electronic medical record (EMR); electronic health record (EHR)

From Aaushi
Jump to navigation Jump to search
[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]

Introduction

Entry, retrieval & maintenance of medical records in electronic form (computerized medical record). Popular electronic medical records include Epic, Cerner, & eClinicalWorks.[20]

Procedure

Complications

Notes

  • no other industry has been under a universal mandate to adopt a new technology before its effects are fully understood[7]
  • operational productivity in the emergency department has remained unchanged by EMRs[4]
  • poorly designed EMRs can detract from the patient encounter rather than enhance it[5]
  • 0.11% of adverse safety events attributed to EMR[17]
    • 0.03% suggested EHR usability contributed to patient harm
      • usability challenges include
        • data entry (27%)
        • safety alerts (22%)
        • interoperability (18%)
        • visual display (9%)
        • availability of information (9%)
        • system automation & defaults (8%)
        • workflow support (7%)
      • usability challenges occurred during
        • order placement (38%)
        • medication administration (37%)
        • review of results (16%)
        • documentation (9%)[17]
  • ~1/3 of ophthalmologists' time with patients is spent using their electronic health record[13]
  • EMR should provide concise, context sensitive, real-time data uncluttered by extraneous information[5]
  • data to be easily shared with other healthcare facilities[5]
  • users should be able to provide feedback easily[5]
  • 49% of physicians' office hours are spent on EHR & desk work while 27% was spent directly with patients[11]
  • physicians in ambulatory care spend ~16 minutes/encounter actively using an electronic health record[19]
  • speech recognition more error prone & time consuming than keyboard/mouse data entry for emergency department doctors entering electronic medical records[14]
  • hackers may 'bring down' a hospital information system, then hold the hospital(s) ransom to restore access[12]

More general terms

Additional terms

References

  1. ↑ Journal Watch 25(10):81, 2005 Garrido T, Jamieson L, Zhou Y, Wiesenthal A, Liang L. Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study. BMJ. 2005 Mar 12;330(7491):581. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15760999 <Internet> http://bmj.bmjjournals.com/cgi/content/full/330/7491/581
  2. ↑ Journal Watch 25(10):81-82, 2005 Johnson KB, Serwint JR, Fagan LM, Thompson RE, Wilson MH. Computer-based documentation: effect on parent and physician satisfaction during a pediatric health maintenance encounter. Arch Pediatr Adolesc Med. 2005 Mar;159(3):250-4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15753268
  3. ↑ Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010 Mar 25;362(12):1066-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20335582
  4. ↑ 4.0 4.1 Ward MJ et al. The effect of electronic health record implementation on community emergency department operational measures of performance. Ann Emerg Med 2014 Jun; 63:723 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24412667
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Young K, Sadoughi S, Saitz R AMA Recommends 8 Ways EHRs Can Be Improved Physician's First Watch. September 18, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief https://download.ama-assn.org/resources/doc/ps2/x-pub/ehr-priorities.pdf
  6. ↑ Payne TH et al Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs. J Am Med Inform Assoc. 2015 May 28 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26024883 <Internet> http://jamia.oxfordjournals.org/content/early/2015/05/22/jamia.ocv066
  7. ↑ 7.0 7.1 7.2 7.3 Rosenbaum L Transitional Chaos or Enduring Harm? The EHR and the Disruption of Medicine. N Engl J Med 2015; 373:1585-1588. October 22, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26488690 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMp1509961
  8. ↑ 8.0 8.1 Ratanawongsa N et al Association Between Clinician Computer Use and Communication With Patients in Safety-Net Clinics. JAMA Intern Med. Published online November 30, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26619393 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=2473628
    Frankel RM Computers in the Examination Room JAMA Intern Med. Published online November 30, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26619228 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=2473626
  9. ↑ 9.0 9.1 Murphy DR, Meyer AN, Russo E The Burden of Inbox Notifications in Commercial Electronic Health Records. JAMA Intern Med. 2016 Apr 1;176(4):559-60. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26974737
  10. ↑ 10.0 10.1 Barnett ML et al Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ 2016;354:i3835 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27471242 <Internet> http://www.bmj.com/content/354/bmj.i3835
  11. ↑ 11.0 11.1 Sinsky C, Colligan L, Li L et al Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. Published online 6 September 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27595430 <Internet> http://annals.org/article.aspx?articleid=2546704
    Hingle S Electronic Health Records: An Unfulfilled Promise and a Call to Action. Ann Intern Med. Published online 6 September 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27595501 <Internet> http://annals.org/article.aspx?articleid=2546705
  12. ↑ 12.0 12.1 Chinthapalli K Heads Up. The hackers holding hospitals to ransom. BMJ 2017;357:j2214 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28490432 <Internet> http://www.bmj.com/content/357/bmj.j2214
  13. ↑ 13.0 13.1 Read-Brown S, Hribar MR, Reznick LG et al Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center. JAMA Ophthalmol. Published online October 12, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29049512 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2656337
  14. ↑ 14.0 14.1 Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the electronic health record. J Am Med Inform Assoc. 2017;24:1127-1133 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29016971 https://psnet.ahrq.gov/resources/resource/31516
  15. ↑ 15.0 15.1 Young KD Doctors Don't Need to Redocument Students' EHR Entries: CMS Medscape - Feb 15, 2018. https://www.medscape.com/viewarticle/892715
  16. ↑ 16.0 16.1 Burton JR The Walking Corpse Syndrome: Geriatrics and the Electronic Health Record. J Am Geriatr Soc. 2018 Feb 20 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29461624 <Internet> http://onlinelibrary.wiley.com/doi/10.1111/jgs.15293/full
  17. ↑ 17.0 17.1 17.2 Howe JL, Adams KT, Hettinger AZ, et al Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29584833 https://jamanetwork.com/journals/jama/article-abstract/2676098
  18. ↑ 18.0 18.1 Melnick ER et al The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians Mayo Clinic Proceedings Nov 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31735343 https://www.mayoclinicproceedings.org/article/S0025-6196(19)30836-5/fulltext
  19. ↑ 19.0 19.1 Overhage JM, Jr DM. Physician Time Spent Using the Electronic Health Record During Outpatient Encounters: A Descriptive Study. Ann Intern Med. 2020. Jan 14. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31931523 https://annals.org/aim/article-abstract/2758843/physician-time-spent-using-electronic-health-record-during-outpatient-encounters
  20. ↑ 20.0 20.1 Brodke D Electronic Medical Records Are Strangling American Medicine. The implications for burnout are staggering MedPage Today. October 23, 2022 https://www.medpagetoday.com/opinion/second-opinions/101354
  21. ↑ SelectHub Top EMR Software https://www.selecthub.com/emr-software/
Retrieved from "https://aaushi.info/w/index.php?title=A7683&oldid=1165511"