In the recent past there has been a significant emphasis for the need to implement Electronic Medical Record systems. However, the benefits and shortcomings of these systems need to be evaluated (Amenwert et al. 2004) and a sufficient evidence base gathered using a well structured scientific approach to justify the change and measure the organizational impact (Wager et al. 2000).
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This essay will address the benefits and challenges of implementing Electronic Record Systems. It will look at applications of these systems in different care settings located in different environments so as to provide a broader view of some of the issues. The roles of the various stakeholders as well as the benefits and challenges they derive from electronic health records will be outlined and a detailed evaluation of paper records and electronic records will be done. Conclusions will then be made based on this analysis.
BACKGROUND
In context of health care, electronic record systems can be defined as any structured record keeping system, specifically designed to support users by providing context specific information which is electronically accessible, relevant, easily transferable, accurate and complete. These records will usually hold information regarding patients care histories, non specific clinical data, medical knowledge or other health care centered information. (Coiera 2003)
As the scope is very broad and Electronic Health Records (EHR) has not been well defined (Hayrinen et al. 2008a), the definition used was limited to EHR and allied systems such as Picture Archiving Systems (PACS), Pharmacy Management Systems, Computer Physician Order Entry (CPOE) amongst other systems used day to day in a clinical setting. These areas are well documented and evidence easily obtainable (Clamp & Keen 2005)
Role of electronic records and patient Information in population based care
A study carried out by Qresearch utilized electronic records extensively with an aim to report on population trends and disease risk factors. The analysis covered a 5 year period and was able to establish that in the UK, London had the highest percentage of patients recorded as being smokers at 25% and the lowest in the South East and South West at 20%. It also established that majority of the smokers ranged from 25-34 years of age across all regions. (Qresearch- NHS 2008). The information obtained provided a platform for decision making to determine the interventions to be undertaken, where resources should be focused and to whom it should target. This kind of data mining is only possible when data is electronically stored (Bocij and chaffey, 2005) as paper records suffer from massive fragmentation (Dick et al. 1997) making it difficult to bring all the data for analysis. It has also been established that manual methods would be ineffective to deal with such large data sets and the multi dimensional analysis required (Fayyad 1996). The ability to perform such operations is a strong argument for electronic record adoption in decision support and knowledge discovery for population based interventions (Kraft et al. 2002).
Furthermore, electronic records encourage consistent recording of clinical information and this becomes a key component when aggregating individual records to form datasets. Use of clinical codes allows relevant data to be derived from these unified datasets enabling reliable analysis across different sites. This in effect is key in providing specific information for health research as well as in public health planning (Ambinder 2005)
Keeping in line with Pawsons model for context specific evaluation the literature was reviewed by looking at studies done in various sites represented on table 1 and later highlighting advantages and disadvantages to various stakeholders identified.
General practitioners
General practitioners are the initial point of contact between clinicians and patients, they play a pivotal role in ensuring that a patient�s Electronic record is accurate, complete and current (Dick et al. 1997). As direct users of Electronic records, GPs benefit from the linkage of these record systems to other systems such as PACS or CPOE. Requests for ancillary care services can be done at a click of a button and results for tests can be accessed immediately they become available. This in effect enhances the completeness of patient records as they are updated in real time (Ambinder 2005) reducing the GPs administrative load as well as accurately populating records for future encounters (Wager et al. 2000). Additionally, GPs are able to view different aspects of a patients care at a glance, preventing duplication in testing or medication and reducing costs (Jones et al. 2008). Attention can also be drawn to areas that require GPs action through medical alerts thereby guiding the clinician in the disbursement of care (Coiera 2003). In effect, this increases the efficiency of the GP and a study done in the Veterans Association has shown electronic records has allowed patients information to be available 100% of the time as opposed to 60% of the time reducing the amount of sessions required to resolve patient issues (Wilson 2009) this, as well as enhance patient safety through, for instance, reduced prescription errors (Kaushal et al. 2001)
Unfortunately, there is a substantial learning curve and clinicians require training to use these systems (Anderson 2007). GPs may spend substantial amounts of time inputting and retrieving data from these systems at the expense of interacting with their patients (Poissant et al. 2005). As information grows exponentially there is also a fear of clinicians becoming overwhelmed due to the explosion of information (Berner 2005) and the paradigm shift in culture also presents opportunities for resistance to change (Hendy 2005). System usability is also a major concern when dealing with electronic records. Young (2006) argues that this has been a major deterrent to widespread adoption of these systems.
Patients and their carers
In the UK, The NHS care record service is responsible for holding Electronic records for all UK citizens centrally (NHS 2008a). There is policy in place that will see all patients� summary records being held nationally and detailed records held locally within the various GP practices (NHS 2008a). This in effect will lighten the burden to the patients and their carers of having to remember the list of drugs, allergies or adverse reactions they may have encountered in the past (Jones et al. 2008).This will reduce the risk from adverse events and near misses that can occur from wrong administration of medication through prescription errors and increase the amount of confidence patients will have on their clinicians (Jones et al. 2008). Furthermore, In the UK, Patients will also be able to view their own summary care records via health space (Greenhalgh et al. 2010) and ensure their records are complete and accurate leading to better patient outcomes (Waegemann et al. 2002). Additionally, in emergencies, where GPs may not be readily available, rapid access to the patient�s medical history can reduce the time taken to provide critical care (Potts et al. 2004) Ultimately, the main benefit to patients will be increased quality of care and patient safety through increased choice in their care options (Eysenbach & Jadad 2001). This will largely be due to portability of these records across different care functions allowing for access by a variety of clinicians.
Unlike paper records, electronic records are easily and readily accessible due to the interconnection of systems through networks making them vulnerable to unauthorized access (Berner 2005) This brings a set of legal challenges as to who has access to this information (Delpierre 2004). Under the UK data protection act of 1997 and the privacy act of 1974 in the USA, data about patients is protected by law (Koeller 2002). However, with records widely distributed and at times held by third parties adequate legislation needs to be put in place and security measures such as firewalls and audit trails need to be implemented to protect this data. This raises complexities in implementation as well as expands cost (Koeller 2002)
Health service teams and clinicians
Health service teams such as pharmacists alongside other health care professional benefit immensely when records are easily shareable and quickly available (Wager et al. 2000) This is information can be used to reconcile medication lists as well as provide key information to multi disciplinary health professionals in a secondary care setting where information is fragmented and spread across different care pathways (Miller & Sim 2004). This will reduce clinical risk as well as save time and associated costs (Koeller 2002). Furthermore, the problem inherent in paper records of ineligible notes becomes nonexistent (Schloefell et al. 2001). Coding systems in electronic records also avoids incidents of ambiguity that may be present in free text during care episodes (Dick et al. 1997).
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On the other hand, there is currently no universal standard for indexing and coding clinical information (Schloefell et al. 2001) this in effect is a challenge to health teams who may have difficulty in accessing patients data across different system platforms (Schloefell et al. 2001)The lack of unanimity in creating uniform standards leads to interoperability across physicians systems, hospitals and pharmacies (Wilson 2009). This limits the amount of choices available to patients and adds unnecessary difficulty to health teams when such incidences occur.
Health providers, and allied organizations
In the UK health providers such as health trusts and Strategic Health Authorities derive their benefits as a result of benefits derived from patients and health care teams (Jones et al. 2008). Other gains are made from quantifying resources not utilized as a result of implementing EHRs (Byrne et al. 2010) these benefits accrue and are reflected as cost savings to these authorities. Funds realized as a result of these savings allow for better planning on both macro and micro levels with resources efficiently allocated to interventions that have greater impact on the populace (Jones et al. 2008). Furthermore, organizations concerned in medical research benefit immensely when records are electronically stored. The nature of the record allows for data to be easily derived for specific research purposes for learning and for use by other allied institutions with minimal overhead (Mathers et al. 2009).
Alternatively, the cost, size and complexity of implementing these systems are prohibitive (Hendy 2005). Many health providers such as the NHS in the UK meet many of these costs. According to the Donabedian perspective, the inputs required in setting up a working electronic record system are both time and cost intensive (Koeller 2002). Infrastructure in terms of hardware and software, expertise, training and associated costs are high especially when these are scaled to a national level (Cressman et al. 2006). In the UK 105BN pounds has been allocated to the NHS for 2010/2011 fiscal year (DoH 2010) and $19BN has been allocated for the year 2011 to promote the adoption of EHR in the USA (Wilson 2009). This however is seen to be inadequate and further investments needs to be done.
Comparison of Electronic and paper records
physical and described as being material objects with concrete locations, attachments and marking (Bearman 1996). Data is usually handwritten and takes the forms of Narrative text in most instances forms can also be used to insert data. Data entry lacks validation and prone to errors.
Conclusions
The literature reviewed provides evidence that supports adoption of electronic health records. An analysis of the literature as represented on table 1 showed good evidence indicating improvement of patient safety and increase in efficiency of clinical staff as a result of implementing EHR. Evidence showing an increase in information quality was mainly qualitative and cost benefit analysis was scarce and hard to find. Future benefits and cost savings were predictive at best and were mostly attached to reduction in risk to patients and the assumed calculation of costs savings associated with this.
Hayrinen et al. (2008b) stated electronic health systems are as yet not properly defined and methods to evaluate these systems are still not well developed as a result. This in effect raises major concerns, the first being the sustainability of these systems over the long term, the safety of the patients and the quality of information provided (Coiera 2009). As we move forward, systems are becoming larger and more complex and the cost to benefits have major implications to the national GDP of most countries implementing a nationwide health strategy. It is in this respect that the top down approach adopted by the NHS has been favored to the bottom up approach or sporadic approaches in other parts of the world (Cressman et al. 2006). This approach aims to reduce incompatibility in data reconciliation across systems which not only hinders the continuity of patient care but also makes deriving data in a coordinated and timely manner for use in public health highly complex. However, both systems are challenged and other arguments have been made that favor a middle out approach where local institutions drive the process but with oversight from governing bodies who set the standards and policy to guide it (Coiera 2009).
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