Background

History
https://www.elationhealth.com/clinical-ehr-blog/history-ehrs/
https://journalofethics.ama-assn.org/article/development-electronic-health-record/2011-03

https://www.aafp.org/practice-management/health-it/product/intro.html

Online not useable link for paper but ideas

https://electronichealthreporter.com/how-electronic-health-records-are-impacting-the-healthcare-
industry/

5 ways EHR changes healthcare

1. Improved treatments
2. Remote treatments
3. Public health protection
4. Changing skill sets
Pros and Cons of HER
1. A single medical record
2. Accessiblitly
3. No duplicate enteries
Cons
1. Security
2. Standardization
3. Operational cost

https://digital.sandiego.edu/dissertations/49/
The Impact of Electronic Health Records on the Quality
Outcomes of the Adult Intensive Care Unit
Purpose: The purpose of this retrospective pre and post descriptive study is to examine how EHR systemic
implementation impacts the quality outcomes of the intensive care unit.
Methods: We utilized Donabedian Triad model of structure, process and outcome to evaluate the significant change
in the ICU outcomes. APACHE IV was used to measure severity of illness and predict length of stay and mortality.
Data collection obtained through chart review abstraction tool.
Conclusion: EHR implementation and utilization had a significant positive impact on antibiotic timeliness,
hyperglycemia control and mortality. However; Despite the decrease in the mean relative stay index and the rate of
medication errors after EHR implementation; this decrease was statistically not significant. The study informs nursing
practice and policy makers of the importance of EHR effective utilization and optimization.

https://journals.sagepub.com/doi/full/10.1177/2377960819850972

Screening and Research Data Collection via Automated EHR Data

Capture and Early Identification of Sepsis
Although providers are able to easily view EHR data for clinical care, the abstraction of
data directly from EHR systems for research purposes remains a challenge. Despite
limitations, improving direct data capture methods can assist in targeting potential
clinical trial participants and reduce the burden of data collection. More research is
needed to determine the best methods for automatically identifying patients with sepsis.

EHR system changes

EHR updates can be required by institutions (programmed internally) to allow for

capture of Core Measures that institutions must report or based on unit specific
needs. This may lead to differences in the way that providers document or differing
internal methods of capturing the data. Change can also arise during system
upgrades and updates from the makers of EHR systems or due to institutional
decisions to add or remove packages (e.g., during this project an add-on package
that enabled daily APACHE II calculation was not repurchased). It is unknown how
often EHR changes occur—internally or externally—but technology is rarely static.
Investigators designing projects designed to collect data from the EHR will be
impacted by changes and should work closely with IT to review changes frequently.

https://journals.sagepub.com/doi/full/10.4137/CIN.S12417

Moreover, CPOE implementation leads to better allocation of pharmacists’ time with

an increased number of order actions processed per hour, thus improving workflow
productivity.42 Data extraction, even in this case, is very useful to analyze resource
allocation and to assess the efficiency of cancer units and physicians. Human
 resources requirements can be estimated from the integration and the analysis of
extracted data, allowing an accurate prediction of staff costs. 43 Furthermore, analysis
of the collected data enables us to monitor unplanned visits and to identify
inappropriate hospital admissions or avoidable interferences with work plan. 44

Compared to a paper-based system, both the CPOE system and CDSS clearly
involve some extra costs, which, however, should be considered acceptable
whenever they help prevent a medical error or a serious adverse event. 45

Therefore, HIT plays a relevant role in modern cancer care enhancing clinical practice
and quality of care, improving resource allocation, and empowering cancer patients to
become more active. The ability of data mining opens a new compelling world for data
representation and management in clinical trials through information technology
platforms for translational and comparative effectiveness research and implementation
of privacy control.54
Moreover, it has not been established yet whether HIT is time-saving: initial teaching as
well as repeated training sessions are necessary to become confident with the system,
and acquiring specific skills requires an even greater time commitment. During these
sessions, medical productivity may decrease significantly. 62 In a recent study conducted
in 215 hospitals in Japan after the introduction of complex informatics systems, no
difference was observed in the time required to produce medical records and the overall
time for each medical care.63 The time needed to set and implement the computerized
healthcare system depends on the size and complexity of the department/hospital, and
periods as long as 7 years have been reported to reach a complete installation of an
EHR.64 Interoperability may also be very complicated. Although a knowledge-based
taxonomy is crucial to create exchangeable files,65 it is not unusual to find that data
stored in different departments of the same hospital do not share a common lexicon and
eventually may not work together properly. 66

https://journals.sagepub.com/doi/full/10.1177/1555343414534242
Resilient Practices in Maintaining Safety of Health Information
Technologies

https://digital.sandiego.edu/law_chlb_research_scholarship/15/
The computer science community has developed a spectrum of techniques for data privacy and confidentiality
protection, many of which have yet to be tested on real-world problems. In this article, we discuss clinical, technical,
and ethical aspects of genome data privacy and confidentiality in the United States, as well as potential solutions for
privacy-preserving genotype-phenotype
https://digital.sandiego.edu/dissertations/49/
EHR can improve safety and quality through communication, automation, streamlines and evidence based decision
support. There is a limited body of knowledge and inconsistency about EHR impact on patients’ care outcomes and
its effect on quality in intensive care settings.

https://journals.sagepub.com/doi/full/10.1177/0046958017713709

Federal investment spurred health information exchange organization (HIO)

development and maturation to provide third-party approaches to electronic health
information exchange across disparate electronic health record (EHR) systems. By
creating opportunities for data aggregation across multiple medical institutions, HIOs
also spur research. Using data from a 2015 national web-based survey of HIOs (N =
64), we identified HIOs supporting or not supporting research, and compared
characteristics of the 2 groups. We found that 15 (23%) of the 64 HIOs reported
supporting research, 30 (47%) reported planning to support research, and 19 (30%) did
not support research. Research-supporting HIOs were more likely than nonresearch
supporting HIOs to offer advanced functionality, such as allowing users to query and
retrieve data from multiple sources. Our study offers encouraging preliminary evidence
that HIOs are supporting research, which could offer a solution to current challenges in
creating comprehensive longitudinal clinical data sources for research.

https://journals.sagepub.com/doi/full/10.1155/2015/549420
Safety and Privacy Considerations for Mobile Application Design in
Digital Healthcare

To support sharing of sensitive data and comply with safety and privacy guidelines
applicable, the app was designed following a concept of bringing software to data
rather than data to software. This is a recently proposed hybrid cloud principle in IoT
environments where privacy and data handling requirements are particularly
demanding, such as in the case of digital healthcare [21]. The approach brings about
two crucial advantages:

(1) Sensitive data is stored locally in the environment where reliability, security,
and privacy risks can be well controlled, that is, on the user's personal
device, and, if the app is integrated into a digital healthcare system, in a
locally provided private cloud (e.g., a secure hospital private cloud
infrastructure); the sensitive data is in this case never sent to a public cloud,
which considerably lowers risks associated with third-party security attacks,
integrity violations, and so forth.
(2) Large volumes of sensed data are stored and processed locally, without the
 need for them to be (in their entirety) transmitted from the edge of the
network, which sits well with the fact that massive amounts of data produced
in IoT continue to grow much faster than the available bandwidth; these
concepts have recently been adopted in the 5G fog computing, which is
looking into the future of IoT and specifically focuses on edge computing and
improved elasticity and mobility, as well as improved user experience as the
core dimensions of the future of sensing and IoT [22].

https://www.ncbi.nlm.nih.gov/pubmed/31445272
Epic had a troubled start in both the UK and Denmark with malfunctions in the
interfaces to other clinical systems, disruptions in the continuity of care, and drops in
performance. While the state of routine use has subsequently been reached in the
UK, the transition process is still ongoing in Denmark. In Norway experiences from,
especially, Denmark are heeded in planning the implementation of Epic, which is
expected to deliver better care more efficiently. We discuss six pitfalls to achieving
these benefits.
CONCLUSION:
Experiences from, especially, Denmark inform the Norwegian preparations, but
these experiences point toward more challenges than solutions. The implementation
of Epic in Norway is currently in a state of considerable uncertainty.

https://www.ncbi.nlm.nih.gov/pubmed/25027492
At first sight, EHR seems to offer considerable potential for assisting health policies, enabling the
development of new tools to facilitate coordination and cooperation among health professionals and
promoting a new approach to sharing medical information. However, as discussed in this article, recent
debates have shown that EHR presents pros and cons (technical, financial, social) that governments
need to clarify urgently.

https://www.ncbi.nlm.nih.gov/pubmed/30808279
EHR phenotyping offers the ability to rapidly assemble a precisely defined cohort of patients prescreened
for eligibility to participate in health-related research. Even so, stakeholders in the process must still
contend with the practical and ethical challenges associated with research recruitment. Patient
perspectives on these matters are particularly important given that the success of research recruitment
depends on patients' willingness to participate.

http://web.a.ebscohost.com.sandiego.idm.oclc.org/ehost/detail/detail?vid=11&sid=d41b0c44-
b234-43fa-bdc8-6062a093164f%40sessionmgr4007&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d
%3d#AN=136195692&db=hch
The article focuses on issues related to electronic health record (EHR) systems. It refers to the need to
preserve the doctor-patient relationship through the EHR system. It highlights new levels of efficiency and
documentation to medical practice brought in by EHR systems. It describes different systems and setups
available for EHR.
https://www.ncbi.nlm.nih.gov/pubmed/31445983

Detecting time-evolving phenotypic topics via tensor

factorization on electronic health records: Cardiovascular
disease case study.

https://journals.sagepub.com/doi/pdf/10.1177/1541931218621117
EHR to EHR Transitions: Establishing and Growing a Knowledge Base

Collecting data through HER to understand the demographics

https://journals.sagepub.com/doi/full/10.1177/1179173X18782879

EHR and how doctors document smokers in it. Potential problem with life insurance if they
happen to see a label of a smoker in the system.

https://journals.sagepub.com/doi/full/10.1177/2150131911435525

Pros and Cons for Patient Portal ( My Chart)

Given previous research and the current challenges associated with ACP delivery, we
believe that an EHR-tethered patient portal-based communication tool can provide an
opportunity for improving the ACP process for patients and physicians, especially in the
outpatient setting. This ACP tool could offer patients educational materials, provide
templates where patients can complete their documentation and have it automatically
reflected in the EHR, provide discussion points for talks with potential health care
agents, and facilitate electronic communication between patients and providers.

https://journals.sagepub.com/doi/full/10.1177/1179597219856564

Cons at this moment

From a technical perspective, international data sharing represents a complex
challenge. There is currently no widely accepted database structure for critical care
databases. Should such a structure be developed, disparate concepts between centers
would require harmonization, and we currently lack a common standard for representing
various sources of clinically relevant information. 16 As medical centers have substantial
differences in the way care is delivered, with variable access to medical technologies,
and cultural differences in the way care is documented, the development of a system for
cross talk between critical care databases would be a major engineering feat.

https://journals.sagepub.com/doi/full/10.1177/1460458218814893
https://www.reviewofophthalmology.com/article/ehr-systems-room-for-improvement

same article but limited access to full text

http://web.a.ebscohost.com.sandiego.idm.oclc.org/ehost/pdfviewer/pdfviewer?
vid=12&sid=d41b0c44-b234-43fa-bdc8-6062a093164f%40sessionmgr4007

ven if having the EHR system in the exam lane makes it more challenging. 
Andrew Iwach, MD, executive director of the Glaucoma Center of San Francisco and
board chair for the Glaucoma Research Foundation, says that when it comes to quality
of care, the primary concern is the patient-doctor interaction. “My job is, number one,
patient quality of care and happiness, and number two, keeping doctors happy,” he
says. “We’re looking at the patient experience and how the value of our practice is
perceived beyond the technical skills that we have. Patients appreciate me looking them
in the eye versus looking at a terminal.” Dr. Wells agrees that understanding the patient
dialogue can be as valuable, if not more valuable, than structured data. “Being a
phenomenal physician vs. being a so-so one, involves utilizing not just your expertise,
knowledge and experience but also skills of observation,” she says. “Your sense of
vision, smell, and hearing in combination with your assessment of body language, and
the patient’s facial affect can optimize diagnosis.”

https://journals.sagepub.com/doi/full/10.1177/1460458215572925
Mobile platform for treatment of stroke: A case study of tele-assistance
Our working team has been part of a research project in which a telemedicine
platform5 has been developed for the diagnosis and treatment of stroke episodes in
static environments. In that project, the neurological team in the Reference Hospital has
the technological means for replying to the consultations made from another hospital
that lacks these kinds of specialists.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.1008.3160&rep=rep1&type=pdf
EHR and EPR confidentiality based on accountability and consent: tools for the Caldicott
Guardian
The delivery of healthcare in the near future will require sophisticated confidentiality systems to
protect data about activities which affect patients and consume resources, and also for data to be
shared widely. This paper shows that both of these requirements can be met using a model which
incorporates accountability, and confidentiality defined in terms of accountability and consent.

Benefits of HER, you can upload your preferences, which allows you for personalized templets
and uploading your forms, but it’s not useful if you don’t actually upload all those things, and it
does take time.
Another con: it will never be perfect. You will need to adjust, in order for it to work for you, you
will need to change some stuff to make it work for you.
HER has technical difficulties by not responding to opening correct files on time causing doctors
to mistaken for a correct file. This leads to unintended safety issues and potential worsening of a
patient.. Here is a great example:
Medstar Health’s Dr. Terry Fairbanks, who studies human factors in health care, explained how a
computer auto-refresh error can cause a problem without the doctor realizing it. Let’s take two
patients. Martha Jones and Daniel Rodriguez, who come into the emergency department on the
same day and have similar issues so they both need a chest x-ray. When the doctor goes to see
Martha Jones, they pull up the patient’s electronic health record to look at the X-ray. And the doctor
actually pulls up Daniel Rodriguez’s X-ray thinking that that it is Martha’s. And this x-ray appears
normal, so the doctor sends Martha home. This all happened in a fraction of the second, so let’s
slow it down and see what actually happened. In between the first and second click, the database
updates, and auto-refreshes. So by the time the doctor finishes the second click, the X-ray icon his
cursor was on now, belongs to Daniel Rodriguez. Daniel’s x-ray looks fine. On the other hand, this is
Martha Jones's actual X-ray. You can see there's a large, white area here, which represents a
pneumonia, which needs antibiotics. Without antibiotics, Martha could get much worse very quickly.
This is one example of a Health-IT facilitated error and there are many others. This is a fixable
problem, but currently there’s not enough research on how and why these errors occur. All patients
deserve the best care possible. We need better data now on how, when and why these challenges
arise so that we can all do a better job protecting our patients.

The Pros and Cons of EHR in Private Practice | Electronic

Health Records
https://www.youtube.com/watch?v=M7MTX3pyiq8

https://www.youtube.com/watch?v=GzeUKKWvC0o

The HITECH Act: Electronic Health Records and Meaningful Use