (O4) after the intervention. Semistructured interviews with participants were held at O3 and O4. Qualitative data were analyzed using thematic analysis. Results In total, 14 PCPs from the overall study participated in interviews (78%). The thematic analysis of the qualitative data revealed seven themes, which fall into two main categories: (1) design and development of EMR video tutorials, and (2) adoption and use of EMR video tutorials. Conclusion PCPs liked the EMR video tutorials for diabetes care, and would like more EMR video tutorials on various topics and EMR use levels. The study offers a roadmap for health informatics professionals everywhere to develop EMR training videos that meet evidence-based design criteria. It also help to identify opportunities to improve the design, delivery, and adoption of EMR video tutorials for future training interventions.
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Kalayou, Mulugeta Hayelom, Berhanu Fikadie Endehabtu, Habtamu Alganeh Guadie, Zeleke Abebaw, Kassahun Dessie, Shekur Mohammed Awol, Nebyu Demeke Mengestie, Abraham Yeneneh, and Binyam Tilahun. "Physicians’ Attitude towards Electronic Medical Record Systems: An Input for Future Implementers." BioMed Research International 2021 (August 28, 2021): 1–9. http://dx.doi.org/10.1155/2021/5523787.
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Background. Electronic medical record (EMR) systems offer the potential to improve health care quality by allowing physicians real-time access to patient healthcare information. The endorsement and usage of EMRs by physicians have a significant influence on other user groups in the healthcare system. As a result, the purpose of this study was to examine physicians’ attitudes regarding EMRs and identify the elements that may influence their attitudes. Method. An institutional-based cross-sectional study design supplemented with a qualitative study was conducted from March 1 to April 30, 2018, among a total of 403 physicians. A self-administered questionnaire was used to collect quantitative data. The validity of the prediction bounds for the dependent variable and the validity of the confidence intervals and P values for the parameters were measured with a value of less than 0.05 and 95 percent of confidence interval. For the supplementary qualitative study, data were collected using semistructured in-depth interviews from 11 key informants, and the data were analyzed using thematic analysis. Result. Physicians’ computer literacy (CI: 0.264, 0.713; P : 0001) and computer access at work (CI: 0.141, 0.533, P : 0.001) were shown to be favorable predictors of their attitude towards EMR system adoption. Another conclusion from this study was the inverse relationship between physicians’ prior EMR experience and their attitude about the system (CI: -0.517, -0.121; P : 0.002). Conclusion. According to the findings of this study, physicians’ attitudes regarding EMR were found moderate in the studied region. There was a favorable relationship between computer ownership, computer literacy, lack of EMR experience, participation in EMR training, and attitude towards EMR. Improving the aforementioned elements is critical to improving physicians’ attitudes regarding EMR.
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Chen, Weizhe, Shunzhi Zhu, Jianmin Li, Jiaxin Wu, Chin-Ling Chen, and Yong-Yuan Deng. "Authorized Shared Electronic Medical Record System with Proxy Re-Encryption and Blockchain Technology." Sensors 21, no. 22 (November 22, 2021): 7765. http://dx.doi.org/10.3390/s21227765.
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With the popularity of the internet 5G network, the network constructions of hospitals have also rapidly developed. Operations management in the healthcare system is becoming paperless, for example, via a shared electronic medical record (EMR) system. A shared electronic medical record system plays an important role in reducing diagnosis costs and improving diagnostic accuracy. In the traditional electronic medical record system, centralized database storage is typically used. Once there is a problem with the data storage, it could cause data privacy disclosure and security risks. Blockchain is tamper-proof and data traceable. It can ensure the security and correctness of data. Proxy re-encryption technology can ensure the safe sharing and transmission of relatively sensitive data. Based on the above situation, we propose an electronic medical record system based on consortium blockchain and proxy re-encryption to solve the problem of EMR security sharing. Electronic equipment in this process is connected to the blockchain network, and the security of data access is ensured through the automatic execution of blockchain chaincodes; the attribute-based access control method ensures fine-grained access to the data and improves the system security. Compared with the existing electronic medical records based on cloud storage, the system not only realizes the sharing of electronic medical records, but it also has advantages in privacy protection, access control, data security, etc.
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Liu, Lina, Qin Cen, Mei Ji, and Li Qiong Chen. "Research on Data Model of Electronic Medical Record Based on XML." Applied Mechanics and Materials 29-32 (August 2010): 1217–22. http://dx.doi.org/10.4028/www.scientific.net/amm.29-32.1217.
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Comparing with the old medical record, EMR(Electronic Medical Record)has more advantages on morden society. While XML plays an important part in EMR, so people make no efforts to study the XML. There are two data models of XML, which are DTD and XML Schema .Firstly the paper introduces these two data models, then analysis advantages and disadvantages through an instance, finally draws the conclusion.
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Mhamdi, Halima, Manel Ayadi, Amel Ksibi, Amal Al-Rasheed, Ben Othman Soufiene, and Sakli Hedi. "SEMRAchain: A Secure Electronic Medical Record Based on Blockchain Technology." Electronics 11, no. 21 (November 6, 2022): 3617. http://dx.doi.org/10.3390/electronics11213617.
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A medical record is an important part of a patient’s follow-up. It comprises healthcare professionals’ views, prescriptions, analyses, and all information about the patient. Several players, including the patient, the doctor, and the pharmacist, are involved in the process of sharing, and managing this file. Any authorized individual can access the electronic medical record (EMR) from anywhere, and the data are shared among various health service providers. Sharing the EMR requires various conditions, such as security and confidentiality. However, existing medical systems may be exposed to system failure and malicious intrusions, making it difficult to deliver dependable services. Additionally, the features of these systems represent a challenge for centralized access control methods. This paper presents SEMRAchain a system based on Access control (Role-Based Access Control (RBAC), Attribute-Based Access Control (ABAC)) and a smart contract approach. This fusion enables decentralized, fine-grained, and dynamic access control management for EMR management. Together, blockchain technology as a secure distributed ledger and access control provides such a solution, providing system stakeholders with not just visibility but also trustworthiness, credibility, and immutability.
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Tegegne, Masresha Derese, Sisay Maru Wubante, Mulugeta Hayelom Kalayou, Mequannent Sharew Melaku, Binyam Tilahun, Tesfahun Melese Yilma, and Hiwote Simane Dessie. "Electronic Medical Record System Use and Determinants in Ethiopia: Systematic Review and Meta-Analysis." Interactive Journal of Medical Research 12 (January 11, 2023): e40721. http://dx.doi.org/10.2196/40721.
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Background The strategic plan of the Ethiopian Ministry of Health recommends an electronic medical record (EMR) system to enhance health care delivery and streamline data systems. However, only a few exhaustive systematic reviews and meta-analyses have been conducted on the degree of EMR use in Ethiopia and the factors influencing success. This will emphasize the factors that make EMR effective and increase awareness of its widespread use among future implementers in Ethiopia. Objective This study aims to determine the pooled estimate of EMR use and success determinants among health professionals in Ethiopia. Methods We developed a protocol and searched PubMed, Web of Sciences, African Journals OnLine, Embase, MEDLINE, and Scopus to identify relevant studies. To assess the quality of each included study, we used the Joanna Briggs Institute quality assessment tool using 9 criteria. The applicable data were extracted using Microsoft Excel 2019, and the data were then analyzed using Stata software (version 11; StataCorp). The presence of total heterogeneity across included studies was calculated using the index of heterogeneity I2 statistics. The pooled size of EMR use was estimated using a random effect model with a 95% CI. Results After reviewing 11,026 research papers, 5 papers with a combined total of 2439 health workers were included in the evaluation and meta-analysis. The pooled estimate of EMR usage in Ethiopia was 51.85% (95% CI 37.14%-66.55%). The subgroup study found that the northern Ethiopian region had the greatest EMR utilization rate (58.75%) and that higher (54.99%) utilization was also seen in publications published after 2016. Age groups <30 years, access to an EMR manual, EMR-related training, and managerial support were identified factors associated with EMR use among health workers. Conclusions The use of EMR systems in Ethiopia is relatively low. Belonging to a young age group, accessing an EMR manual, receiving EMR-related training, and managerial support were identified as factors associated with EMR use among health workers. As a result, to increase the use of EMRs by health care providers, it is essential to provide management support and an EMR training program and make the EMR manual accessible to health professionals.
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Lee, Seungwon, Chelsea Doktorchik, Elliot Asher Martin, Adam Giles D'Souza, Cathy Eastwood, Abdel Aziz Shaheen, Christopher Naugler, Joon Lee, and Hude Quan. "Electronic Medical Record–Based Case Phenotyping for the Charlson Conditions: Scoping Review." JMIR Medical Informatics 9, no. 2 (February 1, 2021): e23934. http://dx.doi.org/10.2196/23934.
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Background Electronic medical records (EMRs) contain large amounts of rich clinical information. Developing EMR-based case definitions, also known as EMR phenotyping, is an active area of research that has implications for epidemiology, clinical care, and health services research. Objective This review aims to describe and assess the present landscape of EMR-based case phenotyping for the Charlson conditions. Methods A scoping review of EMR-based algorithms for defining the Charlson comorbidity index conditions was completed. This study covered articles published between January 2000 and April 2020, both inclusive. Embase (Excerpta Medica database) and MEDLINE (Medical Literature Analysis and Retrieval System Online) were searched using keywords developed in the following 3 domains: terms related to EMR, terms related to case finding, and disease-specific terms. The manuscript follows the Preferred Reporting Items for Systematic reviews and Meta-analyses extension for Scoping Reviews (PRISMA) guidelines. Results A total of 274 articles representing 299 algorithms were assessed and summarized. Most studies were undertaken in the United States (181/299, 60.5%), followed by the United Kingdom (42/299, 14.0%) and Canada (15/299, 5.0%). These algorithms were mostly developed either in primary care (103/299, 34.4%) or inpatient (168/299, 56.2%) settings. Diabetes, congestive heart failure, myocardial infarction, and rheumatology had the highest number of developed algorithms. Data-driven and clinical rule–based approaches have been identified. EMR-based phenotype and algorithm development reflect the data access allowed by respective health systems, and algorithms vary in their performance. Conclusions Recognizing similarities and differences in health systems, data collection strategies, extraction, data release protocols, and existing clinical pathways is critical to algorithm development strategies. Several strategies to assist with phenotype-based case definitions have been proposed.
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Baird, Shawn, and George Boak. "Leading change: introducing an electronic medical record system to a paramedic service." Leadership in Health Services 29, no. 2 (2016): 136–50. http://dx.doi.org/10.1108/lhs-04-2015-0012.
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Purpose Leaders in health-care organizations introducing electronic medical records (EMRs) face implementation challenges. The adoption of EMR by the emergency medical and ambulance setting is expected to provide wide-ranging benefits, but there is little research into the processes of adoption in this sector. The purpose of this study is to examine the introduction of EMR in a small emergency care organization and identify factors that aided adoption. Design/methodology/approach Semi-structured interviews with selected paramedics were followed up with a survey issued to all paramedics in the company. Findings The user interfaces with the EMR, and perceived ease of use, were important factors affecting adoption. Individual paramedics were found to have strong and varied preferences about how and when they integrated the EMR into their practice. As company leadership introduced flexibility of use, this enhanced both individual and collective ability to make sense of the change and removed barriers to acceptance. Research limitations/implications This is a case study of one small organization. However, there may be useful lessons for other emergency care organizations adopting EMR. Practical implications Leaders introducing EMR in similar situations may benefit from considering a sense-making perspective and responding promptly to feedback. Originality/value The study contributes to a wider understanding of issues faced by leaders who seek to implement EMRs in emergency medical services, a sector in which there has been to date very little research on this issue.
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Mattar, Ahmed, David Carlston, Glen Sariol, Tongle Yu, Ahmad Almustafa, Genevieve Melton, and Adil Ahmed. "The prevalence of obesity documentation in Primary Care Electronic Medical Records." Applied Clinical Informatics 26, no. 01 (2017): 67–79. http://dx.doi.org/10.4338/aci-2016-07-ra-0115.
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Summary Background: Although obesity is a growing problem, primary care physicians often inadequately address it. The objective of this study is to examine the prevalence of obesity documentation in the patient’s problem list for patients with eligible body mass indexes (BMI) as contained in the patients’ electronic medical record (EMR). Additionally, we examined the prevalence of selected chronic conditions across BMI levels. Method: This study is a retrospective study using EMR data for adult patients visiting an outpatient clinic between June 2012 and June 2015. International Classification of Diseases, Ninth Revision, (ICD-9) codes were used to identify obesity documentation in the EMR problem list. Univariate and multivariate logistic regression analyses were used. Results: Out of 10,540, a total of 3,868 patients were included in the study. 2,003 (52%) patients met the criteria for obesity (BMI30.0); however, only 112 (5.6%) patient records included obesity in the problem list. Moreover, in a multivariate analysis, in addition to age and gender, morbid obesity and cumulative number of comorbidities were significantly associated with obesity documentation, OR=1.6 and OR=1.3, respectively, with 95% CI [1.4, 1.9] and [1.0, 1.7], respectively. For those with obesity documentation, exercise counseling was provided more often than diet counselling. Conclusion: Based on EHR documentation, obesity is under coded and generally not identified as a significant problem in primary care. Physicians are more likely to document obesity in the patient record for those with higher BMI scores who are morbidly obese. Moreover, physicians more frequently provide exercise than diet counseling for the documented obese.
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Narattharaksa, Kanida, Mark Speece, Charles Newton, and Damrongsak Bulyalert. "Key success factors behind electronic medical record adoption in Thailand." Journal of Health Organization and Management 30, no. 6 (September 19, 2016): 985–1008. http://dx.doi.org/10.1108/jhom-10-2014-0180.
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Purpose The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems. Design/methodology/approach Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel. Findings The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication. Research limitations/implications Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel. Practical implications Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues. Originality/value Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood.
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Paterick, Zachary R., Nachiket J. Patel, and Timothy Edward Paterick. "Unintended consequences of the electronic medical record on physicians in training and their mentors." Postgraduate Medical Journal 94, no. 1117 (November 2018): 659–61. http://dx.doi.org/10.1136/postgradmedj-2018-135849.
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For physicians in training and their mentors, the process of learning and teaching clinical medicine has become challenging in the electronic medical record (EMR) era. Trainees and their mentors exist in a milieu of incessant box checking and laborious documentation that has no clinical educational value, limits the time for teaching and curtails clinical cognitive skill development. These unintended consequences of the EMR are juxtaposed against the EMR’s intended benefits of improved patient care and safety with reduced medical errors, improved clinical support systems, reduced potential for negligence with clinical data and metadata data supporting compliance with the standard of care. Although the mindset was technology would be the solution to many healthcare issues, there was not an appreciation of the cumulative impact of the non-educational workload on physician time and education. The EMR was intended to improve the efficiency of medical care and time management. It appears that the unintended consequences of the EMR with numerous checkboxes, automatic filling of computer screens, pre-worded templates, and automatic history and physical examination functions with detailed administrative oversight and compliance monitoring were not appreciated, and many believe that burden has overwhelmed the intended benefits of the EMR. This juxtaposition of the intended and unintended consequences of the EMR has left trainees and mentors struggling to optimise medical education and development of clinical skills while providing high-quality patient medical care. Physician educators must identify how to use the benefits of the EMR and overcome the unintended consequences. A major unintended consequence of the EMR is time dedicated to automate functions that detract from the time spent with mentors and patients. This time loss has the potential to restrict the physician from meeting the essential canons of medical informed consent and interfere with a physician meeting her fiduciary duties to the patient. To raise awareness and stimulate a search for solutions that benefit medical education and patient care, we will explore the intended and unintended consequences of the EMR and potential solutions using the intelligent systems of the EMR.
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Ota, Hiroshi, Miki Inagaki, Naoko Fujiwara, and Masumi Azuma. "Electronic medical record systems-based simulation for practicum in critical care nursing." Journal of Nursing Education and Practice 8, no. 4 (December 7, 2017): 96. http://dx.doi.org/10.5430/jnep.v8n4p96.
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Electronic medical record (EMR) systems are increasingly used in medical facilities. This study focused on nursing students’ information-gathering ability, an important skill in emergency nursing where patients’ conditions can change rapidly. A simulation exercise was developed based on an educational EMR system and conducted as part of the nursing process exercises that prepare students for on-site practical emergency nursing training. The utility of the EMR system and the educational effectiveness of the simulation exercise were evaluated. To this end, 106 third-year nursing students were surveyed twice: once after they participated in the simulation exercise and once after they undertook their practical training. The results showed that the students evaluated the EMR system’s operability favorably, suggesting that the system has potential as a prototype. Regarding the conditions of the simulation exercise, the results suggested that designing the learning environment so that it features a scenario encountered in practical training settings was effective for helping the students envisage the conditions of practical training.
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Calzoni, Luca, Gilles Clermont, Gregory F. Cooper, Shyam Visweswaran, and Harry Hochheiser. "Graphical Presentations of Clinical Data in a Learning Electronic Medical Record." Applied Clinical Informatics 11, no. 04 (August 2020): 680–91. http://dx.doi.org/10.1055/s-0040-1709707.
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Abstract Background Complex electronic medical records (EMRs) presenting large amounts of data create risks of cognitive overload. We are designing a Learning EMR (LEMR) system that utilizes models of intensive care unit (ICU) physicians' data access patterns to identify and then highlight the most relevant data for each patient. Objectives We used insights from literature and feedback from potential users to inform the design of an EMR display capable of highlighting relevant information. Methods We used a review of relevant literature to guide the design of preliminary paper prototypes of the LEMR user interface. We observed five ICU physicians using their current EMR systems in preparation for morning rounds. Participants were interviewed and asked to explain their interactions and challenges with the EMR systems. Findings informed the revision of our prototypes. Finally, we conducted a focus group with five ICU physicians to elicit feedback on our designs and to generate ideas for our final prototypes using participatory design methods. Results Participating physicians expressed support for the LEMR system. Identified design requirements included the display of data essential for every patient together with diagnosis-specific data and new or significantly changed information. Respondents expressed preferences for fishbones to organize labs, mouseovers to access additional details, and unobtrusive alerts minimizing color-coding. To address the concern about possible physician overreliance on highlighting, participants suggested that non-highlighted data should remain accessible. Study findings led to revised prototypes, which will inform the development of a functional user interface. Conclusion In the feedback we received, physicians supported pursuing the concept of a LEMR system. By introducing novel ways to support physicians' cognitive abilities, such a system has the potential to enhance physician EMR use and lead to better patient outcomes. Future plans include laboratory studies of both the utility of the proposed designs on decision-making, and the possible impact of any automation bias.
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Wu, Ruoyu, Gail-Joon Ahn, and Hongxin Hu. "Towards HIPAA-Compliant Healthcare Systems in Cloud Computing." International Journal of Computational Models and Algorithms in Medicine 3, no. 2 (April 2012): 1–22. http://dx.doi.org/10.4018/jcmam.2012040101.
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In modern healthcare environments, there is a strong need to create an infrastructure that reduces time-consuming efforts and costly operations to obtain a patient’s complete medical record and uniformly integrates this heterogeneous collection of medical data to deliver it to the healthcare professionals. As a result, healthcare providers are more willing to shift their electronic medical record (EMR) systems to clouds that can remove the geographical distance barriers among providers and patients. Since a shared electronic health record (EHR) essentially represents a virtualized aggregation of distributed clinical records from multiple healthcare providers, sharing of such integrated EHRs should comply with various authorization policies from these data providers. In previous work, the authors present and implement a secure medical data sharing system to support selective sharing of composite EHRs aggregated from various healthcare providers in cloud computing environments. In this paper, the authors point out that when EMR systems are migrated to clouds, it is also critical to ensure that EMR systems are compliant with government regulations such as the Health Insurance Portability and Accountability Act (HIPAA). Also, the authors propose a HIPAA compliance management approach by leveraging logic-based techniques and apply it to the cloud-based EHRs sharing system. The authors also describe evaluation results to demonstrate the feasibility and effectiveness of the approach.
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Jedwab, Rebecca M., Elizabeth Manias, Alison M. Hutchinson, Naomi Dobroff, and Bernice Redley. "Nurses’ Experiences After Implementation of an Organization-Wide Electronic Medical Record: Qualitative Descriptive Study." JMIR Nursing 5, no. 1 (July 26, 2022): e39596. http://dx.doi.org/10.2196/39596.
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Background Reports on the impact of electronic medical record (EMR) systems on clinicians are mixed. Currently, nurses’ experiences of adopting a large-scale, multisite EMR system have not been investigated. Nurses are the largest health care workforce; therefore, the impact of EMR implementation must be investigated and understood to ensure that patient care quality, changes to nurses’ work, and nurses themselves are not negatively impacted. Objective This study aims to explore Australian nurses’ postimplementation experiences of an organization-wide EMR system. Methods This qualitative descriptive study used focus group and individual interviews and an open-ended survey question to collect data between 12 and 18 months after the implementation of an EMR across 6 hospital sites of a large health care organization in Victoria, Australia. Data were collected between November 2020 and June 2021, coinciding with the COVID-19 pandemic. Analysis comprised complementary inductive and deductive approaches. Specifically, reflexive thematic analysis was followed by framework analysis by the coding of data as barriers or facilitators to nurses’ use of the EMR using the Theoretical Domains Framework. Results A total of 158 nurses participated in this study. The EMR implementation dramatically changed nurses’ work and how they viewed their profession, and nurses were still adapting to the EMR implementation 18 months after implementation. Reflexive thematic analysis led to the development of 2 themes: An unintentional divide captured nurses’ feelings of division related to how using the EMR affected nurses, patient care, and the broader nursing profession. This time, it’s personal detailed nurses’ beliefs about the EMR implementation leading to bigger changes to nurses as individuals and nursing as a profession than other changes that nurses have experienced within the health care organization. The most frequent barriers to EMR use by nurses were related to the Theoretical Domains Framework domain of environmental context and resources. Facilitators of EMR use were most often related to memory, attention, and decision processes. Most barriers and facilitators were related to motivation. Conclusions Nurses perceived EMR implementation to have a mixed impact on the provision of quality patient care and on their colleagues. Implementing technology in a health care setting was perceived as a complex endeavor that impacted nurses’ perceptions of their autonomy, ways of working, and professional roles. Potential negative consequences were related to nursing workforce retention and patient care delivery. Motivation was the main behavioral driver for nurses’ adoption of EMR systems and hence a key consideration for implementing interventions or organizational changes directed at nurses.
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Randhawa, Gurprit Kaur, Aviv Shachak, Karen L. Courtney, and Andre Kushniruk. "Evaluating a post-implementation electronic medical record training intervention for diabetes management in primary care." BMJ Health & Care Informatics 26, no. 1 (September 2019): e100086. http://dx.doi.org/10.1136/bmjhci-2019-100086.
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ObjectiveThis study evaluated the potential for electronic medical record (EMR) video tutorials to improve diabetes (type 1 and 2) care processes by primary care physicians (PCP) using OSCAR EMR.DesignA QUAN(qual) mixed methods approach with an embedded design was used for the overall research study. EMR video tutorials were developed based on the chronic care model (CCM), value-adding EMR use, best practice guidelines for designing software video tutorials and clinician-led EMR training.ResultsIn total, 18 PCPs from British Columbia, Canada, participated in the study. The video EMR intervention elicited a statistically significant increase in EMR advanced feature use for diabetes care, with a large effect size (ie, F(1,51)=6.808, p<0.001, partial η2=0.286).ConclusionThis small-scale efficacy study demonstrates the potential of CCM-based EMR video tutorials to improve EMR use for chronic diseases, such as diabetes. A larger-scale effectiveness study with a control group is needed to further validate the study findings and determine their generalisability. The demonstrated efficacy of the intervention suggests that EMR video tutorials may be a cost-effective, sustainable and scalable strategy for supporting EMR optimisation and the continuous learning and development of PCPs. Health informatics practitioners may develop video tutorials for their respective EMR/electronic health record software based on theory and best practices for video tutorial design. For patients, EMR video tutorials may lead to improved tracking of processes of care for diabetes, and potentially other chronic conditions.
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Xanthidis, Dimitrios, and Ourania Koutzampasopoulou Xanthidou. "A Proposed Framework for Developing an Electronic Medical Record System." Journal of Global Information Management 29, no. 4 (July 2021): 78–92. http://dx.doi.org/10.4018/jgim.20210701.oa4.
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The deployment of an electronic medical records (EMR) raises several important issues. Those addressed in this study are the access to such a system, the satisfaction on the security and authorization protocols to follow, the awareness of backup and recovery mechanisms in place, and the appreciation of the training of the IT staff. This qualitative study took place in the natural setting of the medical units' environments. A purposive sample of 40 professionals in Greece and Oman was used. The study underlines that the patients should have access to their records, whereas for the pharmacists the professionals' views are seriously divided. Every other person's access to such a record should be restricted and recorded. The professionals are satisfied with the security level, the ICTs training, and the backup and recovery mechanism in place. They almost all admitted there is an authorization schema followed to access the EMR. The main contribution of the study is the proposal of a framework of policies and procedures for the development of such a system.
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Wilshire, Candice L., Carson C. Fuller, Christopher R. Gilbert, John R. Handy, Kimberly E. Costas, Brian E. Louie, Ralph W. Aye, Alexander S. Farivar, Eric Vallières, and Jed A. Gorden. "Electronic Medical Record Inaccuracies: Multicenter Analysis of Challenges with Modified Lung Cancer Screening Criteria." Canadian Respiratory Journal 2020 (March 26, 2020): 1–6. http://dx.doi.org/10.1155/2020/7142568.
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The National Comprehensive Cancer Network expanded their lung cancer screening (LCS) criteria to comprise one additional clinical risk factor, including chronic obstructive pulmonary disease (COPD). The electronic medical record (EMR) is a source of clinical information that could identify high-risk populations for LCS, including a diagnosis of COPD; however, an unsubstantiated COPD diagnosis in the EMR may lead to inappropriate LCS referrals. We aimed to detect the prevalence of unsubstantiated COPD diagnosis in the EMR for LCS referrals, to determine the efficacy of utilizing the EMR as an accurate population-based eligibility screening “trigger” using modified clinical criteria. We performed a multicenter review of all individuals referred to three LCS programs from 2012 to 2015. Each individual’s EMR was searched for COPD diagnostic terms and the presence of a diagnostic pulmonary functionality test (PFT). An unsubstantiated COPD diagnosis was defined by an individual’s EMR containing a COPD term with no PFTs present, or the presence of PFTs without evidence of obstruction. A total of 2834 referred individuals were identified, of which 30% (840/2834) had a COPD term present in their EMR. Of these, 68% (571/840) were considered unsubstantiated diagnoses: 86% (489/571) due to absent PFTs and 14% (82/571) due to PFTs demonstrating no evidence of postbronchodilation obstruction. A large proportion of individuals referred for LCS may have an unsubstantiated COPD diagnosis within their EMR. Thus, utilizing the EMR as a population-based eligibility screening tool, employing expanded criteria, may lead to individuals being referred, potentially, inappropriately for LCS.
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John Armstrong, Michael, Scott Bayus, David M Truxton, Raj Mathur, and Kristine E kalderson. "Electronic Medical Records: Effectively Managing Change." Muma Case Review 4 (2019): 001–16. http://dx.doi.org/10.28945/4512.
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As part of the American Recovery and Reinvestment Act (ARRA), all healthcare providers were required to adopt and show meaningful use of an electronic medical health record (EMR). To avoid a penalty, integration had to occur before January 1, 2014. Many hospitals and older physicians struggled with this. This digital change was new to not only physicians but also the business leaders that ran those businesses.
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Bonner, Joseph, Brandon Stange, Mindy Kjar, Margaret Reynolds, Eric Hartz, Donald Bignotti, Miriam Halimi, et al. "Interdisciplinary Plans of Care, Electronic Medical Record Systems, and Inpatient Mortality." ACI Open 02, no. 01 (January 2018): e21-e29. http://dx.doi.org/10.1055/s-0038-1653970.
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Background Interdisciplinary plans of care (IPOCs) guide care standardization and satisfy accreditation requirements. Yet patient outcomes associated with IPOC usage through an electronic medical record (EMR) are not present in the literature. EMR systems facilitate the documentation of IPOC use and produce data to evaluate patient outcomes. Objectives This article aimed to evaluate whether IPOC-guided care as documented in an EMR is associated with inpatient mortality. Methods We contrasted whether IPOC-guided care was associated with a patient being discharged alive. We further tested whether the association differed across strata of acuity levels and overall frequency of IPOC usage within a hospital. Results Our sample included 165,334 adult medical/surgical discharges for a 12-month period for 17 hospitals. All hospitals had 1 full year of EMR use antedating the study period. IPOCs guided care in 85% (140,187/165,334) of discharges. When IPOCs guided care, 2.1% (3,009/140,187) of admissions ended with the patient dying while in the hospital. Without IPOC-guided care, 4.3% (1,087/25,147) of admissions ended with the patient dying in the hospital. The relative likelihood of dying while in the hospital was lower when IPOCs guided care (odds ratio: 0.45; 99% confidence interval: 0.41–0.50). Conclusion In this observational study within a quasi-experimental setting of 17 community hospitals and voluntary usage, IPOC-guided care is associated with a decreased likelihood of patients dying while in the hospital.
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Jedwab, Rebecca M., Michael Franco, Denise Owen, Anna Ingram, Bernice Redley, and Naomi Dobroff. "Improving the Quality of Electronic Medical Record Documentation: Development of a Compliance and Quality Program." Applied Clinical Informatics 13, no. 04 (August 2022): 836–44. http://dx.doi.org/10.1055/s-0042-1756369.
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Abstract Background Introducing an electronic medical record (EMR) system into a complex health care environment fundamentally changes clinical workflows and documentation processes and, hence, has implications for patient safety. After a multisite “big-bang” EMR implementation across our large public health care organization, a quality improvement program was developed and implemented to monitor clinician adoption, documentation quality, and compliance with workflows to support high-quality patient care. Objective Our objective was to report the development of an iterative quality improvement program for nursing, midwifery, and medical EMR documentation. Methods The Model for Improvement quality improvement framework guided cycles of “Plan, Do, Study, Act.” Steps included design, pre- and pilot testing of an audit tool to reflect expected practices for EMR documentation that examined quality and completeness of documentation 1-year post-EMR implementation. Analysis of initial audit results was then performed to (1) provide a baseline to benchmark comparison of ongoing improvement and (2) develop targeted intervention activities to address identified gaps. Results Analysis of 1,349 EMR record audits as a baseline for the first cycle of EMR quality improvement revealed five out of nine nursing and midwifery documentation components, and four out of ten medical documentation components' completion and quality were classified as good (>80%). Outputs from this work also included a framework for strategies to improve EMR documentation quality, as well as an EMR data dashboard to monitor compliance. Conclusion This work provides the foundation for the development of quality monitoring frameworks to inform both clinician and EMR optimization interventions using audits and feedback. Discipline-specific differences in performance can inform targeted interventions to maximize the effective use of resources and support longitudinal monitoring of EMR documentation and workflows. Future work will include repeat EMR auditing.
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Olson, Steven A., and Maria Manson. "Logistics of Clinical Research in the Age of Electronic Medical Records." Duke Orthopaedic Journal 7, no. 1 (2017): 11–13. http://dx.doi.org/10.5005/jp-journals-10017-1075.
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ABSTRACT The increasing adoption of electronic medical record (EMR) systems has added complexity to performing clinical research in today's care environment. Each of the contributions from Duke University within this journal has interfaced with the systems for performing clinical research described in this study. While the increased use of EMRs has aided many aspects of clinical care, the logistics of doing the work of clinical research is seldom discussed. In this review, we briefly outline current practices regarding clinical research as they relate to interface with the EMR. Olson SA, Manson M. Logistics of Clinical Research in the Age of Electronic Medical Records. The Duke Orthop J 2017;7(1):11-13.