Electronic Medical Record/Electronic Health Record System

Problem Based Learning

3/26/2014

Group Q2

Harsh Sultania 13319

Girish Hemnani 13321

Jithin C Issac 13323

Table of Contents

1. PROBLEM STATEMENT..................................................................................................................1

2. ELECTRONIC MEDICAL/HEALTH RECORDS (EMR/EHR)..................................................................1

3. FINDINGS.......................................................................................................................................2

4. MANAGEMENT OPINION...............................................................................................................5

4.1. Individual and Group Factors.................................................................................................5

4.2. Organizational Level..............................................................................................................6

4.3. Macro Economical Level........................................................................................................7

5. ADOPTION METHODOLOGIES........................................................................................................7

6. ALTERNATIVES FOR EMR/EHR ADOPTION.....................................................................................8

7. IMPLEMENTATION PLAN OF EMR/EHR..........................................................................................8

8. CONCLUSION...............................................................................................................................10

9. LEARNINGS..................................................................................................................................10

10. SELF-ASSESSMENT.......................................................................................................................10

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Group Q2

Harsh Sultania 13319

Girish Hemnani 13321

Jithin C Issac 13323

1. PROBLEM STATEMENTEMR and EHR provide various advantages in managing patient medical records. With

the change in technology many hospitals have moved to this system, however the

system is facing challenges such as computer downtime, threats to confidentiality and

acceptance by the doctors. It is necessary to minimize the threats and issues to

improve the usability for better documentation purposes.

2. ELECTRONIC MEDICAL/HEALTH RECORDS (EMR/EHR)The health information technology has introduced the changes in Health Information

Management (HIM) with the advent of Electronic Medical/Health Records

(EMR/EHR) system. EMR is the electronic version of patient charts which contains

entire patient information. This system has been introduced to make the record-

keeping easier, flexible and accurate. A subset of EMR is EHR which enables the

patient records to span within a region, state or country.

Despite the technological establishment in health sector, the adaptation of EMR/EHR

is confined to very few hospitals in India. Till now EMR/EHRs didn’t exist that

integrates the entire clinical information of a patient. It was observed that technology

alone is not sufficient in successful implementation. There are various challenges in

adopting the EMR/EHR according to standards in various hospitals. Based on our

initial research, it was found that there was a lack of government intervention in the

implementation of Information Technology (IT) in health sector. Also, it was

observed that doctors were reluctant to use this system as they believe it reduces the

clinical productivity. Apart from this, it was also observed that more than 80% of the

hospitals are still following the traditional paper based medical record system despite

the advent of technology in health sector. Though the objective of the hospital is to

cater to the medical needs of the people by adopting latest technological advancement

in the industry, they are not willing to utilize the capabilities to the fullest extent.

EMR/EHRs are the first step in transformation of health care. It offers several benefits

over the traditional paper based medical record system. The shift to EMR is taking

place in a slow pace due to major drawbacks of paper based records such as high

probability of human error, maintenance cost, and quality and security issues.

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whereas, from management view EMR/EHR offers various benefits by providing

better health care, health and decision-making. The ability of this new health

information technology helps in saving time, providing the accurate information,

improving patient experience, reducing storage and allowing for streamlined

information by the implementation of best user-friendly interface. However the

system comes with challenges such as computer downtime, threats to confidentiality

and acceptance by the doctors. In order to achieve a wider reach in India, it is

necessary to minimize the threats and issues to improve the usability for better

documentation purposes.

3. FINDINGSA detail research was conducted in various hospitals in order to understand the usage

of EMR/EHR. The objective was to understand the barriers and advantages of

EMR/EHR implementation at management level and at the staff level in hospitals.

Frequency Percentage

Male 42 60%

Female 28 40%

Total 70

A survey among 70 doctors from 50 hospitals was conducted to analyze the

perception of EMR/EHR at management and staff level. 67% of the total respondents

(70 doctors from 50 hospitals) confirmed that they use both EMR and paper medical

records. 17% the hospitals completely implemented EMR whereas 16% are still using

paper medical records. 82% of the doctors said the management incurred a huge loss

for implementing EMR/EHR in their hospitals. However, 18% of the doctors quoted

that hospitals gained by increasing the number of patients. The breakup can be seen in

the figure below. But we were not able to infer anything about quality of care of

patient.

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Paper medi-

cal records (File sys-tem)17%

Both67%

Elec-tronic medi-

cal record

s17%

Medical records maintenance

A survey was conducted among 81 patients to know their view on sharing the patient

information online. It was found that 52% of the people were willing to store the data

online for easy accessibility and for future reference. But 48% refused to store the

data because of the security concerns and to maintain confidentiality. Further, they

said they were happy with paper records. They were ready to carry and maintain

traditional paper based medical records. The percentage breakup is shown in the

below figure.

52%48%

Would you like your medical records to be stored online

YES NO

Also, it was found that the most of the laboratories are still using paper records which

delays in providing information to doctors. There is a huge scope to increase the

usability of EMR in laboratories, as it will help in increasing the operating efficiency.

The survey also indicated that the traditional system is rated above average in terms of

usability on a scale of 1 to 5. Further, there was high rating when it comes to privacy

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in traditional system. On one hand, the doctors perceived that the data of patient is

stored is private and not accessible to general public. Whereas, the patients had

completely different view, they felt that their privacy could be tampered. Patients and

Doctors both felt that the data is easily accessible when it is required if they use EMR.

Privacy

Accessibility

Adaptability

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

2.8

2.6

2.6

Ratings given by doctors for paper based medical record system

Privacy

Accessibility

Adaptability

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

4.4

4.6

4.4

Ratings given by doctors on EMR

The larger the project in terms of budget, staffing levels, duration and number of

departments affected the greater the risk. The risk is increased if the project team and

organization are unfamiliar with the software or other projects technologies. The

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projects that do not have convenient characteristics have requirements that are volatile

in nature. They are not only difficult to determine and they tend to evolve throughout

the project.

1 2 3 40

5

10

15

20

25

Project Risk

Project Risk

Number of Risk Factors

Proj

ect R

isk

Moderate Risk

High Risk

Very High Risk

4. MANAGEMENT OPINIONAs per the management the health care system can be nested into four levels:

1. Individuals

2. Groups (Care team)

3. Organization Level (Health Care delivery system)

4. Macroeconomic Level (Political and Economic Environment)

Apart from cost as a factor, there are various issues to adopt the EMR/EHR system.

There are hindrances, which prevent the implementation of EMR/EHR in any health

care system. The analysis can be done at two levels macro level and micro level.

4.1. Individual and Group FactorsThere are physicians who bring their patients, but do not work full time in the

premises. These physicians practice independently and under the referral program

they admit their patients. They restrain due to lack of computer skills, cost and return

on investment of EMRs, loss of productivity caused by EMR and technology

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involved. The communication strategy is one of the biggest factors observed in

adoption of a technology. Those people who have adopted technology and have a

strong belief that it helps in decreasing effort and increasing operational efficiency

should surround these people. These people will influence those who disbelief in

EMR System.

An association of doctors can be created who have worked in implementation of

EMR/EHR, this will help in increasing awareness and communicating to those are in

process or yet to implement the technology.

We can also use prototyping as one of the ways to implement EHR & EMR systems.

We can use a trial run system for a senior doctor. One can provide assistance to senior

doctors in entering data and getting familiar with system. A full time employee who

will help doctors in understanding the system and getting him acquainted to new

technology. This trial run can go on for six months.

The physicians lack the customer orientation, understanding of technologies and skills

of creating a new enterprise. This one of the reasons doctors cannot think in that

direction. The large hospitals like Hiranandani Hospital, Apollo Hospitals, Fortis,

Narayana Hrudalaya are among those hospitals had a leader who could take tough

decisions. These leaders have basic understanding that technology will drive the

future. Another need of the hour is the change in culture of customer orientation and

perceptions that lead to adoption of EMR as technology.

4.2. Organizational LevelThe organization culture is a critical factor to support technological adoption.

However, there are various organizational factors which hinder the EMR/EHR

adoption in many hospitals. They include return on investment, technology

adaptation, and incentives or promotions to employees. It’s the need of the hour to

focus on these factors by designing a innovative financial strategy that would help

hospitals for easier adaptation.

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4.3. Macro Economical LevelThe adoption of EMR/EHRs is based on the cost effectiveness of economical

incentives to doctors and innovation of the devices. In terms of economical factors,

failures to understand the full capability of the EMR/EHR system will restraint the

implementation in health organization. When considering the socio-cultural factors,

the values and belief system will influence the adoption of this new system.

5. ADOPTION METHODOLOGIESConsidering various issues from management level, we addressed certain adoption

methodologies to design a plan to be followed in future for effective implementation

of EMR/EHR in a number of hospitals. Some of the ways in which we can project the

EMR/EHR advantages and effectiveness if implemented are discussed below.

i. Generalized Linear Model

A generalized linear model will give a better estimate to analyze the success rates by

comparing the hospitals which adopted EMR/EHR in their hospitals to those hospitals

which didn’t implement. This is done by comparing the outcomes for the two years

before and two years after the year of EMR adoption for various hospitals. The data

thus obtained can be further analyzed by two methodologies. First method draws light

into the quarter on quarter outcome comparison for the period before and after EMR

adoption among hospitals that adopted EMR. Second, we compare the hospitals that

adopted EMR to those that did not, before and after adoption of EMR.

ii. Phase By Phase Implementation

Another methodology is to implement EMR/EHR in phases with the help of a 5 year

support plan by organizing EMR committees in the hospitals. This phase by phase

implementation helps in gaining more trust and confidence among the management

towards the implementation since the perceived risks associated with the service they

offer is less. Moreover the cost incurred would also be in stages of smaller amounts

rather than in one-time payment of large sum.

iii. Incentive Plans

It was observed that the delay is EMR/EHR adoption is caused by lack of incentives

to hospital staff which is acting as a de-motivating factor to move ahead in technology

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era. Therefore, incentive programs can be included in the adoption program to

increase the success rates.

6. ALTERNATIVES FOR EMR/EHR ADOPTIONWe propose two alternatives which will increase the number of hospitals adopting the

EMR/EHR in the hospitals.

Plan 1: One-Time Full Payment Model

Paying the entire amount to the EMR/EHR supplier wherein maintenance and support

services are not included as a part of purchase. These support and maintenance

services can be availed at a fee as and when they are rendered. Apart from these

services, trainings program will be conducted a minimal cost to the hospital staff (IT-

staff, Doctors, Nurses and Technicians). Since the one-time payment involves large

capital outflow from the hospital management, the probability of reluctance to

adopting the EMR/EHR would be more. To cater to this issue, financial support and

schemes from various financial institutions should be provided to better inform them

about the available options with them. Internally for the EMR/EHR supplier should

maintain tie-ups with financial institutions. These tie-ups help reap more benefits out

of the business as and when the business grows.

Plan 2: Subscription Fee Model

Unlike the one-time full payment model, here the systems and devices can be bought

with subscription fee wherein maintenance and support services are included as a part

of the purchase. Here the hospital management doesn’t have to shed out a huge

amount as investment in the EMR/EHR system. Rather they only need to pay a small

amount as subscription fee for the usage of the system. Furthermore, training program

to the hospital personnel can be availed at free of cost. These factors are already

considered in the subscription fee that is charged.

7. IMPLEMENTATION PLAN OF EMR/EHRBased on the alternative options and adoption methodologies, the implementation of

EMR/EHR can be divided into two phases as follows. This plan might give better

results for the problem we have identified.

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Phase 1: Developing EMR/EHR adoption plan

1. Delegate the implementation responsibility to the top management in

organization hierarchy.

2. Create a Budget plan

3. Provide training to hospital personnel by the vendors. This training can be

extended to operating and examination room for the staff to become familiar

with the functioning of the device.

Phase 2: Organize internal EMR Committee

1. Transition from paper based medical records to EMR/EHR

Hospitals can comply with the Government/State requirements for storing or

destruction of medical records. This notion can be taken forward by scanning all

the paper records and later shred the paper records.

2. Increase the number of IT supported staff for management and for guidance to

the hospitals. Though the recruitment of IT staff incurs an additional cost, this

cost can be nullified from the future returns.

3. Hardware decisions for the system would depend upon the alternative the

management chooses to implement. Either the hardware requirements can be

bought out completely or some hardware choices can be on the subscription

basis. This also depends upon the scale and size of the implementation. If the

hospitals cater to large pool of patients then the hardware requirements and

capacity requirements increases and thus the cost too. But it is also seen that the

hospitals which cater to larger patient pool is better off than a hospital of lower

patient pool.

4. Support activities after going live is another key aspect in the system. This also

depends on the alternative chosen by the management. The support can be either

constant as with the subscription model or requirement based as per the one time

full payment model. The plan addresses the support activities for 5 years at

minimal cost to the management. This helps in mentoring/coaching the staffs in

various technological advancement and trending practices followed across the

globe. These kinds of initiatives are also helpful to the EMR/EHR suppliers

since it would create opportunities for close interaction with the clients for them

and would be easy to identify their needs and requirements.

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8. CONCLUSIONFrom our research and analysis, we found that there is a huge scope in health sector in

India to implement EMR/EHRs. Although the demand for EMR/EHRs is not

currently high, the successful establishment would benefit the nation. As per our

analysis and findings, we found various challenges for successful implementation of

EMR/EHRs. They include suppliers cost, training cost, maintenance, and

infrastructure issues. Our survey and in-depth interview with physicians also showed

that primary concern is software and hardware costs as they will shell out the revenue.

As a result, various adoption methodologies are designed through which a plan is

proposed to be implemented in phases. This plan will help many hospitals in India to

understand the benefits of EMR/EHRs for implementation.

9. LEARNINGS1. The management of various hospitals believes even though the required capital is

available to implement EMR/EHR, they are skeptical about the return on

investment.

2. Government can play a vital role in helping the hospitals to manage the transition

from paper based medical records to EMR/EHR.

3. IT in the health industry is slow in India when compared to other industries.

4. The demand for EMR/EHR is not very high in hospitals in India.

5. Management is not ready to provide any incentives for doctors who implemented

6. Management is facing budgeting issues for adopting new EMR/EHR technology

in their hospitals.

10. SELF-ASSESSMENTDuring our initial research we understood that there weren’t many threats for

introducing EMR/EHR in hospitals. However, in the later phase of our research we

found that there were various major reasons behind failure in implementation of

EMR/EHRs in hospitals. All objectives weren’t met because there are major

management and government issues which have to be addressed in-depth. After the

key findings from various doctors and hospitals, 7/10 problems were addressed. We

came up with various adoption methodologies from which a plan is designed to

successfully implement in various hospitals.

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Rank for reaching objectives:

To find various challenges for EMR/EHR introduction – 7

To overcome the threats for implementing EMR/EHR in various hospitals - 6

To find adoption methodologies for EMR/EHR implementation – 7.5

To develop a plan to reach wider range of hospitals – 6.5

References

http://www.hospitalinformationsystem.com/

http://www.healthit.gov/

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