Architecting Transitions to a Fully Electronic Medical Record with an Emphasis on Physician Adoption and Optimal Utilization

James F. Keel III and D. Arlo Jennings

The electronic medical record (EMR) is an electronic means for physicians and other clinical providers to review clinical results, place patient orders, and create appropriate electronic documentation. The EMR actions on the part of physicians include computer order entry (CPOE) and electronic documentation. CPOE is not keyboarding orders as free text into a word processor, but rather it is the process of retrieving orders from an electronic order catalogue by matching specific catalogue orders to the desired order intent as conceived. CPOE additionally provides the means to make available defined order sets that support integrated tasks into a common complex clinical action. The creation of electronic documentation is the physician’s means of providing documentation of history and physical notes, consultations, procedures, operations, progress notes, and discharge summaries, prescriptions, and medication reconciliation. Much of this documentation is free text in nature, but requires adherence to standard formats.

Because the EMR deviates markedly from the traditional paper-based formats, the proposed transition to the EMR has commonly spawned significant physician resistance to the utilization of this new technology platform. This resistance, common with many new users of technology, is generally in reaction to a change in their daily routines forced on them by the use of the proposed technology. In 2009 approximately 10% of the 5000 plus hospitals in the United States had ventured into the world of CPOE. Two factors at that time inhibited a stronger adoption rate of CPOE: first, the expense of the implementation and second, a resistance to adoption on the part of stakeholders. However, following the federal Meaningful Use incentive program, there has evolved a strong national migration to CPOE in the hospital setting such that CPOE is rapidly becoming the standard instrument for executing clinical orders. Migration to a fully electronic record, including physician documentation, is not required by Meaningful Use, and as such is causing a continued lag in further EMR adoption. Nevertheless, physicians and hospital administrators are recognizing that without full EMR adoption, the clinical process remains split between paper and electronic environments, leading to losses in efficiency and effectiveness in the care of patients.

The implementation of the EMR creates added expenses to hospitals’ bottom lines. These expenses derive from the considerable effort needed to effect this major cultural and clinical transformation, including planning, expectation setting, implementation of preparatory prerequisite applications, deployment of adequate computers for access, downtime contingencies, design and build of an electronic processes physicians will accept, education, go-live support, and management of post go-live requests for changes and updates. Each of these is discussed in some detail in this chapter.

The question remains as to how a hospital’s information technology (IT) team should work with clinicians to orchestrate the best approach to ensure a wellfunctioning system that will be readily accepted by physicians and that works efficiently for clinical support staff. The IT team must include the position for a strong chief medical information officer (CMIO) to interface among the design and build team, the administration, and physicians to guide the transformation process and to provide clinical guidance to the design of the system. IT must also have experienced nurses on the informatics staff to help with design and build, but without physician input acceptance will be limited or completely denied. The ultimate success of the implementation depends on the interaction among the administration, support departments, and physicians. The hospital must then devise a project scope, develop a formal implementation plan, and budget appropriate resources, utilizing formal project management methodology. Finally, the hospital administration must fully recognize that this is not “just another project.” This type of transformation is unique and requires uniform leadership alignment, persistence, collaboration with medical staff, and an unwavering commitment to follow through with stated intentions.

Background: Perceptions, Costs, and Outcomes

The EMR transition presents a perception both challenging to administration and threatening to physicians. Hospital administrators react positively to moving in this direction because of the potential saving that might be gained and the potential reduction of medical errors.

Regarding potential savings, measurement of return on investment from the EMR is complex and fraught with pitfalls. Hospital executives may be tempted to significantly underestimate both capital and expense costs of implementation. Global changes in dashboard outcomes for the organization, such as length of stay, cost per case, mortality, and morbidities, are confounded by many factors, including shifting acuity, seasonal variations, adjustments in market share, impact from multiple other projects, changing reimbursement plans, and so on. In addition, reduction in medical errors, particularly those with harm, is commonly cited as a benefit of the EMR but is notoriously difficult to quantify, primarily because of problems inherent in voluntary reporting. Finally, hospital executives must keep in mind that the EMR transition will not be the final product to justify their goal for integration of information technology into the provision of healthcare. The EMR should be viewed as an evolving composite of many pieces that will form the foundation of an electronic underpinning to replace an antiquated and highly limited paper-based system. Although the final solution may be expected to facilitate and yield enormous improvements in hospital care, too much should not be expected of or attributed to this initial EMR implementation alone.

The EMR provides a foundation from which many improvements in data mining and clinical care will ultimately emerge. Nevertheless, a careful process should be put in place before implementing the EMR to facilitate a careful analysis of investment costs tied to clinical and operational outcomes.

 
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