CHAPTER II

REVIEW OF RELATED LITERATURE

Chapter 2 presents the review of related literature and

studies which have the bearing on the study under

investigation. These will serve as guide and practice to

provide direction to the conduct of the study.

The Use of Electronic Medical Records: Communication

Patterns in Outpatient Encounters
By: Gregory Makoul, PhD, Raymond H. Curry, MD, & Paul C.

Tang, MD (2001).

To assess physician–patient communication patterns

associated with use of an electronic medical record (EMR)

system in an outpatient setting and provide an empirical

foundation for larger studies. Advances in electronic

medical record (EMR) technology have made it possible for

the EMR to replace many functions of the traditional paper

chart, and use of EMR systems promises significant advances

in patient care. While the promise is compelling, it is also

important to consider unanticipated effects that may be

associated with EMR use. For instance, any additional point

of focus for the doctor or patient— even a paper chart—can

be distracting. It is also possible that patients find

medical encounters involving a computer less personal or

 16

fear that their confidentiality could more easily be

broached when the record is entered in a computer database.

Similarly, physicians may worry about the need to attend to

the computer rather than the patient or may find the

challenge of adapting to the new technology daunting.

Despite these concerns, empirical studies that have focused

mainly on perceptions of the medical encounter have shown

little or no adverse effect on either patient or physician

satisfaction. In fact, some patients report that having

their physicians use an EMR enhanced satisfaction with the

clinical encounter.

This study presents a focused report about

communication patterns associated with using either an

electronic or paper-based medical record in a sample of

outpatient encounters. Although some of the communication

behaviors of the EMR physicians may be a function of EMR

use, others probably reflect styles established before they

began using the EMR. It would be worth studying whether

coupling education on patient-centered communication with

EMR training would enhance the effective use of this tool.

Further communication research that extends our findings and

educational research that identifies productive training

methods will be needed to understand how to optimize the

 17

potential benefit of EMR systems for both patients and

providers.

([Link]
x.)

The Evolution of Electronic Medical Records

By: Edward H. Shortliffe, MD, PhD (1999)

No clinical computing topic is being given more

attention than that of electronic medical records. Health-

care organizations, finding that they do not have adequate

systems for answering questions crucial to strategic

planning and for remaining competitive with other provider

groups, are looking to information technologies for help.

Many institutions are developing integrated clinical

workstations, which provide a single point of entry for

access to patient-related, administrative, and research

information.

The use of electronic medical records offers many

advantages for carrying out clinical research. Most

obviously, it helps to eliminate the manual tasks of

extracting data from charts or filling out specialized

datasheets. The data needed for a study can be derived

directly from the electronic record, making research-data

 18

collection a byproduct of routine clinical record keeping.

But other advantages accrue as well. On the other hand,

there are at least four major issues that have consistently

constrained our efforts to build effective medical record

systems: (1) the need for standardized clinical terminology;

(2) concerns about data privacy, confidentiality, and

security; (3) challenges of data entry by physicians; and

(4) difficulties associated with the integration of record

systems with other information resources in the health care

setting.

The difficulty in automating medical records is best

appreciated if one analyzes the processes associated with

the creation and use of such records, rather than thinking

of the record as an object that can be moved around as

needed within an institution. For example, on the data input

side, the medical record requires the integration of

processes for data capture and for merging information from

diverse sources. In order to be useful, the record also must

provide facile mechanisms for displaying needed data, for

analyzing them, and for sharing them among different kinds

of individuals (including secondary users of the record who

are not involved in direct patient care). Thus the computer

based medical record is best viewed not as an object or a

product, but rather as a set of processes that an

 19

organization must put into place, supported by technology.

Implementing electronic records is inherently a process

automation and systems integration task, and thus systems

that function well in one environment often do not transfer

well to others in which institutional processes and

traditions may have evolved in different ways.

Physicians are "horizontal" users of information

technology. That is, rather than becoming "power users" of a

narrowly defined software package, they access a wide

variety of systems and resources. Thus routine use of

computers, and of electronic medical records, will be most

easily achieved if the computing environment offers

physicians a critical mass of services that are both

smoothly integrated and useful for essentially every patient

encounter.

([Link]
[Link].)

Extending Feature Usage: A Study of the Post-Adoption of

Electronic Medical Records

By: Norman Shaw & Sharm Manwani (2011).

The success of their EMR adoption and subsequent use is

the responsibility of OntarioMD, which is jointly owned by

the Ontario Medical Association (OMA) and the Ministry of

Health and Long-Term Care (OntarioMD, 2009). Through

 20

OntarioMD we sent out 1,800 e-mails with a request to

participate in a 30-minute interview. In order to guard the

privacy of the physicians, all e-mails were initially sent

by OntarioMD.

Several categories of benefits emerged from the

thematic analysis.

More Organized Information. Over 60 % of the

participants mentioned that they were able to provide

improved healthcare because the information about the

patient was more organized than the paper chart. Data is up

to date and diagnostic decisions are made more quickly based

on more complete information.

More Comprehensive Encounters. Over 35% of the

physicians stated that patient care was improved because the

EMR was able to function as a memory prompt for them. Some

physicians use templates in order to guide them through an

examination so that no important question or data is

forgotten. In addition, tests are scheduled on time due to

the prompts by reminders.

Patient Medications. Over 30% of the physicians stated

that the EMR’s capability to track all the medications that

the patient has taken increases the efficiency of

prescribing. It does take time at the implementation stage

to input the list of medications, but once entered, any

 21

renewal is one keystroke. The EMR also records the history

of patients’ adverse reactions to drugs guiding the

physician at the time of prescribing.

Patient Education. Over 30% of the physicians actively

share results as part of their program of patient education.

Charts can be reviewed with the patient comparing their

results to the ideal as noted in health guidelines. Patients

are shown flowcharts which can be printed for the patient to

take home and reference.

Legibility. Over 20% of the physicians commented on

legibility, stating that legible notes resulted in improved

patient care. Notes in the EMR are typed and legible. The

governing body of medicine also conducts peer reviews in

order to ensure that standards are maintained and improved.

Both the reviewer and the reviewed physician can easily read

the notes.

Managing Routine Tests. Reminders are an effective way

to ensure that routine tests are not missed. Physicians

believed that preventive care was improved when they were

prompted by a reminder during the patient encounter.

Reduction of prescription errors. Patient safety is

enhanced because prescriptions are legible for pharmacists

and drug doses are checked by the computer.

 22

More Efficient use of Clinical Resources. Patients can

be micromanaged and resources used more effectively. On an

individual basis, physicians can ask themselves ‘do I need

to see this patient?’ when responding to a phone call. Other

healthcare professions attached to the clinic, such as

dieticians, may be the right resource for follow-up.

Communication within the clinic is enhanced allowing for

more efficient use of all clinical resources with the

electronic record easily shared simultaneously by multiple

care providers.

Pro-active Patient Management. The search feature

within the EMR allows physicians to proactively manage their

patient population. They can find patients with a specific

condition and

schedule the desired next steps. For drug recalls, although

not frequent, the patient population can be searched and

patients contacted, which is just not possible with paper

records.

Summary. PU was a dominant factor. Physicians only

adopted those features that they perceived to be useful as

part of their everyday routine.

([Link]
article=124&context=ecis2011.)

International Symposium on Affective Science and Engineering

 23

By: Chau VO, Tru CAO, Nam DOAN, Son TU, Anh NGUYEN, Binh

NGUYEN, & Bao HO (2018)

Patient progress tracking is important to a doctor in a

treatment process. In order to have enough information about

a patient and the treatment made for the patient, a doctor

has to view a lot of medical data about symptoms, test

results, drugs and their dosages in a period of time. With

electronic medical records, it is convenient for the doctor

to view and search for any information he/she needs as

compared to paper medical records. It would be even better

if all the related electronic medical records over time of

each patient are visualized appropriately to support the

doctor in patient progress tracking. Therefore, our EMR

Visualization system is proposed as a web-based application

on tablet computers for visualizing all the related medical

data in an integrative manner. The system provides an

interactive visualization with accurate data at different

detail levels, quick access and convenience for a doctor to

keep track of the progress of each patient over time. Its

demonstration with the real data of gastroenterological

Vietnamese patients in Thong Nhat Hospital, Ho Chi Minh

City, Vietnam, has been conducted and showed that every

 24

interaction of a doctor can be accomplished in at most two

steps.

([Link]
E2018_1_14/_article/-char/ja/.)

An Electronic Medical Record System

By: Muhammad Sarfraz, Anwar A. Al-Hussainan, Farah Mohammad

& Hanouf Al-Azmi (2020)

To become more productive, faster, smart and accurate,

almost every major organization or industry has invested for

computerizing their day to day mechanisms. It has helped

easing and smoothing everyday life. Banking, shopping,

airline booking and ticketing are just few to name.

Otherwise, virtually all businesses are going online. Yet,

despite all these advancements in our society, there are a

large number of patients who are being dealt in a

traditional way. For example, they are given handwritten lab

tests, medication prescriptions, appointments and others.

Having electronic medical record (EMR) systems is a need of

the time. It will enormously help to transform the health

care system from a traditional paper-based mechanism to

automated online systems. It will help utilizing clinical

information in delivering higher quality in terms of

 25

accuracy, time, efficiency and care to the patients as well

as medical care staff. Having EMR systems has a high

probability to reduce the possibilities for errors which are

very evident in typical manual operations. It promotes human

friendly environment which improves communication of

information in the medical related activities.

([Link]
record- system/245721.)

Barriers to the acceptance of electronic medical records by

physicians from systematic review to taxonomy and
interventions.
By: Albert Boonstra & Manda Broekhuis (2010)

Electronic Medical Records (EMRs) are computerized

medical information systems that collect, store and display

patient information. They are a means to create legible and

organized recordings and to access clinical information

about individual patients. Further, EMRs are intended to

replace existing (often paper based) medical records which

are already familiar to practitioners. Patient records have

been stored in paper form for centuries and, over this

period of time, they have consumed increasing space and

notably delayed access to efficient medical care. In

contrast, EMRs store individual patient clinical information

 26

electronically and enable instant availability of this

information to all providers in the healthcare chain and so

should assist in providing coherent and consistent care.

([Link]
/1472-6963- 10-231.)

Use of electronic medical records and quality of patient

data: different reaction patterns of doctors and nurses to
the hospital organization
M.S. Lambooij and H.W. Drewes (2017)

As the implementation of Electronic Medical Records

(EMRs) in hospitals may be challenged by different responses

of different user groups, this paper examines the

differences between doctors and nurses in their response to

the implementation and use of EMRs in their hospital and how

this affects the perceived quality of the data in EMRs.

Doctors and nurses differ in their response to the

organizational factors (support of IT, HR and administrative

departments) considering the success of the implementation.

Nurses respond to culture while doctors do not. Doctors and

nurses agree that an EMR that is easier to work with and

better aligned with their work has more added value, but for

the doctors this is more pronounced. The doctors and nurses

perceive that the quality of the patient data is better when

 27

EMRs are easier to use and better aligned with their daily

routine.

([Link]
x.)

Patient satisfaction with the implementation of electronic

medical Records in the Western Region, Saudi Arabia.
By: R. M. Wali, R. M. Alqahtani, S. K. Alharazi, S. A.

Bukhari & S. M. Quqandi (2018)

Findings from this study demonstrated an overall

improvement in patient satisfaction due to the

implementation of EMR Compared to PMR. Similar findings have

been reported the participants experienced that the

physicians were more attentive during the medical

consultation, a finding also reported in the literature.

According to the participants, the physician explained the

reason for tests and management options and that there was

more time available to discuss various health topics.

Support for the statement is provided by a study conducted

in the USA, emphasizing that the physician and patient had

more time to discuss self-care topics and to explain health

issues and medication use. In addition, active listening by

the physician improved after implementing the EMR, and the

participants felt it was convenient to ask questions about

 28

their health status and concerns this can be due to less

time spent in writing and trying to fill the documents. A

qualitative study where physicians were observed during the

clinical consultation, indicated that the physicians were

abler to take an active role, such as encouraging questions

and explaining health topics, but less effective in terms of

exploring a patient-centered agenda, for example, the effect

of the health problem on the patient’s life, ideas and

concerns compared to PMR. A similar study conducted in

Kuwait to measure the level of satisfaction of PHC attendees

reported overall satisfaction with the services except for

two aspects, including explaining the medical procedure and

being able to choose the physician they prefer.

([Link]
75-020-1099-0)

Electronic Medical Records in Family Practice: The Time Is

Now
By: Steven M. Omstein, M D & Charleston, & South Carolina

(1997)

The advantages of electronic medical records compared

with traditional paper records have been described

previously in this Journal and are well recognized by the

prestigious National Academy of Science Institute of

 29

Medicine. In a 1991 report, the Institute of Medicine called

for a national effort to develop a comprehensive computer-

based patient record system. Such a system would be a

distributed, longitudinal, information database with

features such as access to patient information across an

individual’s life span, comprehensive decision-making

support, flexible reporting, a defined vocabulary and coding

system, and transparent connectivity with other systems. At

present, work is ongoing in many academic settings,

government agencies, industrial settings, and coordinating

groups such as the Computer-Based Patient Record Institute

(Schaumburg, 111) to realize this vision, which remains

years away.

Of more practical interest to the practicing family

physician are four recent developments. First, there is

increasing empirical evidence of the clinical value of EMR

systems. Second, despite an occasional contrary report, many

case studies describe the successful application of EMR

systems. The reports are from a broad spectrum of practice

settings, including small private practice, an academic

family medicine center, and a health maintenance

organization. Third, several reports document the favorable

response that patients have to electronic records.

 30

Physicians need not fear that the doctor-patient

relationship will be adversely affected by EMR systems.

Finally, tire marketplace and our professional organization,

the American Academy of Family Physicians (AAFP), have

responded to the need for EMR systems. At the October 1996

AAFP national assembly in New Orleans, more than a dozen

vendors had exhibits showing their EMR systems, and a

computer “petting zoo” gave physicians hands-on experience

with several of these systems. In addition, 3 days of

computer lectures and demonstrations were offered, both in

small group hands-on and larger group formats. Prices for

computer hardware continue to plummet, and more software

vendors enter the EMR market monthly.

Despite these developments, it is widely accepted that

only 2% to 3% of office-based physicians and approximately

5% of family medicine residency programs use EMR systems.

Family physicians, practice managers, and group

administrators need additional exposure to these systems.

Several options are available for this purpose. First,

national and some statewide AAFP meetings have both

presentations and vendor displays of EMR systems. Second,

journals such as the AAFP’s Family Practice Management have

already published and plan to update reviews of available

 31

systems. Third, electronic resources are available. A

discussion group provides a lively discussion about EMR

systems and other computer applications in a practice

setting. Finally, some organizations that have successfully

implemented EMR systems provide opportunities for others to

learn from their experiences. Our department of family

medicine offers a monthly symposium, “The Computer-Based

Patient Record as a Continuous Quality Improvement Tool,”

for this purpose.

([Link]
[Link]/files/s3fs-public/jfp-archived-issues/1997-
volume_44-45/JFP_199701_v44_i1_electronic- medical-records-
[Link].)

The Implementation of the Electronic Medical Records System

in Health Care Facilities
By: Corey Bain (2015)

Electronic medical records (EMR) are seen as a way to

simplify the management of patient information, increase

productivity and lower costs associated with medical

information management. The implementation of the EMR system

in healthcare facilities has not only provided potential

benefits to improved quality of care, but there are

significant factors to consider associated with human

factors, ergonomics, workflows and environmental conditions.

 32

These factors should be considered to improve the quality

and cost of patient care, as well as employee and patient

safety. An ever changing healthcare system includes the

transformation of medical records management to electronic

medical records(EMR). EMR are seen as a way to simplify the

management of patient information, increase productivity and

lower costs associated with medical information management.

The integration of information management to healthcare

providers has enhanced the information that is made

available to physicians. It has also provided a competitive

advantage for organizations. The implementation of the EMR

system in healthcare facilities has not only provided

potential benefits to improved quality of care, but there

are significant factors to consider associated with human

factors, ergonomics, workflows and environmental conditions.

These factors should be considered to improve the quality

and cost of patient care, as well as employee and patient

safety.

(from[Link]
97891500548X.)