This paper evaluates the extent to which electronic medical records (EMR) actually improve patient care within the framework of federal "meaningful use" criteria. While EMR systems promise enhanced accuracy, reduced errors, improved access, and cost savings, the paper critically examines research evidence showing significant gaps between theoretical benefits and real-world implementation. Key concerns include data security breaches, alert fatigue, incomplete cost-benefit analysis, and lack of demonstrated improvements in patient outcomes. The analysis concludes that EMR systems have substantial potential but require more careful deployment, better physician and patient training, privacy safeguards, and realistic cost assessments to achieve genuine meaningful use and patient care improvement.
The concept of "meaningful use" originated with the federal government's attempts to encourage healthcare organizations to make more effective and comprehensive use of electronic medical records (EMR). "Meaningful use" means that organizations can receive financial incentives for deploying EMR and demonstrating that they have improved patient care through the institution of such a system. Advocates of EMR tout the technology as a beneficial use of organizational resources because of its ability to reduce errors due to incomplete data or misinformation. The ability of providers to access the records of their patients also ideally enables patients themselves to keep track of health-related data.
EMR allows the government and other watchdog groups to determine if there are patterns of socioeconomic, racial, and geographic discrimination in the delivery of health services (Layman 2008: 165). Through the use of digital technology, patterns can be analyzed and not only can healthcare be improved, but ideally the "just" or "unjust" ways care is dispensed can be identified. The use of EMR also conveys a greater degree of autonomy to patients, in theory, given that patients have complete and unfettered access to all of their records. Patients can correct their records and use them to improve their care.
However, the availability of records can be a double-edged sword. While providers have greater access to such records, this also means that patients may lose some ability to control to whom they are released, as data can be shared with a point and a click (Layman 2008: 169). Limiting sharing to entities who need to know solely for medical purposes has been the focus of recent privacy legislation regarding EMR and would seem to be an additional, often unrecognized principle of meaningful use: not only is "meaningful use" about who gets to see such records but also who does not, and patient privacy protections.
Not all researchers support EMR in an unequivocal manner, partially because there are concerns that the implications for patient privacy outweigh the benefits. According to Layman (2008), although EMRs are touted as improving access, quality, and cost-cutting, data about accuracy, security, and even decreased costs is not conclusive (Layman 2008: 165). For example, EMR can make patient data more secure given the potential for damage to physical records. However, breaches of data are still occurring with EMR and in fact are occurring at higher rates than breaches of data stored in more conventional formats. Hacking is one source of impingement upon privacy, but there is also the risk of data being stolen in a physical, direct manner in the form of a laptop. The very aspects of EMR that make it so effective—namely its completeness—can also make it especially attractive to hackers.
When EMRs are used for research purposes, there have been concerns about the information being used to determine the participants' identities, despite guarantees of anonymity (Layman 2008: 171). This is yet another example of how the promise of EMR has not been effectively realized, given that it is unlikely that full support will be given to EMR unless patients can feel secure that their data will be kept private.
EMR is supposed to facilitate more accurate record-keeping, given that all patient information can be found in the same location. However, one recent study of data on osteoporosis found that there were a number of differences in data on patients in terms of interpractice information: recording of treatments exceeded the records of actual diagnosis (a significant discrepancy and a possible indication of overuse of medications or other treatments), a lack of appropriate coding, and different versions of diagnostic codes (Layman 2008: 168). Often, manual searches were needed to resolve discrepancies, indicating that the supposed ease and accuracy of use of EMR was not supported by how the records were used in practice. No true "meaningful use" was in evidence in terms of improved care and cost efficiencies.
Another contention by EMR proponents is that the technology can improve primary and preventative care by establishing a patient baseline and even allowing physicians to alert patients before they actually become sick, based upon changes in data. However, studies have noted that there are often high rates of overriding alerts and reminders regarding physician orders and this capacity is not necessarily used for maximum efficacy (Jones et al 2013: 7). Poorly designed alerts can lead to "alert fatigue" (Jones et al 2013: 7). Once again, this highlights how "meaningful use" can be a highly subjective concept—simply deploying the data is not necessarily "meaningful" in nature. When protocols to alert physicians are not specific in the way they direct the provider to take action, the natural impulse is to "tune these out," once again suggesting a lack of true meaningful use of the technology.
A study of the use of EMRs in screening for cervical cancer in Austria did not find any increased benefits as a result of electronic records (Layman 2008: 169). There is also no evidence that constructing EMRs improves patient-physician communications in an empowering fashion, in terms of patient ratings of their perceived interactions with physicians (Layman 2008: 169).
Other problems with "meaningful use" include that when cost savings are touted, it does not necessarily take into consideration the full range of costs of maintenance as well as implementation. For example, in one study, when $380 million was spent in a Florida hospital, it was originally projected that adopting IT with the five meaningful use medication management components would recoup 70% of the initial investment due to a reduction in adverse drug events. Criteria for meaningful use included such suggestions as maintaining a list of active patient allergies and creating a drug-allergy interaction checklist for providers.
However, to sustain the use of the IT would require consistent operating costs, causing the real cost savings to be much lower (Encinosa & Bae 2013: 24). Of course, regardless of cost savings, there is an ethical consideration at stake, namely the need to reduce patient mortality and illness. But regardless, it is important to be realistic about the limits as well as the benefits for IT to enact meaningful savings in an increasingly cost-conscious medical environment.
"Requirements for realistic, evidence-based EMR deployment and governance"
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