A practical framework to assess the

impacts of EMR systems

Greta Nasi

SDA Bocconi School of Management

Bocconi University, Milan Italy

AGENDA

• EMR systems: an impact assessment model

• The model’s methods for data collection

• Findings of an empirical test of the assessment

model in Italy and Spain

• Discussion and recommendations

Relevance of impacts of EMR

systems

• Healthcare efficiency and effectiveness is becoming

increasingly dependent on information and communication

technologies

• EMR systems promise to improve health care quality to

advance inter-organizational integration and data sharing

across different health care providers, and to empower

patients through greater access to personal data

• However the variety and heterogeneity of potential impacts

described in literature has not been framed into a

comprehensive assessment model able to capture all

relevant dimensions of EMR impacts on health care

performance

Main dimensions of the

assessment model• Efficiency includes impacts on the level of efficiency of internal processes

which the application of the electronic medical record system has

produced or will produce in the future in terms of time and cost savings

and quality of information;

• Effectiveness includes impacts in terms of improvement of the

organisation as a whole measured as process integration, organizational

effectiveness, risk management and better care processes;

• Quality of service includes impacts on the overall care process, taking

into account its performance, the continuity of care and the degree of

empowerment of the patient;

• Clinical Governance comprises the group of effects produced in terms of

organisational culture, capacity for change as well as overall clinical

performance.

The EMR assessment framework

Efficiency

Time savings

Cost efficiency

Information Quality

Effictivennes

Improvement of diagnostic and

therapeutic activities

Risk Management

Effectiveness of processes

Quality of

service

Patient Empowerment

Quality systems

Continuity of care

Clinical

Governance

Service

Value

Patient Empowerment

Efficiency of care

Quality Improvement

Accountability

Information management

Clinical Audit

Strategic management

Organizational effectiveness

Quality of service

The model’s methods for data

collection

A mix of quali-quantitive methods have been defined and used

for data collection. Here is a summary of the methodology

adopted:

• “Self-completion questionnaires”, concerning information about the

EMR system implementation which include:• An assessment of the organization’s context;

• The status of EMR system implementation and its functionalities;

• Organizational impacts based on the four dimensions perceived by main stakeholders

including physicians, nurses, CIOs and controllers, Boards, patients

• Semi-structured interview schemes to be used to interview key actors

of the EMR system’ implementation project;

• Document scrutiny and analysis of other relevant information, as

organizational and strategic documents, study reports

A test of the assessment model

in Italy and SpainThe test was aimed at comparing impacts of EMR systems

on the overall performance of different types of health care

providers for:• Contexts (Italy and Catalonia) and types of health care provider,

• Time elapsed since EMR system implementation;

• Functionalities of the EMR systems

• Main objectives of EMR system implementation (continuity of care vs.

standardization and rationalization of processes and resource usage)

The sample:• Italian healthcare providers: a Local Healthcare Authority, which provides both

acute and primary care services and an Acute care hospital;

• Catalonian healthcare providers: five acute and primary care providers and one

acute care provider

All data was collected between March and July 2009

Impact assessment timeframes

Local health care authority

Acute care hospital

6 Spanish

providers

Pre-EMR system EMR system

Go Live

……. LONG RUN After 6 years of EMR

sys implementationAfter 1 year of EMR

sys implementation

Assumption for timeframe of

impact materialization

After 6 years of EMR

sys implementation

……. LONG RUN

Efficiency

Effectiveness

Quality of service

Clinical governance

After 1 year of EMR

sys implementation Pre-EMR system EMR system

Go Live

Preliminary findings: an overlook

ITALIAN HEALTH PROVIDERS CATALONIAN HEALTH PROVIDERS

The Italian health providers show

the greatest effects in terms of

efficiency and time saving in

particular, which in turn might have

an overall effect on the economics

of some wards

The Catalonian health providers

recognize as most important impact

the quality of information in terms

of accuracy, completeness, easy of

understanding and reliability of data

Preliminary Findings: efficiency

Preliminary Findings: effectiveness

Italian health providers argue that EMR

adoption has increased organizational

effectiveness, in terms of improvement of

the interaction between clinicians and

patients and also shows its impacts on the

effectiveness of processes, enhancing

decision making process with time and cost

savings results.

Catalonian health providers show an

improvement of diagnostic, therapeutic

and service activities in terms of better

ability to plan admissions, precision in

diagnosis and treatment and reduction in the

number of errors in ordering diagnostic tests

and in the compiling reports.

Preliminary Findings: other impacts

• In Italy , the adoption of EMR

systems has lead to a higher

awareness of patient

empowerment, with particular

reference to the possibility of

further involvement of patient to

the process due to the increased

availability of information

• In Catalonia, EMR adoption has

strengthened the information

exchange between acute care,

primary care and GPs (due to the

fact that most of the hospitals are

both primary and acute care),

improving the continuity of care

Discussion and recommendations

• Based on the test, we can state that the model can actually

capture impacts of EMR systems at organizational level,

regardless of the status of EMR implementation, the functionalities

adopted, the type and functions of the health provider and the

context

• Short term impacts tend to be forgotten and taken for granted

• These findings are mainly in line with the assumptions made

while drafting the model

• There is no significant difference in long run effects between

acute care and primary care providers

• Adopting these framework systematically may help:

• Health providers in understanding whether EMR adoption might help them in

reaching their goals;

• Policy makers to set guidelines for successful EMR implementations;

• Academics and practitioners to compare different

EMR system uses.

Acknowledgments

• Thanks to Azienda Ospedaliera Ospedale Civile di Legnano,

Azienda USL della Valle d’Aosta, Hospital Clinic, Hospital de Sant

Pau, Hospital del Mar, Hospital General de l'Hospitalet, Institute

Català de la Salut, Hospital de Bellvitge

• Research team: Claudio Caccia, Maria Cucciniello, Greta Nasi,

Xavier Pastor

• Research assistants: Paola Cantarelli, Manish Gawande

• This research project has been co-financed by InterSystems Italia

srl, NoemaLife SpA, Claudio Dematté Research Division and the

Public Policy and Management Area of SDA Bocconi School of

Management