Prof. Greta Nasi. Associate Professor Bocconi University, Head of Ehealth Research Unit at Center for Health and Social Care Management, Bocconi University.

1. Impacts of EMR on healthcare performance:
evidence from the Catalonian health care providers
Greta Nasi
SDA Bocconi School of Management
1

2. Agenda
• EMR systems: an impact assessment model
• The model’s methods for data collection
• Evidence from the Catalonian Health Providers
• Discussion and conclusions

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. The framework’s main dimensions
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
Risk Management Value
Effectiveness
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. Managing complexity
Patient workflow
.
Diffusion

7. 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

8. Some assumptions
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

9. Data Collection
• A pilot data collection was carried out during in 2009
(March – September) in Italy and Spain to:
• Test the framework and methods;
• Compare impact of EMR of new comers and
pioneers.
• An extensive data collection was carried out in 2010
to assess the impacts of EMR among Catalonian
healthcare provider:
• 5 Hospitals and 10 primary care centers
involved, selected based on network analysis
• Data collection: March to December 2010.

10. Organizations involved in the
research

11. Data about respondents
• Three main specialties were interviewed (*):
• Cardiology;
• Gastroenterology;
• Pneumology
(*) Internal Medicine for Hospital General de l’Hospitalet
• A total of 220 questionnaires were retrieved:
• 109 from Physicians;
• 111 from Nurses.
• Data was gathered, based on network analysis,
balancing hospital and “their” primary care centers

12. Findings: an overlook
Catalonian Hospitals Catalonian Primary Care Centers
EFFICIENCY
EFFICIENCY
Hospitals
10 Primary Care
8 10
4,7 Centers
6 8
5,2
4 6
2 4
CLINICAL GOVERNANCE 4,9 0 5,2 EFFECTIVENESS 2
CLINICAL GOVERNANCE 5,9 0 6,8 EFFECTIVENESS
4,7
5,5
QUALITY OF SERVICE
QUALITY OF SERVICE

13. EMR impact:
comparing Italian and Catalonian cases
ITALIAN HEALTH PROVIDERS CATALONIAN HEALTH PROVIDERS
EFFICIENCY
10
8
5,0
6
4
2
CLINICAL GOVERNANCE 5,4 0 6,0 EFFECTIVENESS
5,1
QUALITY OF SERVICE

14. Findings: Efficiency
 In the long run, quality of
Time saving the information prevails in
10
terms of efficiency mainly
due to of its clearness and
Hospitals
Primary Care Centers
8 completeness.
6
 Lower perception of time
3,8
4 and costs savings might be
3,7 due to the routinization of
2
the EMR in the
0 respondents’ activities.
5,4
4,3 6,3
6,2
Cost reduction Information quality

15. Findings: Effectiveness  Great enthusiasm for EMR
enhancement of diagnostic
and therapeutic activities is
enthusiastic in primary care
centers thanks to more
complete and reliable
Improvement of diagnostic and therapeutic activities information.
10 • Hospitals' clinicians find that
Hospitals
7,1
8 EMR does not necessarily
Primary Care Centers 5,6
6 contribute to reduction in the
4 number of clinical errors.
2
4,3 5,2
Risk Management 7,1 0 6,0 Organizational effectiveness
5,8 • Overall, organizational and
process is affected by the
7,0 enthusiasm about the
standardization of processes,
and interchange of
Process effectiveness information among hospital
departments and primary
care centers.

16. Findings: Quality of service
 Respondents appreciate
the integration of the
Patient empowerment clinical information
systems and the all-day
10
Hospitals accessibility to the EMR.
Primary Care Centers 8
6
3,8
4
2,2  Patient empowerment
2
6,0 4,8
was not a priority in EMR
Quality of service 5,8 0 6,3 Quality system implementation in
Catalonia, this explains
the results: patients
5,7 cannot access their EMR.
6,2
Continuity of care

17. Findings: Clinical Governance
 Increased levels of
accountability and good
project management of the
Accountability
EMR - including training – is
10 appreciated by the health
8
6,8
care providers that took part
Hospitals
Primary Care Centers
in the study.
6
6,0
4
2
Information management 6,3 0 3,9 Clinical audit
4,6 3,4
 There is a need for a new
5,7 wave of EMR to enhance how
6,7
information is displayed
 Clinical audit is effected by
Strategic management number of claims that health
care providers still face.

18. Discussion and conclusion 1/3
• Overall the analysis shows positive impacts of
EMR on organizational performance
• Hospitals and Primary care centers show
differences in results due to their different focus,
degree of complexity and mission
• The more time has elapsed since the EMR
implementation, the more evident is the evolution
in impact perceived
• Different EMR implementation approaches have
an overall effect on organization performance
results

19. Discussion and conclusion 2/3
• Overall, Catalonian health care providers state that
EMR contributes to:
• More reliable, comprehensive and complete
information about patient health history;
• Standardized, integrated and efficient
processes;
• Continuity of care and enhanced
communication;
• Holding people more accountable for their
activities
This leads to greater organizational effectiveness

20. Discussion and conclusion 3/3
• Short term impacts tend to be forgotten and taken for
granted
• Some less enthusiastic respondents actually look
forward to new developments of the EMR systems
• Key actors are willing to further steps in ehealth
• A systematic assessment of EMR and complex
ehealth projects’ impacts might suggest the nature
and direction of health care providers’ priorities and
future strategies