Thursday, October 7, 2010

Electronic Medical Records and Handheld Devices in Healthcare

Advances in computer technology and internet use occur rapidly in the medical field, such as the increased use of robotics in surgery, using computer-assisted imaging for diagnostic tests in addition to the physical examination, and the practice of laparoscopic surgical techniques and procedures via computer-based simulator by both resident physicians and attending physicians, to name but a few.  A particular development, which will be examined here, is the recent movement toward adopting and maintaining electronic medical records (EMRs) and electronic health records (EHRs). 
Beyond EMRs and EHRs, recent advances in medicine have been the result of innovation in computer technology and the adapted use of internet resources, frequently via handheld devices such as personal data assistants (PDAs) and smart phones.   These smart phones, PDAs, and handheld devices most commonly used include the Blackberry line by Research-in-Motion, the iPhone and iPad by Apple, and various handsets by different manufacturers using the Android operating system by Google. 
The functionalities of EMRs and EHRs serve the same purpose as paper charting in the medical field.  In paper charts, there are the patient demographics and history, clinical notes on the patient, lab results, prescriptions, test orders and often billing information and history. Electronic records and the use of handheld devices in medicine seem tangentially related.  However, as most of the healthcare field moves toward an increasingly digital mode of practice, away from paper charts and file rooms, the two become increasingly intertwined.  What are EMRs and EHRs?  What is the difference between the two?  Habib (2010) points outs the distinction between EMRs and EHRs as stated by the Office of the National Coordinator for Health Information Technology:  EMRs refer to the legal patient record created in hospitals and ambulatory care centers, forming the basis of the EHR, which is the interface through which physicians, other healthcare providers and patients are able to access the comprehensive medical records of a patient across different facilities.
            The use of handheld devices and smart phones by healthcare providers is also becoming increasingly common.  One reason for this is that numerous applications, or apps, are available for use on these handheld devices which can supplement and streamline the workflow of a healthcare provider.  Some apps have similar functionality to the certified electronic records software, including, for example, viewing imaging results from radiological studies and listing drug interactions, dosing guidelines, and possible contraindications for managing a patient’s prescription medicines (Hsiao, 2009).  On the patient side, medical information is more readily available than ever on the internet, leading many patients to use these resources to become more informed prior to and during their interaction with healthcare providers, and some EHR systems allow patients to access their own record remotely, without having to call the hospital or their physician’s office to inquire about imaging studies or lab results.
Potential Benefits
            There are several major benefits in implementing EMR/EHR and using handheld devices in a clinical setting.  Paper records can be bulky, and require a lot of physical space for storage.  Additionally, the relevant information takes more time to be found before any decisions can be made, when dealing with paper records and charts.  One feature that is common to electronic record systems is the use of reminders embedded in the software for guideline-based interventions, in addition to the consolidation of patients’ history, patient problems, clinical notes, prescriptions, orders and lab results (Hsiao, Beatty et al., 2009). 
Another benefit is that implementing EMRs and EHRs help the bottom line of affected practices and healthcare organizations.  As Hillestad, Bigelow et al. (2005) noted, “effective EMR implementation and networking could eventually save more than $81 billion annually,” but they go on to acknowledge this level of savings would be unlikely without wholesale changes to the health care system.  Before savings can be realized, there are several barriers to adopting electronic records, and these include the high initial cost, downtime for providers during the transition from paper records to electronic records, and the lack of certification and standardization (Hillestad, Bigelow et al., 2005).  Moreover, this lack of standardization is a major problem, as there is no uniform EMR system between all healthcare settings and practices.  Instead the market is fragmented with proprietary systems that may not be interoperable, which is a definite problem as the portability and ease of use of patient records is crucial, especially among patients with chronic conditions managed by multiple specialists.  This is a drawback, as a major goal of EMR and EHR implementation is to ensure that patient information is immediately accessible and easily transferable (Hartzband & Groopman, 2008).
When EMR and EHR are implemented, another major benefit is the potential to reduce medical errors, and also to facilitate coordination of care and the sharing of clinical results between specialists and the patient.  With respect to handheld devices, the major benefit is convenience and ease in accessing information via the internet and applications relevant to the scope of practice.  Application developers usually support several platforms at once, for example, Epocrates is an application that serves as a prescription drug reference and is available for the iPhone, iPad and Android smart phones as well.
Bauchner (2002) presciently observed the greatest potential benefits of EMR/EHR and the usage of handheld devices, noting that, “Combined with EMRs, and advances in e-mail communication, it is quite imaginable that every physician will literally ‘carry’ the medical record of every patient they care for and communicate with them instantaneously.”  A major benefit of this is an increase in responsiveness of physicians and other healthcare providers to their patients’ questions and concerns.  Information is more readily accessible and at their fingertips with the use of handheld devices, smart phones and the right apps.  On a more practical level, the adoption of EMR and EHR, as compared to the use of paper records, requires far less space, can generate additional revenue by converting physical paper record storage to an additional examination room, for instance, and also improves the legibility of the records by moving from the stereotypical chicken scratch physician handwriting to a keyboard or touch screen (Alpers, 2010).  On a patient safety level, the adoption of EMR and EHR have been shown to potentially to reduce the number of medical errors that occur, largely in part to the computerized patient order entry (CPOE) alerts and reminders that pop up to inform a healthcare provider about drug interactions and contraindications (Hillestad, Bigelow et al., 2005). 

Further Required Research
            The further required research with respect to EMR and EHR, and the use of handheld devices and smart phones in the clinical setting requires a three-pronged approach.  First, patient privacy is an utmost concern.  Since patient records are accessed by physicians and other healthcare providers wirelessly on their handheld devices and smart phones, great care must be taken to protect patient information and to ensure privacy.  Along with patient privacy, liability for lapses in security and the legal ramifications must be explicitly relayed to all providers.  Second, studies must be done on the feasibility of standardizing an EMR system.  An essential part of a feasibility study would be examining the potential standardization of a universal EMR system, which is compatible across all of the relevant platforms including the popularly and increasingly used handheld devices, PDAs and smart phones.  Lastly, the financial implications for the adoption of EMR and EHR and handheld device usage must be modeled to include the cost savings for the different practice settings both during implementation and after the inconvenience and downtime of the initial outlay.

Widespread adoption of EMRs and EHRs are advisable for the future.  The trend has been a gradual increase in the use of EMRs by physicians in 2007, from 11.8% for basic EMRs and 3.8% for fully functional EMRs, to respectively 20.5% and 6.3% for basic and fully functional EMRs in 2009 (Hsiao, Beatty et al. 2009).  This trend increases the accessibility of medical information to health professionals, as well as patients.  The patients appreciate the transparency and ability to view their medical records easily, but should be cautioned not to interpret their medical records outside of the context of the advice of their medical professional.  Handheld devices, PDAs and smart phones are increasingly common in clinical practice, and more apps are introduced as time passes, which increase the appeal and utility of these devices to medical professionals.  However, as Hartzband and Groopman (2008) advocate, with the implementation of health IT such as EMRs/EHRs, physicians and other healthcare providers need to remember to maintain their attention on the patients and not on their keyboards and touch screens as they search for and enter information, or they risk missing the subtle clues that may aid their clinical decision-making process.

Alpers, A. (2010, October 5).  Benefits of EMR outweigh the cost and learning curve. Social media’s leading physician voice. Retrieved October 5, 2010, from
Alpers’ post was found on the medical weblog, which frequently features physicians from various fields as guest bloggers, and provides insight from the viewpoint of an insider, a primary care physician, Dr. Alpers.

Bauchner, H.  (2002, March).  Information technology—improving medicine.  Archives of
            Disease in Childhood, 86(3), 223. Retrieved from MEDLINE with Full Text Database.
Bauchner discusses four ways information technology has been responsible for progress made in healthcare.  The Archives of Disease in Childhood is a reputable peer-reviewed journal, a subsidiary of the British Medical Journal.

Habib, J.  (2010, June 4).  EHRs, Meaningful Use, and a Model EMR.  Drug Benefit
Trends.  Retrieved October 5, 2010, from
Habib explains the federal incentives for using and penalties against not using EMR.  Drug Benefit Trends is a trade publication for, in its own words, “medical directors, pharmacy directors, and managed care decision makers.”

Hartzband, P., & Groopman, J. (2008). Off the record—avoiding the pitfalls of going
            electronic. The New England Journal Of Medicine, 358(16), 1656-1658. Retrieved
            from MEDLINE with Full Text database.
Hartzband & Groopman offer the drawbacks and potential issues involved with switching to EMR.  The New England Journal Of Medicine is a peer-reviewed medical journal.

Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., and Taylor, R. 
            Can Electronic Medical Record Systems Transform Health Care? Potential Health
            Benefits, Savings, and Costs.  Health Affairs, 24(5), 1103-1117.  Retrieved October
Hillestad, Bigelow et al. explain the benefits of EMR from patient safety and economic frames of reference.  Health Affairs is a peer-reviewed journal focused on health policy and research.

Hsiao, C., Beatty, P., Hing, E., Woodwell, D., Rechtsteiner, E., and Sisk, J.  (2009, December).
Electronic Medical Record/Electronic Health Record Use by Office-Based Physicians United States 2008 and Preliminary 2009. Centers for Disease Control and Prevention, Division of Healthcare Statistics.  Retrieved October 5, 2010, from
Hsiao, Beatty et al. discuss the federal interest in promoting the adoption of EMR/EHR by healthcare providers, including the incentives, and provide the statistics describing the use of EMR/EHR by healthcare providers, which were obtained via in-person and electronic surveys.
The survey was performed by a division of the Centers for Disease Control and Prevention, a well-known and respected authority and government agency of the federal government.

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