Transforming Healthcare in Emerging Markets with EMR adoption

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1 Transforming Healthcare in Emerging Markets with EMR adoption Author Ann Geo Thekkel User Experience. Accenture, India Abstract Compromising 24 countries, 35 percent of the world s landmass, a whopping two- thirds of the world s population and almost a third of global output, emerging markets offer some of the most dynamic and unique opportunities in Healthcare Information Technology and Electronic Medical Records (EMR). EMR adoption has gained high importance with governments in the west taking up initiatives to implement them across the nations. However, in Emerging markets, esp. in countries like India and China, there is a long way to go before the benefits of EMRs can be realized. This paper broadly examines the potential benefits of EMR adoption and proposes usability solutions to enhance the EMRs focusing on: flexible navigation, personalization and customization, enabling data variations and visualizations. We discuss the benefits of a well designed EMR and safety conclude that effective EMR adoption can eventually improve health care efficiency and patient safety in Emerging Markets. What is EMR & Electronic health record (EHR)? EMR is the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual s health and care. EHR is the aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual s health and care. Hence, an EHR is an EMR with interoperability (i.e. integration to other providers & systems). EMR has proven it can make healthcare workflow more efficient, reduce costs, while at the same time improving the quality of patient care. The Most Important Question Why EMR? With the successful implementation of a welldesigned electronic medical records system, practices can expect significant improvements in the quality of patient care, productivity, and revenue. Improved patient care According to leading health care experts, instituting an EMR may be the most important contribution physicians can make to improve the quality of patient care in the following ways: Overall improved chart quality Reduced medical errors (including errors due to poor legibility of handwriting) Up-to-date patient histories enable physicians to more accurately prescribe and administer medication Accessible, complete clinical information and best practices in physicians hands at the point of care facilitate correct diagnoses Automatically generated reminders for physicians and patients help to ensure that appointments and medication times are not easily overlooked Expanded health promotion, prevention and maintenance activities are facilitated Improved productivity While physicians have made every effort to reduce expenses within the current reimbursement environment, employing EMR 1 P a g e

2 technology is one of the best ways to streamline operations and increase efficiency for the following reasons: EMR saves time locating charts and copying requested medical records Approximately 2.5 full-time employees per physician are needed compared to an industry average of 4 Improved workflow with more than one person able to access a patient s chart at once Reduced paperwork and avoidance of duplicative writing Streamlined health transactions through prompt electronic billing and greater ease in both invoicing and payment Enhanced communications Increased physician productivity Increased revenue Practices can realize significant improvements in revenue resulting from savings in the following areas: Thorough documentation of clinical services Decreases in lost revenue with confident, accurate coding and better reimbursement Increased services rendered due to health maintenance reminders Increased physician productivity Fewer chart materials purchased Elimination of medical record storage costs Lowered or eliminated transcription costs Better control of patient care costs by reducing redundancy and needless duplication of clinical services General reduction in overhead costs and operational expenses Practices are prepared to participate in pay-for-performance and other provider incentive programs To fully realize all of the benefits an EMR can provide, it is essential that physicians choose the system that is right for their practices. EMR Adoption and Implementation Challenges Steep Learning Curve There is a "steep learning curve" in getting used to using EMRs; it takes about 3 months to become familiar enough with the software that it no longer slows the physician's practice. But after that, he said, "your productivity doubles." Research has shown that there are five distinct groups of non-users, defined by their concerns in relation to EMR: Cost Critical, who are concerned about the up-front cost required to purchase and install an EMR. Resource Concerned, who cite major barriers that include not only up-front costs, but also resources required for implementation and on-going maintenance costs. Technology Focused, who are critical about the functionalities of the systems currently available. Fear Practice Disruption, who are concerned about the impact of EMR on their workflow and productivity. Prefer Paper, who are sceptical about technology in general and would prefer to keep working the way they do now. Critical success factors Governance overall structure, clinical involvement, roles, responsibilities and schedule, sustainability Physician Leadership organizational, departmental, champion development Training and Support Clinical training Strategy, tools, resources Communication Strategy communication plan, methods, feedback loop Workflow Redesign clinician workflow, changes from current state, opportunities for best practice adoption, addressing concerns Value Realization targeted redesign with improved clinical and financial outcomes Vendor Capabilities maximizing vendor functionality and mitigating known risks Clinical Content Management content strategy, standardization, development and maintenance 2 P a g e

3 Key Decision Making clinical and executive decision making up front around both the process and the technology Project Management Office project plan development, staffing, responsibilities IT Infrastructure devices, access and security issues Challenges to Studying Usability in Clinics and Hospitals Usability work with EMRs is not straightforward. Usability professionals, in our experience, face significant challenges in clinical environments when tasked with making an EMR more usable. Clinicians use foreign terminology; clinicians have very broad and deep knowledge; physicians have enormous power (political as well as life-and-death) in clinical settings; and privacy as well as limited access to busy physicians can keep usability professionals from observing physicians at work. One challenge to understanding users and their tasks is the depth and breadth of user knowledge. All physicians have broad knowledge of human health, medications, and medical procedures. Typically, though, each physician also has deep knowledge in a specialty area, such as internal medicine, pediatrics, OB/GYN, family medicine, ENT, oncology, radiology, and pharmacology. You can imagine observing three different specialists before lunch where each one discusses a different organ system, orders different tests, and prescribes different medications. To make life more challenging, different specialists also tend to use different aspects of the EMR in their work. Understanding EMR User Groups and their Tasks Understanding medical systems starts with understanding the tasks that providers typically complete. At the highest level, there are the following six major tasks that providers complete for each patient encounter: Nursing or physician s assistant (PA) pre-work Review patient chart Interact with patient Order labs, procedures, medications, and consultations with specialists Compose the note Record billing EMR helps healthcare professionals change and improve the way they practice medicine by providing real-time access to information among clinical care providers, hospitals, labs, pharmacies, payers, and other parties involved in the delivery and receipt of health care. EMR can also provide decision-support and enhanced patient safety to avoid medical and medication errors by facilitating real-time prompts & reminders. EMR enables users to track multiple patients, open charts, laboratory results, and electronic prescriptions, view scans, dictate transcriptions, document patient records and also plan their Clinical schedules. The common EMR user groups include: Doctor/Physician Physician assistant Nurse Advanced practice nurse Nutritionist Patient service coordinator Pharmacist Rehabilitation therapist Social worker Technician Scheduler Applying User Centered Design in EMR Attributes contributing to an effective EMR: Content availability & organization Navigation Efficient Search Workflow System Feedback and alerts User-friendly & Visually appealing UI Data visualization and presentation Appropriate terminology Performance & Reliability Integration with Other Systems Content availability & organization Relevant & real-time information has to be available in the system. Content has to be well organized within relevant modules to facilitate an easy work flow. Research shows that 80% of the time, the information (if well organized) at summary level is adequate for clinical decision making. 3 P a g e

4 Navigation The road to effective patient care can take many paths, not only by the variety of medical personnel but also within the physician category. It is therefore important to create a flexible navigation scheme that can be tailored to a particular medical environment and even customized by individual physicians. The navigation schemes must reflect the mental model of the medical professional and not those of the designer or even the medical administration. The system uses a consistent navigational hierarchy so that users understand where to find information. Similar objects and controls are used consistently throughout the system. The navigation content needs to be customizable by a user according to his frequently accessed modules. Efficient Search User has to be provided efficient search options: Search for a patient by ID number or by Name Search for a Drug by Brand name, by generic name or by company name Time based search functionality for documentation Work flow Users need to accomplish their common task flows seamlessly without having to navigate across multiple modules. There has to be an easy and obvious way for users to quickly return to the main screen of the patient record from any point in the system. One of the most direct ways to facilitate efficient user interactions is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use to frequent and/or experienced users. System Feedback and Alerts The application should provide just in time and appropriate feedback to the users to minimize the chances of critical error. User needs to be prompted with reminders of pending tasks, consultations and alerts about a patients critical medical condition as relevant. Error messages must be clear to explain the reason why the error occurred and suggest what the users should do next. The User must receive a system feedback while performing a task that takes a while to reassure user about this action/decision. User-friendly & Visually appealing UI Learnability is critical to clinical applications since it is extremely difficult to provide extensive training, especially to clinicians whose time is limited. The system should provide support to it s users for better adoption and learning to complete various tasks. Themes, navigational models, or icons which users are already familiar with, or have used somewhere should be consistent across the application so that it s easier for users to relate. Colors should be used in cultural context and the meaning of a color in that context before using a specific color. Some form of visual highlighting is used to draw attention to important information. Labels for icons/symbols and headings for tables and lists should be provided to accurately describe data and avoid confusion. Items such as text fields, checkboxes, radio buttons, menus, tables, etc. are neatly aligned on the screens Similar objects and controls are used consistently throughout the system (For example: Hyperlinks, radio buttons, field labels - system internally consistent) Data visualization and presentation Physicians are intelligent, highly trained individuals solving problems with a very complex system the human physiology. The interrelations and dependencies with the human body are immense. As EMRs enable physicians to access ever greater amounts of information, they will need to see that information displayed in formats that can be integrated and manipulated. This may involve the use of multiple monitors and sophisticated software. Hospitals and clinics promise to be a fertile ground for data visualization software and for the manufacturers of display hardware. Appropriate terminology All language and terminology used in an EMR should be concise and unambiguous with familiarity and meaningful to the end users in the context of their work. Performance & Reliability There's nothing more frustrating for a clinician than watching an hour glass on the computer screen while trying to deliver patient care. 4 P a g e

5 Ensuring shorter log-in times and quicker page loads, increases clinical satisfaction and adoption. Integration with Other Systems EMRs have an ability to integrate with the other systems and serve as a central hub to tie all the systems in the clinic together. EMR systems can communicate with other systems and launch viewing applications of a number of diagnostic devices with a single click. With OIS Symphony, clinics will have Conclusions Obvious problems with EMRs, such as loss of productivity and training times, have deeper causes. These stem from the complex interaction of highly skilled physicians trying to complete complex tasks in a challenging work environment with a complex and not always usable medical information system. Yet, by applying user-centered design in this complex environment, usability professionals can contribute significantly to improving EMR usability. Greater productivity and lower costs with better health care may yet be our destiny. 11. References & Learning Aids [1] John B. Smelcer, Hal Miller-Jacobs, Lyle Kantrovich - Usability of Electronic Medical Records [2] [3] [4] 5 P a g e

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