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Electronic Health RecordsITCS 404: IT for Healthcare Services
Nawanan Theera-Ampornpunt, MD, PhDFaculty of Medicine Ramathibodi Hospital
Jan 18, 2012
http://www.slideshare.net/nawanan
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A Bit About Myself
2003 M.D. (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)
Health Informatician/Systems AnalystHealth Informatics DivisionFaculty of Medicine Ramathibodi HospitalMahidol [email protected]
Research interests:• Health IT applications in clinical settings (including
EHRs)• Health IT “adoption”• Health informatics education
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EHRs: Fundamentals
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What Is A Medical Record?
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What Is A Medical Record?
• A record or documentation of a patient’s medical history, examination, and treatments.
• Medical Record vs. Health Record– Essentially the same
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Class Exercise 1
• Why do we need a health record?
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Class Exercise 1
• Why do we need a health record?
• In other words, why do we need a documentation of a patient’s medical care?
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Potential Uses of Medical Records
• Continuity of providing care– Note important information for later use– Especially important in chronic diseases
(e.g. hypertension, diabetes) or in follow-up (e.g. after surgery)
• Patient safety– Preventing something bad because of lack of information– Such as drug allergies, list of current medications,
“problem list”
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Potential Uses of Medical Records
• Communications between providers– Referral to specialists or other physicians– Consulting among physicians– Communications between physicians and nurses,
pharmacists, physical therapists, etc.– Transfer from a hospital to another
• Medico-legal purposes– e.g. Court evidence against malpractice– What was done or provided to the patient? Why? By
whom? When?– Was the care provided up to the professional standard?
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Potential Uses of Medical Records
• Claims and reimbursements– What services were provided to the patient– How (and how much) will the hospitals/doctors be paid?– Audit of medical records by “payers”
• Patient’s uses– Health insurance claims– Self-education & self-care
• Clinical research– Find ways to improve health care through new knowledge
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Class Exercise 2
• What do you think should be in the medical records?
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Data Elements in Medical Records
• Patient demographics• General information about each visit (visit = encounter)
– Type (outpatient, inpatient, emergency)– Date/Time– Location (clinic or ward)
“Clinical Notes”• Patient’s problems (“Patient history”)
– Chief complaint– Present illness– Past history– Family and social history
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Data Elements in Medical Records
• Clinical findings by physicians (“Physical examination”)– Any important positive (usually abnormal) findings– Also important negative (usually normal) findings
• “Investigations”– Laboratory tests (blood tests, urine, etc.)– Radiological examinations (X-rays, CT, MRI, ultrasound)– Other diagnostic procedures
• Electrocardiography (EKG/ECG) -- heart’s function• Electroencephalography (EEG) -- brain wave scans• Etc.
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Data Elements in Medical Records
• “Problems” or “Diagnoses”– Summary of problems relevant to this visit
• Treatments– Medications– Surgical procedures– Advice to patients– Admission (hospitalization)
• Plans– Surgeries– More investigations to be done later– Follow-up appointments
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Data Elements in Medical Records
• Inpatient clinical notes– Admission notes– Orders (medications, procedures, investigations, nursing
care, etc.)– Medication administration records– Vital signs and other measurements– Results of lab tests and radiological examinations– Progress notes– Discharge summary
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“Electronic” Medical Records
• Electronic Medical Records (EMRs) vs. Electronic Health Records (EHRs)
• Debate about similarities & differences• Summary
– Definitions subjective, depending on how people think– EMRs mostly refer to electronic documentation of
medical care at one visit– EHRs mostly refer to electronic documentation that is
longitudinal in nature (may be several visits)– EMRs commonly used in Thailand (but means the same
as EHRs)
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Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
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Still Many Other Forms of Health IT
m-Health
Health Information Exchange (HIE)
Biosurveillance
Information RetrievalTelemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
Personal Health Records (PHRs)
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Longitudinal Records
• Records documented over time (multiple encounters)• Ideally, “life-long” is a complete record of the patient’s health
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Electronic Medical Records (EMRs)
Computer-Based Patient Records
(CPRs)
Electronic Patient Records (EPRs)Electronic Health
Records (EHRs)Personal Health Records (PHRs)
The Confusing Acronyms
Hospital Information
Systems (HIS)
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Benefits of EHRs and EHR Adoption
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Innovation Adoption
• Innovation: “an idea, practice, or object that is perceived as new by an individual or other unit of adoption”– EHRs and health IT are innovation
• Adoption: “a decision to make full use of an innovation as the best course of action available”
• Diffusion of innovations theory (Rogers, 2003)
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Class Exercise 3
• Why do we need to “adopt” an electronic version of medical records?
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“Computerize”“Go paperless”
“Digital Hospital”
“Modernize”
“Get an electronic copy
“Have EMRs”
“Share data”
Common “Goals” for EHRs/Health IT Adoption
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Is There A Role for Health IT?
(IOM, 2000)
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Landmark IOM Reports
(IOM, 2001)(IOM, 2000)
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Landmark IOM Reports: Summary
• Humans are not perfect and are bound to make errors
• Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality
• Recommends reform that would change how health care works and how technology innovations can help improve quality/safety
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Why We Need Health IT
• Health care is very complex (and inefficient)• Health care is information-rich• Quality of care depends on timely availability &
quality of information• Clinical knowledge body is too large• Short time during a visit• Practice guidelines are put “on-the-shelf”• “To err is human”
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To Err Is Human
• Perception errors
Image Source: interaction-dynamics.com
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Image Source: aafp.org
To Err Is Human
• Lack of Attention
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The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
Class Exercise 3
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The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
Class Exercise 3
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• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
(Ariely, 2008)
16084
The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
6832
# of People
# of People
To Err Is Human
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What If This Happens in Healthcare?
• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)
• What if health IT can help?
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Fundamental Theorem of Informatics
(Friedman, 2009)(Friedman, 2009)
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Underlying Assumption
Adoption of EHRs
Use of EHRs
Better Outcomes
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Underlying Assumption
Individual Adoption & use
• Better clinical outcomes• Improved patient satisfaction• More provider productivity/satisfaction
Organizational Adoption & Use
• Improved operational efficiency• Better data for research, quality improvements• Reduced costs/increased revenues (e.g. better
claims & reimbursements)
Societal Adoption & Use
• Better individual health/quality of life• Better population health• Long-term cost savings
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Benefits of Going Electronic (EHRs)
• Ubiquitous availability (anytime, anywhere, everyone who is authorized)
• Multiple concurrent uses• The end of “Where the heck is the patient’s record?!?”• Ability to control & enforce access security• Structured data entry possible• Data presentation that is easier to understand (e.g. graphs)• Efficiency in data entry? (but sometimes it slows users
down!)• Process improvement (business process
reengineering/redesign, quality improvement)
• No doctor’s handwriting!!!!!
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• Are they just electronic documentation?
• Or do they have some other values?
Diag-nosis
History & PE
Treat-ments ...
Electronic Health Record (EHR) Systems
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• Literature suggests improvement in health care through
– Guideline adherence– Better documentation– Practitioner decision making or process of care – Medication safety– Patient surveillance & monitoring– Patient education/reminder– Cost savings and better financial performance
Literature Shows Benefits of Health IT
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• Patient Demographics• Physician Notes• Computerized Medication Order Entry• Computerized Laboratory Order Entry• Computerized Laboratory Results• Problem Lists• Medication Lists• Discharge Summaries• Diagnostic Test Results• Radiologic Reports
Functions That Should be Part of EHR Systems
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Adoption of Health IT: United States
18.2 17.3 17.3 20.823.9 29.2 34.8 42.0
48.3 50.7
9.3 10.5 11.816.9 21.8
24.9
0
10
20
30
40
50
60
70
80
90
100
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
% o
f Phy
sici
ans
Year of Study
Any EHR EHR with Basic Features
Source: National Ambulatory Medical Care Survey (NAMCS) 2001-2010
U.S. Ambulatory Setting
Basic Features: Demographics, problem lists, clinical notes, test results, imaging results, order entry for medications
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2008 2009– Basic EHRs 7.2% 9.2%
– Comprehensive EHRs 1.5% 2.7%
– Computerized 17% 34%Order Entry for Medications
Adoption of Health IT: United States
U.S. Inpatient Setting
Sources: Jha et al., 2009 & 2010
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Definitions for Adoption RatesFunctions Jha et al.
Basic EHR Comprehensive EHRDemographics Physicians’ notes Nursing assessments Problem lists Medication lists Discharge summaries Advanced directives Test and imaging resultsLaboratory reports Radiologic reports Radiologic images Diagnostic-test results Diagnostic-test images Consultant reports Computerized provider-order entryLaboratory tests Radiologic tests Medications Consultation requests Nursing orders Decision supportClinical guidelines Clinical reminders Drug-allergy alerts Drug-drug-interaction alerts Drug-laboratory interaction alerts Drug-dose support
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EHR Adoption: Thailand (2011)
Estimate (Partial or Complete Adoption)
Nationwide
Basic EHR, combined inpatient & outpatient settings
49.8%
Comprehensive EHR, combined 5.3%order entry of medications, combined 90.2%order entry of all orders, combined 79.4%
Basic EHR: a score > 1 in a 5-point scale for IT support for demographics, MD notes, nursing assessments (inpatient only), discharge summaries (inpatient only), test results, order entry for medications
Comprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, order entry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts
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EHR/HIS Adoption in Thailand (2004)
Pongpirul et al., 2004
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EHR/HIS Adoption in Thailand (2011)
HOSxP50%
Self-developed or outsourced16%
Hospital OS7%
SSB4%
Mit-Net2%
MRecord2%
H.I.M. Professional2%
MedTrak/TrakCare
2%
HoMC2%
None 2% THIADES2% HIMS
1%
Abstract ePHIS1%
Other7%
Theera-Ampornpunt, 2011 [Dissertation]
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EHRs: Implementation Issues
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EHR Systems/HIS: Issues
• Functionality & workflow considerations• Structure & format of data entry
– Free text vs structured data forms– Usability– Use of standards & vocabularies (e.g. ICD-10, SNOMED CT)– Templates (e.g. standard narratives, order sets)– Level of customization per hospital, specialty, location, group, clinician– Reduced clinical value due to over-documentation (e.g. medico-legal, quality
accreditation)– “Copy & Paste” garbage– Special documents (e.g. operative notes, anesthetic notes)– Integration with paper systems (e.g. scanned records, legal documents)
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• Reliability & contingency/business continuity planning
• Roll-out strategies & change management• Are they going to slow down patient care
process?• System Interfaces
EHR Systems/HIS: Issues
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Class Exercise 4
• What do you think is better for EHRs: structured or unstructured data?
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Increasing EHR Adoption
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Facilitators of EHR Adoption
Jha et al. (2009)
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Barriers to EHR Adoption
Jha et al. (2009)
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• “Workarounds”
EHR Adoption Barriers(Why People Don’t Use EHRs?)
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• Technical & design issues– Poor software implementation
• Does not meet requirements• Buggy
– Poor usability and user experience• Complex/clunky UI• Easy to make error or miss something
– Poor system performance• Slow• Unreliable
EHR Adoption Barriers(Why People Don’t Use EHRs?)
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• Management issues– Does not seem to improve their work process– Too much work entering data– Unclear values to users (or even negative outcomes!)
• “Unintended consequences” of using health IT– Executives not fully supporting the project– “Power shift” among users– Communications and engagement (involvement) of users
early and repeatedly during various phases of the project– Poor training and technical support– Users perceived they are treated poorly or their voices are
not heard
EHR Adoption Barriers(Why People Don’t Use EHRs?)
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The Importance of “Change Management”
“One of the most important lessons learned to date is that the complexity of human change management may be easily underestimated”
Langberg ML (2003) in “Challenges to implementing CPOE: a case study of a work in progress at Cedars-Sinai”
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Public Policy on EHR Adoption
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Political Support Behind Health IT
“...We will make wider use of electronic records and other health information technology, to help control costs and
reduce dangerous medical errors.”
Source: Wikisource.org Image Source: Wikipedia.org
President George W. BushSixth State of the Union Address
January 31, 2006
?
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President Obama Backs Health IT
“...Our recovery plan will invest in electronic health records and new technology
that will reduce errors, bring down costs, ensure privacy, and save lives.”
President Barack ObamaAddress to Joint Session of Congress
February 24, 2009
Source: WhiteHouse.gov
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American Recovery & Reinvestment Act
• Contains HITECH Act(Health Information Technology for Economic and Clinical Health Act)
• ~ 20 billion dollars for Health IT investments
• Incentives & penalties for providers
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National Leadership (U.S.)
Office of the National Coordinator for Health Information Technology (ONC -- formerly ONCHIT)
David Blumenthal, MD, MPPNational Coordinator for Health Information Technology (2009 - 2011)
Photos courtesy of U.S. Department of Health & Human Services
Farzad Mostashari, MD, ScMNational Coordinator for Health Information Technology (2011 - Present)
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What is in HITECH Act?
Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):382-5.
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“Meaningful Use”
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“Meaningful Use”
“Meaningful Use” of a PumpkinPumpkin
Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
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“Meaningful Use” of Health IT
Stage 1- Electronic capture of health information- Information sharing- Data reporting
Stage 2
Use of EHRs to improve processes of care
Stage 3
Use of EHRs to improve outcomes
Better Health
(Blumenthal D, 2010)
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• Electronic capture of information– Demographics– Vital signs– Medication list– Allergies– Problem list– Smoking
• Medication order entry• Drug-allergy & drug-drug interaction checks• Patient access to/copy of health information
Meaningful Use Final Rule: Core Objectives (Selected)
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• Drug formulary checks• Lab results incorporation into EHRs• Generate lists of patients by specific conditions• Medication reconciliation• Electronic reporting to governmental agencies• Advanced directives for elderly patients• Patient reminders for certain services (for clinics)• Patient access to health information (for clinics)
Meaningful Use Final Rule: Menu Set (Selected)
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• Content Exchange Standards– HL7 CDA Release 2 & CCD– NCPDP SCRIPT
• Vocabularies– SNOMED CT– LOINC®
– RxNorm ®
• Security– NIST-certified encryption algorithms
• Etc.
Final Rule on Standards & Certification Criteria (Selected)
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Personal Health Records (PHRs)
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Personal Health Records (PHRs)
• “An electronic application through which individuals can access, manage and share their health information, and that of others for whom they are authorized, in a private, secure, and confidential environment.” (MarkleFoundation, 2003)
• “A PHR includes health information managed by the individual... This can be contrasted with the clinician’s record of patient encounter–related information [a paperchart or EHR], which is managed by the clinician and/or health care institution.” (Tang et al., 2006)
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Types of PHRs
• Patient portal from a provider’s EHRs (“tethered” PHRs)
• Online PHRs– Stand-alone– Can be integrated with EHRs from multiple providers
(unidirectional/bidirectional data sharing)
• Stand-alone PHRs– PC-based applications– USB Drive– CD-ROM or other data storage devices– Paper
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Ideal PHRs
• Integrated• Accessible• Secure• Comprehensive• Accurate & current• Patient able to
manage sharing & update information
• Engaging & educational
• User-friendly, culturally & literacy appropriate
The “Hub and Spoke” Model(Kaelber et al., 2008)
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Use Cases of PHRs
• Data entry/update by patients• Data retrieval by providers
– With patient’s consent
– “Break-the-glass” emergency access
• Data update from EHRs• Privacy settings• Personalized patient education• Communications with providers
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EHRs and the Bigger Picture
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Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
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Google Flu Trends (Biosurveillance)
Source: Google.org/FluTrends
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• This is why we need standards!!!– Information exchange from one EHR system to
another needs standards– Seamless exchange of information would
improve quality, continuity, and efficiency of care
Implications
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• EHRs (or EMRs) are both– Electronic documentation of patient care and– a broad term for an information system used to
improve the process of patient care through better documentation and other care processes such as ordering medications, lab tests, or x-rays and viewing lab results and x-ray reports (among others)
Summary
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• It is important to focus both on the technical aspect of EHR implementation as well as the management aspect (such as change management)
• Otherwise, a well-designed system may not be used, and patient care is not improved
• Many countries are trying to improve the EHR“adoption rate”
• EHRs are just one piece of the big puzzle for the whole healthcare system
• PHRs are a separate, but related concept of EHRs
Summary
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Questions?