Running head: STUDY: ELECTRONIC MEDICAL RECORD
Case Study: Developing an Electronic Medical Record Beaches Clinic
Margie Pokorski
Siena Heights University
LDR 620 Information Systems Management
Barry I Schoenbart, MD, Professor
October 31, 2013

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Case Study: Developing an Electronic Medical Record Beaches Clinic
The case study focuses on the development of an electronic medical record for the
Beaches Clinic, “a highly specialized, 180 member integrated physician office practice offering
32 specialty services” (White & Wakefield, 1998, p. 316). This paper will critique and review the processes utilized by the Beaches Clinic organization which began implementing the electronic medical record (EMR) in 1992. Areas reviewed include the organizational culture, benefits and disadvantages of the process used, suggestions for improving the planning and implementation of the EMR, data integrity, communication, and the benefits of the EMR.
According to the Institute of Medicine (2001), “Information technology . . . holds potential for transforming the health care delivery system…” (Crossing the quality chasm: A new health system for the 21st century, 2001). Additionally, “The challenges of applying information technology should not be underestimated, however” (p. 5). Although the end result was successful, Beaches Clinic faced many challenges in implementing the medical record. “It will not be an easy road, but it will be most worthwhile” (p. 7).
Organizational Culture of Beaches Clinic
The organizational culture of the Beaches Clinic is based on their threefold mission: patient care, research, and education. “Patient care is the primary mission but interdependent with the other two” (White & Wakefield, 1998, p. 316). “The clinic was built on the premise that serving the whole patient is of paramount importance” (p. 316). This is a physician owned clinic affiliated with a neighboring PrimaCare Hospital. The steering committee was comprised of the chief executive officer of the clinic, the associate administrator of PrimaCare Hospital, the president of the clinic’s medical staff, seven clinic physicians, and the director of the clinic’s information services department. Their culture is considered patient centric but also physician
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ELECTRONIC MEDICAL RECORD 3 driven. The physician culture is autonomous in nature meaning that “doctors have historically seen themselves as their patient’s sole advocates . . .” (p. 58). “Medicine is in for a radical change as the old guard gives way to performance-driven teams” (Lee, 2010, p. 50). Resistance to change will be realized through the EMR implementation process. The motivation of developing an EMR was to reduce administrative inefficiencies and improve access to patient information, research data, and improve patient care. In addition the goal was to “allow data integration between the clinic, the hospital, the newly developing HMO, and other primary care physician practices, which were increasingly being networked into the Beaches Medical System”
(White & Wakefield, 1998, p. 318). Because the primary stakeholders are physicians, the selection of a physician owned vendor was a good fit. The EMR steering committee only had a choice of three vendors. After going on site visits and submitting, Request for Proposals (RFP)’s the committee realized that none of the vendors would meet their needs, but they “were intrigued” by the vendor that was owned by physicians. They stated that the physician owned vendor “could speak their language” (p. 319). The vendor had also developed the clinic’s laboratory system and therefore was somewhat familiar to the organization. The physician vendor offered to develop a clinical repository that would allow the integration of patient data.
The committee also wanted the data to become its medical record. The physician vendor was also intrigued by the physicians in wanting to use the system in developing a medical record.
“EMR adoption not only requires technological and financial capability, but also a cultural, philosophical shift in the way medical treatment is delivered – and this requires ongoing participation and buy-in among end users, and an evolutionary change rather than a big-bang, top-down approach” (Buell, 2011, p. 14).
Advantages and Disadvantages of the Process Used in Implementing the EMR
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Advantages of the Process Used in Implementing the EMR
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The steering committee had shared and specific goals of EMR implementation based on their mission and organizational culture, patient centric care.
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The vendor that was selected was physician owned and could “speak their language” and had worked with the clinic in the past.
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The vendor offered customization, and the ability to interface with other software vendors with the goal to be an EMR and interoperable with the neighboring hospital and HMO.
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Incremental approach
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Process included training by the clinic information systems (IS) department and accessibility for problem solving
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Support by administration that allowed decreased productivity during the training phase
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Administration allocated additional employee resources.
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Appointment of Health Information Systems (HIS) Director of Prima Hospital to serve as an advisor and liaison to the steering committee and eventually HIS
Director of Beaches Clinic
The benefits of the process used by the Beaches Clinic include a steering committee with stakeholders having shared goals based on the organization’s mission and culture. The vendor was physician owned and offered to act as a “consultant in helping the clinic select other systems that would work well with its clinical data repository and help facilitate its functioning as a medical record” (White & Wakefield, 1998, p. 319). The vendor offered to customize the system to meet the needs of the clinic through a development partnership for an alpha product.
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The alpha products support coding, compliance and reimbursement. The vendor provided system updates and the ability to interface with other vendors.
An integrated system consists of modules that are designed to be compatible and work with one another so that data transfer among modules proceeds smoothly. “Advantages of an integrated system include compatibility among the modules and the need to have only a single source for system support and maintenance” (Glandon, Smaltz, & Slovensky, 2008, p. 144). An interfaced system acts as a bridge between two modules which are different and which, for example, translates the data format into one that the receiving module can handle. The advantage of the interfaced system is that it “. . . allows users to choose the leading system for a given module can sometimes result in lower costs by leveraging one vendor against another, obviating the need to replace all existing modules when updates are considered” (p. 144). The advantage of the interfaced system would allow the organization to choose the best vendor that would meet their need to integrate the different nursing, pharmacy and diagnostic components.
The incremental approach of piloting the program on one floor, internal medicine was an advantage. This approach rather than an all or nothing strategy, allows for lessons learned to be applied before moving to the next floors. The roll out was planned to implement the EMR with the easier specialty services first and then to more complicated services. In addition, the last departments, surgery and hematology/oncology were the most complex, difficult, and resistant to transition to the EMR. The previous experiences and lessons learned would assist with that difficult transition. “Recognizing the very real barriers physicians face, Garber and his colleagues elected to roll out their electronic health record (EHR) in three phases – approach that was kinder and gentler than an immediate switch from paper one day to computer the next”
(Garber, 2013).
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Advantages to the implementation process included training which was provided by an individual designated by the information systems (IS) department for five physicians. The trainer was readily available to offer assistance. “The IS department also instituted a help line”
(White & Wakefield, 1998, p. 320). Training continued with formal sessions and “train the trainer” method. The Beaches Clinic demonstrated consistency with training and identified the need for appropriate resource utilization. The implementation of the EMR interfered with productivity. Clinic physicians were employed by the clinic and were expected to meet certain productivity standards. They saw less patients and spent less time with patients. The clinic physicians received support from administration to permit decreased productivity while learning the system. Additional resources for dictation, transcription and scanning the reports were provided. This would allow the physicians to access the scanned information from the terminals.
Administrative support is critical in successful information technology (IT) projects.
Collaboration between the hospital and clinic was enhanced when the HIS director of
PrimaCare Hospital was asked to serve in an advisory capacity on the steering committee and to spend some time each week consulting in the HIS department of the clinic. This individual had expertise in the presentation of data, data integrity, and the legal aspects of confidentiality and security of patient information. She was able to act as a liaison between the IS staff and the clinicians using the EMR. She may have been a good candidate for the position of project manager with her background, expertise, and relationship with the hospital and clinic.
Disadvantages of the Process Used in the EMR Implementation
Disadvantages of the process used in implementing the EMR included:
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Lack of representation of all stakeholders on the steering committee
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Lack of a project manager until the pilot phase and too much reliance on the vendor as a project manager and for IT planning
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Poor communication to the physicians
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Underestimating the autonomy of physicians and their resistance to change
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Lack of a clear project plan and master project timeline resulting in extended timelines and delays
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Did not follow project management principles for IT implementation with initiation of a finite scope
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Lack of a service level agreement
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Underestimated timelines of project, budget, and employee resources required
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No formal feedback or monitor in place to track success of the project, realized after implementation phase
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Lack of patient privacy, emergency policies and procedures
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Parallel Operation with dual use of paper and EMR supported regulatory requirements but added increased costs and extended timelines
The disadvantage of the steering committee is that it did not include all representative stakeholders nor did they designate a project manager at the onset. A formal IT steering committee needs to include all stakeholder groups. Although, this is an integrated physician office practice, the EMR expectations are to “allow data integration between the clinic, the hospital, the newly developing HMO, and other primary physician practices” (p. 318). In addition they wanted “diagnostic and procedural billing data to be electronically transmitted to the business office” (p. 318). Other recommended stakeholders for the committee should include IT, nursing, facility services, patient and financial management, human resources
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ELECTRONIC MEDICAL RECORD 8 management, and clinical support services staff. These additional members would oversee that new and replacement IT priorities are consistently applied across the multiple operating units within the organization. The system design and implementation will require a coordinated effort between the IT department, physicians, hospital leaders, clinicians, and non-clinical areas in order to standardize the information and ensure that the system is interoperable and useful to all of the departments and “meets their functional requirements” (Stratis Health, 2013, p. 1). An extended steering committee was created for implementation of the pilot program – with seven physicians, one clinic administrator, one hospital associate administrator, one information systems director, and the vendor project manager. “The role of this committee is to provide strategic direction for information systems decisions” (Glandon, Smaltz, & Slovensky, 2008, p.
37). The steering committee has the “specific responsibility for overseeing major projects and managing IT priorities, IT costs and IT resource allocation” (DeHaes & VanGrembergen, 2004, p. 2). According to Bahel (2009), success of major IT projects rely on five “execution planning” steps which begins with establishing a steering committee. “Successful steering committees are primarily responsible for naming the members of the core project team, approving plans and providing strategic guidance to the core project team” (p. 14). The other four areas are: establish the core project team, establish sub-teams, define roles and responsibilities and build a one-page master project timeline (p. 14).
The steering committee agreed to partner with the vendor. The vendor began planning how it would implement the system. “It recommended the use of an optical imaging system and suggested an imaging vendor” (White & Wakefield, 1998, p. 319). There is too much reliance on the vendor for planning and implementation. They would have benefited from “the use of information technology to hold the system together” (Glandon, Smaltz, & Slovensky, 2008, p.
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13). The steering committee should have entered into a service level agreement with the vendor to define the costs, ability to upgrade, timelines, security, and privacy issues. A project manager should have been designated at the onset to lead and oversee the processes of the EMR implementation rather than the vendor planning the implementation. The responsibilities of a project manager include establishing timelines, resource allocation, budgets, communication, data, and follow up reports. A project manager was added at the implementation of the pilot program and was a vendor.
A disadvantage to their process involved minimal communication to the physicians.
With the exceptions of the physicians on the steering committee, the clinic physicians had only been minimally informed about the EMR. “There had been no formal announcement or communication informing the physicians that a plan was being considered and tested” (p.320).
Improved communication would have assisted in addressing the issues of the physicians’ reluctance to change. Some of the physicians did not want to break with tradition and were comfortable with the paper medical record even though they realized it was inefficient. “. . . innovation is often highly disruptive to an organization, “he said. That disruption can be met with resistance from the often well-educated people who are being asked to change their habits”
(Birk, 2011, p. 29). Underestimating the resistance to change by the physicians was a challenge to the implementation process. Sharing the plans and goals of implementing the EMR with the physicians and how they support the mission and vision of the organization to be patient centric would have assisted with increased physician buy-in and support. Providing data and research supporting quality care and safety benefits of the EMR would engage the physicians
The pilot program was initially planned to last three months but continued for six months.
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Problems were addressed by the steering committee. At the end of six months there was no formal evaluation of the system. The steering committee was confident in its commitment to the project and in its decision that there was no turning back (White & Wakefield, 1998). The extended timelines, delays, and lack of a formal evaluation of the system is considered a disadvantage. The project manager will review the work plan and the duration of the project.
The project manager utilizes a work plan with includes all project related tasks with specific timeframes . This workplan will list the individuals and teams responsible for each task. The project manager ensures that staff resources are deployed and utilized appropriately for the project. “Mitigating risks is an important responsibility of the project manager and the whole team should support it by pointing out possible barriers to the project” (Guglielmo, 2011, p. 3).
In this case, the steering committee underestimated the timelines of the project, budget, and employee resources required. There were no formal tools or monitors to evaluate feedback.
Even though the Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996, prior to the onset of the Beaches Clinic EMR development, patient privacy should have been addressed. HIPAA requires healthcare organizations to develop enterprisewide standards and policies to maintain data security and protect the confidentiality of certain information. Although, the Health Information Systems (HIS) Director from the hospital had a background in the legal aspects of privacy, the case study did not detail the steps for ensuring security of the records. Studies have indicated that electronic health record vendors often include contract provisions that may require providers to violate patient privacy standards (Conn
2007) as cited by (Glandon, Smaltz, & Slovensky, 2008, p. 123). Policies should include vendors’ compliance with HIPAA. In addition to implementing policies and procedures,
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ELECTRONIC MEDICAL RECORD 11 healthcare organizations should conduct privacy and security audits, education, training, and incorporating these rules in performance evaluations.
The pilot program allowed the dual use of the paper medical record and the EMR. Plans included that handwritten notes would be scanned into digital format from the year 1992 forward. Maintaining a parallel operation of the paper record and electronic record was necessary in this case study due to government regulations. The electronic signature was not yet sanctioned at that time. This dual operation permitted training and transition to the EMR but resulted in increased labor costs, monitoring, and added time to the project. The paper record also served as a backup for computer downtimes. A quality control process had to be implemented and was “extremely labor intensive”. The increased implementation timelines extended to four years for the dual operation of the paper record and EMR (White & Wakefield,
1998).
Recommendations to Improve the Planning and Decision Making Process
Expanding the steering committee to include IT, clinicians, patient and financial services, laboratory, and nurses would assist in hardwiring the process. The committee should have designated a progect manager such as the HIS Director of the Hospital instead of relying on planning and project management by the vendor. The project manager would follow the principles of managing IT Projects. IT Projects require six clinical principle domains to be successful: “physician leadership and governance, change management, process redesign, clinical adoption principles, benefit realization and technology fundamentals” (Fickenscher &
Bakerman, 2011, p. 72). According to Glandon, Smaltz & Slovensky (2008), the five key processes of project management are:
1.
Project initiation: defining and authorizing a project
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2.
Project planning: defining the objectives, scope, and plan of action to achieve the desired outcomes
3.
Project execution: actions to complete the work that was defined in the project planning process
4.
Project monitoring and controlling: measurements designed to assess how well a project is being executed to budget and deliverables as well as to alert project managers to potential corrective actions that might be necessary from time to time
5.
Project closing: actions to formally terminate all activities associated with the project either by delivering a finished product or by ceasing effort on a canceled project. (p. 101)
In order to overcome ambiguity in projects, defining the project and its scope is the starting point. “In this phase, project objectives are established, scope is defined, and responsible parties and deliverables are identified” (ASAE, p. 1). In addition, the purpose of the initiation process is to commit the organization to a project or phase, set the overall solution direction, obtain the necessary approvals and resources, make sure the project is aligned with the business objectives of the organization, and assign a project manager. The Beaches Clinic carried out the
Project initiation phase without a project manager and did not execute the other four key processes. Project planning requires a finite scope in determining the best course of action on how to proceed with the plan.
During this phase, a team should prioritize the project, calculate a budget and schedule, and determine what resources are needed. This can be further broken down into core planning processes and facilitating processes. The core process planning includes ‘scope planning’, schedule development, resource planning, and cost budgeting. (ASAE, p. 1)
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Facilitating processes are performed as needed depending upon the project such as staffing needs or risk management concerns. Project execution involves delegating the assignments and responsibilities to carry out the project. In the fourth phase, project perfomance and control is the use of reports and tracking tools which monitor the cost, quality, timelines, and progress of the project. This is the phase in which changes and corrections would be made to address problems or issues. This ensures that the project is on track. The project closing stage includes activities such as “verifying product/service acceptance, update records based on final contract results, archive contract documentation of completed work results, notification to enduser of contract completion, and obtain formal acceptance” (PMI, Initiating Projects). According to Gunasekaran (2008),
A project has milestones, and to achieve thse milestones we must commit resources to certain tasks to achieve certain pre-defined goals (scope); many of these tasks will be related (dependencies) and to complete tasks we will often need to overcome obstacles (risks) in a timely manner. (p. 87)
The system design and implementation will require a coordinated effort between the IT department and Beaches Clinic and hospital physicians in order to standardize the information so that it can be useful to all of the clinicians in the different physician offices and hospital. The
Beaches Clinic should make sure that their design includes data standardization, should promote care coordination and management at point of care, clinical decision support integration, EMR interoperability, medical evidence-based rules, real-time analytics and high clinical accuracy.
Communication was identified as integral to the success of the project and was significantly lacking throughout the implementation process.
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Communication
Communication is essential among administrators, clinicians, information systems personnel, and the vendor because “. . . the most crucial success factor in project management is effective communications to all stakeholders—a critical core competency to all organizations”
(PMI, 2013). The Pulse study further emphasized that “In a complex and competitive business climate, organizations cannot afford to overlook this key element of project success and longterm profitability” (PMI, 2013). The lack of communication was identified as a disadvantage to the Beaches Clinic process as no formal announcements were sent to the physicians resulting in unclear direction and misunderstanding of the scope of the EMR integration project.
Communication is essential and the project manager should provide regular communication on project information and progress to project stakeholders. These communications may be in the form or tools and instruments such as meeting minutes, logs, work plans, communication plans, forms, and templates to provide updates. Key performance indicators will be shared through dashboards which help visualize project progress and keep track of goals, budget, and schedule. The project manager needs to facilitate discussions between stakeholders of varying backgrounds (PMI, Initiating Projects). The Project
Management Institute (PMI) also recommends “joined up” thinking between the project team and committed leadership from the executive levels of the organization (p. 2).
Data Integrity
Data standardization is essential for healthcare organizations in order to share information between the multiple areas of the delivery system. These components include nursing, labs, emergency departments, and radiology which all collect, store, analyze, and
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ELECTRONIC MEDICAL RECORD 15 transmit patient information. Electronic data is captured for storage in a data repository
(Glandon, Smaltz, & Slovensky, 2008, p. 203).
Data standardization is important in healthcare to ensure safety and interoperability.
“The Institute of Medicine (IOM) identified some of the data standards necessary for patient safety in Patient Safety: Achieving a New Standard for Care” (Hammond, 2005, p. 1205).
“Health data standards are key to the U.S. quest to create an aggregated patient-centric electronic health record” (p. 1205). In order to be interoperable, “data must be built upon common words
(data elements and terminology), structures, and organization” (p. 1205). The Joint Commission states that the “principle reason for the standardization is to protect patients from the effects of miscommunication” (Joint Commission 2003) in their discussion regarding standardizing terminology, definitions, vocabulary, and data comparison. They also support standardized abbreviations, acronyms, and symbols. “. . . the industry must publish well-defined standards for the synchronization and exchange of data. An example of this is the Continuity of Care (CCD), based on the HL7 standard, which has greatly streamlined the transmission of patient data from one healthcare facility to another” (Ingari, 2013, p. 20).
“Unfortunately, universal and standardized language is not the norm and a communication breakdown often occurs with multiple interpretations and inconsistent instrument citations” (Sabrosky, 2007, p. 56).
The Benefits of the EMR
Impact and benefits of the EMR were “numerous” for the Beaches Clinic (White &
Wakefield, 1998, p. 325). “Adoption of electronic medical record (EMR) systems will
[ultimately] lead to major health care savings, reduce medical errors, and improve health”
(Hillestad, September/October, p. 10).
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Immediate Access
The electronic medical record provides benefits of immediate physician access to patient information from within the hospital or clinic. “Order-entry and results-reporting applications provide for efficient entry of orders for diagnostic tests and patient treatments for subsequent reporting of test results to the ordering provider and the patient care unit” (Glandon, Smaltz, &
Slovensky, 2008, p. 209). Computerized physician order entry (CPOE) is the application that electronically transmits physician orders to the appropriate clinical service units” (p. 209).
“E-prescribing has the potential to improve patient safety, enhance medical outcomes, reduce unnecessary costs, prevent errors, and streamline the process of issuing and filling prescriptions . . .” (Pulley, 2008).
Benefits of more robust health IT include more rigorous adherence to treatment protocols and guidelines, reduction in adverse drug reactions, fewer redundant treatments and tests, less paperwork, administrative efficiency better coordination of treatment, early detection of infectious-disease outbreaks, improved disease management, and new opportunities for medical research, the report states. (Pulley, 2008)
The EMR will improve the continuity of patient care by providing “real-time electronic exchange of patient health information” (Hyatt Thorpe, 2013, p. 231). When the patient arrives to the physician’s office or emergency room, the medical history including current medication use and treatments provided, should be readily available for review. This will also improve communication through transparent exchange of information and allow efficient and safe coordination of care for the patient. The healthcare providers will make informed decisions about the patient’s care by having access to the patient’s record across the continuum and reduce
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ELECTRONIC MEDICAL RECORD 17 errors. Health care costs will decrease by eliminating unnecessary and duplication of services.
Accountability of care will be realized through data collection and benchmarks.
According to Glandon, Smaltz, and Slovensky (2008) "medication errors constitute the largest percentage of medical errors" (p. 207). There is a lot of focus on vendors to supply organizations with the best product to meet safety expectations with medications. Checks for IV compatibility, screening for drug-food interactions, and drug-drug interactions are other initiatives that help reduce errors (Glandon, Smaltz, & Slovensky, 2008).
“Computer systems interface directly with patient-monitoring devices in critical care units of the hospital. Patient-monitoring systems employ the computer for continuous surveillance of a patient’s vital signs and periodic display of physiological data for use by trained monitoring personnel” (Glandon, Smaltz, & Slovensky, 2008, p. 225). These results are readily available to healthcare providers, providing trending and a “microprocessor that helps control, enhance, and interpret the results of the testing or treatment process” (p. 225). As a result of the
EMR the Beaches Clinic physicians have “immediate online access to patient information”
(White & Wakefield, 1998, p317).
“For example, scanning devices provide an efficient and accurate means for tracking many types of inventory items. Medical supplies, pharmaceuticals, and even patient identification bands may be tagged with bar codes or marking that perform several functions when scanned” (Glandon, Smaltz, & Slovensky, 2008, pp. 139-140). Scanning a patient ID bracelet can lead to improved quality of care in a hospital by improving safety.
Improvement in creation of a timely and complete medical record
The benefits of the EMR “includes the potential for real-time data, decision support for the health-care team (including patients and families), immediate access to answers that prevent
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ELECTRONIC MEDICAL RECORD 18 problems that could lead to rehospitalization, and the elimination of redundant laboratory tests, diagnostic imaging, and procedures” (Escobedo, Kirtane, & Berman, 2012-2013, p. 59).
“Providers have access to diagnostic and treatment information in real time, via workstations or remote devices” (Glandon, Smaltz, & Slovensky, 2008, p. 203). This includes “real time” order entry and test results applications” (p. 203). “Another consideration in today’s increasingly connected healthcare environment is how diagnostic and therapeutic devices can share information with each other and output data collectively to enhance clinical decision making”
(Nadeau Della Vecchia, 2013, p. 26). “The real-time availability of patient information to medical providers, for example, enables evidence-based care, which can include everything from identifying targeted patients from outreach in a chronic care setting, to guiding medical interventions and alerting physicians to dangerous drug interactions” (Ingari, 2013, p. 20).
Elimination of “lost” information in the record
“One of the most common ways to manage the storage, retrieval, distribution, and presentation of medical images is via a picture archiving and communications system (PACS).
A PACS involves online storage and rapid retrieval of images transmitted over communications networks to user work-stations that can display both digital information and images. Benefits of
PACS include faster turnaround of images and reports, elimination of film loss, reliable retrieval of archived films, and greatly reduced storage space requirements” (Glandon, Smaltz, &
Slovensky, 2008, p. 209). “Teleradiology also enables physicians to call up images at workstations in remote locations, including their own homes (Luccichenti et al. 2004)” (p. 209).
The Beaches Clinic process of having the paper medical record follow the patient to each medical encounter resulted in mutiple personnel handling the information and delays in filing reports and lost documents. As a result of the optical imaging of paper documents, the problem
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ELECTRONIC MEDICAL RECORD 19 of “lost” information has been eliminated. The EMR can be accessed immediately and provides real-time data entry and review of the medical record.
Improvement in turnaround time for scheduling patient appointments
“Patient scheduling systems are used for advance booking and scheduling of facilities, both for patient and physician convenience and for efficient allocation of resources, particularly staffing” (White & Wakefield, 1998, p. 215). “Office automation helps to coordinate and manage people and workflow, link organizational units and projects, and coordinate work in the organization across levels and functions” (219). The Beaches Clinic EMR improved access for patients resulting in improved turnaround times for patient appointments and follow up visits, decreased cancellations, and obtaining billing information.
Improvement in timeliness and access to billing information
“Precise records also are important for accurate billing to ensure optimum revenue generation” (Glandon, Smaltz, & Slovensky, 2008, p. 207). “Information systems monitor inpatient occupancy rates, clinic and emergency department activity, and utilization of individual service facilities such as the operating suite” (p. 215). “Advance bed booking and preadmissions systems are particularly useful in situations where most of the admissions are elective (e.g., a specialized surgical facility)” (p. 216). HIS’s are able to track a hospital’s patient census and assist in projecting income and budget and adjusting staffing (p. 216). “Financial informatics is just as important; without the integration of clinical and financial informatics, risk-adjusted contracts cannot be created” (Ingari, 2013, p. 20).
Records of charges for services provided are transmitted electronically to the appropriate business office application for processing and entry into the accounting system. Through
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ELECTRONIC MEDICAL RECORD 20 use of drop-down menus and edit checks, the system minimizes errors in data entry as well. (Glandon, Smaltz, & Slovensky, 2008, p. 210)
The aspects of clinical application that support quality management and cost control programs are “documenting medical necessity for procedures performed” (Glandon, Smaltz, &
Slovensky, 2008, p. 206). “Clinical practice guidelines and other treatment protocols can be embedded in the application, along with the programming to require clinical justification for ordering tests and procedures not addressed in the protocols, thus allowing the avoidance of unnecessary tests and procedures” (p. 206). “Incorporating evidence-based protocols into clinical decision making supports providers in delivering patient care that is both clinically effective and cost efficient” (p. 206).
An easy-to-navigate claims management system is essential. Real-time claims adjudication tells a provider within seconds how much the payer will cover and what the patient owes, allowing collection from the patient at the point of care. Also helpful is a searchable explanation of benefits tool that offers the patient’s claims history (Bogoslaw,
2013, p. 50).
“Physicians also want to obtain real-time prior authorization for prescriptions online”
(Bogoslaw, 2013) (p. 51). “Besides eliminating a lot of paperwork ‘there’s a decision logic functionality built into the tool that pulls up the right kind of form and the right kinds of prepopulated answers”.(p. 51)
Improvement in capability for abstracting research data
The goal of the Beaches Clinic physicians and steering committee was to enter statistical data that could be used for research. “Evidence-based clinical practice guidelines are intended to assist clinicians and healthcare organizations in standardizing decisions about the care of
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ELECTRONIC MEDICAL RECORD 21 individul patients to achieve cost and quality benefits” (Glandon, Smaltz, & Slovensky, 2008, p.
224).
“Information systems and medical databases are used extensively to support biomedical education and research. Computerized patient records serve as the basis for epidemiological studies of a variety of diseases and their potential linkages to social and environmental factors”
(p. 226). “Computers are an integral component of most medical research projects” (p. 226).
Improvements in access to quality management data
“Physicians can identify clinical practices used by higher performing colleagues on key outcome metrics to improve their own performance” (Glandon, Smaltz, & Slovensky, 2008, p.
224). “Clinical decision support (CDS) systems are computer-based information systems designed to assist physicians and other providers in diagnosis and treatment planning” (p. 222).
“Computers can aid decision making by simplifying access to data needed to make decisions, providing reminders and prompts, assisting in order entry, assisting in diagnosis, and reviewing new clinical data to issue alerts when important patterns are recognized” (p. 223).
The Medicare Physician Quality Reporting Initiative (PQRI) lists 100+ Quality Measures that may lead to improvements in quality of care. EMR is seen as a logical progression of a system that allows physicians to identify measures they wish to track, and provides payments for those that successfully monitor and report on measures. (Jones & Kessler,
2010)
“From a quality improvement and risk management perspective, data can be extracted to monitor risk management issues, morbidity and mortality statistics, lists of cancellations, and reasons for surgical procedures. All of these data are gathered with less clinical overhead, and this quality improvement tracking promotes improved patient safety and more efficient access
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ELECTRONIC MEDICAL RECORD 22 and use of the surgical suite” (Holly, 2006). The EMR will improve the continuity of patient care by providing “real-time electronic exchange of patient health information” (Hyatt Thorpe, 2013, p. 231). When the patient arrives to the physician’s office or emergency room, the medical history including current medication use and treatments provided, should be readily available for review. This will also improve communication through transparent exchange of information and allow efficient and safe coordination of care for the patient. The healthcare providers will make informed decisions about the patient’s care by having access to the patient’s record across the continuum and reduce errors. Health care costs will decrease by eliminating unnecessary and duplication of services. Accountability of care will be realized through data collection and benchmarks. Hospitals and IT departments will collect information that supports quality outcomes and values based purchasing. IT implementation with business operation departments will provide assistance in payment reform and analyze methods of achieving cost reductions.
Elimination of faxing, copying, and mailing of patient information between hospital and clinic
The Beaches Clinic EMR implementation benefited the support staff through improved efficiencies such as decreased paper flow. Physicians also benefited by sharing information through real-time reporting rather than waiting for reports to be sent. “Duplication of work in sharing information between physician offices and the hospital has been greatly reduced; no longer is information needed to be copied, faxed, or mailed to different locations” (White &
Wakefield, 1998, p. 325).
Reduction of clerical personnel involved in record movement and record retrieval
The Beaches Clinic employed “17 clerical people” in the information services department to file, maintain the records, and obtain signatures. In addition the secretaries required access to
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ELECTRONIC MEDICAL RECORD 23 the information to contact patients. “IT required the employment of an exorbitant number of people just to manage a record” (p. 318).
By the first quarter of the third year however,a significant reduction in clerical staff associated with paper record movement was achieved. The number of desk attendants and completion assistants was substantially reduced. Paper record maintenance is currently being accomplished by the use of low-cost temporary staffing. (p. 325)
Additional cost reductions projected as system performance improves
We examined the potential health and financial benefits of health information technology
(HIT) and compared health care with the use of IT in other industries. We also estimated potential savings and costs of widespread adoption of electronic medical record (EMR) systems, models important health and safety benefits, and concluded that effective EMR implementation and networking could eventually save more than $81 billion annually – by improving health care efficiency and safety – and that HIT enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. (Hillestad, September/October, p. 11)
“The adoption of interoperable EMR systems could produce efficiency and safety savings of $142-$371 billion” (p. 11). “The eventual benefits of an HER/EMR system include the saving of nursing time, which allows the nurse more to spend with patients” (Kabachinski, 2011, P. 27).
The EMR has resulted in multiple benefits for the Beaches Clinic which included increased revenue . “In the third conversion year, the clinic realized a $6 million increase in revenue. This increase reduced an existing $8 million deficit to $2 million. The trend in revenue enhancement is expected to exceed the five-year revenue enhancement projections” (White &
Wakefield, 1998, p. 325).
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Conclusion
Beaches Clinic’s planning and process design resulted in the successful implementation of the EMR. Advantages of their process included a strong organizational culture of being patient centric, physician driven, and having a shared goal of developing an EMR. Strengths of their plan included the selection of a vendor that was owned by a physician who understood
“their language”. The vendor was willing to work with the physicians to provide an EMR rather than a data repository and engaged companies that provided software that could interface with their requirements. The steering committee also used an incremental approach rather than an all or nothing method which allowed the transition of physician offices in a systematic way.
Disadvantages of the process included poor communication to the physicians, underestimating the autonomy and the difficulty of change for the physicians, not involving all stakeholders, relying on the vendor for planning and project management, lack of a designated a project manager until the implementation phase, lack of IT support, extended timlines with delays, and not following the steps of project management. The parallel operation of using paper and the
EMR was not considered an effficient process, but was necessary due to the government regulations of electronic signature. Although technology has advanced since this case study, the underlying principles of implementation are relevant throughout time. Communication, having the right stakeholders, supporting the organizational culture, and following the key principles of project management execution will promote successful implementation of the EMR.
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