Progress of Digital Health Applications in Medicine

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Digital applications in medicine have rapidly evolved, transforming healthcare delivery through advancements like electronic health records (EHRs) for streamlined patient data access, telehealth platforms enabling remote consultations, wearable devices for real-time health monitoring, and artificial intelligence (AI) algorithms for improved diagnostics and treatment planning. These technologies have significantly increased patient engagement, facilitated proactive care, and enhanced healthcare accessibility, particularly in underserved areas, while simultaneously optimizing clinical workflows and decision-making processes. As the field continues to develop, further integration of sophisticated digital tools is expected to revolutionize personalized medicine and further elevate healthcare outcomes.

Key points:

• EHRs:

  Centralized digital patient records for improved information sharing and care coordination. EHR came on the scene in the late 2000s as the result of a federal incentive program to offset the considerable expense of acquiring software and hardware by physicians, clinics, and hospitals. CMS defined requirements for certification for reimbursement to physicians.  Many legacy systems were discarded and replaced by certified applications
• Telehealth:

  Virtual consultations with healthcare providers, bridging geographical gaps. The greatest impetus for telehealth was the COVID 19 Pandemic to minimize transmission by office attendance and to relieve the large increase in demand for services due to COVID illness.
• Wearables:

  Real-time monitoring of vital signs like heart rate and activity levels. Remote monitoring allows for the management of chronic illnesses, such as hypertension and cardiac arrhythmia. Chronic care management is encouraged by many insurance companies/
• AI:

  Advanced analysis of medical data for enhanced diagnosis and treatment recommendations. A.I. is being evaluated and used for some applications.  Monitoring and transcribing in real time improves clinician efficiency.  Symptoms and signs may be interpreted and translated into possible diagnoses, however, AI must be monitored for accuracy by a clinician. AI is also used for drug development and research. AI is also used for developing and writing reports and letters for consultation by specialists.

A.I for analysis of imaging

A.I for Robotics

A.I is used by insurance companies to deny prior authorizations for patient services. A.I. has unlimited potential for increasing efficiency throughout the entire health care system.

A.I. will require regulation for ethical concerns. 

A.I. will improve as the training model expands.

Stay tuned for updates.

Journal of Medical Internet Research - 25 Years of Electronic Health Record Implementation Processes:

The results published here are from a meta-study. 

 Identifying Relevant Studies

A systematic literature search was conducted across 5 databases to identify all relevant literature: EBSCO, PubMed, EMBASE, IEEE Explore, and Scopus. The following specific keywords were used in the search strategy: (EHR OR EHRS OR Electronic Health Record* OR EMR OR EMRS OR Electronic Medical Record*) AND implement* AND process (all in the abstract). Detailed search strategies are provided in 

Multimedia Appendix 2. The research period was from January 1999 to August 2024 in line with the focus of this special issue looking at the past 25 years. We chose to include the word “process” in our search string, in addition to variations of the word “implement” in order to refine our results to include discussions focused on the process of implementing EHRs rather than those centered on the outcomes of EHR implementation. We also chose to search for the term “electronic medical records,” in addition to EHRs in the initial stage, even though the focus of our paper was on EHRs. This inclusion of EMRs in the initial search allowed us to account for discrepancies in the language used when discussing EHRs. This initial inclusion in our search criteria also meant we were able to manually exclude EMR studies that were purely discussions of EMRs and manually include EMR studies that also discussed EHRs or possessed the same functionalities of an EHR. This broadening of our search terms meant that our analysis of the literature was more thorough. We chose only empirical studies because we sought evidence of specific experiences of EHR implementation processes.

Over the past 25 years, electronic health record (EHR) systems have undergone remarkable development, becoming an important element of modern health care [1]. Since their inception in the late 20th century, EHRs have advanced substantially, propelled by both technological innovations and critical policy reforms [2]. Key legislation, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, was instrumental in accelerating the widespread adoption of EHRs, solidifying their role in Enhancing health care delivery. Today, EHRs are indispensable for improving patient safety, and operational efficiency, and ensuring vital patient information is securely stored and easily accessible across healthcare settings [3].

Research to date has examined some of the key pre-implementation indicators of EHR adoption and success. Studies have revealed how certain organizational characteristics are likely to predict success, such as the organization's size [4,5] and where it is located [6,7]. Other research has provided important details on postimplementation evaluations by users. These evaluations may include an increase or a decrease in the difficulty of tasks for the physician [8], the impact on patient care [9], and effects on privacy and security [10].

There is an extensive body of literature reviews published over the past 2 decades that explore the success factors and challenges associated with EHR implementation [11-20]. This has substantially and importantly improved our understanding of those factors that must be considered when planning EHR implementation. Fennelly et al [20], for example, identified 15 interlinked organizational, human, and technological factors that affect successful EHR implementation across primary, secondary, and long-term care settings. Our study built on this body of work by returning to the source literature with a process focus—digging beneath the success factors and challenges to examine the underpinning processes of EHR implementation. A process focus allows us to examine the connections between the factors already identified, unveiling new aspects, such as flow, activity, and temporality [21]. We, therefore, foregrounded and synthesized those papers that center on this vital process of implementing an EHR rather than delving into the technical intricacies of EHR technology itself.

Defining an EHR

The World Health Organization defines the EHR as “a longitudinal record of patient health information generated by one or more encounters in any care delivery setting” [22]. These records may include details such as demographics, progress notes, vital signs, medications, immunizations, lab results, and radiology reports, which all provide a comprehensive view of a patient’s health. Similarly, the Centers for Medicare and Medicaid Services (CMS) emphasizes that EHRs play a crucial role in helping health care providers maintain accurate and up-to-date patient data over time, ensuring that key clinical and administrative information is easily accessible and securely shared among authorized users [23].

Electronic medical records (EMRs), in contrast, are records created by practitioners for specific encounters, examples of which may be hospital visits or the use of facilities within ambulatory environments. Finally, a personal health record (PHR) is data controlled by the patient through the use of an electronic application that they are able to provide to their health practitioners. PHRs support patient-centered health care by making medical records and other relevant information accessible to patients, assisting patients in health self-management [24]. We focused exclusively on EHRs rather than EMRs or PHRs. The scope of EHRs is generally larger than that of EMRs or PHRs. They require a broad range of data types and need to be able to connect these across systems, whereas EMRs are generally confined to an individual practice [25], limiting their scope, and PHRs are generally subject to personal management [26]. This makes them less complex, and therefore less interesting from a research perspective, than EHRs. EHRs require higher levels of interoperability, regulatory challenges, stakeholder involvement, and cost and time investment than EMRs or PHRs, making them the ideal focus of this research.

Although the terms “EHR” and “EMR” are conceptually distinct, they are often used interchangeably in the literature. We recognize that the definitions we used for EHRs and EMRs in our review are not universally observed, and the terminology used in the literature and in practice often reflects the contexts in which these systems are implemented rather than the strict definitional boundaries placed upon them. In instances where studies, such as Felt-Lisk et al [27], have examined systems referred to as EHRs but may have operationally aligned with our definition of EMRs, we opted for a more inclusive approach. This definitional ambiguity may mean that some of our recommendations may equally apply to systems labeled as EMRs rather than EHRs. Addressing this overlap is essential for advancing a more unified understanding of electronic records in health care; however, it was not the purpose of this research.

Implementation Process

Rather than the broader issue of EHR adoption, which relates to the widespread acceptance and use of the technology across healthcare settings, our focus was on implementation as the practical, often complex, process of integrating EHR technology into healthcare environments. Adoption is the “phase of investigation, research, consideration and decision making to introduce a new innovation into the organization” [28,29]. Implementation is the “phase of internal strategy formation, project definition and activities in which an adopted application is introduced within the organization, to remove reservations and stimulate the optimum use of the application” [29]. Although adoption can occur both before and after implementation, these terms describe separate, distinct actions. We discussed EHRs in terms of the process of implementation, as defined by Bouwman et al [29].

Implementing an EHR may be the most challenging part of the process.

1.Stafftraining requiresdedicated assistance and should  be provided by the vendor, preferably on site or with group meetings.

2. Practice efficiency and productivity will suffer during the learning period.

Revenue will decrease for some time.It is advisable to establish either a cash reserve or a line of credit., Expect staff resignations. Some employees find it difficult to adapt to an EHR.

Some vendors also supply revenue management using a contracted billing service.  This may be advisable during the ininital training period. This will allow the staff to focus on the operations of the new EHR.

Process Costs in EHR Implementation

Cost considerations were shown to be an important part of the implementation process, with 41 (45.6%) papers making reference to cost. Adoption of appropriate processes is crucial regarding system development time and budget [42]. As such, successful implementation should have sustainable funding that aligns with a national strategy for eHealth [41]. Determining costs and measures of success is a vital part of project management, especially in pre-implementation [108]. The role of monetary incentives in this stage of the process is also an enabler [36]. One of the challenges of a national project is that funding sources depend largely on the government [31]. Implementing a system on a national scale is an extremely complex activity [52]. It is difficult to manage, costly to maintain, and hard to sustain [89]. Financially, the most serious obstacle in implementing EHRs is the cost of electrification [38]. Further customization also leads to increased maintenance costs [60]. The high upfront cost of EHRs for small practices is a major factor limiting their use [27]. Most hospitals report substantial financial challenges in EHR implementation and use, including EHR and broadband implementation costs and the limited availability of grants and loans to support EHR implementation and use [113]. A lack of capital resources can hinder the EHR implementation process [43]. Other issues include inadequate capital for investment and maintenance costs [110], large-scale procurement being undertaken to save costs [52], attempts to implement EHRs halting due to financial issues [54], and the high costs of implementing a system [97].

Compliance Processes in EHR Implementation

Our review suggested that compliance processes in EHR implementation center around the government, policy, regulations, and vendors. The literature referenced government-related processes in 29 (32.2%) papers. There were discussions of policy-related processes in 21 (23.3%) papers. Regulation-related processes were considered in 10 (11.1%) papers, and vendor-related processes were referenced throughout 20 (22.2%) papers.

Government-Related Compliance Processes

EHR implementation problems often arise at the national level rather than at regional or health service–specific levels. This is a result of the increased complexity of national implementation [38]. Nationwide implementation requires a huge change from stakeholders [42]. In a national project, practitioners operating in public and private domains require different engagement strategies to secure their buy-in [51]. A national strategy is, therefore, needed for a national EHR implementation process [110]. National EHRs require adaptation with clinician practices nationwide to ensure workflow processes are consistent [91]. Further recommendations from the literature include changing from a top-down implementation model to increased involvement of local organizations in decision-making [35]. Planners need to ensure potentially unclear areas are clarified with program management and that clinicians are informed and consulted [51]. National-level implementation is not just simple system installation; it is discovering ideas from private institutions and using them to drive best practices across the system nationwide [49]. Bottom-up implementation is, however, time-consuming and may hinder future collaborations [94], whereas the top-down nature of some projects contributes to a lack of organizational and user involvement in decision-making [52].

The role of the government in initiating and maintaining momentum around EHR implementation processes came through strongly from our review. Government leadership is considered a strategic advantage when the goal is the sustained enforcement of EHR initiatives [31]. Mature EHR systems benefit from being well integrated into the national health-planning documents of the government [39], while national reimbursement policies can increase EHR dissemination [49]. To maintain momentum, government commitment must be both strong and continued and accompanied by political support [36]. eHealth experts are, therefore, generally in favor of a strong central solution for political regulation problems [62]. It is, however, not just the national government that matters. Support from the local government also plays a crucial role in terms of finances, provision of resources, and technical support [41]. Indeed, implementation processes suffer where they lack sufficient coordination with the local government [41]. However, strong national or local government policies mandating the use of specific eHealth solutions may support EHR implementation processes [41]. Excessive regulation may also hinder the long-term sustainability of EHR initiatives [31].

Changes in the government may lead to having to modify an overall implementation process [35]. Shifts in the government strategy affect the power dynamics between national branches of large IT companies compared to national information and communication technology companies [55]. A change in the government also has the potential to result in uncertainty about the future of national programs [52,58]. It is, therefore, advisable for system evaluators to form close relationships with policy makers [35]. Alternatively, if there is a lack of a government-level information policy at the time of design and development, the sustainability of the EHR implementation is endangered [48].

The Role of Vendors

Governments are not, however, the only organizational actors who can manage or lead EHR compliance processes. Vendor organizations that have strong centralized administrative and medical structures are drivers of organizational policies and processes that are crucial to compliance [64]. Indeed, in some instances, large private vendors may enter a market specifically to provide unified access to health care data [49]. It is the process of compliance of large technology companies with uniform national standards and rules that enables EHR implementation in this instance [55,60].

Vendor recommendations influence software choice processes [69]. EHR implementors cannot simply buy from the same vendor as their existing financial system and assume turnkey, seamless interoperability [71]. There are often limitations to existing vendor-based EHRs when compared with in-house systems, including autonomy of practice decisions at each hospital [70]. These limitations are also seen in difficult-to-assess EHR usability as a result of restrictive vendor license agreements [59].

EHR vendors are generally at least partly responsible for the amount of training received by users [69] and sometimes also responsible for providing technical support [27]. Indeed, vendors may use the provision of ongoing technical support as a form of training [77]. Both peer and technical support may be issued from these vendors, which can help end-users optimize their use of the EHRs and solve issues [67]. Even large vendors may need to consider EHR adaptations for small practices as part of the sale of the EHR, ensuring that a person within the practice conducts training and adapts it to the specific needs of the practice rather than relying on training by IT specialists [53].

Collaboration Processes in EHR Implementation

Collaboration in the literature includes communication and relationships throughout the management of the implementation process. Communication was mentioned in 40 (44.4%) papers. Relationships were discussed in 30 (33.3%) papers.

Collaboration among team members is important [60], as is communicating clear expectations and guidelines [61]. Consistent, reliable communication fosters trust [83], and well-articulated visions are important for the management of expectations [74]. Strong communication practices are an enabler of successful implementation outcomes [84]. However, a lack of communication during planning can cause issues [49].

Collaborating facilitates successful EHR implementation [95]. Cuccinello et al [36] illustrate this in their study of a vendor’s collaborative relationship with a health care department in Italy. Relationships with vendors build confidence within the organization and ensure strong external support [60]. Where, however, communication breaks down, it can jeopardize implementation processes [41]. Relationships between contractors and suppliers may become more impersonal and distant as a result [34]. Direct and close channels of communication between the implementer hospitals and software suppliers are, therefore, essential from the outset [89]. Kiepek and Sengstack [84] suggest an open and transparent relationship with external support from vendors, beginning with initial negotiations.

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Journal of Medical Internet Research - 25 Years of Electronic Health Record Implementation Processes: Scoping Review