Electronic medical record implementation in the emergency department in a low-resource country: Lessons learned

OBJECTIVE

There is paucity of information regarding electronic medical record (EMR) implementation in emergency departments in countries outside the United States especially in low-resource settings. The objective of this study is to describe strategies for a successful implementation of an EMR in the emergency department and to examine the impact of this implementation on the department's operations and patient-related metrics.

METHODS

We performed an observational retrospective study at the emergency department of a tertiary care center in Beirut, Lebanon. We assessed the effect of EMR implementation by tracking emergency departments' quality metrics during a one-year baseline period and one year after implementation. End-user satisfaction and patient satisfaction were also assessed.

RESULTS

Our evaluation of the implementation of EMR in a low resource setting showed a transient increase in LOS and visit-to-admission decision, however this returned to baseline after around 6 months. The bounce-back rate also increased. End-users were satisfied with the new EMR and patient satisfaction did not show a significant change.

CONCLUSIONS

Lessons learned from this successful EMR implementation include a mix of strategies recommended by the EMR vendor as well as specific strategies used at our institution. These can be used in future implementation projects in low-resource settings to avoid disruption of workflows.

Documentation Completeness and Nurses' Perceptions of a Novel Electronic App for Medical Resuscitation in the Emergency Room: Mixed Methods Approach

BACKGROUND

Complete documentation of critical care events in the accident and emergency department (AED) is essential. Due to the fast-paced and complex nature of resuscitation cases, missing data is a common issue during emergency situations.

OBJECTIVE

This study aimed to evaluate the impact of a tablet-based resuscitation record on documentation completeness during medical resuscitations and nurses' perceptions of the use of the tablet app.

METHODS

A mixed methods approach was adopted. To collect quantitative data, randomized retrospective reviews of paper-based resuscitation records before implementation of the tablet (Pre-App Paper; n=176), paper-based resuscitation records after implementation of the tablet (Post-App Paper; n=176), and electronic tablet-based resuscitation records (Post-App Electronic; n=176) using a documentation completeness checklist were conducted. The checklist was validated by 4 experts in the emergency medicine field. The content validity index (CVI) was calculated using the scale CVI (S-CVI). The universal agreement S-CVI was 0.822, and the average S-CVI was 0.939. The checklist consisted of the following 5 domains: basic information, vital signs, procedures, investigations, and medications. To collect qualitative data, nurses' perceptions of the app for electronic resuscitation documentation were obtained using individual interviews. Reporting of the qualitative data was guided by Consolidated Criteria for Reporting Qualitative Studies (COREQ) to enhance rigor.

RESULTS

A significantly higher documentation rate in all 5 domains (ie, basic information, vital signs, procedures, investigations, and medications) was present with Post-App Electronic than with Post-App Paper, but there were no significant differences in the 5 domains between Pre-App Paper and Post-App Paper. The qualitative analysis resulted in main categories of "advantages of tablet-based documentation of resuscitation records," "challenges with tablet-based documentation of resuscitation records," and "areas for improvement of tablet-based resuscitation records."

CONCLUSIONS

This study demonstrated that higher documentation completion rates are achieved with electronic tablet-based resuscitation records than with traditional paper records. During the transition period, the nurse documenters faced general problems with resuscitation documentation such as multitasking and unique challenges such as software updates and a need to familiarize themselves with the app's layout. Automation should be considered during future app development to improve documentation and redistribute more time for patient care. Nurses should continue to provide feedback on the app's usability and functionality during app refinement to ensure a successful transition and future development of electronic documentation records.

How Can Out-of-Hospital Cardiac Arrest (OHCA) Data Collection in Slovenia Be Improved?

Background and Objectives: The prevalence of out-of-hospital cardiac arrest (OHCA) has been established as a significant contributor to mortality rates in developed nations. Due to the challenges associated with conducting controlled randomized trials, there exists a necessity for the collection of high-quality data to enhance the comprehension of the impact of interventions. Several nations have initiated efforts to gather information pertaining to out-of-hospital cardiac arrest (OHCA). The Republic of Slovenia has been collecting data from interventions; however, the variables and data attributes have not yet been standardized to comply with international standards. This lack of conformity poses a challenge in making comparisons or drawing inferences. The aim of this study is to identify how to better gather OHCA data in Slovenia. Materials and methods: The Utstein resuscitation registry protocol (UP) was compared to the Slovenian data points that must be gathered in accordance with the Rules on Emergency Medical Service (REMS) during interventions. In addition, we have proposed alternative measures of digitization to enhance pre-hospital data. Results: Missing data points and attribute mismatches were detected in Slovenia. Eight data points necessitated by the UP are gathered in several databases (hospitals, the National Institute of Public Health, dispatch services, intervention reports from first responders, and defibrillator files), but not in the mandated protocols based on REMS. Two data points have variables that do not match those of the UP. A total of 16 data points according to UP are currently not being collected in Slovenia. The advantages and potential drawbacks of digitizing emergency medical services have been discussed. Conclusions: The study has identified gaps in the methods employed for collecting data on OHCA in Slovenia. The assessment conducted serves as a basis for enhancing the process of data collection, integrating quality control measures across the nation, and establishing a nationwide registry for out-of-hospital cardiac arrest (OHCA) in Slovenia.

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study

Introduction

To explore the impact of a three-week downtime to an electronic pathology system on patient safety and experience.

Methods

Qualitative study consisting of semi-structured interviews and a focus group at a large NHS teaching hospital in England. Participants included NHS staff (n = 16) who represented a variety of staff groups (doctors, nurses, healthcare assistants) and board members. Data were collected 2–5 months after the outage and were analysed thematically.

Results

We present the implications which the IT breakdown had for both patient safety and patient experience. Whilst there was no actual recorded harm to patients during the crisis, there was strong and divided opinion regarding the potential for a major safety incident to have occurred. Formal guidance existed to assist staff to navigate the outage but there was predominantly a reliance on informal workarounds. Junior clinicians seemed to struggle without access to routine blood test results whilst senior clinicians seemed largely unperturbed. Patient experience was negatively affected due to the extensive wait time for manually processed diagnostic tests, increasing logistical problems for patients.

Conclusion

The potential negative consequences on patient safety and experience relating to IT failures cannot be underestimated. To minimise risks during times of crisis, clear communication involving all relevant stakeholders, and guidance and management strategies that are agreed upon and communicated to all staff are recommended. To improve patient experience flexible approaches to patient management are suggested.

Medical and Undergraduate Student Perceptions on Scribing in an Emergency Department

Background 

A shift towards electronic medical records (EMR) has increased physician burnout and decreased physician satisfaction and productivity. One solution to alleviate EMR stressors is the implementation of medical scribes. Scribes have been shown to increase physician productivity and satisfaction. The study objective was to elucidate medical and undergraduate student scribing experience to determine if that experience can incentivize scribes to work in the emergency department.

Methods 

Ten students scribed and shadowed at a tertiary ED between July 4, 2019, and August 10, 2019. Medical students participated in two scribing and two non-scribing (shadowing) sessions, each lasting four hours. Undergraduate students only had a scribing condition. To facilitate scribing, a laptop with a wireless keyboard was provided, as well as a stand-up laptop tray. 

An exit survey and semi-structured interviews were conducted after the scribing experience. The majority of insights were extracted from interviews. Transcripts were coded into thematic coding trees and analyzed using thematic analysis. 

Results 

All undergraduate students preferred volunteering in the ED over other volunteer experiences. All undergraduates cited direct access to the medical field, resume building, and perceived value added to the health care team as motivators to continue scribing. Most students credited demystification of the medical profession as a motivator. Most medical students felt scribing should be integrated into their curriculum. Based on survey results, five undergraduate students would volunteer 40 hours/week.

Conclusion

Our study showed that a volunteer model of scribing is feasible. Importantly, scribing may be an invaluable experience for directing career goals and ensuring that students intrinsically interested in medicine pursue the profession. Although a volunteer model may not provide the desired benefit in terms of ED efficiency, it may be an integral part of training the next wave of physicians.

Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department

OBJECTIVE

The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework.

MATERIALS AND METHODS

In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system.

RESULTS

Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record.

DISCUSSION

Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses.

CONCLUSION

Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

Technology Perception and Productivity Among Physicians in the New Norm Post-pandemic: A Dynamic Capabilities Perspective

Healthcare service is experiencing a paradigm shift due to the COVID-19 pandemic. The pandemic has caused unprecedented fatalities and taken a toll on medical resources globally. Researchers and healthcare professionals value how data accessibility and analytics can save lives. Developing countries are fast leveraging on the electronic medical record (EMR) system to enhance decision-making effectiveness and patient care. However, for many healthcare professionals, there remain unexplored possibilities of how the use of this ‘normally’ operational-centric EMR might change post-pandemic. We investigate the antecedents (perceived usefulness, perceived ease of use, habit) of the intention to use EMR, and its impact on dynamic capabilities and physician productivity pre- and post-pandemic, focusing on physicians who are at the frontline of Intensive Care Units (ICUs) in Malaysia. This study evidences two significant findings: (1) before the pandemic in the ‘normal’ condition of EMR use, technology perception has significant indirect impact on physician productivity via the key role of dynamic capabilities. However, (2) after the pandemic in the ‘abnormal’ condition, technology perception no longer has any significant impact on physician productivity though their intention to use EMR may have a very weak direct impact on their productivity. A key significant change in the new norm post-pandemic is that dynamic capabilities no longer mediate but strongly and directly impact physician productivity. This direct positive effect is much stronger than before the pandemic. Theoretically, the study is among the first few to integrate perspectives from information systems and dynamic capabilities to examine the impact of EMR use on physician dynamic capabilities for knowledge acquisition and deployment towards enhancing their productivity. The study also offers insights into how a pandemic could accelerate technology perception and contributes to the dynamic use of technology to aid physicians.

Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review

BACKGROUND

The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.

OBJECTIVE

This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.

METHODS

A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.

RESULTS

The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.

CONCLUSIONS

The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

Association between Full Electronic Medical Record System Adoption and Drug Use: Antibiotics and Polypharmacy

Objectives

We investigated associations between full Electronic Medical Record (EMR) system adoption and drug use in healthcare organizations (HCOs) to explore whether EMR system features such as electronic prescribing, medicines reconciliation, and decision support, might be related to drug use by using the relevant nation-wide data.

Methods

The study design was cross-sectional. Survey data of the level of adoption of EMR systems were collected for the Organization for Economic Co-operation and Development benchmarking information and communication technologies (ICT) study between November 2013 and January 2014, in Korea. Survey respondents were hospital chief information officers and medical practitioners in primary care clinics. From the national health insurance administrative dataset, two outcomes, the rate of antibiotic prescription and polypharmacy with ≥6 drugs, were extracted.

Results

We found that full EMR adoption showed a 16.1% lower antibiotic drug prescription than partial adoption including paper-based medical charts in the hospital only (p = 0.041). Between EMR adoption status and polypharmacy prescription, only those clinics which fully adopted EMR showed significant associations with higher polypharmacy prescriptions (36.9%, p = 0.001).

Conclusions

The findings suggested that there might be some confounding effects present and sophisticated ICT may provide some benefits to the quality of care even with some mixed results. Although a negative relationship between full EMR system adoption and antibiotic drug use was only significant in hospitals, EMR system functions searching drugs or listing specific patients might facilitate antibiotic drug use reduction. Positive relationships between full EMR system adoption and polypharmacy rate in general hospitals and clinics, but not hospitals, require further research.

Reduced medical spending associated with increased use of a remote diabetes management program and lower mean blood glucose values

Aims: Many new mobile technologies are available to assist people in managing chronic conditions, but data on the association between the use of these technologies and medical spending remains limited. As the available digital technology offerings to aid in diabetes management increase, it is important to understand their impact on medical spending. The aim of this study was to investigate the financial impact of a remote digital diabetes management program using medical claims and real-time blood glucose data. Materials and methods: A retrospective analysis of multivariate difference-in-difference and instrumental variables regression modeling was performed using data collected from a remote digital diabetes management program. All employees with diabetes were invited, in a phased introduction, to join the program. Data included blood glucose (BG) values captured remotely from members via connected BG meters and medical spending claims. Participants included members (those who accepted the invitation, n = 2,261) and non-members (n = 8,741) who received health insurance benefits from three self-insured employers. Medical spending was compared between people with well-controlled (BG ≤ 154 mg/dL) and poorly controlled (BG > 154 mg/dL) diabetes. Results: Program access was associated with a 21.9% (p < 0.01) decrease in medical spending, which translates into a $88 saving per member per month at 1 year. Compared to non-members, members experienced a 10.7% (p < 0.01) reduction in diabetes-related medical spending and a 24.6% (p < 0.01) reduction in spending on office-based services. Well-controlled BG values were associated with 21.4% (p = 0.03) lower medical spending. Limitations and conclusions: Remote digital diabetes management is associated with decreased medical spending at 1 year. Reductions in spending increased with active utilization. It will be beneficial for future studies to analyze the long-term effects of the remote diabetes management program and assess impacts on patient health and well-being.

Association between Electronic Medical Record System Adoption and Healthcare Information Technology Infrastructure

Objectives

The objective of this study was to investigate the relationship between the level of Electronic Medical Record (EMR) system adoption and healthcare information technology (IT) infrastructure.

Methods

Both survey and various healthcare administrative datasets in Korea were used. The survey was conducted during the period from June 13 to September 25, 2017. The chief information officers of hospitals were respondents. Among them, 257 general hospitals and 273 small hospitals were analyzed. A logistic regression analysis was conducted using the SAS program.

Results

The odds of having full EMR systems in general hospitals statistically significantly increased as the number of IT department staff members increased (odds ratio [OR] = 1.058, confidence interval [CI], 1.003–1.115; p = 0.038). The odds of having full EMR systems was significantly higher for small hospitals that had an IT department than those of small hospitals with no IT department (OR = 1.325; CI, 1.150–1.525; p < 0.001). Full EMR system adoption had a positive relationship with IT infrastructure in both general hospitals and small hospitals, which was statistically significant in small hospitals. The odds of having full EMR systems for small hospitals increased as IT infrastructure increased after controlling the covariates (OR = 1.527; CI, 1.317–4.135; p = 0.004).

Conclusions

This study verified that full EMR adoption was closely associated with IT infrastructure, such as organizational structure, human resources, and various IT subsystems. This finding suggests that political support related to these areas is indeed necessary for the fast dispersion of EMR systems into the healthcare industry.

Implementation of electronic charting is not associated with significant change in physician productivity in an academic emergency department

Objectives

To compare physician productivity and billing before and after implementation of electronic charting in an academic emergency department (ED).

Materials and methods

This retrospective, blinded, observational study compared the 6 months pre-implementation (January to June 2012) with the 6 months post-implementation 1 year later (January to June 2013). Thirty-one ED physicians were recruited, with each physician acting as his/her own control in a before-after design. Productivity was measured via total number of encounters and “productivity index” defined as worked relative value units divided by the clinical full-time equivalent. Values for charges, encounters, and productivity index were determined during each study period and separately for procedures, observational stays, and critical care.

Results

No differences were found for total productivity index per month (758 [623-876] pre-group vs. 756 [673-886] post-group; P = 0.30). There was, however, a 9% decrease in total encounters per month (138 [101-163] pre-group vs. 125 [99-159] post-group; P = 0.01). Significant decreases were seen across all observation stay categories. Conversely, significant increases were seen across all critical care categories. There was no difference in total charges per month.

Discussion

This is one of few studies to demonstrate minimal disruption in physician productivity after transitioning to electronic documentation. The reasons for these findings are likely multi-factorial.

Conclusion

In this study, implementation of electronic charting was not associated with decreases in productivity or billing for total ED care, but may be associated with increases for critical care and decreases for observational stays.

Do Years of Experience With Electronic Health Records Matter for Productivity in Community Health Centers?

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory

Background

To explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become ‘normalised’ into routine practice was also explored.

Methods

Qualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives of different grades, health care assistants) and wards within a maternity unit at a NHS teaching hospital. Interviews were conducted during the first year of the phased implementation of ERS and were analysed thematically. The four mechanisms of Normalisation Process Theory (NPT) (coherence, cognitive participation, collective action and reflexive monitoring) were adapted for use within the study and provided a theoretical framework to interpret the study’s findings.

Results

Coherence (participants’ understanding of why the ERS has been implemented) was mixed – whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced. Participants’ willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records. Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system. Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge. The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use. When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.

Conclusions

Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of ‘clinical benefits’. The study highlights the complexity of implementing electronic systems and the associated longevity before they can become ‘embedded’ into routine practice. Through the identification of barriers to the employment of electronic systems this process could be streamlined with the avoidance of any potential detriment to clinical services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0406-0) contains supplementary material, which is available to authorized users.

Lower rates of EMR use in rural hospitals represent a previously unexplored child health disparity

OBJECTIVES

Rural hospitals face significant barriers to adoption of advanced-stage electronic medical records (EMRs), which may translate to an unexplored disparity for children in rural hospitals. Our objective was to determine whether children hospitalized in rural settings are less likely to be cared for using advanced-stage EMRs.

METHODS

We merged the 2009 Healthcare Cost and Utilization Project Kids Inpatient Dataset with the 2009 Healthcare Information and Management Systems Society database. Logistic regression determined the independent relationship between receiving care in a rural hospital and advanced-stage EMRs.

RESULTS

A total of 430 055 (9.3%) of the 4 605 454 pediatric discharges were rural. Logistic regression analysis determined that even when an extensive list of various patient and hospital characteristics are accounted for, rurality continues to be a strong predictor of a child's care without advanced-stage EMRs (odds ratio 0.3; 95% confidence interval, 0.2-0.5).

CONCLUSIONS

Children hospitalized in a rural hospital are less than half as likely to be treated using advanced-stage EMRs. A focus of government and hospital policies to expand the use of EMRs among rural hospitals may reduce this child health care disparity.

A comparison of paper documentation to electronic documentation for trauma resuscitations at a level I pediatric trauma center

INTRODUCTION

Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations.

METHODS

The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n=200) was compared with a random sample of trauma resuscitations documented electronically (n=200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation.

RESULTS

The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P<.00), primary assessment (94% vs 88%, P<.036), arrival time of attending physician (98% vs 93.5%, P<.026), intravenous fluid volume in the emergency department (94% vs 88%, P<.036), and disposition (100% vs 89.5%, P<.00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P<.00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation.

DISCUSSION

Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations.

4000 clicks: a productivity analysis of electronic medical records in a community hospital ED

OBJECTIVE

We evaluate physician productivity using electronic medical records in a community hospital emergency department.

METHODS

Physician time usage per hour was observed and tabulated in the categories of direct patient contact, data and order entry, interaction with colleagues, and review of test results and old records.

RESULTS

The mean percentage of time spent on data entry was 43% (95% confidence interval, 39%-47%). The mean percentage of time spent in direct contact with patients was 28%. The pooled weighted average time allocations were 44% on data entry, 28% in direct patient care, 12% reviewing test results and records, 13% in discussion with colleagues, and 3% on other activities. Tabulation was made of the number of mouse clicks necessary for several common emergency department charting functions and for selected patient encounters. Total mouse clicks approach 4000 during a busy 10-hour shift.

CONCLUSION

Emergency department physicians spend significantly more time entering data into electronic medical records than on any other activity, including direct patient care. Improved efficiency in data entry would allow emergency physicians to devote more time to patient care, thus increasing hospital revenue.

Electronic medical record adoption in hospitals that care for children

OBJECTIVE

Hospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use.

METHODS

The American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use.

RESULTS

The analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry.

CONCLUSIONS

In 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.

The effect of electronic medical record system sophistication on preventive healthcare for women

OBJECTIVE

To observe the effect of electronic medical record (EMR) system sophistication on preventive women's healthcare.

MATERIALS AND METHODS

Providers in the National Ambulatory Medical Care Survey (NAMCS), 2007-8, were included if they had at least one visit by a woman at least 21 years old. Based on 16 questions from NAMCS, the level of a provider's EMR system sophistication was classified as non-existent, minimal, basic, or fully functional. A two-stage residual-inclusion method was used with ordered probit regression to model the level of EMR system sophistication, and outcome-specific Poisson regressions to predict the number of examinations or tests ordered or performed.

RESULTS

Across the providers, 29.23%, 49.34%, 15.97%, and 5.46% had no, minimal, basic, and fully functional EMR systems, respectively. The breast examination rate was 20.27%, 34.96%, 37.21%, and 44.98% for providers without or with minimal, basic, and fully functional EMR systems, respectively. For breast examinations, pelvic examinations, Pap tests, chlamydia tests, cholesterol tests, mammograms, and bone mineral density (BMD) tests, an EMR system increased the number of these tests and examinations. Furthermore, the level of sophistication increased the number of breast examinations and Pap, chlamydia, cholesterol, and BMD tests.

DISCUSSION

The use of advanced EMR systems in obstetrics and gynecology was limited. Given the positive results of this study, specialists in women's health should consider investing in more sophisticated systems.

CONCLUSIONS

The presence of an EMR system has a positive impact on preventive women's healthcare; the more functions that the system has, the greater the number of examinations and tests given or prescribed.

Hospital electronic medical record use and cost of inpatient pediatric care

OBJECTIVE

Electronic medical record (EMR) systems are costly for hospitals to implement and maintain, and the effects of EMR on the cost of care for inpatient pediatrics remain unknown. Our objective was to determine whether delivering care with advanced-stage EMR was associated with a decreased cost per case in a national sample of hospitalized children.

METHODS

The Healthcare Cost and Utilization Project Kids Inpatient Dataset 2009 identified pediatric discharges. The Healthcare Information and Management Systems Society 2009 database identified hospitals' EMR use. EMR was classified into 3 stages, with advanced-stage 3 EMR including automation of ancillary services, automation of nursing workflow, computerized provider order entry, and clinical decision support. Multivariable linear regression was used to determine the independent effect of advanced-stage EMR on cost per case. Propensity score adjustment was included to control for nonrandom assignment of EMR use.

RESULTS

This analysis included 4,605,454 weighted discharges. EMR use by hospitals that care for children was common: 24% for stage 1, 23% stage 2, and 32% advanced stage 3. The multivariable model demonstrated that advanced stage EMR was associated with an average 7% greater cost per case ($146 per discharge).

CONCLUSIONS

The care of children across the United States with EMRs may create a safer health care system but is not associated with inpatient cost savings. In fact our primary analysis shows a 7% additional cost per case. This finding is contrary to predicted savings and may represent an added barrier in the adoption of EMR for inpatient pediatrics.

Differences in Electronic Medical Record Implementation and Use According to Geographical Location and Organizational Characteristics of US Federally Qualified Health Centers

Electronic medical records (EMRs) are at the forefront of the national healthcare agenda and this paper examines EMR implementation and usage based on data from the 2009 Commonwealth Fund National Survey of Federally Qualified Health Centers (FQHC). Chi-square analysis was used to examine differences in EMR implementation and usage. Logistic regression analysis was used to understand the adjusted associations between EMR implementation and usage. A significant finding of this study was that simple EMRs were implemented in more than half of FQHCs in the Northeast, Southern, and Western regions of the United States and EMRs in more than half of the FQHCs in the Southern and Western regions are not even utilized. These findings indicate simple EMR usage and full EMR implementation need improvement to meet the requirements of the American Recovery and Reinvestment Act by 2014, or face reduction in Medicare and Medicaid reimbursements.

Medication administration quality and health information technology: a national study of US hospitals

OBJECTIVE

To determine whether the use of computerized physician order entry (CPOE) and electronic medication administration records (eMAR) is associated with better quality of medication administration at medium-to-large acute-care hospitals. DATA/STUDY SETTING: A retrospective cross-sectional analysis of data from three sources: CPOE/eMAR usage from HIMSS Analytics (2010), medication quality scores from CMS Hospital Compare (2010), and hospital characteristics from CMS Acute Inpatient Prospective Payment System (2009). The analysis focused on 11 quality indicators (January-December 2009) at 2603 medium-to-large (≥ 100 beds), non-federal acute-care hospitals measuring proportion of eligible patients given (or prescribed) recommended medications for conditions, including acute myocardial infarction, heart failure, and pneumonia, and surgical care improvement. Using technology adoption by 2008 as reference, hospitals were coded: (1) eMAR-only adopters (n=986); (2) CPOE-only adopters (n=115); and (3) adopters of both technologies (n=804); with non-adopters of both technologies as reference group (n=698). Hospitals were also coded for duration of use in 2-year increments since technology adoption. Hospital characteristics, historical measure-specific patient volume, and propensity scores for technology adoption were used to control for confounding factors. The analysis was performed using a generalized linear model (logit link and binomial family).

PRINCIPAL FINDINGS

Relative to non-adopters of both eMAR and CPOE, the odds of adherence to all measures (except one) were higher by 14-29% for eMAR-only hospitals and by 13-38% for hospitals with both technologies, translating to a marginal increase of 0.4-2.0 percentage points. Further, each additional 2 years of technology use was associated with 6-15% higher odds of compliance on all medication measures for eMAR-only hospitals and users of both technologies.

CONCLUSIONS

Implementation and duration of use of health information technologies are associated with improved adherence to medication guidelines at US hospitals. The benefits are evident for adoption of eMAR systems alone and in combination with CPOE.