EMR and Healthcare Improvement Measuring / Assessing Organisational Impacts. Nasi G. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. A practical framework to assess the
impacts of EMR systems
Greta Nasi
SDA Bocconi School of Management
Bocconi University, Milan Italy

2. AGENDA
• EMR systems: an impact assessment model
• The model’s methods for data collection
• Findings of an empirical test of the assessment
model in Italy and Spain
• Discussion and recommendations

3. Relevance of impacts of EMR
systems
• Healthcare efficiency and effectiveness is becoming
increasingly dependent on information and communication
technologies
• EMR systems promise to improve health care quality to
advance inter-organizational integration and data sharing
across different health care providers, and to empower
patients through greater access to personal data
• However the variety and heterogeneity of potential impacts
described in literature has not been framed into a
comprehensive assessment model able to capture all
relevant dimensions of EMR impacts on health care
performance

4. Main dimensions of the
assessment model
• Efficiency includes impacts on the level of efficiency of internal processes
which the application of the electronic medical record system has
produced or will produce in the future in terms of time and cost savings
and quality of information;
• Effectiveness includes impacts in terms of improvement of the
organisation as a whole measured as process integration, organizational
effectiveness, risk management and better care processes;
• Quality of service includes impacts on the overall care process, taking
into account its performance, the continuity of care and the degree of
empowerment of the patient;
• Clinical Governance comprises the group of effects produced in terms of
organisational culture, capacity for change as well as overall clinical
performance.

5. The EMR assessment framework
Time savings
Efficiency Cost efficiency
Information Quality
Improvement of diagnostic and
therapeutic activities
Service
Effictivennes Risk Management Value
Effectiveness of processes
Organizational effectiveness
Patient
Empowerment
Patient Empowerment
Efficiency of
Quality of service care
Quality of
service Continuity of care Quality
Improvement
Quality systems
Accountability
Information management
Clinical
Governance Strategic management
Clinical Audit

6. The model’s methods for data
collection
A mix of quali-quantitive methods have been defined and used
for data collection. Here is a summary of the methodology
adopted:
• “Self-completion questionnaires”, concerning information about the
EMR system implementation which include:
• An assessment of the organization’s context;
• The status of EMR system implementation and its functionalities;
• Organizational impacts based on the four dimensions perceived by main stakeholders
including physicians, nurses, CIOs and controllers, Boards, patients
• Semi-structured interview schemes to be used to interview key actors
of the EMR system’ implementation project;
• Document scrutiny and analysis of other relevant information, as
organizational and strategic documents, study reports

7. A test of the assessment model
in Italy and Spain
The test was aimed at comparing impacts of EMR systems
on the overall performance of different types of health care
providers for:
• Contexts (Italy and Catalonia) and types of health care provider,
• Time elapsed since EMR system implementation;
• Functionalities of the EMR systems
• Main objectives of EMR system implementation (continuity of care vs.
standardization and rationalization of processes and resource usage)
The sample:
• Italian healthcare providers: a Local Healthcare Authority, which provides both
acute and primary care services and an Acute care hospital;
• Catalonian healthcare providers: five acute and primary care providers and one
acute care provider
All data was collected between March and July 2009

8. Impact assessment timeframes
EMR system After 1 year of EMR After 6 years of EMR ……. LONG RUN
Pre-EMR system
sys implementation sys implementation
Go Live
Local health care authority
Acute care hospital
6 Spanish
providers

9. Assumption for timeframe of
impact materialization
EMR system After 1 year of EMR After 6 years of EMR ……. LONG RUN
Pre-EMR system
sys implementation sys implementation
Go Live
Efficiency
Effectiveness
Quality of service
Clinical governance

10. Preliminary findings: an overlook
ITALIAN HEALTH PROVIDERS CATALONIAN HEALTH PROVIDERS

11. Preliminary Findings: efficiency
The Italian health providers show
the greatest effects in terms of
efficiency and time saving in
particular, which in turn might have
an overall effect on the economics
of some wards
The Catalonian health providers
recognize as most important impact
the quality of information in terms
of accuracy, completeness, easy of
understanding and reliability of data

12. Preliminary Findings: effectiveness
Italian health providers argue that EMR
adoption has increased organizational
effectiveness, in terms of improvement of
the interaction between clinicians and
patients and also shows its impacts on the
effectiveness of processes, enhancing
decision making process with time and cost
savings results.
Catalonian health providers show an
improvement of diagnostic, therapeutic
and service activities in terms of better
ability to plan admissions, precision in
diagnosis and treatment and reduction in the
number of errors in ordering diagnostic tests
and in the compiling reports.

13. Preliminary Findings: other impacts
• In Italy , the adoption of EMR
systems has lead to a higher
awareness of patient
empowerment, with particular
reference to the possibility of
further involvement of patient to
the process due to the increased
availability of information
• In Catalonia, EMR adoption has
strengthened the information
exchange between acute care,
primary care and GPs (due to the
fact that most of the hospitals are
both primary and acute care),
improving the continuity of care

14. Discussion and recommendations
• Based on the test, we can state that the model can actually
capture impacts of EMR systems at organizational level,
regardless of the status of EMR implementation, the functionalities
adopted, the type and functions of the health provider and the
context
• Short term impacts tend to be forgotten and taken for granted
• These findings are mainly in line with the assumptions made
while drafting the model
• There is no significant difference in long run effects between
acute care and primary care providers
• Adopting these framework systematically may help:
• Health providers in understanding whether EMR adoption might help them in
reaching their goals;
• Policy makers to set guidelines for successful EMR implementations;
• Academics and practitioners to compare different
EMR system uses.

15. Acknowledgments
• Thanks to Azienda Ospedaliera Ospedale Civile di Legnano,
Azienda USL della Valle d’Aosta, Hospital Clinic, Hospital de Sant
Pau, Hospital del Mar, Hospital General de l'Hospitalet, Institute
Català de la Salut, Hospital de Bellvitge
• Research team: Claudio Caccia, Maria Cucciniello, Greta Nasi,
Xavier Pastor
• Research assistants: Paola Cantarelli, Manish Gawande
• This research project has been co-financed by InterSystems Italia
srl, NoemaLife SpA, Claudio Dematté Research Division and the
Public Policy and Management Area of SDA Bocconi School of
Management