Recently in Healthcare Kiosk Category

by Mathew Hegarty  -- More and more healthcare organizations are turning to virtual desktops to address their challenges with the management, security and cost of their organizations end-point devices, namely workstations and laptops. This has long been a complicated subject for healthcare executives due to the complexities within in the healthcare environment. The fact is, end-point devices are the one piece of the technology chain not physically placed in a secured environment.  Servers and switches are hosted in secured and environmentally controlled Data Centers and IDF closets, but laptops and workstations do their work in the Emergency Room, admitting office, or on one of the Nurses mobile carts. This introduces not only additional support costs and challenges but security concerns as well.

Even for the IT administrators managing a traditional technology infrastructure consisting of servers, desktops and laptops creates serious challenges. Ensuring software is consistently updated, hardware is running optimally and data is secure and safely backed-up is a time-intensive monotonous effort that puts IT departments in reaction mode rather than focused on proactive system maintenance and innovation. 

The economics of Healthcare IT are simple. The cost of maintaining IT infrastructure is becoming untenable given the complexity of new systems; the need for flexible and scalable deployments are a requirement for all new projects with executive buy-in. Add to that increasing healthcare costs relative to inflation and newfound political pressure to keep costs down while maintaining the quality of the care being provided. One thing is certain, healthcare organizations are challenged as never before to do more with less.

Enter virtual desktops to save the day - and the bottom line - for healthcare. For the uninitiated, virtual desktops represent a philosophical shift in how end-point devices are deployed and supported across an organization. The traditional approach of managing hardware, software and data at the individual machine level is extremely costly, typically in an uncontrolled environment, and near impossible to keep consistent.

The simple fact is virtual desktop technology allows Healthcare IT departments to deploy desktops, laptops and portable devices at a lower cost and from a controlled, secure data center. By running the software on a centralized server and having users access only necessary applications, the resources required to support the network are minimized while network uptime can actually be increased; because we are ìpushingî the applications and configurations from a central point, consistency is maintained across the environment.

This isn't exactly a new concept.  IBM had seen the value of running centralized servers with terminals back in the late 1950's with the advent of the Mainframe.    The concept was simple: centralize the key resources in a secured, controlled data center and use lower cost ìdumbî terminals at each desk to communicate with the mainframe.  Well, whatís old is new again.  The main difference between the Mainframes of old and todays virtual desktops are the familiar graphical interface of Microsoft Windows.

Hospitals and clinics can now make technology work for them, not the other way around. Virtual desktops loaded on thin clients, old workstations or laptops mounted on rolling carts have transformed the way physicians and caregivers treat patients. Instant access to patient records and integrated prescription management means healthcare workers now have real-time information at the point of care, which translates into faster, more effective care for patients.

Compliance with HIPAA is made even easier by virtual desktop technology. By accessing applications and data stored on a centralized server, the risk of losing sensitive patient data through the theft of hardware is nearly eliminated. What's more, once data is entered by a caregiver the device used does not retain the patient data. In short, applications and data stored on servers in a data center are subject to the highest level of control and security possible.

From my perspective as an experienced Systems Integrator, a virtual desktop solution makes sense for just about every healthcare organization.  From small physician practices up to the largest hospital groups, the fundamental benefits are the same. Translation? Gone are the days of your IT staff having to troubleshoot individual desktops because of a problem with an application. Gone too is the need for updates and patches for individual applications and printers on every physical desktop. Application performance is raised to a higher level because the computing environment and configuration is controlled in the data center.

What's our prognosis on the future of healthcare IT? Virtual desktop technology brings too many benefits to healthcare at a time when cost containment and data control are paramount. The transformation of healthcare technology is happening now and will never be the same. Because the most efficient delivery of healthcare information always wins in the end, we're seeing the age of virtual desktops take form.


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Virtualization , Virtual Desktops , HIPAA , Healthcare IT , Compliance


Looking at VistA EHR and VA

Timely brief on VistA which is the EHR software available from the Department of Veteran Affairs.  With the recent activity by the VA for it is good background.  

Stephen Bowerman knows a bargain. He's chief financial officer at 320-bed Midland (Texas) Memorial Hospital, among the first users of OpenVista, one of several versions of the "free" VistA electronic health record software available from the Department of Veterans' Affairs. (OpenVista is developed and supported by Medsphere, Carlsbad, Calif.)

The system had been in place for two years when he arrived at the county-owned hospital in 2009, and Midland had just been validated as Stage 6 in the HIMSS Analytics EMR adoption model. The presence of advanced information technology helped induce Bowerman to take the job despite Midland's $14 million loss in 2008. Switching to a new accounting information system and tightening procedures such as co-pay collection and insurance verification helped Midland move to a $1.5 million surplus in 2009.

Bowerman describes himself as a "dangerous" CFO for the I.T. department, because he started his health care career on the I.T. side, implementing a cost accounting system for a government hospital. "At least I can ask intelligent questions," he says.

 On costs

OpenVista is not free. The code is free, but how you implement it is not. If you had the resources and the right team you could implement it yourself, but we didn't feel like we had the resources. Medsphere helped tailor some of that free source code to our needs. We paid them to come out and help us implement the system and it wasn't cheap, but it was probably 30 percent to 40 percent of the cost of going with Epic or McKesson. It was early on and I'm sure Medsphere today could offer even more than they offered us. We were a beta site for some of their development and they've learned from us and can do it better. Our maintenance ticket is cheaper than it would be with one of the other guys.

Rest of article and source

American are taking a shine to self-service healthcare.

They may not be snatching the scalpel out of their doctor's hands and doing their own surgery, but they are registering on their own - in doctors' offices, clinics and hospitals - thanks to the advent of healthcare kiosks. Taking their cue from airlines, retail stores and banks, healthcare providers are using kiosks to speed up the registration process, enter valuable data into the electronic health record and push revenue cycle management capabilities to the front end - all while advancing the concept of consumer-directed healthcare.

"The uniqueness of this application is that the patient is involved - this is the first application to focus on the patient," said Josh Napua, vice president of the healthcare group at Fujitsu, which has teamed with Allscripts-Misys Healthcare Solutions to launch a kiosk. "This creates a portal for the patient into two key areas: billing and the EMR."

Jeffery M. Kendall, director of business development for NCR, said kiosks are popular with healthcare providers seeking to clean up their front-office efficiencies. Tying the kiosk into a Web-based portal, providers are able to push appropriate clinical content to the patient prior to the appointment, as well as establish payment plans and set up billing procedures.

NCR recently teamed up with Passport Health Communications of Franklin, Tenn., to integrate revenue cycle management solutions into NCR’s MediKiosk. “Increasing the efficacy and efficiency of front office activities can have a direct impact on improving revenue cycle. Integrating with Passport increases the benefit NCR solutions can have in this critical area,” said Raj Toleti, general manager of NCR Healthcare.

The list of kiosk vendors in the healthcare market is large and growing larger by the day. It includes GE Healthcare, Siemens, the NCR Corp., Healthcare Kiosk Management, DynaTouch, Gokis, Medfusion, McKesson and D2 Sales, to name just a few. Another new entry to the market is Navicure, which partnered with Clearwave to unveil the Navicure Check-In solution in March. And The CBORD Group, based in Ithaca, N.Y., markets a series of kiosks designed specifically for food service in hospitals.

According to a study undertaken by the Pittsburgh VA Medical Center, the healthcare kiosk market is expected to top $800 million by 2013. 

Kiosks are popping up in hospitals and clinics from one end of the country to the other. The Carle Clinic Association in Illinois, one of the nation's largest private physician groups, implemented D2's My Patient Passport Express kiosks earlier this year at 11 offices in central Illinois. Following the rollout of 90 self-service kiosks in 60 medical clinics in southern California, Kaiser Permanente conducted a patient satisfaction survey. The survey indicated 75 percent of those using the kiosks found it to be faster than checking in with a receptionist.

According to Lynn Dunbrack of Health Industry Insights, kiosks will work in the healthcare setting if they improve the patient experience - and that means reduce the time spent waiting, making the technology easy to use and linking patients to billing services. With so many hospitals operating in the red, she pointed out, a technology that improves revenue cycle management is a good sell.

"There is the concern that you're removing the clinician from the encounter, but you're actually freeing up time for the clinician to talk to the patient," she added.

Merge Healthcare is in the "proof of concept" phase for its own kiosk, which will feature registration, billing and management applications. Company officials were impressed by how kiosks had caught on in airports, but understand the airline and healthcare industries are vastly different.

"The variations on a theme are pretty spectacular," said Tim Kulbago, Merge Healthcare's chief strategy officer. "Unlike airplanes, healthcare is still very much a person and a patient."

Kulbago said a kiosk by itself won't work in a hospital setting. Merge is working with avatars, he said, to make the experience more personal for healthcare consumers.

"It comes down to a comfort factor," he said. "It's a little impersonal, and sometimes you just want to talk to somebody."

"The worst thing you can do is walk up to a kiosk and it tells you to go talk to somebody at the front desk," he added.

As for concerns that kiosks would put nurses on the unemployment line or be too impersonal, Fujitsu's Napua said kiosks will actually free up nurses to make better use of their time.

"The human interface doesn't go away," he said. "It actually enhances their jobs."

Not everyone is enamored with kiosks. Kelvin Buncum, of Atlanta-based International Medical Solutions, says providers and patients need something more mobile - something that can be carried with the patient or doctor and be used by different people. To that end, IMS is marketing the Mobile Patient Communicator, which looks like a tablet PC and has all the functions of the kiosk.

"It's a better alternative than the standard kiosk," said Buncum. "Kiosks have been out there for a bit and they haven't really penetrated well."

Buncum said the MPC can be customized for each patient, capturing data and providing access to a portal that can provide educational material as well as directions and messaging. 
"We think this is the missing piece of the puzzle for healthcare," he said.

In an era of consumerism, physician group practices are looking for ways to improve customer service and gain loyalty. So when surveys of patients at Springfield (Ill.) Clinic revealed dissatisfaction with the time-consuming, inefficient check-in process, CIO James Hewitt decided to take action.

Hewitt determined that installing self-service kiosks could help resolve the problem. But when he shopped for devices, he was disappointed with what he found. The hardware was too costly and took too long to implement, he says. And, more important, the kiosks did not integrate well with practice management and electronic health record software.

So he took the extraordinary step of working with two vendors as a co-developer of new kiosk technology. In this way, he was able to build into the kiosk every feature he desired and roll out the devices at a deep discount. Special features include new technology that uses palm scanning for patient identification.

The 195-physician multi-specialty practice, which has two dozen locations in Central Illinois, expects to install as many as 50 kiosks this year after recently testing the hardware at one location. "At our test site, we're seeing, on average, three pieces of registration information changed by patients," Hewitt says. For example, patients are entering new information about their employer, insurer, mailing address or emergency contact.

In addition to the development and testing efforts at Springfield Clinic, George Washington University Medical Faculty Associates, Washington, D.C., is serving as a beta site for the kiosks.

Springfield Clinic collaborated on the project with Tokyo-based Fujtisu Ltd., which manufactures the hardware, and Allscripts-Misys Healthcare Solutions Inc., Chicago, which markets the devices.

Hewitt and several members of his I.T. team did much of the software development work. The CIO has expertise in this arena, having formerly served as CIO at Allscripts.

"I wanted it to look like an airport check-in kiosk with big buttons," Hewitt says. The kiosks have 19-inch touch-screen monitors that patients use to make selections or type in information.

EHR Interface

The kiosks link to both Springfield Clinic's EHR system from Allscripts and its practice management software from GE Healthcare, Waukesha, Wis. When patients initially register to use the kiosks, they can use the Fujitsu palm scanner technology or just scan their credit card or other identification card.

The biometric technology uses near-infrared light to capture a patient's palm vein pattern, generating a template that is then matched against a database of enrolled users' palm-vein patterns.

The palm scanners "give the patient a sense of added security for their records," Hewitt says. "And they have that coolness factor."

The kiosks also have a camera to capture a photo that's displayed every time a patient signs in. The photo is included in the patient's electronic record.

In addition to confirming all scheduled appointments for the day, the kiosks, by linking to electronic records, show reminders, such as the need to slate an eye exam or schedule attendance at a prevention program. Users can update demographic information and make co-payments using a credit card. "The kiosk will even tell you if you are in the wrong location and print out directions to the right one," Hewitt says

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Projections that showed there would be 2,500 retail clinics operating by 2010 are coming up short as the industry has seen more clinic closings than openings in recent months.

MinuteClinic, the first and largest retail clinic chain, now owned by CVS, closed 100 of its clinics for the summer, leaving 452. In two years, the number of clinics housed in Wal-Mart dropped from almost 80 to 30. The retail giant recently acknowledged it would not reach the goal it set in 2007: having 400 retail clinics in operation by 2010.

Despite high satisfaction among patients who use retail clinics, investors have found the industry is slow to turn a profit. Many clinics were forced to close when they ran out of cash and were unable to shoulder the financial losses.

Analysts say the current dip doesn't mean the demise of the industry. But it may indicate it's time to change strategy.

Many analysts believe the key to sustainability will be clinics partnering with hospitals that are better prepared to shoulder the initial losses. Clinics also can build on hospital name recognition to attract more patients.

There are about 1,100 retail clinics nationwide.

But the downside is that hospitals move much more slowly than capital investment firms, leading to a drastic slowdown in opening new clinics. In addition, the recession has forced some hospitals to scale back plans for clinics, or choose between funding clinics or other capital projects.

When Wal-Mart first entered the retail clinic market, its strategy was to partner with venture capital-backed chain operators for whom Wal-Mart served solely as the landlord. After RediClinic shut down 15 of its Wal-Mart clinics in 2008 and other independent chains followed suit, Wal-Mart shifted gears and said it would partner with hospital groups.

Its plan was to have 400 hospital-affiliated clinics open by 2010. Half of the clinics were expected to open through a deal with RediClinic, which also cited the benefits of co-branding with hospital groups.

Bruce Shepard, director of health business relationship development for Wal-Mart, said the company decided that hospital partnerships would lead to a more sustainable business model. He said more hospitals are willing to take on the initial financial loss as part of an overall marketing strategy focused on access to care. The clinics can serve as an entry point for new patients to eventually become connected to primary care physicians.

But, Shepard said, the company underestimated the time it would take to get the clinics up and running. "As we learned more and more about the process and the time that it takes to get clinics to fruition with hospitals and health systems, generally, I think that's when we saw that [while] we're still committed to the [400] number, it's going to take a little bit longer."

Partnerships moving slowly

Paul Storey, vice president of physician services for Northwest (Arkansas) Health System, said the hospital system jumped at the chance to open clinics in two of the former RediClinic sites. But it is moving slowly on opening more clinics.

"This is kind of a new business for us, so we are constantly tinkering with how to do things and what to do and how to refine it," he said.

Northwest, which is part of Community Health Systems, has been analyzing locations for new clinics since March. Storey said it is looking at how to make the clinics a success before expanding in that area.

Shepard said that's the case with many of Wal-Mart's potential hospital partners. But he is still getting calls from health systems interested in entering the market. "They see the value and they're wanting to move forward, but ... it's a calculated risk."

Mary Kate Scott, principal of the Marina del Rey, Calif.-based consulting firm Scott & Co., authored a study in 2006 projecting 2,500 retail clinics by 2010. There are now about 1,100 nationwide.

At the time of the study, venture capital firms were still driving much of the growth. These investors not only underestimated the time it would take to turn a profit, Scott said, but they also underestimated the value of marketing. "I am very surprised it's taken that long to market these clinics."

It also takes time -- up to 36 months -- for hospitals to build a new clinic. Still, the partnering strategy makes sense, she said.

Just as hospitals enter the market with the goal of a long-term relationship with that community, so does a retailer like Wal-Mart. "You're actually creating a relationship with someone that could last 30, 40 or 50 years. So why wouldn't you think it would take 18 to 36 months?" Scott said.

Tom Charland, president and CEO of Merchant Medicine, a Shoreview, Minn.-based retail clinic consultancy firm, agreed the hospital-partnered model has the greatest chance of success. But he cautioned that it's not fail-proof.

Hospitals hoping for success must have their physicians behind the idea, he said. If the clinics are to be an extension of the health care delivery strategy, physicians must be willing to work with clinic operators on coordinating care.

But extending the delivery system too far can lead to failure. Aurora Health Care in Milwaukee, for example, had 19 clinics at one time. It's now down to 10.

Aurora did not comment by this article's deadline. But Charland said there was too much saturation in the market, especially after Take Care Health Systems entered the Milwaukee area.

"I think we'll see the slowdown last a couple of years," Charland said. "But I think once some of the things are sorted out with health care and the economy has turned around ... we'll see some shifting, and I think it'll be positive for this industry."

By Pamela Lewis Dolan, AMNews staff. Posted July 27, 2009.


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Report from New England Journal of Medicine on Electronic Health Records. Concludes - very low levels of adoption in U.S. hospitals suggest policymakers face obstacles to goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.




ABSTRACT

Background Despite a consensus that the use of health information technology should lead to more efficient, safer, and higher-quality care, there are no reliable estimates of the prevalence of adoption of electronic health records in U.S. hospitals.

Methods We surveyed all acute care hospitals that are members of the American Hospital Association for the presence of specific electronic-record functionalities. Using a definition of electronic health records based on expert consensus, we determined the proportion of hospitals that had such systems in their clinical areas. We also examined the relationship of adoption of electronic health records to specific hospital characteristics and factors that were reported to be barriers to or facilitators of adoption.

Results On the basis of responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive electronic-records system (i.e., present in all clinical units), and an additional 7.6% have a basic system (i.e., present in at least one clinical unit). Computerized provider-order entry for medications has been implemented in only 17% of hospitals. Larger hospitals, those located in urban areas, and teaching hospitals were more likely to have electronic-records systems. Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with electronic-records systems were less likely to cite these barriers than hospitals without such systems.

Conclusions The very low levels of adoption of electronic health records in U.S. hospitals suggest that policymakers face substantial obstacles to the achievement of health care performance goals that depend on health information technology. A policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of electronic-records systems in U.S. hospitals.


The U.S. health care system faces challenges on multiple fronts, including rising costs and inconsistent quality.1,2,3 Health information technology, especially electronic health records, has the potential to improve the efficiency and effectiveness of health care providers.4,5 Methods to speed the adoption of health information technology have received bipartisan support among U.S. policymakers, and the American Recovery and Reinvestment Act of 2009 has made the promotion of a national, interoperable health information system a priority. Despite broad consensus on the potential benefits of electronic health records and other forms of health information technology, U.S. health care providers have been slow to adopt them.6,7 Using a well-specified definition of electronic health records in a recent study, we found that only 17% of U.S. physicians use either a minimally functional or a comprehensive electronic-records system.8

Prior data on hospitals' adoption of electronic health records or key functions of electronic records (e.g., computerized provider-order entry for medications) suggest levels of adoption that range between 5%9 and 59%.10 This broad range reflects different definitions of what constitutes an electronic health record,10,11 use of convenience samples,12 and low survey response rates.13 To provide more precise estimates of adoption of electronic health records among U.S. hospitals, the Office of the National Coordinator for Health Information Technology of the Department of Health and Human Services commissioned a study to measure current levels of adoption to facilitate tracking of these levels over time.

As in our previous study,8 we identified key clinical functions to define the minimum functionalities necessary to call a system an electronic-records system in the hospital setting. We also defined an advanced configuration of functionalities that might be termed a comprehensive electronic-records system. Our survey then determined the proportion of U.S. hospitals reporting the use of electronic health records for either of these sets of functionalities. We hypothesized that large hospitals would have a higher prevalence of adoption of electronic health records than smaller hospitals. Similarly, we hypothesized that major teaching hospitals would have a higher prevalence of adoption than nonteaching hospitals and private hospitals a higher prevalence than public hospitals. Finally, to guide policymakers, we sought to identify frequently reported barriers to adoption and potential mechanisms for facilitating it.

Methods

Survey Development

We developed our survey by examining and synthesizing prior hospital-based surveys of electronic-records systems or related functionalities (e.g., computerized provider-order entry) that have been administered in the past 5 years.9,13,14 Working with experts who had led hospital-based surveys, we developed an initial draft of the instrument. To get feedback, we shared the survey with chief information officers, other hospital leaders, and survey experts. We then obtained input from a consensus panel of experts in the fields of health information technology, health services research, survey research, and health policy. Further survey modifications were approved by our expert panel. The final survey instrument was approved for use by the institutional review board of Partners HealthCare.

Survey Sample and Administration

We collaborated with the American Hospital Association (AHA) to survey all acute care general medical and surgical member hospitals. The survey was presented as an information technology supplement to the association's annual survey of members, and like the overall AHA questionnaire, was sent to the hospital's chief executive officer. Hospital chief executive officers generally assigned the most knowledgeable person in the institution (in this case, typically the chief information officer or equivalent) to complete the survey. Nonresponding hospitals received multiple telephone calls and reminder letters asking them to complete the survey. The survey was initially mailed in March 2008, and our in-field period ended in September 2008.

Survey Content

We asked respondents to report on the presence or absence of 32 clinical functionalities of an electronic-records system and on whether their hospital had fully implemented these functionalities in all major clinical units, had implemented them in one or more (but not all) major clinical units, or had not yet fully implemented them in any unit in the hospital. We asked respondents to identify whether certain factors were major or minor barriers or were not barriers to the adoption of an electronic-records system and whether specific policy changes would have a positive or negative effect on their decision to adopt such a system. The questions and response categories used are listed in the Supplementary Appendix, available with the full text of this article at NEJM.org.

Measures of Electronic-Records Use

The Institute of Medicine has developed a comprehensive list of the potential functionalities of an inpatient electronic health record,15 but there is no consensus on what functionalities constitute the essential elements necessary to define an electronic health record in the hospital setting. Therefore, we used the expert panel described earlier to help define the functionalities that constitute comprehensive and basic electronic-records systems in the hospital setting. The panel was asked to identify whether individual functionalities would be necessary to classify a hospital as having a comprehensive or basic electronic health record. With the use of a modified Delphi process, the panel reached a consensus on the 24 functions that should be present in all major clinical units of a hospital to conclude that it had a comprehensive electronic-records system.16 Similarly, the panel reached a consensus on eight functionalities that should be present in at least one major clinical unit (e.g., the intensive care unit) in order for the hospital to be classified as having a basic electronic-records system. Because the panel disagreed on the need for two additional functionalities (physicians' notes and nursing assessments) to classify a hospital as having a basic system, we developed two definitions of a basic electronic-records system, one that included functionalities for nursing assessments and physicians' notes and another that did not. We present the results with the use of both definitions.

Statistical Analysis

We compared the characteristics of respondent and nonrespondent hospitals and found modest but significant differences. We estimated the propensity to respond to the survey with the use of a logistic-regression model that included all these characteristics and used the inverse of this propensity value as a weight in all analyses.

We examined the proportion of hospitals that had each of the individual functionalities and subsequently calculated the prevalence of adoption of an electronic-records system, using three definitions of such a system: comprehensive, basic with physicians' and nurses' notes, and basic without physician and nursing notes. For all subsequent analyses, we used the definition of basic electronic health records that included clinicians' notes.

We explored bivariate relationships between key hospital characteristics (size, U.S. Census region, ownership, teaching status, urban vs. rural location, and presence or absence of markers of a high-technology institution) and adoption of a basic or comprehensive electronic-records system. We considered the use of various potential markers of a high-technology institution, including the presence of a dedicated coronary care unit, a burn unit, or a positron-emission tomographic scanner. Because the results were similar for each of these markers, we present data based on the presence or absence of only one -- a dedicated coronary care unit. We subsequently built a multivariable model to calculate levels of adoption of electronic-records systems, adjusted according to these hospital characteristics. We present the unadjusted results below and those from the multivariate models in the Supplementary Appendix.

Finally, we built logistic-regression models (adjusting for the hospital characteristics mentioned above) to assess whether the presence or absence of electronic health records was associated with respondents' reports of the existence of specific barriers and facilitators of adoption. Since the number of hospitals with comprehensive electronic-records systems was small, we combined hospitals with comprehensive systems and those with basic electronic-records systems and compared their responses with those from institutions without electronic health records. In all analyses, two-sided P values of less than 0.05 were considered to indicate statistical significance.

Results

We received responses from 3049 hospitals, or 63.1% of all acute care general hospitals that were surveyed. After excluding federal hospitals and those located outside the 50 states and the District of Columbia, we were left with 2952 institutions. There were modest differences between respondents and nonrespondents (Table 1), and all results reported below have been adjusted for potential nonresponse bias.

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Table 1. Characteristics of Responding and Nonresponding U.S. Acute Care Hospitals, Excluding Federal Hospitals.

 
Adoption of Clinical Functionalities in Electronic Format

We found large variations in the implementation of key clinical functionalities across U.S. hospitals. Only 12% of hospitals had instituted electronic physicians' notes across all clinical units, and computerized provider-order entry for medications was reported as having been implemented across all clinical units in 17% of hospitals (Table 2). In contrast, more than 75% of hospitals reported adoption of electronic laboratory and radiologic reporting systems. A sizable number of hospitals reported having implemented several key functionalities in one or more (but not all) units, having begun such implementation, or having identified resources for the purpose of such implementation. These functionalities included physicians' notes (among 44% of the hospitals) and computerized provider-order entry (38%).

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Table 2. Selected Electronic Functionalities and Their Level of Implementation in U.S. Hospitals.

 
Adoption of Electronic Records

The presence of certain individual functionalities was considered necessary for an electronic-records system to be defined as comprehensive or basic by our expert panel (Table 3). On the basis of these definitions, we found that 1.5% (95% confidence interval [CI], 1.1 to 2.0) of U.S. hospitals had a comprehensive electronic-records system implemented across all major clinical units and an additional 7.6% (95% CI, 6.8 to 8.1) had a basic system that included functionalities for physicians' notes and nursing assessments in at least one clinical unit. When defined without the requirement for clinical notes, a basic electronic-records system was found in 10.9% of hospitals (95% CI, 9.7 to 12.0). If we include federal hospitals run by the Veterans Health Administration (VHA), the proportion of hospitals with comprehensive electronic-records systems increases to 2.9% (95% CI, 2.3 to 3.5), the proportion with basic systems that include clinicians' notes increases to 7.9% (95% CI, 6.9 to 8.8), and the proportion with basic systems that do not include clinicians' notes increases to 11.3% (95% CI, 10.2 to 12.5).

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Table 3. Electronic Requirements for Classification of Hospitals as Having a Comprehensive or Basic Electronic-Records System.

 
Hospitals were more likely to report having an electronic-records system if they were larger institutions, major teaching hospitals, part of a larger hospital system, or located in urban areas and if they had dedicated coronary care units (Table 4); these differences were small. We found no relationship between ownership status and level of adoption of electronic health records: the prevalence of electronic-records systems in public hospitals was similar to that in private institutions. Even when we compared for-profit with nonprofit (public and private) institutions, there were no significant differences in adoption. In multivariable analyses, each of these differences diminished further and was less consistently significant (see the Supplementary Appendix).

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Table 4. Adoption of Comprehensive and Basic Electronic-Records Systems According to Hospital Characteristics.

 
Barriers to and Facilitators of Electronic-Records Adoption

Among hospitals without electronic-records systems, the most commonly cited barriers were inadequate capital for purchase (74%), concerns about maintenance costs (44%), resistance on the part of physicians (36%), unclear return on investment (32%), and lack of availability of staff with adequate expertise in information technology (30%) (Figure 1). Hospitals that had adopted electronic-records systems were less likely to cite four of these five concerns (all except physicians' resistance) as major barriers to adoption than were hospitals that had not adopted such systems (Figure 1).

Figure 1
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Figure 1. Major Perceived Barriers to Adoption of Electronic Health Records (EHRs) among Hospitals with Electronic-Records Systems as Compared with Hospitals without Systems.

Hospitals with electronic-records systems include hospitals with a comprehensive electronic-records system and those with a basic electronic-records system that includes functionalities for physicians' notes and nursing assessments. P<0.01 for all comparisons except physicians' resistance (P=0.20). IT denotes information technology, and ROI return on investment.

 
Most hospitals that had adopted electronic-records systems identified financial factors as having a major positive effect on the likelihood of adoption: additional reimbursement for electronic health record use (82%) and financial incentives for adoption (75%). Other facilitators of adoption included the availability of technical support for the implementation of information technology (47%) and objective third-party evaluations of electronic health record products (35%). Hospitals with and those without electronic-records systems were equally likely to cite these factors (P>0.10 for each comparison) (Figure 2).

Figure 2
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Figure 2. Perceived Facilitators of Adoption of Electronic-Records Systems among Hospitals with Systems as Compared with Hospitals without Systems.

Hospitals with electronic-records systems include hospitals with a comprehensive system and those with a basic system that includes functionalities for physicians' notes and nursing assessments. P>0.10 for all comparisons. EHR denotes electronic health record, and HIT health information technology.

 
Discussion

We found that less than 2% of acute care hospitals have a comprehensive electronic-records system, and that, depending on the definition used, between 8 and 12% of hospitals have a basic electronic-records system. With the use of the definition that requires the presence of functionalities for physicians' notes and nursing assessments, information systems in more than 90% of U.S. hospitals do not even meet the requirement for a basic electronic-records system.

Although levels of adoption of electronic health records were low, many functionalities that underlie electronic-records systems have been widely implemented. A sizable proportion of hospitals reported that laboratory and radiologic reports, radiologic images, medication lists, and some decision-support functions are available in electronic format. Others reported that they planned to upgrade their information systems to an electronic-records system by adding functionalities, such as computerized provider-order entry, physicians' notes, and nursing assessments. However, these functionalities are typically more difficult to implement than the others that we examined, and it remains unclear whether hospitals will be able to do so successfully.

We found high levels of decision support in the absence of a comparable prevalence of computerized provider-order entry. It is possible that respondents reporting that their hospitals have implemented electronic decision support were including in that category decision-support capabilities that are available only for electronic pharmacy systems, thereby overstating the preparedness of hospitals to provide physicians with electronic decision support for patient care.

We found somewhat higher levels of adoption among larger, urban, teaching hospitals, probably reflecting greater availability of the financial resources necessary to acquire an electronic-records system. We expected to find lower levels of adoption among public hospitals, which might be financially stressed and therefore less able to purchase these systems. Although our results do not support this hypothesis, we did not directly examine detailed indicators of the financial health of the hospitals, such as their operating margins.

In 2006, we performed a comprehensive review of the literature on hospital adoption of electronic-records systems in the United States and found that the most rigorous assessment made was for computerized provider-order entry and that its prevalence was between 5 and 10%.6,9,14 An earlier AHA survey showed a higher prevalence of computerized provider-order entry,13 but the response rate was only 19%. A Mathematica survey showed that 21% of U.S. hospitals had computerized provider-order entry and 59% had electronic clinical documentation.10 However, this survey's definition of clinical documentation allowed for the inclusion of systems that were only capable of recording demographic characteristics of patients, a definition that is likely to have inflated adoption levels, given that Medicare requires electronic reporting of demographic data. A recent analysis, based on a proprietary database with an unclear sampling frame and an unknown response rate, showed that 13% of the hospitals had implemented computerized provider-order entry, a prevalence similar to that in our study.11

Most reports of a beneficial effect of electronic-records systems involved systems capable of computerized provider-order entry with clinical-decision support.4 Our experts took a lenient approach by not requiring the presence of clinical-decision support as part of a basic electronic-records system and by requiring adoption of computerized provider-order entry in only one clinical unit. Whether a hospital that has successfully implemented computerized provider-order entry in one unit can easily implement in other units and add clinical-decision support is unclear. Furthermore, a nonuniform information system within the hospital (paper-based in some units and electronic in others) may increase clinical hazards as patients move from one unit to another. Whether the benefits of adoption of an electronic-records system in some clinical units outweigh the theoretical hazards posed by uneven adoption within the hospital requires examination.

Respondents identified financial issues as the predominant barriers to adoption, dwarfing issues such as resistance on the part of physicians. Other studies have shown that physicians' resistance, partly driven by concerns about negative effects of the use of electronic health records on clinical productivity,17 can be detrimental to adoption efforts.18 Whether our respondents, most of whom have not adopted electronic health records, underestimated the challenges of overcoming this barrier or whether physicians are becoming more receptive to adoption is unclear. Either way, obtaining the support of physicians -- often by getting the backing of clinical leaders -- can be helpful in ensuring successful adoption.19

Another potential barrier to adoption is concern about interoperability: few electronic-records systems allow for easy exchange of clinical data between hospitals or from hospitals to physicians' offices. Low levels of health information exchange in the marketplace20,21 reduce the potential value of these systems and may have a dampening effect on adoption.

From a policy perspective, our data suggest that rewarding hospitals -- especially financially vulnerable ones -- for using health information technology may play a central role in a comprehensive approach to stimulating the spread of hospital electronic-records systems. Creating incentives for increasing information-technology staff and harmonizing information-technology standards and creating disincentives for not using such technology may also be helpful approaches.

Some providers, such as the VHA, have successfully implemented electronic-records systems. VHA hospitals have used electronic health records for more than a decade with dramatic associated improvements in clinical quality.22,23 Their medical records are nearly wholly electronic, and including them in our analyses led to a doubling of our count of U.S. hospitals with a comprehensive system. Some developed countries, such as the United Kingdom and the Netherlands, have also successfully spurred adoption of health information technology, although most of their progress has been in ambulatory care. Few countries have yet to make substantial progress in the inpatient setting.24

There are limitations to our study. First, although we achieved a 63% response rate, the hospitals that did not respond to our survey were somewhat different from those that did respond. We attempted to compensate for these differences by adjusting for potential nonresponse bias, but such adjustments are imperfect. Given that nonresponding hospitals were more likely to have characteristics associated with lower levels of adoption of electronic health records, residual bias may have led us to overestimate adoption levels. Second, we focused on adoption and could not accurately gauge the actual use or effectiveness of electronic-records systems. Third, we did not ascertain whether the systems that were adopted had been independently certified (by parties such as the Certification Commission for Health Information Technology). Fourth, given low adoption levels, we had limited power to identify predictors of the adoption of comprehensive electronic-records systems as compared with basic systems. Finally, we did not ascertain whether users of electronic health records were satisfied with them.

In summary, we examined levels of electronic health record adoption in U.S. hospitals and found that very few have a comprehensive electronic system for recording clinical information and that only a small minority have even a basic system. However, many institutions have parts of an electronic-records system in place, suggesting that policy interventions could increase the prevalence of electronic health records in U.S. hospitals faster than our low adoption levels might suggest. Critical strategies for policymakers hoping to promote the adoption of electronic health records by U.S. hospitals should focus on financial support, interoperability, and training of information technology support staff.


March 2009 -- Patient self-service kiosks are being used with growing frequency in hospital ambulatory settings and emergency departments. These interactive computer stations, which come in a variety of designs, perform self-service tasks such as patient check-in, collection of co-payments, and wayfinding. In a hospital waiting area, they can speed the process for patients and take some of the workload from registration personnel, who are then freed up to help patients with more complicated registration or payment needs.

Compared to other technologies such as electronic medical records or clinical systems, patient kiosks are relatively easy to implement, require a small investment, and can be deployed selectively to the departments that are likely to benefit from their use. Kiosks can be freestanding (like those at the airport), wall-mounted (like bank ATMs), placed on a countertop, or they can be mobile (like a tablet PC). In addition to the relatively simple functions of check-in and co-payments, kiosks can be designed to facilitate language translation, the signing of patient consent forms, gathering demographic and clinical information for triage, and performing satisfaction questionnaires.

The experiences of leading hospitals have shown that kiosks can increase patient satisfaction by reducing waiting times and offering greater convenience and privacy. Many organizations also achieve significant operational benefits, including increased patient throughput and improved accuracy of demographic data in patient records.

Although fewer than 10% of health delivery organizations have implemented patient kiosks, the experiences of early adopters show that kiosks can be effective tools for improving service and efficiency and meeting rising consumer expectations. 


Healthcare_2009_TouchscreenCheckInKiosks.pdf


Wal-Mart Stores is striding into the market for electronic health records, seeking to bring the technology into the mainstream for physicians in small offices, where most of America's doctors practice medicine.

Wal-Mart's move comes as the Obama administration is trying to jump-start the adoption of digital medical records with $19 billion of incentives in the economic stimulus package.

The company plans to team its Sam's Club division with Dell for computers and eClinicalWorks, a fast-growing private company, for software. Wal-Mart says its package deal of hardware, software, installation, maintenance and training will make the technology more accessible and affordable, undercutting rival health information technology suppliers by as much as half.

"We're a high-volume, low-cost company," said Marcus Osborne, senior director for health care business development at Wal-Mart. "And I would argue that mentality is sorely lacking in the health care industry."

The Sam's Club offering, to be made available this spring, will be under $25,000 for the first physician in a practice, and about $10,000 for each additional doctor. After the installation and training, continuing annual costs for maintenance and support will be $4,000 to $6,500 a year, the company estimates.

Wal-Mart says it had explored the opportunity in health information technology long before the presidential election. About 200,000 health care providers, mostly doctors, are among Sam Club's 47 million members. And the company's research showed the technology was becoming less costly and interest was rising among small physician practices, according to Todd Matherly, vice president for health and wellness at Sam's Club.

The financial incentives in the administration plan -- more than $40,000 per physician over a few years, to install and use electronic health records -- could accelerate adoption. When used properly, most health experts agree, digital records can curb costs and improve care.

But many, especially physicians in small offices, doubt the wisdom of switching to electronic health records, given their cost and complexity.

Only about 17 percent of the nation's physicians are using computerized patient records, according to a government-sponsored survey published last year in The New England Journal of Medicine. The use of electronic health records is widespread in large physician groups, but three-fourths of the nation's doctors work in small practices of 10 physicians or fewer.

Wal-Mart, however, has the potential to bring not only lower costs but also an efficient distribution channel to cater to small physician groups. Traditional health technology suppliers, experts say, have tended to shun the small physician offices because it has been costly to sell to them. Taken together, they make up a large market, but they are scattered.

"If Wal-Mart is successful, this could be a game-changer," observed Dr. David J. Brailer, former national coordinator for health information technology in the Bush administration.

In the package, Dell is offering either a desktop or a tablet personal computer. Many physicians prefer tablet PCs because they more closely resemble their familiar paper notepads and make for easier communication with the patient, since the doctor is not behind a desktop screen.

EClinicalWorks, which is used by 25,000 physicians, mostly in small practices, will provide the electronic record and practice management software, for billing and patient registration, as a service over the Internet. This "software as a service" model can trim costs considerably and make technical support and maintenance less complicated, because less software resides on the personal computer in a doctor's office.

Dell will be responsible for installation of the computers, while eClinicalWorks will handle software installation, training and maintenance. Wal-Mart is using its buying power for discounts on both the hardware and software.

Wal-Mart's role, according to Mr. Osborne, is to put the bundle of technology into an affordable and accessible offering. "We're the systems integrator, an aggregator," he said.

The company's test bed for the technology it will soon offer physicians has been its own health care clinics, staffed by third-party physicians and nurses. Started in September 2006, 30 such clinics are now in stores in eight states. The clinics use the technology Wal-Mart will offer to physicians.

"That's where the learning came from, and they were the kernel of this idea," Mr. Osborne said.