Traditional utilization of paper based medical records leads to the dispersion of clinical information as a result of the heterogeneous character of hospital systems. Due to this, the development of a clinical information system that can integrate hospital information as well as enable cooperation amongst legacy systems became a difficult task. System integration as well as the development of an efficient clinical information management system was thereby dependent upon the creation of conceptual and architectural tools that will enable such an integration.
In line with this, many healthcare institutions are currently seeking to establish the integration of their workstations through the utilization of technological tools. Such tools are effective in the arrangement of clinical matters as well as in the arrangement of administrative and financial information. Clinical information systems are utilized by healthcare institutions in their integration of information. At this point, the utilization of electronic medical systems in healthcare delivery is evident in countries such as the United States, United Kingdom, Sweden, Hong Kong, Canada, as well as Australia.
The current shift from a human memory based paradigm to a technological paradigm can be traced to the recent emphasis given on health care quality improvement and cost reduction. In lieu of this, policymakers started to adopt health information technology such as the Electronic Medical Record (EMR). According to Tim Scott in Implementing an Electronic Medical Record System, most information regarding the use of EMR systems are derived from the Regenstrief Institute, Brigham and Women’s Hospital, the Department of Veterans Affairs, LDS Hospital, and Kaiser Permanente.
The information derived from the following medical institutions shows the following. First, success is dependent upon the organizational tools rather than on the type of technology used. Second, minimal changes were noted in terms of increase of quality and efficiency as a result of the system’s adaptation. Such findings thereby led to the slow adoption and implementation of EMR systems since majority of medical institutions as well as healthcare systems required the high verifiability of the system’s utility.
True enough, researches within these institutions also showed that EMR systems increase the quality of patient care as it decreases medical errors, however, the economic aspect regarding its use has not been well documented leaving most medical institutions adamant regarding its implementation. In lieu of this, the paper is divided into three parts. The first part will present the rationale behind the formation of the technology based medical paradigm.
It will be formulated within the parameters of Thomas Kuhn’s conception of scientific revolutions. The second part present a discussion of the various EMR components and the problems encountered in its implementation at Kaiser. The last part, on the other hand, will concentrate on presenting possible solutions to the problems evident in the utilization of the EMR systems within the Kaiser program while giving specific emphasis on the role of the agent in successful implementation.
Thomas Kuhn, in his work entitled The Structure of Scientific Revolutions, discusses the very nature and necessity of what he calls scientific revolutions. In this particular work, Kuhn sees an apparent parallelism between political revolutions on the one hand, and scientific revolutions on the other. Kuhn writes: “scientific revolutions… (are) those non-cumulative developmental episodes in which an older paradigm is replaced in whole or in part by an incompatible new one” (2000, p. 50).
On a preliminary note, paradigms are frameworks in and through which we approach phenomena, in general. They are models, so to speak. Naturally enough, different models employ different methodologies, different methodologies in turn, generate different types of knowledge, which, consequently, have different criteria of proof or validity. Scientific development, as Kuhn contends, may appropriately be characterized by paradigm shifts and this he calls scientific revolutions.
It is important to note that scientific developments do not occur in a vacuum. For the aforementioned reason, there is a felt need to situate scientific developments in the historical context within which they are conceived, proposed and ultimately, institutionalized and integrated as part of society’s shared knowledge. This is to say that scientific revolutions are also proper objects of historical analysis and discourse in as much as political revolutions are.
Kuhn contends that there is a parallelism between political and scientific revolutions. As pointed out earlier, it is important to note that he characterizes scientific revolutions as “those non-cumulative developmental episodes in which an older paradigm is replaced in whole or in part by an incompatible new one. ” Kuhn’s characterization emphasizes two important points. First, “that there is a replacement of an old paradigm by a new one”. Second, “that the new paradigm is not merely something new; it is also incompatible with the old paradigm”.
This is to say that the incompatibility or the irreconcilability of the new paradigm with the old paradigm serves as warrant for the necessity of such a revolution. Although there are significant differences in both scientific and political developments, Kuhn argues that one may be justified in using the notion of revolution as a metaphor for understanding them. He writes: Political revolutions are inaugurated by a growing sense, often restricted to a segment of the political community, that existing institutions have ceased adequately to meet the problems posed by the environment that they have in part created.
In much the same way, scientific revolutions are inaugurated by a growing sense, again often restricted to a narrow subdivision of the scientific community that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which that paradigm itself had previously led the way. (2000, p. 150) Kuhn’s parallelism is thus, founded on the idea that in both cases, a sense of malfunction (in our institutions as for the case of the political, and in our paradigms as for the case of the scientific) necessitates for the occurrence of a revolution.
In relation to this, the shift from a human memory based paradigm to the technological paradigm may be likened to a revolutionary development within the field of medical data acquisition and retention. The difference between the human memory based paradigm as opposed to the technological paradigm stems from the ascription of greater subjectivity in relation to human memory based data as opposed to technologically maintained data.
As was stated in the first part of the paper, the heterogeneous characteristic of medical institutions stems from the existence of various separate holistic systems within it. As a result of this, deriving and correlating clinical information becomes tedious. The main reason for this stems from human memory based paradigm’s utilization of paper based records which has a high probability of non-viability and unreliability. Examples of this are evident in evidence-based medicine’s non-adherence to the traditional methods of training and practice.
Second, paper based records fall short of their original expectations. The objective of the healthcare record is “to identify problems and to understand the impact of the illness on the individual” thereby enabling the “amelioration of the problem to the patient’s satisfaction, within the bounds of medical capabilities and society’s resource limitations”(Simpson and Robinson, 2002, p. 115). The main limitation of the paper bound records, therefore, stem from their inability of being multiply accessible to members of society.
On the other hand, Scott related the reasons for the development of a technology based paradigm with the high verifiability of the positive results of technologically determined medical care processes. According to Scott, “new technologies make it possible to evaluate and intervene to improve care in ways not heretofore possible” (2002, p. 2). In line with this, members of both the public and private sector lobby for the accessibility of technological improvements.
For the members of the private sector, this is due to the inclusion of the medical industry within the business sphere. For the members of the public sector, on the hand, demands for greater accountability for health care stems from the prevailing belief that technological advancements must be made accessible to the general public. According to the IOM, information technology’s role in the substantial improvement of the redesign of the healthcare system is important since it ensures the formation of “a strong infrastructure in supporting efforts to reengineer care processes… oordinate patient care across clinicians and settings and overtime, support multidisciplinary team functioning, and facilitate performance and outcome measurement for improvement and accountability” (qtd in Scott, 2002, p. 4). The results of the success of the EMR are traceable to the developments within the field of e-Health. According to Silber, EMR serves as the fundamental building block for the development of various applications such as the use of ICT by the Primary Health Care Team.
Others involve the use of ERM for validation of research or as an instrument in Continuing Medical Education. Information necessary for the functions ascribed above, in relation to the personal health record, are possible since the health record’s functionality enables the inclusion of the following: practitioner order entry, electronic patient record, document management, clinical decision support, administrative data, integrated communication support, as well as access to knowledge and resources.
According to Raymonds and Dolds, the functions of each component are as follows. The electronic patient record presents the patient’s history. Document management, on the other hand contains the actions undertaken in relation to the patient’s diagnosis. Clinical decision support as compared to the later contains “the alerts based on current data from the electronic medical record, evidence based practical guidelines or more complex artificial intelligence systems for diagnostic support”.
Access to administrative related information such as admission and discharge are contained within the section encompassing administrative data. Integrated communication support however provides the tools for the facilitation of effective and efficient communication amongst members of the patient’s health team. The last part enables access to other sources of information regarding the patient’s condition (Scott, 2007, p. 4). The Kaiser Permanente EMR implementation presented one of the main problems in relation to the utilization of the components of the technologically based paradigm.
It was recognized that the problems arose due to several factors which range from the software’s lack of efficiency up to the non adherence of specific qualities of the program with the social conditions in the region as well as the team’s lack of background in relation to the efficiency the program necessitates with regards to the division of the work flow as well as its dependence upon all the players within the medical institutions that the program was implemented.
Scott however stated that what should be given credence with regards to the above failed project is not so much as the failure of the program but the possibilities it opened in relation to the creation and implementation of new EMR programs in the future. Scott states, “success and failure are socially negotiable judgments, not static categories” (2007, p. 43). Hence if such is the case it is thereby possible to conceive of the problems noted by Hartswood et al (2003) in relation to the user-led characteristic of EMR.
The social negotiability of judgments thereby ensures the possibility of reversals in judgments as soon as occasions arise wherein a perceived failure may be reconnected with an overall success. In line with this, the continuous developments within the various EMR systems produced and implemented within the country ensures the viability and possibility of a near success and perfection within the system which in a sense also ensures the possibility of another scientific revolution in the near future whose scope may extend beyond that of the technological sphere.