Chapter six: thesis structure and content analysis

¶ … ERM

There have been a great many changes in the healthcare industry in the past two decades, largely due to the globalization of the workforce and changing demographic patterns, and technological advances. It was interesting to think about the vast changes occuring in and to look at the ways in which technology, privacy laws, and stakeholder expectations have changed. The industry changed in terms of a reliance on hospital-based care to more emergency clinics, outpatient and nursing home services, and managed care. More hosptitals merged, and many doctor's have banded together to form larger, more cost-effective, speciality groups. One of the largest and most obvious changes has been in cost of healthcare. In 1990 the avereage cost of care per person was $2,800, rising in 2000 to $4,700, and then in 2010 exceeding $7,500. In 1990, 14.1% of Americans had no insurance and in 2010, and additional 50 million people, or 16.3%. Certainly these issues are concerns, but there have been incredible innovations that have changed the lives of all those involved in the healthcare industry. For example, doctors can turn their I-phones into an EKG monitor and transmit data in real time to a cardiologist, will cost less than $100, and will change the way patients interact with their physicins (Chideya, 2012).

We must also realize that the healthcare system is its own ecosystem, and as such, has different levels of dependence from a number of different departments and stakeholders. When implementing a system of medical records that is so vastly different than the norm, every single aspect of the healthcare ecosystem is involved. Many in the industry heartely support the idea of ERM systems, but are also concerned about change, the workload, accuracy, privacy, and a host of other issues that are changed when a new system is introduced. For an ERM system to be viable, it must be able to travel with the patient every step of the way in their healthcare -- from regular checkups, to eye-exams, dental-exams, tests, insurance, pscyhology, and more. It must be holistic to be valuable, for looking at only a piece of the patient's life or medical history brings us back to the previous paradigm and manner of doing things in an outmoded and rather inefficient manner. Note on Figure Y that there is a circular pattern between the patient, the provider, the community, and any other aspect of their lifestyle. Technology is a tool, and as a tool it has the potential for great good, or great error. As technology evolves, though, so do the aspects of functionality it may provide. In the holistic healthcare ecosystem, EMR should, in theory, be accessible anywhere at anytime to any patient, medical professional, or professional that has an interest in the patient and consent from the patient to view records; or, in the case of an emergency procedure, to save a life. Thus, EMR planning and implementation must be done based on strategic healthcare initiatives, not technological tactics (Knickrehm and Ficery, 2011).

Any implementation of an ideal Electronic Medical Record system would require not just a technology side within the clinic or office, but an important exteral reach to the outside providers, services and other interested parties in terms of Internet and telecommunications components. An example of this would be Tele-health, which esssentially focuses on the manner in which medical information is shared (exchanged) using electronic communication between interested parties and patients, with the overall goal of providing better, more up-to-date, medical care (Wasson, 2012; Telehealth, 2012). The clinical side of Tele-health is called telemedicine, defined by the American Telemedicine Organization as "the use of medical information exchanged from one site to another via electronic communications to improve patients' health status." Specific examples of telemedicine include video consultations, remote patient data monitoring, nursing call centers and searching for or saving personal health information online (Gray, 2011).

Tele-medicine is a global phenomenon that has benefits for individuals in all walks of life. It helps expand access to care, education, new research and technology, in particular in populations that tend to be more isolated or communities (or regions) that cannot afford to support full time clinics and have had to rely on travelling medical care. This also applies to homebound patients or patients who are chronic and can more easily (and less expensively) use email or video conferencing with specialists in any location worldwide -- benefits that would not normally be available to most populations. In addition, test results, lab studies, etc. can be available quicker, and can more easily be discussed with the patient on a more interactive basis. For the individual, so much information is now available that is vastly superior than anything they could access even a decade ago (Web.md, the Mayo Clinic, scholarly articles, support groups, etc.). An informed patient can then be more of a participant in their own health care paradigm, ask more pertinent questions, and above all, provide more details to their healthcare provider while taking more responsibility for their own participation in their personal situation (Gray).

A Robust Configuration Management Database is very much needed for this any adequate ERM implementation. The various issues inside the center can be noted by this system and suitable solutions can be formulated. It is necessary to feed all the information about the IM/it department of the center into this system and so it can work efficiently. For example, this system is used to provide complete accurate information about the people, processes and technologies that compromise the it environment. It also helps to map the performance of all the systems in this center. If there is an infrastructure problem in the center, then the center can easily find out the affected databases, servers and users. It is also very useful in implementing certain changes in the center. The use and accuracy of any EMR program may be enhanced in terms of robustness and reliability with a CMBD (Catalog and Confirmation Management) process. This technique controls hardware and software assets far better, helps diagnose issues, improves the efficiency of such issues as network management, sharing of disparate information from alternative sources, most especially in the legal and regulatory sectors. It is especially effective in helping to reduce redundancy and duplication of effort (Aeritae, 2010; Messineo, 2009).

Immediate Access to Patient Information

A clear benefit to EMR systems is their portability: healthcare personnel can easily carry a laptop or tablet to the examination room, pull up details of tests, vital signs, drugs, histories, x-rays, and more. Special software can provide potential interactions, as well as a more thorough history of what was prescribed when, and at what dose, something not all patients remember clearly. This system also alerts the physicians and the nurses if there is a difference in the details, or if healthcare has been given in different locations. . This technology helps the nurses to detect the faults made by the doctor in the treatment of the patient (Tutela, 2009).

Electronic medical records allow for easier retrieval of patient information and are typically integrated into billing systems and scheduling, thus providing clients an incentive for coming back to the particular office or clinic. A health care professional within the hospital can also access continuing education and attend seminars online, and contact specialists for disease information outside his area of expertise. They also have more control over the continued management of health intervention and knowledge of patient progress. In an interview with educators who served as telemedicine case managers for adults with diabetes, "the nurses and dietitians calling these patients reported satisfaction with both the feasibility and effectiveness of telemedicine" (Gray; Gomez, et.al., 1996). Advantages specifically named were "more frequent contact with patients, greater relaxation and information due to the ability to interact with the patients in their own homes, increased ability to reach the underserved, more timely and accurate medical monitoring, and improved management of data"(Sandberg, et.al. 2009).

More and more, increased access to information and the ease of using technology has increased collaboration between doctor and patient. This has, however, encouraged a more patient-driven medical system. Patients are less content to let the doctor prescribe or order tests without knowing more about their own condition, the medications they must take, and even costs of procedures. Nursing theory is also pushing that the patient take more responsibility for their health and healthcare, rather than being passive participants and allowing others to make decisions that will impact their lives. This change has given rise to the term "e-patient," describing someone who actively seeks out health information and communication online. Advantages include emotional support and information sharing, access to physician question and answer forums, online records to capture progress and goals and access to clinical trial databases. A sense of empowerment is the common thread running through these patient portals that connect patients to providers and to each other (Gray).

Of course, immediate and robust access to patient information brings up issues of privacy and confidentiality as well. HIPAA, or the Health Information Privacy Act, is designed to protect the individual and sets national standards of compliance on who may view patient information, and at what level of detail. This 1996 Act was part of a Civil Rights concern that as information became more electronically disseminated, it would lead to misuse of that information (U.S. Department of Health and Human Services, 2010). Certainly, one of the benefits of electronic information is that on one hand it is available to a larger number of people, but it is also verifiable on who views that information at what time. This protection, though, is part of the ethics of individual rights. It has, however, affected scholarly research and the ability to perform retrospective, chart-based research and evaluations. One study, in fact, said that HIPAA managed rules led to a 73% decrease in patient accrual, triple the time recruiting patients, and tripling (at least) of mean recruiting costs (Wold and Bennett, 2005). However, despite the few incidents in which the regulation of this information is detrimental, most civil rights advocates praise the legislation -- believing that each individual should control access to not only their bodies, but information about their bodies and conditions as well.

Too much security and a lockdown of information, and the benefits of immediate access to information and patient benefit will be lost. Too little security and there is an increased potential of fraud. Patients however, have far more trust that healthcare providers will keep their information save, secure, and private for particular use than they do with banks, governmental institutions, employers, or even credit card companies (Shinkman, 2012).

Accuracy

One of the selling points for ERM is that data tends to be more accurate because it is entered only once. This, of course, forces the person doing the initial entry to be even more aware of the issues surrounding the data, but also has some issues relating to privacy concerns. Accuracy of the information is completely dependent upon two major paradigms: the initial set up of the system and the quality and expertise (training) of input personnel. Adopting a four-part program will solve the initial concerns about accuracy, and focusing on appropriate training (see below) will alleviate some of the worry on the second issue. However, a continuous and rigorous training program will be necessary when there are new hires; people have been out of the office for vacations, etc., when there are system upgrades, and the like. Part 1 ensures initial data accuracy for the system; Part 2, the training, Part 3, network implementation and testing of accuracy of information; and Part 4, Ensuring appropriate equipment so that there are no hardware or software issues that cause inaccuracies, down-time, calculation mistakes, etc.

Part 1 - Conversion of existing patient records -- Preloading is one of the most essential steps to convert medical records (patient histories) into the new system. This creates a standard record with minimal information, but that can be added to once the structure is complete. We will begin by entering the patient's name and vital demographic information (point of contact, insurance information, etc.). Then move to past medical history, problem list, medication history, and allergy history. It is important to use ICD-9 codes as much as possible, and for this reason, it might be advisable to hire temporary help to load data; individuals with nursing experience and/or insurance data entry so they are familiar with the correct codes and terminology. Each chart on the active list (can be 12-24 months) should be completely preloaded prior to using for charting (live use). It is important to hire the right people for this crucial step -- anyone not comfortable with technology will have a difficult time.

Part 2 - Once the preloading is done, it will be time to customize the HER based on the provider of the hardware/software. This should be done with an implementation team consisting of the Medical Office Manager, 1-2 nurses, and the data entry staff, a physician if at all possible, or the MOM trains the physician later. The provider source customization training should take 1-2 days, and would be most effective if the office was shut down for a day -- preloading finished and QC'd (Quality Control) by Thursday, training on Friday and Saturday, live on Monday. If not possible, then training in a conference room on Friday with minimal interruptions. If the training is offsite, then as many of the implementation team as possible should attend. It may take a full day to customize some of the options per office, and any technical support should be there to ensure that modems, printers, etc. are all working. This might need to be done on a Sunday, if the office wishes to go live Monday. Finally, if at all possible, the first few days of going live should be done with reduced schedules so that the patient load will allow for a learning curve.

Part 3 - Network Implementation -- at each step, we must ensure we are protecting patient privacy and meeting HIPAA and ARRA mandates as well as all insurance and local/state regulations. Implementing a new network can be problematical, depending on whether it is wireless. Network implementation planning should be in partnership with the selected vendor or their representatives and will consist of a 10 stage entry process to include: 1) Identification of needs/goals/equipment; 2) Produce timetable and milestones/responsibilities; 3) Diagram equipment and workstation flow (topology diagrams); 4)Order equipment, test equipment; 5) Cabling plan and implementation; 6) Confirm power sources, wiring and surge protection; 7) Install and load basic firmware; 8) Test firmware and all ancillary devices and basic applications; 9)Customize Network for office; 10)Load and test software, begin moving into transition plan and pre-loading applications.

Part 4 - Equipment for transition -- the software we use will be a complex database program specifically designed for a small medical office. We will ensure that it includes branching logic that supports alerts and reminders, and allows for subscriptions to drug formulary services and regulatory bodies. In today's marketplace, it is not necessary to spend thousands of dollars per machine for staff. Instead, lightweight notebooks with wireless capabilities can be used in exam rooms, desks, offices, or off site if necessary. We are committed to using our HER system (hardware, software, human resources, and processes) to: collect and use data from multiple sources; use by doctors, nurses and office staff as primary point of information for patient care; and to provide important an robust decision making support for a model of evidence-based health care. Basic equipment should include: 1) at least 1 server and workstation; 2) wireless routers and boosters, depending on location; 3) monitor/keyboard workstations; 4) Laptops, 5) scanners; 6) Digital Scanners; 7) Tablet computers; 8) Desktop computers and monitors; 9) backup server or offsite data protection or both; 10) Backup power sources and surge protectors (Ten Steps, 2012; Walker, et.al., eds., 2005).

Finally, a check and accuracy plan should be in place to ensure data integrity. This is often done by having two people check every Xth record, or randomly pulling insurance files for review. Besides the issue of privacy, because so many healthcare providers are using ERM systems, the public is becoming even more aware of their use. "The CDC's National Center for Health Statistics estimates that more than half of office-based physicians have adopted a basic HER, while more than 10% have adopted a fully functional system." Research done in this area shows that the majority of patients and physicians have a positive perception of electronic documentation. Most also agree that ERM systems will help improve patient care, more efficiency in the work environment, and therefore an eventual cost benefit for all stakeholders. In addition, because of the amount of real-time data, access to as much historical data as possible, physicians believe the ERM implementation will improve diagnoses. (Study: Patients Believe, 2011).

Cultivation of Customers

The clinical side of Tele-health is called telemedicine, defined by the American Telemedicine Organization as "the use of medical information exchanged from one site to another via electronic communications to improve patients' health status." Specific examples of telemedicine include video consultations, remote patient data monitoring, nursing call centers and searching for or saving personal health information online (Gray; Carter, 2001). In addition, E-power technology allows the patients to act in charge for his healthcare management on a daily basis. This provides better satisfaction for the patients, as they know their body conditions. They can make their own decisions with discussing their physicians. The E-power technology also helps the patients to boost their fitness. There are certain products for helping the patients in tracking their own health conditions. If there are any symptoms for the defects they will alert the patient about the exact conditions. There are also certain devices that can track and record the heartbeats and other biometrics of the patients (Turisco, 2009). Situations like chronic blood pressure issues, effects of new medications, or even vital signs are more accessible to physicians on an almost real-time basis, saving the patient the need to travel into the office, particularly when not feeling well. Remote diagnosis, while not ideal, is certainly better than not being able to diagnosis the patient due to extreme weather, natural disasters, geography, and more (Telemedicine Benefits, 2011).