EMR

Electronic Medical Records



Electronic Medical Records

Introduction

As health care becomes ever more integrated, community based and quality demanding, electronic medical records (EMRs) become necessary supporting technology. Potential advantages over current paper-based systems include faster, portable and more reliable access to charts, instantaneous access to decision support from the simple (drug interaction flags) to the complex (patient-specific messages, re: prescribing recommendations), ability to rapidly formulate patient summaries for referrals and letters, integration of laboratory and pharmacy data directly into the patient record, ability to query the practice population to support preventive health manoeuvres or research, and tighter security.

The validity of many of these claimed advantages in mainstream primary care remains unproven.

The COMPETE (Computerization of Medical Practices for the Enhancement of Therapeutic Efficacy) study, the first of its kind in Canada, aimed to study the entire process of computerizing community-based primary care physicians in Southwestern Ontario (Johnson, 2006).

This included research on EMR selection, willingness-to-pay by physicians, change management, EMR implementation, provider and patient privacy concerns, and automated, EMR-based prescribing review and intervention.

An early phase of the study involved the development and application of a rigorous EMR software assessment process. This degree of rigor applied to EMR selection has not previously been described in the literature (Ornstein, 2007). We present here our methodology and results.

Methods

A literature review of MEDLINE and EMBASE, from inception to March 2003 using keywords “medical records systems, computerized” (Giacomini, et al., 2007) as MESH heading and “selection” as text word yielded no relevant hits. At the time of our selection process, attendance at the standard informatics meetings (HIMMS, TEPR, AMIA, COACH) and review of their proceedings revealed (a) no discussions of EMR selection within a standard health technology assessment approach, (b) emphasis on EMRs based in hospitals or large HMOs or clinics with centralized clinicians and IT staff (Giacomini, et al., 2007). Our target population was primary care in the usual small office, community practice.

Therefore, a software selection team, which comprised of technical, clinical and research methodology expertise was assembled to carry out all phases of the subsequent evaluation. Specifically, team members combined expertise in the assessment of hardware and software, database and network configurations, user interface, feasibility in primary care, EMR content and research methodology. The main working premises of the group included the following:

The “average” Ontario family physician is in solo or small group fee-for-service community practice, is the gatekeeper for all health services, does not personally use a computer in the office (<5% using EMR in practice) and sees 25-60 patients per day. Virtually all physicians bill for services electronically.

EMR data architecture is a key variable. Since COMPETE is examining clinical outcomes, utilization and processes of care, standard database designs with coded data are preferable to text entry EMRs (Strasberg, et al., 2006).

Physician usability of the EMR is a major issue. Interfaces inhibiting speedy, intuitive, flexible charting are likely to fail.

Measures to protect patient privacy are essential.

The selected EMR software must be compatible with provincial and national health care developments, which may involve data and ...