Implementation of electronic medical records in a rural healthcare setting

Background The United States health care system is arguably the world's largest but the most fragmented and inefficient. It is widely believed that adoption of electronic medical record (EMR) will help remedy the inefficiencies and lead to major health care savings, reduced medical errors and improved health outcomes. Funding was made available to promote adoption of EMR as part of the American Recovery and Reinvestment Act (AARA) of 2009 and the Patient Protection and Affordable Care Act (ACA) of 2010 and included a mandate for all practitioners to transition to EMR by 2014. Many health care agencies are scrambling to implement EMR in order to meet the deadline and avoid penalties. Rural providers face many barriers that cause them to trail behind their urban counterparts in transitioning to EMR. Those barriers include social differences, educational disparities and provider shortages.;Purpose The purpose of the capstone project was to assist and analyze the change process occurring in a rural health care outpatient clinic as it transitioned from paper charts to an EMR. The process was detailed using Keshavjee's framework consisting of three phases of EMR adoption: pre-implementation, implementation and post-implementation which are juxtaposed with the elements of people, process and technology.;Plan of Resolution and Outcomes The pre-implementation plan included many aspects of process mapping starting with the development of a project team. Hospital and clinic employees were assigned team membership by the hospital administrator according to the strengths and skills of personnel required to complete the project and included administrators, information technology (IT) personnel, vendor representatives and clinical personnel. A priorities list was assembled after conducting chart reviews and observing daily work flow. Provider input was important to facilitate favorable acceptance and was obtained through a series of surveys and interviews. Vendor selection was made with consideration of cost and functionality of the marketed software available. A medical chart template was designed to suit the needs of the agency after collection of data obtained during the chart reviews, observation of the daily work flow and collation of provider input collected in the surveys and interviews. Before implementation, a three day training schedule was developed so that employees were comfortable with the basic operations of the software system.;During the implementation phase problems such as increased documentation time, system shut-downs, provider irritability and dysfunction of the electronic prescribing capabilities caused a moderate amount of disorder during the initial two weeks. Many of the problems were remedied as proficiency with the system improved. Problems related to software issues required more time to solve by the IT personnel. The post-implementation phase was a period of evaluation. Providers and patients reactions to implementations were mixed. Some of the negative outcomes included provider complaints of increased delays in their schedules resulting in reduced time spent with patients. Patients were concerned the computers occupied the providers' attention during the office visits. Positive outcomes included improved legibility throughout the chart and the ability of the system to record complete and accurate information easily accessed. Comparison of health outcomes pre and post EMR implementation of a small group of diabetic patients found a slight improvement in glucose control and increased easily documentation of laboratory results and medication adjustments.;Conclusions and Recommendations Evaluation of the project indicated that EMR implementation is a multifaceted process influenced by many factors. The seeds of success sown in the pre-implementation phase included development of a project team, an organized priority list, provider input and a standardized training schedule. Although the implementation phase proved to be intense and frustrating for both staff and patients, it provided the opportunity for initial use of the system supported by vendor representatives and IT. The post-implementation phase of evaluation was limited to a short period, but improvements such as increased legibility and easily accessed patient information were able to be documented. Recommendations for the future include ongoing evaluation of patient outcomes, incorporation of evidence based practice guidelines into the software and maintenance of the current system continuing to upgrade as technological advancements become available.