Electronic Medical Records
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Transcript of Electronic Medical Records
Electronic Medical Records and Handheld Computing by Physician Assistants
in Clinical Practice
An Applied Dissertation Submitted to the Fischler School of Education and Human
Services in Partial Fulfillment of the Requirements for the
Degree of Doctor of Education
Calvin R. Finley, Ed.D., PA-C
Assistant Professor
Physician Assistant Department
College of Allied Health and Nursing
Nova Southeastern University
Purpose of the Study
This applied dissertation was designed to assess the use of personal digital assistants (PDAs) in association with electronic medical records (EMRs) by physician assistants (PAs) in clinical practice.
The use of PDAs is becoming commonplace in the day-to-day activities of many individuals, including health care providers.
It is important to have an understanding of the dynamics involved in the diffusion of PDAs and EMRs into the day-to-day clinical practices of PAs and other health care providers.
Hypotheses
It can be assumed that the combined use of PDAs and EMRs help PAs to better manage the care of their patients through increased and easier access to key patient information.
This improved access would benefit the PA, as well as the patient
– access to critical patient data helps to improve patient care and diagnosis
– saves time for the PA
Resulting in – better informed clinical decisions – higher-quality care at lower costs
for the patient the medical facility
PAs who utilize a PDA in conjunction with an EMR application in their day-to-day clinical practice are most likely influenced by the practice setting
the adoption of an EMR system by the facility in which they practice
PAs who utilize a PDA in conjunction with an EMR application perceive a positive influence in the overall care provided to their patients
Purpose of the questionnaire – Determine how many PAs were using PDAs in their daily
clinical practice– How many were using PDAs in conjunction with EMRs– What were the factors that influenced the adoption of the
use of PDAs in conjunction with EMRs– Of those PAs using a PDA in conjunction with EMRs, what
was their perception of the way this diffusion of innovation changed their practice of medicine
A questionnaire was mailed to the members of the 2002, 2003, and 2004 graduating classes of the PA program of Nova Southeastern University
The questionnaires were mailed to a total of 229 graduates and responses were received from 122 (53%):– 38 from the class of 2002
– 38 from the class of 2003
– 45 from the class of 2004
– 1 graduation year left blank
Of the respondents, there were 72 PDA users– A total of 5 were using PDAs in conjunction with EMR
systems
This suggests that there remains a huge gap between early and late adopters of this innovation
An analysis of the data indicates that further studies are needed to explore the barriers to the adoption of the use of PDAs in conjunction with EMRs
Background
Past studies have shown that family practice residency programs are increasingly making use of handheld computers during residency training
– (Criswell & Parchman, 2002)
There is little evidence that PA programs are providing formal training in the use of PDAs
– Empirical evidence suggested that increasing numbers of PA students are utilizing PDAs during their training, especially during the clinical portion of their training
(Helopoulos, 2003; McCabe & McGehee, 2004; Schaller, 2001)
Rogers (2003) related that scholars of diffusion have found that individuals gain awareness knowledge through behavior that must be initiated, adding that the need for an innovation must usually precede awareness knowledge of the innovation.
The results of this study may lead to the development of guidelines that, when put into effect, would increase the effective use of PDAs in association with EMRs to meet the needs of clinicians and patients during the medical encounter.
If the research suggests that PDAs and EMRs are critical to providing greater efficiency and capabilities in the delivery of health care by PAs
– then it may be beneficial to ensure that PAs are properly prepared during their training to incorporate this technology into their clinical practice.
If the trend towards the diffusion of technology into the delivery of health care continues
– it would be prudent to prepare PAs to be proficient in the use of handheld technology to meet the real-world standards of performance in the health care arena.
Literature Review
Explore available data about use of PDAs by healthcare practitioners in association with EMRs
Limited studies on use of PDAs in clinical setting– Fewer studies on utilization of EMR systems– Virtually no studies on use of PDAs in conjunction with EMR
systems
Evolution of technology in the form of EMR systems in healthcare– How EMRs and handhelds can be combined to manage
patient information and provide support for clinical decisions and outcomes
Breakdown of Lit Review
Diffusion of Innovations [12]
Health Professionals and PDAs [4]
Health Professionals and EMRs [8]
Handheld and EMRs [5]
Innovation Diffusion Theories
The familiarity of an innovation and its compatibility with the existing environment and behavior
– Is strongly linked to its diffusion
The more an innovation can integrate and coexist with technologies and social patterns already in place
– The greater its prospects for adoption and diffusion
Summary of Literature Review
Widespread acceptance of use of PDAs by healthcare providers
– Especially among residents and medical students Main uses of handhelds by clinicians
– Reviewing electronic medical databases– Accessing online drug reference materials– Inputting electronic medical information
Summary of Lit Review
Adoption of EMRs is not as widespread– Problems of non-interoperability– High cost of implementation
Main impetus behind incorporation of handhelds and EMRs into deliver of healthcare
– Federal government – under the direction of President George W. Bush
Summary of Lit Review
Groundwork of this innovation diffusion
– Widespread adoption individually Use of the Internet Wireless technology Handheld technology
Instrument for Study
Divided into two major components– 1. Several sections of specific questions
If respondents are using PDAs and how they are using PDAs [47]
If respondents are using the PDA/EMR combination in their specific practice setting [28]
Determine the driving forces for implementation of PDA/EMR combination [3]
Survey Instrument
– Additional demographic information [10] Draw inferences about likelihood of use of a PDA
– Male or female
– Younger or older
– Practice size
Survey Instrument
– 2. Perception of benefits of using a PDA in conjunction with EMR
Four-point Likert scale
– “strongly agree” to “strongly disagree” Provided information showing the effects that the use of
PDA/EMR combination have on delivery of healthcare by PAs
Informal Review and Feedback
Dr. Cheryl Hill, a professor in the Physical Therapy Department of the College of Allied Health and Nursing
Dr. Patrick Hardigan, the director of the Health Professions Division’s Statistical Consulting Center
Mr. Chris Helopoulos, a physician assistant and operations director of Barry University PAs Program Expansion at St. Petersburg College
PA colleagues
Limitations and Delimitations
Limitations– Limited demographic view
South and central Florida– Members of most recent graduating classes
Delimitations– Subjects were required to be using a PDA
Otherwise, excluded from results and discussion– Limited to graduates of NSU PA program– Generalizing results to all graduates of NSU or to graduate
PAs nationwide might be problematic
Results
0
10
20
30
40
50
2002 2003 2004
Fre
quen
cy
0
10
20
30
40
50
60
70
80
90
100
Male Female
Fre
quen
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0
5
10
15
20
25
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35
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45
1 2 3 4 5
Fre
quen
cy
Figure 3. Number of respondents using PDAs in daily clinical practice. 1 = not using a PDAs in daily clinical practice; 2 = less than once a week; 3 = once a week; 4 = several days a week; and 5 = everyday.
Clinical Application Use of a PDA Only
Clinical Application Frequency
Access patient files from remote location 3
Access medically related Web sites 18
Electronically capture and store lab results 3
Electronically store scanned photos 4
Generate and print patient educational material 3
Generate recall lists and reminder notices 13
Access embedded clinical practice guidelines 5
Alert to drug-patient interactions or drug allergies 35
Alert to drug-drug interactions 42
Personal Application Use of a PDA Only
Personal Application Frequency
Education 56
Personal finances 8
Personal word processing 7
Personal or private scheduling 52
Electronic communications 10
Games 27
Coordination with Outlook 8
Do not use for personal activities 6
Clinical Application Use of a PDA in Conjunction With an EMR
Clinical Application Frequency
Access patient files from remote location 2
Electronically transfer patient files to other locations 2
Alert to drug-patient interactions or drug allergies 4
Alert to drug-drug interactions 4
Print prescriptions 2
Enter patient visit notes via keyboard 2
Benefits of Using a PDA in Conjunction With an EMR System
Clinical Skills Strongly Agree
Agree Disagree
Shares patient record information 2 2 0
Improves quality of patient care 3 2 0
Improves workflow efficiency 3 1 1
Improves patient safety 2 3 0
Provides access at remote locations 2 0 2
Facilitates clinical decision support 3 2 0
Improves clinical data capture 0 3 1
Improves patient satisfaction 2 2 1
Benefits of Using a PDA in Conjunction With an EMR System
Clinical Skills Strongly Agree
Agree Disagree
Improves efficiency of post-visit patient education
0 2 2
Provides better access to laboratory results
2 1 2
Provides better access to radiology results
0 2 2
Provides a more complete patient medical record
1 2 2
Saves time 3 1 1
Increases the number of patients that are seen
2 1 2
Benefits of PDA and EMR Integration on Clinical Skills
Clinical Skills Strongly Agree
Agree Disagree
Enhances your problem solving skills 3 2 0
Assists in logically organizing information
2 3 0
Assists in readily obtaining answers to complex patient management problems
2 2 1
Improves your treatment planning skills
3 0 2
Improves your patient communication skills
1 1 3
Changed the way in which you practice medicine
3 1 1
Results Summary
There is widespread use of PDAs by recent graduates of the PA program
– 59% of respondents reported routine use– Combined frequency use was relatively low
Five respondents report routine PDA/EMR use– Access-transfer patient files to-from remote location– Alert to drug-patient, drug-drug interactions– Print prescriptions– Enter patient visits notes via keyboard
Results Summary
General agreement among the 5 combined-use respondents– Benefited their deliver of health care
Improving quality of patient care Improving workflow efficiency Improving patient safety Improving patient satisfaction Facilitating clinical decision making skills
Discussion
Study supported findings of previous studies
– PDAs have gained wide acceptance by healthcare providers (Carroll & Christakis, 2004; Criswell & Parchman, 2002;
McLeod et al., 2003; Porn & Patrick, 2002)
– Acceptance of EMR applications remains slow among physicians
Sittig et al., 1999
– Despite the high interest in adoption of EMR (Lowes, 2002; Miller et al., 2004) , the diffusion into daily practices of health care providers lags behind adoption of handhelds
A survey by the Healthcare Financial Management Association (HFMA, 2006) found the most significant barriers to EHR adoption:
– Lack of national information standards and code sets (62%)
– Lack of available funding (59%)
– Concern about physician usage (51%)
– Lack of interoperability (50%)
There is a large disconnect between the number of PAs that use a PDA on a regular basis (59%) and those that use PDA/EMR (6.9%)
Use of PDA/EMR lags way behind adoption of either technology, when compared individually
– PDA use = 59%
– EMR use = 20%
– PDA/EMR use = 6.9%
The challenge is to decrease the gap between those who use the PDA alone and those who use the PDA/EMR combination
Rao (2002) and Criswell and Parchman (2001) noted that medical residents-in-training were the agents of change for integrating PDAs into clinical practices
This is a great opportunity for PAs to become the agents of change to incorporate the PDA/EMR concept into the medical settings in which they provide healthcare
Summary - Conclusion
The use of PDAs by PAs and other health care providers is widespread
The impetus to go digital with health care records is strong
There is an urgency to adopt interoperable EHRs to reduce medical errors and cut health care costs through increased efficiency
– With the goal of improving medical care to patients
Many questions remain to be researched concerning the level of involvement of PAs in the diffusion of this technology partnership of PDAs and EMRs
Future studies should survey a broader group of PAs across the nation to get a better idea of PDA/EMR use among PAs
Investigate the role of the PA as change agent in the implementation of the use of PDA/EMR in the delivery of health care in the U.S.
HFMA, 2006– Universal implementation of EHRs will produce a
profound societal return---improving care and reducing costs . . . Enhanced quality and patient safety through improved continuity of care and clinical decision making, reduced clerical and administrative costs, and more effective use of health services. (p. 13)
With a large percentage of PAs and other health care providers using PDAs and a greater emphasis on the implementation of EMRs by organizations that provide health care:
– The integration of PDAs and EMRs should be given a higher priority for the overall success of the diffusion of these innovations into the health care delivery system
– Future studies should concentrate on isolating the major factors that influence the adoption of PDA use in conjunction with EMRs, so that efforts to support the positive factors and remove barriers can be more focused
– Unless there is a concerted effort on a national level to negate the barriers to PDA/EMR integration, we may have to give a new meaning to the term “digital divide”