Electronic Health Records and Healthcare Laws Journal Articles Review
Review
Abstract
Background: Electronic records could meliorate quality and efficiency of health intendance. National and international bodies propagate this conventionalities worldwide. However, the evidence base apropos the effects and advantages of electronic records is questionable. The outcome of health care systems is influenced by many components, making assertions about specific types of interventions hard. Moreover, electronic records itself found a circuitous intervention offer several functions with possibly positive as well as negative effects on the outcome of health care systems.
Objective: The aim of this review is to summarize empirical studies near the value of electronic medical records (EMRs) for hospital care published between 2010 and bound 2019.
Methods: The authors adopted their method from a serial of literature reviews. The literature search was performed on MEDLINE with "Medical Record System, Computerized" as the essential keyword. The option process comprised 2 phases looking for a consent of both authors. Starting with 1345 references, 23 were finally included in the review. The evaluation combined a scoring of the studies' quality, a clarification of data sources in example of secondary data analyses, and a qualitative assessment of the publications' conclusions apropos the medical record's touch on on quality and efficiency of health care.
Results: The majority of the studies stemmed from the Us (19/23, 83%). Generally, the studies used publicly available data ("secondary data studies"; 17/23, 74%). A total of 18 studies analyzed the result of an EMR on the quality of wellness care (78%), 16 the effect on the efficiency of health care (70%). The primary data studies achieved a mean score of 4.3 (SD 1.37; theoretical maximum 10); the secondary data studies a hateful score of 7.one (SD 1.26; theoretical maximum 9). From the primary data studies, 2 demonstrated a reduction of costs. There was not 1 study that failed to demonstrate a positive upshot on the quality of health care. Overall, 9/16 respective studies showed a reduction of costs (56%); 14/eighteen studies showed an increase of health care quality (78%); the remaining 4 studies missed explicit information well-nigh the proposed positive upshot.
Conclusions: This review revealed a clear evidence about the value of EMRs. In improver to an awesome majority of economic advantages, the review likewise showed improvements in quality of intendance by all respective studies. The apply of secondary data studies has prevailed over principal data studies in the meantime. Futurity work could focus on specific aspects of electronic records to guide their implementation and performance.
doi:10.2196/26323
Keywords
Introduction
This review is an update of 2 previous literature analyses on the benefits and costs of electronic medical records (EMRs), based on articles from 1966 to January 2004 [] and from 2004 to 2010 []. Using the same method, this review explores the progress in evidence from empirical studies. The World Health Organization (WHO) has a articulate position concerning the testify for eHealth in full general. Already in 2005, the WHO noted, "the potential impact that advances in data and communication technologies could have on health-care delivery..." []. 10 years later, the WHO put this straight by stating several advantages of electronic health records (EHRs) in the report of the third global survey on eHealth, which was produced past the Global Observatory for eHealth []:
- EHRs improve the quality, accuracy, and timeliness of patient information at the point of care.
- EHRs provide insights into wellness care costs, utilization, and outcomes.
- EHRs promote quality of intendance, reduce costs, support patient mobility, increment reliability of information, and provide access to patient data to multiple health care providers.
- Analyses from EHR data can highlight areas of concern and wellness services delivery.
The latter is emphasized in the electric current European digital strategy for data by creating a common European health data space that ensures interoperability of health data and in which every citizen has secure access to his or her EHR []. Consequently, many states adopted these visions and implemented national strategies for eHealth in full general and for the EHR in particular (come across [] for an overview of Europe or [] for country profiles from the Global Observatory for eHealth). In the United states, the meaningful employ of health care information technology (It) was fostered by the implementation of EHRs for all citizens until 2014 through the Health Information Technology for Economic and Clinical Health (HITECH) Act [,]. HITECH was successful, increasing the hospitals' adoption rate of a basic EHR from 9.4% in 2008 and 15.half dozen% in 2010 to 97% in 2014 []. In Germany, the Patient Data Protection Act "obliges the public sickness funds to offer their clients an electronic patient record (EPR) not after than i January 2021" []. Furthermore, doc practices and hospitals are requested to support and to utilise the EPR based on the legal basis of an informed consent by the patients. In 2017, half of the High german hospitals quoted the existence of an institutional electronic record similar to the state of affairs in Republic of austria []. Merely the Swiss hospitals reported a higher proportion with 78%, a statistically pregnant deviation to Deutschland.
EHRs will offering bones values by providing "the correct data at the right time in the correct place" []. This aim is achieved past improving the traditional office of patient records to shop information relevant to the care. However, EHRs should additionally guide the process of clinical problem solving and should support clinical conclusion making []. In 1991, the Institute of Medicine (IOM) listed 4 ways to positively influence quality of care []: (1) improving quality of and access to clinical data, (2) integrating data over time and settings, (3) making knowledge bachelor, and (4) providing decision back up. Looking at costs, the IOM expected positive effects in 3 ways: (1) reducing unnecessary tests and services, (2) reducing administrative costs, and (iii) increasing the productivity of health intendance professionals.
One might argue that a further discussion about the proposed value of an EMR is needless because of its almost complete implementation. Nobody will vote for a fallback to paper. Notwithstanding, the implementation does not guarantee a positive perception by the users. In a recent survey including 208 physicians from 3 Norway hospitals [], 72% of the physicians reported interrupted or delayed work at least one time a week considering the EHR hangs or crashes, and 53% of the physicians indicated that the EHR is cumbersome to use and adds to their workload. These results demonstrate a reasonable room for improvements, also noncontroversial advantages that were reported in the written report from Kingdom of norway. Even if up-to-appointment wellness care cannot exist imagined without an EMR, an ongoing evaluation of its advantages and disadvantages is a prerequisite for a well-considered further development and aligning. In our sequence of literature reviews, we put the ultimate goals of health care in the middle, to provide a high level of care for reasonable costs in terms of effectiveness and efficiency []. Furthermore, the serial of reviews allows a monitoring of the EMR's value over time past preserving the criteria for the selection and the appraisal of the included studies. The research questions were twofold. What is the effect of EMRs on the quality of inpatient care? What is the effect of EMRs on the costs for inpatient care?
Methods
Terminology of Electronic Records in Health Care
Concepts and terms denoting electronic records in health care are still non unambiguously defined []. Differences and similarities of "electronic medical records," "electronic patient records," and "electronic wellness records" are a matter of a long-lasting debate. In our reviews, nosotros focused on electronic records used by health professionals and administrative staff for inpatient care, including, for example, physicians, nurses, radiologists, pharmacists, laboratory technicians, and radiographers []. Those records must non necessarily follow a patient lifelong. Therefore, we adopted the definition of an EMR by Waegemann []: an EMR is a "figurer-stored collection of health information about a person, linked by a person identifier", with the application environment existence a hospital and including any care delivery existence the total responsibleness of the health intendance provider.
Search Strategy
The literature search was performed between March 10, 2019, and April 2, 2019, using MEDLINE. MEDLINE was accessed via PubMed []. The keyword "Medical Records Systems, Computerized" from the MeSH was separately combined with the MESH terms "technology cess, biomedical", "costs and cost analysis", "health care costs", "cost savings", "cost effectiveness", "cost benefit", "cost analysis", "benefits and costs", "quality of health care", "outcome study", "consequence assessment, patient", and "disquisitional care outcomes". Additionally, January 1, 2010, was defined equally the earliest date of publication. Later an exclusion of duplicates, interactive tutorials and reviews, and a brake to the languages German and English language, 1345 references remained.
Study Selection
Using titles and abstracts, both authors independently reviewed the 1345 literature references regarding the existence of an EMR, the application of an EMR in inpatient intendance, and an empirical analysis of benefits or costs. Explicitly excluded were studies in md offices or about convalescent care provided past hospitals, studies about picture archiving and advice systems, and studies near systems for computerized medico social club entry (CPOE). The rating comprised the categories have, refuse, and unclear. References rated equally accept/accept and have/unclear were qualified, references rated as refuse/pass up and turn down/unclear were rejected. References rated as accept/pass up or unclear/unclear were discussed and a final decision was reached based on a consensus. Herewith, 84 publications were qualified for the further evaluation (six.25%). From these, full texts of 79 papers could be obtained; for 5 papers, this was non possible. shows the inclusion and exclusion criteria of both stages.
Inclusion and exclusion criteria.
Inclusion criteria
- Acute care hospital
- Inpatient care
- Electronic medical record
- Empirical effect
- Argument about costs
- Statement about benefits
Exclusion criteria
- Physician office
- Convalescent care
- Moving picture archiving and communication system
- System for computerized dr. social club entry
Both authors again carried out the evaluation of the remaining 79 publications independently. This time, the evaluation was based on the total texts of the references. Both authors looked at concrete statements on benefits and costs, and gave a final recommendation about the inclusion into the review. References were finally included if they reached two or 3 positive votes from both authors (xvi/79 references, 20%). References were finally excluded if neither authors gave at least two positive votes (43/79 references, 54%). The remaining 20 references were discussed to achieve a consensus virtually their inclusion for the review (25% from 79 references). Overall, the option procedure produced 23 relevant studies that ultimately formed the subject area of the detailed analysis, being i.71% from the initially identified references (N=1345; ).
Interrater reliability during study choice was verified by calculating Cohen κ. In the first evaluation level based on titles and abstracts, the κ value was 0.185, indicating a slight agreement betwixt the reviewers according to the estimation of Landis and Koch [] (). In the second evaluation level of full texts, the κ value was 0.428, indicating a moderate understanding. The interrater reliability was comparable to the previous reviews.
| κ value | Level of understanding |
| <0.00 | Poor |
| 0.00-0.20 | Slight |
| 0.21-0.40 | Fair |
| 0.41-0.threescore | Moderate |
| 0.61-0.80 | Substantial |
| 0.81-1.00 | Virtually perfect |
Written report Evaluation
For a semiquantitative evaluation of the studies, a catalog of criteria was drawn up focusing on the report design, the formal quality of the publication, the number of users included, the study elapsing, and the utilize of statistical tests. Each aspect of a study was rated ii, 1, or 0 points, with two being the best score for a study. Missing data was rated 0 points. The maximum number of points that could be accomplished was therefore 10. In improver, the studies were described with regard to their origin, their application scenarios, and their target values. The approach proposed by Johnston et al [] was adopted every bit ground for the evaluation method. The definition of the criteria was partly different between studies collecting primary data and studies analyzing existing, secondary information. The definition was carried out equally described below.
Report Design
The assessment of the study design was based on the classification depicted in , according to Roine et al []. Different types of studies were ranked from 1 to 9 apropos the prove hierarchy. The commencement stage, meta-analyses from randomized, controlled studies, was not a component of the inclusion criteria. The remaining report types were combined into the following 3 groups: randomized controlled studies (testify stages ii and 3); nonrandomized controlled studies (evidence stages four, 5, 6, and 7); and uncontrolled clinical series, descriptive studies, consensus methods, awarding observations, and empirical reports (evidence stages 8 and 9). Studies in the first group received 2 points, studies in the second group one signal, and the remaining studies 0 points. Co-ordinate to the proposal of Nathan and Gorman [], all secondary data analyses were assigned to bear witness stage 7 of and were uniformly assigned 1 point. Therefore, the maximum number of points was reduced to 9 for those studies.
| Testify stage | Study design |
| 1 | Meta-analyses of randomized controlled trials |
| 2 | Big-sample randomized controlled trials |
| iii | Small-sample randomized controlled trials |
| 4 | Nonrandomized controlled prospective studies |
| five | Nonrandomized controlled retrospective trials |
| half-dozen | Cohort studies |
| 7 | Instance–control studies |
| viii | Noncontrolled clinical series, descriptive studies, consensus methods |
| nine | Anecdotes or case reports |
Formal Quality of Publication
The publication should follow the international standard structure of scientific articles, that is, authors' names and affiliations on the championship folio, abstract, introduction, material and methods, results, discussion, conclusions, and references. For a publication in full compliance with this construction, 2 points were assigned; if the article provided a separate introduction and an explicit naming of authors and the medical environment, 1 signal was assigned; otherwise, 0 points were given.
Number of Users
The number of EMR users can touch on the reliability and the generalizability of the results. Therefore, ii points were given for studies based on primary data with xx or more than users, ane point for six-19 users, and 0 points for less than 6 users or if no number of users was specified. For studies analyzing secondary data, the number of hospitals included was scored as follows: two points for a infirmary number of 2000 and to a higher place; 1 point for a hospital number of 500 to 1999; and no points for a infirmary number of 0-499 or missing data.
Implementation Elapsing
Primary data studies implemented for at least one year received two points, ane point was given for a half to less than 1 year, and 0 points for less than a half year. For the secondary data studies, the evaluation periods were scored every bit follows: 2 points were awarded to a written report for an evaluation period of three years or longer, ane point for a period of one or 2 years, and no points for an implementation period of less than 1 yr or in case of missing information.
Statistical Evaluation
Assessment and evaluation of scientific statements gain in evidential ability with inferential statistical statements. Ii points were given for studies reporting the outcome(southward) of statistical analyses with full information concerning the level of significance, and 1 indicate for the description of a statistical test performed without indication of the level of significance. Otherwise, 0 signal was given.
Results
Origins and Locations of the Studies
The 23 studies selected for the principal evaluation [-] consisted of 6 master and 17 secondary data studies (). 3 (7, 18, and 23) of the six primary data studies were conducted in the U.s. (Wisconsin, N Carolina, and Massachusetts), 1 study each was conducted in Communist china (21), Germany (3), and Japan (17). Sixteen secondary information studies originated from the United States, 1 from the Netherlands.
In the secondary information studies, 15 dissimilar data sources were used to analyze the issues of treatment quality, costs, and EMR equipment (). The most often used data sources stemmed from the American Hospital Clan (AHA; nineteen studies), the Healthcare Information and Management Systems Society (HIMSS; 11 studies), and the Centers for Medicare & Medicaid Services (CMS; ix studies). They were followed by the Hospital Quality Brotherhood database (HQA), the National Database of Nursing Quality Indicators (NDNQI), and the Office of Statewide Health Planning and Development (OSHPD). The remaining sources were used only in 1 study.
| Study number | Reference | Land | Sample size | Menstruation | Main outcomes |
| 1 | Adler-Milstein et al [] | United States | 191 hospitals | 2 years | EHRa adoption is associated with better operation in terms of payment and length of stay in well-run institutions. EHR adoption may be associated with worse performance in poorly run institutions. |
| two | Adler-Milstein et al [] | United States | 2591 hospitals (2011) | 4 years | Degree of EHR adoption is positively correlated with process adherence, patient satisfaction, and efficiency. |
| 3 | Castellanos et al [] | Federal republic of germany | Not indicated | 6 years | Small increment in turn a profit in the yr after the introduction of the patient data management system. |
| 4 | DesRoches et al [] | United states of america | 3049 hospitals | vi months | Presence of clinical determination support is associated with small quality gains. No relationship between EHR level and overall risk-adjusted length of stay, take a chance-adjusted thirty-twenty-four hour period readmission rates, and risk-adjusted inpatient costs. |
| five | Elnahal et al [] | United States | 3101 hospitals | 9 months | Higher rates of adoption of key EHR functions among loftier-quality hospitals. |
| 6 | Encinosa and Bae [] | Usa | 2619 hospitals | i twelvemonth | EMRsb do not reduce the rate of patient safety events. In instance of patient safety events, EMRs reduce deaths, readmissions, and spending. |
| 7 | Feblowitz et al [] | United States | Non indicated | ii years | Length of stay increased after implementation of an electronic documentation. Mean fourth dimension to disposition for admitted patients remained stable. |
| 8 | Furukawa et al [] | United States | 5066 hospitals | ten years | Advanced EMR applications may increase hospital costs and nurse staffing levels, as well every bit increment complications and decrease bloodshed for some conditions. |
| 9 | Furukawa et al [] | United States | 509 hospitals | five years | Nurse-sensitive patient outcomes improved. EMR implementation may be associated with reduced demand for nurses. |
| 10 | Himmelstein et al [] | United States | 4000 hospitals | 6 years | Hospital computerization has non achieved savings on clinical or administrative costs. More than computerized hospitals might have a slight quality reward for some conditions. |
| xi | Jarvis et al [] | The states | 2988 hospitals | one year | Most advanced EHRs have the greatest payoff in improving clinical process of care scores. |
| 12 | Jones et al [] | United States | 6057 hospitals | four years | Availability of basic EHR is associated with a significant increment in wellness care quality for heart failure. |
| thirteen | Joynt et al [] | Us | 1236 hospitals | 4 years | Patients with stroke are more probable to receive guideline-driven components of care at hospitals with EHRs. Patients are slightly less probable to have a hospital stay longer than four days at hospitals with EHRs. |
| 14 | Kazley et al [] | United States | 1000 hospitals | 1 year | In hospitals with avant-garde EHRs, patient costs are less compared with hospitals without advanced EHRs. |
| 15 | Lee et al [] | United states of america | 708 hospitals | 8 years | Hospitals adopting EMRs experience shorter length of stay and lower thirty-mean solar day mortality. |
| xvi | McCullough et al [] | United States | 3401 hospitals | 4 years | Utilise of EHRs results in improvements in process-of-care measures for patients with heart failure or pneumonia. |
| 17 | Nakagawa et al [] | Japan | Not indicated | 7 years | EMR may decrease medical risks, merely profitability does not rise more than the investments. |
| 18 | Schenarts et al [] | The states | Not indicated | 40 months | Implementation of the EMR is associated with an comeback in several complications and process measures. |
| xix | Teufel et al [] | U.s.a. | 2307 hospitals | 1 twelvemonth | Advanced-phase EMR is associated with greater costs per instance. |
| 20 | van Poelgeest et al [] | Netherlands | 67 hospitals | 1 yr | No statistically meaning association between a hospital'south EMR adoption and an overall quality or safety functioning. |
| 21 | Xue et al [] | China | 251 physicians and 298,760 patient visits | five years | Length of stay declines and bloodshed rate decreases with EMR. An EMR has no positive consequence on patient costs. |
| 22 | Yanamadala et al [] | United States | 448,767 patients | 1 year | Patients at hospitals with full EHR have the lowest rates of inpatient bloodshed, readmissions, and patient safe indicators. |
| 23 | Zlabek et al [] | United States | Not indicated | Non indicated | Implementation of an inpatient EHR results in a rapid improvement in measures of cost of care. |
aEHR: electronic health tape.
bEMR: electronic medical record.
| Study number | Source (included years) | |||
| | Quality | Costs | Electronic medical record | Other |
| 1 | AHAa (2009) | AHA (2009) | AHA Information technology Supplement (2009) | World Management Survey (2009) |
| ii | AHA (2009-2012) CMS'sb Infirmary Compare (2009-2012) | CMS' EHRc Incentive Program reports (2009-2012) | AHA It Supplement (2008-2011) CMS' EHR Incentive Plan reports (2009-2012) | AHA annual survey (2008-2011) |
| 4 | AHA (2008) HQAd database (2009) | AHA (2008) Medicare Provider Assay and Review (2006) | AHA IT Supplement (2008) | |
| 5 | HQA database (2006) | | AHA IT Supplement (2009) | |
| half-dozen | MarketScan Commercial Claims and See Database (2007) AHA (2007) | MarketScan Commercial Claims and Encounter Database (2007) AHA (2007) | AHA (2007) | |
| eight | OSHPDe (1998-2007) | OSHPD (1998-2007) | HIMSSf (1998-2007) | OSHPD (1998-2007) |
| nine | NDNQIg (2004-2008) | NDNQI (2004-2008) | HIMSS (2004-2008) | |
| 10 | Dartmouth Wellness Atlas (2008) | The Medicare Cost Reports | HIMSS (2003-2007) | |
| xi | AHA (2008-2010) | CMS | HIMSS (2012?) | |
| 12 | AHA (2004-2007) | | HIMSS (2003-2006) | |
| thirteen | AHA (2007-2010) | AHA (2007-2010) | GWTG-Strokeh (2007-2010), linked with the AHA annual survey | |
| 14 | | NISi (2009) | HIMSS (2009) | |
| 15 | MEDPARj (2000-2007) | | HIMSS (2000-2007) | |
| 16 | AHA (2004-2007) | CMS (2004-2007) | HIMSS (2004-2007) | |
| 19 | | HCUP Kidk (2009) | HIMSS (2009) | |
| 20 | EMRAMfifty (2014) | EMRAM (2014) | | |
| 22 | HCUP, SIDm (2011) | AHA annual survey (2008, 2011) | | |
aAHA: American Hospital Clan.
bCMS: Centers for Medicare & Medicaid Services.
cEHR: electronic health record.
dHQA: Hospital Quality Alliance database.
due eastOSHPD: Office of Statewide Health Planning and Development.
fHIMSS: Healthcare Information and Management Systems Social club.
gNDNQI: National Database of Nursing Quality Indicators.
hGWTG-Stroke: Get With the Guidelines-Stroke.
iNIS: nursing information system.
jMEDPAR: Medicare Provider Assay and Review
chiliadHCUP Kid: Healthcare Price and Utilization Projection Kids Inpatient Data.
fiftyEMRAM: HIMSS Analytics EMR Adoption Model.
chiliadSID: Country Inpatient Databases.
Methodical Quality
The results of the semiqualitative assessment are presented in and . In the evaluation of the primary data studies, 2 (18 and 21) publications achieved a score of six points, 3 (iii, 7, and 17) scored 4, and 1 (23) achieved simply 2 points. No primary data study scored 0, 1, iii, 5, and seven-10 points. While in the secondary data studies 2 papers (2 and 10) achieved the maximal score of 9 points, another iv (9, thirteen, fifteen, and 16) scored 8, 7 (four-6, viii, 11, 12, and 19) scored vii, 2 (1 and 14) scored 6, ane (22) scored 5, and i (twenty) scored four. No secondary data written report scored 0-3 and 10 points. A total of 18 of the 23 studies scored v and more points (78%), while 5 remained beneath this score (22%). Only ii/vi (33%) main data studies achieved 5 points or more. By contrast, sixteen/17 (94%) secondary data studies accomplished a score of 5 points or more.
Two (i and 19) of the main information studies were randomized controlled trials; i (4) was a nonrandomized controlled trial; the remaining iii belonged to a lower evidence stage. Past definition, the 17 secondary studies were all assigned to evidence level seven. Fifteen (1-half dozen, nine-11, 13-16, 19, and 20) studies followed the internationally accepted structure of scientific articles. The remaining 8 studies (7, 8, 12, 17, 18, and 21-23) lacked any formal structure.
Three (17, 18, and 21) of the 6 primary data studies had a user population of at to the lowest degree twenty or more than. The remaining three (iii, seven, and 23) did not provide any information. Five (3, 7, 17, eighteen, and 21) primary data studies had an implementation period of at least one twelvemonth, 1 (23) less than vi months. Xi (2, 4-half-dozen, 8, 10-12, sixteen, 19, and 22) of the 17 secondary studies included at least 2000 hospitals, 4 (nine, thirteen-15) 500 to less than 2000 hospitals, and 2 (1 and 20) less than 500 hospitals. Eight (ii, 8-10, 12, 13, 15, and sixteen) of the secondary data studies analyzed data from at least three years, 1 (1) from 1 or 2 years, and eight (four-6, 11, xiv, 19, xx and 22) from less than 1 year.
Nineteen (one, 2, four-xv, 18, 19, and 21-23) of the 23 studies supported the value of their results by statistical tests with full information on the level of significance. Two (16 and 20) studies stated that they had performed statistical tests but did non proper noun them, and ii (3 and 17) studies did not provide whatever information on them.
| Study number | Reference | Information source | Terminal score | Toll reduction | Improvement in quality of intendance |
| ane | Adler-Milstein et al [] | Sa | 6 | pb | p |
| 2 | Adler-Milstein et al [] | S | 9 | p | p |
| iii | Castellanos et al [] | Pc | 4 | p | n.a.d |
| 4 | DesRoches et al [] | Due south | vii | n | xeast |
| v | Elnahal et al [] | Due south | 7 | n.a. | p |
| 6 | Encinosa and Bae [] | S | vii | p | p |
| 7 | Feblowitz et al [] | P | 4 | northwardf | x |
| 8 | Furukawa et al [] | Southward | 7 | n | p |
| 9 | Furukawa et al [] | South | viii | p | p |
| 10 | Himmelstein et al [] | S | 9 | due north | x |
| 11 | Jarvis et al [] | S | vii | north.a. | p |
| 12 | Jones et al [] | S | 7 | north.a. | p |
| xiii | Joynt et al [] | Southward | 8 | p | p |
| 14 | Kazley et al [] | S | half dozen | p | n.a. |
| 15 | Lee et al [] | Due south | 8 | p | p |
| xvi | McCullough et al [] | Due south | 8 | n.a. | p |
| 17 | Nakagawa et al [] | P | 4 | n | n.a. |
| eighteen | Schenarts et al [] | P | 6 | north.a. | p |
| 19 | Teufel et al [] | S | 7 | n | north.a. |
| 20 | van Poelgeest et al [] | S | four | n.a. | x |
| 21 | Xue et al [] | P | half-dozen | n | p |
| 22 | Yanamadala et al [] | S | 5 | n.a. | p |
| 23 | Zlabek et al [] | P | 2 | p | n.a. |
aS: secondary data studies.
bp: positive effect.
cP: primary data studies.
dn.a.: non assessed.
eten: positive effect without specific data.
fn: no positive outcome.
Main Subjects
A total of five out of the 23 studies (iii, 14, 17, 19, and 23) dealt solely with economic aspects of the utilise of an EMR, 7 (5, 11, 12, 16, eighteen, 20, and 22) dealt solely with the effects on the quality of care, and 11 studies (1, 2, 4, half-dozen-10, thirteen, 15, and 21) dealt with both aspects ( and ). Primary information studies and secondary data studies were institute in all groups. While 9 (39%) of the 23 studies (one-3, vi, 9, 13-15, and 23) showed an economically positive impact, vii (thirty%) (4, 7, 8, 10, 17, nineteen, and 21) did not reveal monetary advantages due to the use of the EMR. Eighteen studies (1, ii, 4-13, xv, sixteen, 18, 20-22) looked at the impact of the utilise of an EMR on the quality of care. All of them (18/23 studies, 78%) plant a positive effect. However, iv (4, seven, x, and 20) did non provide specific information about it. No study indicated show of disadvantages in the quality of treatment from the apply of an EMR. Principal data studies and secondary data studies showed like results.
One of the striking studies, Zlabek et al [] looked at the furnishings of an EMR organisation on selected measures of cost of care and patient safety. They demonstrated the following outcomes (ways and % modify):
- Laboratory tests per week per hospitalization decreased from xiii.nine to 11.iv (18).
- Radiology examinations per hospitalization decreased from 2.06 to ane.93 (6.iii).
- Monthly transcription costs declined from United states of america $74,596 to US $eighteen,938 (74.6).
- Numbers of copy paper ordered per calendar month decreased from 1668 to 1224 (26.vi).
- Medication errors per 1000 hospital days decreased from 17.9 to 15.4 (14.0), while almost misses per thou hospital days increased from 9.0 to 12.v (38.ix), and the percentage of medication events that were medication errors decreased from 66.5% to 55.2%.
In a national report about hospital calculating and the costs and quality of care, Himmelstein et al [] analyzed whether highly computerized hospitals had lower costs of intendance or assistants, or better quality. They acquired the post-obit outcomes in their work:
- College overall computerization scores correlated weakly with better quality scores for astute myocardial infarction, simply not for heart failure, pneumonia, or the 3 conditions combined. In multivariate analyses, more computerized hospitals had a slightly amend quality.
- Hospitals on the "Near Wired" list performed not improve than others on quality, costs, or administrative costs.
- Hospitals' administrative costs increased slightly but steadily, from 24.4% in 2003 to 24.9% in 2007. Higher administrative costs weakly predicted higher total Medicare spending, inpatient spending, and outpatient spending.
According to the study performed past Encinosa and Bae [], many reforms in the Patient Protection and Affordable Care Human activity (ACA) underlie the apply of EMRs to help incorporate costs. In this regard, the authors constitute that EMRs practise not reduce the charge per unit of patient safe events. However, once an upshot occurs, EMRs reduce expiry by 34%, readmissions by 39%, and spending past US $4850 (16%), a price offset of United states of america $ane.75 per U.s.a. $1 spent on IT majuscule. Thus, the authors ended that EMRs comprise costs past improve analogous intendance, a coordination that rescues patients from medical errors once they occur.
The study past Castellanos et al [] analyzed toll and reimbursement information from a 25-bed intensive care unit of measurement at a German academy hospital in a retrospective assay, 3 years before and iii years after the implementation of a patient information management system (PDMS). Costs and revenues increased continuously over the years. The profit of the investigated intensive care unit of measurement was fluctuating over the years and seemingly depending on other factors as well. They found a small increase in profit in the year afterwards the introduction of the PDMS, but not in the following years. Therefore, a articulate evidence for cost savings later the introduction of PDMS was non seen.
Discussion
Main Findings
This review is an update of 2 previous analyses on the benefits and costs of EMRs, based on articles from 1966 to January 2004 [] and 2004 to 2010 []. Using the same method, this review explored the progress in evidence from empirical studies. With a total of xix of the 23 publications selected for evaluation (83%), studies from the United states of america dominated. Of the remaining 4 studies, ii were conducted in Europe. Asia was represented by i Chinese and Japanese study each. South America, Africa, and Australia were not represented at all. Results of our reviews over the iii periods showed a number of significant developments (). For example, the total number of initial hits had almost doubled. While the number of studies relevant to the evaluation remained more than or less the same for the first and the current review, the 2nd review produced almost one-third fewer studies. Remarkable in the current review was the predominant use of secondary data studies compared with main data studies. In this context, highlighting the differences between primary and secondary studies should assist to ameliorate assess the conclusions drawn from the results. While the primary information studies collected new and yet unexplored data, the secondary data studies used statistical processing of already existing data. In full general, secondary information studies practise not attain the bear witness level of meta-analyses comprising also already existing but initially primary data. The most important advantage of principal data studies is that data can be collected and statistically evaluated in a targeted and trouble-oriented manner. Their disadvantage is that specific surveys of patient data are oftentimes time-consuming and expensive compared with secondary data studies. Furthermore, in case of complex interventions, as it is the example for EMRs, primary information studies are often not feasible []. The advantage of secondary information studies is that comparatively few resources are required to prepare them. Their disadvantage is that the data were not collected specifically to respond the research questions as part of a specifically designed written report design.
The annual number of studies on EMRs showed a continuous increment over our three review periods (). The aforementioned was true for the annual number of finally included studies. The methodological quality of the studies inverse as well. While only 35% of the studies scored more than v points in the kickoff review (7/20), 74% of the studies scored more 5 points in the third review (17/23). Amid the finally included studies in the first review, costs were analyzed in 100% of the publications (20/20), with just 20% also focusing on quality of care (iv/20). In the second review, both aspects were analyzed in 71% of the publications (5/7). In this review, costs were analyzed in 70% of the publications (16/23), quality of intendance in 78% (18/23).
The comparison of the 3 periods revealed a twofold shift. On the one mitt, the studies' focus switched from an economic ane to a clinical one. The per centum of studies concerned solely with costs decreased from 80% (16/20, 1966-2004) to 14% (1/vii, 2002-2010) and 22% (5/23, 2010-2019). On the other hand, the positive effects of EMRs on quality of care became apparent over time. In the outset review, none of the 4 studies concerned with quality of intendance presented well-defined advantages. In this review, this was the case in 14 of xviii studies analyzing the effects of EMRs on quality of care. The reasons for this shift remain speculative. The focus of EMRs might have changed from an authoritative ane to a patient-oriented 1. Technological progress could take helped to achieve the clinical benefits that were an important motivator for the introduction of EMRs even in the early years []. In 1997, information technology was reported that costs remained a significant bulwark for EHRs []. Now, experiences concerning the introduction, implementation, and an accompanying change management might have better prepared hospitals for the harvesting of clinical benefits and simultaneously for the limiting of boosted costs.
| Review | Years, due north | Hits without duplicates, n | Hits per year, mean | First option, north | Finally included studies, n | Finally included studies per year, mean |
| Commencement (1966-2004) | 38 | 588 | 15.5 | 117 | 20 | 0.five |
| Second (2004-2010) | 6 | 578 | 96.three | 64 | seven | 1.two |
| This (2010-2019) | 9 | 1345 | 149.four | 84 | 23 | 2.6 |
Limitations
The reliability betwixt the ii authors in selecting the papers was slight in the start stage (κ=0.185) and moderate in the second phase (κ=0.428). Both results were nigh equal compared with the ii previous reviews, first phase 0.26 (review 1) and 0.192 (review ii), 2d phase 0.36 (review one) and 0.399 (review ii). Unfortunately, measures of interrater reliability are usually non presented in systematic reviews. We assume that our results are not junior in comparison to comparable reviews. The agreement was high in excluding references that do not fulfill the inclusion criteria. Differences occur in the detection of appropriate studies. To avoid the exclusion of simulated negatives, opposite votes and unclear votes were dissolved in a consensus. Yet, the extraction of the papers' main conclusions was a complex procedure. Misunderstandings and errors in this process cannot be completely ruled out. For case, authors' conclusions summarized in a newspaper'southward abstract could differ from individual results plant in the paper's principal text. The results of univariate and multivariate analyses may non hold and positive effects in one medical condition could be absent in another condition. Therefore, the review'southward rating is a pragmatical compromise to reach a meaningful conclusion.
The authors kept the EMR as type of intervention for all 3 reviews and fastened slap-up importance to an unaltered approach. This immune the comparing of results over the whole series of reviews. The determination to maintain the focus on the EMR might be questioned because the literature addresses many different levels of IT used in hospitals. The results are therefore neither tailorable to more than detailed types of IT providing but selective functionalities as CPOE nor generalizable to lifelong EPRs or to health data and communication technology overall. Nevertheless, through the clear and persistent focus, the authors gained reliable and valid conclusions beyond transitory trends and fashions.
Furthermore, the series maintained the same set of keywords. The authors could not rule out that newer functionalities of EMRs are not accordingly covered by this set. Still, even and then, the hitting results supporting an indisputable positive event of EMRs would exist an underestimation of the actual state of affairs. It is unlikely that newer functionalities pass up the furnishings of EMRs on quality of care.
The detected studies stand for primarily the perspectives of the United States and developed countries. Adult countries have the economic power to implement EMRs and to realize respective evaluation studies. This will not be the case for developing countries. Nevertheless, the perspective for developing countries is similar. For instance, Odekunle et al [] reported for Sub-Saharan Africa the same vision as it was uncovered in our review. EHRs will meliorate quality of intendance in Sub-Saharan Africa, merely high costs of procurement and maintenance of the EHR system hindered their widespread adoption until now.
Comparison With Prior Work
In 1963 the then American President, John F. Kennedy, was pointed to the potential of health record systems: "The awarding of computer applied science to the recording, storage, and analysis of information collected in the course of observing and treating large numbers of ill people promises to accelerate our understanding of the cause, course, and control of disease" []. Forty-5 years later, another American President (in 2009) proposed a cardinal change to the utilize of IT in the national wellness care system past passing the HITECH Act []. Besides other regulations, each person in the United States should have an EHR by 2014 []. With the idea of a meaningful utilise, health care providers and hospitals should be rewarded for using an EHR under the Medicare and Medicaid schedule. The time gap between expectations and routine application makes it clear that the proposed advantages were neither like shooting fish in a barrel to demonstrate nor like shooting fish in a barrel to achieve []. Fifty-fifty a proposal in 1991 for a nationwide implementation of electronic records in the next decade failed []. Whether an evaluation of a technology in one country could exist transferred to another i remains questionable, considering different health care systems and unlike strategies implemented with regard to the digitization of health intendance [].
Our outcome of the positive impact of EMRs on the quality of care is supported past a systematic review by Campanella et al []. Their meta-analysis of 47 studies revealed a reduction of documentation time, a higher guideline adherence, and a lower number of medication errors and adverse drug events in the intervention group using an EHR. However, no clan with mortality was plant. Unlike to our review, the authors included studies on CPOE and did not focus on a specific area. The effect on mortality might be besides small to be statistically meaning even in a meta-analysis. Therefore, the inclusion of secondary data studies in our review serial was reasonable. Thompson et al [] also did non detect a positive bear upon of EMRs on bloodshed. Likewise, they did not observe a positive affect on length of stay and costs. Their results were similar for record systems, CPOE, clinical determination support systems (CDSSs), and surveillance systems. In dissimilarity to our results, Thompson et al [] ended that there "is non enough evidence to confidently land that electronic interventions take the ability to achieve the goal of improving quality and prophylactic". Moja et al [] also did non notice effects of CDSSs on mortality in their meta-analysis based on 16 randomized controlled trials []. The authors stated, "most of the studies were underpowered and besides brusque to prove or exclude an consequence on bloodshed, and effects equally large as a 25% increase or reduction could still be possible." In this day and historic period, where digitization is anywhere, information technology could become hard to fill this gap with randomized controlled trials about EMRs using an advisable control group. Besides secondary data analyses, ecological analysis might be worthwhile, even though the take a chance of an ecological fallacy exists []. With regard to CPOE as another subfunctionality of an EMR, Folio et al [] analyzed the evidence apropos a positive affect of quality of care. Defining a catamenia overlapping with our report, 2000-2016, they included 23 studies with a control group. About half of the studies reported beneficial effects. However, the authors did not clearly distinguish between the effects of medication prescribing alerts as intervention and CPOE systems as infrastructure.
In summary, the impact of EMR subfunctionalities remains unclear in the literature. At a level across electronic records, the impact of health information substitution (HIE) as "the electronic transfer of patient data and health information between health care providers" is discussed []. Having EMRs every bit the condition, the exchange of data via HIE might bring the quantum in terms of quality of care and toll reduction. In their recent review, Sadoughi et al [] considered 32 studies published between 2005 and 2016 that analyzed the financial or clinical bear upon of HIE. In that review, studies on EMRs were explicitly excluded. The bulk of the studies were conducted in the United states of america (28/32), which is similar to our results. Furthermore, xix studies were labeled as cohort studies, supporting our observation of a rather small number of controlled trials. Virtually all studies analyzing an improvement of quality showed a positive impact (16/17, 94%); 15/19 (79%) corresponding studies showed a positive effect on cost-effectiveness. With a similar span, these results from Sadoughi et al [] lucifer our review, with 78% of studies demonstrating an increase in quality of intendance and 56% demonstrating a reduction of costs. Reverse to a review including studies between 2003 and 2014 [], Sadoughi et al [] revealed a considerable progress in the utilise of HIE.
Still, the advantages of EMRs have to be balanced with risks that are linked to Information technology not necessarily considered in evaluation studies. The relationship betwixt the level of digitization and effects on quality and costs of care must not be linear. College levels of digitization might be correlated with higher risks that could lead to a reversion of the consequence, as indicated past a study near the HITECH Act []. Therefore, it might be worthwhile to focus on the appropriate level of health It instead of looking for global furnishings. Furthermore, the type of technology might non make the divergence but rather the usability of the engineering. For example, Roman et al [] analyzed navigation-related issues in the field of EHRs. A lack in usability could induce risks for health care that lower the provided level of intendance. Finally, one should not forget that software, hardware, or electrical ability supply can fail or tin can exist a target for criminal attacks []. An overall perspective on the value of EMRs must therefore include a broader definition of assets and drawbacks.
Conclusions
Our literature review revealed a clear evidence well-nigh the value of EMRs. Merely some primary information studies failed to demonstrate a reduction of costs after the implementation of an EMR. Quality of intendance improved in all corresponding studies. In comparison with our outset review covering the flow betwixt 1996 and 2004, the film changed completely. At that point, just 4 of twenty studies published benefits for the quality of intendance and nineteen reported a reduction of costs. In parallel with the appearance of the first secondary data studies, the proportions turned around in the 2d review from 2004 to 2010. Interestingly, the positive furnishings on costs could non be completely confirmed by chief data studies at present. To promote an extended utilise of EMRs, at that place must exist a financial refund of additional costs, given the current scientific evidence. The switch from interventional studies to observational studies using publicly available information might have induced a bias in confirming everyday perceptions about electronic records in health care. Broader and better designed studies are needed to establish better scientific show regarding benefits of EMRs in infirmary care. Nevertheless, further studies could focus on specific aspects of electronic records to guide their implementation and operation.
Acknowledgments
We admit support by the Open Access Publication Fund of the University of Duisburg-Essen.
Conflicts of Interest
None declared.
Abbreviations
| ACA: Affordable Care Human activity |
| AHA: American Hospital Association |
| CDSS: computer decision back up systems |
| CMS: Centers for Medicare & Medicaid Services |
| CPOE: computerized doctor order entry |
| EHR: electronic wellness record |
| EMR: electronic medical tape |
| EPR: electronic patient record |
| GWTG-Stroke: Get With the Guidelines-Stroke |
| HCUP Kid: Healthcare Cost and Utilization Project Kids Inpatient Data |
| HIE: health information exchange |
| HIMSS: Healthcare Information and Management Systems Society |
| HITECH: Health Information Applied science for Economic and Clinical Wellness |
| HQA: Hospital Quality Brotherhood database |
| IOM: Found of Medicine |
| IT: information engineering |
| NDNQI: National Database of Nursing Quality Indicators |
| NIS: nursing information system |
| OSHPD: Role of Statewide Health Planning and Development |
| PDMS: patient data management system |
| RCT: randomized controlled trial |
| SID: State Inpatient Databases |
| WHO: World Health System |
Edited by R Kukafka; submitted 07.12.xx; peer-reviewed by C Gibson, Due west Sermeus; comments to author 26.03.21; revised version received 27.04.21; accepted 08.ten.21; published 23.12.21
Copyright©Aykut Uslu, Jürgen Stausberg. Originally published in the Periodical of Medical Internet Research (https://www.jmir.org), 23.12.2021.
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Source: https://www.jmir.org/2021/12/e26323
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