ArticlePDF AvailableLiterature Review

Electronic Medical Records in the American Health System: challenges and lessons learned



Electronic medical records have been touted as a solution to many of the shortcomings of health care systems. The aim of this essay is to review pertinent literature and present examples and recommendations from several decades of experience in the use of medical records in primary health care, in ways that can help primary care doctors to organize their work processes to improve patient care. Considerable problems have been noted to result from a lack of interoperability and standardization of interfaces among these systems, impairing the effective collaboration and information exchange in the care of complex patients. It is extremely important that regional and national health policies be established to assure standardization and interoperability of systems. Lack of interoperability contributes to the fragmentation of the information environment. The electronic medical record (EMR) is a disruptive technology that can revolutionize the way we care for patients. The EMR has been shown to improve quality and reliability in the delivery of healthcare services when appropriately implemented. Careful attention to the impact of the EMR on clinical workflows, in order to take full advantage of the potential of the EMR to improve patient care, is the key lesson from our experience in the deployment and use of these systems.
Electronic Medical Records in the American Health System:
challenges and lessons learned
Registros Eletrônicos de Saúde no Sistema de Saúde norte-
americano: desafios e lições aprendidas
Resumo Os registros médicos eletrônicos (RME)
têm sido apontados como uma solução para muitas
das deficiências dos sistemas de saúde. O objetivo
deste ensaio é revisar a literatura pertinente e apre-
sentar exemplos e recomendações de várias déca-
das de experiência no uso de registros médicos na
atenção primária à saúde, de maneira a ajudá-los
na organização de seus processos de trabalho para
melhorar o atendimento ao paciente. Observou-se
que problemas consideráveis resultam da falta de
interoperabilidade e padronização de interfaces
entre esses sistemas, prejudicando a colaboração
efetiva e a troca de informações no atendimento
a pacientes complexos. É extremamente impor-
tante que políticas regionais e nacionais de saúde
sejam estabelecidas para garantir a padronização
e interoperabilidade dos sistemas. A falta de inte-
roperabilidade contribui para a fragmentação do
ambiente de informações. O prontuário eletrônico
(RME) é uma tecnologia disruptiva que pode revo-
lucionar a maneira como cuidamos dos pacientes.
Foi demonstrado que o RME melhora a qualidade
e a confiabilidade na prestação de serviços de saú-
de quando implementada adequadamente. Uma
atenção cuidadosa ao impacto do RME nos fluxos
de trabalho clínicos, a fim de aproveitar ao máximo
o potencial do RME para melhorar o atendimento
ao paciente, é a principal lição de nossa experiência
na implantação e uso desses sistemas.
Palavras-chave Registros eletrônicos de saúde,
Atenção primária à saúde
Abstract Electronic medical records have been
touted as a solution to many of the shortcomings
of health care systems. The aim of this essay is to
review pertinent literature and present examples
and recommendations from several decades of ex-
perience in the use of medical records in primary
health care, in ways that can help primary care
doctors to organize their work processes to im-
prove patient care. Considerable problems have
been noted to result from a lack of interoperabili-
ty and standardization of interfaces among these
systems, impairing the effective collaboration and
information exchange in the care of complex pa-
tients. It is extremely important that regional and
national health policies be established to assure
standardization and interoperability of systems.
Lack of interoperability contributes to the frag-
mentation of the information environment. The
electronic medical record (EMR) is a disruptive
technology that can revolutionize the way we care
for patients. The EMR has been shown to improve
quality and reliability in the delivery of healthcare
services when appropriately implemented. Care-
ful attention to the impact of the EMR on clinical
workflows, in order to take full advantage of the
potential of the EMR to improve patient care, is
the key lesson from our experience in the deploy-
ment and use of these systems.
Key words Electronic medical records, Primary
health care
Robert S. Janett ( 1
Peter Pano Yeracaris ( 2
DOI: 10.1590/1413-81232020254.28922019
1 Cambridge Health
Alliance. 237 Hampshire
Street. 02139 Cambridge
Massachusetts USA.
2 Care Transformation
Collaborative Rhode Island.
Providence Rhode Island
Janett RS, Yeracaris PP
Electronic medical records have been touted as a
solution to many of the shortcomings of health
care systems1-3. Others have criticized the move
toward the electronic medical record (EMR) as
a threat to the physician patient relationship, to
patient privacy, and as an additional adminis-
trative burden to the health system contribut-
ing to physician burn-out4,5. A modern EMR is
not simply a digitized paper chart. Rather, it is a
digital application that can actively interact with
providers and patients and is composed of a se-
ries of data fields that lend themselves to analysis,
processing, and reporting to support communi-
cation, appropriate clinical interventions, quality
improvement, and patient safety.
As authors of this article, we both have prac-
ticed medicine using paper charts and were pres-
ent for the painful transition from paper to elec-
tronic records. We are primary care physicians
and have been users and implementers of elec-
tronic health records in public and private health
systems, locally and regionally in the northeast
United States. The first section of this paper
will describe the evidence for the benefits and
drawbacks of electronic medical records. In the
second section we will then describe, from the
literature and our experience, some of the ways
that electronic records can be optimally used to
support better health care delivery for individual
patients while simultaneously improving health
care delivery to populations.
There is no perfect electronic medical record
system, but there are features of systems that have
been shown to improve reliability, quality, and ef-
ficiency over time. There is no better tool than an
EMR to integrate patient care among members
of the care team at a specific facility (horizontal
integration), and among providers and various
facilities at the primary, secondary, and tertiary
levels of care (vertical integration). A high func-
tioning EMR helps reduce fragmentation in the
care delivery system and this improves quality
and efficiency by reducing gaps in care. An EMR
can offer reminders of important interventions
that are needed at the time of an office visit and
can track and flag patients who do not present
themselves for follow up care in an appropriate
At the same time, EMR systems are costly
to implement and to maintain, and can also be
challenging because an EMR impacts virtually all
of the workflows and care processes in a clinical
The EMR is particularly useful in primary
care settings, especially because primary care is
the locus of most care coordination activities
that occur in health systems. Comprehensive in-
tegrated primary care6-8 is perhaps the most sig-
nificant contributor to reform of the American
health system. Electronic records are an essential
component of this evolving care model and are
designed to support many of the unique features
of robust primary care, as we will describe in
detail. Key features of this comprehensive care
model9 include empanelment of patients with
specific provider teams, advanced access to ap-
pointments, team-based multidisciplinary care,
shared responsibility among team members for
providing evidence-based patient interventions
in a reliable way, shared access to clinical infor-
mation across members of the care team, elec-
tronic communication with patients, checklists
to support the closure of gaps in care at the time
of the office visit, and active outreach to patients
who do not visit the office but who are identified
to have gaps in care. Moreover, coordination of
complex care with specialists and hospitals in-
volves shared access to clinical information and
secure channels of communication.
Evidence for the Impact of the EMR
on Medical Practice
There is ample evidence from the global lit-
erature on the impact of the EMR on clinical
practice. A systematic review10 showed that adop-
tion of an EMR improved structural and process
components in primary care, with less clear evi-
dence of the EMR’s impact on outcomes. A 2006
study on pediatric practices11 showed that larger
practices were more likely to adopt an EMR than
smaller practices because of cost concerns, and
the lack of decision support features in EMRs
of that era limited the impact on quality of care.
Kaiser Permanente, the largest private integrat-
ed health system in the United States, showed
that implementation of the EMR significantly
reduced demand for primary care and special-
ist office visits, with a concomitant increase in
e-mail and telephonic communications between
patients and providers, resulting in operational
efficiencies while offering more patient-centric
access to providers12,13.
Costs of implementing an EMR have been
studied and analyzed. Costs are classified into
two broad categories: the direct economic cost
of the system with associated expenses, and the
costs in person-hours of implementation and
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
use of the EMR. Implementation time is signifi-
cant, as one physician network in Texas showed14.
A practice-based information technology team
required 611 hours on average to prepare and
deploy a new EMR system. End user physicians
and other clinical team members required 134
hours, on average, per physician to prepare to use
the system in clinical encounters. The financial
cost to this group was estimated to be $162,000
for a five-physician practice, with $85,000 in
maintenance expenses during the first year. An-
other study15 showed that the economic benefit
of an EMR was 308.6% of the annual cost of the
system. A time motion study in five practices
showed that the overall time spent face-to-face
with patients after implementation of an EMR
decreased by about 30 seconds16.
Primary care providers vary in their attitudes
to the adoption of an EMR. A systematic re-
view of the world literature17 demonstrated that
younger, more computer literate primary care
physicians who are based in larger practices view
the EMR positively, compared to older physicians
who are less skilled in the use of technology and
who are based in solo practices. Factors such as
training, policies and procedures, and financial
incentives can be used to favorably influence
physician attitudes toward the EMR. Another
study from the U.S. Veterans Administration18
has similar findings.
The impact of the EMR on the physician-pa-
tient relationship has been extensively studied.
Capture of biomedical information improved
while collection of emotional and psycho-social
information was felt to be compromised. At the
same time, patient access to the information in
the EMR and reliably secure messaging functions
increased patient engagement, empowerment,
and self-management19. Physician-patient eye
contact is a critical element of communication
and a study showed that the EMR alters physician
and patient interactions with regard to gaze20.
Impact on patient satisfaction with the use of an
EMR in the examination room was found to neu-
tral to positive but the evidence for this impact
was weak21,22. One systematic review21 revealed
communication behaviors in the examination
room that were potentially beneficial (facilitat-
ing questions) and others that were potentially
negative (low rates of screen sharing, interrupt-
ed speech). Screen sharing with the patient is
one strategy that has been used to mitigate some
of the barriers. Another review23 found positive
impact on information exchange with a negative
impact on patient-centeredness, noting that the
characteristics of some physicians (behavioral
style and computer skills) overcame the negative
influences of the EMR on patient-doctor com-
A systematic review of the literature on the
use of EMRs to support population health24
identified factors that facilitate and others that
are barriers to adoption of the technology for
this purpose. Of twenty-six factors, 63% were fa-
cilitators and 37% were barriers. Factors that fa-
cilitate population health include improved pro-
ductivity and efficiency, improved quality, data
management, surveillance, and preventive care.
Factors that were deemed barriers to population
health management include missing data, lack of
standards for interoperability of different EMR
systems, loss of productivity, and overly complex
technology. The authors concluded that wider
adoption of EMRs with more comprehensive
standards for interoperability among systems
will improve the capacity to conduct surveillance
and disease management and prevention.
A meta-analysis on the impact of the EMR
on healthcare quality25 found a 22.4% reduction
in documentation time, higher adherence to
clinical guidelines, and a lower number of med-
ication errors. There was a striking reduction in
the number of adverse drug events. A study of
the pharmaceutical component of safety alert
features of EMRs in the United States26 showed
statistically significant reduction in medication
errors in patients with chronic kidney disease,
reduction in dispensing of potentially terato-
genic drugs to pregnant women, reduction of
inappropriate prescribing for geriatric patients,
reduction of co-dispensing of interacting drugs,
and a reduction of adverse drug events related to
hyperkalemia. Care processes are clearly impact-
ed by adoption of an EMR. A study of a prima-
ry care group27 showed marked improvement of
performance on quality metrics after adoption of
an EMR, a near doubling of the rate of obtain-
ing mammograms, varicella immunizations, and
glycosylated hemoglobin testing and influenza
immunization in patients with diabetes.
The EMR’s impact on a variety of health im-
provement interventions has been systematically
studied. Automated reminders and prompts to
administer the human papilloma virus vaccine
to appropriate patients performed significantly
better compared with EMRs that did not include
these features28. Changes in systems of care along
with the use of an EMR had a salutary effect on
tobacco screening and treatment rates in public
hospitals serving low income patients29, with a
Janett RS, Yeracaris PP
significant reduction in tobacco use among pa-
tients at these hospitals. Advance care planning
to ensure that care is concordant with patients
wishes was positively impacted by the use of
tools including documentation templates, auto-
mated prompts and electronic order sets within
the EMR30. This systematic review showed more
frequent documentation of advance care plan-
ning conversations, placement of code status or-
ders, and improvement in advance care planning
Management of diabetes mellitus using an
EMR has been carefully evaluated. Adherence to
diabetes care standards improved 35.1 percentage
points and achievement of composite standards
for diabetes outcomes improved 15.2 percentage
points in a large study of 27,207 adults seen at
46 practices31. Thirty-eight percent of these pa-
tients were seen at ‘safety net’ facilities that treat
predominantly low-income individuals. The
availability of a patient portal to facilitate secure
electronic messaging between providers and
patients32 was associated with a significant im-
provement in patients’ glycohemoglobin levels.
A meta-synthesis of articles on diabetes care and
management using an EMR33 showed that diabe-
tes patients benefit most from decision support
tools to notify physicians of drug interactions,
communication tools to keep patients engaged
in treatment and informed of their progress, as
well as reporting and tracking tools to inform
providers of gaps in care and their performance
in closing those gaps.
In any discussion of the EMR, it is import-
ant to elucidate some of the significant draw-
backs and potential risks in adopting an EMR
system. As noted, implementation and main-
tenance costs can be high. Disruption of estab-
lished workflows and at least a transient initial
decrease in patient visit volumes and revenue are
common concerns. Electronic systems also raise
the specter of potential violations of patient con-
fidentiality and breaches of private personal in-
formation34. The failure of various EMR systems
to standardize protocols for interoperability can
impair appropriate information sharing among
providers caring for a patient. Environments
with multiple different electronic medical record
systems or with a mixture of electronic and pa-
per systems present impediments to the EMR’s
potential to improve collaboration and care co-
ordination through vertical integration4. In these
circumstances, practices often revert to scanning
of printed documents, degrading the power of
an EMR to search and compare clinical data that
would otherwise be entered into specific fields.
National and regional policies are required to es-
tablish standards for EMR interoperability.
Moreover, the proprietary nature of most
EMR systems can result in a lack of transparen-
cy that can hide coding defects within the EMR
systems themselves, which can cause systematic
errors in reportable fields and other important
elements. Specific errors related to usability have
also been documented. Complex user interfaces
make it more difficult to navigate the EMR and
can increase the likelihood of erroneous orders
for medications, testing, and other interven-
tions35. Patient safety issues in medication man-
agement have been noted when weights are en-
tered in pounds rather than kilograms, resulting
in incorrect dosing of weight-based medicines34.
Key Features and Functions of Electronic
Medical Records that Support an Integrated
Care Model
Our experience from several decades of work
are presented to illustrate ways in which the EMR
offers features and functions that support and
improve care, making it more reliable and safer
for patients.
Quality of care
Improving care quality is a challenge in all
health systems. Quality improvement is a system-
atic approach to improving care using metrics to
inform results. Quality improvement methods
are applied to many components of care, includ-
ing provider access and availability, efficiency of
patient flow, patient satisfaction, chronic disease
management, provision of preventive services,
effective use of acute care services, transitions
of care, and care coordination, among others. As
we discussed in Section I, the use of an EMR has
been shown to improve performance on a vari-
ety of quality indicators, compared to practices
that use paper records. But quality improvement
requires more than an electronic record. More
effective and reliable systems of care and work-
flows, guided by information contained in the
electronic record, are required for sustainable
performance improvement36,37. With established
standards of care and clinical protocols encoded
into the system software, reminders, checklists,
registries, patient outreach and engagement, and
reporting, the EMR supports the clinical team’s
efforts to optimize the structure, process, effi-
ciency, effectiveness, and outcome of care. Since
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
performance measurement is an essential ele-
ment of quality improvement work, an essential
contribution of an EMR can be to streamline the
measurement and analysis of data on clinical
performance metrics, assuming that the system
is properly configured, data fields are accurately
completed, and that the software application is
sophisticated enough to support the measure-
ment and reporting process.
This is an example of ways in which an EMR
and the associated changes in the care model can
improve management of patients with type II
diabetes. First, a nationally recognized care pro-
tocol is endorsed by the provider organization,
is accepted as a care standard, and is encoded
into the EMR software. The EMR is organized
to detect patients who are overdue for specific
testing such as glycohemoglobin, nephropathy
screening, or retina examination or who have
other care interventions that are not compliant
with the care protocol. The EMR can generate a
check list of these gaps in care on any patient on
any given day. Patients who are scheduled to be
seen in the office can be offered the missing ser-
vices regardless of the reason for the visit. And
patients who are not scheduled to be seen can be
reviewed in a diabetes registry. Those with gaps
in care who do not have appointments can be
contacted by e-mail, letter, or telephone as part
of the active outreach process. These workflows,
guided by EMR based information, reliably im-
prove performance on diabetes care measures.
By embedding quality improvement work in the
daily care activities, performance improvement is
sustained over time (Chart 1).
Support for the Team-based Care Model
Team-based care is an essential component
of comprehensive integrated primary care and
a well-functioning EMR can be strategically de-
ployed to support the essential functions of the
multidisciplinary team9,38,39. High functioning
primary care practices have teams composed of
physicians, advanced practice nurses, physician
assistants, clinical pharmacists, nurse care man-
agers (for coordination of chronic disease care
and for patient education), behavioral health
specialists, social workers, nutritionists, medi-
cal assistants, nurses, receptionists and popula-
tion health managers. This care model has been
shown to improve quality of care and to increase
the capacity to care for more patients, while si-
multaneously decreasing physician workload.
Ideal staffing requires the deployment of 2 or
2.5 full-time-equivalent well-trained medical as-
sistants per full time physician38. An important
task of the medical assistant in these settings is
to assist with record keeping of the clinical en-
counter as a “scribe”, carefully documenting the
clinical encounter in the EMR, in real time, as the
physician cares for the patient38. “Scribes” have
been shown to document clinical notes that are
as accurate, or more accurate, than those of a
With appropriate guidance and training,
medical assistants are able to perform a num-
ber of routine functions such as cancer screen-
ing, provision of preventive services, scheduling
appointments with specialists, obtaining pro-
tocol-driven lab testing, among others. These
clinical processes and pathways make care more
reliable and result in more efficient and effective
patient visits. With routine interventions man-
aged by an information-system driven protocol
that guides the activities of non-physician team
members, physicians are able to better focus on
care activities that depend on their specialized
knowledge, training and professional expertise
to establish and strengthen the patient-physi-
cian relationship38,41 and attend to the subtleties
of formulating difficult diagnoses, engaging in
shared decision making, and attending to the pa-
tient’s psycho-social needs (Chart 2).
The EMR as a tool to facilitate
A high functioning EMR will support ef-
fective and efficient communication between
patients and health care providers, support hor-
izontal integration within the clinic, and sup-
port vertical integration between primary care,
specialists, hospitals, laboratories and imaging
With Patients
Patient portals support bidirectional com-
munication, offering patients easier ways to
interact with providers without the need for a
face-to-face office visit or telephone call. While
younger patients may be accustomed to e-mail
and text messaging, electronic messaging can
be more challenging to older patients. But ex-
perience is showing us that even older patients
with chronic disease are starting to use patient
portals and are enjoying enhanced access to their
provider teams. The goals of an effective patient
portal include; fostering better patient-physician
relationships, improving clinical outcomes, and
Janett RS, Yeracaris PP
optimizing office workflows. While health sys-
tems have been slow to adopt many of the cus-
tomer-friendly electronic tools used in other sec-
tors (such as banking, travel, and on-line retail,
among others) the patient portal is an important
step in that direction.
Providers and team members can use patient
portals to efficiently communicate the results
and interpretation of diagnostic tests, inform pa-
tients of upcoming appointments and referrals,
and can answer patient questions asynchronous-
ly, without requiring that both parties be avail-
able at the same time to talk on the telephone.
Furthermore, these electronic links can help re-
mind patients of pending or overdue care inter-
ventions, such as health screenings and chronic
disease management follow up, to avoid gaps in
care. Active outreach can be simple and efficient
when patients and providers are linked electron-
ically (Chart 3).
Among members of the care team
(horizontal integration)
In order to effectively collaborate in the ef-
ficient and reliable care of patients, members of
multi-disciplinary teams must be able to easily
communicate and share information about pa-
tients. Teams engage in care planning in four
phases: before the office visit, during the visit,
after the visit, and between visits. The EMR sup-
ports the work of the multidisciplinary care team
each of these four phases. In advance of the visit,
gaps in care are identified on an EMR-generated
evidence-based-protocol-driven check list and
Chart 1. Examples of EMR and Workflows to Support Quality Improvement Activities at the Point of Care of
Patients with Diabetes Mellitus.
Function Workflow Example
Reduce unwarranted
variations in care
care protocols
and clinical
Provide guidance to
all members of the
multidisciplinary team
on standards for care of
patients with diabetes
Adopt the American Diabetes Association
standards of care for adults with type II
diabetes mellitus and embed these care
standards in the EMR
Enhance reliability
of care model by
improving provider
adherence to type
II diabetes care
protocols and clinical
practice guidelines
Checklists Flag patients who present
for care and who are due
for clinical interventions.
1)A1c twice a year
2)Urine microalbumin yearly
3)Diabetic retina exam
4)Diabetic foot exams twice a year
5)Blood pressure above standard target
Registries Flag patients who are due
for clinical interventions
but who do not present
for care
Best practice
Alert multidisciplinary
team members to these
potential gaps in care
Reduce medication
errors and improve
adherence in diabetes
Allergy lists Alert prescriber to the
presence of drug allergies
to avoid patient harm
Prior episode of angioedema due to
angiotensin converting enzyme inhibitors
Prior episodes of drug-induced
pancreatitis due to dulaglutide
Alert prescriber to drug
interactions to avoid
patient harm
Potential for hypoglycemia due to co-
administration of sulfonylurea and azole
antifungal medications
Avoid prescription errors
due to communication
gaps between prescriber
and pharmacy
Prescriptions are transmitted directly
to the pharmacy, avoiding transcription
errors and errors in interpreting
Improve patient adherence
to prescription regimens
Detect failure to refill prescribed
Source: Elaborated by the authors.
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
standing orders. This permits staff to offer rou-
tine required interventions to patients, allowing
those interventions to be assigned to specific staff
members and relieves the physician of the bur-
den of ordering routine interventions at the time
of the visit. During the visit, all team members
have real-time access to the patient’s medical his-
tory and other clinical information. At the end of
the visit, the EMR prints a summary of care with
instructions for the patient and informs staff
members of needed lab tests, imaging studies,
specialist consultations, and follow up visits, so
that these can be arranged in a reliable way. Care
planning between visits is supported by the EMR
registry functions, to track patients who are over-
due for preventive or disease management inter-
ventions and to guide active outreach to these
patients and to engage them in care (Chart 4).
Between primary care, specialists,
hospitals and community providers
(vertical integration)
Transfer of responsibility for care of a patient,
during transitions of care, is a time of high risk.
It is estimated that 80% of serious medical er-
rors result from miscommunication during these
hand-offs42. Better bidirectional communication
between primary care physicians, specialists, and
Chart 2. Examples of Workflows Supported by a Multi-Disciplinary Team and an EMR.
Workflow Example EMR Function
Close gaps in care identified during the pre-visit planning process:
Checklist, registries, embedded
clinical protocols, and standing
1) Health screening and
preventive care interventions
Occult blood testing for colon
cancer screening, scheduling
mammography, administer
behavioral health screens (PHQ9,
SBIRT, GAD7, etc.)
2) Chronic disease
management and testing
Point of care
A1C testing, scheduling diabetic
eye exam
3) Alert the physician of
needed interventions
Blood pressure measured noted
to be higher than target, remove
shoes for diabetic foot exam
Medication reconciliation Reconcile medication list with
patient and family
Medication and allergy lists
“Scribe” functions Document patient history,
physical examination, assessment,
diagnosis, and plan at the time of
the visit
Templates, reportable fields,
diagnosis look-up tables
Reliably performing all clinical
interventions ordered at the visit
Scheduling specialist consults,
scheduling follow up visits,
ordering non-routine imaging
studies and labs
Team communication protocols
through secure messaging, routing
sheet, after-visit summary
Avoiding gaps in care during the between-visit planning process:
1) Identify patients who have
not visited the health unit in the
desired timeframe
Contact patients and engage them
in follow up care
Patient registries, links to the
scheduling module to find patients
who do not have upcoming
2) Identify patients who
require advanced support for chronic
conditions or because of frailty
Medical and behavioral health
case management services, social
work outreach
Patient registries, risk stratification
3) Identify patients who have
poorly controlled disease indicators
Identify and outreach to patients
with hyperglycemia, uncontrolled
hypertension, or who are overdue
for follow up on abnormal test
Patient registries, links to lab data
and imaging data modules, patient-
generating home monitoring data
Source: Elaborated by the authors.
Janett RS, Yeracaris PP
hospitals during times of transitions of care is
supported by an EMR’s secure messaging func-
tions and by the ability of providers to seamless-
ly forward clinical information to one another.
This is accomplished either with a common re-
cord shared by all members of an integrated care
system or by using health information exchange
protocols to link disparate records systems. Shar-
ing information, communicating ideas and ad-
vice, and organizing referrals and appointments
from primary care to other providers and from
those providers back to primary care promotes
collegiality, confidence, and collaboration be-
tween primary care and specialists (Chart 3).
Effective management of transitions of care
requires more than just good communication.
Chart 3. Essential features of a high functioning patient portal, best communication practices for vertical
integration, best practices for medication management, best practices with regard to checklists.
1—Essential features of a high functioning patient portal
· Sending messages to and receiving information from the care team
· Allowing patient to schedule appointments online
· Viewing medications and making prescription refill requests
· Viewing bills and making payments
· Viewing and updating health information
· Filling out forms in advance of the visit
2—Best communication practices for vertical integration:
· Important information is readily visible and easily to understand.
· An effective note from a primary care physician to a specialist or a hospital has the reason for referral,
pertinent history, physical findings, and relevant test results.
· Specialist recommendations and conclusions are highlighted in the report back to the primary care doctor.
· Hospital discharge communications detail the final diagnoses, test results, medication changes, and timing of
appropriate follow up care.
3—Best practices for medication management
· Assiduous attention to medication reconciliation at every encounter
· Share of current medication list with every provider
· Use of drug-drug interaction software
· Automated cross referencing of allergies and prescriptions
· Electronic prescribing
· Including cost and insurance-coverage information to inform cost-effective prescribing
4—Best practices with regard to checklists include:
· Information shared by and accessible to all members of clinical multidisciplinary team
· Automated updating and refreshing of data by the EMR, minimizing the need for manual updates of data fields
· Flexibility to vary the targeted time interval between interventions ( For example: Follow up CT scan of a
pulmonary nodule at 3 months, six months, or one year. Follow up of a mammogram at 6 months, one year, or
two years )
· Flexibility to mark certain interventions as ‘not consistent with goals of care’ ( For example, to stop colon
cancer screening in patients with life expectancy of less than ten years )
Update the checklist specifications periodically as evidence-based clinical guidelines change over time
Source: Elaborated by the authors.
It also involves coordination, standardization of
work processes, training, and accountability43.
Responsibilities of the referring physician and
the receiving physician must be established in
advance of the transfer.
Medication Management within the EMR
Medication errors represent a major threat
to patient safety in ambulatory practice, con-
tributing to an estimated 1 out of 131 outpa-
tient deaths per year in the United States36. The
electronic record offers unsurpassed tools to
improve accuracy and efficiency in medication
management. Medication lists can be automat-
ically updated with each new prescription and
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
Chart 4. Four Phases of Care Planning Supported by an EMR.
EMR Function Workflow Example
Pre-visit Checklist Assign task to specific team members
before the patient arrives in the office
Multidisciplinary team
huddles before the clinical
session to identify patients
who are overdue for
preventive services or
chronic disease management
During the
Medication List
Immunization List
Administer screening tests immunizations,
and chronic disease management testing
and treatment. Medication reconciliation
Reliably provide necessary
services at the time of the
After the
Electronic order
After visit summary
Schedule specialist appointments and
ancillary testing.
Draw labs ordered at the visit.
Schedule follow up appointment.
Review prescriptions and follow up care
with patient.
Reliably complete all tasks
ordered at the visit.
Assure that the patient
understands follow-up plan.
Registries Identify and contact patients who have not
followed up at the appropriate interval.
Identify patients with clinical parameters
that are outside of established goals, i.e.
blood pressure or glycemic control above
targeted values.
Detect patients who have gaps
in care and are not scheduled
for follow up.
Active outreach to those
Source: Elaborated by the authors.
rigorous attention to reconciling the medica-
tions that the patient is actually using with the
medication list helps to avoid omission of essen-
tial medication or the prescription of duplicate
medication. Sharing of medication lists among
all providers who treat the patient helps to im-
prove vertical integration and care coordination.
Automated drug-drug interaction software helps
to reduce unintentional prescriptions of drugs
with adverse interactions. In some EMR systems,
the cost and insurance-coverage of drugs is avail-
able to the physician at the point of care, allow-
ing for more cost-effective choices of drugs. Very
sophisticated electronic prescribing systems link
prescribers and pharmacies, eliminating the need
for paper prescriptions and thereby improving
accuracy and efficiency in the prescribing and the
drug dispensing processes (Chart 3).
Use of EMR-generated care checklists
An essential feature of the EMR, and one
that improves the reliable delivery of services at
the point of care, is the EMR-generated check
list. The EMR produces a list of patient care
interventions that should be provided at the
visit. These interventions include vaccinations,
screening procedures such as fecal occult blood
tests or pap smears, mammography, depression
screening, diabetes metabolic labs, follow up on
abnormal imaging studies, and other interven-
tions governed by the standards established in
evidence-based care protocols. All members of
the multidisciplinary team have access to this
checklist. Needed interventions can be assigned
to team members before the patient arrives at the
office for a visit. Using standing orders, non-phy-
sician staff have the authority to obtain lab tests,
schedule appointments with specialists, and per-
form other routine interventions
Use of Registries to Guide Active Outreach
to Patients with Gaps in Care
It is always a challenge to engage some sub-
sets of patients in appropriate follow up care. Pa-
tients commonly fail to schedule or do not keep
follow up appointments and gaps in care result
when patients do not present for necessary health
services. Health systems are constantly trying to
improve their performance on rates of cancer
screening, vaccinations, and other preventive ser-
Janett RS, Yeracaris PP
vices, and improve their management of chron-
ic disease (such as glycemic and blood pressure
control in diabetes, follow up of abnormal test
results, and adherence to the use of controller
inhaler medications in asthma). The EMR offers
tools, in the form of patient registries, to identify
patients who do not present themselves for care
but who have unmet care needs.
The registry function in many EMR systems
has been slow to evolve. Flexibility in creating
new registries or modifying fields and decision
support rules are important functionalities. For
example, being able to enter a due date for a fol-
low up colonoscopy based on latest examination
or biopsy results or being able to track and sort
patient depressions screening/PHQ 9 scores to
ensure appropriate outreach and follow up, can
help systematize and streamline efforts to im-
prove care.
There is strong evidence for the benefits of an
EMR in terms of efficiency, reliability, and care
quality, especially in primary care. Some of these
benefits are counterbalanced by clearly defined
risks and drawbacks of EMR systems. Key features
of EMR systems have been identified as facilita-
tors of or barriers to effective implementation
and use of these systems to support population
health, chronic disease management, the reliable
delivery of preventive services, and improved
patient safety through the avoidance of medical
errors, especially with regard to pharmaceuticals.
Effective use of the technology requires care-
ful attention to workflows, teamwork, and other
key clinical practice reforms. The best way to take
advantage of the EMR’s advanced functionalities
is to deploy a multidisciplinary team in a com-
prehensive care model. The EMR is unsurpassed
as a tool to enhance communication among
members of the care team and between providers
at various levels of care, supporting horizontal
and vertical integration. To maximize the effec-
tiveness of the new capabilities, cultural changes
at the practice and system level are necessary to
support behavior norms, compacts, and mutual
expectations among providers on collaboration
in the care of patients.
There are many reasons why the EMR has yet
to live up to its full potential and it is important
to learn the lessons from past and current efforts
in order to ensure the most effective design and
implementation of an EMR system. Important
functionalities such as modifiable check lists and
registries, the ability to easily design and run re-
ports, user friendly provider interfaces and a sim-
ple and easily accessible patient portal contribute
to effective use of the EMR’s complex capabilities.
The United States has seen the deployment
of a variety of EMR systems with various degrees
of sophistication. Considerable problems have
been noted due to a lack of interoperability and
standardization of interfaces among these sys-
tems, impairing the effective collaboration and
information exchange in the care of complex pa-
tients. It is extremely important that regional and
national health policies be established to assure
standardization and interoperability of systems.
Vendors of EMR systems have engaged in exten-
sive lobbying and marketing efforts to advance
the commercial and proprietary interests of their
companies. These efforts contribute to the frag-
mentation of the information environment.
The EMR is a disruptive technology that can
revolutionize the way we care for are patients.
The key lessons from the US experience in the
deployment and use of these systems are (1) at-
tention to interoperability among various sys-
tems, and (2) careful attention to the impact of
the EMR on clinical workflows, in order to take
full advantage of the potential of the EMR to im-
prove patient care.
Ciência & Saúde Coletiva, 25(4):1293-1304, 2020
1. Dick RE. The Computer-Based Patient Record. Wash-
ington: National Academies Press; 1997.
2. National Coordinator for Health Information Tech-
nology (ONC). (2017, October 5).
Health IT and Health Information Exchange Basics.
[cited Sept 10, 2019]. Available from: https://www.
3. Hillestad RE, Bigelow J, Bower A, Girosi F, Meili R,
Scoville R, Taylor R. Can Electronic Medical Record
Systems Transform Health Care? Potential Health
Benefits, Savings, and Costs. Health Affairs 2005;
4. Schulte F, Frye E. Death by a Thousand Clicks. Fortune
2019; Mar 18.
5. Gorn D. These doctors think electronic records are
hurting their relationships with patients. 2017, July 21.
[cited Sept 10, 2019]. Available from: https://www.
6. Peikes DE. Independent Evaluation of Comprehensive
Primary Care Plus (CPC+). Princeton: Mathematics
Policy Research; 2019.
7. World Health Organization (WHO). WHO Frame-
work on Integrated Person Centered Health Services.
Geneva: WHO; 2019. [cited Sept 10, 2019]. Available
8. American Academy of Family Physicians, American
Academy of Pediatrics, American College of Phy-
sicians, American Osteopathic Association. (2017,
March). Joint Principles of the Patient Centered Medi-
cal Home. [cited Sept 10, 2019]. Available from: http:// man-
9. Wagner ECK. Guiding Transformation: How Medical
Practices Can Become Patient Centered Medical Homes.
New York: The Commonwealth Fund; 2012.
10. Holroyd-Leduc JL, Straus S, Sykes L, Quan H. The
impact of the electronic medical record on structure,
process, and outcomes within primary care: a system-
atic review of the evidence. J Am Med Inform Assoc
2011; 18(6):732-737.
11. Kemper A., Uren R, Clark S. Adoption of electronic
health records in primary care pediatric practices. Pe-
diatrics 2006; 118(1):e20-24.
12. Chen C, Garrido T, Chock D, Okawa G, Liang L. The
Kaiser Permanente Electronic Health Record: trans-
forming and streamlining modalities of care. Health
Aff (Millwood) 2009; 28(2):323-333.
13. Zhou Y, Garrido T, Chin H, Wiesenthal A, Liang L. Pa-
tient access to an electronic health record with secure
messaging: impact on primary care utilization. Am J
Manag Care 2007; 13(7):418-424.
14. Fleming N, Culler S, McCorkle R, Becker E, Ballard D.
The financial and nonfinancial costs of implementing
electronic health records in primary care practices.
Health Aff (Millwood) 2011; 30(3):481-489.
15. Gallego A, Gagnon M, Desmartis M. Assessing the
cost of electronic health records: a review of cost indi-
cators. Telemed J E Health 2010; 16(9):963-972.
16. Pizziferri L, Kittler AF, Volk LA, Honour MM, Gup-
ta S, Wang S, Wang T, Lippincott M, Li Q, Bates DW.
Primary care physician time utilization before and af-
ter implementation of an electronic health record: a
time-motion study. J Biomed Inform 2005; 38(3):176-
RS Janett and PP Yeracaris collaborated exten-
sively in the writing of this paper and it was a true
joint effort. RS Janett took primary responsibility
for the evidence review, the quality section, the
medication management section, and the devel-
opment of the figures. PP Yeracaris took prima-
ry responsibility for the sections on team based
care, facilitating communication among team
members, with specialists, with patients and the
use of registries to address gaps in care.
Janett RS, Yeracaris PP
17. O’Donnell A, Kaner E, Shaw C, Haighton C. Primary
care physicians’ attitudes to the adoption of electron-
ic medical records: a systematic review and evidence
synthesis using the clinical adoption framework. BMC
Med Inform Decis Mak 2018 13; 18(1):101.
18. Saleem JJ, Flanagan ME, Russ AL, McMullen CK, Elli
L, Russell SA, Bennett KJ, Matthias MS, Rehman SU,
Schwartz MD, Frankel RM. You and me and the com-
puter makes three: variations in exam room use of the
electronic health record. J Am Med Inform Assoc 2014;
19. Rathert C, Mittler J, Banerjee S, McDaniel J. Pa-
tient-centered communication in the era of electronic
health records: What does the evidence say? Patient
Educ Couns 2017; 100(1):50-64.
20. Montague E, Asan O. Dynamic modeling of patient
and physician eye gaze to understand the effects of
electronic health records on doctor-patient com-
munication and attention. Int J Med Inform 2014;
21. Alkureishi MA, Lee WW, Lyons M, Press VG, Imam S,
Nkansah-Amankra A, Werner D, Arora VM. Impact
of Electronic Medical Record Use on the Patient-Doc-
tor Relationship and Communication: A Systematic
Rev iew. J Gen Intern Med 2016; 31(5):548-560.
22. Irani JS, Middleton JL, Marfatia R, Omana ET, D’Am-
ico F. The use of electronic health records in the exam
room and patient satisfaction: a systematic review. J
Am Board Fam Med 2009; 22(5):553-562.
23. Shachak A, Reis S. The impact of electronic medical
records on patient-doctor communication during
consultation: a narrative literature review. J Eval Clin
Pract 2009; 15(4):641-649.
24. Kruse C, Stein A, Thomas H, Kaur H. The use of Elec-
tronic Health Records to Support Population Health:
A Systematic Review of the Literature. J Med Syst
2018; 42(11):214.
25. Campanella P, Lovato F, Marone C, Fallacara L, Rioc-
ciardi W, Specchia M. The impact of electronic health
records on healthcare quality: a systematic review and
meta-analysis. Eur J Public Health 2016; 26(1):60-64.
26. Ojeleye O, Avery A, Gupta V, Boyd M. The evidence
for the effectiveness of safety alerts in electronic pa-
tient medication records systems at the point of phar-
macy order entry: a systematic review. BMC Med In-
form Decis Mak 2013; 13:69.
27. Gill J, Ewen E, Nsereko M. Impact of an electronic
medical record on quality of care in a primary care
office. Del Med J 2001; 73(5):187-194.
28. Ruffin M, Plegue M, Young A, Patel D, Yeazel M. Im-
pact of an Electronic Health Record (EHR) Reminder
on Human Papillomavirus (HPV) Vaccine Initiation
and Timely Completion. J Am Board Fam Med 2015;
29. Moody-Thomas S, Nasuti L, Yi Y, Celestin MD Jr,
Horswell R, Land TG. Effect of systems change and
use of electronic health records on quit rates among
tobacco users in a public hospital system. Am J Public
Health 2015; 105(Supl. 2:e1-7).
30. Huber M, Highland J, Krshnamoorthi V, Tang J. Uti-
lizing the Electronic Health Record to Improve Ad-
vance Care Planning: A Systematic Review. Am J Hosp
Palliat Care 2018; 35(3):532-541.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
31. Cebul R, Love T, Jain A, Hebert C. Electronic health
records and quality of diabetes care. N Engl J Med
2011; 365(24):2338-2339.
32. Kuo A, Dang S. Secure Messaging in Electronic Health
Records and its Impact on Diabetes Clinical Out-
comes: A Systematic Review. Telemed J E Health 2016;
33. Lessing SE, Hayman LL. Diabetes Care and Manage-
ment Using Electronic Medical Records: A Systematic
Rev iew. J Diabetes Sci Technol 2019; 13(4):774-782.
34. Menachem N, Collum T. Benefits and drawbacks of
electronic health systems. Risk Manag Healthc Policy
2011; 4:47-55.
35. Howe J, Adams K, Hettinger A, Ratwani R. Electronic
Health Record Usability Issues and Potential Contri-
bution to Patient Harm. JAMA 2018; 319(12):1276-
36. Agency for Healthcare Research and Quality (AHRQ).
Patient Safety Primer--Ambulatory Care Safety. (2019,
January). [cited Sept 10, 2019]. Available from: https://
37. American College of Physicians. Patient Safety in the
Office-Based Practice Setting. Philadelphia: American
College of Physicians; 2017.
38. Sinsky C, Bodenheimer T. Powering-Up Primary Care
Teams: Advanced Team Care with in-room support.
Annals of Family Medicine; 2019.
39. Bodenheimer T. Building Powerful Primary Care
Teams. Mayo Clin Proc 2019; 94(7):1135-1137.
40. Misra-Herbert A, Amah L, Rabovsky A, Morrison S,
Cantave M, Hu B, Rothberg M. Medical scribes: How
do their notes stack up? J Fam Pract 2016; 65(3):155-
41. Anderson P, Halley M. A New Approach to Making
Your Doctor-Nurse Team More Productive. Fam Pract
Manag 2008; 15(7):35-40.
42. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost
in translation: challenge and opportunities in phy-
sician-to-physician communication during patient
hand-offs. Acad Med 2005; 80(12):1094-1099.
43. The Joint Commission. (2018, January). Transitions
of Care: The need for a more effective approach to con-
tinuing patient care. [cited Sept 10, 2019]. Available
Article submitted on 02/10/2019
Approved on 20/10/2019
Final version submitted on 22/10/2019
... Today, more than 100 million RBC units are transfused each year worldwide [2,3] and the use of big data in these transfusion data has the potential to further enhance the safety, efficiency, and effectiveness of transfusion medicine [4]. One way to conceptualize the application of big data to transfusion medicine is to combine various types of health data, including electronic health records [5,6], electronic medical records [7], personal health records [8], laboratory information systems [9], medical practice management [10] software, and hemovigilance data [11]. This combination creates a large database that healthcare professionals can use to identify patterns and trends, leading to improved practices in blood product usage, inventory management, and more, ultimately, improving patient outcomes [4,12]. ...
... Using data and samples collected as part of the REDS-III program, the study [32] investigated how the metabolism of stored RBCs is impacted by the heterogeneity of blood processing and storage additives at different centers, emphasizing the crucial role of standardization in blood processing and storage to minimize the variability of blood products across different centers. The relative abundance of metabolites (energy metabolism, amino acids, and nucleotides) in RBCs stored for varying durations (1,7,14,21,28, and 42 days) from three different centers is shown in Figure 2. The figure highlights the importance of standardizing blood processing and storage procedures to reduce heterogeneity between centers. And it indicates that the heterogeneity of blood processing and storage additives at different centers significantly impacted RBC metabolism, and this impact was as significant as the effect of storage time. ...
Full-text available
Background: "Artificial intelligence" and "big data" increasingly take the step from just being interesting concepts to being relevant or even part of our lives. This general statement holds also true for transfusion medicine. Besides all advancements in transfusion medicine, there is not yet an established red blood cell quality measure, which is generally applied. Summary: We highlight the usefulness of big data in transfusion medicine. Furthermore, we emphasize in the example of quality control of red blood cell units the application of artificial intelligence. Key messages: A variety of concepts making use of big data and artificial intelligence are readily available but still await to be implemented into any clinical routine. For the quality control of red blood cell units, clinical validation is still required.
... To design the TARGET segmentation tool as truly holistic, it should be expanded with social data, as acknowledged by other studies into segmentation tools as well [48]. However, these data are often lacking as the internationally classified codes for registering social issues, Z-codes, are systematically underutilized by healthcare professionals and exchange of patient information between domains is complicated [17,[49][50][51][52]. Instead, the PCAM can be used for registering social data: we recently found evidence that PCAM has adequate measurement properties [34]. ...
Full-text available
Objective: The TARGET program for integrated, person-centered care for people with chronic conditions offers primary care (PC) professionals a set of tools and trainings to actively engage in population segmentation and person-centered needs assessments (PCNAs). A pilot study was conducted to gain insight into the program's feasibility and acceptability, and identify preconditions for successful implementation. Design and setting: Seven Dutch PC practices participated in a half-year pilot study starting in August 2020. We performed a review of the population segmentation tool, observed four training sessions and 15 PCNAs, and interviewed 15 professionals and 12 patients. Results: Regarding feasibility and acceptability, we found that the tools and trainings provided professionals with skills to use the segmentation tool and take a more coaching role in the well-appreciated PCNAs. Concerning implementation preconditions, we found that team commitment and network connections need improvement, although work pleasure increased and professionals generally wanted the program to continue. Conclusions: While the content of the TARGET program is supported by its users, the implementation process, for instance team commitment to the program, needs more attention in future upscaling efforts.
... The digitalisation of medical reports and medical records through innovative and advanced mobile applications alsot aims to create a flow of digital documents with full legal value. This process has proven successful in many circumstances and in the near future it is hoped that it will lead to the replacement of paper equivalents and the improvement of the services provided to citizens (89). ...
Full-text available
Background and aim: Websites, social media networks and mobile applications constitute important communication tools, while simultaneously enabling the population to increase their knowledge of health issues. This study aims to describe digital health experiences in Public Health to examine the different possible uses of digital technologies by Public Health Operators (PHOs) and Health Care Workers (HCWs) and the role these tools play in the efficiency of the health interventions undertaken. Methods: A narrative literature survey was conducted by consulting the PubMed and Scopus databases to find articles relevant to the topic of interest. The selection criteria adopted for manuscript screening involved including the survey studies dealing with the use of digital means such as new media in Public Health, published between 1 January 2012 and 31 May 2021. Results: Based on the keywords, 2,019 manuscripts were identified, of which 45 were included. The articles were grouped according to the digital tool (social media network, mobile application and websites) employed by PHOs and/or HCWs in health promotion initiatives. Specifically, this was broken down into: i) the use of social media in public health: 24 articles, ii) the use of mobile applications: 10 articles, iii) the use of websites: 8 articles and iv) the use of the three digital tools combined: 3 articles. Conclusions: The results of this study indicate that digital technologies may play a useful role in Public Health to improve communication between health professionals and patients, provide quality care even remotely and facilitate the achievement of health outcomes for the population from a Health Literacy perspective.
... 2020]. Esses aumentos podem indicar uma evolução no nível e na complexidade dos sistemas eletrônicos adotados, que resultam em menor fragmentação na prestação do cuidado, favorecendo a qualidade e eficiência, e reduzindo lacunas no atendimento [Janett e Yeracaris, 2020]. No entanto, avanços na adesão de práticas de digitalização de dados e o consequente aumento significativo nos dados sensíveis gerados, expõe diversos desafios a serem abordados pelos sistemas. ...
... EMRs are computerized medical information systems that gather, store, and display patient data. While maintaining the patient's privacy and security, it may include a variety of data such as socio-demographics, insurance, past and present medication information, allergies, laboratory and test results, histories of immunizations and medical procedures, hospitalizations, progress evaluations, and others [5][6][7]. ...
Full-text available
Background The adoption of Electronic Medical Records (EMR) by the healthcare sector can improve patient care and safety, facilitate structured research, and effectively plan, monitor, and assess disease. EMR adoptions in low-income countries like Ethiopia were delayed and failing more frequently, despite their critical necessity. The most popular way to solve the issue is to evaluate user preparedness prior to the adoption of EMR. However, little is known regarding the EMR readiness of healthcare professionals in this study setting. Therefore, the objective of this study was to assess the readiness and factors associated with health professional readiness toward EMR in Gamo Zone, Ethiopia. Methods An institution-based cross-sectional survey was conducted by using a pretested self-administered questionnaire on 416 study participants at public hospital hospitals in southern Ethiopia. STAT version 14 software was used to conduct the analysis after the data was entered using Epi-data version 3.2. A binary logistic regression model was fitted to identify factors associated with readiness. Finally, the results were interpreted using an adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value less than 0.05. Results A total of 400 participants enrolled in the study, with a response rate of 97.1%. A total of 65.25% (n = 261) [95% CI: 0.60, 0.69] participants had overall readiness, 68.75% (n = 275) [95% CI: 0.64, 0.73] had engagement readiness, and (69.75%) (n = 279) [95% CI: 0.65, 0.74] had core EMR readiness. Computer skills (AOR: 3.06; 95% CI: 1.49–6.29), EMR training (AOR: 2.00; 95% CI: 1.06–3.67), good EMR knowledge (AOR: 2.021; 95% CI: 1.19–3.39), and favorable attitude (AOR: 3.00; 95% CI: 1.76–4.97) were factors significantly associated with EMR readiness. Conclusion Although it was deemed insufficient, more than half of the respondents indicated a satisfactory level of overall readiness for the adoption of EMR. Moreover, having computer skills, having EMR training, good EMR knowledge, and favorable EMR attitude were all significantly and positively related to EMR readiness.
... Rekam medis elektronik mempunyai peranan yang cukup penting didalam penyelenggaraan pelayanan kesehatan karena informasi yang terkandung di dalam rekam medis merupakan sumber data dan informasi kesehatan sehingga dapat digunakan sebagai parameter baik buruknya sistem penyelenggaraan pelayanan kesehatan [3]. Pentingnya rekam medis dalam berbagai aspek diantara rekam medis dapat memberikan gambaran mutu dan kualitas pelayanan rumah sakit, sebagai dokumen yang menjadi sumber utama pelaporan dan bahan untuk pengambilan keputusan, rekam medis juga merupakan sebuah sumber data untuk penelitian dan riset, sebagai data dasar untuk penilaian akreditasi rumah sakit [4]. ...
Full-text available
Rekam medis elektronik mempunyai peran yang cukup penting didalam penyelenggarakan pelayanan kesehatan di rumah sakit dimana rekam medis elektronik merupakan sumber data dan informasi kesehatan yang dapat digunakan dalam menilai baik buruknya pelayanan kesehatan. Rumah sakit X telah mengimplementasikan penggunaan rekam medis elektronik sejak tahun 2020 akan tetapi belum pernah dilakukan evaluasi terhadap penerapan rekam medis elektronik sehingga diperlukan upaya evaluasi yang formatif untuk melihat kualitas rekam medis elektronik dengan menggunakan Technology Acceptance Model yaitu menilai sebuah sistem berdasarkan dimensi kemudahan (ease of use) dan persepsi manfaat (usefulness) yang dapat mempengaruhi penggunaan sistem (attitude toward using) dan mengaplikasian sistem secara berkelanjutan (actual usage). Penelitian ini menggunakan pendekatan kuantitatif dengan menggunakan analisis uji korelasi bivariat untuk dapat menilai hubungan antara variabel yang diteliti. Hasil penelitian didapatkan bahwa terdapat hubungan positif yang signifikan (p-value 0.001, r = 0,717) antara keyakinan bahwa EMR dapat digunakan dengan mudah (perceived ease of use) dan manfaat dalam performa kinerja dan produktivitas kinerja (perceived usefulness), Hubungan positif signifikan (p-value 0.001, r = 0,747) antara variabel EMR dapat memberikan manfaat dalam performa kinerja dan produktivitas kinerja (perceived usefulness) dan sikap penggunaan EMR (Attitude toward using). Keyakinan bahwa EMR dapat digunakan dengan mudah (perceived ease of use) berpengaruh positif dan signifikan terhadap sikap penggunaan EMR (Attitude toward using) dengan nilai p-value 0.001, r = 0,7, serta hubungan yang signifikan nilai p-value 0.001, r = 0,717 antara keyakinan bahwa sikap penggunaan EMR (Attitude toward using) dan signifikan terhadap penggunakan EMR secara aktual (actual usage)
Full-text available
Objetivo: compreender as potências e os limites da tecnossocialidade, bem como e as estratégias de boa comunicação e prevenção de circulação de fake news no cquotidiano dos profissionais da atenção primária na pandemia dae covid-19. Materiais e métodos: estudo de casos múltiplos integrado-qualitativo, fundamentado na sSociologia cCompreensiva do cQuotidiano, com inclusão de 47 profissionais de saúde de um município de Santa Catarina e de dois municípios de Minas Gerais, Brasil. A coleta de dados foi realizada entre os meses de abril e outubro de 2021, e teve como fontes de evidências a entrevista individual aberta e as notas de campo. Resultados: constituem-se potências a continuidade de cuidados à saúde em meio àa pandemia, o estreitamento da comunicação entre profissionais e usuários, e o recebimento de resultados de exames por usuários pelo WhatsApp. Contudo, limites ainda precisam sersuperados, como a infodemia e a desinformação pela disseminação das fake news nas redes sociais, e a inacessibilidade à internet, principalmente em classes sociais baixas. Conclusões: a aceleração do uso da tecnossocialidade na pandemia proporcionou avanços no campo da saúde, porém ocasionou a infodemia e o aumento da circulação de notícias falsas. Uma parte da população ainda enfrenta dificuldade de acesso e uso da internet, principalmente em classes sociais baixas. Dessta forma, os profissionais de saúde apresentam o importante papel educativo, ao compartilhar informações verídicas àa população com uso de ferramentas virtuais.
Introduction: Electronic health records (EHR) are a rich data source for both quality improvement and clinical research. Natural language processing can be harnessed to extract data from these previously difficult to access sources. Objective: The objective of this study was to create and apply a natural language search query to extract EHR data to ask and answer quality improvement questions at a pediatric aerodigestive center. Methods: We developed a combined natural language search query to extract clinically meaningful data along with International Statistical Classification of Diseases (ICD10) and Current Procedural Terminology (CPT) code data. This search query was applied to a single pediatric aerodigestive center to answer key clinical questions asked by families. Data were extracted from EHR data from first clinic visit, operative note, microbiology lab report, and pathology report for all new patients from 2020 to 2021. Included as three queries were: 1) if I bring my child to a pediatric aerodigestive center, how often will my child obtain a medical diagnosis without needing an intervention? 2) if my child has a diagnostic procedure, how often will a diagnosis be made? 3) if a diagnosis is made, can it be addressed during that endoscopic intervention? Results: For the 711 new patients coming to the pediatric aerodigestive center from 2020 to 2021, only 26-32% required an interventional triple endoscopy (rigid/flexible bronchoscopy with esophagoduodenoscopy). Of these triple endoscopies, 75.7% resulted in a positive finding that enabled optimization of that child's care. Of the 221 patients who underwent diagnostic triple endoscopies, 40.7% underwent intervention at the same time for laryngeal cleft (injection or suture, dependent upon age). Conclusion: Here we created an effective model of open language search query to extract meaningful metrics of patient experience from EHR data. This model easily allows the EHR to be harnessed to create retrospective and prospective databases that can be readily queried to answer clinical questions important to patients. Such databases are widely applicable not just to pediatric aerodigestive centers but to any clinical care setting using an EHR.
Why are there no more steam locomotives running on the rails of any modern railroad? Because they were notoriously inefficient, for each hour on the rails, they spent 2 h in the shop. Much like EMR today. For each hour of patient care, the physician must spend 2 h entering data, much like a secretary, except, unlike the secretary, the time the physician spends on entering data in an EMR is not compensated.
Full-text available
Background: Recent decades have seen rapid growth in the implementation of Electronic Medical Records (EMRs) in healthcare settings in both developed regions as well as low and middle income countries. Yet despite substantial investment, the implementation of EMRs in some primary care systems has lagged behind other settings, with piecemeal adoption of EMR functionality by primary care physicians (PCPs) themselves. We aimed to review and synthesise international literature on the attitudes of PCPs to EMR adoption using the Clinical Adoption (CA) Framework. Methods: MEDLINE, PsycINFO, and EMBASE were searched from 1st January 1996 to 1st August 2017 for studies investigating PCP attitudes towards EMR adoption. Papers were screened by two independent reviewers, and eligible studies selected for further assessment. Findings were categorised against the CA Framework and the quality of studies assessed against one of three appropriate tools. Results: Out of 2263 potential articles, 33 were included, based in North and South America, Europe, Middle East and Hong Kong. Concerns about the accessibility, reliability and EMR utility exerted an adverse influence on PCPs’ attitudes to adoption. However many were positive about their potential to improve clinical productivity, patient safety and care quality. Younger, computer-literate PCPs, based in large/multi-group practices, were more likely to be positively inclined to EMR use than older physicians, less-skilled in technology use, based in solo practices. Adequate training, policies and procedures favourably impacted on PCPs’ views on EMR implementation. Financial factors were common system level influencers shaping EMR adoption, from start-up costs to the resources required by ongoing use. Conclusions: By using the CA Framework to synthesise the evidence, we identified a linked series of factors influencing PCPs attitudes to EMR adoption. Findings underline the need to involve end-users in future implementation programmes from the outset, to avoid the development of an EMR which is neither feasible nor acceptable for use in practice. Trial registration: PROSPERO CRD42016038790. Keywords: Electronic health records, Primary health care, General practitioners, Clinical adoption framework
Full-text available
Electronic health records (EHRs) have emerged among health information technology as “meaningful use” to improve the quality and efficiency of healthcare, and health disparities in population health. In other instances, they have also shown lack of interoperability, functionality and many medical errors. With proper implementation and training, are electronic health records a viable source in managing population health? The primary objective of this systematic review is to assess the relationship of electronic health records’ use on population health through the identification and analysis of facilitators and barriers to its adoption for this purpose. Authors searched Cumulative Index of Nursing and Allied Health Literature (CINAHL) and MEDLINE (PubMed), 10/02/2012–10/02/2017, core clinical/academic journals, MEDLINE full text, English only, human species and evaluated the articles that were germane to our research objective. Each article was analyzed by multiple reviewers. Group members recognized common facilitators and barriers associated with EHRs effect on population health. A final list of articles was selected by the group after three consensus meetings (n = 55). Among a total of 26 factors identified, 63% (147/232) of those were facilitators and 37% (85/232) barriers. About 70% of the facilitators consisted of productivity/efficiency in EHRs occurring 33 times, increased quality and data management each occurring 19 times, surveillance occurring 17 times, and preventative care occurring 15 times. About 70% of the barriers consisted of missing data occurring 24 times, no standards (interoperability) occurring 13 times, productivity loss occurring 12 times, and technology too complex occurring 10 times. The analysis identified more facilitators than barriers to the use of the EHR to support public health. Wider adoption of the EHR and more comprehensive standards for interoperability will only enhance the ability for the EHR to support this important area of surveillance and disease prevention. This review identifies more facilitators than barriers to using the EHR to support public health, which implies a certain level of usability and acceptance to use the EHR in this manner. The public-health industry should combine their efforts with the interoperability projects to make the EHR both fully adopted and fully interoperable. This will greatly increase the availability, accuracy, and comprehensiveness of data across the country, which will enhance benchmarking and disease surveillance/prevention capabilities.
Full-text available
Methods: A systematic search of PubMed was conducted, and 320 results were returned. Of these, 11 were selected based on outlined criteria. Conclusions: Evidence from 7 of the 11 included studies suggests significant improvement in patients' hemoglobin A1c (HbA1c) with the use of secure messaging. However, improvements in patients' secondary outcomes, such as blood pressure and cholesterol, were inconsistent. Further work must be done to determine how to best maximize the potential of available tools such as secure messaging and EHRs to improve patient outcomes.
Primary care teams are underpowered. Teams do not maximally redistribute team functions when clinicians are diverted from activities where they add the most value. This commentary describes "advanced team care with in-room support" as a way to "power-up" primary care teams. In this core team model, each clinician is paired with 2 or 3 highly trained medical assistants or nurses-care team coordinators (CTCs).Early evidence suggests that this model is more satisfying to clinicians, staff, and patients and is financially sustainable. Yet its spread has been hobbled by several misguided beliefs, such as that the physician can and should do most tasks, that technology replaces people, that health care is a transactional endeavor more than a therapeutic relationship, that regulation is the main lever by which to advance quality, and that the principal way to increase net revenue is to reduce overhead. A shift in mindset is needed to energize primary care.
Background:: Diabetes treatment and management provide a unique opportunity for examination of the effectiveness of electronic health records (EHRs) on patient health outcomes, continuity of care, and areas for further development. This systematic literature review was designed to identify the strengths and limitations of EHR and opportunities for improvement proposed in original research and recent rigorous systematic reviews. Methods:: This review utilized methodology adapted from PRISMA. Inclusion criteria for original research were published between March 2003 and November 2017; included randomized controlled trial design with participants ≥18 years of age with diabetes diagnosis ≥1 year; measured outcomes included HbA1c, blood pressure, and LDL cholesterol levels. Criteria for systematic reviews included research focused on EHR outcomes, improvement of care for patients with diabetes, prevention of adverse outcomes, web-based communication, and limitations of EHR regarding chronic disease management. Thirteen articles qualified for inclusion. Results:: Meta-synthesis of articles suggests that chronic disease patients benefit most by decision support tools that alert physicians of drug interactions, communication tools that keep them informed and engaged in their treatment regimens and detailed reporting and tracking designed to inform progress. Collective results suggest that EHR technology is advancing rapidly; however, patient outcomes documented via EHR systems remain largely unknown. Conclusion:: A fertile area for inquiry designed to enhance patient outcomes in diabetes and chronic disease management is determining how EHR systems can be utilized for new drug and treatment options in addition to enhancing the quality, cost-effectiveness, and continuity of care.
Electronic health record (EHR) usability, which is the extent that EHRs support clinicians in achieving their goals in a satisfying, effective, and efficient manner, is a point of frustration for clinicians and can have patient safety consequences.¹,2 However, specific usability issues and EHR clinical processes that contribute to possible patient harm across different health care facilities have not been identified.³ We analyzed reports of possible patient harm that explicitly mentioned a major EHR vendor or product.
Purpose: Advance care planning may ensure care that is concordant with patient wishes. However, advance care plans are frequently absent when needed due to failure to engage patients in planning, inability to access prior documentation, or poor documentation quality. Interventions utilizing tools within the electronic health record (EHR) may address these barriers at the point of care. We aimed to identify EHR interventions previously utilized to improve advance care plans. Methods: We systematically searched 7 databases for observational and experimental studies of EHR interventions associated with advance care plans. We abstracted information on the study populations, EHR and non-EHR components of the interventions, and the efficacy for advance care plan-related outcomes. Results: We identified 16 articles that contained an EHR intervention to improve advance care plans. Study populations, study designs, and EHR components of the interventions were heterogeneous. Documentation templates were the most common EHR tool reported (n = 8), followed by automated prompts (n = 7) and electronic order sets (n = 5). The most common reported outcomes were documentation of an advance care planning conversation in the EHR (n = 7) and the placement of code status orders (n = 7). All studies reporting efficacy (n = 9) demonstrated an improvement in 1 or more advance care planning outcomes. Conclusions: The use of EHR interventions may improve advance care plan completion and availability at the point of care. Further work should seek to develop and evaluate standardized EHR tools for advance care planning.
Objective Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known. Method A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis. Results Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management. Conclusion More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care. Practice implications Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians’ and patients’ abilities to effectively communicate.
Objective u Medical scribes are increasingly employed to improve physician efficiency with regard to the electronic medical record (EMR). The impact of scribes on the quality of outpatient visit notes is not known. To assess the effect, we conducted a retrospective review of ambulatory progress notes written before and after 8 practice sites transitioned to the use of medical assistants as scribes. Methods u The Physician Documentation Quality Instrument 9 (PDQI-9) was used to compare the quality of outpatient progress notes written by medical assistant scribes with the quality of notes written by 18 primary care physicians working without a scribe. The notes pertained to diabetes encounters and sameday appointments and were written during the 3 to 6 months preceding the use of scribes (pre-scribe period) and the 3 to 6 months after scribes were employed (scribe period). Results u One hundred eight notes from the pre-scribe period and 109 from the scribe period were reviewed. Scribed notes were rated higher in overall quality than unscribed notes (mean total PDQI-9 score 30.3 for scribed notes vs 28.9 for nonscribed notes; P=.01) and more up-to-date, thorough, useful, and comprehensible. The differences were limited to diabetes encounters. For same-day appointments, scribed and nonscribed notes did not differ in quality. The total word count of all scribed and nonscribed notes was similar (mean words 618, standard deviation (SD) 273 for scribed notes vs 558 words, SD 289 for nonscribed notes; P=.12). Conclusions u In this retrospective review, ambulatory notes were of higher quality when medical assistants acted as scribes than when physicians wrote them alone, at least for diabetes visits. Our findings may not apply to professional scribes who are not part of the clinical care team. As the use of medical scribes expands, additional studies should examine the impact of scribes on other aspects of care quality.