computer and our society; medicine

8/16/2019 Computer and Our Society; Medicine

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COMPUTER & OUR

SOCIETY {MEDICINE}


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CONTENTS

Chapter 1 Introduction 3

Chapter 2 Literature Review 7

Patient Monitoring 10

Remote patient monitoring 13

Maintaining patient history & other records 19

Electronic Health Record 23

Health Information Management 48

Home Health Care Software 52

Diagnosing and Surgery 54

Computer Aided Diagnosing 62

Computer Aided Surgery 69

Research 86

Chapter 3 Findings and Discussion 83

Chapter 4 Conclusion 88

REFERENCES


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ABSTRACT


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CHAPTER ONE

INTRODUCTION

The history of computerization in medicine started in 70s. At that time, the main

purpose of computerization was labor-saving for the process of insurance claim and the

scope was limited only within administrative section in medical institutions. The physician

order entry system (POES) appeared in 80s by a centralized system of a host computer

and based on the computerization of clinical laboratory and pharmacy.

The POES contributed reducing patient's waiting time in clinical institutions and

also making the process of Insurance claim efficient. The growth of networking, especially

the Internet in 90s enhanced cooperation among clinical professionals or clinical

institutions. Also, the electronic medical record (EMR) came into realistic and a hospital

in the west of Japan implemented EMR and got rid of paper first in 1999.

In 2001, Japanese government established e-Japan policy, and health care and social

welfare is one of the main target fields. Then, the ministry of health labor and welfare

(MHLW) published "IT ground design for healthcare system" in the end of 2001.

It focused on EMR and the national standard software for electronic prcH2ess of

insurance claim. It made target to implement by the end of 2006; over of institutions

which has more than 400 beds should install EMR and over of institutions should install

the national standard software for electronic process of insurance claim. According to the

survey by the MHLW in 2002, only 1.3% out of total 8,023 hospitals have EMR and 15.3%

have the POES.


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It is also only 2.3% that the percentage of hospitals installed the national standard

software for electronic process of insurance claim. However, such numbers are

dramatically increasing recently.

As overall, computers are very popular among Japanese people and international

survey in 2003 showed that had laptop or desktop computers in 2002 and had a mobile

phone in 2003 in Japan. The corresponding numbers for the US were 66% and 54%. The

percentage of the Internet users were 45% for Japan and 55% for the US in 2002 (ITU

Telecommunication Indicators).

There has been a rapid expansion of computer use in medicine recently in the US

for a number of uses including medical education at all levels, point of service medical

information (especially diagnostic, treatment, and medications), medical research,

EMRs, electronic billing, electronic prescribing, and the collection of data to determine

quality of care and quality of medical education.

Some possible reasons why computers are increasingly used in US medical care are

availability of high speed connections, availability of personal digital assistants (PDAs),

availability of wireless connections, decreasing cost of hardware and software, public and

government demands for increased quality of care and documentation of that quality,

too much information to process without electronic help. Wireless LANs are much more

common today in hospitals than in doctors ' offices. Only about 8 percent of physician

practices have gone wireless. By comparison, 61 percent of integrated delivery networks

and 36 percent of stand-alone hospitals have some wireless capability in the US.

In terms of security, wireless network should be protected, at least, by a

combination of wireless-specific ways such as WPA/EAP according to IEEE802.1X with


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IPSec/VPN technologies. In addition, a separation of traffic by creating VIANs, and

installation of a firewall between wired and wireless networks tightened the security of

the MIPA/EAP-equipped wireless networks.

How can computers Improve quality of care and document that quality? They can

avoid illegible hand- writing, can be programmed to find errors in dosage, medication

name, medication interactions, and identifying allergic patients or the wrong patient,

computerized records can be backed up and are less likely to be lost or unavailable,

computerized records can more easily be transferred even over long distances, more

easily collect data such as mortality or number of patients seen or types of diagnosis seen.

How can computers improve medical education? They can decrease the amount of

class time where there is information transfer without interaction, Increase the amount

of class time available to answer questions and concentrate on confusing or difficult

topics, teach medical students and residents how to efficiently get the most accurate,

useful, and up to date information through computer programs. They can then use thistechnique for the rest of their career. Computers can decrease the amount of information

needed to be memorized and reduce the chance of error due to faulty memory. Finally,

they can decrease the amount of time needed to read journals and books while still

maintain high quality knowledge.

What are the disadvantages of computer use in medicine? They can be less useful

for those physicians who cannot type quickly, take extra time and effort to get used to,

create psychological discomfort with a new way of practicing medicine, be vulnerable to

viruses and technical problems that risk loss of data unless backed up, be vulnerable to


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breaches of patient confidentiality, sometimes increase the amount of time needed to

get work done, create fear that computerized data can be used by the legal system against

doctors and hospitals, create the fear of making the interaction between the patient and

doctor seem less personal and have


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CHAPTER TWO

LITERATURE REVIEW

The electronic devices supplied with processing units became an important

component of our everyday life. Computers, smartphones and other apparatuses that

give us mobile access to Internet are fundaments of modern business, education and

sometimes even relationships. Health care as a vital part of contemporary society model

is also affected by the same technical trends as the other branches of business. As

personal healthcare is among most important aspects of everyone life many efforts areput into medical researches on new treatment techniques. Because of that, all computer

methods that have proven to have technical and scientific potential are quickly developed

and utilized in medicine.

Now it is impossible to mention all possible applications of computers in

contemporary medicine because nearly all aspects of applied informatics are used in

practical medical solutions. The motivation of this article is presenting subjective list of

up to date applications of computer methods in medicine that might be good introduction

to this subject. In our opinion the role of computer methods in medicine is changing as

quick as computer science itself and there is a need for this type of review. Moreover, we

will describe our contribution to the state of the art methodology by introducing some of

our projects and achievements in this subject.

Our work is mainly concentrated on two- three- and four dimensional image data:

image processing and recognition (classification tasks), semantic interpretation, as well

as visualization and user interfaces. The data we are dealing with are mainly medical


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images acquired from patients with suspicious of early stages of brain stroke. The proper

diagnosis of medical data in first hours after appearing the stroke syndromes is crucial not

only for patience live but also for further convalescence.

Computer is playing very important role in medical fields. Nearly every area of the

medical field uses computers. They are helping the doctors to diagnose diseases and for

many other purposes.

The four main/major uses of computer in medical field are described below:

1- Patient Monitoring

Different electronic scanning devices (medical equipment) are used in hospitals. They

are connected with computers. These devices are used to monitor the patient

continuously. Thus computers are normally used in the following medical units of

hospitals for monitoring patients.

o ICU (Intensive Care Unit)

o Operation Theater

o Recovery Room

o Medical Ward

o ECG (Electrocardiograph)

The medical equipment with sensors is attached to the patient. It detects changes in

heart rate, pulse rate, blood pressure, breathing and brain activity. If any unbalancing

situation occurs, computer activates the alarming device, which creates sound and

alerts the medical staff.


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2- Maintaining Patient History & Other Records

The complete bio-data as well as medical history of a patient is recorded into the

computer. The medical history is delivered to the related doctor for the checkup of the

patient. In this way, much of the doctor's time is saved.

In addition to patient history, other information about doctors, medicines, and

medical equipment is also maintained through computers. This information can be

retrieved very easily and quickly.

3- Diagnosis & Surgery

Computer is also used in hospitals for diagnosing diseases. Different medical tests

depend upon the computerized devices such as laboratory test of blood. One common

use of computer in hospitals is to scan the body of patient. A special scanner is used for

this purpose. For example, the CAT (Computerized Axial Tomography) scanner passes

rays over the patient. It displays an image of bone and tissue structure of patient on a

computer screen. This image is printed on the printer. It is also store in computer for

later use.

4- Research.

We would look at them one by one.


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PATIENT MONITORING

In medicine, monitoring is the observation of a disease, condition or one or several

medical parameters over time. It can be performed by continuously measuring certain

parameters by using a medical monitor (for example, by continuously measuring vital

signs by a bedside monitor), and/or by repeatedly performing medical tests (such as blood

glucose monitoring with a glucose meter in people with diabetes mellitus). Transmitting

data from a monitor to a distant monitoring station is known as telemetry or

biotelemetry.

Classification by target parameter

Monitoring can be classified by the target of interest, including:

Cardiac monitoring, which generally refers to continuous electrocardiography

with assessment of the patient’s condition relative to their cardiac rhythm. A

small monitor worn by an ambulatory patient for this purpose is known as aHolter monitor. Cardiac monitoring can also involve cardiac output monitoring via

an invasive Swan-Ganz catheter.

Hemodynamic monitoring, which monitors the blood pressure and blood flow

within the circulatory system. Blood pressure can be measured either invasively

through an inserted blood pressure transducer assembly, or noninvasively with an

inflatable blood pressure cuff. Respiratory monitoring, such as:

https://en.wikipedia.org/wiki/Vital_signhttps://en.wikipedia.org/wiki/Vital_signhttps://en.wikipedia.org/wiki/Medical_testhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Glucose_meterhttps://en.wikipedia.org/wiki/Diabetes_mellitushttps://en.wikipedia.org/wiki/Telemetryhttps://en.wikipedia.org/wiki/Biotelemetryhttps://en.wikipedia.org/wiki/Cardiac_monitoringhttps://en.wikipedia.org/wiki/Cardiac_monitoringhttps://en.wikipedia.org/wiki/Electrocardiographyhttps://en.wikipedia.org/wiki/Holter_monitorhttps://en.wikipedia.org/wiki/Cardiac_outputhttps://en.wikipedia.org/wiki/Swan-Ganz_catheterhttps://en.wikipedia.org/wiki/Hemodynamichttps://en.wikipedia.org/wiki/Blood_pressurehttps://en.wikipedia.org/wiki/Blood_flowhttps://en.wikipedia.org/wiki/Transducerhttps://en.wikipedia.org/wiki/Respiratory_monitoringhttps://en.wikipedia.org/wiki/Respiratory_monitoringhttps://en.wikipedia.org/wiki/Respiratory_monitoringhttps://en.wikipedia.org/wiki/Transducerhttps://en.wikipedia.org/wiki/Blood_flowhttps://en.wikipedia.org/wiki/Blood_pressurehttps://en.wikipedia.org/wiki/Hemodynamichttps://en.wikipedia.org/wiki/Swan-Ganz_catheterhttps://en.wikipedia.org/wiki/Cardiac_outputhttps://en.wikipedia.org/wiki/Holter_monitorhttps://en.wikipedia.org/wiki/Electrocardiographyhttps://en.wikipedia.org/wiki/Cardiac_monitoringhttps://en.wikipedia.org/wiki/Biotelemetryhttps://en.wikipedia.org/wiki/Telemetryhttps://en.wikipedia.org/wiki/Diabetes_mellitushttps://en.wikipedia.org/wiki/Glucose_meterhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Medical_testhttps://en.wikipedia.org/wiki/Vital_signhttps://en.wikipedia.org/wiki/Vital_sign


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o Pulse oximetry which involves measurement of the saturated percentage of

oxygen in the blood, referred to as SpO2, and measured by an infrared

finger cuff

o Capnography, which involves CO2 measurements, referred to as EtCO2 or

end-tidal carbon dioxide concentration. The respiratory rate monitored as

such is called AWRR or airway respiratory rate)

o Respiratory rate monitoring through a thoracic transducer belt, an ECG

channel or via capnography

Neurological monitoring, such as of intracranial pressure. Also, there are special

patient monitors which incorporate the monitoring of brain waves

(electroencephalography), gas anesthetic concentrations, bispectral index (BIS),

etc. They are usually incorporated into anesthesia machines. In neurosurgery

intensive care units, brain EEG monitors have a larger multichannel capability and

can monitor other physiological events, as well.

Blood glucose monitoring

Childbirth monitoring

Body temperature monitoring through an adhesive pad containing a

thermoelectric transducer

Medical monitor

A medical monitor or physiological monitor is a medical device used for monitoring.

It can consist of one or more sensors, processing components, display devices (which are

sometimes in themselves called "monitors"), as well as communication links for displaying

or recording the results elsewhere through a monitoring network.

https://en.wikipedia.org/wiki/Pulse_oximetryhttps://en.wikipedia.org/wiki/Oxygenhttps://en.wikipedia.org/wiki/Bloodhttps://en.wikipedia.org/wiki/Infraredhttps://en.wikipedia.org/wiki/Capnographyhttps://en.wikipedia.org/w/index.php?title=EtCO2&action=edit&redlink=1https://en.wikipedia.org/wiki/Carbon_dioxidehttps://en.wikipedia.org/w/index.php?title=Airway_respiratory_rate&action=edit&redlink=1https://en.wikipedia.org/w/index.php?title=Neurological_monitoring&action=edit&redlink=1https://en.wikipedia.org/w/index.php?title=Neurological_monitoring&action=edit&redlink=1https://en.wikipedia.org/wiki/Intracranial_pressurehttps://en.wikipedia.org/wiki/Electroencephalographyhttps://en.wikipedia.org/wiki/Bispectral_indexhttps://en.wikipedia.org/wiki/Neurosurgeryhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Childbirth#Monitoringhttps://en.wikipedia.org/wiki/Childbirth#Monitoringhttps://en.wikipedia.org/wiki/Body_temperaturehttps://en.wikipedia.org/w/index.php?title=Adhesive_pad&action=edit&redlink=1https://en.wikipedia.org/wiki/Thermoelectrichttps://en.wikipedia.org/wiki/Medical_devicehttps://en.wikipedia.org/wiki/Sensorhttps://en.wikipedia.org/wiki/Display_devicehttps://en.wikipedia.org/wiki/Display_devicehttps://en.wikipedia.org/wiki/Sensorhttps://en.wikipedia.org/wiki/Medical_devicehttps://en.wikipedia.org/wiki/Thermoelectrichttps://en.wikipedia.org/w/index.php?title=Adhesive_pad&action=edit&redlink=1https://en.wikipedia.org/wiki/Body_temperaturehttps://en.wikipedia.org/wiki/Childbirth#Monitoringhttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Neurosurgeryhttps://en.wikipedia.org/wiki/Bispectral_indexhttps://en.wikipedia.org/wiki/Electroencephalographyhttps://en.wikipedia.org/wiki/Intracranial_pressurehttps://en.wikipedia.org/w/index.php?title=Neurological_monitoring&action=edit&redlink=1https://en.wikipedia.org/w/index.php?title=Airway_respiratory_rate&action=edit&redlink=1https://en.wikipedia.org/wiki/Carbon_dioxidehttps://en.wikipedia.org/w/index.php?title=EtCO2&action=edit&redlink=1https://en.wikipedia.org/wiki/Capnographyhttps://en.wikipedia.org/wiki/Infraredhttps://en.wikipedia.org/wiki/Bloodhttps://en.wikipedia.org/wiki/Oxygenhttps://en.wikipedia.org/wiki/Pulse_oximetry


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Examples and applications

The development cycle in medicine is extremely long, up to 20 years, because of

the need for U.S. Food and Drug Administration (FDA) approvals, therefore many ofmonitoring medicine solutions are not available today in conventional medicine.

Blood glucose monitoring

In vivo blood glucose monitoring devices can transmit data to a computer that can

assist with daily life suggestions for lifestyle or nutrition and with the physician can make

suggestions for further study in people who are at risk and help prevent diabetes mellitus

type 2 .

Stress monitoring

Bio sensors may provide warnings when stress levels signs are rising before human

can notice it and provide alerts and suggestions.

Serotonin biosensor

Future serotonin biosensors may assist with mood disorders and depression.

Continuous blood test based nutrition

In the field of evidence-based nutrition, a lab-on-a-chip implant that can run 24/7

blood tests may provide a continuous results and a computer can provide nutrition

suggestions or alerts.

https://en.wikipedia.org/wiki/Food_and_Drug_Administrationhttps://en.wikipedia.org/wiki/In_vivohttps://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/Lifestyle_(sociology)https://en.wikipedia.org/wiki/Nutritionhttps://en.wikipedia.org/wiki/Physicianhttps://en.wikipedia.org/wiki/Diabetes_mellitus_type_2https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2https://en.wikipedia.org/wiki/Serotoninhttps://en.wikipedia.org/wiki/Mood_(psychology)https://en.wikipedia.org/wiki/Depression_(mood)https://en.wikipedia.org/w/index.php?title=Evidence-based_nutrition&action=edit&redlink=1https://en.wikipedia.org/wiki/Lab-on-a-chiphttps://en.wikipedia.org/wiki/Implant_(medicine)https://en.wikipedia.org/wiki/Blood_testhttps://en.wikipedia.org/wiki/Blood_testhttps://en.wikipedia.org/wiki/Implant_(medicine)https://en.wikipedia.org/wiki/Lab-on-a-chiphttps://en.wikipedia.org/w/index.php?title=Evidence-based_nutrition&action=edit&redlink=1https://en.wikipedia.org/wiki/Depression_(mood)https://en.wikipedia.org/wiki/Mood_(psychology)https://en.wikipedia.org/wiki/Serotoninhttps://en.wikipedia.org/wiki/Diabetes_mellitus_type_2https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2https://en.wikipedia.org/wiki/Physicianhttps://en.wikipedia.org/wiki/Nutritionhttps://en.wikipedia.org/wiki/Lifestyle_(sociology)https://en.wikipedia.org/wiki/Blood_glucose_monitoringhttps://en.wikipedia.org/wiki/In_vivohttps://en.wikipedia.org/wiki/Food_and_Drug_Administration


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Psychiatrist-on-a-chip

In clinical brain sciences drug delivery and in vivo Bio-MEMS based biosensors may

assist with preventing and early treatment of mental disorders.

Epilepsy monitoring

In epilepsy, next generations of long-term video-EEG monitoring may predict

epileptic seizure and prevent them with changes of daily life activity like sleep, stress,

nutrition and mood management.

Toxicity monitoring

Smart biosensors may detect toxic materials such mercury and lead and provide

alerts.

REMOTE PATIENT MONITORING

Remote patient monitoring (RPM) is a technology to enable monitoring of patients

outside of conventional clinical settings (e.g. in the home), which may increase access to

care and decrease healthcare delivery costs.

Incorporating RPM in chronic disease management can significantly improve an

individual’s quality of life. It allows patients to maintain independence, prevent

complications, and minimize personal costs. RPM facilitates these goals by delivering care

right to the home. In addition, patients and their family members feel comfort knowing

that they are being monitored and will be supported if a problem arises. This is particularly

important when patients are managing complex self-care processes such as home

https://en.wikipedia.org/wiki/Drug_deliveryhttps://en.wikipedia.org/wiki/Bio-MEMShttps://en.wikipedia.org/wiki/Biosensorhttps://en.wikipedia.org/wiki/Epilepsyhttps://en.wikipedia.org/wiki/Long-term_video-EEG_monitoringhttps://en.wikipedia.org/wiki/Epileptic_seizurehttps://en.wikipedia.org/wiki/Sleephttps://en.wikipedia.org/wiki/Stress_(biology)https://en.wikipedia.org/wiki/Nutritionhttps://en.wikipedia.org/wiki/Mood_(psychology)https://en.wikipedia.org/wiki/Mercury_(element)https://en.wikipedia.org/wiki/Leadhttps://en.wikipedia.org/wiki/Leadhttps://en.wikipedia.org/wiki/Mercury_(element)https://en.wikipedia.org/wiki/Mood_(psychology)https://en.wikipedia.org/wiki/Nutritionhttps://en.wikipedia.org/wiki/Stress_(biology)https://en.wikipedia.org/wiki/Sleephttps://en.wikipedia.org/wiki/Epileptic_seizurehttps://en.wikipedia.org/wiki/Long-term_video-EEG_monitoringhttps://en.wikipedia.org/wiki/Epilepsyhttps://en.wikipedia.org/wiki/Biosensorhttps://en.wikipedia.org/wiki/Bio-MEMShttps://en.wikipedia.org/wiki/Drug_delivery


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hemodialysis. Key features of RPM, like remote monitoring and trend analysis of

physiological parameters, enable early detection of deterioration; thereby, reducing

number of emergency department visits, hospitalizations, and duration of hospital stays.

The need for wireless mobility in healthcare facilitates the adoption of RPM both in

community and institutional settings. The time saved as a result of RPM implementation

increases efficiency, and allows healthcare providers to allocate more time to remotely

educate and communicate with patients.

Technological components

The diverse applications of RPM lead to numerous variations of RPM technology

architecture. However, most RPM technologies follow a general architecture that consists

of four components.:

Sensors on a device that is enabled by wireless communications to measure

physiological parameters.

Local data storage at patients’ site that interfaces between sensors and other

centralized data repository and/or healthcare providers.

Centralized repository to store data sent from sensors, local data storage,

diagnostic applications, and/or healthcare providers.

Diagnostic application software that develops treatment recommendations and

intervention alerts based on the analysis of collected data.

Depending on the disease and the parameters that are monitored, different

combinations of sensors, storage, and applications may be deployed.


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Applications

Physiological data such as blood pressure and subjective patient data are collected

by sensors on peripheral devices. Examples of peripheral devices are: blood pressure cuff,

pulse oximeter, and glucometer. The data are transmitted to healthcare providers or third

parties via wireless telecommunication devices. The data are evaluated for potential

problems by a healthcare professional or via a clinical decision support algorithm, and

patient, caregivers, and health providers are immediately alerted if a problem is detected.

As a result, timely intervention ensures positive patient outcomes. The newer

applications also provide education, test and medication reminder alerts, and a means of

communication between the patient and the provider. The following section illustrates

examples of RPM applications, but RPM is not limited to those disease states.

Dementia and falls

For patients with dementia that are at risk for falls, RPM technology promotes

safety and prevents harm through continuous surveillance. RPM sensors can be affixed to

the individual or their assistive mobility devices such as canes and walkers. The sensors

monitor an individual’s location, gait, linear acceleration and angular velocity, and utilize

a mathematical algorithm to predict the likelihood for falls, detect movement changes,

and alert caregivers if the individual has fallen. Furthermore, tracking capabilities via Wi-

Fi, global positioning system (GPS) or radio frequency enables caregivers to locate

wandering elders.

https://en.wikipedia.org/wiki/Blood_pressurehttps://en.wikipedia.org/wiki/Blood_pressure_cuffhttps://en.wikipedia.org/wiki/Pulse_oximeterhttps://en.wikipedia.org/wiki/Glucometerhttps://en.wikipedia.org/wiki/Dementiahttps://en.wikipedia.org/wiki/Wi-Fihttps://en.wikipedia.org/wiki/Wi-Fihttps://en.wikipedia.org/wiki/Global_positioning_systemhttps://en.wikipedia.org/wiki/Global_positioning_systemhttps://en.wikipedia.org/wiki/Wi-Fihttps://en.wikipedia.org/wiki/Wi-Fihttps://en.wikipedia.org/wiki/Dementiahttps://en.wikipedia.org/wiki/Glucometerhttps://en.wikipedia.org/wiki/Pulse_oximeterhttps://en.wikipedia.org/wiki/Blood_pressure_cuffhttps://en.wikipedia.org/wiki/Blood_pressure


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Diabetes

Diabetes management requires control of multiple parameters: blood pressure,

weight, and blood glucose. The real-time delivery of blood glucose and blood pressurereadings enables immediate alerts for patient and healthcare providers to intervene

when needed. There is evidence to show that daily diabetes management involving RPM

is just as effective as usual clinic visit every 3 months.

Congestive heart failure

A systematic review of the literature on home monitoring for heart failure patients

indicates that RPM improves quality of life, improves patient-provider relationships,

shortens duration of stay in hospitals, decreases mortality rate, and reduces costs to the

healthcare system.

Infertility

A recent study of a remote patient monitoring solution for infertility demonstrated

that for appropriately screened patients who had been seeking In-Vitro Fertilization (IVF)

treatment, a six-month remote monitoring program had the same pregnancy rate as a

cycle of IVF. The remote patient monitoring product and service used had a cost-per-

patient of $800, compared to the average cost of a cycle of IVF of $15,000, suggesting a

95% reduction in the cost of care for the same outcome.

Whole System Demonstrator Trial in UK

The UK’s Department of Health’s Whole System Demonstrator (WSD) launched in

May 2008. It is the largest randomized control trial of telehealth and telecare in the world,

https://en.wikipedia.org/wiki/Diabeteshttps://en.wikipedia.org/wiki/Blood_pressurehttps://en.wikipedia.org/wiki/Heart_failurehttps://en.wikipedia.org/wiki/Quality_of_lifehttps://en.wikipedia.org/wiki/Telehealthhttps://en.wikipedia.org/wiki/Telehealthhttps://en.wikipedia.org/wiki/Quality_of_lifehttps://en.wikipedia.org/wiki/Heart_failurehttps://en.wikipedia.org/wiki/Blood_pressurehttps://en.wikipedia.org/wiki/Diabetes


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involving 6191 patients and 238 GP practices across three sites, Newham, Kent and

Cornwall. The trials were evaluated by: City University London, University of Oxford,

University of Manchester, Nuffield Trust, Imperial College London and London School of

Economics.

45% reduction in mortality rates

20% reduction in emergency admissions

15% reduction in A&E visits

14% reduction in elective admissions

14% reduction in bed days 8% reduction in tariff costs

In the UK, the Government's Care Services minister, Paul Burstow, has stated that

telehealth and telecare would be extended over the next five years (2012-2017) to reach

three million people.

Limitations

RPM is highly dependent on the individual’s motivation to manage their health.

Without the patient’s willingness to be an active participant in their care, RPM

implementation will likely fail.

Cost is also a barrier to its widespread use. Devices and peripherals currently cost

thousands of dollars, and for RPM to take hold in health care, costs need to come down

to the $300 to $500 range.

There is a lack of reimbursement guidelines for RPM services, which may deter its

incorporation into clinical practice. The shift of accountability associated with RPM brings

https://en.wikipedia.org/wiki/London_Borough_of_Newhamhttps://en.wikipedia.org/wiki/Kenthttps://en.wikipedia.org/wiki/Cornwallhttps://en.wikipedia.org/wiki/City_University_Londonhttps://en.wikipedia.org/wiki/University_of_Oxfordhttps://en.wikipedia.org/wiki/University_of_Manchesterhttps://en.wikipedia.org/wiki/Nuffield_Trusthttps://en.wikipedia.org/wiki/Imperial_College_Londonhttps://en.wikipedia.org/wiki/London_School_of_Economicshttps://en.wikipedia.org/wiki/London_School_of_Economicshttps://en.wikipedia.org/wiki/Telehealthhttps://en.wikipedia.org/wiki/Telehealthhttps://en.wikipedia.org/wiki/London_School_of_Economicshttps://en.wikipedia.org/wiki/London_School_of_Economicshttps://en.wikipedia.org/wiki/Imperial_College_Londonhttps://en.wikipedia.org/wiki/Nuffield_Trusthttps://en.wikipedia.org/wiki/University_of_Manchesterhttps://en.wikipedia.org/wiki/University_of_Oxfordhttps://en.wikipedia.org/wiki/City_University_Londonhttps://en.wikipedia.org/wiki/Cornwallhttps://en.wikipedia.org/wiki/Kenthttps://en.wikipedia.org/wiki/London_Borough_of_Newham


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up liability issues. There are no clear guidelines in respect to whether clinicians have to

intervene every time they receive an alert regardless of the urgency. The continuous flow

of patient data requires a dedicated team of health care providers to handle the

information, which may, in fact, increase the workload. Although technology is

introduced with the intent to increase efficiency, it can become a barrier to some

healthcare providers that are not technological.

There are common obstacles that health informatics technologies encounter that

applies to RPM. Depending on the comorbidities monitored, RPM involves a diverse

selection of devices in its implementation. Standardization is required for data exchangeand interoperability among multiple components. Furthermore, RPM deployment is

highly dependent on an extensive wireless telecommunications infrastructure, which may

not be available or feasible in rural areas. Since RPM involves transmission of sensitive

patient data across telecommunication networks, information security is a concern.

https://en.wikipedia.org/wiki/Health_care_providershttps://en.wikipedia.org/wiki/Comorbiditieshttps://en.wikipedia.org/wiki/Wireless_telecommunicationshttps://en.wikipedia.org/wiki/Wireless_telecommunicationshttps://en.wikipedia.org/wiki/Comorbiditieshttps://en.wikipedia.org/wiki/Health_care_providers


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MAINTAINING PATIENT HISTORY & OTHER RECORDS

Before the introduction of computers all medical records were kept in a patient

folder with handwritten notes by the doctor, other staff. Patients and ID details were on

the outside typed or handwritten by staff, all family's records went into one folder.

Outpatient’s records were kept in a printed folder with date stamped sheets of

notes inside it. when a patient came up for an appointment, he/she got a ticket and when

he came in to see the doctor -the doctor had the folder selected from the records room

and placed in advance on his table.

Examination notes were handwritten/ prescription were written too and tokens or

prescription cards were given to the patient. the patient then walked over to the

dispensary/pharmacy and collected his meds. All under one roof! records were accurate.

records were kept in a locked room, arranged in filing cabinets or similar cabinets. Records

were rarely ever lost!

Problems accompanied with this method were;

1. Costs of manual medical records

There are several types of costs associated with manual patient records. One type,

duplication of the record, requires paper and copying supplies, as well as the staff tocreate and distribute the copies. Staff hired to assemble, file, retrieve, or distribute the

hard copy chart is a costly expense. Storage of the paper record necessitates the use of


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valuable space that could be better utilized. The records also need to be protected from

water, fire, or mishandling of the paper to preserve their physical integrity.

One of the most expensive disadvantages of the paper record is duplicate patienttesting required to replace lost or missing test results. Repeating procedures may

jeopardize the patient’s health, creating a potential opportunity for an adverse medical

event. Duplicate testing wastes scarce medical resources (time, staff, supplies, and

equipment) that could be used for other patients. It is a contributing source to the rising

costs of health care by generating additional charges to be billed to the patient, insurance

company, or other third- party payer.

A related issue pertains to ordering procedures or tests that are either unnecessary

or contraindicated. These types of decisions, when based on inadequate information or

delayed results, create a potentially harmful situation for the patient and a needless

expense for all concerned. Claims submitted for medical errors that could have been

prevented with accurate and accessible patient information are issues that are seen with

the use of a paper record.

2. Lost productivity from manual medical records

Lost productivity results from various inadequacies of the paper record. This affects

multiple departments in a healthcare facility. Searches for misfiled charts waste time.

Staff members’ time is required to deliver paper records to a specific location. If the paper

record is not readily available, clerical staff responsible for filing documentation may need

to make several attempts before the task is completed. Medical errors may be made if

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There is no ability to sort data fields in a paper record. Staff responsible for

reporting mandated data elements to the appropriate organizations must perform a

manual review. This is a very labor-intensive process, and inaccuracies can occur.

3. Accessibility of medical records

Of great concern is the lack of access to the record. Only one person at a time may

use the chart and the chart has to be in a single location. Staff needing access to the record

must wait until it is available for their use. This also contributes to the difficulty of

updating the paper record, especially for an active patient’s chart since that chart travels

with the patient to each location of care. Delivering documentation by hand to the

patient’s temporary location lends itself to the potential for losing or misplacing the

records. Delayed access to the chart negatively affects coding, billing, and reimbursement

processes.

4. Quality of manual medical records

The issue of quality encompasses the physical record, the documentation, and

patient care. There are limitations to the physical quality of the paper record. The paper

is fragile and does not last permanently. Normal use of the record may result in torn or

stained documents. Also, over the years, the ink used to complete documentation can

fade. Actual damage resulting from water or fire is another threat to the physical integrity

of the paper record.

The quality of the actual documentation varies based on the health care provider’s

documentation skills and knowledge level. While standardization of the data

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abbreviations, terminology, format, or chart organization. This can result in incomplete

or inaccurate healthcare data collection. Handwritten information may be illegible,

creating the potential for errors in patient treatment or medication orders.

5. Fragmentation caused by manual medical records

Fragmentation of the patient’s record occurs as the result of multiple encounters

with different healthcare providers. Due to disparate patient documentation and billing

systems, there is often minimal or no exchange of information that contributes to

compiling a longitudinal medical history for the patient. Each provider or facility has a

limited portion of the patient’s overall health information. Some minor communication

may be provided between referring and consulting physicians, but only for a specific

encounter. The level of fragmentation varies based on several factors. These factors

include:

• the patient’s ability to communicate pertinent health information to the provider;

• the ability of the provider to collect information that is accessible to other providers;

• the provider’s ability to directly elicit health information from the patient and any

written documentation to create an appropriate treatment plan; and

• the limitations of the patient record system(s) that are being utilized to collect and

disseminate information.

A well planned and implemented electronic medical record system should address

and/or alleviate many of the general disadvantages of the paper record. This is an

immense undertaking that requires an in-depth review of current processes, a detailed


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strategy for determining the organization’s future needs and goals, an organization’s

willingness and ability to make significant changes, and the financial investment to

achieve the desired results. It is also a very time-intensive project that demands the

utmost dedication and commitment by the entire health system. Patients, providers, and

other interested parties could all expect to derive benefits from a properly planned and

installed an automated system.

ELECTRONIC HEALTH RECORD

An electronic health record (EHR), or electronic medical record (EMR), refers to

the systematized collection of patient and population electronically-stored health

information in a digital format. These records can be shared across different health care

settings. Records are shared through network-connected, enterprise-wide information

systems or other information networks and exchanges. EHRs may include a range of data,

including demographics, medical history, medication and allergies, immunization status,

laboratory test results, radiology images, vital signs, personal statistics like age and

weight, and billing information.

EHS systems are designed to store data accurately and to capture the state of a

patient across time. It eliminates the need to track down a patient's previous paper

medical records and assists in ensuring data is accurate and legible. It can reduce risk of

data replication as there is only one modifiable file, which means the file is more likely up

to date, and decreases risk of lost paperwork. Due to the digital information being

searchable and in a single file, EMR's are more effective when extracting medical data for

the examination of possible trends and long term changes in a patient. Population-based

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studies of medical records may also be facilitated by the widespread adoption of EHR's

and EMR's.

Terminology

The terms EHR, electronic patient record (EPR) and EMR have often been used

interchangeably, although differences between the models are now being defined. The

electronic health record (EHR) is an evolving concept defined as a more longitudinal

collection of the electronic health information of individual patients or populations.

The EMR is, in contrast, defined as the patient record created by providers for

specific encounters in hospitals and ambulatory environments, and which can serve as a

data source for an EHR. It is important to note that an "EHR" is generated and maintained

within an institution, such as a hospital, integrated delivery network, clinic, or physician

office, to give patients, physicians and other health care providers, employers, and payers

or insurers access to a patient's medical records across facilities. (Please note that the

term "EMR" would now be used for the preceding description, and that many EMR's now

use cloud software maintenance and data storage rather than local networks.)

In contrast, a personal health record (PHR) is an electronic application for recording

personal medical data that the individual patient controls and may make available tohealth providers.

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Comparison with paper-based records

Federal and state governments, insurance companies and other large medical

institutions are heavily promoting the adoption of electronic medical records. The USCongress included a formula of both incentives (up to $44,000 per physician under

Medicare, or up to $65,000 over six years under Medicaid) and penalties (i.e. decreased

Medicare and Medicaid reimbursements to doctors who fail to use EMRs by 2015, for

covered patients) for EMR/EHR adoption versus continued use of paper records as part

of the Health Information Technology for Economic and Clinical Health (HITECH) Act,

enacted as part of the American Recovery and Reinvestment Act of 2009.

One VA study estimates its electronic medical record system may improve overall

efficiency by 6% per year, and the monthly cost of an EMR may (depending on the cost of

the EMR) be offset by the cost of only a few "unnecessary" tests or admissions.

Jerome Groopman disputed these results, publicly asking "how such dramatic

claims of cost-saving and quality improvement could be true". A 2014 survey of the

American College of Physicians member sample, however, found that family practice

physicians spent 48 minutes more per day when using EMRs. 90% reported that at least

1 data management function was slower after EMRs were adopted, and 64% reported

that note writing took longer. A third (34%) reported that it took longer to find and review

medical record data, and 32% reported that it was slower to read other clinicians' notes.

The increased portability and accessibility of electronic medical records may also

increase the ease with which they can be accessed and stolen by unauthorized persons

or unscrupulous users versus paper medical records, as acknowledged by the increased

security requirements for electronic medical records included in the Health Information

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and Accessibility Act and by large-scale breaches in confidential records reported by EMR

users. Concerns about security contribute to the resistance shown to their widespread

adoption.

Handwritten paper medical records may be poorly legible, which can contribute to

medical errors. Pre-printed forms, standardization of abbreviations and standards for

penmanship were encouraged to improve reliability of paper medical records. Electronic

records may help with the standardization of forms, terminology and data input.

Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

EMRs can be continuously updated (within certain legal limitations – see below). If

the ability to exchange records between different EMR systems were

perfected("interoperability") would facilitate the co-ordination of health care delivery in

non-affiliated health care facilities. In addition, data from an electronic system can be

used anonymously for statistical reporting in matters such as quality improvement,

resource management and public health communicable disease surveillance.

Implementation, end user and patient considerations

Quality

Several studies call into question whether EHRs improve the quality of care.

However, a recent multi-provider study in diabetes care, published in the New England

Journal of Medicine, found evidence that practices with EHR provided better quality care.

EMR's may eventually help improve care coordination. An article in a trade journal

suggests that since anyone using an EMR can view the patient's full chart, that it cuts

down on guessing histories, seeing multiple specialists, smooths transitions between care

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settings, and may allow better care in emergency situations. EHRs may also improve

prevention by providing doctors and patients better access to test results, identifying

missing patient information, and offering evidence-based recommendations for

preventive services.

Costs

The steep price of EHR and provider uncertainty regarding the value they will derive

from adoption in the form of return on investment has a significant influence on EHR

adoption. In a project initiated by the Office of the National Coordinator for Health

Information (ONC), surveyors found that hospital administrators and physicians who had

adopted EHR noted that any gains in efficiency were offset by reduced productivity as the

technology was implemented, as well as the need to increase information technology

staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occur

only in large integrated institutions like Kaiser Permanente, and not in small physician

offices. They challenged the Rand Corporation's estimates of savings. "Office-based

physicians in particular may see no benefit if they purchase such a product —and may

even suffer financial harm. Even though the use of health IT could generate cost savings

for the health system at large that might offset the EHR's cost, many physicians might not

be able to reduce their office expenses or increase their revenue sufficiently to pay for it.

For example, the use of health IT could reduce the number of duplicated diagnostic tests.

However, that improvement in efficiency would be unlikely to increase the income of

many physicians." One CEO of an EHR company has argued if a physician performs tests

in the office, it might reduce his or her income.

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Doubts have been raised about cost saving from EHRs by researchers at Harvard

University, the Wharton School of the University of Pennsylvania, Stanford University, and

others.

Time

The implementation of EMR can potentially decrease identification time of patients

upon hospital admission. A research from the Annals of Internal Medicine showed that

since the adoption of EMR a relative decrease in time by 65% has been recorded (from

130 to 46 hours).

Software quality and usability deficiencies

The Healthcare Information and Management Systems Society (HIMSS), a very

large U.S. healthcare IT industry trade group, observed that EHR adoption rates "have

been slower than expected in the United States, especially in comparison to other

industry sectors and other developed countries. A key reason, aside from initial costs and

lost productivity during EMR implementation, is lack of efficiency and usability of EMRs

currently available." The U.S. National Institute of Standards and Technology of the

Department of Commerce studied usability in 2011 and lists a number of specific issues

that have been reported by health care workers. The U.S. military's EHR, AHLTA, was

reported to have significant usability issues. It was observed that the efforts to improve

EHR usability should be placed in the context of physician-patient communication.

However, physicians are embracing mobile technologies such as smartphones and

tablets at a rapid pace. According to a 2012 survey by Physicians Practice, 62.6 percent of

respondents (1,369 physicians, practice managers, and other healthcare providers) say

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they use mobile devices in the performance of their job. Mobile devices are increasingly

able to synch up with electronic health record systems thus allowing physicians to access

patient records from remote locations. Most devices are extensions of desk-top EHR

systems, using a variety of software to communicate and access files remotely. The

advantages of instant access to patient records at any time and any place are clear, but

bring a host of security concerns. As mobile systems become more prevalent, practices

will need comprehensive policies that govern security measures and patient privacy

regulations.

Eventually, EHR will be more secured because the cyber security professionals havenever stopped pursuing better ways to protect data with an enhanced software and

technology. At the same time, they need to beware that the system will be significantly

complicated and not user-friendly anymore as the data is growing and technology is more

advancing. While we have a better secured system, it could lead to an error-prone.

Therefore, efficient and effective trainings are needed along with a well-designed user

interface.

Unintended consequences

Per empirical research in social informatics, information and communications

technology (ICT) use can lead to both intended and unintended consequences.

A 2008 Sentinel Event Alert from the U.S. Joint Commission, the organization that

accredits American hospitals to provide healthcare services, states that "As health

information technology (HIT) and 'converging technologies' —the interrelationship

between medical devices and HIT —are increasingly adopted by health care organizations,

users must be mindful of the safety risks and preventable adverse events that these

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implementations can create or perpetuate. Technology-related adverse events can be

associated with all components of a comprehensive technology system and may involve

errors of either commission or omission. These unintended adverse events typically stem

from human-machine interfaces or organization/system design." The Joint Commission

cites as an example the United States Pharmacopeia MEDMARX database where of

176,409 medication error records for 2006, approximately 25 percent (43,372) involved

some aspect of computer technology as at least one cause of the error.

The National Health Service (NHS) in the UK reports specific examples of potential

and actual EHR-caused unintended consequences in their 2009 document on themanagement of clinical risk relating to the deployment and use of health software.

In a Feb. 2010 U.S. Food and Drug Administration (FDA) memorandum, FDA notes

EHR unintended consequences include EHR-related medical errors due to (1) errors of

commission (EOC), (2) errors of omission or transmission (EOT), (3) errors in data analysis

(EDA), and (4) incompatibility between multi-vendor software applications or systems

(ISMA) and cites examples. In the memo FDA also notes the "absence of mandatory

reporting enforcement of H-IT safety issues limits the numbers of medical device reports

(MDRs) and impedes a more comprehensive understanding of the actual problems and

implications."

A 2010 Board Position Paper by the American Medical Informatics Association

(AMIA) contains recommendations on EHR-related patient safety, transparency, ethics

education for purchasers and users, adoption of best practices, and re-examination of

regulation of electronic health applications. Beyond concrete issues such as conflicts of

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interest and privacy concerns, questions have been raised about the ways in which the

physician-patient relationship would be affected by an electronic intermediary.

During the implementation phase, cognitive workload for healthcare professionalsmay be significantly increased as they become familiar with a new system.

Privacy and confidentiality

In the United States in 2011 there were 380 major data breaches involving 500 or

more patients' records listed on the website kept by the United States Department of

Health and Human Services (HHS) Office for Civil Rights. So far, from the first wall postings

in September 2009 through the latest on 8 December 2012, there have been 18,059,831

"individuals affected," and even that massive number is an undercount of the breach

problem. The civil rights office has not released the records of tens of thousands of

breaches it has received under a federal reporting mandate on breaches affecting fewer

than 500 patients per incident.

Goals and objectives

Improve care quality, safety, efficiency, and reduce health disparities

Quality and safety measurement

Clinical decision support (automated advice) for providers

Patient registries (e.g., "a directory of patients with diabetes")

Improve care coordination

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Engage patients and families in their care

Improve population and public health

Electronic laboratory reporting for reportable conditions (hospitals)

Immunization reporting to immunization registries

Syndromic surveillance (health event awareness)

Ensure adequate privacy and security protections

Quality

Studies call into question whether, in real life, EMRs improve the quality of care.

2009 produced several articles raising doubts about EMR benefits. A major concern is the

reduction of physician-patient interaction due to formatting constraints. For example,

some doctors have reported that the use of check-boxes has led to fewer open-ended

questions.

Barriers to adoption

Costs

The steep price of EMR and provider uncertainty regarding the value they will

derive from adoption in the form of return on investment have a significant influence on

EMR adoption. In a project initiated by the Office of the National Coordinator for Health

Information (ONC), surveyors found that hospital administrators and physicians who had

adopted EMR noted that any gains in efficiency were offset by reduced productivity as


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the technology was implemented, as well as the need to increase information technology

staff to maintain the system.

The U.S. Congressional Budget Office concluded that the cost savings may occuronly in large integrated institutions like Kaiser Permanente, and not in small physician

offices. They challenged the Rand Corporation's estimates of savings. "Office-based

physicians in particular may see no benefit if they purchase such a product —and may

even suffer financial harm. Even though the use of health IT could generate cost savings

for the health system at large that might offset the EMR's cost, many physicians might

not be able to reduce their office expenses or increase their revenue sufficiently to payfor it. For example, the use of health IT could reduce the number of duplicated diagnostic

tests. However, that improvement in efficiency would be unlikely to increase the income

of many physicians. "Given the ease at which information can be exchanged between

health IT systems, patients whose physicians use them may feel that their privacy is more

at risk than if paper records were used."

Doubts have been raised about cost saving from EMRs by researchers at Harvard

University, the Wharton School of the University of Pennsylvania, Stanford University, and

others.

Start-up costs

In a survey by DesRoches et al. (2008), 66% of physicians without EHRs cited capital

costs as a barrier to adoption, while 50% were uncertain about the investment. Around

56% of physicians without EHRs stated that financial incentives to purchase and/or use

EHRs would facilitate adoption. In 2002, initial costs were estimated to be $50,000 –

70,000 per physician in a 3-physician practice. Since then, costs have decreased with

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increasing adoption. A 2011 survey estimated a cost of $32,000 per physician in a 5-

physician practice during the first 60 days of implementation.

One case study by Miller et al. (2005) of 14 small primary-care practices found thatthe average practice paid for the initial and ongoing costs within 2.5 years. A 2003 cost-

benefit analysis found that using EMRs for 5 years created a net benefit of $86,000 per

provider.

Some physicians are skeptical of the positive claims and believe the data is skewed

by vendors and others with an interest in EHR implementation.

Brigham and Women's Hospital in Boston, Massachusetts, estimated it achieved

net savings of $5 million to $10 million per year following installation of a computerized

physician order entry system that reduced serious medication errors by 55 percent.

Another large hospital generated about $8.6 million in annual savings by replacing paper

medical charts with EHRs for outpatients and about $2.8 million annually by establishing

electronic access to laboratory results and reports.

Maintenance costs

Maintenance costs can be high. Miller et al. found the average estimated

maintenance cost was $8500 per FTE health-care provider per year.

Furthermore, software technology advances at a rapid pace. Most software

systems require frequent updates, often at a significant ongoing cost. Some types of

software and operating systems require full-scale re-implementation periodically, which

disrupts not only the budget but also workflow. Costs for upgrades and associated

regression testing can be particularly high where the applications are governed by FDA

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regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and

ability to continually customize, without large-scale reimplementation.

Training costs

Training of employees to use an EHR system is costly, just as for training in the use

of any other hospital system. New employees, permanent or temporary, will also require

training as they are hired.

In the United States, a substantial majority of healthcare providers train at a VA

facility sometime during their career. With the widespread adoption of the Veterans

Health Information Systems and Technology Architecture (VistA) electronic health record

system at all VA facilities, few recently-trained medical professionals will be

inexperienced in electronic health record systems. Older practitioners who are less

experienced in the use of electronic health record systems will retire over time.

Software quality and usability deficiencies

The Healthcare Information and Management Systems Society (HIMSS), a very

large U.S. health care IT industry trade group, observed that EMR adoption rates "have

been slower than expected in the United States, especially in comparison to other

industry sectors and other developed countries. A key reason, aside from initial costs

and lost productivity during EMR implementation, is lack of efficiency and usability of

EMRs currently available. The U.S. National Institute of Standards and Technology of the

Department of Commerce studied usability in 2011 and lists a number of specific issues

that have been reported by health care workers. The U.S. military's EMR "AHLTA" was

reported to have significant usability issues.

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Lack of semantic interoperability

In the United States, there are no standards for semantic interoperability of health

care data; there are only syntactic standards. This means that while data may be packagedin a standard format (using the pipe notation of HL7, or the bracket notation of XML), it

lacks definition, or linkage to a common shared dictionary. The addition of layers of

complex information models (such as the HL7 v3 RIM) does not resolve this fundamental

issue.

Implementations

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-

wide health information system that includes an electronic medical record, known as

the Veterans Health Information Systems and Technology Architecture (VistA). A key

component in VistA is their VistA imaging System which provides a comprehensive

multimedia data from many specialties, including cardiology, radiology and orthopedics.

A graphical user interface known as the Computerized Patient Record System (CPRS)

allows health care providers to review and update a patient's electronic medical record

at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place

orders, including medications, special procedures, X-rays, patient care nursing orders,

diets, and laboratory tests.

Need for Electronic Health Records (EHR)

The following are the most significant reasons why our healthcare system would

benefit from the widespread transition from paper to electronic health records.

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Figure 4.2: Outpatient paper-based patient encounter form

With the relatively recent healthcare models of pay-for-performance, patient

centered medical home model and accountable care organizations there are new reasons

to embrace technology in order to aggregate and report results in order to receive

reimbursement. It is much easier to retrieve and track patient data using an EHR and

patient registries than to use labor intensive paper chart reviews. EHRs are much better

organized than paper charts, allowing for faster retrieval of lab or x-ray results. It is also

likely that an EHR will have an electronic problem summary list that outlines a patient’s

major illnesses, surgeries, allergies and medications. How many times does a physician


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open a large paper chart, only to have loose lab results fall out? How many times does a

physician re-order a test because the results or the chart is missing? It is important to

note that paper charts are missing as much as 25% of the time, according to one study.

Even if the chart is available; specifics are missing in 13.6% of patient encounters,

according to another study. Table 4.1 shows the types of missing information and its

frequency. According to the President’s Information Technology Advisory Committee,

20% of laboratory tests are re-ordered because previous studies are not accessible. This

statistic has great patient safety, productivity and financial implications.

Table 4.1: Types and frequencies of missing information

Information Missing During Patient Visits % Visits

Lab results 45%

Letters/dictations 39%

Radiology results 28%

History and physical exams 27%

Pathology results 15%

EHRs allow easy navigation through the entire medical history of a patient. Instead

of pulling paper chart volume 1 of 3 to search for a lab result, it is simply a matter of a few

mouse clicks. Another important advantage is the fact that the record is available 24 hours

a day, seven days a week and doesn’t require an employee to pull the chart, nor extra

space to store it. Adoption of electronic health records has saved money by decreasing

full time equivalents (FTEs) and converting records rooms into more productive space,

such as exam rooms. Importantly, electronic health records are accessible to multiple


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said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trillion-

dollar healthcare bill is for administration.

EHRs are more efficient because they reduce redundant paperwork and have thecapability of interfacing with a billing program that submits claims electronically. Consider

what it takes to simply get the results of a lab test back to a patient using the old system.

This might involve a front office clerk, a nurse and a physician. The end result is frequently

placing the patient on hold or playing telephone tag. With an EHR, lab results can be

forwarded via secure messaging or available for viewing via a portal. Electronic health

records can help with productivity if templates are used judiciously. As noted, they allowfor point and click histories and physical exams that in some cases may save time.

Embedded clinical decision support is one of the newest features of a comprehensive

EHR. Clinical practice guidelines, linked educational content and patient handouts can be

part of the EHR. This may permit finding the answer to a medical question while the

patient is still in the exam room.

Several EHR companies also offer a centralized area for all physician approvals and

signatures of lab work, prescriptions, etc. This should improve work flow by avoiding the

need to pull multiple charts or enter multiple EHR modules. Although EHRs appear to

improve overall office productivity, they commonly increase the work of clinicians,

particularly with regard to data entry. We’ll discuss this further in the Loss of Productivity

section.

Quality of care and patient safety

As previously suggested, an EHR should improve patient safety through many

mechanisms: (1) Improved legibility of clinical notes, (2) Improved access anytime and


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anywhere, (3) Reduced duplication, (4) Reminders that tests or preventive services are

overdue, (5) Clinical decision support that reminds clinicians about patient allergies,

correct dosage of drugs, etc., (6) Electronic problem summary lists provide diagnoses,

allergies and surgeries at a glance.

In spite of the before mentioned benefits, a study by Garrido of quality process

measures before and after implementation of a widespread EHR in the Kaiser Permanente

system, failed to show improvement. To date there has only been one study published

the authors are aware of that suggested use of an EHR decreased mortality. This particular

EHR had a disease management module designed specifically for renal dialysis patientsthat could provide more specific medical guidelines and better data mining to potentially

improve medical care.

The study suggested that mortality was lower compared to a pre-implementation

period and compared to a national renal dialysis registry. It is likely that healthcare is only

starting to see the impact of EHRs on quality. Based on internal data Kaiser Permanente

determined that the drug Vioxx had an increased risk of cardiovascular events before that

information was published based on its own internal data. Similarly, within 90 minutes of

learning of the withdrawal of Vioxx from the market, the Cleveland Clinic queried its EHR

to see which patients were on the drug. Within seven hours they deactivated

prescriptions and notified clinicians via e-mail. Quality reports are far easier to generate

with an EHR compared to a paper chart that requires a chart review. Quality reports can

also be generated from a data warehouse or health information organization that

receives data from an EHR and other sources. Quality reports are the backbone for

healthcare reform which are discussed further in another chapter.


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Public expectations

According to a 2006 Harris Interactive Poll for the Wall Street Journal Online, 55%

of adults thought an EHR would decrease medical errors; 60% thought an EHR wouldreduce healthcare costs and 54% thought that the use of an EHR would influence their

decision about selecting a personal physician.

The Center for Health Information Technology would argue that EHR adoption

results in better customer satisfaction through fewer lost charts, faster refills and

improved delivery of patient educational material. Patient portals that are part of EHRs

are likely to be a source of patient satisfaction as they allow patients access to their

records with multiple other functionalities such as online appointing, medication

renewals, etc.

Governmental expectations

EHRs are considered by the federal government to be transformational and integral

to healthcare reform. As a result, EHR reimbursement is a major focal point of the HITECH

Act. It is the goal of the US Government to have an interoperable electronic health record

by 2014. In addition to federal government support, states and payers have initiatives to

encourage EHR adoption. Many organizations state that healthcare needs to move from

the cow path to the information highway. CMS is acutely aware of the potential benefits

of EHRs to help coordinate and improve disease management in older patients.

Financial savings

The Center for Information Technology Leadership (CITL) has suggested that

ambulatory EHRs would save $44 billion yearly and eliminate more than $10 in rejected


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claims per patient per outpatient visit. This organization concluded that not only would

there be savings from eliminated chart rooms and record clerks; there would be a

reduction in the need for transcription. There would also be fewer callbacks from

pharmacists with electronic prescribing. It is likely that copying, faxing and mail expenses,

chart pulls and labor costs would be reduced with EHRs, thus saving full time equivalents

(FTEs). More rapid retrieval of lab and x-ray reports results in time/labor saving as does

the use of templates. It appears that part of the savings is from improved coding. More

efficient patient encounters mean more patients could be seen each day. Improved

savings to payers from medication management is possible with reminders to use the

drug of choice and generics. It should be noted that this optimistic financial projection

assumed widespread EHR adoption, health information exchange, interoperability and

change in workflow.

EHRs should reduce the cost of transcription if clinicians switch to speech

recognition and/or template use. Because of structured documentation with templates,

they may also improve the coding and billing of claims. It is not known if EHR adoptionwill decrease malpractice, hence saving physician and hospital costs. A 2007 Survey by

the Medical Records Institute of 115 practices involving 27 specialties showed that 20%

of malpractice carriers offered a discount for having an EHR in place. Of those physicians

who had a malpractice case in which documentation was based on an EHR, 55% said the

EHR was helpful.

Technological advances

The timing seems to be right for electronic records partly because the technology

has evolved. The internet and World Wide Web make the application service provider


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(ASP) concept for an electronic health record possible. An ASP option means that the EHR

software and patient data reside on a remote web server that users can access via the

internet from the office, hospital or home. Computer speed, memory and bandwidth have

advanced such that digital imaging is also a reality, so images can be part of an EHR

system. Personal computers (PCs), laptops and tablets continue to add features and

improve speed and memory while purchase costs drop. Wireless and mobile technologies

permit access to the hospital information system, the electronic health record and the

internet using a variety of mobile technologies.

The chapter on health information exchange will point out that health informationorganizations can link EHRs together via a web-based exchange, in order to share

information and services.

Need for aggregated data

In order to make evidence based decisions, clinicians need high quality data that

should derive from multiple sources: inpatient and outpatient care, acute and chronic

care settings, urban and rural care and populations at risk. This can only be accomplished

with electronic health records and discrete structured data. Moreover, healthcare data

needs to be combined or aggregated to achieve statistical significance. Although most

primary care is delivered by small practices, it is difficult to study because of relatively

small patient populations, making aggregation necessary. For large healthcare

organizations, there will be an avalanche of data generated from widespread EHR

adoption resulting in “big data” requiring new data analytic tools.


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Need for integrated data

Paper health records are standalone, lacking the ability to integrate with other

paper forms or information. The ability to integrate health records with a variety of otherservices and information and to share the information is critical to the future of

healthcare reform. Digital, unlike paper-based healthcare information can be integrated

with multiple internal and external applications:

Ability to integrate for sharing with health information organizations (another

chapter)

Ability to integrate with analytical software for data mining to examine optimal

treatments, etc.

Ability to integrate with genomic data as part of the electronic record. Many

organizations have begun this journey. There is more information in the chapter

on bioinformatics

Ability to integrate with local, state and federal governments for quality reporting

and public health issues

Ability to integrate with algorithms and artificial intelligence. Researchers from

the Mayo Clinic were able to extract Charlson Comorbidity determinations from

EHRs, instead of having to conduct manual chart reviews

EHR is a transformational tool

It is widely agreed that US Healthcare needs reform in multiple areas. To modernize

its infrastructure healthcare would need to have widespread adoption of EHRs. Large

organizations such as the Veterans Health Administration and Kaiser Permanente use


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robust EHRs (VistA and Epic) that generate enough data to change the practice of

medicine.

In 2009 Kaiser Permanente reported two studies, one pertaining to themanagement of bone disease (osteoporosis) and the other chronic kidney disease. They

were able to show that with their EHR they could focus on patients at risk and use all of

the tools available to improve disease management and population health. In another

study reported in 2009 Kaiser-Permanente reported that electronic visits that are part of

the electronic health record system were likely responsible for a 26.2% decrease in office

visits over a four-year period. They posited that this was good news for a system thataligns incentives with quality, regardless whether the visit was virtual or face-to-face.

Other fee-for-service organizations might find this alarming if office visits decreased and

e-visits were not reimbursed. Kaiser also touts a total joint registry of over 100,000

patients with data generated from its universal EHR.

As a result of their comprehensive EHR (KP HealthConnect) and visionary

leadership they have seen improvement in standardization of care, care coordination and

population health. They also have been able to experience advanced EHR data analytics

with their Virtual Data Warehouse, use of artificial intelligence and use of computerized

simulation models (Archimedes). In addition, they have begun the process of collecting

genomic information for future linking to their electronic records.

Need for coordinated care

According to a Gallup poll it is very common for older patients to have more than

one physician: no physician (3%), one physician (16%), two physicians (26%), three

physicians (23%), four physicians (15%), five physicians (6%) and six or more physicians


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(11%). Having more than one physician mandates good communication between the

primary care physician, the specialist and the patient. This becomes even more of an issue

when different healthcare systems are involved. O’Malley et al. surveyed 12 medical

practices and found that in-office coordination was improved by EHRs but the technology

was not mature enough to improve coordination of care with external physicians.

Electronic health records are being integrated with health information

organizations (HIOs) so that inpatient and outpatient patient-related information can be

accessed and shared, thus improving communication between disparate healthcare

entities. Home monitoring (tele-homecare) can transmit patient data from home to anoffice’s EHR also assisting in the coordination of care. It will be pointed out in a later

section that coordination of care across multiple medical transitions is part of Meaningful

Use.

HEALTH INFORMATION MANAGEMENT

Health information management (HIM) is information management applied

to health and health care. It is the practice of acquiring, analyzing and protecting digital

and traditional medical information vital to providing quality patient care. With the

widespread computerization of health records, traditional (paper-based) records are

being replaced with electronic health records (EHRs). The tools of healthinformatics and health information technology are continually improving to bring

greater efficiency to information management in the health care sector.

https://en.wikipedia.org/wiki/Information_managementhttps://en.wikipedia.org/wiki/Healthhttps://en.wikipedia.org/wiki/Health_carehttps:

computer and our society; medicine

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