Advantages, Disadvantages: Electronic Record Systems

In the recent past there has been a significant emphasis for the need to implement Electronic Medical Record systems. However, the benefits and shortcomings of these systems need to be evaluated (Amenwert et al. 2004) and a sufficient evidence base gathered using a well structured scientific approach to justify the change and measure the organizational impact (Wager et al. 2000).

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This essay will address the benefits and challenges of implementing Electronic Record Systems. It will look at applications of these systems in different care settings located in different environments so as to provide a broader view of some of the issues. The roles of the various stakeholders as well as the benefits and challenges they derive from electronic health records will be outlined and a detailed evaluation of paper records and electronic records will be done. Conclusions will then be made based on this analysis.
BACKGROUND
In context of health care, electronic record systems can be defined as any structured record keeping system, specifically designed to support users by providing context specific information which is electronically accessible, relevant, easily transferable, accurate and complete. These records will usually hold information regarding patients care histories, non specific clinical data, medical knowledge or other health care centered information. (Coiera 2003)
As the scope is very broad and Electronic Health Records (EHR) has not been well defined (Hayrinen et al. 2008a), the definition used was limited to EHR and allied systems such as Picture Archiving Systems (PACS), Pharmacy Management Systems, Computer Physician Order Entry (CPOE) amongst other systems used day to day in a clinical setting. These areas are well documented and evidence easily obtainable (Clamp & Keen 2005)
Role of electronic records and patient Information in population based care
A study carried out by Qresearch utilized electronic records extensively with an aim to report on population trends and disease risk factors. The analysis covered a 5 year period and was able to establish that in the UK, London had the highest percentage of patients recorded as being smokers at 25% and the lowest in the South East and South West at 20%. It also established that majority of the smokers ranged from 25-34 years of age across all regions. (Qresearch- NHS 2008). The information obtained provided a platform for decision making to determine the interventions to be undertaken, where resources should be focused and to whom it should target. This kind of data mining is only possible when data is electronically stored (Bocij and chaffey, 2005) as paper records suffer from massive fragmentation (Dick et al. 1997) making it difficult to bring all the data for analysis. It has also been established that manual methods would be ineffective to deal with such large data sets and the multi dimensional analysis required (Fayyad 1996). The ability to perform such operations is a strong argument for electronic record adoption in decision support and knowledge discovery for population based interventions (Kraft et al. 2002).
Furthermore, electronic records encourage consistent recording of clinical information and this becomes a key component when aggregating individual records to form datasets. Use of clinical codes allows relevant data to be derived from these unified datasets enabling reliable analysis across different sites. This in effect is key in providing specific information for health research as well as in public health planning (Ambinder 2005)
Keeping in line with Pawsons model for context specific evaluation the literature was reviewed by looking at studies done in various sites represented on table 1 and later highlighting advantages and disadvantages to various stakeholders identified.
General practitioners
General practitioners are the initial point of contact between clinicians and patients, they play a pivotal role in ensuring that a patient�s Electronic record is accurate, complete and current (Dick et al. 1997). As direct users of Electronic records, GPs benefit from the linkage of these record systems to other systems such as PACS or CPOE. Requests for ancillary care services can be done at a click of a button and results for tests can be accessed immediately they become available. This in effect enhances the completeness of patient records as they are updated in real time (Ambinder 2005) reducing the GPs administrative load as well as accurately populating records for future encounters (Wager et al. 2000). Additionally, GPs are able to view different aspects of a patients care at a glance, preventing duplication in testing or medication and reducing costs (Jones et al. 2008). Attention can also be drawn to areas that require GPs action through medical alerts thereby guiding the clinician in the disbursement of care (Coiera 2003). In effect, this increases the efficiency of the GP and a study done in the Veterans Association has shown electronic records has allowed patients information to be available 100% of the time as opposed to 60% of the time reducing the amount of sessions required to resolve patient issues (Wilson 2009) this, as well as enhance patient safety through, for instance, reduced prescription errors (Kaushal et al. 2001)
Unfortunately, there is a substantial learning curve and clinicians require training to use these systems (Anderson 2007). GPs may spend substantial amounts of time inputting and retrieving data from these systems at the expense of interacting with their patients (Poissant et al. 2005). As information grows exponentially there is also a fear of clinicians becoming overwhelmed due to the explosion of information (Berner 2005) and the paradigm shift in culture also presents opportunities for resistance to change (Hendy 2005). System usability is also a major concern when dealing with electronic records. Young (2006) argues that this has been a major deterrent to widespread adoption of these systems.
Patients and their carers
In the UK, The NHS care record service is responsible for holding Electronic records for all UK citizens centrally (NHS 2008a). There is policy in place that will see all patients� summary records being held nationally and detailed records held locally within the various GP practices (NHS 2008a). This in effect will lighten the burden to the patients and their carers of having to remember the list of drugs, allergies or adverse reactions they may have encountered in the past (Jones et al. 2008).This will reduce the risk from adverse events and near misses that can occur from wrong administration of medication through prescription errors and increase the amount of confidence patients will have on their clinicians (Jones et al. 2008). Furthermore, In the UK, Patients will also be able to view their own summary care records via health space (Greenhalgh et al. 2010) and ensure their records are complete and accurate leading to better patient outcomes (Waegemann et al. 2002). Additionally, in emergencies, where GPs may not be readily available, rapid access to the patient�s medical history can reduce the time taken to provide critical care (Potts et al. 2004) Ultimately, the main benefit to patients will be increased quality of care and patient safety through increased choice in their care options (Eysenbach & Jadad 2001). This will largely be due to portability of these records across different care functions allowing for access by a variety of clinicians.
Unlike paper records, electronic records are easily and readily accessible due to the interconnection of systems through networks making them vulnerable to unauthorized access (Berner 2005) This brings a set of legal challenges as to who has access to this information (Delpierre 2004). Under the UK data protection act of 1997 and the privacy act of 1974 in the USA, data about patients is protected by law (Koeller 2002). However, with records widely distributed and at times held by third parties adequate legislation needs to be put in place and security measures such as firewalls and audit trails need to be implemented to protect this data. This raises complexities in implementation as well as expands cost (Koeller 2002)
Health service teams and clinicians
Health service teams such as pharmacists alongside other health care professional benefit immensely when records are easily shareable and quickly available (Wager et al. 2000) This is information can be used to reconcile medication lists as well as provide key information to multi disciplinary health professionals in a secondary care setting where information is fragmented and spread across different care pathways (Miller & Sim 2004). This will reduce clinical risk as well as save time and associated costs (Koeller 2002). Furthermore, the problem inherent in paper records of ineligible notes becomes nonexistent (Schloefell et al. 2001). Coding systems in electronic records also avoids incidents of ambiguity that may be present in free text during care episodes (Dick et al. 1997).
On the other hand, there is currently no universal standard for indexing and coding clinical information (Schloefell et al. 2001) this in effect is a challenge to health teams who may have difficulty in accessing patients data across different system platforms (Schloefell et al. 2001)The lack of unanimity in creating uniform standards leads to interoperability across physicians systems, hospitals and pharmacies (Wilson 2009). This limits the amount of choices available to patients and adds unnecessary difficulty to health teams when such incidences occur.
Health providers, and allied organizations
In the UK health providers such as health trusts and Strategic Health Authorities derive their benefits as a result of benefits derived from patients and health care teams (Jones et al. 2008). Other gains are made from quantifying resources not utilized as a result of implementing EHRs (Byrne et al. 2010) these benefits accrue and are reflected as cost savings to these authorities. Funds realized as a result of these savings allow for better planning on both macro and micro levels with resources efficiently allocated to interventions that have greater impact on the populace (Jones et al. 2008). Furthermore, organizations concerned in medical research benefit immensely when records are electronically stored. The nature of the record allows for data to be easily derived for specific research purposes for learning and for use by other allied institutions with minimal overhead (Mathers et al. 2009).
Alternatively, the cost, size and complexity of implementing these systems are prohibitive (Hendy 2005). Many health providers such as the NHS in the UK meet many of these costs. According to the Donabedian perspective, the inputs required in setting up a working electronic record system are both time and cost intensive (Koeller 2002). Infrastructure in terms of hardware and software, expertise, training and associated costs are high especially when these are scaled to a national level (Cressman et al. 2006). In the UK 105BN pounds has been allocated to the NHS for 2010/2011 fiscal year (DoH 2010) and $19BN has been allocated for the year 2011 to promote the adoption of EHR in the USA (Wilson 2009). This however is seen to be inadequate and further investments needs to be done.
Comparison of Electronic and paper records
physical and described as being material objects with concrete locations, attachments and marking (Bearman 1996). Data is usually handwritten and takes the forms of Narrative text in most instances forms can also be used to insert data. Data entry lacks validation and prone to errors.
Conclusions
The literature reviewed provides evidence that supports adoption of electronic health records. An analysis of the literature as represented on table 1 showed good evidence indicating improvement of patient safety and increase in efficiency of clinical staff as a result of implementing EHR. Evidence showing an increase in information quality was mainly qualitative and cost benefit analysis was scarce and hard to find. Future benefits and cost savings were predictive at best and were mostly attached to reduction in risk to patients and the assumed calculation of costs savings associated with this.
Hayrinen et al. (2008b) stated electronic health systems are as yet not properly defined and methods to evaluate these systems are still not well developed as a result. This in effect raises major concerns, the first being the sustainability of these systems over the long term, the safety of the patients and the quality of information provided (Coiera 2009). As we move forward, systems are becoming larger and more complex and the cost to benefits have major implications to the national GDP of most countries implementing a nationwide health strategy. It is in this respect that the top down approach adopted by the NHS has been favored to the bottom up approach or sporadic approaches in other parts of the world (Cressman et al. 2006). This approach aims to reduce incompatibility in data reconciliation across systems which not only hinders the continuity of patient care but also makes deriving data in a coordinated and timely manner for use in public health highly complex. However, both systems are challenged and other arguments have been made that favor a middle out approach where local institutions drive the process but with oversight from governing bodies who set the standards and policy to guide it (Coiera 2009).
 

Electronic Health Record Benefits

The electronic health record is a mean of organizing patient’s data making use in the field of information technology. Its purpose is to fulfill the various needs for information not only of patients and healthcare providers but also of other beneficiaries. The implementation of electronic health record system in health care organization is very complex and involves many parameters.
Introduction
Electronic health record is currently used by 12% of the physicians and 11% of the hospitals nationwide. Industry and government have promoted Electronic health record as a means of controlling costs and improving patients care. The electronic health record has become one of president obama main agenda and the investment necessary to ensure that within the coming years, all of America’s medical records are computerized. Today with the advance of globalization the electronic health record is still highly unlikely to advance in the next five years, governmental, technical and industry advances are adopting, which will drive the electronic health record in the hands of medical providers. The electronic health record (E.H.R) is a digital record of patient health information generated by one or more encounters in any care delivery setting. It contains information of the patient includes demographics, problems, medications, vital signs, past medical history, laboratory data and radiology report .

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The electronic health record also promises the removal of many barriers in the medical field such as – saving lives, money, and time, but unfortunately the fulfillment of this promise in the real world application has remained with a big question mark due to many factors cost of implementation, privacy and security. The following graph is the result of survey experts at nearly 3000 group practice nationwide. The table below lists barriers to Electronic health record adoption.
well known factors such as security and cost are cited as key factors, but other factors which is usability is not mentioned frequent is another barrier to the electronic health record adoption.
Usability is a primary concern
Usability issues are also a factor why electronic health record implementation fails. In a survey paper primary care physicians were asked the reasons why they did not use the electronic health record system. From the research finding 35% of the physicians listed specific electronic health record usability issues, the most common were: Problems with the screen navigation, and the lack of functioning and the concern that the data will be lost.
Anecdotal support for usability and Electronic health record failure comes from Cedars- Sinai medical centre of Los Angeles. They developed a $ 34 million computerized physician order entry system, but only included the input of a few physicians before launching it hospital wide in 2002 without thorough training Physicians who previously used to take notes by hand now required going through nearly a dozen screens and responding through numerous alerts for even common orders. Traditional doctors around 400 of them demanded its removal within three months of its launch. Poor usability can also endanger patient’s health. The electronic health record should be modernized helping the clinician workflow. In the year 1991, the institute of medicine released a report supporting the idea of implementing the Electronic health record within the coming years. In 2010, researchers believe only a small portion of health providers both public and private implementing the system. The implementation of electronic health record provides answers to many barriers in the medical world.
Background
An electronic health record is a digital or electronic record of the patient health information gathered over the history of the patient’s interaction with the health care system. An electronic health record stores all information concerning the patient health statues. Information varies and includes the following age/sex, medications, and vital signs, past medical history, laboratory data and radiology report. The concept of a medical report goes back to the fifth century B.C developed by the Greek physician Hippocrates, also known as the Hippocratic Oath. Hippocrates described two main goals behind his findings 1- a medical record should accurately reflect the course of disease 2- a medical record should indicate the problem cause of the disease. In the present days, the electronic health record first began to appear in the 1960s. Reported that at least 73 hospitals began to use the electronic health record system. In 1991, the institute of medicine released a landmark report recommending the electronic health record be implemented in health system within 10 years. Almost 20 years later, according to the latest researchers only a small portion of health providers have implemented electronic health record. A Meta analysis of diffusion rates of the electronic health record in the United States shows that an uptake has slowed in recent years. The study concludes Electronic health record is the future. President Obama administration has the electronic health record as one of its primarily agenda ‘the investment necessary to ensure that within the next five years, all of Americas medical records are computerized’. While still with the advance of globalization the electronic health record is highly unlikely within the next five years, governmental, technical and industry advances are adopting, which will drive the electronic health record in the hands of medical providers. The electronic health record also promises the removal of many barriers in the medical field such as – saving lives, money, and time. The question is still debatable whether the whole world will move towards the implementation of the Electronic health record. The electronic health record is one of the most important electronic patient data collection of our time and with the expanding population of the world it has become a necessity to implement the system in all public and private hospitals. The G.C.C region
Literature review
The opinions concerning the positive effects an E.H.R can have on patient’s health and whether all the healthcares in the world should step in and implement the system. The collection of personal health data is described to have many formats when speaking of systems that manage it. Reduction of the storage necessary to keep paper charts is also a noted as a reason to leverage an E.H.R freeing up of space better used for revenue generation. Paper charts have their own risk associated with them in terms of getting lost, productivity impacts to maintain and retrieve paper records and the resulting negative patient care (Carpenter 2002). An electronic health record system is the collection of data that is central to the patient (Rishel, Handler &Edwards, 2005). These opinions agree the importance of the E.H.R and implementation of the system. An E.H.R system exists to facilitate the storage, revival and continuity of the record itself (Gans, Kralewski, Hammons & Does, 2005). These opinions also strongly agree with the improvisation of the Medical record with the advances with science and technology. reversing the scenario, an E.H.R system can collect and aggregate information from other sources such as laboratory, X-ray and unstructured data like faxes or handwritten notes ( Wojcik, 2006) the scholar Wojcik agrees strongly with the use of E.H.R talking about the positive of the E.H.R reduces the storage of handwritten notes and stacks and piles of paper. The near term presents providers with realizing the digitization of the boxes of paper that is generated by patient encounters. These paper databases represent the clinical data that is ultimately needed to take EMR systems to the next level. The near term presents providers with realizing the digitization of the boxes of paper that is generated by patient encounters. These paper databases represent the clinical data that is ultimately needed to take EMR systems to the next level. Clinical data is the baseline in which all healthcare processes subscribe including decision support, health outcome analysis, billing and claims processing and health maintenance. Correlation and access to this data is what EMR systems seek to facilitate (Handler & Hieb, 2007). Electronic health record systems, once materially implemented across the healthcare spectrum, will itself become the framework in which more overarching goals can be accomplished, such as the centralization of a person’s health history. With Clinical data as a basis, further utilization of EMR systems can occur. EMR systems, once materially implemented across the healthcare spectrum, will itself become the framework in which more overarching goals can be accomplished, such as the centralization of a person’s health history (Gartner. Currently, about 25 percent of U.S physicians are using systems that facilitate electronic health records (Murdock, 2007). E.H.R has become a primary concern in the medical world and the according to past literature review in this generation we find that it some of the scholars are concerned with the paper works as they say that the E.H.R will help save doctors a lot of time and makes the process more efficient. Some scholars say that paper based system is very negative as it leads to losing important patient data which might confuse the doctor in prescribing proper medication to the patient. There are differences of opinion but according to most scholars the E.H.R is a vital tool in solving many of the issues that both public and private hospitals face around the world
Questionnaire Results
The questionnaire focuses on the importance of the E.H.R system and its implementation in the United States of America at a nation wide level. With growing medical demands around the world
Hypothesis one results
Our research finding indicate that the U.S government is encouraging the country medical networks to start using the E.H.R
Hypothesis two results
Our research finding according to 430 surveyors say that 55.1 % of their medical practices use the Electronic health record system
Hypothesis three results
Our research finding shows that majority of the surveyors have a positive outlook that majority of the medical practices will start using the E.H.R between the next 1 to 2 years
Hypothesis four results
Our research finding shows that 41.8% of the surveyors believe that their medical providers will qualify for the Medicare and Medicaid programs
Hypothesis five results
Our research finding again shows a positive outlook of the near future as 65% of the surveyors say that their practices will qualify for the Medicare and Medicaid programs by the end of 2011
Hypothesis six results
Our research finding again shows that the U.S government financial incentive can upgrade the performance of E.H.R surveyors helped us with the conclusion that government financial backing to the Medicaid and Medicare programs can improve the medical performance in the near future
Hypothesis seven results
Our research finding states the importance of the U.S government testing the E.H.R program before purchasing them according to the surveyors 71% agreed the importance of testing the systems before implementing them nationwide
Hypothesis eight results
Our research finding concluded that most of the clinicians hire 1-5 physicians which is low according to the demands of medical needs of our current era
Case Study
Questions and answers regarding on implementing the electronic health record (Case Study).
The case study focuses on the systematic reviews and the effects of electronic health record system can have in the medical sector if implemented at nationwide level. In the G.C.C the electronic health record is still new and according to our case study taken from the united states we want to find whether implementing the electronic health record system will add value to the medical sector or not.
Will electronic health record improve patient’s health outcome?
In a review evidence results in two study cases came up with the following result
In 2004 a systematic review conducted 3 study cases that reported patient’s outcomes, no benefit was the conclusion
In 2008 an analytical survey of several U.S patients found very few data or no association between the use of electronic health records and the improvement of patient’s outcomes
In the end of the study there was no evidence linking between electronic health record with better patient outcomes
Will electronic health record improve the quality of care?
Evidence proves that the following result might occur on the electronic health record if implemented in practice
In 2004 a review of 26 studies analyzed several outcomes related to the quality of patient physician encounters and with the research it discovered a sharp incline in provision of preventing care
In 2006 a review on health information technologies and their impact on quality, efficiency and cost findings were: Increased adherence to guidelines based care, advanced surveillance and monitoring and a decline in medication errors
In 2007 a study of data from some community health centers over the course of one year concluded that while electronic health record related costs had not been recovered, the quality of care improved In 2008 a review on the advantages and costs of electronic patient Concluded that concerning the influence of EPRs on the quality of care The studies did not clearly identify a clear answer to the questions of Benefit
In 2009 a review of 7 countries experience implementing health information systems concluded that they had a neutral experience where neither benefit nor harm between the system implementation and quality of care
The conclusion of the study indicates that the electronic health record has a positive effect on the quality of care; however some of the reviews still find it neutral so the opinions of the doctors and physicians are still conflicting.
Will the Electronic health record be cost effective?
In 2003 cost benefit analysis on the electronic health record in primary care settings concludes that electronic health record can result in positive return on investment
In 2007 review on informatics system designed to improve care of chronic disease found that both cost effectiveness and adherence were significantly improved
In 2008 report on the United States budget office summarized evidence supporting the practice of health information technologies describes the benefits on cost saving as limited
In 2010 assessment on the quality of care resulting from hospital computerization concludes that currently implemented hospital computing might improve process measures of quality but not administrative or overall costs
The research cite modest cost benefit associated with electronic health record, however based on results for small trails or projections based on modeling: empirical evidence supporting the cost effectiveness on electronic health record remains limited or conflicting
Will the electronic health service save time and improve the efficiency of health services delivery?
In 2006 a review of quality measures on the use of electronic health records indicated that the lack of implementing health services has been demonstrated, but the author notes that the outcome is limited to a wider health service provider
A systematic review in the year 2008 analyzed six studies that addressed electronic health record with respect to consultation time, one study found the decrease in consultation time and the other found no difference
A 2008 report from the United States congressional budget office summarized evidence supporting the adoption of health information technologies described the evidence around efficiency as conflicting
In 2009 a review examined the impact on regional health information system and figured that, studies were of variable scope and quality improves the medical data access, timely information, and medical data exchange and improvement in communication and coordination within a region between health care professionals
While there are some evidence supporting an association between the electronic health record and efficiency, there is also evidence which does not support this conclusion
Will electronic health record improve physicians and patients satisfaction?
In 2004 a review found that results were mixed with both the patients and physicians expressing enthusiasm for electronic health record and on the other hand expressing significant concerns about the impact of their use on a variety of outcomes
A 2009 review of seven united based studies examined patient satisfaction with the electronic health record and figured that: one out of seven studies reported a positive effect on patient satisfaction, five out of seven studies reported a neutral effect and one out of seven studies reported a negative effect
Evidence on patients and physician satisfaction is scarce
An interview with Dr Michael Shuskho on the electronic health record
As a professional in your field how do you find the electronic health record system?
Michael: the E.H.R is an advanced system which is very useful for doctors especially in the current Era. It provides better patient care, and makes a permanent record that is legible that other doctors can review the system and also actually streamlines patient care
Will the electronic health record improve efficiency and reduce time
Michael: yes, the electronic health record is a valuable system to most of the doctors because it replaces the piles of paper and with a few click on your computer screen the doctor can view all the patients past medical record and send all the information to the other doctor within minutes
Is the electronic health record system better than the manual paper based system?
Michael: yes, the E.H.R is clearer and safer than the manual system provided that it is used carefully. Exg: a doctor can view patients X-Ray, picture of his electro cardio graph in a much clearer and digitalized form while in the paper based system the pages might wear or get old and by the time the picture of the X-Ray gets more aged, it makes it hard for the doctor to identify the exact diagnosis
Is it cheaper to implement an electronic health record?
Michael: The electronic health record system is expensive and the start up cost of the Medicaid and Medicare programs is high but in the long term it will eventually become cheaper for the clinics and hospitals to use them
What are the barriers that prevents the electronic health record system by being in practice at a larger scale
Michael: some doctors who aren’t familiar with updated technology and use practical manuals prefer not to implement the E.H.R in their clinics. Another barrier to the electronic health record is the upfront cost which is expensive and the some doctors find it hard adapting to the system
Dr. Michael one last question before we conclude our interview. In your personal opinion will the E.H.R be mandatory by 2015 in the U.S
Michael: I assume the probability that the electronic health record system might be mandatory in the U.S and the government might take actions in seeing that all the practices and clinics use the system
The implementation of the E.H.R IN Kuwait and Bahrain
Based on our research we have found that the electronic health record still needs to adapt at a global scale and the system is new to the G.C.C countries compared to the western countries such as United States, United Kingdom. Kuwait started using the E.H.R in 2005 in private and public clinics replacing the paper based system. According to the hypothesis questions and results in the U.S case studies it shows clearly that the E.H.R is on the way of improving and use the E.H.R rather than the traditional filing system. Bahrain is also taking a step further in implementing the system and the public and private clinics and with the help of the MGA methodology and the case study we have come with proposed solutions and the benefits that the kingdom of Bahrain and other G.C.C countries will achieve through the E.H.R
December 2010
The health ministry in Bahrain will launch its national e-files project early 2011. It will cost the ministry between BD 25 Million to BD 30 million. Files of patients at salmaniya Medical complex and health centers will be converted into e-files. The first phase will cost BD 1.5 million and include all SMC and health care patients. Private hospitals and clinics can also be part of the system by paying a fee
The health minister stated that many countries were struggling to meet the challenges of providing adequate health care for citizens. ‘ Changing demographics increased patients expectations, a global shortage of health professionals and rising costs associated with innovative technologies and new drugs means that healthcare is consuming an increasingly large proportion of gross domestic product and is becoming a priority for most governments’.
The minister also discussed Bahrain healthcare agenda through some strategic objectives which includes health promotion and prevention by strengthening primary healthcare services, the provision of quality health services by maintaining international accreditation of facilities and enhancing access to all health care services (Gulf Daily News- Sandy@gdn.com.bh)
Plan for online health service
Patients in Bahrain may soon be able to manage their healthcare online. Patients know best (PKB) enables people to communicate securely with doctors and nurses, access their medical records and send and receive health data. The medical group was founded two years ago by Bahraini Dr Mohammed Al Ubaydli in the United Kingdom. He has more than 15 years of experience in the medical software and trained as a physician at the Cambridge University. The expert worked as a staff scientist at the national institutes of health and was a management consultant to US hospitals at the Advisory board company and is the author of six books. PKB is the first company to integrate into Britain’s NHS secures connecting for patients to work online with clinicians. The group was voted as the best social innovation start up at tech crunch europas European start up awards 2010. At least two hospitals in Bahrain as well as others in the UAE and Malta have shown interest in signing up to the initiative. In the U.K, PKB affiliates includes great Ormond St hospital, Thalidomide Trust, Cure Parkinson and Two NHS hospitals will also sign up soon
Access
Dr Al Ubaydli said hospitals and medical centers that have affiliated with the PKB give their patients an online ability to securely access their medical documents, history and test results, have online consultations with their doctors and receive prescriptions. Once you give the medical record to the patient they can give them to their GP, relatives, social workers and so on he told the GDN. The patient can start an online consultation with any doctor they have added, it works a bit like the face book. They can also reach their doctor at any time say, for example, their child is taking medication but develops a fever at 3am and they can go online and ask the doctor how to adjust their medication. ‘The system asks automated questions that your doctor would ask so that when the doctor sees this in the morning it saves them a lot of time and they can quickly respond with advice’. ( Gulf Daily News 8 Dec 2010)
The articles concludes the following results
The kingdom of Bahrain is taking new measures in implementing the E.H.R in the G.C.C and mena region
Many of today healthcares can be solved through networking
Globalize E.H.R System
Networking communication is an intermediary between practicing doctors implementing the E.H.R in their private clinics or public clinics. The information process is much faster through communication networks which reduces time, saves lives and improves efficiency Exg: Steve Dr Akram Favorite doctor has a patient and needs emergency solution to a problem through a communication network can achieve his goal browsing the Globalize E.H.R network finding solutions through other Doctors specialized in that field.
An E.H.R system that works like a face book
Doctors can log on their account and log on the system with other health professionals and discuss emergency situations and provide solutions
The problems can be solved through fast communication and accurate knowledge the tacit knowledge
key challenges to health practitioners implementing the E.H.R in the GCC countries
Cost of implementation is not offset by the efficiencies in the E.H.R
Technical support needs to be modified due to the advancement in IT
Stress on staff and the practice in general was significant
A 2007 review article recommended strong physician leadership and a staged approach to successful implementation
In 2010 an article challenged conventional assumptions that the physicians were to blame for low uptake of electronic health record. Electronic medical records vary greatly in capability, quality, and cost. Doctors will become enthusiastic users if the electronic medical records are helpful in the care of their patients
There are significant challenges associated with implementing E.H.R in the Mena or G.C.C countries
Benefits of networking for the G.C.C Region
Improves patient care through greater access to information
Reduces test result times
Decrease paper work for clinicians
Integrate communication
Helps ensure that patient medical data and stats are there when patients need to find his/ her test results
Compliance with privacy regulations
Proposed solutions for the electronic health record
A 2008 synthesis of 3 qualitative studies identifies essential components of successful electronic health record implementation
A project champion
Realistic expectation of the challenges of implementing an electronic health record
Addressing existing staff attitude towards IT
Provide adequate training to staff
A systematic review of 7 countries experience implementing health information system in primary care identified the following factors
Quality of the graphical user interface and feature functionality
Quality of implementation project management
User’s previous experience with information technology systems
The Electronic health record today application
The adoption of the electronic health record is difficult to overcome due to the lack of the return on investment. Scholars and writers on the subject noted that health care decision makers find it difficult to demonstrate return on investment to undertake a comprehensive electronic health record system within their organization. The health care costs continue to increase and the fact that the initial investment on equipment can be quite expensive. Another fact that complicates the adoption of the electronic health record is that the data is heavily structured, being recorded in the allotted space. Training is an important issue and this is required by a large amount of population. One should keep in mind that the population has different levels of computer literacy (Upham 2004). These contributors of the electronic health services contributed to a slow increase in the adoption of such systems in many hospitals. In a survey question regarding the E.H.R and the implementation of the method out of 436 who have responded to the question, 35.6% said that they have already implemented the electronic health services. The percentage is expected to grow in the coming years of application. The G.C.C is taking all the necessary step in implementing the system with an enhanced knowledge in the field and the governments should test all the Medicare and Medicaid programs before implementing the system
The Evolution of the Electronic Health Record
The electronic health record is an open field of debate amongst the doctors, physicians, clinicians and scholars. In the electronic implementation of such records, we may also expect to find populations of patients, integrated access to biomedical literature and interactive environment for offering clinical guidelines or consultative advice. Throughout ages the world is becoming more globalized and in the age of science and technology the computer is being the number one tool. The (local area network) is connected to the full internet, with an integrated access to a wide variety of information sources that are geographically distributed well beyond local institutions.
The electronic health record system is expanding worldwide and some of the future implementation
An enhanced internet: an internet with much higher bandwidth and reliability, increased response time and financial models that makes the application cost effective and practical is required. Major research effort is underway to address some of these concerns, including the federal next generation Internet activity in the United States exploratory effort that continue to push the state of art in internet technology, and all significant implication for the future of health care delivery in general for computer- based health record in particular
Better Education and health care training for health care providers: there is a difference between computer literacy (familiarity with computers and the routine users in society) and the knowledge of the role that computing and communication technology can and should play in our health care system. More medical information training programs and the expansion of existing programs are needed. Junior faculty in health science schools who may wish to seek additional training in this area should be supported
Changes in the management and organization of health care institution: health care provide some of the most complex organizational structures in society, and it is simplistic to assume the off shelf products will be smoothly introduced into a new institution without major analysis.
Discussion
The project mainly discusses on electronic health record system that the implementation of the idea goes back to Hippocrates who laid the foundation in the 5th century and by the following years doctors, physicians, pharmacists and clinicians tried to improvise the idea of the health record system on paper but in the 1960s the standards of the paper based changed to the electronic health record systems and hospitals welcomed the new system which was more efficient and reduces paperwork and time. The electronic health record according to numerous researches and articles emphasized that the system should be introduced worldwide. the G.C.C region is expanding in both size and capacity since the countries like Bahrain, Kuwait, Qatar, Uae opened door to foreign investment in their respected countries. Our research focuses on the implementation of the E.H.R in the U.S and the results of the case study gave us a better understanding on whether to implement the system in the G.C.C countries. The results were positive and the need of the system is becoming compulsory in our world today. Kuwait have already
 

Middle Stone Age Record of Africa

Is there evidence for the establishment of modern behaviour patterns in the Middle Stone Age record of Africa?
Behavioural modernity refers to developed behavioural traits we associated with ‘modern’ humans (Jacobs & Richard, 2009). These behavioural traits are what distinguish modern humans & their recent ancestors from other extinct hominids as well as both current & past primates. What we now classify as modern human behaviours are cultural universals shared by all individuals, these behaviours include traits like language, religion & decoration, or what’s known as the behavioural B’s: blades, beads, burials, bone-tool making & beauty (Calvin, 2004). This essay discusses the evidence for the establishment of modern behaviour patterns in the Middle Stone Age (MSA) record of Africa.
What is the Middle Stone Age record?
The MSA was a period of African prehistory generally considered to have spanned between 280,000 years ago & 50–25,000 years ago. The term MSA is used synonymously with the term “Middle Palaeolithic”, used in the remainder of the Old World where comparable artefacts & traditions are found & is now closely associated with the appearance of behavioural modern humans. (Clark, 1998)
Innovations
A range of innovations characterise the MSA, this following section talks about some of these, why & how they came about.
Technology
There is marked variation in Middle Stone Age assemblages, which could have been caused by a number of factors including environmental conditions, resource type & availability, choice of different reduction techniques & strategies of tool manufacture. Technological patterns in these asemblages reflect early stages of modern human behaviour, with little standardisation within them.
The beginning of the Middle Stone Age is identified by changes in the lithic components of the industries, namely, by the disappearance of bifaces (handaxes and cleavers) of the Acheulean type and the appearance of of composite tools which incorporated points signalling the beginning of the reorganisation of technology(Zenobia & Roberts, 2009).
Tool kits of this time included prepared core technology aka the Levallois method of flake production in which a core was carefully prepared on one side so that a flake of a certain, predetermined shape and size could be produced with a single blow (______). Composite tool kits also became common in this time period. These composite tools allowed tools to be hafted to other items, most commonly wood to create spears, and included triangular flakes, denticulates (tools retouched to form a serated edge), awls used to perferte hides and retouched points and scrapers. Occasional grinding stones and bone points have also been found during this time period

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The most potent evidence for behaviourally modern stone tools come from the sites of Still Bay (SB) & Howieson’s Poort dated between 72-71 ka & 65-60 ka respectively (Zenobia & Roberts, 2009). Among the Still Bay toolkit are bifacial flaked points that probably formed parts of spearheads, whereas the Howieson’s Poort toolkits include blade-like tools that were blunted on one side & hafted as part of composite weapons.
These Middle Stone Age assemblages contain significant evidence of modern human behaviour which is reflected in raw material procurement, exchange patterns, adaptive behaviour, & mastery of craftsmanship (Onjala, 2006).
Hunting & gathering
The emergence of modern hunting capabilities is one of the behavioural traits which classify modern human behaviour, there is a great deal of debate as to the effectiveness of the hunting strategies of MSA humans & thus weather the individuals of this time period were in fact ‘behaviourally modern’.
One argument presented is that MSA individuals were less effective hunters than their LSA successors (Faith, 2008), Klein in his paper The problem of modern human origins argued that this was a result of a major neural change that took place between 50-40 ka, creating humans with a fully modern intellect. Klein believes there were several behavioural & technological consequences of this change such as the development of more effective hunting capabilities, & the ultimate dispersal of modern humans into Eurasia (Klein, 1994). Most researchers however, maintain that MSA individuals were fully adept hunters & thus the emergence of modern hunting skills is one of the modern behavioural traits that appeared during the MSA (Faith, 2008)
Many sites from across Africa show accumulation of fish remains from fresh water, brackish & marine environments, these sites include Klasies River, Herolds bay & Hoedjies Punt open sites among many others. The fish found at these sites are often to large to have been introduced by costal birds & therefore point to the development of fishing techniques. At blombos cave, South Africa, these include deep water varaieties pointing to a large increase in technology. Some sites also contain marine mammals such as Die Kelders where remains of Cape fur seals have been found.
Inland sites contain remains of many mammals, usually medium sized herbavores such as zebra, eland & antelopes, all of which were common during the time period. Unlike the LSA, hunting of larger dangerous animals appears rare, which Richard Klein suggests indicates the individuals of this time period had not developed the technologies to deal with this kind of behaviour. Mortality profiles for animals from the MSA suggest the key target range for hunting during this time period was the young or the old animals which were weak or vulnerable.
While hunting is one possible accruement of meat resources it is likely that a large range of meat gathering strategies were used during this time period including scavenging, long distance hunting & ambush hunting (Scarre, 2013)
Site modification, Art, Ornamentation & Symbols
A major signifier of modern behaviour is the organized use of space. While this is not common during the MSA there are a few examples of site modification, most commonly arc-shaped “walls” of stone, possibly created as wind breaks. (Scarre, 2013)
Evidence for art, ornamentation & symbolism however have been found at several sites across Africa. Many items from sites across Africa have been found to have been intentionally marked with abstract geometric symbols both carved & painted (Wurz, 2014). These items most notably include engraved ochre, bone & ostrich shell; Engravings & paintings & beads.
Of the engraved items, possibly the most notable from this time period is a ~ 77,000-
year-old piece of dark-red ochre with a cross-hatched pattern bounded by parallel lines engraved on one side recovered from Still Bay (Wurz, 2014) while other engraved items include bone from Blombos Cave & at Klasies River a bone engraved with four parallel lines has been found (Wilkins, 2010). Egg shell is another item which has frequently been engraved upon, examples include from the site of Diepkloof in the Western Cape, where 270 fragments of intentionally marked ostrich eggshell believed to have been used as containers have been recovered dating to 60kya & including geometric motifs such as straight parallel lines, cross-hatching, & a hatched band (Wurz, 2014). Other sites including engraved egg shells in their assemblages include Howieson’s Poort & Apollo 11 (Wilkins, 2010)
Beads as personal ornamentation are the last aspect of art, ornamentation & symbolism that will be discussed in this essay. Beads made from shell occur from around 100,000 years ago in some sites in Africa (Wurz, 2014) the most notable of which being the collection from Still Bay at Blombos Cave where over 40 beads made of Nassarius kraussianus shells. Keyhole perforations had been created in each shell, most likely with a bone tool, were then strung & worn as personal ornament. Some beds also contain ochre residue, although wether this is from deliberate colouring or from transfer when worn is unknown (Henshilwood & Dubreuil).
Conclusion
The innovative technologies and social practices mentioned above are only one part of a behavioral montage that spread through Africa during the MSA. Rapid advances in human cognition were manifested in material-culture practices not previously observed in the Africa or anywhere else in the world supplying evidence for Africa as the place of establishment of modern behaviour.
 

The implementation of electronic health record

Only 4 percent of U.S. doctors are using an electronic medical record system (EHR) because of a diverse range of barriers and perceptions involved with implementing an EHR system. The health care portion of the American Recovery and Reinvestment Act (ARRA) called Health Information Technology for Economic and Clinical Health or HITECH promotes the “Meaningful Use” of information technology in the form of EHR systems for every American by 2014 (Hoffman, 2009). Just having an EHR system is not enough; “meaningful use” means the system must improve the quality, efficiency, security, access, and communication in the delivery of health care among other functions. The United States government has provided $17 billion in available incentives to assist physicians and health care facilities implement certified EHR systems that meet Federal qualifications by the year 2014 (Blumenthal, 2009). This important health care issue affects everyone in this country because of the nature of private health information. The U.S. government mandate for the implementation of electronic health records presents a wide variety of issues for and responses by physicians who want to retain their diversity relating to the way they practice medicine, while meeting the “Meaningful Use” requirements that will positively affect their investment and efficiency.

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“Meaningful use” depends on interoperability, which means that physicians systems will be able to communicate with each other for information exchange. Currently some physicians may have systems that are interoperable, but some may have invested in software that does not provide that function. Numerous vendors often market more than one type of system. Currently, estimates of physicians using a complete, fully functional EHR system are only at four percent (DesRoches, et al., 2008). This leaves the majority in need of researching software systems, purchasing, and implementing an EHR system to meet the “Meaningful Use” requirements. The practice of medicine is a highly individualized field where every physician has their own ways to provide for their patients. A general practitioner will have different software needs than a surgeon or obstetrician. An issue the physicians have to address is that they have to choose a certified EHR system that will provide the functions they need for their particular practice of medicine. Many physicians are starting with a basic system and customizing it to fit their practice needs (Baron, et al, 2005). HITECH will need to certify systems that provide functions that the physicians require with enough flexibility to meet the diverse needs of every type of practice. Some EHR systems are designed for primary care practices or large hospitals and may not meet the needs of a specialist. Physicians will have to choose a certified system that will have the required functions as well as those his practice will require.
Whichever system a physician chooses will require training in order to benefit from the functions the software can provide. A basic knowledge of computer use is a skill many physicians do not even have. In fact, some physicians have technophobia when it comes to computers in their practice (Hayes, 2009). Statistics have shown that younger physicians are more apt to have a positive outlook on the EHR systems. Younger physicians also appear to have earlier adoption of an EHR system because of their prior exposure to computers. In-depth training to learn the functions and processes of the system are necessary to prevent severe disruptions in the workflow of the office. Many offices will train a few employees to be “Super Users” to be a resource for others in the office who have had less training. “Super Users” will be able to adjust the work processes when needed. Some physicians’ offices close for a period of days to bring the system online and prepare the office for going live. The diversity in computer abilities and comfort levels will affect the complexity, price, and amount of training required for each physician and his office staff for the chosen system.
Cost is the biggest issue in the adoption of EHR systems. Cost estimates are between $12,000 and $24,000 to implement a fully functional EHR system (Baron, 2005). The equipment, software, training and one year of support can cost $140,000 or more (Baron, 2005). The HITECH incentives will cover some, but not all the cost of the conversion from paper to electronic records. Incentive payments can total $18,000 in the first year, for physicians implementing in 2011 and 2012 and will continue for 5 years at reducing amounts. The available incentive amounts will decline each year and end completely in 2016. In other words, physicians who adopt in 2011 could collect $44,000 over the five-year period while physicians who adopt in 2013 would receive $27,000 in incentive payments over 3 years (Blumenthal, 2009). The incentives will provide more funding for physicians that implement early. Surveys indicate that the incentives are a facilitator for approximately 55 percent of physicians who see the incentives as a reason to make the transition now, and receive maximum financial benefit (Blumenthal, 2009). The diversity in size of practices will affect how the physicians perceive capital costs.
Due to the diversity in the types and ways physicians practice, issues that need to be considered and addressed, and the many solutions available, physician’s attitudes and opinions on EHRs and “Meaningful Use” vary from very enthusiastic to resentful and wary. Studies have shown that physicians who have already adopted an EHR system are generally satisfied with their system and the benefits it provides. However, although the physicians will be the ones assuming approximately 89 percent of the cost of the system, they will not receive much of a return on their investment (Hoffman, 2009). The insurance companies will save money on reduced testing, streamlined billing, and overall efficiency. The government will save money on the same things as well as have a medium for monitoring fraud. Physicians will save some money on record storage, employee salaries previously paid for filing and transcribing records, and paper office supplies, but in comparison to the cost of the system, savings are minimal. Physician concern over return on investment is 50 percent for physicians who do not have an electronic system but only 33 percent for physicians who are already using an electronic system (DesRoches, 2008). The results may reflect Medicare and Medicaid patient numbers, size of the physician practice or perhaps the diverse perceptions physicians have over the dollar value versus the benefits to their actual income.
Seemingly, the biggest numbers of implementers are the larger practices who are often better able to absorb the large investment than a small practice or single physician office. Statistics show that large primary care practices are more apt to implement EHR systems than other types of practices. These large group practices of fifty or more physicians were four times more likely to have a fully functional system than with physicians in practices of three or less physicians (DesRoches, 2008). The increased cash flow from a large practice makes the large capital expense less detrimental to the practice. This diversity in the size of physician practices is a significant basis for EHR implementation.
EHR implementation itself will not provide for full Medicare and Medicaid reimbursement. In order for a physician to receive full reimbursement from Medicare and Medicaid, an EHR system must meet the “Meaningful Use” requirements. Physicians who do not have an EHR system that meets the “meaningful use” requirements will see penalties in the form of reduced Medicare payments. The reduction of payments will start at one percent in 2015, increase to two percent in 2016, and increase again to three percent in 2017 (Blumenthal, 2009). Physicians with large amounts of Medicare and Medicaid patients will have a significant reason to implement a system that meets the” Meaningful Use” guidelines. This issue will not affect all physician practices and some physicians do not feel it is a significant impediment to their practice income to warrant the large expense involved with implementing an EHR system. The diversity in the types of patients a physician or practice routinely cares for will have an effect on their financial return and willingness to implement an EHR system.
For those who may not see a financial return there are many other benefits to adopting an EHR system for patients, insurance companies, and the government, and to some degree physicians. One benefit for physicians is a more efficient and streamlined insurance claims process, which will aid in cash flow. Physicians will also be better able to provide for their patients because the patient record will be able to go where the patient goes, including to hospitals and specialists, resulting in better coordination of the patient’s care. The EHR will provide a reduction in clinical errors because of the ability of the EHR to provide clinical decision support and monitor medication dosing and contraindications, and allergies. However, a group of physicians feel that this is questioning their judgment and do not want the interference in the way they practice medicine. Of physicians who are using a fully functional EHR system 86 percent appreciate the avoidance of medication error function that their system provides. The diversity in the physicians’ response to clinical decision support may be due to age of the physician, the number of years he or she has been in practice or any number of reasons including the personality of the physician.
Along with those benefits, there is disruption of the office workflow. This is a significant cause for physician concern (DesRoches, 2009). The learning curve for an EHR system slows down all the processes in the office. Some physicians are better able to deal with the chaos that ensues while converting to an electronic system. Everyone within the practice has to relearn his or her job processes. All the office procedures of the practice have to be redesigned to work with the EHR system and the practice requirements. There is a period even after implementation of changes and adjustments that must be made to customize the system to the practice. Physician practices have reduced their patient load as much as fifty percent during implementation to try to reduce the waiting time for patients (Braon, et al., 2005). This essentially means a reduction in revenues until everyone can perform their jobs smoothly and handle the normal patient load again. Estimates are anywhere from four to six months before normal patient load is fully resumed. Physicians have reported losing patients because the wait time to see the physician was too long during the early stages of implementation (Baron, 2005). This is a major barrier for 41 percent of physicians in making the switch to electronic records (DesRoches, 2008). Physicians are very busy by nature and a slowdown in the office creates a diverse level of frustration that has caused some physicians to put off implementation or even to reverse the work already done in adopting an EHR system and return to their paper system.
Those who do make the switch from paper to electronic records will have to consider HIPAA requirements for security of an EHR system. EHR systems require the secure storage of EHRs, which contain patient’s private health information and interoperability requires secure access to patient EHRs. Some physicians will choose to be on an encrypted network to share information with their local hospital, laboratories, and other health care providers. A verification process will be required to allow authorized physicians access to patient’s private health information and to deny access to unauthorized persons. Security of patient records is a concern for many physicians. Some physicians feel this is something that needs more regulation before they will expose their patients to the risk of a breach. The diversity in the EHR systems in operation now creates issues for secured patient PHI with system interoperability.
With all the diversity involved in implementing an EHR system, physicians perceive the challenges of the U.S. government mandate for the implementation of electronic health records in different ways. Some feel there are too many barriers to address before implementation of an EHR and others feel the benefits outweigh the barriers. There are as many opinions on the issues of switching to an EHR system as there are physicians themselves. Addressing issues such as cost, security, training without a major loss in cash flow, which stems from disruption to the workflow of the office, will all stress the doctor patient relationship at least for a time. This is important because it will effect how and when the physicians adopt and use the nationwide system. The diversity in the way physicians practice medicine is individualized and the approved EHR systems will have to be flexible enough to allow for that individuality. The one thing all physicians want is to practice medicine they way they always have and meet the required mandate for “Meaningful Use” so they may recoup some of their investment.
References
Baron, R. J., Fabens, E. L., Schiffman, M., & Wolf, E. (2005, August 2). Electronic health records: Just around the corner? Or over the cliff? Annals of Internal Medicine, 143(3), 222-226. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=17875478&site= ehost-live
This article is written by physicians in a 4-internist practice describing the processes involved with converting from traditional paper medical records to electronic medical records. Baron and colleagues address the problems and issues involved, and how they worked through them. Some topics of interest include both planned and unexpected finances, training, workflow and accommodations and the overall office environment. The article describes the realized benefits and lacking areas of standardization and interoperability. I chose this source for its overall description of actual process of implementing an electronic records system. This article also addresses computer skills and requirements.
Blumenthal, D. (2009, April 9). Stimulating the adoption of health information technology. New England Journal of Medicine, 360(15), 1477-1479. doi:10.1056/
This article describes the portions of the American Recovery and Reinvestment Act of 2009 (ARRA) that pertains to health information technology. The article addresses barriers physicians have for implementing the mandated electronic medical record. Financial issues including incentives, costs and financial penalties are of adopting the mandate are covered. Other areas to promote and ease the transition, such as support systems, state and regional medical information exchanges, education initiatives, and extended HIPAA guidelines with regard to electronic records and transmissions are included in this article. This article explains the incentives for implementing the electronic records system. I chose this article to explain the diversity involved in the governments promotion for adopting an electronic health record system.
DesRoches, C. M., Campbell, E. G., Rao, S. R., Karen, D., Timothy, F. G., Jha, A., . . . Blumenthal, D. (2008, July 3). Electronic records in ambulatory care: A national survey of physicians. New England Journal of Medicine, 359(1), 50-60. doi:10.1056/
This article is a summary of statistics and results compiled from a survey of physicians in the US regarding the adoption of electronic health records. Documented in the survey are physician statistics and opinions in areas of usage, implementation, and satisfaction with the electronic health record systems. Issues addressed are quality of care, age groups of physicians who have adopted an electronic system and size of practices more apt to adopt electronic health records. The positive effects on practice processes, barriers that hinder adoption of electronic health records, incentives for and reservations with switching to electronic health records are included in the survey. I chose this source because it provides actual statistics of the usage of electronic health record systems as well as the diversity in physicians’ perceptions of the process, the systems, the benefits, and problems associated with compliance.
Hayes, F. (2009, February 2). No Rx for ROI. Computer World, 43(5), 40. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=36487540&site=ehost-live
In this article, the senior news columnist addresses the issue of “return on investment” (ROI) for the adoption of electronic health records. The definition of ROI is given and how it applies to aspects of electronic health record adoption for physicians and hospitals is examined. Risks to, benefits of, and improvements needed regarding electronic health records are noted. The author confirms that those assuming the expenses for electronic health records will not be the ones reaping the benefits. I chose this article because it covers reflects my opinion one of the most important reasons for physician resistance to implementing the government mandated electronic health record system.
Hoffmann, L. (2009, November). Implementing electronic medical records. Communications of the ACM, 52(11), 18-20. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=45021143&site=ehost-live
In this article, a basic history of George W. Bush’s goals for every American to have an electronic health record is presented along with the progress of the government in making those goals real. Usage of electronic records is briefly mentioned. The article focuses on some major barriers and concerns of physicians for implementation and usage. The article also addresses some of the positive aspects for electronic health records. I chose this article because it provides concise overall answers to who, what, when, where, and why answers to the implementation of the electronic health record and health information technology.
 

Fossil Record Evidence for Evolution

Introduction
In general, the term ‘evolution’ can imply a drastic or gradual change from a very broad perspective. Life on earth, the universe,galaxies, as also the earth in general have evolved through millions of years. In this essay we consider only one aspect of evolution emphasizing on evolution as a biological tool for change among species and consider fossil record as supportive of both evolution theories and also the other theories contrary to evolution. Evolution is the central unifying concept, a theory that successfully connects biology, palaeontology and other branches of science. Evolution is a gradual descent of organisms accompanied by changes that help the organisms to adjust and adapt to the surroundings. ‘Descent with modifications’ as Darwin contended implies changes in organisms in successive generations (Mayr, 1976). These changes are triggered by the derivation of new species and there is a change in the properties of populations of organisms and these properties tend to transcend the lifetime of any single individual. Newers pecies are modified versions of older species.

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Although, individual organisms do not biologically evolve,populations evolve when heritable genetic materials are transmitted from one generation to another. Biological evolution can range from very limited changes to drastic transformations on a large scale changing the entire special together and bringing in new forms. Evolution can thus be defined as inheritable changes in populations of species that are spread and transmitted over many generations (Zimmer, 2002). It is also more scientifically defined as changes in the frequency of alleles within a gene pool carried through different generations as understood in the Darwinian version of the theory(Dawkins, 1989). Evolution studies are supported by detecting changes in gene frequency within a population and the fact that the theory of evolution emphasizes on a common ancestor, only indicates that two or more species show successive heritable changes in populations since they are separated from each other as distinct forms (Allen and Briggs, 1989). Most popular definitions of evolution however highlight not the transmission of heritable traits and changes but the processes of diversity that has given rise to millions of species from the most primitive organisms. Here however we move on to the evidence for and against evolution theories and the role of fossil record in this context. Some researchers claim that the theory of evolution has been supported by four primary sources that serve as evidence (Zimmer, 2002; Allenand Briggs, 1989):

The fossil record that tracks changes in early and primitive forms of life
The anatomical and chemical similarities in the constitutions of different species.
The genetic changes observed and recorded in several living organisms over several generations
The geographical spread and distribution of species that seems to suggest a definite pattern, and

The Fossil Record
Fossils are buried in rock layers as indentations of dead plant and animal materials. The totality of these artefacts and their impressions on the rock formations is considered a fossil record. Fossil record as we have briefly mentioned is the primary source of evidence supporting the theory of evolution and the gaps in these records ironically also forms the bone of contention taken up by anti-evolution theorists. Fossil records are used by scientists to understand the process of evolution in general, and the subsequent changes in several species at several times of the earth’s existence(Donovan and Paul, 1998).
The Fossil Record seems to provide an important clue to the changes in primitive and even now extinct species and this definitely helps us to frame a conceptual graph on how evolution has taken shape. Fossil and rock record forms the primary source of evidence collected by scientists for nearly400 years and the consequent database obtained is mainly observational. The fossil record among all other evidence gives a large database of documented changes in past life on earth. The use of Fossil record to study life forms on earth dates back to pre-Darwinian times and the changes in life forms could be studied from a sequence of layers of sedimentary rocks and fossils of different groups of species were found in each of these successive layers (SA, 1982).Sedimentary rocks are found widely across the earth’s surface and are formed when small particles of sand, mud or gravel, shell or other materials withered off by water or wind accumulates in sea beds and oceans. As these sediments pileup they bury shells, leaves, bones, and parts of living organisms. Layers of sediments are thus formed for every large period of time and all these layers become subsequently cemented to each other to become different layers of sandstone,limestone, shale and so on. Within these layers of sedimentary rocks the plant and animal remains become buried as fossils and are later revealed as fossil records (Allen and Briggs, 1989). From these fossil records several species have been identified, some of which are extinct and some of which have traits transitional between different major groups of organisms. Fossils of transitional forms actually give considerable evidence of species evolution over time. However there is not enough evidence through fossil records to conclusively prove evolution, as there are still talks of ‘missing links’ as very few and according to some, no transitional forms have been actually discovered. The Fossil record data available to us is incomplete and in conclusive at present.
During the late eighteenth and early nineteenth centuries,William Smith, a British Engineer observed different assemblages of fossils preserved at different levels and different ages of rocks. These assemblages succeeded one another in a regular and determinable order (cited in, Wikipedia,2004). This was further bolstered by the fact that rocks collected from different locations showed similar fossil formations according to the different times they represented. Smith named this correlation of rock fossil data as the principle of faunal succession. The occurrence of faunal succession was one of the primary arguments of Darwin who used fossil evidence as supporting the theory of evolution.
Various modern approaches to the theory of evolution have been recently developed. Mayr claims that the theory of Punctuation for instance has two basic points that

most or all evolutionary change occurs during speciation events, and
most species usually enter a phase of total stasis after the end of the speciation process (which involves formation of new species).

Speciation thus involves transformation of species in geological time (Erwin and Anstey, 1995). Formation of new species is explained either by phyletic gradualism or a gradual steady transformation of species by phyletic evolution highlighting the deficiency of the fossil records, or by sympatric saltational speciation that highlighted punctuational equilibria and branching of species rather than transformation as lineages as the real explanation for evolution (Mayr and Provine, 1998). Biologists like Gould and Eldredge have also supported punctuation theories. Richard Dawkins on the other hand stresses on the principle of gene multiplication where genes as replicators seems to be the focal point of defining evolution (Sterelny, 2001).
In quite an important paper Volkenstein (1987) suggests that there can be no contradiction between punctuated equilibrium and phyletic gradualism if synergetics and theory of information are incorporated within the theory of evolution. Punctualism can be seen as phase transition maintaining the directionality of evolution. Volkenstein argues that Punctualism, non-adaptationism and neutralism form the triad of internally connected features of evolution.
Problems with Fossil Records
Of course at that point, the absence of a proper theory of evolution prevented Smith or other researchers from providing an explanation of the actual cause of faunal succession. The cause of faunal succession as is known today is mainly due to evolution of organisms and species that change,transform or become completely extinct, leaving behind their traces on earth as fossils. Age of rocks and the changes in species features are both determined by fossil record and faunal succession used as tools in bio stratigraphy. However fossil data show extremely few records of transitional species,organisms that can conclusively suggest how and when evolution of new and different species occurred (Donovan and Paul, 1998). Darwin himself suggested that the geological record itself is imperfect and incomplete and this is further strengthened by the fact that transitional species were short lived and had very narrow geographical range.
Radiometric and Carbon dating have made it possible to identify fossils more than 3.5 billion years old and have indicated that animal species may have appeared abruptly, a phenomenon which Darwin himself found difficult to accept. Even though one or two forms of organisms which may be considered as transient have been identified, there are no records of transitional plants and thus an evolutionary plant history could not be drawn as of yet. Along with these issues it has also been seen that most of the fossils found are of species which have existing forms and are either similar to existing species or are completely identical. The intermediate temporary stages as serve to act, as links between two related species seems to have been completely downplayed by the fossil data obtained. Animals seem to have remained more or less unchanged through all these years. Despite the collection of a huge number of fossils,nearly all of them being fossils of presently existing animals have created problems for the theory of evolution. It is a general belief that based on fossil discoveries already made, there will be little or no evidence that evolution had actually occurred and continues to occur (Donovan and Paul,1998). If animals die a natural death, they are usually decomposed even before being fossilized. However during sudden catastrophes can bury the animals and embed them deep in the earth. Some rocks and organisms that transformed to show fossils for years and decades were actually deposited within a short period of time.
Although Darwin based his arguments heavily on fossil record, most scientists now believe that fossil record is actually incompatible with evolutionary theory as no transitional links or intermediate forms have been discovered among this huge collection of fossils in all these years. This suggests that there is no real evidential data that the theory of evolution is in fact true. There is no evidence of partially evolved species or intermediate forms either in the past or in the present fossil record and the fossil record available is quite representative of all fossil data that will ever be collected. Evolution seems to point out towards more undefined and partially evolved species, fact completely undermined by available fossil record that shows well-defined organisms rather than gradual gradations. The incomplete fossil record is the primary bone of contention in the evolutionary debate and seems to give an edge to non-evolutionists.
Conclusion:
Considering all the aspects of the debate and gaps in fossil records and weighing this against evolution theories highlighting either generational transformation of lineages or drastic changes and speciation at specific periods, we can conclude that available gaps in fossil record may be more indicative and supportive towards speciation and abrupt changes rather than gradual evolution through phyletic transformation.
 

Patient Medical Record Dispatch System

 Project Charter: Patient Medical Record Dispatch System

 

Patient Medical Record Dispatch

 Electronic patient medical record dispatch provides an efficient and streamlined data collection process. The system produces an accurate, complete, and legible electronic patient data, thereby reducing liability as well as improving the quality of patient care and reimbursement. Patient medical record dispatch intends to use the system for both internal and business purposes including the delivery of patient care services.

Our study contributes several key findings to the literature on the outcomes of providing patients access to medical records. Most of the patients were uniformly positive about the idea of having facilitated access to their records. Providing patients access to their medical records may facilitate a more collaborative relationship between provider and patient

The patient medical record, seen as a life-time’s accumulating of health care information, presents fascinating issues in database arrangement. The essential may be a database where structure is to some degree controlled by customers at terminals. The objective of this project is to develop a software module to make the medical record dispatching easier.

Problem Statement

Paper based records has many disadvantages. The records also needs to be protected from natural calamities. Paper Based records may not be readable and hence may result in health mistakes. The digitization of health-care records eases the search of the terms. The healthcare organizations today need to make sure that medical information, such as doctor’s notes and lab reports, can be accessed immediately from anywhere and anytime when required.

Hospitals now not only must care for and educate patients but also confirm that they are using their electronic medical record. It’s something hospitals haven’t used, and it’s a very great change and is very much useful for the patients and also the doctors.

Project Description

In a hospital, doctors order many medical tests for patients. The order goes to the testing lab and the results of a test is sent back to doctors. This a highly manual-intensive. The entire reporting activity can be automated. The purpose of this project is to develop a software module to automate the request and report process. The digitalization of this process is specifically done among the doctor, patient and the testing lab. This automation is done in such a way that the doctor sends the prescribed tests for a particular patient to the testing lab. The testing lab will perform the tests and instead of giving the reports manually, they upload them into the system which can be viewed by both the doctor and the patient. Patients, doctors and lab technicians are given an id and password to access the system.

The authorization of the users is checked by validating their information. To provide an extra layer of security the passwords are stored in encrypted format in the database. Providing patients access to their medical records may facilitate a more collaborative relationship between provider and patient. Existing literature suggests that patient-accessible records can improve patient–provider communication, self-management, and patient satisfaction.

Scope

•         Assist the physician or doctor in providing the best possible care to the patient.

•         Offer legal protection to those who provide care to the patient.

•         Provide statistical information that is helpful to researchers.

•         Vital for financial reimbursement.

•         The system should provide easy retrieval, organized storage.

•         Implement the following functionalities and flow of data as listed in the diagram.

Project Goals and Objectives

The goals of this project are:

•         Decrease transcription turnaround time and reduce transcription cost.

•         Decrease waiting room time for patients.

•         Improve the quality of patient care.

•         Increase the quantity/quality of patient education materials given to the patient.

Assumptions

•         Admin is the only one who has an access to create and view new receptionists, doctors and lab technicians in this system.

•         Patients can view his lab reports given by the lab technician and the treatment given to him by the doctor.

•         If a patient needs to take some tests then the doctor sends a request to the lab technician to perform the tests like Blood test, ECG, MRI, X-ray.

•         Lab technician can view new lab tests to be done to the patient suggested by doctor and then he uploads those reports and submit them both to the doctor and patient once the tests are complete.

•         Receptionist suggests all the available doctors based on his problem.

Constraints

•         All work is able to be completed prior to May1, 2020. The development team must begin and complete all work listed in milestone deliverables within specified dates without variation.

•         Resources must be available to execute assigned tasks as defined in the project plan/schedule.

Success Criteria

•         Developing the doctor, patient and lab technician module within the assigned time and toolset.

•         Implementation of object oriented API for the interaction of doctor and technician and support secure report transfer.

•         Developing services that provide safe storage as well as retrieval of secured data.

 

Performance Indicators

Goal

Action Plan

Performance Indicator

 

Decrease the number of pharmacy phone calls regarding prescriptions.

Use the e-prescribing feature in PMRDS to eliminate paper prescriptions.

In six months, there should be 40% decrease in pharmacy phone calls.

Reduction in the transcription cost.

Use of PMRDS eliminates the need of transcription service.

In 6 months, the transcription cost will decrease by 45%

 

 

Cost & Budget

Stage

Budget

Effort(months)

Define

$20,000.00

2

Develop

$70,000.00

7

Deploy

$20,000.00

2

Evaluate

$10.000.00

1

Total

$120,000.00

12

Risk Management

Description

Likelihood

Risk Mitigation

Impact

Contingency

Sponsor

withdraws from

the project.

1

The team will maintain

communication and a positive rapport with the sponsor to minimize the likelihood of conflict-based withdrawal.

10

In the event the sponsor is unable to continue with the project, the team will attempt to identify a substitute, such as a faculty member with an interest in game development.

 

Team member withdraws from the project.

 

3

The team will uphold a set of behavior guidelines to avoid conflict related attrition. Other sources of attrition are assumed to be unlikely.

 

7

If one or two members withdraw, the team will adjust the schedule and requirements. The project is unlikely to succeed if more than two members withdraw.

 

Major requirements change during later iterations.

3

The iterative process defers effort investment in requirements prior to implementation

5

The requirements change management procedures will allow the team to evaluate the most appropriate course of action.

Realized level of significantly exceeds estimates for an iteration.

 

5

Rapid prototyping and feasibility reviews at the beginning of each iteration will minimize investment in features which are too costly.

5

The schedule change management procedures will allow the team to adjust the schedule as necessary. The methodology also allows for additional team members to be assigned construction duties for complex iterations.

Realized level of effort significantly exceeds estimates for the project.

 

7

During the initial planning process, the team will attempt to refine the effort estimates based on actual development progress.

 

3

The iterative process with continuous integration is proposed primarily to address this risk. Beyond the first iteration, a functional system that satisfies a subset of the requirements will exist. If one or more iterations must be cancelled, this system will be deliverable.

 

Resources

•         Analyst- Performs accessibility audits, assessments, application and service testing and analysis of accessibility capabilities; design and recommend remediation tasks.

•         Architect- Provides expertise regarding compliance with technology standards, campus ICT strategy, interoperability and reusability objectives across multiple technology platforms supported by campus ICT.

•         Designer- Constructs and documents solutions for each specific domain, service and application.  May also serve as an implementer.

•         Implementer- Tests implements and manages application and service specific accessibility and compliance remediation tasks.

•         Project Manager- Manages overall project, including resources, scope, cost, schedule, constraints, stakeholder expectations and communications activities in coordination with team leads and ICT accessibility coordinator.

•         Subject Matter Expert- Provides application and service specific expertise, consulting, and vendor coordination.

•         Team/Tech Lead- Leads one or more teams, performing tasks including implementation and management of application and service specific accessibility and compliance remediation activities.

•         Verification & Validation- Creates plans, quality assurance and solution validation tasks for one or more application and service specific accessibility and compliance remediation activities and scope of work.

 

Milestones and Work breakdown Structure (WBS)

TASK NAME

START DATE

DUE DATE

DURATION

DESCRIPTION

MILESTONE

Task 1

4/1/19

4/15/19

14

Project Planning.

Release 1

Task 2

4/15/19

4/22/19

7

Technical Configuration and Work space set up.

Release 1

Task 3

4/22/19

5/20/19

28

Database design and analysis for admin, doctor and patient modules.

Release 1

Task 4

5/20/19

6/10/19

21

Home screen and admin login development.

Release 1

Task 5

6/10/19

7/8/19

28

Doctor registration screen: UI and services development.

Release 1

Task 6

7/8/19

8/5/19

28

Patient problems and treatment screen.

Release 2

Task 7

8/5/19

9/2/19

28

Doctor and patient integrated functionalities.

Release 2

Task 8

9/2/19

9/30/19

28

Integration, regression testing and bug fixes for doctor an patient modules.

Release 2

Task 9

9/16/19

10/14/19

28

Patient report screen.

Release 3

Task 10

10/14/19

11/11/19

28

Receptionist registration screen.

Release 3

Task 11

11/11/19

12/2/19

21

Lab technician registration screen.

Release 3

Task 12

12/2/19

1/13/20

42

Lab tests: UI and services development.

Release 3

Task 13

1/13/20

2/10/20

28

Lab technician to doctor report transfer module.

Release 4

Task 14

2/10/20

3/2/20

21

Integrated functionality development for all modules.

Release 4

Task 15

3/2/20

3/30/20

28

Regression testing and bug fixes for all modules as part of final deliverable.

Release 4

Task 16

3/30/20

4/3/20

4

Project Closeout.

Release 4

 

Schedule

Deliverables

•         Fully functioning PMRDS system that is visually pleasing.

•         Provision the  Test and Prod infrastructure environments.

•         Benchmarks of performance testing.

•         The system should meet the acceptance criteria and Negotiation Contract terms.

•         Support documents which includes troubleshooting steps for key issues.

•         ‘How to doc’ document which will help the end-user in navigation and understanding the functionality of each module.

Project Charter Approval

Approver Name

Title

Signature

Date

John Payonk

Vice President

 

 

Dean Stasio

Associate Vice President

 

 

Keith Cyktor

Director

 

 

 

 

References

Minseon Park, Using Patient Medical Records for Medical Research, Korean J Fam Med (2013 May; 34(3): 159).

Ben Sutherly, Hospitals must help patients access digital records — or else, The Columbus Dispatch (Sunday August 17, 2014 6:39 AM)

Tom Murphy & Brandon Bailey, Health-care records are easy targets for hackers, Associated Press (Sunday February 15, 2015 9:19 AM)

Traber Davis Giardina, Shailaja Menon, Danielle E Parrish, Dean F Sittig and Hardeep Singh, Patient access to medical records and healthcare outcomes:  a systematic review, DOI: http://dx.doi.org/10.1136/amiajnl-2013-002239 737-741 first published online: 1 July 2014

MARK A. EARNEST, MD, PHD, STEPHEN E. ROSS, MD, LORETTA WITTEVRONGEL, BA, LAURIE A. MOORE, MPH, CHEN-TAN LIN, MD, Use of a Patient-Accessible Electronic Medical Record in a Practice for Congestive Heart Failure: Patient and Physician Experiences, 2004 Sep-Oct;11(5):410-7. Epub 2004 Jun 7.

CLEMENT J. MCDONALD, MD, RAYMOND MURRAY, MD, DAVID JERIS, MS, BHARAT BHARGAVA, PHD, JAY SEEGER, BS, AND LONNIE BLEVINS, BS, A Computer-Based Record and Clinical Monitoring System For Ambulatory Care, Am J Public Health(1977 March; 67(3): 240–245).

Moira Stewart, PhD, Amardeep Thind, MD, PhD, Amanda L. Terry, PhD, Vijaya Chevendra, BEd, MSc, and J. Neil Marshall, MB, BCh, Implementing and Maintaining a Researchable Database from Electronic Medical Records: A Perspective from an Academic Family Medicine Department, Healthc Policy(2009 Nov; 5(2): 26–39).

[Kim Murphy-Abdouch, MPH, RHIA, FACHE, Patient Access to Personal Health Information: Regulation vs. Reality, Online Research Journal, Perspectives in Health Management, Jan 4, 2015.

RANDOLPH C. BARROWS, JR., MD, PAUL D. CLAYTON, PHD, Privacy, Confidentiality: and Electronic Medical Records, Journal of the American Medical Informatics Association Volume 3 Number 2 Mar / Apr 1996.

Jinhyung Lee, Yong-Fang Kuo and James S Goodwin,  The effect of electronic medical record adoption on outcomes in US hospitals, BMC Health Services Research 1, February, 2013, 13:39