Electronic Medical Records in Healthcare

¶ … Electronic Medical Records in Healthcare

In the implementation of an electronic medical records system, a team must be designed and delegated with the task of guiding the implementation of the project. The team should comprise of representatives of each department in the organization in order to reduce their resistance to the change and also to create a two-way communication channel with other members of the organization. The team will also be charged with the responsibility of developing a strategic plan for the implementation which should be in line with the goals and objectives of the organization as well as its stated mission, vision and values. A phased approach was chosen for implementation in the organization in the case study and is also deemed to be the best approach for any organization that seeks to implement their electronic medical records system in the best way possible. There were various challenges embraced by the organization in implementing their electronic medical records system with the first being that different departments needed to go live at different times. This was a challenge because it introduced new bugs to the system. This challenge was resolved by choosing the phased approach of implementation and also by thoroughly testing the entire system each time a new department went live. A second challenge was that each department had its own set of functionalities. It was resolved by making sure the system for each department accommodated their unique set of functionalities and that these coexisted with the other departments' functionalities. The last challenge was physician resistance which was resolved by initiating a culture change in the organization and also by creating communication channels to actively involve them in the implementation by incorporating their feedback in the whole process.

Implementation of electronic medical records in healthcare

Introduction

Electronic medical records refer to a computerized system of storing medical records which help health care organizations to improve the quality of care provided. Using an EMR, all records are stored in electronic form and there are many benefits of the introduction of an EMR that make it worthy for any hospital to spend money to implement one. The system allows for easy storage, retrieval and modification of the medical records as compared to the paper-based record system which is still the most common in most hospitals and physician hospitals in the U.S. This is because majority of the doctors find greater ease in using paper-based methods which are less time-consuming and ease their data entry Pagliari, Don, & Singleton, 2007.

This for them is thus a more efficient method of recording medical data. Paper-based systems are disadvantaged in the amount of storage space required to store records as compared to electronic records. They also create an issue in record retrieval since it is a manual process that is time-consumer for the health records professionals. An even greater challenge arises in tracking the movement of records since it is a challenge to collate the files from different locations Hillestad et al., 2005.

Another major disadvantage of paper-based medical record systems is that they do not allow sharing of records. Though it can be argued that paper-based medical record systems can allow sharing of records through copying, transportation and faxing of information, there is a flaw in the system in that it becomes difficult to ensure that once one copy is updated, all of them are updated at the same time Kumar & Aldrich, 2010.

This is the major reason why federal and state governments alongside health insurance providers are recommending the adoption of electronic medical record systems. Electronic medical records create many advantages for health care providers which are the major drive for their adoption in both hospitals and private practices.

Major or overarching theme

The implementation of an electronic medical records system should be in allowing health care providers to continue performing their roles and maintain the practice while the system is being rolled out. This requires the health care providers to implement the electronic medical records system in a carefully planned manner which ensures the staff in the health care practice are aware of the advantages of the electronic medical records system as well as how they will need to change their tasks and activities in order to make maximum use of the electronic medical records system. The major or overarching theme in any implementation of an electronic medical records system is that the system should create efficiencies for the staff in the practice and they should be made aware of how it will affect their day-to-day activities in order to reduce resistance Jensen, 2005.

The implementation should be made in a guided fashion which ensures there are certain guidelines set for the implementation as well as a timeline.

In ensuring each department has advantages as a result of the electronic medical records system, the implementation of the system should focus on the day-to-day activities in each department of the organization and how these can be made efficient. This means that each department will need to have a different set of functionalities to make their system more efficient Laerum, Ellingsen, & Faxvaag, 2001()

Though electronic medical records have a steep price, by ensuring these efficiencies to each department are significant, the cost-to-benefit ratio for the organization will be improved which makes the return on investment higher for the whole organization or physician's office. The efficiency that is brought about by electronic medical record systems has been researched to lead to an estimated savings of more than 80 billion dollars for each year with a move away from paper-based medical records Nixon & Ulmann, 2006()

Context or drivers

The drivers of this case study were the drivers of implementation of the electronic medical records system in the physician's office which were the advantages that the system brought to the physician. The first advantage is the reduction in staff costs as a result of decrease in the number of staff needed for storing, retrieval and updating of medical records. The paper-based medical records system requires many members of staff to be hired for the records department since the storage, retrieval and maintenance of records is a daunting task Garrido, Jamieson, Zhou, Wiesenthal, & Liang, 2005.

A study that was conducted by the University of California which focused majorly on solo physicians or those who worked in small groups of between 1 and 5 found that the cost savings as a result of decline in staff costs for these physicians varied from $20,000 to $50,000 per year Greenhalgh, Potts, Wong, Bark, & Swinglehurst, 2009()

In addition to cost savings from staff costs, electronic medical records systems bring cost savings in incentive payments made under Medicare and Medicaid programs. These programs have received federal funding under the 2009 American Recovery and Reinvestment Act (ARRA) which allows qualified health care providers who have implemented electronic medical records systems to receive incentive payments as a result of what is terms as meaningful use of the electronic medical records system. The ARRA gives a detailed description of what constitutes meaningful use but under the act, the physicians receive incentive payments in terms of grants which amount to about $44,000 for Medicare claims over a five-year period and $64,000 for Medicaid over a period of six years Greenhalgh et al., 2009()

Cost savings of electronic medical record systems also come from the ability of the physicians to use their space more efficiently. Since paperless systems are less bulky and take up less space, the physicians are able to have more space to increase the number of services provided in their practices or to collaborate with other specialists so as to create a more comprehensive healthcare environment Dixon, 2007()

Apart from the benefits that electronic medical records systems bring to physicians and medical organizations, there are also benefits to the patients. The first benefit is that electronic medical record systems are more secure than paper-based systems which means that patient's data such as demographic and insurance information, allergies, immunizations, diagnoses, medications and other vital information is less likely to be stolen and used to target their patients in other ways Choo et al., 1999()

Electronic medical records systems also save time for the patients since when they visit a new physician or health care organization, their previous information can be securely transmitted to the new place which reduces the need for patients to fill out the same forms each time they visit a new physician. Patients also benefit from other advantages such as electronic transmission of information to laboratories and pharmacies which reduce the need for patients to carry prescription and test request forms around. Patients also benefit from marked reduction in errors in prescription and adverse drug interactions since the electronic medical records system checks the patient's allergies to ensure the drugs prescribed will not cause any allergic reactions or other adverse effects as result of drug interactions Bentley, Effros, Palar, & Keeler, 2008.

Further to this, since the electronic medical records system integrates laboratory and x-ray reports alongside other data such as previous diagnoses and prescriptions, the physician is able to get a more detailed and exact view of the medical information of the patient which enables them to treat the patient more accurately. In case of referrals, the physicians are able to share information with ease allowing a more accurate diagnosis to be made and the sending of reports between the two physicians becomes easy since it is electronic. In these ways, electronic medical records systems help physicians and healthcare organization to improve the quality of care provided to patients as well as improving the relationship between the patient and the physician since the electronic medical records system allows a better organized and more efficient way of collecting and transmitting data Raghupathi & Kesh, 2007()

Other advantages of electronic methods include the safety of medical records from disasters such as fires and water since the records are held electronically and it is easier to create secure backups offsite. They also enable the physician or medical organization to comply with HIPAA standards such as the ANSI 5010 which claims that all submissions and the transition from coding of diagnoses and procedures from the ICD-9 system to ICD-10 which are made much easier since these changes are done electronically and the system can be designed to do this automatically. Electronic medical records also integrate easily other functions such as billing and insurance claims thus allowing the billing department to do their work with ease through being able to submit claims more efficiently and in a timely fashion Sharon et al., 2005()

It is also argued that electronic medical record systems can enable the physician to build longitudinal patient records which allow them to gather data in a broad-based fashion with greater efficacy. Therefore epidemiological data is collected with ease enabling the physician to improve the quality and efficiency of health care provided Benin et al., 2005.

Electronic medical records also allow physicians to view medical records from anywhere via the internet using computers and handheld devices such as mobile phones and tablets which allow them to continue treating their patients despite where they are or to pass this information on to other health care providers Peabody, Luck, Jain, Bertenthal, & Glassman, 2004()

Players or stakeholders

In the implementation of an electronic medical records system, there are several key players or stakeholders involved in the process. These stakeholders are involved in building a wide array of skills and knowledge which help to ensure the implementation is successful and that it incorporates the different perspectives of the various stakeholders Gertzog, 1970.

These stakeholders are also involved in specifying the set of goals and objectives of the implementation of the electronic medical records system as well as specifying the activities and timeline for implementation.

Project manager

The project manager is the first stakeholder and is responsible for keeping the project in check and ensuring that it meets the set goals and objectives. In a physician's office, the physician may be the project manager or can choose another person to act in this capacity. In this case, the physician delegated the role of project manager to the practice manager. The project manager is also involved in monitoring and evaluating the project work plan, progress and milestones to ensure that the project is going according to schedule and that any issues arising in the implementation of the project are resolved as soon as possible and that the project schedule is updated as needed. The project manager also checks the delivery of any equipment for the electronic medical records system such as the computers, servers, cables and other vital equipment to ensure they meet the specifications needed and that they are on time. The project manager is also involved in delegating tasks to other members of the team to make sure each of them is involved in the process. He or she also has the crucial role of ensuring each of the team members is properly motivated to perform their function towards the implementation of the electronic medical records system.

Physician champion

The physician champion was the person who acted as a liaison between the physicians in the group and the team involved in implementing the electronic medical records system. This person acts as the point of reference between how the activities for the implementation are conducted in the physician's officer from a clinical perspective and provides insight on how the physicians need the electronic medical records system to work. This person keeps the physician up-to-date with the progress that is made in implementation of the electronic medical records system and gives approvals on behalf of the physician. The physician champion in this case was the personal assistant to the physician.

System builder

The system builder was the company or organization chosen to build the electronic medical records system and to customize it to make it work as the physician needs. The system builder works closely with the project manager and the physician champion to make sure the system functions as needed and that there is regular updates on the progress of building the system. The system builder in this case also functioned as the trainer for the application once it was completed. This was the person who trained the staff in the practice on the electronic medical records system and provided technical assistance such as maintenance of the system, regular updating and backing up data when it was needed.

Medical records user liaison officer

The medical records user liaison was the super user for the medical records system and was responsible for checking the system to ensure it meets the set goals and objectives of implementation and that where any issues with the system are noted, they are relayed to the system builder to ensure the changes are made as soon as possible. This person also acted as a system administrator and helped in conversion of data from the paper-based system to this new electronic medical records system and also ensured that the system had the necessary security measures to ensure it protected sensitive data held in the system in compliance with HIPAA. The it manager in the office was chosen to be the medical records user liaison officer since it was felt that he was most knowledgeable on the requirements of the system from a technical perspective. The medical records user liaison officer also collaborated with the system builder to ensure the system was built to the goals and objectives of the organization and also complied with security standards set by HIPAA.

Head nurse

The head nurse helped a lot in input of past data into the electronic medical records system since this was a time-consuming task and needed many users to assist. He also helped by providing support and assistance to ensure that all members of staff were conversant with the electronic medical records system. The head nurse also helped collecting feedback from other members of staff and patients regarding the system and what changes need to be made in order to better the system. The head nurse will have the role of informing the nurses of the benefits of the electronic medical records system as well as what is required of them. The head nurse also helped to identify the members of staff who were resistant to the change and forwarded them to the super user for coaching and counseling so that they can change their attitudes by understanding the importance of the electronic medical records system. The head nurse also provided support and assistance to the nurses regarding the system.

Situation

Beacon Hills Health Care is a medical center with 15 beds and consolidates 10 physicians. The board of the health care center made a commitment to implement an electronic medical records system in the year 2010 as a 2-year plan in order to improve the quality and safety of patient care at the facility. The board also acknowledged that the system would provide timely access to medical information about patient and provide alerts when any allergies or adverse drug interactions were expected. The system would need to be built to the best practice standards and support clinical decision-making. A consultancy firm was thus engaged in order to guide the selection of the system builder. The chosen system was that of Epic systems, one of the leading electronic medical records system vendors. The name of the system was chosen to be GROOVE.

The goals of the project were defined in order to guide the implementation. The overarching goal was to take advantage of the efficiencies that were brought about by the electronic medical records system. The second goal of the project was to improve the quality of care provided to patients.

The project was divided into three phases. These phases described which department had their data transferred to the system first. The first phase was the outpatient department, pharmacy, laboratory and emergency departments which were the most utilized departments in the facility. The second phase was the oncology department and inpatient departments. The last phase involved the billing department and the creation of a secure web-based portal through which patients would be able to access their data on the system in order to update it. Each phase was to take 8 months since it involved transferring information from the paper-based system to the electronic system and also training staff and personnel to ensure they understood how the system works.

Challenges in implementation of the electronic medical records system

The first challenge in implementation of the system was in the departments going live at different times. This was a challenge to the organization since it meant that each time after a department had gone live, the other department's systems had to be tested to ensure they worked well with the new department that had been added to the system. This was necessary in order to ensure flow of information in the system was effective and that the system resulted in few unexpected consequences. It was also decided to work this way in order not to disrupt the day-to-day functions of the organization. This challenge was present because the hospital did not have funds to implement the system in a hospital wide basis all at once and also it was felt that a systematic implementation of the system was more beneficial since it allowed the super user and head nurse sufficient time to understand the system and train staff in the system. This challenge also came about as a two-part challenge since each department needed its own set of modules. For example the pharmacy department needed a stock keeping function to ease stock keeping of drugs in the facility while the laboratory department also needs a similar though different function for management of inventory. This was also a challenge since it means that each department's system was slightly different from the other though they shared certain information such as patient demographic and insurance information. In making these systems integrate efficiently, it was quite a challenge. These challenges were mitigated through careful design and implementation of the electronic medical records system and regular monitoring and debugging of the system to ensure there were no bugs that were introduced once a new department went live.

Physician resistance was also a significant challenge in implementation of the electronic medical records system. From the onset of the project, there was resistance in the members of staff who though were loyal to the organization felt that the ongoing implementation of the electronic medical records system would significantly impact their day-to-day activities by making it harder for them. Research has found that physician resistance is the single largest challenge in implementation of an electronic medical records system Winthereik, Ploeg, & Berg, 2007.

Resistance towards the implementation came as a result of reluctance of the practitioners to adopt new ways of conducting their activities and also their negative attitude towards the system. This resistance was minimized by creating a cooperative environment from the early stages of implementation of the electronic medical records system which involved collaborating with the physicians and other members of staff in every step of the project so that they feel involved in the transition. The use of a directive leadership style also helped to ensure the minimization of resistance.

The cost of implementation of the electronic medical records system was also a challenge in the project. The total cost of this project was $50,000 which for the five physicians in the practice came to about $10,000 for each physician. Some felt that it was too high considering the returns of the project. This challenge was handled by educating the physicians on the cost savings as a result of implementation of the electronic medical records system and the efficiencies it would bring to their practice.

Outcomes and impact

To date, the first two phases of the project has been completed with the last phase nearing completion in March of 2013. The largest impact of the implementation of this electronic medical records system has been on the records department which has since been scrapped and integrated with the it department. This has led to cost savings totaling to $75,000 for the organization since many of the staff in the department were laid off as a result of them not being needed anymore. The system has also helped to reduce the number of errors in the facility from an average of 100 per day to just 10 per day. With time, it is expected that these errors will be reduced to 2 per day. These errors occur majorly as a result of patient information such as date of birth being entered wrongly but with the final phase of the project enabling patients to update their data, these errors will be greatly minimized.

Analysis

The success of implementation of the electronic medical records system in the facility can majorly be attributed to three activities that took place before the actual implementation began. The first activity was the development of the team to lead the implementation of the electronic medical records system. In creation of the team, representatives from each section of the facility were chosen with the nurses represented by the head nurse and the physicians involved in each stage of the implementation. The project manager participated greatly in forming a close working relationship among the team members which ensured that all aspects of the operations of the hospital were covered in the implementation and that there was visible backing from all members of the team. This ensured the success of the activities of the team and created motivation for team members to be involved in other activities as personal initiatives in order to stay abreast with the specifics of the implementation in their normal workstations.

The second activity was the initiation of a culture change. This involved actively communicating information from the team members involved in the implementation to all members of the organization in order to set the project's tone and lay out the various projected steps in the implementation process. In this way, the members of the organization were kept abreast with the progress of the design and implementation of the software and feedback channels were created to collect their input on the project. The project was also linked to the overall vision of the organization which enabled a smooth transition to the system. The project champion was also tasked with handling any members of staff that were resistant to the change by educating them on the importance of the electronic medical records system and counseling those who had extreme levels of resistance. The project manager also ensured there was absolute transparency and honesty in the design and implementation of the project by making sure all milestones were clear to the members of the organization and that any tenders, quotes and payments were made in accordance with the set guidelines of the organization. Celebrations were also held after each department went live in order to give the members of the organization the feeling that the implementation was successful and was going according to plan.

The last activity which created the success of the implementation of the electronic medical records system in this case study is redesign of the workflow processes. This was a continuous process throughout the project which was done to improve on the current processes in the organization. In redesigning of the workflow processes, the implementation team was focused on creating an understanding of the processes involved in design and implementation of the electronic medical records system and how they connected in order to optimize them to optimum results. These activities as well as the project goals and objectives were also related to the organization's goals to ensure that the workflow was in line with the organization's goals and objectives and that there were no unseen barriers that were created as a result of having to work around the current culture and goals of the organization. In redesigning the workflow, the members of the implementation team were the key personnel. However, other members of the organization were also involved in this through the feedback channel created. This helped to collect meaningful and crucial input from the other members of the organization and helped to guide the implementation of the electronic medical records system.