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Feb 27, 2014

IMPLEMENTATION OF ELECTRONIC MRD- A FEASIBILITY STUDY IN A TERTIARY CARE HOSPITAL


Exactly, as shared by one of the follower of my blog for use of students all over- Thanks  a lot! if you wish  I will put your name here any time!

As the medical care gets more and more complex and as the stock of information enlarges the physicians need new technologies to help them cope and be more efficient. This makes essential the use of information technology and need for a digital to allow capture of patient data that can then be processed and mined for insights into better treatment for patients.
With the many advances in information technology over the past 20 years, particularly in healthcare, a number of different forms of electronic health records (EHR) have been discussed, developed, and implemented.[1] The electronic medical record (EMR) is the tool that promises to provide the platform from which new functionality and new services can be provided for patients.
Around the globe, there has been a significant improvement in the healthcare industry standards and use of various tools to define quality. Quality of patient information is one such tool which helps the health care organizations provide excellence in the industry. But, there are many misconceptions about various terminologies and concepts of use of information technology and electronic medical records.
Electronic Medical Record: “An application environment composed of the clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy, and clinical documentation applications. This environment supports the patient’s electronic medical record across inpatient and outpatient environments, and is used by healthcare practitioners to document, monitor, and manage health care delivery within a care delivery organization (CDO). The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO”  by HIMSS
A feasibility study is an evaluation and analysis of the potential of the proposed project which is based on extensive investigation and research to give full comfort to the decisions makers.
Feasibility studies aim to objectively and rationally uncover the strengths and weaknesses of an existing business or proposed venture, opportunities and threats as presented by the environment, the resources required to carry through, and ultimately the prospects for success.
In its simplest terms, the two criteria to judge feasibility are cost required and value to be attained. As such, a well-designed feasibility study should provide a historical background of the business or project, description of the product or service, accounting statements, details of the operations and management, marketing research and policies, financial data, legal requirements and tax obligations.
Till late fifties in India, there was no awareness among the hospital clinicians as well as administrators and usually the Medical records departments that have come up were not planned as a part of total health care.
Various Organizations face various problems with medical records they are:
  • Incomplete records, for which the physicians are asked to complete causing duplication of work
  • Inadequacy of space, causing the decentralized storage of records
  • Frequent requests of changing patient’s name
  • Loss of records
Despite of above problems been faced for a long time there is no Information technology coming in, in spite of the availability of many efficient Electronic medical records systems. It was thus decided to conduct a study of the medical records department of ABC a hospital, to understand the barriers and facilitators of Implementation of EMRs.
While it is important to determine what is “in the EMR” it is also critical to understand what is not considered part of the EMR. Gartner has put forth a model for the Healthcare environment which contains all of the IT systems needed to run healthcare organizations.
AIM AND METHODOLOGY OF THE STUDY
The study was intended to find the feasibility of Electronic Medical records in a tertiary care hospital.
The study was based on the Observations of the policies and procedures, the cost estimation and Closed End Questionnaire from the medical professionals with the sample size of 354.
LITERATURE REVIEW
HEALTH INFORMATION SYSTEMS
Health Information Systems are designed to integrate data collection, processing, reporting, and the use of information necessary for improving the effectiveness and efficiency of the health service through better management at all levels of health care (WHO, 2000).
Medical records institute defines five distinct stages [Figure 3.2] of health care information system towards the development of true Electronic Health Record (EHR) (Weagermann, 1999) in Gash (1999). [15]

Definitions:
The market has confused the electronic medical record (EMR) and the electronic health record (EHR). The NAHIT has produced the following definitions for EMR and EHR and PHR:
EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.
EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.
PERSONAL HEALTH RECORD: An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.


DIMENSIONS OF EMR:
 EMR is more than just electronic storage of records/ data. It is a system. There are 10 DIMENSIONS OR CORE CAPABILITIES OF EMR as defined by Gartner

10 Dimensions of EMR , Fig 3.3

CHALLENGES IN IMPLEMENTATION OF EMR:

A.     Transition (Paper Chart to Electronic) – Hybrid
B.     Total Cost  (Return on Investment)
C.     Integration with the Workflow
  • Current workflow cleanup
  • Customization and configuration
D.     Usability (Clinicians)
  • EMR slows down the clinicians productivity
  • Configurable (Data Capture)
E.      Usability (Nurses)
F.      Interface with rest of the system
G.     Interface with Devices
H.     Down time management – Availability, Disaster Recovery
The above challenges can be overcome by a planned and effective implementation
IMPLEMENTATION OF EMR
American Society Of Cataract And Refractory Surgery  and  American Society Of Ophthalmic Administration have stated Five Steps of Implementation:
1.     Advance preparation
2.     System selection
3.     Implementing right fit
4.     Training/ maintenance
5.     Go live (continuous improvement)
ADOPTION SCENARIO OF ELECTRONIC MEDICAL RECORDS: India
Majority of the hospitals in Asian countries such as India, China, Thailand, Malaysia and Indonesia are still in the early stages of IT adoption. These hospitals are far behind in terms of IT adoption when compared to USA." said SourabhKankhar Research Analyst, Asia Pacific Healthcare Practice, Frost& Sullivan.
Reasons of faster adoption in West than India are perhaps based on certain specific factors dominating the Western healthcare scene, such as increased patient awareness, new government initiatives encouraging EMR, high penetration of computers, new product innovations, economic pressures on healthcare organizations and increased legal compulsions for greater accountability and well-maintained records.
The EMR market is a fast developing market in India. Barriers of EMR Adoption in India are: most importantly lack of awareness among medium and small scale providers   about the benefits and advantages. Resistance to adoption are lack of compatible technology with existing systems and lack of user friendly interface, high cost of implementation, long implementation process, the decrease in productivity during implementation, vendors lack domicile knowledge in healthcare.
GLOBAL MARKET:
Accenture conducted a study of leading health care software, hardware, and services companies to gauge the attractiveness of eight international electronic medical record (EMR) markets of considerable size and EMR maturity. Those markets include Australia, Canada, France, Germany, Japan, The Nordics, Spain and the United Kingdom (UK). Other large markets— namely, India and China— were not studied due to conflicting opinions of overall EMR maturity.
The market is expected to grow at a rate of 6.6 to 9.7% across North America, Europe, Latin America and Asia Pacific. The global market is expected to be $19.7 billion in 2013.
Asia Pacific’s EMR market is expected to grow at 7.6 percent Compound annual growth rate (CARG) from $2.3 billion to $2.9 billion (which is highly dependent on the growth rate of INDIA and CHINA) as compared to North America with highest growth rate of 9.7% CARG from $7.4 billion in 2010 to $9.8 Billion in 2013. The acceleration in the market is due to ARRA incentives and penalties.
Europe, Africa, and Latin America will grow at 7.6% through 2013 driven by government incentives.
The study states that there are four primary forces which have the most impact on EMR growth:
1.Emerging Markets: Many emerging markets (for example, Malaysia, Thailand, Brazil, Russia, India and China) and can potentially utilize innovative approaches such as cloud-based solutions. The future of these markets will be largely dependent on regulatory standards, government support and future trends affecting domestic health care systems.
2.Government funding: Government incentives (e.g. The United States’ ARRA incentives and penalties
3.Regional National and multicountry integration
4. Labor Shortage: with rapid increase of information technology in health care, there is expected increase in demand of the clinically trained IT personnel and because of more shortage of nurses in near future the need to have Electronic Medical Records is definitively going to arise.
OBSERVATIONS:
1.     The Major problems with manual medical records were identified to be:
·       Delay in patient care because of dispersed records.
·       Multiplicity  of form types used to document the patient records.
2.     The awareness levels among the health care workers was highest among health care workers with post graduates and lowest among those with diploma holders.
3.     The Acceptance Levels of the EMR which was seen among the health care providers (nurses and Post graduate doctors 75% and 86% respectively) in the tertiary care hospital were seen to be 75% andmajority of the health care providers are willing to take up the training.
Acceptance Levels for Paper and Electronic Records among Nurses

1.     There was need to increase the infrastructure to 25% of number of computers and 15 % of printers (keeping in mind the security of patient information).
2.     Cost of Implementation:
Ø  The total health IT includes:
v The initial fixed cost of the hardware, software, and technical assistance necessary to install the system;
v Licensing fees;
v The expense of maintaining the system; and
v The “opportunity cost” of the time that health care providers could have spent seeing patients but instead must devote to learning how to use the new system and how to adjust their work practices accordingly. Various studies have stated that the productivity decreases by 10%  to 15%
v Social costs: Risk of lost privacy because of such system and such situations can be avoided by complying to the governmental standards in their respective countries, also by providing the ability to track who accesses the patient’s record.
Ø  The costs of implementing vary widely based on the:
v Size and complexity of providers’s operations.
v The extent to which the providers want to perform their work electronically.
v Differences in the amounts and types of associated training and labor costs (for operating the system).
The cost calculated was Rs. 2,31,00,000 based on all the above factors.
There were few areas where recurring cost due to increase in infrastructure increased (because of cost of maintenance, increase in electricity expenses).
The areas of cost saving were the decrease in the labor, the stationery, which was estimated to be Rs.38,00,000
CONCLUSION:
If the patients’ records are made electronic the space used presently for paper records can be used for other purposes. As MRD is in the OPD block various other services can be provided.
The major problems faced by nurses and post graduates with the present paper records are:
Ä Delay in service delivery because of dispersion of records by 66.9% nurses whereas 86.1% of post graduates face this problem
Ä Multiplicity of form types consumes their major time (65.9%) whereas (83%) post graduates face this problem.
graduates highly agree and agree that health care should devote time to the training
The Capital cost of implementation of EMR was calculated to be 2 Crore 31 lakhs .Once the EMR is fully functional the expected cost saving can be somewhere more than 35 lakhs per year.
SUGGESTIONS:
v First of all the users’ needs and problems should be identified and their acceptance to change must be evaluated. Orientation is important at this stage.
v The institution must ensure that the inefficiencies in the department must be removed first then the implementation must commence
v The cost of implementation is very high so the implementation can be stepwise and the costs can be divided into two financial years.
SUGGESTIONS:
v First of all the users’ needs and problems should be identified and their acceptance to change must be evaluated. Orientation is important at this stage.
v The institution must ensure that the inefficiencies in the department must be removed first then the implementation must commence
v The cost of implementation is very high so the implementation can be stepwise and the costs can be divided into two financial years.
v The dependency on vendor should be minimized thus vendor operated systems should be avoided
v The EMR should be easy to learn, understand, operate i.e. no requirement of opening of multiple windows, which tends the user make mistakes.