Abstract of Dissertation

Keyword : XEMR Software; Medical Record; Outpatient Medical Records; Electronic Medical Record Adoption Model

Objective : • To Study the compliance requirements of Outpatient Electronic Medical Record in Eight stages • To Understand an EMR Software resonating with Outpatient EMR Adoption model stages • To Assess the existing O EMRAM stage of X Hospital and provide suggestion for up gradation from existing stage

Background : Historically in United States healthcare, documentation of the patient records are generally paper based. Paper records are also not capable that they do not qualify for the checks of decision tools, as they are kept in inaccessible formats. Eventually the information pertaining to patient health care diagnostics and treatment raised an issue of confidentiality in many developed countries like United States, Canada etc. Paper based records were found to impede the provision of clinical decision support for the Doctor. Later to compensate, the concept of Health Information System came and transitioned to Electronic Medical Record. Healthcare Information and Management Systems Society (HIMSS) founded in 1961 as the Hospital Management Systems Society, headquartered in Chicago, Illinois. HIMSS is a non-profit organization deliberately dedicated to improve quality,safety, cost-effectiveness in healthcare. It also helps in providing access through the best use of information technology and management systems. Electronic Medical Records (EMR) EMR means where the patient data and the health information is compiled and exchanged in the digital format. Through connected networks, enterprise –wide information systems or other third-party exchange networks the records are shared across different healthcare settings. EMRs may include a range of data, such as demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information. It helps in reducing the risk of data replication and eliminates redundant data reduces, as there is only one modifiable file, which means the file is more likely up to date and decreases the risk of lost paperwork. Outpatient Electronic Medical Records Adoption Model (EMRAM) Outpatient Electronic Medical Record Adoption Model (O-EMRAM) sets a benchmark in establishing methodology and algorithms to grade clinics on the maturity of their EMR environments. This eight-stage (0-7) model is for clinics where there is an encounter between a caregiver and a patient, and the caregiver has licensed access to diagnose, treat, prescribe and generate orders and documentation. The O-EMRAM tests for clinician documentation, including orders, e-prescribing, patient engagement and population health analytics. It helps in moving the outpatient setting closer to achieve a near paperless environment through technology use that improves patient care by compliant to each stage of OEMRAM model.

Methodology : Study Design: • For the first objective, the study design is Qualitative systematic review as review of literature is done for studying the requirements for eight-stage OEMRAM model through the internet and research articles. • For the second objective, the intern used the checklist to match the system inside the facility. • For third objective cross-sectional study design, as the respondents are not present only the checklist is made out of a systematic review of reports and matched with the existing EMR software operating in the study area at one go. Sampling technique: Purposive sampling for objective three, mapping done from the checklist to match the Clinic in location A. Inclusion: Standalone Clinics for one specialty which practice the studied Electronic Medical Record Software • 500 bedded Hospital. • Average Outpatient visit/Day in a clinic should be 50 patients. • Studied specialty is family Medicine as a clinic. Exclusion: • Facilities, which uses two or three types of EMR for their outpatient services. • Specialty in clinics other than Family Medicine for the Outpatient setting. The method of data collection: Reviewing secondary data, of the facilities from the EMR software with the checklist made Data collection tool: Checklist based on prerequisites required in Outpatient EMR adoption Model for certification. Study duration: One month (March 2017-April 2017)

Findings : The study helps in providing an orientation for the healthcare providers with respect to the Outpatient EMR Adoption Model and focuses on adoption and implementation of the EMR model through meaningful use. The study will also emphasize on the established benchmarks set by the EMR adoption Model for a comparison by the healthcare providers to achieve better outcomes.