Original Contribution
Motivations and barriers to implementing electronic health records and ED information systems in Japan,☆☆,

https://doi.org/10.1016/j.ajem.2014.03.035Get rights and content

Abstract

Background

Although electronic health record systems (EHRs) and emergency department information systems (EDISs) enable safe, efficient, and high-quality care, these systems have not yet been studied well. Here, we assessed (1) the prevalence of EHRs and EDISs, (2) changes in efficiency in emergency medical practices after introducing EHR and EDIS, and (3) barriers to and expectations from the EHR-EDIS transition in EDs of medical facilities with EHRs in Japan.

Materials and methods

A survey regarding EHR (basic or comprehensive) and EDIS implementation was mailed to 466 hospitals. We examined the efficiency after EHR implementation and perceived barriers and expectations regarding the use of EDIS with existing EHRs. The survey was completed anonymously.

Results

Totally, 215 hospitals completed the survey (response rate, 46.1%), of which, 76.3% had basic EHRs, 4.2% had comprehensive EHRs, and 1.9% had EDISs. After introducing EHRs and EDISs, a reduction in the time required to access previous patient information and share patient information was noted, but no change was observed in the time required to produce medical records and the overall time for each medical care. For hospitals with EHRs, the most commonly cited barriers to EDIS implementation were inadequate funding for adoption and maintenance and potential adverse effects on workflow. The most desired function in the EHR-EDIS transition was establishing appropriate clinical guidelines for residents within their system.

Conclusion

To attract EDs to EDIS from EHR, systems focusing on decreasing the time required to produce medical records and establishing appropriate clinical guidelines for residents are required.

Introduction

Developed primarily for use in general inpatient and outpatient care, electronic health record systems (EHRs) have improved patient care worldwide [1], [2], [3]. However, extending EHRs to the emergency department (ED) setting has been a challenge due to differences between the requirements of general medical practice and those of an ED. Specifically, EDs must routinely treat several patients simultaneously, and many patients do not schedule their visits [4], [5], [6]. Therefore, EDs require customized emergency department information systems (EDISs) that reflect the unique procedures and treatments performed in emergency care settings [4], [7].

First proposed in 1975 [8], EDISs are now defined broadly as “EHRs designed specifically to manage data and workflow in support of ED patient care and operations [9].” Cumulative evidence indicates that EDISs have improved workflow and patient care in the ED [10]. However, to the best of our knowledge, although there has been only one report on the prevalence of EDIS from the United States [11], the prevalence of EDISs in Japan is not known.

In Japan, EHR adoption started in the 1990s [12], [13], but it is assumed that the prevalence of EDISs remains low [14], [15]. Considering the shortage of medical staff and the increasing number of patients visiting EDs, widespread adoption of user-friendly EDISs is urgently needed to improve workflow and the quality of patient care [13]. To facilitate hospitals’ adoption of such systems (thereby supporting prompt, safe medical treatment in the ED), it is particularly important to determine why hospitals with EHRs hesitate to introduce EDISs. The aim of this multicenter survey was to identify current problems with EHR and the barriers to EDIS adoption in Japan. To this end, we conducted a questionnaire survey on (1) the prevalence of EHR and EDIS adoption, (2) the changes made after EHR introduction, and (3) the barriers to and expectations for EHR-EDIS transitions in Japanese emergency medical facilities with existing EHRs.

Section snippets

Setting: emergency medical facilities in Japan

In Japan, emergency medical facilities are designated as primary, secondary, or tertiary care facilities [16], and paramedics choose the appropriate health care facilities depending on the patient’s condition. Primary care facilities do not have beds, as they are designed for walk-in patients who do not require in-hospital care. Secondary care facilities provide inpatient care to both walk-in patients and those transported by ambulance; these facilities are used to examine and treat patients

Results

Among the 466 hospitals contacted, 215 completed the survey (46.1% response rate) (Table 2). There were no significant differences in hospital size between respondent and nonrespondent hospitals.

Discussion

To the best of our knowledge, this is the first comprehensive national survey of EHRs and EDISs in Japanese hospitals to explore barriers to and expectations for EDISs implementation in hospitals with existing EHRs. First, the current survey identified that only 9 hospitals (4.2%) had comprehensive EHR, and only 4 hospitals (1.9%) had EDIS. Second, ED directors reported that the introduction of EHR did not change the time required to create medical records and did not reduce overall clinic

Limitations

The present study has several limitations. First, we achieved only a 46.1% response rate, and the hospitals that did not respond to our survey were somewhat different from those that did respond. We found no significant hospital size difference between the hospitals that did and did not respond to our survey. However, because this survey was completed anonymously, it was difficult for us to follow the nonrespondents. According to the supplemental small-scale phone interviews after the survey,

Conclusion

We found that very few hospitals have comprehensive EHR systems or EDIS in Japan. As EHR-EDIS transitions become faster, providers and emergency physicians together should focus on developments that decrease cost, shorten the time to create medical records, and incorporate clinical guidelines.

Acknowledgments

We thank the physicians who participated in the survey and Ms Takako Sakamaki, who assisted with data collection. Finally, we thank the Japanese Association of Healthcare Information Systems for providing data.

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    Grant: This work was funded by a grant-in-aid for Young Scientists (C) (127100000424) to HS, MG, NY, and SN and a Health Labour Sciences Research Grant to HS, NY, and SN.

    ☆☆

    Author contribution: RI conceived the study. RI, HS, YK, and SN designed the analysis plan. RI and HS performed the statistical analyses. RI wrote the first draft of the study. KN and YA contributed to draft of the study. RI, KN, MG, TM, YK, NY, and SN obtained the data. YA, KS, and NY critically reviewed the manuscript. All authors contributed to the design, interpretation of results, and critical revision of the article for intellectually important content.

    Conflicts of interest statement: The authors declare that they do not have any conflicts of interest.

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