Electronic health record
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[[Image:immune auto.jpg|thumb|300px|right|'''Electronic health record (EHR)''' with image and document links.]]
[[Image:VistA Img.png|thumb|300px|Sample patient record view from an '''image-based electronic health record''' (VistA)]]
An '''electronic health record (EHR)''' refers to an individual patient's [[medical record]] in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a [[Computer networking|network]]. It may be made up of electronic medical records (EMRs) from many locations and/or sources. A variety of types of healthcare-related information may be stored and accessed in this way.
EHR systems can reduce medical errors.<ref name="VA">{{cite journal|journal=BusinessWeek, Red Oak, IA (USA)|date=[[July 16]], [[2006]]|url=http://www.businessweek.com/magazine/content/06_29/b3993061.htm?chan=tc&chan=technology_technology+index+page_best+of+the+magazine|title=The Best Medical Care In The U.S. How Veterans Affairs transformed itself – and what it means for the rest of us}}</ref> In one ambulatory healthcare study, however, there was no difference in 14 measures, improvement in 2 outcome measures, and worse outcome on 1 measure.<ref name="ambulatory">[http://archinte.ama-assn.org/cgi/content/short/167/13/1400 Electronic Health Record Use and the Quality of Ambulatory Care in the United States], Jeffrey A. Linder, et al., Arch Intern Med. 2007;167:1400-1405.</ref>
EHR systems are believed to increase physician efficiency and reduce costs, as well as promote standardization of care. Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, less than 10 percent of hospitals as of 2006 have a fully integrated system.<ref name="SM001">Smaltz, Detlev and Eta Berner. ''The Executive's Guide to Electronic Health Records.'' (2007, Health Administration Press) p.03</ref>
== Overlap in Terminology ==
Multiple terms have been used to define electronic patient care records, with overlapping definitions.<ref>{{cite journal | last = Waegemann | first = C. Peter | title = Status Report 2002: Electronic Health Records | journal = Medical Record Institute | format = PDF | date = 2002 | url = http://www.medrecinst.com/uploadedFiles/MRILibrary/StatusReport.pdf}}</ref> Both electronic health record (EHR) and [[electronic medical record]] (EMR) have gained widespread use, with some [[health informatics]] users assigning the term EHR to a global concept and EMR to a discrete localised record. For most users, however, the terms EHR and EMR are used interchangeably. An EHR ''system'' is also often abbreviated as EHR or EMR.
Health Information Technology is an even broader term that describes any computer-based electronic aid to healthcare delivery.
An electronic health record is a patient’s health record that has been compiled into a digital format.
== Types of data stored in an electronic medical record ==
An [[electronic medical record]] might include:
*Patient [[demographics]].
*Medical history, examination and progress reports of health and illnesses.
*Medicine and allergy lists, and immunization status.
*Laboratory test results.
*Radiology images ([[X-ray]]s, [[Computed tomography|CT]]s, [[MRI]]s, etc.)
*Photographs, from endoscopy or laparoscopy or clinical photographs.
*Medication information, including side-effects and interactions.
*[[Evidence-based medicine|Evidence-based recommendations]] for specific medical conditions
*A record of appointments and other reminders.
*Billing records.
*Advanced directives, living wills, and health powers of attorney
== Advantages of electronic medical records over paper records ==
A [[medical record]] includes any of an individual's health documents of the types listed above. Medical records may be on "physical" media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to pariticiate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure and may violate the patient's HIPAA privacy.
Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage.
When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance.
In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic medical records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.<ref>{{cite web|title=Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration|url=http://journals.cambridge.org/action/displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367.tomcat1?fromPage=online&aid=416400| publisher=Health Economics: Policy and Law (2006): 1, 163-169}}</ref><ref>{{cite web|title=VistA:Winner of the 2006 Innovations in American Government Award|url=http://www.innovations.va.gov/innovations/docs/InnovationsVistAInfoPackage.pdf|publisher=The Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government|format=PDF}}</ref>
Handwritten paper medical records can be associated with poor legibility, which can contribute to [[medical error]]s.<ref>{{cite web | last=Institute of Medicine | first= | year=1999 | url=http://fermat.nap.edu/catalog/9728.html#toc | title=To Err Is Human: Building a Safer Health System (1999) | publisher=The National Academies Press | accessdate=2006-06-20}}</ref> Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.
Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption.<ref name="VA"/><ref>{{cite web | last=Institute of Medicine | first= | year=2001 | url=http://www.nap.edu/books/0309072808/html | title=Crossing the Quality Chasm: A New Health System for the 21st Century | publisher=The National Academies Press | accessdate=2006-06-29}}</ref>
== Lack of adoption of EHRs in the United States ==
[[Image:EHRadoption.gif|thumb|200px|US medical groups' adoption of EHR (2005)]]
Outside of the Veterans Administration Healthcare system, the vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s.
As of 2000, adoption of EHRs and other health information technology (HITs) (such as [[computer physician order entry]] (CPOE)) was minimal in the United States (outside of the VA system). Less than 10% of American hospitals had implemented HIT,<ref>{{cite journal|last=DJ Ringold, JP Santell, and PJ Schneider|title=ASHP national survey of pharmacy practice in acute care settings: dispensing and administration—1999|journal=American Journal of Health-System Pharmacy|volume=57|issue=19|pages=1759–75|date=2000|url=http://www.ajhp.org/cgi/content/abstract/57/19/1759?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=57&firstpage=1759&resourcetype=HWCIT
|accessdate=2006-08-04|pmid=11030028}}</ref> while a mere 16% of [[primary care physicians]] used EHRs.<ref>Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." Wellesley, MA: Center for Information Technology Leadership, 2003</ref> In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.<ref name="ambulatory"/><ref name="abulatoryuse">National Center for Health Statistics: [http://www.cdc.gov/nchs/products/pubs/pubd/hestats/electronic/electronic.htm Electronic Medical Record Use by Office-Based Physicians:, United States, 2005] Retrieved [[July 24]], [[2006]]</ref>
In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.<ref name="abulatoryuse"/> However, less than one-tenth of these physicians actually had a "complete EMR system" (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).<ref>CDC's National Center for Health Statistics: [http://www.cdc.gov/od/oc/media/pressrel/a060721.htm More Physicians Using Electrical Medical Records] Retrieved [[July 27]], [[2006]]</ref>
The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.<ref>{{cite web|author=Raymond, B. and C. Dold|title=Clinical Information Systems: Achieving the Vision|publisher=Kaiser Permanente Institute for Health Policy|date=2002|url=http://www.informatics-review.com/thoughts/vision.html}}</ref>
ref>Simon SR, K. R., Cleary PD, Jenter CA, Volk LA, Poon EG, Oray EJ, Lo HG, Williams DH, Bates DW (2007). "Correlates of electronic health record adoption in office practices: a statewide survey." Journal of American Informatics Association 14(1): 8</ref><ref>Menachemi N, P. R., van Durme DJ, Brooks RG (2006). "Examining the Adoption of Electronic Health Records and Personal Digital Assistants by Family Physicians in Florida." Informatics In Primary Care 14(1): 8.</ref>
== Ideal characteristics of an electronic health record (EHR) ==
* Information should be able to be continuously updated.
*The data from an electronic health records system should be able to be used anonymously for statistical reporting for purposes of quality improvement, outcome reporting, resource management, and public health communicable disease surveillance.<ref>Healthcare Information and Management Systems Society (2003): {{PDF|[http://www.himss.org/content/files/EHRAttributes.pdf EHR Definition, Attributes and Essential Requirements]|152 [[Kibibyte|KiB]] Retrieved [[July 28]], [[2006]]</ref>
* The ability to exchange records between different electronic health records systems ("interoperability"<ref>Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601)</ref>) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities.
== Attempts to facilitate EHR compatibility in the United States ==
The Veterans Administration health care system in the United States, with over 155 hospitals and 800 clinics, represents one of the largest integrated healthcare delivery systems in the world. It relies on a single EHR system called [[Veterans Health Information Systems and Technology Architecture|VistA]], which has been in use for years. Data exchange is facilitated by a protocol called [[BHIE]] (Bidirectional Health Information Exchange), and the VA healthcare network is being expanded in 2007 to integrate the Department of Defense healthcare facilities using the BHIE networking protocol.
This EHR has been made publicly available for download and has been adapted for use in many non-VA hospitals and healthcare networks. As BHIE becomes more widely available, a national healthcare network will be facilitated.
Outside of the VA's EHR system, however, there are currently at least 25 major competing vendors of EHR systems, many selling software incompatible with competitors.
This lack of interoperability provides a significant barrier to a "National Health Information Network."<ref>Centers for Medicare and Medicaid Services: [http://www.cms.hhs.gov/MissionVisionGoals/Downloads/CMSStrategicActionPlan06-09_061023a.pdf Strategic Action Plan]</ref> In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by [[David Brailer]]. Under the ONC, Regional Health Information Organizations ([[RHIO]]s) have been established in many states in order to promote the sharing of health information. The US Congress is currently working on legislation to increase funding to these and similar programs.
=== Benefits of EHR standardization / National Healthcare Information Network ===
====Improved billing accuracy====
Although billing is now largely accomplished electronically in the United States, these claims often require additional documentation from a patient's medical record. This is a tedious task when records are in an electronic format not compatible with the billing program, or when the records are in paper format. An integrated electronic medical record / billing system, therefore, both expedites and makes billing more accurate.
====Reduction in duplication of services====
Duplication of lab tests, diagnostic imaging, work-ups, and other services can be prevented by good record-keeping of any type. However, because electronic records can be available at many locations at once, integration of services and awareness of duplication is facilitated.
====Facilitation of clinical trials====
Clinicians and researchers suggest benefits to integrating electronic health records with data collection and analysis in clinical trials.<ref name="NCI">{{cite web|title=Confidentiality, Data Security, and Cancer Research: Perspectives from the National Cancer Institute|url=http://www3.cancer.gov/confidentiality.html}}</ref>
Potential clinical trial participants may be more easily identified, administrative overhead costs may be lessened, data errors may be reduced, and adverse outcomes may more rapidly identified.<ref name="NCI"/>
Some institutions have already been partially successful in implementing and integrating co-ordinated data collection and analysis systems. For example, the Shared Pathology Network (SPIN) of the National Cancer Institute has effectively established a web-based network for locating pathological tissue samples at various institutions across the nation.<ref>{{cite journal|title=A submission model for use in the indexing, searching, and retrieval of distributed pathology case and tissue specimens|journal=Medinfo 11 (2): 1264-7|date=2004|url=http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15361017&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAsn1}}</ref> The electronic nature of reports within the system allows the use of search engines to find specific text with the reports, facilitating analysis.<ref>{{cite journal|title=Development and evaluation of an open source software tool for deidentification of pathology reports|journal=BMC Medical Informatics and Decision Making 6(12)|date=2006|url=http://www.biomedcentral.com/content/pdf/1472-6947-6-12.pdf}}</ref>
=== Organizations to evaluate standardization proposals ===
Several models of standardization for electronic medical records and electronic medical record exchange have been proposed and multiple organizations formed to help evaluate and implement them.<ref>{{cite journal | author = Nainil C. Chheda, MS | year = 2007 | month = January | title = Standardization & Certification: The truth just sounds different | journal = Application of Healthcare Governance | url = http://www.nainil.com/research/whitepapers/Standardization_and_Certification.pdf | format = PDF | accessdate = 2007-01-16 }}</ref><ref>{{cite journal | author = Nainil C. Chheda, MS | year = 2005 | month = November | title = Electronic Medical Records and Continuity of Care Records - The Utility Theory | journal = Application of Information Technology and Economics | url = http://www.emrworld.net/emr-research/articles/emr-ccr.pdf | format = PDF | accessdate = 2006-07-25 }}</ref>
==== Organizations ====
* [http://www.hhs.gov/healthit/chiinitiative.html CHI] (Consolidated Health Informatics Inititiative) - recommends nationwide federal adoption of EHR standards in the United States
* [[Certification Commission for Healthcare Information Technology|CCHIT]] (Certification Commission for Healthcare Information Technology) - a federally funded, not-for-profit organization that evaluates and develops the certification for EHRs and interoperable EHR networks (USA)
* [[IHE]] (Integrating the Healthcare Enterprise) - a consortium, sponsored by the [[HIMSS]], that recommends integration of EHR data communicated using the HL7 and DICOM protocols
* [[ANSI]] (American National Standards Institute) - accredits standards in the United States and co-ordinates US standards with international standards
* [[Healthcare Information and Management Systems Society]] (HIMSS) - an international trade organization of health informatics technology providers
* [[ASTM International|American Society for Testing and Materials]] - a consortium of scientists and engineers that recommends international standards
* [[openehr|openEHR]] - provides open specifications and tools for the 'shared' EHR
* [[Canada Health Infoway]] - a federally funded, not-for-profit organization that promotes the development and adoption of EHRs in Canada
* [[World Wide Web Consortium]] (W3C) - promotes Internet-wide communications standards to prevent market fragmentation
* [[Clinical Data Interchange Standards Consortium]] (CDISC) - a non-profit organization that develops platform-independent healthcare data standards
*[[ELINCS|EHR-Lab Interoperability and Connectivity Standards (ELINCS)]] - run by the HL7 group to help provide lab data and other EHR interoperability
==== Standards ====
* [[HL7]] - a standardized messaging and text communications protocol between hospital and [[physician]] record systems, and between practice management systems
* [[DICOM]] - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by [[National Electrical Manufacturers Association|NEMA]] (National Electrical Manufacturers Association)
* [[ANSI X12]] ([[Electronic Data Interchange|EDI]]) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of [[billing]] data.
* [[ISO]] - [[ISO TC 215]] provides international technical specifications for EHRs. ISO 18308 describes EHR architectures
* [[European Committee for Standardization|CEN]]'s TC/251 provides EHR standards in Europe including:
** [[EN 13606]], communication standards for EHR information
** [[CONTSYS]] (EN 13940), supports continuity of care record standardization.
** [[HISA]] (EN 12967), a services standard for inter-system communication in a clinical information environment.
== Barriers to implementing an EHR system ==
===Difficulty in adding older records to an EHR system===
Older paper medical records ought to be incorporated into a patient's electronic health record.
One method is to merely scan the documents and retain them as images. However, surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone rather than fully electronic data-based systems.<ref>{{cite journal | author = Hallvard Lærum, MD, Tom H. Karlsen, MD, and Arild Faxvaag, MD, PhD | year = 2003 | title = Effects of Scanning and Eliminating Paper-based Medical Records on Hospital Physicians' Clinical Work Practice | journal = Journal of the American Medical Informatics Association | volume = 10 | pages = 588–595 | url = http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=264437 | accessdate = 2006-07-30 | doi = 10.1197/jamia.M1337 | pmid = 12925550 }}</ref> EHR systems with image archival capability (such as [[Vista imaging|VistA Imaging]]) are able to integrate these scanned records (along with other types of image-based records) into fully electronic health records systems.
Another method to convert written records (such as notes) into electronic format is to [[Image scanner|scan]] the documents then perform [[optical character recognition]]. For typed documents, accurate recognition may only achieve 90-95%, though, requiring extensive corrections. Furthermore, illegible handwriting is poorly recognized by optical character readers.
Some states have proposed making existing statewide database data (such as immunization records) available for download into individual electronic medical records.<ref>{{cite journal | year = 1998 | title = CHILD profile: an immunization registry and more - a new approach to tracking and surveillance. Children's Health, Immunization, Linkages and Development | journal = Vaccine | volume = 18 | pages = v-vi}}</ref>
===Long-term preservation and storage of records===
An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives.
Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al have noted that “choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.”<ref>Mandl KD, Szolovits P, Kohane, IS (2001). Public standards and patients' control: how to keep electronic medical records accessible but private. BMJ, 322:283-287.</ref>
The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."<ref>Ruotsalainen P, Manning B, (2007). A notary archive model for secure preservation and distribution of electrically signed patient documents. Int J Med Inform., 76(5-6):449-53. </ref>
In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.
While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that “the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."<ref>Olhede T, Peterson HE (2000). Archiving of care related information in XML-format. Stud Health Technol Inform, 77:642-6.</ref>
===Synchronization of records===
When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. This is a problem that plagues distributed computer records in all industries.
Two models have been used to satisfy this problem: a [[Client-server|centralized data server solution]], and a peer-to-peer [[file synchronization]] program (as has been developed for other [[Peer-to-peer|peer-to-peer networks]]).
In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.<ref>{{cite web|url=http://www.e-health-insider.com/news/3343/opposition_calls_for_rethink_on_data_storage|title=Opposition calls for rethink on data storage|publisher=e-Health Insider (UK)|date=December 2007}}</ref><ref>{{cite web|url=http://www.e-health-insider.com/news/3384/german_doctors_say_no_to_centrally_stored_patient_records|title=German doctors say no to centrally stored patient records|publisher=e-Health Insider (UK)|date=January 2008}}</ref>
Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.
Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.<ref>{{cite journal | year = 2004 | title = Integrating the New York citywide immunization registry and the childhood blood lead registry | journal = Journal of Public Health Management and Practice | pages = S72–80}}The Master Child Index consolidated 4,610,585 records that were contained in both databases into 2,977,290 records through a match and merge system.</ref><ref>{{ cite journal | year = 2001 | title = Quality improvements in pediatric well care with an electronic record | journal = Proc AMIA Symp | pages = 209–13}}</ref><ref>{{cite journal | year = 2004 | title = Perspectives on integrated child health information systems: Parents, providers, and public health | journal = Journal of Public Health Management Practice | pages = S57–S60 }}</ref>
===Privacy===
Privacy concerns in healthcare apply to both paper and electronic records. According to the ''Los Angeles Times'', roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.<ref>{{cite news | last = Health & Medicine | title = At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded. | publisher = Los Angeles Times | date = [[2006-06-26]] | url = http://www.latimes.com/features/health/medicine/la-he-privacy26jun26,1,3180537.column?ctrack=1&cset=true |accessdate = 2006-08-08 }}</ref> Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.<ref>CNN.com ([[May 23]], [[2006]]): [http://www.cnn.com/2006/US/05/22/vets.data/index.html FBI seeks stolen personal data on 26 million vets] Retrieved [[July 30]], [[2006]]</ref> Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.
The [[Health Insurance Portability and Accountability Act| Health Insurance Portability and Accountability Act (HIPAA)]] was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of implementation of these standards.
In the [[European Union]] (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.<ref>European Parliament and Council ([[24 October]] [[1995]]): [http://www.dataprivacy.ie/viewdoc.asp?m=&fn=/documents/LEGAL/6aii.htm EU Directive 95/46/EC - The Data Protection Directive] Retrieved [[July 30]], [[2006]]</ref>
[[Personal Information Protection and Electronic Documents Act]] (PIPEDA) was given Royal Assent in Canada on [[April 13]], [[2000]] to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.<ref>"Personal Information Protection and Electronic Documents Act - Implementation Schedule." ''Office of the Privacy Commissioner of Canada''. [[April 1, 2004]]. Accessed [[February 12, 2008]] <http://www.privcom.gc.ca/legislation/02_06_02a_e.asp>.</ref> There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec.
[[Privacy and Security of the Electronic Health Record]]:
As the ever-changing healthcare industry evolves, one key topic within the electronic health record (EHR) is privacy. The Federal government has set guidelines that all healthcare organizations will have to comply with in regards to electronic health transactions. Most supporters believe that the EHR will improve care and reduced costs, while transforming the health care system, but whether the privacy of the records will be upheld is yet to be determined. A successful partnership for administrative health data standards can promote the development of clinical data standards and their application in computer based patient record systems.<ref>Fitzmaurice, JM. “A New Twist in US health care data standards development: adoption of electronic health care transactions standards for administrative simplification. Int J Med Inform. 1998 Feb; 48(1-3): 19-28.</ref>
One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. President Bush calls for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”<ref>Pear, Robert. “Warnings Over Privacy of U.S. Health Network.” New York Times, [[February 18]], [[2007]].</ref> Not enough attention is being placed on the security of the information in EHR. This is a significant barrier for the adoption of an EHR. At the federal level, there needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records if adoption of an EHR is to occur.<ref>Nulan, C. “HIPAA – a real world perspective.” Radiol Manage. 2001 Mar-Apr; 23(2); 29-37.</ref>
Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.<ref>Nulan, C. “HIPAA – a real world perspective.” Radiol Manage. 2001 Mar-Apr; 23(2); 29-37.</ref>
Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.<ref>Pear, Robert. “Warnings Over Privacy of U.S. Health Network.” New York Times, [[February 18]], [[2007]].</ref> So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.
Many issues have risen on the privacy of the U.S. network for electronic health records. Federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”<ref>Pear, Robert. “Warnings Over Privacy of U.S. Health Network.” New York Times, [[February 18]], [[2007]].</ref> Not enough attention is being placed on the security of the information in EHR, thus accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the U.S. There needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records by all involved.<ref>Nulan, C. “HIPAA – a real world perspective.” Radiol Manage. 2001 Mar-Apr; 23(2); 29-37.</ref>
===Hardware limitations===
Computer access is required to use an electronic health record system. A sufficient number of workstations, laptops, or other mobile computers must be available to accommodate the number of healthcare providers at any one facility.<ref name="Hutchinson">Hutchinson, Christine., Matthews, Tony., & Sharples, Christine. (2007). Get ready for the records switch. Nursing Standard, January 21(21), p.64.</ref> EHR software ought to be backwards compatible with older technology so that existing technology infrastructure can be used. Furthermore, most healthcare facilities have at least some degree of existing computerization, whether in the lab or in billing services. EHR systems need to interface with existing systems, again mandating a modular approach.<ref>Cross, Michael. (2007) Will connecting for health deliver its promises? British Medical Journal. March 332(7541) pp. 599-601. </ref>
===Cost Advantages and Disadvantages===
Most practitioners and healthcare organizations will agree that both quality healthcare and medical error reduction take precedence over many other healthcare concerns. Common knowledge to most, the U.S. allocates a vast amount of funds towards the health care industry—more than $1.7 trillion per year.<ref>Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005[http://64.233.169.104/search?q=cache:Hqus71_PhKAJ:www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf+%E2%80%A2+%22Can+Electronic+Medical+Record+Systems+Transform+Health+Care%3F+Potential+Health+Benefits,+Savings,+and+Costs%22&hl=en&ct=clnk&cd=5&gl=us], Retrieved [[February 19]], [[2008]]</ref> Unfortunately, these distributed funds have not significantly improved the U.S.’s quality of healthcare. The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.<ref>Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005[http://64.233.169.104/search?q=cache:Hqus71_PhKAJ:www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf+%E2%80%A2+%22Can+Electronic+Medical+Record+Systems+Transform+Health+Care%3F+Potential+Health+Benefits,+Savings,+and+Costs%22&hl=en&ct=clnk&cd=5&gl=us], Retrieved [[February 19]], [[2008]]</ref> Of course, such savings will not occur overnight and will require EHR adoption by most healthcare businesses. Obviously, these savings can lead to healthcare quality promotion. In addition, these savings are not limited to businesses alone: If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.<ref>Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005[http://64.233.169.104/search?q=cache:Hqus71_PhKAJ:www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf+%E2%80%A2+%22Can+Electronic+Medical+Record+Systems+Transform+Health+Care%3F+Potential+Health+Benefits,+Savings,+and+Costs%22&hl=en&ct=clnk&cd=5&gl=us], Retrieved [[February 19]], [[2008]]</ref> Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.<ref>.Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005[http://64.233.169.104/search?q=cache:Hqus71_PhKAJ:www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf+%E2%80%A2+%22Can+Electronic+Medical+Record+Systems+Transform+Health+Care%3F+Potential+Health+Benefits,+Savings,+and+Costs%22&hl=en&ct=clnk&cd=5&gl=us], Retrieved [[February 19]], [[2008]]</ref> Furthermore, If patients are aware of their opportunities, they are more likely to comply with their doctors’ recommendations; thus, reducing future hospital visits and saving money. Despite the advantages, many providers have not adopted EHR due to its expensiveness: The cumulative cost for 90 percent of hospitals to adopt an EHR system is $98 billion [and] $17.2 billion for physicians.<ref>Hillestad, Richard et al.: "Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs", Health Affairs, 2005[http://64.233.169.104/search?q=cache:Hqus71_PhKAJ:www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf+%E2%80%A2+%22Can+Electronic+Medical+Record+Systems+Transform+Health+Care%3F+Potential+Health+Benefits,+Savings,+and+Costs%22&hl=en&ct=clnk&cd=5&gl=us], Retrieved [[February 19]], [[2008]]</ref> The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.<ref>RWIF,GWUMC, and IHP Staff: "Health Information Technology in the United States: The Information Base for Progress", Robert Wood Johnson Foundation, George Washington University Medical Center, and Institute for Health Policy, 2006[http://www.rwjf.org/files/publications/other/EHRReport0609.pdf], Retrieved [[February 17]], [[2008]]</ref> In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.<ref>RWIF,GWUMC, and IHP Staff: "Health Information Technology in the United States: The Information Base for Progress", Robert Wood Johnson Foundation, George Washington University Medical Center, and Institute for Health Policy, 2006[http://www.rwjf.org/files/publications/other/EHRReport0609.pdf], Retrieved [[February 17]], [[2008]]</ref> Overall, physicians in the focus groups did not see any financial incentives for adopting an EHR. In other words, if providers do use an EHR system, not only do they have to pay for it, but they also have to pay for the maintenance of the system and classes to train staff. Moreover, technology is not perfect. On occasion, systems crash and experience technical difficulties, which is very costly to repair. Such issues make providers question if EHR is a step they are willing to take. Overall, EHR systems provide more benefits than disadvantages to patients and the economy. These systems can improve savings and the quality of healthcare to a superior level.
The U.S. Congressional Budget Office concluded that the cost savings may only occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product – and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." If a physician performs tests in the office, it might reduce his or her income. "Given the ease at which information can be exchanged between health it systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."<ref>[http://www.cbo.gov/doc.cfm?index=9168 Evidence on the costs and benefits of health information
technology.] Congressional Budget Office, May 2008.</ref>
===Start-up costs and software maintenance costs===
In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.<ref>[http://www.medrecinst.com/ Medical Records Institute], Retrieved [[December 6]], [[2006]]</ref> At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the [[amortization]] of startup investment).<ref>{{cite journal|title=We've got to adopt health information technology, and get on with it|journal=Healthcare IT News|date=2006-10-11|url=http://www.healthcareitnews.com/printStory.cms?id=5709}}</ref><ref>{{cite web|url=http://www.nqfexecutiveinstitute.org/executiveinstitute/EHRbookfinal.pdf|title=CEO Survival Guide to Electronic Health Records|date=2006|Publisher=National Committee for Quality Health Care|format=PDF}}</ref><ref>{{cite journal|author=Columbus, Suzanne.|title=Small Practice, Big Decision: Selecting an EHR System for Small Physician Practices|journal=Journal of AHIMA 77, no.5 (May2006):4246|date=May 2006|url=http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031357.hcsp?dDocName=bok1_031357}}</ref> Vendor costs only account for 60-80% of these costs.<ref>{{cite web|title=Towards the Electronic Patient Record: Ambulatory Market Trends: Discussion and Analysis|publisher=AC Group (Presentation)|url=http://www.acgroup.org/images/2007_TEPR_Meeting_-_Ambulatory_Care_Market_Trends_v2.pdf}}</ref>
There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 - $7500/provider and $67 - $750/month per provider.<ref>{{cite web|title=An Evaluation of Vista-Office EHR in the Small Practice Setting: Functional Performance, Economic Costs, and Implementation/Support Processes|publisher=Sujansky & Associates, LLC|url=http://www.sujansky.com/docs/VistaOfficeEHR_EvaluationReport_2006-11-30.pdf}}</ref>
Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.<ref>{{cite web|title=The Value of Electronic Health Records in Solo or Small Group Practices |publisher=The Commonwealth Fund|url=http://www.cmwf.org/publications/publications_show.htm?doc_id=296446}}</ref> A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.<ref>{{cite web|title=Potential Benefits of Electronic Medical Records|publisher=LBJ School of Public Affairs|url=http://www.wcit2006.org/Healthcare/media/whitepaper/emr.pdf|accessdate=2007-07-10|format=PDF}}</ref>
Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.<ref>{{cite journal|author=Meinert, D.B.|title=Resistance to Electronic Medical Records (EMRs): A Barrier to Improved Quality of Care|journal=Issues in Informing Science and Information Technology|date=2006|url=http://proceedings.informingscience.org/InSITE2005/I41f100Mein.pdf}}</ref><ref>http://www.himss.org/content/files/vantagepoint/pdf/vantagepoint_0405.pdf</ref>
Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.<ref name="CALAO">{{cite web|title=A State Policy Approach: Promoting Health Information Technology in California|publisher=California Legislative Analyst Office|url=http://www.lao.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx|date=February 2007}}</ref>
Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.
Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.<ref name="Parish">Parish, Colin ([[March 20]], [[2006]]). Edging towards a brave new IT world. ''Nursing Standard'' 27:15-16</ref>
In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the [[Veterans Health Information Systems and Technology Architecture|VistA]] electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems eventually retire.
===The problem of temporary workers===
=== Inertia ===
Most large organizations resist change. The institutional stress of implementing any new large-scale system must be anticipated by management. According to the [[Agency for Healthcare Research and Quality]]'s [[National Resource Center for Health Information Technology]], EHR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of [[change management]], while only 20% is spent on technical issues related to the technology itself.
The healthcare industry has more licensed professionals with advanced degrees than any other industry. However, systems analysis and computer science has not, until recently, been an integral part of healthcare training. Most health administrators also lack training in computer science.
=== Legal barriers ===
==== Liability barriers ====
Legal liability in all aspects of healthcare in the 21st century was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys<ref>{{cite web| url=http://www.newsbatch.com/tort-lawyerinc.html|title=Lawyers Per 100,000 Population 1980-2003|publisher=Congressional Budget Office| accessdate=2007-07-10}}</ref> and changes in the [[tort]] system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.<ref>{{cite web| url=http://www.newsbatch.com/tort.htm|title=Tort reform|publisher=News Batch|date=2006-05}}</ref>
Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.<ref>{{cite web| url=http://www.healthimaging.com/content/view/5885/89/|title=Bigger focus on compliance needed in EMR marketplace|publisher=Health Imaging News|date=2007-02-05}}</ref>
This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.<ref>[http://docs.mirrormed.org/index.php/Medical_Manager_History Medical Manager History]</ref> Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.
In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.<ref>{{cite web|author=Laura Dunlop|date=2007-04-06|title=Electronic Health Records: Interoperability Challenges and Patient's Right for Privacy|publisher=Shidler Journal of Computer and Technology 3:16|url=http://www.lctjournal.washington.edu/Vol3/a016Dunlop.html}}</ref> In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.<ref>{{cite web|url=http://www.gklaw.com/publication.cfm?publication_id=525|title=Newly Issued Final Rules under Stark and Anti-kickback Laws Permit Furnishing of Electronic Prescribing and Electronic Health Records Technology|Publisher=GKLaw|date=August 2006}}</ref><ref>{{cite web|url=http://www.ssd.com/publications/pub_detail.aspx?pubid=9675|title=New Stark Law Exceptions and Anti-Kickback Safe Harbors For Electronic Prescribing and Electronic Health Records|publisher=SSDlaw|date=August 2006}}</ref>
==== Ownership of electronic records ====
[[HIPAA]] standards allow patients the right to review the content of their medical records.
When records are centralized, it is often difficult to determine whose responsibility it is to maintain the records. If a company agrees to manage and maintain records but goes out of business, how does that impact the healthcare provider whose ultimate responsibility it is for record maintenance?
If a healthcare provider retires or goes out of business, what arrangements to convert records to archival formats are available?
If an individual physician and a hospital system share a record database system but then the individual physician leaves that healthcare system, how does she separate her practice's records from the hospital's central database to take them with her for archival, as often required by law?
Who determines the frequency of "purging" of records?
A patient may store a portion of his/her health records online or with an independent storage service (in a [[health record trust]]), in which case that subset of records is no longer under the control of the healthcare provider. This transfers HIPAA liabilities to the databank that stores the records for the individual. Concerns about loss of data integrity and lessened HIPAA adherence arise, because these records are no longer part of the health record maintained by the healthcare provider.
====Unalterability of records, spurious records, and digital signatures====
Medical records must be kept in unaltered form and authenticated by the creator. However, simple mistakes often create spurious documents. How are spurious documents identified so that they do not clutter the medical record without altering or disposing of them illegally?
Most national and international standards now accept [[electronic signatures]].<ref>American Bar Association, Section of Science and Technology, Information Security Committee: [http://www.abanet.org/scitech/ec/isc/footnotes.html#29 Jurisdictions with legislation regarding electronic signatures] Retrieved [[July 31]], [[2006]]</ref> However, a database of electronic signatures must be created as an EHR system is implemented.
===Customization ===
Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system.
An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.
This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.<ref>Clayton L. Reynolds MD, FACP, FACPE (March 2006): [http://www.infor-med.com/downloads/why_praxis_downloads/Charting_Bass_Ackward.pdf Paper on Concept Processing] Retrieved [[July 27]], [[2006]]</ref>
At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.<ref>Maekawa Y, Majima Y.; ”Issues to be improved after introduction of a non-customized Electronic Medical Record system (EMR) in a Private General Hospital and efforts toward improvement”; Studies in Health Technology and Informatics 2006</ref> Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.<ref>Tüttelmann F, Luetjens CM, Nieschlag E.; "Optimising workflow in andrology: a new electronic patient record and database"; Asian Journal of Andrology March 2006</ref>
Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.
Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.<ref>The Digital Office, September 2007, vol 2, no.9. HIMSS</ref><ref>Gina Rollins."The Perils of Customization." Journal of AHIMA 77, no.6 (2006):24-28.</ref>
These hurdles make customizations that can be made publicly available through an open source model more desirable.
== Successful implementations of EHR systems ==
In the United States, the [[Department of Veterans Affairs]] (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the [[Veterans Health Information Systems and Technology Architecture]] or VistA. A [[graphical user interface]] known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.
The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.
As of 2005, the [[National Health Service]] (NHS) in the [[United Kingdom]] also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing [[general practice|general practitioners]] in England access to the [[National Programme for IT]] (NPfIT).<ref>[http://www.connectingforhealth.nhs.uk/delivery/ NHS Connecting for Health:Delivering the National Programme for IT] Retrieved [[August 4]], [[2006]]</ref>
The Canadian province of [[Alberta]] started a large-scale operational EHR system project in 2005 called [[Alberta Netcare]], which is expected to encompass all of Alberta by 2008.
== Failures in Health Information Technology implementation ==
In 2002 at [[Cedars Sinai]] Medical Center in Los Angeles, physician dissatisfaction forced the administration to scrap a proprietary $34 million Central Physician Order Entry system that was developed within the medical center itself. Physicians were reported by nurses as being embarrassed by the number of errors the system caught and corrected, as well as being frustrated by the slow performance of the system.<ref name="Cedars">{{cite news|title=Cedars-Sinai Doctors Cling to Pen and Paper|publisher=The Washington Post|date=2005-03-21|url=http://www.washingtonpost.com/wp-dyn/articles/A52384-2005Mar20.html}}</ref> It is notable that the system had never been used or tested outside of Cedars-Sinai.
As many as 30% of EHR implementation attempts have failed over the past few years, according to the National Health Information Network Co-ordinator, David Brailer.<ref name="Cedars"/> Brailer's Santa Barbara County Care Data Exchange failed for a variety of reasons including poor project management, technical challenges, and a failure to create a compelling business model for the participants.<ref>Castro, Daniel, “Improving Health Care: How a Dose of IT May Be Just What the Doctor Ordered, October 2007, http://www.itif.org/files/HealthIT.pdf</ref>
Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The [[Certification Commission for Healthcare Information Technology]] (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. [[Department of Health and Human Services]] to develop a set of standards and certify vendors who meet them. As of October 2006, CCHIT had certified 34 ambulatory EHR products.<ref>Certification Commission for Healthcare Information Technology ([[July 18]], [[2006]]): [http://www.cchit.org/media/CCHIT+Announces+First+Certified+Electronic+Health+Record+Products.htm CCHIT Announces First Certified Electronic Health Record Products] Retrieved [[July 26]], [[2006]]</ref><ref>Certification Commission for Healthcare Information Technology ([[October 23]], [[2006]]): [http://www.cchit.org/media/press+releases/CCHIT+Announces+New+Certified+Electronic+Health+Record+Products.htm CCHIT Announces New Certified Electronic Health Record Products]</ref>
== Personal Health Records (PHR)==
A [[personal health record]] is medical information that is in the possession of an individual patient (or patient's non-professional caregiver). The format may be either paper (or similar types of) documents, electronic media, or a combination of both. Any of the types of data listed above may be included. It may also include information that a doctor may not have, such as exercise routines, dietary habits, herbal or nonprescription medications, or results of home testing (such as home blood pressure or blood sugar readings).
Organizations such as the [[American Health Information Management Association]] (AHIMA) encourage individuals to keep their own complete PHR.<ref>{{cite web|url=http://www.ahima.org/dc/positions/documents/MicrosoftWord-AHIMA-AMIAPHRStatement-final2-2007.pdf|title=The Value of Personal Health Records A Joint Position Statement for Consumers of Health Care|publisher=[[American Health Information Management Association]], American Medical Informatics Association|month=February|year=2007|accessdate=2007-10-09}}</ref> According to AHIMA, 42 percent of US adults surveyed said they keep some form of a personal health record. Personal health information storage is offered online at several Internet sites.
[[Veterans Health Administration|Veterans Administration]] patients are able to access their personal health records, called Personal Health Journals, through HealtheVet,<ref>{{cite web|url=http://www.health-evet.va.gov/|title=My HealtheVet Pilot|accessdate=2007-10-09}}</ref> an online service linked to the [[Veterans Health Information Systems and Technology Architecture|VistA]] electronic health record system.
== Continuity of Care Records (CCR) ==
The [[Continuity of Care Record]] (CCR) is meant to represent a brief synopsis of recent healthcare encounters, to include only significant data. It is meant to enable a rapid assessment of the patient's overall health and recent visits to healthcare providers. CCRs may be transmitted in paper or electronic form.
Almost all electronic health record systems have a CCR function built in (often called the cover sheet or health care summary). If a patient receives care in a healthcare setting using the same electronic health record system, the CCR can usually be instantly accessed. However, if the patient visits a healthcare setting that uses paper records or a different or non-compatible type of electronic health record system, the data may not be transferrable.
For this reason, a standard format for the CCR has been approved.<ref>ASTM International [http://www.astm.org/cgi-bin/SoftCart.exe/DATABASE.CART/PAGES/E2369.htm?L+mystore+bgrj4942+1167285575 E2369-05 Standard Specification for Continuity of Care Record (CCR)]</ref>
The CCR could be transferred directly (over a network connection, for example) or could be stored in a Personal Health Record storage device, such as a portable [[flash drive]] or [[smart card]] that the patient can bring from location to location.
== Software criteria of interoperability ==
The Center for Information Technology Leadership described four different categories ("levels") of data structuring at which health care data exchange can take place.<ref>{{cite journal|author=Walker J, et al.|title=The Value Of Health Care Information Exchange And Interoperability|journal=Health Affairs|date=2005-01-19|url=http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.10/DC1|doi=10.1377/hlthaff.w5.10|pmid=15659453}}</ref> While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.
The four levels are:<ref>{{cite web | last=NAHIT Levels of EHR Interoperbility | first= | year= | url=http://www.nahit.org/cms/index.php?option=com_docman&task=doc_download&gid=3&Itemid=197 | title=What is interoprability? | publisher=National Alliance for Health Information Technology | accessdate=2007-04-04}}</ref>
{| class="wikitable"
|-
! Level
! Data Type
! Example
|-
| 1
| Non-electronic data
| Paper, mail, and phone call.
|-
| 2
| Machine transportable data
| Fax, email, and unindexed documents.
|-
| 3
| Machine organizable data (structured messages, unstructured content)
| HL7 messages and indexed (labeled) documents, images, and objects.
|-
| 4
| Machine interpretable data (structured messages, standardized content)
| Automated transfer from an external lab of coded results into a provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.
|}
== Related and supporting technologies ==
An unusual form of Health Information Technology is the [[VeriChip]] system, an [[RFID]] microchip that can be implanted under the skin to give instant access to a patient's records. The tiny electronic device, produced by Applied Digital Solutions Inc. of [[Delray Beach, Florida]], transmits a unique code to a scanner that allows doctors to confirm a patient's identity and obtain detailed medical information from a database maintained by Applied Digital. Only the identification is provided by the implant, so the system remains limited to hospitals, doctors and patients having access to the scanner.<ref>{{cite news | last = Stein | first = Rob | title = Implantable Medical ID Approved By FDA | pages = A01 | publisher = The Washington Post |date = [[2004-10-14]] | url = http://www.washingtonpost.com/wp-dyn/articles/A29954-2004Oct13.html | accessdate = 2006-07-30 }}</ref>
==See also==
*[[Canada Health Infoway]]
*[[Certification Commission for Healthcare Information Technology]]
*[[Continuity of Care Record]]
*[[Electronic medical record]]
*[[European Institute for Health Records]] (EuroRec)
**[[TC 251]]
*[[Good European Health Record]] (GEHR)
*[[Health informatics]]
*[[Health information management]]
*[[Healthcare Information and Management Systems Society]]
*[[EN 13606]]
*[[Health Level 7]]
*[[MUMPS]]
*[[openEHR]]
*[[Veterans Health Information Systems and Technology Architecture|Veterans Health Information Systems and Technology Architecture (VistA)]]
*[[List of open source healthcare software|List of open-source Electronic Health Record systems]]
==References==
{{reflist|2}}
==Further reading==
*Murphy, G. F. et al. (1999), ''Electronic Health Records: Changing the Vision'' (ISBN 0-7216-7386-4), W.B. Saunders Company ([[Elsevier]]), [[Philadelphia, Pennsylvania]], p.5.
*{{cite web|title=A State Policy Approach: Promoting Health Information Technology in California|publisher=California Legislative Analyst Office|url=http://www.lao.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx|date=February 2007}}
==External links==
{{external links|date=January 2008}}
*[http://www.eecs.harvard.edu/cs199r/readings/RAND_benefits.pdf Can Electronic Health Record Systems Transform Health Care?]*[http://www.rwjf.org/files/publications/other/EHRReport0609.pdf Health Information Technology in the United States]
*[http://www.chcf.org/topics/view.cfm?itemID=133551 Open-Source EHR Systems for Ambulatory Care: A Market Assessment] (California HealthCare Foundation, January 2008)
*[http://www.ehrcentral.com Electronic Health Record information resource (ehrCentral)]
*[http://www.etransx.com/hl7-interface-integration-messaging-engine-xml.asp eTransX - EHR Integration Engine]
*[http://ping.chip.org open source Harvard EHR system]
*[http://www.hhs.gov/healthit/ US Department of Health and Human Services (HHS), Office of the National Coordinator for Health Information Technology (ONC)]
*[http://healthit.ahrq.gov/emr US Department of Health and Human Services (HHS), Agency for Healthcare Research and Quality (AHRQ), National Resource Center for Health Information Technology]
*[http://recordaccess.icmcc.org/ ICMCC portal: EHR info and blogs]
*[http://www.emrconsultant.com/glossary.php Glossary of EHR terms]
*[http://content.healthaffairs.org/cgi/content/full/24/5/1103 Health Affairs The Policy Journal of the Health Sphere]
* [http://ehrscope.com/downloads/april_articles/termonology_healthcare_industry.pdf The term EHR seems to be gaining in prevalence over EMR, according to this article in EHR Scope] .
[[Category:Medical informatics]]
[[Category:Health standards]]
[[Category:International standards]]
[[de:Elektronische Patientenakte]]
[[fr:Dossier médical personnel]]
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