Electronic Medical/Health Records

Digitalization of healthcare services were started from transformation of paper-based health/medical data into paperless of electronic medical/health records. Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) are foundations in building e-health or mobile health systems [4]. EMRs are medical data in the form of digital that is easy to store, update, and exchange between healthcare institutions anywhere and anytime [5]. [6] explained EMRs as the digital medical data that composes of reports about patients’ medical conditions, histories, checkups reports, medicines and medical treatment. In addition, EMR systems can include patient records and management, electronic medication histories, and even costing and payment systems [7], [8]. Therefore, health information systems (HIS) needs new mechanisms in drawing customers’ interests to medical or health records. In order to support the idea of empowerment and customers’ participation, the concept of object-oriented design can be used to offer systems flexibility for medical and health information.

Prevalence and incidence are essential measures for disease surveillance, to describe the burden of disease in a population and compare health status across populations and over time. Routinely-collected electronic health data- bases, such as administrative health records (AHRs), which are captured for healthcare system management and remuneration, are important sources for estimating disease prevalence and incidence because they provide information for the entire population and can therefore be used for surveillance of both common and rare conditions [1–5]. As well, they systematically capture information over time, which enables monitoring of trends. Electronic medical records (EMRs), digital versions of patient me- dical charts, are also increasingly being used for disease surveillance because they have many of the same advan- tages as AHRs and they also capture clinical information such as body mass index, smoking, and alcohol use [6–9].

Professional Software for Nurses is a nurse-owned software company whose mission is to make the work of the school nurse easier, efficient and more effective. As president of the company, and a clinical specialist with 9 years of school nursing experience, I strongly believe technical advances must be tempered with a human touch and expert judgment. “Caring Through Technology” is our company’s motto and we are committed to blending the best of nursing informatics with state of the art computer science. Our company prides itself on providing friendly, personalized and knowledgeable service. We continue to expand our product line with innovative software solutions focused on the unique health needs of students within the school environment.

Software  ‐ Scheduling. 31[r]

National governmental agencies including the Institute of Medicine have called for the widespread adoption of elec- tronic health records (EHRs) [1,2]. Evidence suggests that use of EHRs can increase delivery of preventive care, enhance monitoring of drug therapy, and improve adher- ence to evidence based guidelines [3-6]. In response to this call to integrate information technology into patient care, US academic medical centers are increasingly incor- porating electronic health records into teaching settings [3,7,8]. As more universities adopt electronic information systems, medical students are increasingly learning to conduct and document ambulatory visits using the EHR. Medical educators are now trying to assess the impact of EHRs on medical students and post-graduate trainees. Keenan and colleagues, in a recent review article, described that residents were satisfied with electronic medical records for a number of reasons: easy access of clinical data, legibility of notes, improved problem lists and medication lists, better preventive care documenta- tion, and reduced medical errors [9]. The authors also found that the EHR-related education included point-of- care knowledge delivery, computerized decision support systems, profiling ACGME competencies, and daily work- flow management. As for the medical students, educators are also experimenting computerized order entry, tem- plated care notes, and virtual patients, mostly during busy clinical clerkships [9].

Medical records have been around since the advent of healthcare. In the very early days, the medical record was used to record the disease and the probable cause of that disease (National Institutes of Health, 2006). In the early part of the twentieth-century, medical records were kept on three by five cards (Hufford, 1999). The 1960’s and 1970’s saw a rapidly changing era in healthcare when the federal government passed legislation that established Medicare (Hufford, 1999). At the same time, other third-party payers entered the healthcare market, healthcare lawsuits starting immerging, healthcare quality became important, and the government passed more stringent laws regulating the industry (Hufford, 1999). This is the time frame when medical records really became a necessity in healthcare, and the first electronic health record appeared (History of the Electronic Medical Record, n.d.)

At the government level, Medicare and Medicaid are likely to follow the examples of the large employers with respect to financial incentives for documentation of quality care. Although there is currently no federal mandate to use EMRs, in July 2003 the Department of Health and Human Services (HHS) announced two important initiatives that promote the technology (Healthcare Informatics 2003). HHS will license the American College of Pathology’s Systemitized Nomenclature of Medicine Clinical Terms (SNOWMED-CT) medical vocabulary.This tool will be available for free from the National Library of Medicine. HHS also commis- sioned the Institute of Medicine (IOM) to design a standard definitional model of Electronic Health Records (EHR) to share with all stakeholders.

Little research has been done to study systematic changes to the referral process that could improve these deficits in communication. Computerizing the referral process and substituting electronic messaging for paper-based communications could help solve the problem of insufficient information exchange. Implementing referrals within a net- worked environment could facilitate communication between primary care physicians and specialists by making it easier to send a complete referral letter and more quickly receive feedback (Sittig et al. 1999). Computerized referral templates could require necessary data elements, and, unlike paper-based forms, can enforce those require- ments. Coded information already stored within the electronic medical record could be automatically included in the communications, eliminating time-consuming data re- entry. Referral messages also could be routed to multiple recipients, ensuring that the clinical process and managed care approval process proceed in tandem without physi- cian intervention. Finally, the status of referrals on multiple patients could be tracked in a central location, so that primary care providers can more quickly know when a specialist’s evaluation is complete.

future-oriented context, EHR and personal health records (PHR) will bridge this gap, but neither is widely used (eg, Google Health, Microsoft Health Vault, and various health plan systems, ie, Aetna, Kaiser) (Google Health is a personal health information centralization service or a personal health record services which allows users to volunteer their health records – either manually or by logging into their accounts at partnered health services providers – into the Google Health system, thereby merging potentially separate health records into one centralized Google Health profile. Microsoft HealthVault is a platform to store and maintain health and fitness information. Started in October 2007, the website is accessible at www.healthvault.com and addresses both lay- men and healthcare professionals. PHR also confound the dataset by allowing patients to directly enter information which raises data-quality issues.

A researcher-made questionnaire for data collection was developed on the basis of Wilkins‟ (2008), Nair‟s (2011), Morton‟ (2008) and Conrad‟s (2009) questionnaires. Wilkins evaluated heath information mangers‟ PU and PEOU toward electronic heath care record system [37]. Nair used technology acceptance model to elucidate the heath care behavior in adopting electronic health records [38]. Morton applied integrated model of TAM and DOI to recognize factors affecting physicians‟ attitudes toward using Electronic Health Records (EHRs) [18]. Also, Conrad conducted a study to examine some key determinants of individual willingness to use a new technology by utilizing a framework grounded in TAM and DOI [33].

Evaluating data within an EMR at the clinic or practice levels can be challenging, as many vendors provide a user-friendly interface but are unable to easily capture and evaluate aggregate data. The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) enables a practice or clinic to improve data quality and manage the health of its patients at the population level. It extracts data from EMRs and aggregates them into a national database. Data within CPCSSN can be used to drive strategies to improve electronic record measurement fields that are missing or outdated, particularly risk factor fields such as type of smoker. This field is particularly important because cigarette smoking is recognized as one of the most important risk factors for many chronic diseases, including lung cancer, hypertension, Alzheimer disease, and chronic obstructive pulmonary disease. 5-9 High-quality data are essential to managing

results by the exclusion of significant populations of EHR/EMR users. Second, self-selection bias may have occurred in the form of (a) having an email address, (b) responding to the survey and (c) being a member of AAFP. However, we believe that because those with the greatest interest in this topic are the most likely to respond, our findings are an underestimate of the true extent of the problem of non-standardisation of EHR/ EMR software. Third, our age findings may be biased due to the smaller number of respondents over the age of 65. Fourth, our assumption of standardisation among unique EHR/EMR may be flawed. Alterna- tively, it may also be true that ‘standard’ software cannot exchange records with itself easily. Despite the desirability and economic benefits of an integrated clinical software infrastructure, the near-term prospects for widespread use of standard EHR/EMR software appear poor. This is due to the devaluation of EHR/ EMR software through hundreds of unique systems. Fundamental change through the use of EHR/EMR software is widely recognised as necessary, but a specific mechanism for such change is lacking. Free and Open Source Software shows promise as a means to achieving the true potential of EMR software in improving health care.

Certain researchers have suggested that simply having or implementing an electronic health (medical) record alone is insufficient to improve quality (Poon et al., 2010; Zhou et al., 2009). Other studies have suggested that use of a sophisticated EHR alone could improve outcomes of care (Cebul, Love, Jain, & Hebert, 2011). However, any improvements in quality and outcomes of care require full adoption and use of advanced EHRs. Again, the inconsistent use of terminology and the functions within EHRs make synthesizing the literature difficult. Researchers must carefully evaluate the EHR definition, functionality, and components included in the various studies. As previously suggested, simply implementing and reporting use does not necessarily translate into actual use of a fully functional EHR. Based on the recent findings, it still appears that EMR implementation is far more prevalent than true EHR use (Terry, 2013), Therefore, the focus should be on adoption of robust EHRs and increasing appropriate use of advanced EHR features (Poon et al., 2010). This also provides significant opportunities for future research.

Physician adoption Training, communication, leadership support. Productivity decreases Workflow analysis, training[r]

Proposals are to be submitted in a sealed envelope, plainly marked “Proposal: Electronic Health Records and Medical Practice Management System” along with the Company’s name and date and time of the scheduled opening. Minnesota State University Moorhead, its employees, officers or agents shall not be responsible for any pre-opening or post-opening of any proposal not properly addressed and identified. Proposals made in pencil or forwarded using e-mail and the internet will be rejected.

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• Electronic medical records dramatically increase the ability of physicians to use patient information for new purposes, based on the ability to search, aggregate, correlate and otherwise manipulate individual information. Care must be taken to ensure that any use or disclosure of health information complies with the Health Information Act and as such, appropriate measures such as patient consents and ethics reviews are undertaken when utilizing this enhanced functionality. Personal health information should only be used for the purpose it was collected unless additional consent is obtained. Release of medical information is permitted or required in certain circumstances as defined by legislation. Uses and disclosures of personally identifiable health information for the secondary purpose of research must have appropriate ethics review and approval, and patient consent if required.

Our dataset consists of 2000 Chinese clinical notes of EHRs, coming from a third-level grade-A hospital in China. We annotated the History of Present Illness Section of the clinical notes. By observing the data, we found that there are blocks consist of several consecu- tive short sentences as a semantic unit. For example, the four short sentences, ”, 39, , (there is fever on the next day, body temperature 39 degrees, no rash, no chills)”, integrally describe the symptoms of fever. If we only sep- arately detect medical concepts such as “fever”, “body temperature”, “rash” and “chills”, it will destroy the seman- tic integrity and relevance of the short sentences. There- fore, we treat this text as a whole, a medical event called “Description of Symptoms”.

As the EMR technology moves in the direction of open access to the entire medical record by any treating health care provider, there are substantial concerns as to w[r]

• Around 0.7% of hospitals are at stage 7 which means the full hospital is now electronic based. It no longer uses paper charts. Clinical data warehouses are being used to analyze patterns of clinical data to improve quality of care and patient safety. Clinical information can be readily shared via standardized electronic transactions (i.e. CCD) with all entities that are authorized to treat the patient or a health information exchange (i.e., other employers, non-associated hospitals, sub-acute environments, ambulatory clinics, patients & payers in a data sharing environment). The hospital demonstrates summary data continuity for all hospital services (e.g. inpatient, outpatient, ED, and with any owned or managed ambulatory clinics). [17]