EHR Implementation in a New Clinic: A Case Study of Clinician Perceptions

The role of information systems in emergency department decision-making-a literature review

OBJECTIVES

Healthcare providers employ heuristic and analytical decision-making to navigate the high-stakes environment of the emergency department (ED). Despite the increasing integration of information systems (ISs), research on their efficacy is conflicting. Drawing on related fields, we investigate how timing and mode of delivery influence IS effectiveness. Our objective is to reconcile previous contradictory findings, shedding light on optimal IS design in the ED.

MATERIALS AND METHODS

We conducted a systematic review following PRISMA across PubMed, Scopus, and Web of Science. We coded the ISs' timing as heuristic or analytical, their mode of delivery as active for automatic alerts and passive when requiring user-initiated information retrieval, and their effect on process, economic, and clinical outcomes.

RESULTS

Our analysis included 83 studies. During early heuristic decision-making, most active interventions were ineffective, while passive interventions generally improved outcomes. In the analytical phase, the effects were reversed. Passive interventions that facilitate information extraction consistently improved outcomes.

DISCUSSION

Our findings suggest that the effectiveness of active interventions negatively correlates with the amount of information received during delivery. During early heuristic decision-making, when information overload is high, physicians are unresponsive to alerts and proactively consult passive resources. In the later analytical phases, physicians show increased receptivity to alerts due to decreased diagnostic uncertainty and information quantity. Interventions that limit information lead to positive outcomes, supporting our interpretation.

CONCLUSION

We synthesize our findings into an integrated model that reveals the underlying reasons for conflicting findings from previous reviews and can guide practitioners in designing ISs in the ED.

Benefits, facilitators, and barriers of electronic medical records implementation in outpatient settings: A scoping review

This scoping review examined the breadth and depth of evidence on Electronic Medical Record (EMR) implementation benefits in outpatient settings. Following PRISMA guidelines for scoping reviews, five databases were searched, and 24 studies were retained and reviewed. Benefits, facilitators, and barriers to EMR implementation were extracted. Direct benefits included improved communication/reporting, work efficiency, care process, healthcare outcomes, safety, and patient-centredness of care. Indirect benefits were improved financial performance and increased data accessibility, staff satisfaction, and decision-support usage. Barriers included time and financial constraints; design/technical issues; limited information technology resources, skills, and infrastructure capacity; increased workload and reduced efficiency during implementation; incompatibility of existing systems and local regulations; and resistance from healthcare professionals. Facilitators included training, change management, user-friendliness and alignment with workflow, user experience with EMRs, top management support, and sufficient resources. More rigorous, systematic research is needed, using relevant frameworks to inform healthcare policies and guide EMR projects in outpatient areas.

Management Opportunities and Challenges After Achieving Widespread Health System Digitization

The adoption of electronic health records (EHRs) and digitization of health data over the past decade is ushering in the next generation of digital health tools that leverage artificial intelligence (AI) to improve varied aspects of health system performance. The decade ahead is therefore shaping up to be one in which digital health becomes even more at the forefront of health care delivery - demanding the time, attention, and resources of health care leaders and frontline staff, and becoming inextricably linked with all dimensions of health care delivery. In this chapter, we look back and look ahead. There are substantive lessons learned from the first era of large-scale adoption of enterprise EHRs and ongoing challenges that organizations are wrestling with - particularly related to the tension between standardization and flexibility/customization of EHR systems and the processes they support. Managing this tension during efforts to implement and optimize enterprise systems is perhaps the core challenge of the past decade, and one that has impeded consistent realization of value from initial EHR investments. We describe these challenges, how they manifest, and organizational strategies to address them, with a specific focus on alignment with broader value-based care transformation. We then look ahead to the AI wave - the massive number of applications of AI to health care delivery, the expected benefits, the risks and challenges, and approaches that health systems can consider to realize the benefits while avoiding the risks.

The appropriateness of clinical decision support systems alerts in supporting clinical workflows: A systematic review

A CDSS generates a high number of inappropriate alerts that interrupt the clinical workflow. As a result, clinicians silence, disable, or ignore alerts, thereby undermining patient safety. Therefore, the effectiveness and appropriateness of CDSS alerts need to be evaluated. A systematic review was carried out to identify the factors that affect CDSS alert appropriateness in supporting clinical workflow. Seven electronic databases (PubMed, Scopus, ACM, Science Direct, IEEE, Ovid Medline, and Ebscohost) were searched for English language articles published between 1997 and 2018. Seventy six papers met the inclusion criteria, of which 26, 24, 15, and 11 papers are retrospective cohort, qualitative, quantitative, and mixed-method studies, respectively. The review highlights various factors influencing the appropriateness and efficiencies of CDSS alerts. These factors are categorized into technology, human, organization, and process aspects using a combination of approaches, including socio-technical framework, five rights of CDSS, and Lean. Most CDSS alerts were not properly designed based on human factor methods and principles, explaining high alert overrides in clinical practices. The identified factors and recommendations from the review may offer valuable insights into how CDSS alerts can be designed appropriately to support clinical workflow.

Modeling patient-related workload in the emergency department using electronic health record data

INTRODUCTION

Understanding and managing clinician workload is important for clinician (nurses, physicians and advanced practice providers) occupational health as well as patient safety. Efforts have been made to develop strategies for managing clinician workload by improving patient assignment. The goal of the current study is to use electronic health record (EHR) data to predict the amount of work that individual patients contribute to clinician workload (patient-related workload).

METHODS

One month of EHR data was retrieved from an emergency department (ED). A list of workload indicators and five potential workload proxies were extracted from the data. Linear regression and four machine learning classification algorithms were utilized to model the relationship between the indicators and the proxies.

RESULTS

Linear regression proved that the indicators explained a substantial amount of variance of the proxies (four out of five proxies were modeled with R² > 0.80). Classification algorithms also showed success in classifying a patient as having high or low task demand based on data from early in the ED visit (e.g. 80 % accurate binary classification with data from the first hour).

CONCLUSION

The main contribution of this study is demonstrating the potential of using EHR data to predict patient-related workload automatically in the ED. The predicted workload can potentially help in managing clinician workload by supporting decisions around the assignment of new patients to providers. Future work should focus on identifying the relationship between workload proxies and actual workload, as well as improving prediction performance of regression and multi-class classification.

Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content

Despite the great advances in the field of electronic health records (EHRs) over the past 25 years, implementation and adoption challenges persist, and the benefits realized remain below expectations. This scoping review aimed to present current knowledge about the effects of EHR implementation and the barriers to EHR adoption and use. A literature search was conducted in PubMed, Web of Science, IEEE Xplore Digital Library and ACM Digital Library for studies published between January 2005 and May 2020. In total, 7641 studies were identified of which 142 met the criteria and attained the consensus of all researchers on inclusion. Most studies (n = 91) were published between 2017 and 2019 and 81 studies had the United States as the country of origin. Both positive and negative effects of EHR implementation were identified, relating to clinical work, data and information, patient care and economic impact. Resource constraints, poor/insufficient training and technical/educational support for users, as well as poor literacy and skills in technology were the identified barriers to adoption and use that occurred frequently. Although this review did not conduct a quality analysis of the included papers, the lack of uniformity in the use of EHR definitions and detailed contextual information concerning the study settings could be observed.

Transitions from One Electronic Health Record to Another: Challenges, Pitfalls, and Recommendations

OBJECTIVE

We address the challenges of transitioning from one electronic health record (EHR) to another-a near ubiquitous phenomenon in health care. We offer mitigating strategies to reduce unintended consequences, maximize patient safety, and enhance health care delivery.

METHODS

We searched PubMed and other sources to identify articles describing EHR-to-EHR transitions. We combined these references with the authors' extensive experience to construct a conceptual schema and to offer recommendations to facilitate transitions.

RESULTS

Our PubMed query retrieved 1,351 citations: 43 were relevant for full paper review and 18 met the inclusion criterion of focus on EHR-to-EHR transitions. An additional PubMed search yielded 1,014 citations, for which we reviewed 74 full papers and included 5. We supplemented with additional citations for a total of 70 cited. We distinguished 10 domains in the literature that overlap yet present unique and salient opportunities for successful transitions and for problem mitigation.

DISCUSSION

There is scant literature concerning EHR-to-EHR transitions. Identified challenges include financial burdens, personnel resources, patient safety threats from limited access to legacy records, data integrity during migration, cybersecurity, and semantic interoperability. Transition teams must overcome inadequate human infrastructure, technical challenges, security gaps, unrealistic providers' expectations, workflow changes, and insufficient training and support-all factors affecting potential clinician burnout.

CONCLUSION

EHR transitions are remarkably expensive, laborious, personnel devouring, and time consuming. The paucity of references in comparison to the topic's salience reinforces the necessity for this type of review and analysis. Prudent planning may streamline EHR transitions and reduce expenses. Mitigating strategies, such as preservation of legacy data, managing expectations, and hiring short-term specialty consultants can overcome some of the greatest hurdles. A new medical subject headings (MeSH) term for EHR transitions would facilitate further research on this topic.

Health Outcomes and Healthcare Efficiencies Associated with the Use of Electronic Health Records in Hospital Emergency Departments: a Systematic Review

Healthcare organisations and governments have invested heavily in electronic health records in anticipation that they will deliver improved health outcomes for consumers and efficiencies across emergency departments. Despite such investment, electronic health records designed to support emergency care have been poorly evaluated. Given the accelerated development and adoption of information technology across healthcare, it is timely that a systematic review of this evidence base is updated in order to drive improvements to design, interoperability and overall clinical utility of electronic health record systems implemented in emergency departments. To assess the impact of electronic health records on healthcare outcomes and efficiencies in the emergency department we carried out a systematic review of published studies on this topic. This is the first review to summarise the cost efficiencies associated with electronic health record use outside of just the United States of America. A systematic search was performed in three scientific databases (MEDLINE, EMcare and EMBASE), of literature published between January 2000 and September 2019. Studies were included in this review if they evaluated electronic health records or health information exchanges (and synonyms for these terms), reported patient outcome and/or healthcare efficiency benefits, were peer-reviewed and published in English. Out of 6635 articles, 23 studies met our inclusion criteria. Wide variation regarding electronic health record access in the emergency department was reported (1.46-56.6%), yet was most frequently reported as less than 20%. Seven different types of health outcomes and three different types of efficiency improvements associated with electronic health record use in the emergency department were identified. The most frequently reported findings were efficiencies, including reductions in diagnostic tests, imaging and costs. This review is the first to report moderate to significant increases in admission rates are associated with electronic health record use in the emergency department, contrasting the findings of previous reviews. Diversity in the methodology employed across the included studies emphasises the need for further research to examine the impact of electronic health record implementation and system design on the findings reported, in order to ensure return on investment for stakeholders and optimised consumer care.

Evaluation of Electronic Health Record Implementation in an Academic Oculoplastics Practice

PURPOSE

Despite increasing electronic health record (EHR) adoption, perceptions of EHRs are negative among ophthalmologists due to concerns about productivity, costs, and documentation. The authors evaluated the effects of EHR adoption in an oculoplastics practice, which had not been previously studied.

METHODS

Clinical volume, documentation time, time spent with patients, reimbursement, relative value units, and patient satisfaction were examined for 2 academic oculoplastics attendings between April 2018 and April 2019, with EHR implementation in September 2018.

RESULTS

The mean number of patients seen in a half-day clinic was 31.8 versus 27.7 (p = 0.018) pre- and post-EHR implementation, respectively. EHR implementation had no effect on total monthly reimbursement (p = 0.88) or total monthly relative value units (p = 0.54). Average reimbursement (p = 0.004) and relative value units (p = 0.001) per patient encounter were significantly greater with EHR use. Patient satisfaction scores improved (p = 0.018). Mean physician time per patient increased from 6.4 to 9.0 minutes (p < 0.001). Mean documentation time per patient increased from 1.7 to 3.6 minutes (p < 0.001). Average patient wait times decreased by 9 minutes (p = 0.03) with EHR use. No scribes were used.

CONCLUSIONS

EHR implementation was associated with decreased patient volume without significant differences in total reimbursement. Although EHR adoption was associated with increased physician time devoted to patients and greater time expenditure on documentation, patients experienced decreased wait times. This suggests that EHR use streamlined the overall clinic flow without sacrificing physicians' time with the patient. The author's findings suggest that EHR implementation can be accomplished in an academic oculoplastics setting without negative impact on patient experience or reimbursement considerations.

Overlaying multiple sources of data to identify bottlenecks in clinical workflow

The pursuit of increased efficiency and quality of clinical care based on the analysis of workflow has seen the introduction of several modern technologies into medical environments. Electronic health records (EHRs) remain central to analysis of workflow, owing to their wide-ranging impact on clinical processes. The two most common interventions to facilitate EHR-related workflow analysis are automated location tracking using sensor-based technologies and EHR usage data logs. However, to maximize the potential of these technologies, and especially to facilitate workflow redesign, it is necessary to overlay these quantitative findings on the contextual data from qualitative methods such as ethnography. Such a complementary approach promises to yield more precise measures of clinical workflow that provide insights into how redesign could address inefficiencies. In this paper, we categorize clinical workflow in the Emergency Department (ED) into three types (perceived, real and ideal) to create a structured approach to workflow redesign using the available data. We use diverse data sources: sensor-based location tracking through Radio-Frequency Identification (RFID), summary EHR usage data logs, and data from physician interviews augmented by direct observations (through clinician shadowing). Our goal is to discover inefficiencies and bottlenecks that can be addressed to achieve a more ideal workflow state relative to its real and perceived state. We thereby seek to demonstrate a novel data-driven approach toward iterative workflow redesign that generalizes for use in a variety of settings. We also propose types of targeted support or adjustments to offset some of the inefficiencies we noted.

A prospective investigation of direct and indirect home care activities in three rural Norwegian municipalities

BACKGROUND

Home care providers struggle to manage their day-to-day work, which is increasing in volume and complexity. In general, they are expected to achieve more with the same planning methods, resources, and capacity. To meet emerging needs and use the available resources more effectively and efficiently, evidence and strategies are needed to inform planning methods for home care services. However, limited data are available to inform this change. This paper investigated the amount of time used to carry out direct activities and six indirect activities across three rural Norwegian municipalities (M1, M2 and M3).

METHODS

Home care staff recorded data over 8 weeks in 2016; the majority of the staff used a smartphone application and some staff used a manual form to report the durations of the activities.

RESULTS

The median time spent on direct activities was 11-13 min, and this work constituted less than 50% of the total work in the three municipalities. The median driving time was 5-7 min, which accounted for 43-54% of the total indirect work. Administration, particularly reporting and documentation, displayed greater differences across the municipalities, together accounting for 38-50% of the total indirect time. M2 and M3 used substantially more time for documentation, including 20 min in M2 and M3, in contrast to only 1 min in M1. Similarly, the median reporting times were 30 min (M2) and 28 min (M3), compared with only 17 min in M1.

CONCLUSIONS

Home care staff spent less time on direct activities than on indirect activities, of which several activities have the potential for change. These results may help managers utilize resources effectively and plan appropriately, and they may also serve as a basis for future research to identify areas with improvement opportunities and, in turn, make more time available for direct patient care.

E-health in Switzerland: The laborious adoption of the federal law on electronic health records (EHR) and health information exchange (HIE) networks

Within the framework of a broader e-health strategy launched a decade ago, in 2015 Switzerland passed a new federal law on patients' electronic health records (EHR). The reform requires hospitals to adopt interoperable EHRs to facilitate data sharing and cooperation among healthcare providers, ultimately contributing to improvements in quality of care and efficiency in the health system. Adoption is voluntary for ambulatories and private practices, that may however be pushed towards EHRs by patients. The latter have complete discretion in the choice of the health information to share. Moreover, careful attention is given to data security issues. Despite good intentions, the high institutional and organisational fragmentation of the Swiss healthcare system, as well as the lack of full agreement with stakeholders on some critical points of the reform, slowed the process of adoption of the law. In particular, pilot projects made clear that the participation of ambulatories is doomed to be low unless appropriate incentives are put in place. Moreover, most stakeholders point at the strategy proposed to finance technical implementation and management of EHRs as a major drawback. After two years of intense preparatory work, the law entered into force in April 2017.

How electronic health records can unmask the hidden value of PAs

The Fee for Value (FFV) Task Force, a subgroup of the American Academy of PAs' Research and Strategic Initiatives Commission, has examined tools and mechanisms aimed at better clarifying the volume and value of PA work and how that work contributes to improving access to high-quality care. Establishing the value of PAs has been a challenging task for many healthcare providers. Often, PA value has been defined by their clinical productivity, without any clear direction as to what constitutes value versus productivity. The objective of this article is to unmask the value of PAs through the role of electronic health records and highlight PAs' ability to produce services that are value-oriented and quantifiably productive.

Participants' perceptions of an intervention implemented in an Action Research Nursing Documentation Project

AIMS AND OBJECTIVES

The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway.

BACKGROUND

Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue.

DESIGN

A qualitative descriptive design was used.

METHODS

An action research project was conducted between 2010-2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used.

RESULTS

Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success.

CONCLUSIONS

Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of electronic health record systems, and on the role of leadership when implementing changes in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Stronger cooperation among policymakers, electronic health record system vendors, and healthcare professionals is essential for improving electronic health record systems and documentation practices. Involvement of end-users in these improvements can make a difference in the way the systems are perceived in the clinical workflow.

Exploring the potential of social networking sites for public service professionals

Social networking sites (SNSs) have established an important presence in our daily lives and at work. This study explores how public service professionals use SNSs and how they perceive the potential of SNSs. This study further examines the relationship between the use of SNSs and social trust and civic participation. Last, this study identifies the challenges and opportunities facing public administration practitioners who use SNSs to build collaboration and promote public interests. Based on the nationwide survey results, this study provides a broader understanding of SNS use among public service professionals. Furthermore, it also provides management recommendations on how public service professionals can make full use of SNSs to facilitate their interactions with other public service professionals and citizens, and foster collaboration to pursue public interests.

Use of electronic medical records and quality of patient data: different reaction patterns of doctors and nurses to the hospital organization

BACKGROUND

As the implementation of Electronic Medical Records (EMRs) in hospitals may be challenged by different responses of different user groups, this paper examines the differences between doctors and nurses in their response to the implementation and use of EMRs in their hospital and how this affects the perceived quality of the data in EMRs.

METHODS

Questionnaire data of 402 doctors and 512 nurses who had experience with the implementation and the use of EMRs in hospitals was analysed with Multi group Structural equation modelling (SEM). The models included measures of organisational factors, results of the implementation (ease of use and alignment of EMR with daily routine), perceived added value, timeliness of use and perceived quality of patient data.

RESULTS

Doctors and nurses differ in their response to the organisational factors (support of IT, HR and administrative departments) considering the success of the implementation. Nurses respond to culture while doctors do not. Doctors and nurses agree that an EMR that is easier to work with and better aligned with their work has more added value, but for the doctors this is more pronounced. The doctors and nurses perceive that the quality of the patient data is better when EMRs are easier to use and better aligned with their daily routine.

CONCLUSIONS

The result of the implementation, in terms of ease of use and alignment with work, seems to affect the perceived quality of patient data more strongly than timeliness of entering patient data. Doctors and nurses value bottom-up communication and support of the IT department for the result of the implementation, and nurses respond to an open and innovative organisational culture.

Patient-centered communication in the era of electronic health records: What does the evidence say?

OBJECTIVE

Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known.

METHOD

A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis.

RESULTS

Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management.

CONCLUSION

More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care.

PRACTICE IMPLICATIONS

Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians' and patients' abilities to effectively communicate.

Leveraging Electronic Health Record Implementation to Facilitate Clinical and Operational Quality Improvement in an Ambulatory Surgical Clinic

The implementation of electronic health records is a challenging, complex process requiring significant resources. The temptation is to convert a paper process into electronic format. This strategy fosters a familiar product to the users but is fraught with pitfalls. We chose to utilize the opportunity of the implementation of an enterprise-wide ambulatory electronic health record to foster an overreaching clinical and operational improvement project in a multispecialty surgical ambulatory clinic practice. We interrogated every aspect of the practice: clinic design, scheduling, physical space, staffing, and clinical and operational workflows. We present here the results of a 3-year process improvement.

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

OBJECTIVES

A key element of the implementation and ongoing use of an electronic prescribing (ePrescribing) system is ensuring that users are, and remain, sufficiently trained to use the system. Studies have suggested that insufficient training is associated with suboptimal use. However, it is not clear from these studies how clinicians are trained to use ePrescribing systems or the effectiveness of different approaches. We sought to describe the various approaches used to train qualified prescribers on ePrescribing systems and to identify whether users were educated about the pitfalls and challenges of using these systems.

METHODS

We performed a literature review, using a systematic approach across three large databases: Cumulative Index Nursing and Allied Health Literature, Embase and Medline were searched for relevant English language articles. Articles that explored the training of qualified prescribers on ePrescribing systems in a hospital setting were included.

KEY FINDINGS

Our search of 'all training' approaches returned 1155 publications, of which seven were included. A separate search of 'online' training found three relevant publications. Training methods in the 'all training' category included clinical scenarios, demonstrations and assessments. Regarding 'online' training approaches; a team at the University of Victoria in Canada developed a portal containing simulated versions of electronic health records, where individuals could prescribe for fictitious patients. Educating prescribers about the challenges and pitfalls of electronic systems was rarely discussed.

CONCLUSIONS

A number of methods are used to train prescribers; however, the lack of papers retrieved suggests a need for additional studies to inform training methods.

How organizational escalation prevention potential affects success of implementation of innovations: electronic medical records in hospitals

BACKGROUND

Escalation of commitment is the tendency that (innovation) projects continue, even if it is clear that they will not be successful and/or become extremely costly. Escalation prevention potential (EPP), the capability of an organization to stop or steer implementation processes that do not meet their expectations, may prevent an organization of losing time and money on unsuccessful projects. EPP consists of a set of checks and balances incorporated in managerial practices that safeguard management against irrational (but very human) decisions and may limit the escalation of implementation projects. We study whether successful implementation of electronic medical records (EMRs) relates to EPP and investigate the organizational factors accounting for this relationship.

METHODS

Structural equation modelling (SEM), using questionnaire data of 427 doctors and 631 nurses who had experience with implementation and use of EMRs in hospitals, was applied to study whether formal governance and organizational culture mediate the relationship between EPP and the perceived added value of EMRs.

RESULTS

Doctors and nurses in hospitals with more EPP report more successful implementation of EMR (in terms of perceived added value of the EMR). Formal governance mediates the relation between EPP and implementation success. We found no evidence that open or innovative culture explains the relationship between EPP and implementation success.

CONCLUSIONS

There is a positive relationship between the level of EPP and perceived added value of EMRs. This relationship is explained by formal governance mechanisms of organizations. This means that management has a set of tangible tools to positively affect the success of innovation processes. However, it also means that management needs to be able to critically reflect on its (previous) actions and decisions and is willing to change plans if elements of EPP signal that the implementation process is hampered.

Cost-Effectiveness Evaluation of EHR: Simulation of an Abdominal Aortic Aneurysm in the Emergency Department

Health care organizations have installed electronic systems to increase efficiency in health care. Empirically assessing the cost-effectiveness of technologies to the health care system is a challenging and complex task. This study examined cost-effectiveness of additional clinical information supplied via an EHR system by simulating a case of abdominal aortic aneurysm devised and acted professionally by the Israel Center of Medical Simulation. We conducted a simulation-based study on physicians who were asked to treat a simulated patient for the prevalent medical scenario of hip and leg pain that actually corresponded to an abdominal aortic aneurysm. Half of the participating physicians from the Department of Emergency Medicine at Tel-Hashomer Hospital - Israel's largest - had access to an EHR system that integrates medical data from multiple health providers (community and hospitals) in addition to the local health record, and half did not. To model medical decision making, the results of the simulation were combined with a Markov Model within a decision tree. Cost-effectiveness was analyzed by comparing the effects of the admission/discharge decision in units of quality adjusted life years (QALYs) to the estimated costs. The results showed that using EHR in the ED increases the QALY of the patient and improves medical decision-making. The expenditure per patient for one QALY unit as a result of using the EHR was $1229, which is very cost-effective according to many accepted threshold values (less than all these values). Thus, using the EHR contributes to making a cost-effective decision in this specific but prevalent case.

Unintended adverse consequences of electronic health record introduction to a mature universal HIV screening program

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline (p < 0.0001), leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

The effect of electronic medical record application on the length of stay in a Chinese general hospital: a department- and disease-focused interrupted time-series study

A key purpose of electronic medical records (EMR) introduced in medical institutions is to improve work efficiency. The average length of stay (LOS) is just an important indicator to evaluate work efficiency of medical care in hospitals. Recently, there have been reports about effects of EMR application on LOS in medical institutions, but they have been mostly based on the overall analysis of a region or a hospital and not of specific clinical departments and diseases or based on longer time periods. Therefore, in this study, we selected four clinical departments and four diseases with the largest number of inpatients from January 2004 to December 2012 in a Chinese 3A general hospital and used an interrupted time-series method by the departments and diseases to analyze the relationship of EMR application and LOS. Through our analyses, we concluded that, under unadjusted condition, LOS were all reduced (P < 0.001) after EMR application in four departments and for four diseases. After adjustment by gender, age or admission condition, LOS still all decreased after EMR application (P < 0.05) regardless of departments or diseases. The trend changes in LOS reversed from increasing to decreasing in the orthopedics department (coefficient: 0.016 to -0.079), the cardiovascular surgery department (coefficient: 0.007 to -0.126) and all departments overall (coefficient: 0.004 to -0.070), as well as for the intervertebral disc disorders (coefficient: 0.026 to -0.068). Furthermore, the decreasing trend gained a larger slope in the cardiology department (coefficient: -0.017 to -0.023), the neurology department (coefficient: -0.012 to -0.043) and for the coronary heart disease (coefficient: -0.010 to -0.018), the ventricular septal defect (coefficient: -0.024 to -0.059), and the cerebral infarction (coefficient: -0.031 to -0.040). Together, these findings indicate that EMR application coincided with a decrease in LOS and may have a contribution to the decrease.