The implementation of the electronic medical records has been on the US healthcare agenda for the past couple of decades. Nevertheless, even now, twenty years after the Institute of Medicine’s initiation of the computerization process of the nation’s healthcare system, many of the hospitals and private physicians are still using the paper-based medical records (Haupt, 2011). Through the study of the history of medical records, the definition of the disadvantages of the paper-based records and analysis of the EMR, this research shows the significant positive changes that have happened in the US healthcare system with the implementation of the electronic medical records. Despite all the disadvantages noted by the opponents of the EMR, the new system of collecting, storing and accessing medical information is able to improve the healthcare provision system in the United States, while decreasing the costs of medical care.
The Purpose of Medical Records
Medical records are used to follow the patient’s health and present patient’s symptoms, as well as notes from the healthcare specialists who provide assistance for the person. Over time, the focus of medical records has changed. The first records were time-oriented and focused on the chronological development of diseases. The next step was the introduction of the patient-centered medical records in the beginning of the twentieth century (Luo, 2006, p. 20). At this time, records remained disorganized, and in order to somehow standardize the system of recording information, the problem-oriented system was introduced in the 1960s. Moreover, the SOAP (subjective, objective, assessment and plan) note has added more clarity to the system of recording medical information. Throughout the history of the medical record development, all the information was kept in a paper form.
Disadvantages of Paper Records
Although the paper-based medical records have a long history, in the late twentieth century, healthcare institutions have started a massive campaign for the replacement of the paper medical records with electronic ones. In order to understand the reasons for implementation of the computerized record system, it is necessary to see the disadvantages of the paper-based one.
One of the major concerns with the paper-based medical record system was the space that was required to keep all the information on patients. Even with all the improvements in the system of recording information, large hospitals require separate storage facilities, which usually have limited access; thus, information on patients is not always available, or its’ access requires additional time. Moreover, this access is even more limited, in case the patient comes in the emergency room, because all records are usually stored either in the office or clinic of the medical facility.
Another crucial problem of the paper-based medical data is legibility. One of the studies has shown that in a Spanish hospital, 15 percent of medical data was illegible (Luo, 2006, p. 20). It means that part of the patients either has no medical records at all or, what is worse, might have records that are interpreted wrongly by the healthcare specialists. Illegibility of medical records might lead to wrong treatment and prescriptions, which will consequently have a negative impact on the patient’s health.
Moreover, paper can be affected by both fire and water; thus, medical records can be easily destroyed. Taking into consideration the fact that paper-based medical records do not usually have back-ups, it is clear that this form of storing medical information of patients can be easily destroyed. At the same time in terms of security, only the locks on storage doors provide the safety of documents.
Although medical records have for centuries existed in the paper form, they have many disadvantages such as vulnerability to the influences of fire and water, lack of back-up information, complicated and time-consuming access (Rector, Nolan, & Kay, 1991). Therefore, in order to improve the healthcare and patient care systems, the new medical records were implemented in the computerized medical institutions.
With the development of technologies, increasingly more spheres of human life become digitalized; therefore, electronic resources and ways of storing information are already the most common ones (Haupt, 2011). Moreover, the use of computes has simplified many of routine procedures and increased the possibilities for information access. These changes have also influenced the development of medical practices and the form of medical records. A bit more than twenty years ago, in 1991, the Institute of Medicine (IOM) of the National Academy of Sciences has urged all the health providers to adopt computer-based records (Lenhart, Honess, Covington, & Johnson, 1998, p. 109). The IOM has set the goal of standardizing the computerized US healthcare system by the year 2000.
By the new millennium, only a small part of the US hospitals and other healthcare specialists have implemented the electronic medical record (EMR) systems. After the IOM initiation of the nation-wide implementation of EMR, its rates remained relatively unchanged, and the use of the electronic medical record has increased only by five percent over the decade (Loomis, Ries, Saywell, & Thakker, 2002, p. 636). Between 2003 and 2004, the hospital computerization has increased, followed by the next computerization wave between 2005 and 2007 (Himmelstein, Wright, & Woolhandler, 2010, p. 3). Even after the two increases of computerization and the implementation of EMR, only 64 percent of certified medical programs were implemented in an average US hospital, with large urban and teaching hospitals, showing higher percent of computerization with a contrast to the public ones (Himmelstein et al., 2010, p. 3).
The US healthcare system is fully prepared to the implementation of the EMR. The majority of healthcare professionals already use computers in their everyday life and practice. In the beginning of the new millennium, the study conducted by Loomis, Ries, Saywell, & Thakker (2002) has showed that 67% of physicians used Internet in medical practice, while more than 90% of them were already computerized (p. 639). Thus, there was a steady basis for the implementation of the EMR.
In the basis of any EMR is a “real-time transaction-processing” set of data of various patient information (Garets & Davis, 2005, p. 2). Moreover, the EMR is not only a digital copy of the paper-based medical record. It is a whole computer-based system for patient data management and delivery, which has a number of different functions (Luo, 2006, p. 21). Currently, the EMR systems vary from one institution to another, but there are some common features that all the EMRs have: assessments and plans for patient care, patient demographics, scheduling and patient information.
In the study of the EMR, it is also essential to understand the difference between electronic medical records (EMR) and electronic health records (EHR), which many tend to ignore. EMRs are the “computerized legal clinical records” (Garets & Davis, 2005, p. 1), while EHRs give a possibility to share medical information with stakeholders and allow following the patient on different stages in various healthcare organizations.
The Advantages of Electronic Records
The Electronic Medical Records have managed to cope with all the disadvantages of the paper-based medical recording. They are secure, reliable and provide real-time access to patient information (Handler et al., 2003, p. 2). The EMR is easily back-upped and gives a possibility to store large amounts of information in relatively small spaces. Moreover, it is much harder to destroy medical records by the external influences. Overall, the EMR seems to be a successful replacement of the paper-based records that has not only improved the form of information storage, but also has significantly influenced the quality of the healthcare provision process in the United States (Steward, 2005, p. 491).
The real-time access to the medical information of patients has increased the efficiency of the healthcare provision process. The time, which was earlier spent on the search of the patient’s information in the large storage within the medical care facility, is now used for the actual care provision. Therefore, patients get proper support within a shorter period of time. Moreover, the EMR is available 24/7 and from different locations, which also increases the speed and proficiency of medical support (Handler et al., 2003, p. 2). The quick access to medical information gives medical staff a possibility to react to unexpected situations faster and more efficiently, which is essential in the cases when urgent decisions are required (Hannan, 2010, p. 6).
Being a multifunctional system, the EMR stores all kinds of patient information, which provides doctors and other healthcare specialists with not only faster, but also a more detailed and diverse information on the patient’s health. The efficiency of this integrated information is shown by the high percent (81-99%) of healthcare specialists who routinely access this data, while providing care for patients (Handler et al., 2003, p. 4). The access to the diverse data on the patients gave clinicians a possibility to provide a considerably better care. Moreover, with the possibility of reviewing the diversified information on a patient, doctors are able to provide an adequate diagnosis at a shorter period of time (Hannan, 2010, p. 7).
The research of Himmelstein et al. (2010) has showed that the computerization and introduction of the electronic medical records has resulted in consistent improvements of healthcare quality (p. 5). Even though the authors note that the pace is quite slow at the moment, the long-term results are expected to be exceptionally positive.
The implementation of the EMR is able to significantly decrease healthcare expenses. For example, the extensive alerting system that is based on the analyzing of the results of laboratory tests has decreased the patient’s time spent in a hospital (Hannan, 2010, p. 9). Hannan (2010) also describes a research which confirmed that the care plans based on the EMR and computerized systems have decreased the costs without the decrease in the quality of healthcare (p. 9).
The computerization of medical records has improved access to information not only for the healthcare professionals, but also for the patients. Freudenheim (2012) describes a case, when patients in different hospitals can access own healthcare information at any time of the day. The technological advancement has even given a possibility to see everything with a special iPhone application. This access allows people to be aware of own health and, thus, trust the healthcare system.
In order to protect the confidential information of patients, the Health Insurance Portability and Accountability Act (HIPAA) was introduced to set standards for both paper and electronic medical records (Loomis, Ries, Saywell, & Thakker, 2002, p. 640). Therefore, compliance with the HIPAA gives healthcare providers, as well as patients, faith in security and confidentiality of all patient information within the EMR system.
Preventive care is one of the main directions of the healthcare system nowadays. The development of preventive care results in the decrease of healthcare costs, because it is easer to stop a disease at the earlier stages than to treat a patient in the hospital. With the alert system introduction within the EMR and the electronic reminder system, it is much easier to implement preventive care, immunization procedures and utilization of vaccines (Hannan, 2010, p. 9). This results in the decrease of the morbidity and mortality from infectious diseases, as well as in the decrease of healthcare costs.
The Argument against EMR
Both current users of the EMR and non-users of electronic records define a number of disadvantages that arise with the implementation of the new system in hospitals. These include financial expenses, time for training of medical staff, the protection of patient records etc. With the implementation of the EMR, more problems become visible; therefore, many healthcare professionals have not switched to the EMR yet and are not planning to implement the new record-keeping system.
It is essential to emphasize that the EMR users and non-users have different perceptions of the obstacles that one might face on the way of implementing the EMR system. Those who are already working with the electronic medical records define the biggest problems of the system in longer patient data entry times and resistance to use the EMR systems by both the faculty and the residence. The price of software as an obstacle is seen as a common misperception of professionals who have not implemented the EMR system (Lenhart, Honess, Covington, & Johnson, 1998, p. 112).
The data entry procedure is one of the greatest concerns in the process of the EMR implementation. Loomis, Ries, Saywell, & Thakker (2002) has described this concern as “medicine requires varied skills, fast pace, treating patients from multiple age groups, diagnosing conditions from a myriad of potentially unrelated complaints, and keeping a comprehensive record from multiple sources” (p. 640). Taking into consideration all these factors, many consider the process of data entry one of the main obstacles on the way of effective computer use in the healthcare system. With the increased time spent on data entry, there is a danger of the change of the doctor-patient relationship and interaction (Luo, 2006, p. 23). Healthcare professionals might spend less time with patients and even see less of them. Freudenheim (2012) notes that some doctors have complained that because of the EMR, they were able to see only half of the patients.
While with the paper medical records, doctors have experienced some cases of lost medical information, with the EMR, these losses can be of significant scale. With the crash of a computer server, medical information of a vast majority of patients can be lost. Along with loosing healthcare information, there are also crucial concerns about its security and confidentiality within an electronic system. The loss or inappropriate exposure of patient’s data can be caused by the mistakes in programming or operating the system (Luo, 2006, p. 23).
One of the main arguments for the implementation of the EMR system was the possibility to decrease healthcare costs. At the same time, on the initial stages of the introduction of a new record system, it is considered to be an expensive process. The basic costs include the purchase of computers, servers, software applications (Lenhart, Honess, Covington, & Johnson, 1998, p. 112), as well as the system support (Luo, 2006, p. 23). Due to the initial purchase of equipment and trainings, hospitals that have implemented the EMR system have faced a rapid increase of costs (Himmelstein et al., 2010, p. 5). Therefore, at least in a short term, computerization only increases the costs of medical institutions.
Thus, neither of the studies has shown the evidence of lowering administrative costs with the implementation of the electronic medical records. Moreover, the administrative costs have shown a slight increase by a half percent over the period of four years, but this increase is not attributed to the implementation of the EMR system (Himmelstein et al., 2010, p. 3).
The standardization of medical information is another complication in the process of the EMR implementation. While the EMR programs are only on the first stages, there is a lack of common standards of documentation and formatting. As a result, the documents created in Microsoft Word on a Windows computer might not be correctly opened on a Macintosh (Luo, 2006, p. 23). Thus, it is essential to set the nation-wide standard of medical recording and insure easy access to the correct information from different types of computers.
Many of the disadvantages of the EMR are exaggerated and come from the misperception of the EMR system and the lack of information. Studies show that the levels of satisfaction with the electronic medical records are high among the healthcare providers that are already using the system. It is highly significant that the patients are also expressing their support for the EMR. Many studies have also shown that the hazards and obstacles of the EMR implementation that are perceived by the non-users are not the ones defined by the medical staff using the system. Therefore, it would be logical to assume that due to the lack of information and improper perceptions of the electronic medical records, many patients and health care specialists form an inadequate opinion about the EMR. This argument will be explained on one example which is the cost efficiency of computerization and the implementation of EMR.
The majority of studies have not proven the bright expectations for the significant decrease of costs with the computerization of hospitals and implementation of the electronic medical records. At the same time, these results should not be perceived as unsatisfactory as they show only the short-term effect of computerization. Himmelstein et al. (2010) define two main reasons why the opponents of the EMR should not focus on the economic loss of the system. Firstly, the initial costs of purchasing and maintaining the computerized system only increase the administrative expenditures of the healthcare institutions (p. 6). Secondly, the authors state that the financial gain from the EMR can be achieved in a long-term perspective, when the initial costs of equipment will be slowly covered by the financial benefits of the computerization. Hillestad et al. (2005) state that over fifteen years, the savings from the implementation of the EMR will be more than $350 billion only from the hospital systems, with the additional savings of $142 billion from the physician practice (p. 1114). Therefore, despite the initial dissatisfaction with the expenditures of the electronic medical records, there are significant long-term results. The possibility of healthcare cost savings is especially crucial in terms of the constantly increasing healthcare costs in the United States.
With the global computerization and digitalization of information, it is not surprising that the healthcare system has to adapt to the world tendencies. The introduction of the electronic medical records and computerization of healthcare institutions became the new steps in the development of the US healthcare system. Undoubtedly, the EMR still has a lot of opponents who question the system’s security, efficiency and the financial stability. However, at the same time, various study results have shown that hospitals are increasing their performance with the implementation of the EMR, and on the long-term scale the new system of keeping medical records will also bring significant financial benefits. The main advantage of the EMR is that it not only stores medical records, but also effectively utilizes information, which gives healthcare professionals a faster access to a more diverse healthcare data. Therefore, despite some of the negative arguments concerning the EMR, the system is actually working and improving the level of healthcare support in the country. The US healthcare system is currently going through transformations, and those are undeniably positive ones.