Lakewood Resource and Referral Center

212 2nd Street

Lakewood NJ, 08701
Introduction to EMRs
 Why do we need Electronic Medical Records
(EMRs)?
 Many problems with the current healthcare system
(underuse and overuse)
 30% of children receive excessive antibiotics for otitis
 20-50% of surgical procedures are not necessary
 50% of back pain x-rays not necessary
 50% of elderly patients don’t get a pneumovax
Introduction to EMRs
 Why do we need EMRs?
 Clinical practice is a data intensive operation
 Inadequate data communication causes medical
errors
 Human cognition is good at pattern recognition but not
at remembering lists or evaluating multiple business
rules.
Why do we need EMRs?
 Available 24 x 7
 Can be viewed by more than one user at a time
 Is available from remote locations
 To covering MDs
 Others with appropriate needs
 Data can nearly always be found
 Is legible
Why do we need EMRs?
 Enhances Communication:
 Between providers--clinical messaging
 Can tag EMR location with message
 Referrals
 Half of specialists didn’t know what the main question was
 A third of the time no information came back to PCP
Why do we need EMRs?
 Cost Savings:
 Dictation cost savings
 $170/FTE/month
 Chart pull savings
 $217/FTE/month
 Savings accrue to practice, apply to all payers
Why do we need EMRs?
 Assist with Decision Support:
 Many domains—cost and selection of:
 Drugs
 18% reduction found by Researchers
 Lab tests
 10-15% reduction in cost for charges, last result, probability of
abnormal
 Radiological studies
Why do we need EMRs?
 Decision Support:
 In inpatients, computerizing ordering decreased
 Serious medication errors by 55%
 All medication errors by 81%
 EMR can help by
 Structuring medication orders
 34% error rate with paper vs. 6% with electronic

 Alerting about
 Allergies
 Duplicate medications
 Many other issues
Introduction to EMRs
 Do EMRs make a difference?
 UNEQUIVOCALLY YES, BUT AT A COST!
 In multiple studies, EMRs have been shown to:
 Shorten Length of Stay in a Hospital setting
 Decrease Adverse Drug Events (ADEs)
 Improve Readability, Consistency and Content of the medical
record
 Improve Continuity of Care
 Reduce practice variation

 Most benefits come from Decision Support.

EMR Use in the United States
 Even though the US Health Care system is the costliest
in the world, its performance ranks 37th in the world
according to the World Health Organization
 Only 5% of US primary care providers use EMRs (Bates
et. Al., JAMIA 2003), 7% of all physicians (Wang,
Bates, et. Al., American Journal of Medicine, April
2003)
EMR Use Around the World
Use PCs Use EMR
 Australia 90% 53%
 Denmark 95% 62%
 Netherlands 95% 88%
 Sweden 95% 90%
 United Kingdom 95% 58%
(c) 2001 Harris Interactive
Breakdown by Function - 2002
Australia UK
 Use EMR 90% 99%
 Of Those:
 Prescription 100% 80%
 Notes Unknown 45%
 Reminders Unknown 70%
 Clinical Vocabulary 15% (ICPC) 100% (Read)
 Paperless Unknown 45%

 $2B initiative by UK to get all physicians online

What is an EMR?
 At their heart, EMRs are just a database
 This database hold many kinds of information (coded and
not coded)
 This database is organized by date, time, patient ID and
contains:
 Patient registration data (name, contact info, DOB, SSN, etc.)
 Test results (laboratory, radiology, nuclear med etc.)
 Medications (active, inactive) and Allergies
 Current list of diagnoses and problems
 Appointment Data
 Clinical Notes
 Billing Information
What is an EMR?
 So if an EMR is just a database, how is it different
from other databases, and why is it so useful?
 Value Added:
 A Clinical Knowledge Heirarchy (term dictionary)
 How do clinical concepts work together
 Ex: Digoxin toxicity can occur with hypokalemia

 A List of Current Clinical Recommendations

 A List of Appropriate Medication Indications, Doses,
Adverse Effects and Interactions and Cost Estimates
 Costs, Indications and Utility of Tests
What is an EMR?
 What are some typical EMR Components:
 Lab System: Contains all lab tests ordered and their
results and stored as coded results in many systems
 Radiology System: Stores test reports
 Pharmacy System:List of current medications, inactive
meds and when they were last dispensed or ordered
 Billing System : A list of diagnostic codes used for
billing
 Registration System: Names, Contact Info, Personal
Info, etc. for patients
What is an EMR?
 Additionally, many EMRs have:
 An Order Entry System (where physicians enter orders,
prescriptions, notes etc. online)
 A Decision Support System
 Often linked to the order entry system to
provide guidance at the point of care
 Contains databases for clinical knowledge,
guidelines, list of medication indications,
doses etc.
What is an EMR?
 The spectrum of EMRs
 EMRs target specific user bases, from solo office-based
practices to large, multispecialty care centers
 Many features are thus directed at managing workflows
specifically to these user bases
 For example, large commercial EMRs unbundle services such
as clinical documentation, results display etc. while office
systems typically integrate all of these under the same
interface.
How do Clinicians Interact with EMRs
Patients

REGISTRATION SYSTEM
Clerks

LAB SYSTEM
Nursing Staff

PHARMACY SYSTEM

Physicians
RADIOLOGY SYSTEM

Coding Staff
BILLING SYSTEM

Insurance Co.
Order Entry/Results Reporting
Different Types of EMRs
 EMRs don’t necessarily need to be expensive and
complicated or require that a computer be used to
enter data
 Can have hybrid computer/paper based
approaches
 Ex: In the CHICA™ System, paper is used to interact with
an electronic data repository
 Standardized paper forms are printed and then
“scanned”
 Characters are recognized and the electronic data so
generated interacts with the data repository
Different Types of EMRs
 At Indiana University, pediatric clinics use this
system:
 A data repository was developed using Microsoft SQL Server
 A clinical guideline system was written in Arden Syntax
 An optical character recognition system called Cardiff Teleforms is
used to process handwritten numerical data on preprinted scanned
forms
 The data so generated is stored in the database and dynamic
reminders are generated for the physician
 These are printed on the clinic computer
 The entire operation takes < 2-3 minutes!
Different Types of EMRs
 The Mosoriot Medical Record System™
 Indiana University has an HIV Effort in Kenya
 A Simple MS Access based database holds all patient
records (3 years worth!)
 Provides forms for data entry, standard term dictionary,
medication listings, registration system, clinical
documentation system etc.
 Created by 1 programmer over 2-3 weeks!
 Highly effective, easy to maintain, inexpensive!
Data Sources
 So how can EMRs populate their databases?
 Data can come from many many sources:
 Admission/Discharge/Billing
 Anesthesia Systems
 Cytology Systems
 Diagnostic Imaging Management Systems
 EKG Carts
 Endoscopy Systems
 ER Systems
Data Sources
 More Data Sources:
 Home Care Systems
 ICU Monitoring Systems
 IV Fluid Infusion Control Systems
 Laboratory Systems
 Nurse Triage
 Order Entry Systems
 Pharmacy Systems (Inpatient/Outpatient)
 Pulmonary Function Systems
Data Sources
 More Data Sources
 Radiology systems
 Risk Management systems
 Registration Systems
 Scheduling and Clinic Charge Systems
 Transcription Systems
 Unit Dose Dispensing machines
 Ventilator Management systems
 Thank You

Q&A

Acknowledgments: William Tierney, MD Atif Zafar, MD AHRQ PBRN Resource Center