Storm Born Chapter Twenty-Two

I didn't give Lara all the details the next day, only that I'd just broken up with a guy. â€Å"Ice cream,† she advised me through the phone. â€Å"Lots of ice cream. And tequila. That's the key.† â€Å"I can't do a lot of drinking right now.† â€Å"Hmm. Well, maybe get one of those liqueur-flavored ice creams. Like with Kahla or Irish cream.† â€Å"Any other hot tips?† â€Å"Chick flicks.† â€Å"Good God. I'm disconnecting right now.† â€Å"Well, then, try this.† She sounded huffy. â€Å"I just got a call from a guy who thinks there's a troll in his basement. Seems like beating one of those up would be therapeutic.† â€Å"Lara's full of shit,† Tim told me later when I recounted the phone call. â€Å"Why do women turn to ice cream? It makes them fat, then they hate themselves and start going on and on about how they'll never find anybody, blah, blah. It's stupid. Now, if you've got some peyote squirreled away, that'd be a different matter†¦.† â€Å"No,† I said. â€Å"No peyote. Not after what happened last time.† He made a face. â€Å"All right, then. My best advice? Don't call him. He's probably going through all sorts of regret and guilt. You call him, he'll feel smothered and put up his defenses. Let him stew for a while, and he'll call you.† â€Å"I don't want him to call.† â€Å"Sure, Eug.† I ended up taking down the troll later that day, but it didn't really do much for me. Neither did the Kiss puzzle I put together that night. With my doldrums growing, I was only too happy when my next lesson with Dorian came the following day. Considering his fascination with human things and novelty in general, I thought he'd like eating out somewhere. I didn't know why I bothered; we probably should have gone straight to the lesson. Maybe I felt guilty about the sex thing. Maybe I was lonely. After a quick drive, I arrived at the Catalina Lodge, a prissy hotel about a mile or so from Catalina State Park. I parked in a remote spot, hopefully away from watchful eyes, and sat down on the ground with crossed legs. The ring sat beside me on the asphalt. Slipping on my sunglasses, I leaned against the car and waited. My timing couldn't have been more perfect. A few minutes later, I felt the pressure and tingling, and then Dorian materialized beside me. He'd left the robes and cloaks at home, wearing dark pants and a blousy, sage-colored shirt that looked only moderately out of place. He squinted up at the bright sunlight and then noticed me on the ground. â€Å"Isn't it ever cloudy in this infernal place?† I straightened up, and he offered a hand to help me rise. â€Å"I could arrange that if you wanted.† â€Å"And risk you wiping out half of your fair city? No thank you.† â€Å"Figured you'd appreciate that. It'll make your world domination easier. One less place to conquer.† â€Å"No. I need this place intact. I plan on keeping prisoners and exiled enemies here. Where exactly are we today?† â€Å"Mere steps away from the best food of your life, if rumors are true.† He flashed me one of his trademark grins. â€Å"Pleasure before business? My, my, you never fail to astound me.† â€Å"Hell, wait'll you hear me identify every water source in the restaurant.† That, at least, had been a good thing to come from Beltane. I could now feel cactuses, wells, and any other water source within a certain distance. I could even sense people now since the human body was supposed to be, what, 65 percent water? That meant no one could sneak up on me. Inside and seated, Dorian found watching his surroundings far more fascinating than anything on the menu. â€Å"Pick something for me,† he said distractedly, watching a family leave with four small children in tow. He cocked his head curiously. â€Å"By the gods, do all those little ones belong to them?† I glanced up. â€Å"Likely.† â€Å"And their mother looks pregnant again. Incredible. Back home, those people would be worshipped as fertility deities. A family with two children is remarkable enough.† The waitress returned. I ordered spinach-stuffed ravioli for me and some sort of spicy chicken for him. â€Å"A lot of middle-and upper-class families actually go out of their way to only have two kids. And a lot of them don't even start until they're older than me.† â€Å"Baffling.† He propped his elbow on the table, resting his chin in his hand. â€Å"A woman your age could have had that many children by now.† â€Å"Hey, I'm like twenty-six. I'm not that old. I don't even look my age.† â€Å"That's your father's blood. And I wasn't insulting your age – merely making an observation.† He sighed. â€Å"I'd give up half my kingdom for just one child.† I smiled slyly. â€Å"And the chance to be the father of Storm King's grandson?† â€Å"I'd be just as happy to father his granddaughter too. I'd be happy to father anyone's child.† â€Å"Then why don't you find some nice girl and do it?† â€Å"Believe me, it hasn't been for lack of trying.† His face held a rare seriousness, but the expression vanished as quickly as it came. â€Å"Ah, now there's a fetching young woman.† Following his gaze across the restaurant, I saw a tall blond woman exit the restroom. She was stuffed into a tiny spandex dress, her chest practically spilling out. I didn't have the heart to tell Dorian there was probably a lot of silicone in there. His eyes lingered on her, then his charm-alarm must have gone off for fear of neglecting me. He turned back around. â€Å"Not that you don't look lovely today too.† â€Å"You don't have to pacify me.† I laughed. â€Å"You're welcome to ogle other women.† Our late-afternoon meal proceeded nicely, and everything about it continued to enchant Dorian. The credit card I used to pay with at the end especially captivated him. â€Å"It has information about me stored in it,† I tried to explain. â€Å"That information lets the restaurant get money from me.† He picked up the returned card gingerly, turning it over and over in his fingers. â€Å"Intriguing. I imagine this has to do something with electricity? The blood of your culture?† His wry tone made me smile. â€Å"Something like that.† It wasn't until we were on the mile and a half walk to Catalina State Park that things got a little tense. â€Å"Heard from the kitsune lately?† â€Å"He has a name,† I snapped. â€Å"Heard from Kiyo lately?† â€Å"No.† â€Å"Really? He hasn't tried to contact you and beg for forgiveness?† â€Å"No,† I repeated between gritted teeth. Something about the way he said it made it sound like I'd been dealt a great insult. â€Å"Odd. I think that's what I'd do if I'd offended my ladylove. Of course, I suppose when a man spends half his existence as an animal, you can't really expect him not to act like one.† I halted and turned on Dorian. â€Å"Stop it. Just stop it, okay? Stop trying to poison me against him.† â€Å"You don't need me to do what he's already done.† â€Å"Damn it, Dorian. I'm serious.† We started walking again, but it was me who brought up the subject again after several minutes of silence. â€Å"You knew. You knew Maiwenn was pregnant and didn't tell me.† â€Å"It wasn't my secret to tell. Besides, I got in trouble the last time I spoke badly of her. You accused me of trying to turn you against her.† â€Å"I'm not sure this is really the same thing. We're talking about Kiyo now. Last time it was about Maiwenn wanting to kill me.† â€Å"And you don't think they're the same thing?† I stopped walking. â€Å"What do you mean?† â€Å"Kiyo is her friend, formerly her lover, and now the father of her child. He stands firmly with her against Storm King's invasion. Yet, where would he stand if it came to a choice between you or her? What if Maiwenn decided you were too great a threat? What would he do? What would he do if you accidentally got pregnant?† A chill ran through me at his words. I abruptly turned away and barely recognized my own voice when I spoke. â€Å"I don't want to talk about this anymore.† He held up his hands in a pacifying gesture, face calm and affable. â€Å"I honestly intended no harm. Pick another topic. We'll discuss anything you like.† But I didn't really feel like talking anymore, so the rest of the walk proceeded in silence. When we finally entered the park, the sun was well into its descent. We still had plenty of light and set out to pick a good place to work. We ended up following one of the less traveled trails and then deviated from it into a semi-treed area. We had nothing even close to dense forest coverage, but rock outcroppings, some scraggly pines, and distance from the path promised relative privacy. The routine proved to be the same. Dorian had me sit on the ground, leaning against a rock. He had another stash of those silk cords and again wrapped them around me. The rock didn't make a suitable attachment, so he simply let my hands rest in my lap and bound them together at the wrist. Naturally, he did his usual artistic weave on them, intricately wrapping red and blue cords together. When he moved on to wrapping the cords around my chest and arms, his eyes flicked to mine and then back to his handiwork. â€Å"You aren't really going to stay mad at me for the rest of the day, are you?† â€Å"I'm not mad.† He laughed. â€Å"Of course you are. You're also a terrible liar. Lean forward, please.† I did, letting him tie the knots behind me. â€Å"I just don't like you playing games, that's all. I don't trust them.† â€Å"And pray, what games am I playing?† â€Å"I don't even know half the time. Gentry games, I guess. You speak the truth, but it always has an ulterior motive behind it.† He leaned me gently back against the rock and crouched on his knees to look me in the face. â€Å"Ah, but I do speak the truth.† â€Å"I just can't tell what you want sometimes, Dorian. What your plans are. You're hard to read.† That delighted smile of his spread over his face. â€Å"I'm hard to read? This from the woman who alternately hates and fucks Otherworldly denizens? The same woman who claims not to trust me even while I tie her up, putting her completely at my mercy?† I wiggled in my bonds. â€Å"Well, I trust you with this.† â€Å"Are you sure?† He pressed a hard kiss against my lips. It startled me, but I couldn't do anything about it. This man, this gentry – the one who could be either helping me or using me – had me trapped. I couldn't do anything except let him keep kissing me. The realization triggered a response in me that was quite startling, considering my issues with control and helplessness. It made me feel vulnerable†¦and excited. I turned my head away as much as I could, attempting to break off the kiss. â€Å"Stop that.† He leaned back on his heels. â€Å"Just making a point.† â€Å"No, you weren't. You were just trying to kiss me.† â€Å"Well, yes, you've got me there. But the fact remains: Tied up or free, you can trust me. I do nothing that I don't firmly believe is in the interest of your well-being. The same holds true for casual comments about your love life. Now then.† He stood up. â€Å"Shall we commence this lesson?† â€Å"No blindfold?† I asked, still a little shaken. â€Å"Not needed. You know where the water is. Or you will in just a moment.† He produced the canteen I'd brought along and took off its lid. Searching the area, he found a large boulder, reaching almost to his shoulders. He set the open canteen on top of it and then selected a spot for himself near some scrubby bushes where he had a clear vantage of me and the canteen. â€Å"You feel the water?† â€Å"Yes.† â€Å"Make sure of it. If you accidentally reach one of the trees and end up calling its water, you'll kill the poor thing.† I extended my senses, considering what he said. After a few moments, I felt certain I had the water sources all differentiated. â€Å"No, I've got it.† â€Å"All right, then. Call it to you.† â€Å"Am I supposed to make the canteen rise or something?† â€Å"No. You have no connection to it. But you do connect with the water. You feel it. You touch it with your mind. Now coax it to come to you, to come out of its container. You've already done it with storm systems. The trick now is doing it on a small, specific level. Forget about your body – it's useless to you now. This is all in your mind.† â€Å"That's all the instruction I get, coach?† â€Å"Afraid so.† He stretched out, rolling onto his side to get comfortable. For someone who took such care with his clothes, he seemed nonchalant about getting them dirty. I supposed laundry was a small concern when you had a full staff to take care of it. Sighing, I turned back to the canteen. What I attempted seemed ludicrous – but, then, so had feeling the water in the first place. So, I followed what he said as best I could. My grip on the water was so tight, I might as well have held it in my hand already. But no matter how hard my concentration focused, I couldn't make the water move. It reminded me of the wind. I could feel it but not control it. Well, actually, if my training progressed, I might actually be able to control it some day. But the analogy stood, nonetheless. Time dragged. Extensively. I tried and tried to order the water around, but it refused to obey. More time passed. It crawled. I finally decided it was a good thing the cords covered my watch because I'd be pissed off if I discovered how much time had elapsed. Hours had slipped by; I felt certain of it. The light had grown dimmer and dimmer. Looking over at Dorian, I swore he was asleep. â€Å"Hey,† I said. No response. â€Å"Hey!† He opened one eye. â€Å"I'm not getting anywhere with this. We should call it a night.† He sat up. â€Å"Giving up already?† â€Å"Already? It's been like two hours. Probably three.† â€Å"Miracles don't happen overnight. These things take time.† â€Å"How much time? I'm starting to wonder if you made this magic rule just to procrastinate on getting Jasmine.† â€Å"Well. You can believe that if it makes it easier for you. The truth – if you trust me enough to hear it – is that this is for your own protection. In a perfect world, we would go in and extract the girl quietly. In the real world, we will likely fight Aeson's guards and Aeson himself. I would prefer we both walk out of this alive. You didn't fare so well last time.† â€Å"This is going to take forever. This training.† I knew I was being whiny and petulant, but my back hurt, and mosquitoes had come out. At least in identifying the water source, I'd been able to take guesses. Here I could do nothing more than just wait and stare. If nothing happened, nothing happened. â€Å"I'm sorry,† I told him. â€Å"I'm just tired, that's all. Didn't mean to bitch you out.† He seemed untroubled by my reaction, just like always. Indeed, I could see his face regarding me kindly in the twilight. â€Å"No problem at all. Let's go, then.† He walked over to the canteen and recapped it. Closing my eyes, I leaned my head back against the rock to wait for him to release me. As I did, I felt something cool and wet, like mist, spread out behind my back and neck. To my new water senses, it didn't feel†¦right. Moments later, before I could ponder the difference, the mist coalesced into slimy skin. â€Å"Dori – â€Å" My scream was cut off by cold, clawed hands. One covered my mouth, and the other gripped my throat. Dorian had spun around before my cry, making me think he'd sensed something before I had. He leaped toward me, but four wet, human forms materialized in the air before him, blocking his way. Nixies. Water spirits. Two were male; two were female. Legends whispered they could shape-shift into more beautiful forms, but here they appeared drab. Clammy skin, mottled and gray. Clothes sodden and dripping. Seaweedlike hair hanging down. The one holding me pushed me down flat to the ground, all the better to cut off my oxygen that much faster. Water dripped onto me from her hair, and her eyes gleamed a sickly green in the waning light. She hissed with pleasure and pressed harder while I frantically assessed my options. I finished the assessment pretty quickly because I had no options. I was fully armed but unable to reach anything because of Dorian's fucking bondage fetish. Covering my mouth stopped me from summoning a minion. The world flickered with starbursts as my air disappeared. My lungs and throat heaved, trying desperately to latch onto something. Her claws dug into the tender flesh of my neck, and I half-wondered if she'd rip it out rather than wait for suffocation. My only hope was Dorian, but he wouldn't get to me anytime soon, not with his own army of – Every stone and pebble in the area suddenly lifted off the ground. Shortly thereafter, the really large stones and boulders followed suit. Those big ones exploded, fracturing into thousands of tiny shards. All those little pieces of rock rose higher, joining each other, slowing rotating in a clockwise manner. My captor's grip had lessened slightly, probably from surprise. It didn't return my air, but I twisted my head enough to see Dorian standing with his arms raised up like some sort of symphony conductor. Above him, that cyclone of sharp rocks spun faster and faster, a blur to the eye. Then, as though giving the song's grand finale, he brought his arms down sharply. And down came the rocks. A portion of that maelstrom swooped and soared, the primitive predecessors of bullets. At first their movements seemed chaotic, and I feared falling into their path. But it turned out every rock had its own plan, its own target. Those sharp pieces honed down on the nixie holding me, piercing and slicing with a fierce precision. She opened her mouth in a silent scream as blood splashed onto me, and her torn body collapsed in a bloody, wet pile. I twisted out from under her, taking in big gulping breaths of air. Beyond her, Dorian gave another downward motion, urging his orchestra to its next climactic moment. The rocks swooped into another nixie, cutting it to pieces. Then another†¦and another†¦until the nixies were nothing but ribbons of blood and gore. Their task complete, the rocks gently fell to the earth, as soft and placid as drops of rain. The entire counterattack had taken less than a minute. Immediately, Dorian knelt by my side, helping me sit up as I gasped my way back to life. â€Å"Easy, easy,† he warned. Blood covered both of us. â€Å"Small breaths.† â€Å"Untie me! Get me out of this!† He pulled the silver athame from my belt. In moments, he sliced open the cords, freeing my arms and hands. I jerked away, my adrenaline still surging. He reached for me, but I flailed against him. â€Å"Damn you! You almost got me killed!† I yelled, hearing the hysteria in my voice. â€Å"You almost got me killed!† He grabbed my upper arms with a solid strength, pulling me to him and forcing me to stillness. â€Å"Eugenie, calm down. Eugenie!† He shook me – hard – where I still struggled, and I halted abruptly, quelled by the harsh sound of his voice and ferocity of his grasp. I could no longer find the silly, languid gentry king. There was a stranger holding me, his face hard and commanding. â€Å"Do you think I'd let anything happen to you?† he demanded, almost shouting. â€Å"Do you think I'd let anything harm you?† I swallowed, still in pain from the nixie's claws on my throat, and found my body shaking. His grip was so tight, I might as well have been tied up again. He scared me, having turned into someone else. Someone powerful and awe-inspiring. Looking into his eyes and seeing the sweat on his face, I realized fear had touched more than just me. He was scared too, not for himself, but for what had almost happened to me. Something inside me eased up, and I nearly slumped into him. â€Å"I can't believe what you did,† I whispered. I killed all the time without much thought or effort, but this†¦this had been something else entirely. And he wasn't even at full strength in this world. â€Å"You slaughtered them.† â€Å"I did what I had to do.† The heat in his voice had faded, replaced with a deadly calm. â€Å"And you'll be able to do the same someday.† One of his hands released me and moved to my head, smoothing my hair back. He pressed our bodies together and rested his cheek against mine so his soft words could spill into my ear. â€Å"You will surpass me, Eugenie. Your power will be so great, none will stand against you. Armies and kingdoms will fall, and they will bow down before you.† I found myself trembling again, feeling the same fear and excitement that had filled me during our last kiss. Only this time, I didn't know if my feelings came from his body's proximity†¦or the promise of power he offered.

Communication Theories Matrix Essay

Instructions: Complete the following matrix by filling in the box for each of the five communication theories with the following four items: the theory definition, the main principles of the theory, a real-world theory example, and an application of each theory to virtual communication. Theory definition Main principles of the theory Real-world theory example Application of each theory to virtual communication Social Exchange Theory Theory that attempts to explain human behavior in terms as behavioral psychology. The main principle of this theory is social relationships are the outcome of an exchange process with the purpose of maximizing the benefits and minimizing costs. An example of this theory is asking someone out on a date, but you dislike the fact that he/she lacks money or good looks, but he/she is caring and fun to hang out with the therefore you go because the benefits outweigh the cost. The rewards of virtual communication include freedom from the constraints of time and space but the costs is the possibility for misunderstanding when we are not able to see each other’s facial expressions or tone of voice. Systems Theory Systems theory is an open system of interdependent elements, employing input variables and process variables to yield output. The main principle is to receive input, process input and yield an output An example would be in a group you collectively develop a task from input and expect productivity as a output. Connection through the internet can alter patterns in many ways making the system more open. Symbolic Convergence Theory Theory of communication that explains how certain  types of communication shape a group’s identity and culture, which in turn influence other dynamics. Share group fantasies create symbolic convergence.  In a business symbolic convergence is used to determine what the customers like about the business and that allows the business to cater to the customer. In, virtual communication the possibilities for visual, verbal, or auditory communication can make new avenues for fantasy themes and group identity. Structuration Theory Theory that provides a general framework  and explains how people structure their groups by making active use of rules and resources. The main function of this theory is to focus attention on individuals’ behaviors in groups rather than on dynamics of groups. Basketball team is a example of structuration theory, because it has structure and rules that all members must follow. The coach is the leader and implements the rules for the team to follow. use of computers, e-mail,  and the internet as resources can expand the repertoire of structures available to group members. Functional Theory Communication in groups that functions to promote sound reasoning, prevent errors, and build relationships among all members. Focus on results and outcomes of group behaviors and structure. In a group where members use this theory to make decisions and to solve problems. Use of virtual group communication to enhance areas of group interaction by extending dialogue beyond a meeting room.

Advanced Research Writing Essay

The topic of online education, specifically relating to teaching writing in a distant learning environment was covered by Professor Kate Kiefer. Kiefer is a Professor and Writing Integration Coordinator at Colorado State University. She has a PH.D in rhetoric from Carnegie Mellon University and has written numerous published articles, including three textbooks. In the book â€Å"Brave New Classrooms†, Professor Kiefer writes a chapter titled, â€Å"Do Students Lose More Than They Gain In Online Classrooms?† Professor Kiefer tackles the difficult questions of just how much are students getting out of online writing classes. What is the goal of an online student? Kiefer clearly has an issue with distance education and voices her opinion of its inferiority to a classroom environment. Her numerous assertions of distance learning students not getting the complete education experience must be taken for what it is, an instructor’s point of view and not a student’ s. Online education is becoming more prevalent every day, because not everyone has the time or funding to get to and from a college campus. This method should be embraced by instructors and not talked down on, simply because there is no other option for so many. Professor Kiefer wholeheartedly states in her article, that she believes taking an online writing class is inferior to a traditional structured classroom environment. She states that she is not in the majority on this issue, but she speaks of the many difficulties that face a student and teacher online. One of Professor Kiefer’s most adamant points against online writing classes is the true lack of interaction a student can have. She talks of how so many online classrooms have students who do not participate and do only what is needed to pass the class. Kiefer suggests that on-line classes are often full of students who are looking to check a box and get that next check mark, which will take them to finish line and a degree. She also states how not having peer to peer interaction robs the online student of so much valuable education. In a writing class it is pivotal she states to have your fellow  students peer review your work and not just have the teacher looking at your assignment. She covers the issue of how universities are trying to add more and more students online, because when it all boils down to it, money is what they are after. Professor Kiefer goes over a few ideas of how to make an online writing class better, such as requiring participation in discussions, but eventually she feels that online instruction in writing classes, leave the student short of what a teacher would like them to learn in a class. Professor Kiefer is very adamant on the loss of personal interaction in online writing classes and how it diminishes the importance of personal interaction, which to some extent is very true. In a recent article published by the â€Å"Journal of Asynchronous Learning Networks†, documenting over 125 traditional face to face classes, it found â€Å"very strong support for the existence of a community of inquiry that is shared within each class section†. (Fernandes, Oct 2013) While It may be almost impossible to capture the same type of peer to peer interaction in a distance learning course compared to a traditional classroom, the study does not take into account that many online students have a network of support they are able to bounce ideas off of. While the journal study names student networking as a weakness to online classrooms, it does not really mention the fact that many physical classroom environments have students that do not want to participate. Professor Kiefer also addresses the high dropout rate of online students. This makes me wonder if the dropout rate is due to non-flexibility within the school offering the classes of if it is students just not taking it seriously. A recent study published in â€Å"Journal of Asynchronous Learning Networks† by the Dean of Online Education at Dallas Baptist University noted that â€Å"their university offers thirty-four online degree programs and Dallas Baptist University has maintained a 92% cou rse completion rate† (Shelton, Oct 2009). I would have liked to have seen professor Kiefer give the standard dropout rate of traditional classroom students at a university. It is very possible that online education is still in such an evolving state, that there are many different factors leading to a high dropout rate. Many schools have not properly trained their faculty in correctly dealing with online education, while some of it is definitely the daily lives of online students that get it in the way. Professor Kiefer makes many valid points on her topics, however the reasons  she gives regarding why students take online courses, are the exact reasons they must continue. People with jobs and forty hour work week can’t take time out to drive to the university every day. Online classes have been going for a number of years now, but it is still in its infancy compared to classroom instruction. There are still so many ideas created each day that can make this learning environment better. Professor Kiefer makes a good argument regarding the negative impacts of online writing classes, but the reason we have online classes to start with are why they can’t stop. The goals of online students are the same as other students, they want to better their lives and further educate themselves. That lifeline cannot be taken away, because there are doubts about its effectiveness. It is up to everyone to keep making strides and improving the experience of online education. Bibliography Fernandes, B. R. (Oct 2013). Measuring the Community in Online Classes. Journal of Asynchronous Learning Networks, 17(3), pp 115-136. Kiefer, K. (2007). Do Students Lose More than They Gain in Online Writing Classes? In Brave New Classrooms. (Vol. 37, pp. 141-151). New York, NY: Peter Lang USA. Shelton, K. (Oct 2009). Does Strong Faculty Support Equal Consistent Course Completion?: It Has for Dallas Baptist University. Journal of Asynchronous Learning Networks, 13(3), pp 63-66.

Electronic Medical Records

Electronic Medical Records Essay Cynthia Jones Grand Canyon University: HCA 450 November 11, 2012 Electronic Medical Records Essay Medical record keeping has change in the last couple of decades. In the past patients records were kept in a file on paper taking up excessive room. In the past, paper charts were the only means of keeping a patient’s medical diagnoses documented. Some of these charts are still used today in healthcare facilities, however they are slowly being replaced with a more advance method; electronic medical records (EMR’s).This virtual data–information center can serve as a vehicle to promote and to disseminate standardized data definitions and best practices to providers, consumers, and others interested in quality improvement efforts nationally and internationally (Varkey, 2010). The Electronic Medical Records is an advance computerizes medical record system that delivers medical data for physician’s office and hospitals within a matt er of seconds while offering care. This system allows the healthcare staff and physicians to modified, store and retrieves patient’s medical records.Electronic medical records are legible and organized. The Electronic Medical Record (EMR) has been around since the late 1960‘s, when Larry Weed introduced the concept of the Problem Oriented Medical Record into medical practice (NASBHC, 2012). Weeds innovation introduces the concept of the Problem Oriented Medical Record into the medical practice, which verifies the diagnosis (NASBHC, 2012). However, it wasn’t until 1972 when the Regenstreif Institute developed the first medical records system. Although it was a great invention, physicians didn’t seek to use it right away.This new system would help physicians improve patients care. Although, $19 billion in stimulus funds have been invested into the Electronic health record (EHRs) another name for EMRs; the Obama administration highly suggested that health car e and hospitals facilities start to digitize patient data and start making better use of the advance technology(Greenemeier, 2010). The health care industry has been slow to adapt to this new system. Although the EMR system is intended to make patients records more accessible for the physicians and staff, still many have not implemented it yet.Given the lack of EMR adoption throughout the health care industry, less than 10 percent of U. S. hospitals have adopted electronic medical records. Cost is the primary reason many have resisted or are unwilling to adopt the EMR system and shortage on staff as well. In a recent interview on November 9, Jessica in human resource at Vineville Internal Medicine, with Dr. Mary Bell Vaughn presiding as the physician over the practice. The practice has been using electronic medical records systems since the practice open in 2002. Dr.Vaughn thought patients and staff needed easy access to their records when needed. Some of her other reasons are as fo llow: †¢ Paperless, Less storage †¢ No physician running around ( Patient info available at finger tips) †¢ Saves time spent with patient †¢ Good for tracking information †¢ Financial Good This system is web based and uses an E-Clinical program through a portal. This system also allows prescriptions to be sent to the local pharmacy as well. Blood work results are also put into the patients charts as well.Recently, the practice took on new patients with paper charts, because their physician retired. In this cause their most recent charts were converted over to EMRs. However those paper charts still exist in a small storage area if further information is needed on the patient. Though the practice implements the EMRs system from the very beginning, the physician and staff are very happy with the system. Most patient information is put into the system via computer on the spot while the patient is telling the nurse or physician what is ailing them.Although there system is a web based system, it has two backup systems in two different locations just in case the systems go down or power outage. The EMR system has had great quality impact on the practice. The patients care has been improve by the system. It allows the physician to track and effectively treat the patient. In some cases if the patient is located at another healthcare facility this system allows them to send information to multiply people for care, no matter where they are. Dr.Vaughn’s practice is already looking into the future to implement sending out text message to patients to inform them of appointments. Patients have access to their care anytime. EMR adoption is slow to be implemented into some practices. Although there is some disapproval of the electronic medical records today, it is merely a digitized version of paper chart. This system will reduce medical errors and help put information in front of researchers This new form of technology is here to stay and the s ooner healthcare facilities start using it the more efficient results they will receive.References Prathibha Varkey (2010). Medical Quality Management, Sudbury, Massachusetts: Jones and Bartlett Publishers. History of the Electronic Medical Record system (2012) Retrieved November 8, 2012 www. nasbhc. org Will Electronic Medical Records Improve Health Care? (2009) Retrieved November 8 2012 http://www. scientificamerican. com/article. cfm? id=electronic-health-records Electronic Medical Records Engineering Management Field Project Electronic Medical Records: A Case Study to Improve Patient Safety at Royal Victoria Teaching Hospital By Annie Bittaye Spring Semester, 2009 An EMGT Field Project report submitted to the Engineering Management Program and the Faculty of the Graduate School of The University ofK. ansas in partial fulfillment of the requirements for the degree of Master's of Science )= †¢ , , Tom Bowlin Cotntnittee Member ‘~k Committee Member Date accepted: _ _&-4–_':'†/~,,,,,,†1_-. -Q:;,,.. r5c—-_ _ Table of ContentsTable of Contents †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 2 List of Figures †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 3 List of Tables †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 Acknowledgments†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ Executive Summary †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 5 1. 1. 1. 2. 3. 3. 1. 3. 2. 3. 3. 3. 4. 4. 4. 1. 4. 2. 5. 6. 7. Introduction†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Background of Royal Victoria Teaching Hospital †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 Literature Review †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 0 Procedure and Methodology †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 17 Exp erimental Design †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 17 Survey Procedure †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 18 Data Analysis †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 9 Limitations of the study †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 19 Resultsâ⠂¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 20 Reasons why EMR is not being used at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 23 Benefits and challenges of EMR†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 24 Summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 0 Conclusion †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 30 Suggestions for Additional Work †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 32 References †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 34 Glossary †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 5 Appendix †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 36 2 List of Figures Figure 1: Sources of funding, RVTH 2008 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 22 Figure 2: Averages ofEMR functions in order of relevance to work at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 29 List of Tables Table 1: Number of patients seen at RVTH in 2008 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7 Table 2: List of Professionals, RVTH 2009 †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 0 Table 3: Computer ownership and previous computer training received by the respondents at RVTH †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 28 Acknowledgments My journey towards my Master's degree was a long and fruitful one. The Engineering Management (EMGT) program has not just exposed me to much information and ideas but also opened a way towards my career path. Thank you to my parents, Ebrima and Lucy who have always been a source of great inspiration and strength to me. They taught me the value ofeducation and their prayers has always been with me.Thanks to my brother, Baboucar who encouraged me to pursue my Master's degree and the never ending support I receive from him. Special thanks to my six year old son, Ebrima for his understanding that I'm at school when I'm not home to read him a bedtime story. I also want to thank all my EMGT instructors especially Professor Herb Tuttle, Dr Tom Bowlin and Ray Dick who worked with me recently, for the wonderful information and feedback they provided on this project. Thanks to Parveen Mozaffar for her extreme support and encouragement during the course of my studies.Thanks to the staff at Royal Victoria Teaching hospital for providing me with all the needed information for this project. Last but not least, my gratitude goes out to Dr Don Anthony Woods. It is because of his influence that brought me where I am today. He always had my best interest at heart and I want to thank him for that. May God bless you! Executive Summary Most countries in Europe and the USA are increasingly using an electronic medical record (EMR) system to help improve healthcare quality. Unfortunately, The Gambia government faces a series of health crises including but not limited to HIVIAIDS, malaria, diabetes and tuberculosis.These diseases threaten the lives of thousands of people. Lack of infrastructure and trained, experienced staff are considered important barriers to scaling up treatment for these diseases. The contribution of this field proj ect outlines the benefits of an EMR system at Royal Victoria Teaching Hospital (RVTH) and how it will improve patient safety. This is a descriptive study using interview questionnaires from officials at the Royal Victoria Teaching Hospital. The study also looks into other facilities in similar developing countries with advanced systems, but not so advanced as to be at the level of state-of-the ­ art facilities in the U.S. Results from this study indicates the importance of an EMR system at RVTH to facilitate effective and efficient data collection, data entry, information retrieval and report generation. As a catalyst for development, the implementation of an EMR system at RVTH may make it one on the best hospitals in the West African region. 5 1. Introduction According to Dick and Steen, Electronic Medical Record (EMR) is the compilation of patient medical information in a computer-based format that allows the collection, storage, retrieval, and communication of this data.An electronic medical record replicates a paper chart and contains both clinical information (diagnoses, allergies, drug resistance and treatments) and demographic information about a patient; it provides a comprehensive medical picture and can be used by clinicians as a tool to determine appropriate treatment for patients. EMR is not only being welcomed by healthcare providers as a way to improve care delivery but also serves as a catalyst and gold standard for development (porter, Kohane, & Goldman; Reifsteck, Swanson, & Dallas).Unfortunately, Africa, a continent faced with many challenges ranging from epidemics, civil wars, and disasters, lacks robust healthcare infrastructure in the form of computerized h ealth care systems. For instance, Ghana has one the best health institutions in the region, Korle-Bu Teaching Hospital. This Hospital, for example, is currently the only institution in the West African sub-region which performs surgery. Due to the quality of outcome, it now receives referrals from most parts of the continent namely the Gambia, Sierra Leone, Liberia, Togo Benin, Tanzania, Nigeria, Cameroon, Cote d' Ivoire, and Ethiopia.Despite its exemplary performance, the hospital has no computerized information system which can help improve care delivery in the region. Therefore, the purpose of this study is to examine the potential benefits of EMR and its ultimate contribution to improving healthcare delivery development in less developed countries like The Gambia. 6 1. 1. Background of Royal Victoria Teaching Hospital The Gambia is a small country in West Africa, with a population of approximately 1. 5 million. RVTH has been in existence for over 100 years in The Gambia's capita l, Banjul.It used to be called Royal Victoria Hospital until in the late 1990s, when its name was changed to RVTH. The Gambian Government decided that it had to reduce its dependency on foreign doctors by establishing a medical school in the University of The Gambia (UTG). The UTG now uses RVTH to teach its clinical students. In recent years, The Gambia has been doing much on its own initiative to take to improve the healthcare of the nation. There are 540 beds in the hospital and the two largest Departments are Pediatrics and Maternity.The biggest â€Å"killer† disease in The Gambia is malaria, with young children and pregnant women being particularly vulnerable to this disease. Diabetes, high blood pressure, pneumonia and eye problems such as trachoma and cataracts are also major health problems. The following table provides an estimation of how many patients were seen at RVTH in the year 2008. Procedure Inpatient Admissions Children admitted to Pediatrics Patients treated in the Eye Center Out-Patient Appointments Out-Patients in the ER Number of Patients 25,281 9,352 986 over 184,365 24,334 Table 1: Number of patients seen at RVTH in 2008 7Unfortunately, RVTH does not have any EMR system in place to facilitate patient safety. As noted by participants, â€Å"EMR software is not used at RVTH because administration keeps complaining of money. It looks expensive to them and also they are more used to the paper folder†. Currently, information is very fragmented and therefore does very little to help patient safety and consistency in care. Another important issue here is that a large number of these patients are illiterates. To ensure they receive the appropriate treatment, they will have to explain to the physician current medications they are taking etc.This can be a very challenging and fatal to the patient sometimes. The typical paper medical record contains sections including information on demographics, admissions, discharge summaries, progre ss notes, protocols, laboratory results, radiology results, surgical and pathology reports, orders for, treatment and nursing notes. Most documentation regarding treatment of a patient is written directly in the patient's medical chart. On a given day a patient arrives at the hospital for care, sign in his name and waits anywhere from 30 minutes to six hours o get their records pulled depending on the day. Physicians, nurses, medical residents who need access the information in the medical record must wait till it's available. Typically, medical records are transported to the outpatient clinic where the patient would be seen, and then returned to storage center to be filed again. It is necessary for the medical record to follow the patient throughout their visit. If the patient was seen in one clinic where orders were written, it was necessary to physically transport the record when the patient moved to the medicine room for treatment. The purpose of this field project is to examine the potential benefits of an EMR system and its ultimate contribution to improving patient safety at the Royal Victoria Teaching Hospital in The Gambia. 9 2. Literature Review The first generation of EMRs was extensions of medical billing systems in large US hospitals. Over the last four decades, they have been used as tools to organize and store medical data. EMRs are widely accepted as important tools to support high quality health care in the US, Europe and other developed countries.Evidence shows that using EMRs that include decision support systems improves quality of care and both reduce medical errors and unnecessary medical investigations (Partners in Health), Experience with the use of EMRs in developing countries, if available, is much more limited than it is in the US and Europe. Now there is considerable interest in using medical information systems to support the treatment of HIV and TB in Africa, Latin America, and Asia. In most African countries, healthcare informati on systems have been driven mainly by the need to report aggregate statistics for government or funding agencies.Such data collection can be performed with simple paper forms at the clinic level, with all electronic data entry done centrally, but that approach tends to be difficult and time ­ consuming and may provide little or no feedback to the staff collecting data. Individual patient data that are collected and accessible at the point of care can support clinical management. Clinicians can easily access previous records, and simple tools can be incorporated to warn of potential problems such as incompatible drugs.Physicians or nurses can check on the outcomes of individuals or groups of patients and perform research studies. Many of these functions will work well on paper or with simple spreadsheets for up to 100 patients but become very time-consuming and potentially unreliable with more than 1,000 records, and virtually impossible with 10,000 or more. 10 Experience with the use ofEMRs in developing countries is much more limited than it is in the US and Europe, but there is now considerable interest in using medical information systems to support the treatment of HIV and TB in Africa.Some examples of EMR use in Africa include: †¢ The Regenstrief Institute in collaboration with Moi University in Kenya developed an EMR for general patient visits to clinics in western Kenya. This system was subsequently modified to support the care of several thousand HIV patients. †¢ Baobab Health Partnership in Malawi has developed an EMR system using innovative, low-power touch-screen PCs for data entry and display. This system is now used to support the care of more than 7,000 HIV patients in the Lighthouse clinic in Lilongwe and has been chosen by the national HIV program for use throughout the country. [email  protected], an HIV medical information system developed for US patients, has now been deployed in Uganda and is planned for use in other African c ountries and in Latin America. (Partners In Health) A wide-ranging literature review of electronic medical record implementation over the past decade reveals that clinical, workflow, administrative, and revenue enhancement benefits of the EMR outweigh barriers and challenges. Among other key efforts, organizations must train and motivate users to navigate EMR systems, as well as develop a common structured language.Clinicians who used CPRs found that electronic 11 access to clinical infonnation saves time and provides a thorough and efficient way to manage patient information To reap the full benefits of an EMR, organizations must redesign current workflows and practices to evolve into efficient providers of care. EMR systems are developed to meet the following goals: improve quality of care, reduce organizational expense, and produce a data stream for electronic billing. (Dassenko and Slowinski).The EMR meets these goals through workflow automation, connectivity, and data mining. ( Gaillour) The Computer-based Patient Record Institute's (CPRI) definition concurred with the other researchers, but added that the EMR provides protection of patient and provider confidentiality, has a defined vocabulary and standardized coding, produces documentation as a by-product of patient care, connects local and remote systems and provides electronic support for secondary users (payers, policymakers, researchers). Fromberg and Arnatayakul) Unfortunately, most EMR systems are unable to offer all of the components defined by the CPRI because †the technology is too complex and too expensive, doctors won't use computers, and standards don't exist. â€Å"(Gaillour) The advantages associated with implementing EMRs are well documented and are straightforward. The difficulty comes with placing a dollar figure to these advantages; consequently, few organizations have published studies describing the actual costs and benefits attained from implementing EMRs. Bingham) The benefit s associated with CPRs are organized into four categories: clinical, workflow, administrative, and revenue enhancement. Renner, states that measuring all the benefits associated with EMRs is 12 virtually impossible, and that it is probably safe to select those that can make the greatest financial difference, and incorporate them into a financial model.Clinical benefits seen after implementing an EMR include: better access to the chart, improved clinical decision making and disease management, enhanced documentation, simplified patient education, and increased free time to spend with patients, accompanied by improved perception of care and quality of work life. These benefits ultimately result in better delivery ofpatient care and safety. Despite all of these benefits, EMRs are not a standard in today's healthcare systems. It is evident that EMR technology is still a hot topic for discussion when browsing through current healthcare technology and management journals.The following bar riers have kept healthcare leaders discussing EMR technology instead of adopting it: cost, leadership, ROI, vendors keeping up with users' needs, and deficits in the following categories: public policy, standards, security, and a true definition. First of all, cost has kept organizations from implementing EMR systems. These costs can be organized into the following categories: software, hardware, infrastructure development and maintenance, implementation, education, planning, and administration.Software costs include development or purchase, maintenance, and upgrades over time, while hardware costs include purchase of workstations. (Mohr) Infrastructure development and maintenance costs include servers, interfaces, workstations, network cables, network maintenance, and help desk operations. Planning costs include development of an implementation plan, identifying measurable outcomes, and choosing meaningful metrics and goals, while implementation costs include training, overtime 13 ssociated with entering patient data, business disruption during transition, employee resistance to change, and lost productivity. Drazen, suggested that leadership was probably a more significant barrier than cost because, in the past, healthcare leaders have raised capital for essential business initiatives such as major building programs, acquiring a physician network, or starting up a managed care organization. This amount of capital is on the same scale as an EMR. Next, Drazen stated that a lack of government support is a major issue holding up EMR implementation.Unfortunately, the federal government does not contribute fmancially to EMR implementation projects. Without standards and structured data definitions, computer systems are not guaranteed to interface easily with each other, and databases are not easily developed. Most individual departments within a healthcare system have already invested in computerized patient information systems; however, these systems are isolated and do not communicate well with one another. Getting these systems to interface is one challenge facing EMRs. Data security continues to be an ongoing challenge.Bergman, found that politicians, consumer advocates, and the general public have voiced concerns about risks to the privacy and confidentiality of patient information. However, when compared with the security of the paper chart, the EMR's electronic audit trails and passwords actually improves internal security. The EMR may be more secure for internal breeches of confidentiality, but must also be protected from external breeches such as hackers, who could potentially enter the EMR from an off-site location and download volumes of 4 confidential information. Firewalls and encryption software are methods used to protect patient data from these violators. Clinicians who use EMRs recognize two benefits: First, electronic access to clinical information saves time. Second, electronic access provides a thorough and efficient way to manage patient information. With EMR systems, comprehensive information can be located and presented in a way that is relevant to the task at hand. Dassengko and Slowinski) The obstacles identified have thus far been insurmountable, but the considerable achievements identified in the benefits section of this discussion suggest that the advantages are well worth the effort. As Lenhart et al state, â€Å"Success comes at the price of considerable effort, persistence and optimism, as well as dedicated leadership. † (p. 114) some organizations that invested in early EMR systems are struggling to show the qualitative benefits promised by vendors because an electronic version of current work processes is not cost effective. Sandrick) â€Å"If the ROI were a function of the information tool itself, the financial benefits would be experienced universally. † (ROI: The White Paper. A Business Case for Electronic Medical Records) To get the most value out of an EMR, healthcare organizations must reengineer the following work processes to make full use of the system: Healthcare organizations must first train and motivate their users on how to navigate and operate the EMR tools. To optimally use the EMR, it must be implemented from registration through billing, thus allowing the organization to realize full potential benefits across the delivery system.These benefits include clear, concise, and comprehensive documentation, greater efficiency, care consistent with best practice guidelines and improved claims processing. 15 It is difficult to measure the economic value associated with less tangible benefits such as higher quality of care, patient service, provider and employee satisfaction, and competitive advantage. It is even more difficult to allocate necessary resources and commit to institutional change when the paper chart is â€Å"getting the job done,† even if it is not in the most efficient style.However, Carlon, suggests that all providers s hould embmce the EMR to deliver safe medical care. The information in the EMR can reduce medical errors to avoid dangerous, sometimes lethal, mistakes. If organizations can't show that EMRs have a positive ROI, they may decide that the EMR is just another expense of running a business. The expense is to improve patient safety and reduce medical errors. This review of literature emphasizes that the use of EMR systems contributes to the ultimate goal of delivering effective care while improving patient safety. 16 3.Procedure and Methodology The study is an exploratory study conducted in Banjul, The Gambia, to examine the potential benefits ofEMR and its contribution to improving patient safety. For the most part, this study is descriptive and categorized as a non-experimental qualitative study. Initial contacts were made with the Chief Medical Director, Development Officer and the Head of Medical Records at the RVTH to solicit participants for the study. 3. 1. Experimental Design Surv ey approach was used to gather data from healthcare professionals who are considered potential users of EMR.Copies of the questionnaires were sent through e-mail to participants. A total of 50 surveys containing 15 questions were sent out and 30 of them were returned. The content of the survey designed was open-ended questions based on the following areas: knowledge of EMR, benefits and challenges of EMR, transition from paper-based system to EMR, security issues associated with EMR use and assistance given to developing countries by developed nations to implement or use EMR. Other areas include, demographic details of respondents based on profession, length of practice, age and sex.The survey questions can be found in the Appendix. Participants were selected based on their level of healthcare training. The population set for the study was healthcare professionals from the RVTH, which includes physician consultants, surgeons, pharmacists, nurses, midwives, pathologists, radiologists , and laboratory technicians. Study participants were limited to these previously mentioned health professionals, since they would be the principle users of an EMRsystem. 17 RVTH has a total population of about 500 professionals and a sample size of 50 was chosen for the study.Since this was the first time such a study was being conducted in the country, there was limited knowledge of professionals on the subject as well as difficulty in getting volunteers to participate. 3. 2. Survey Procedure Survey questionnaires were converted into a PDF file and mailed electronically to all 50 participants on February 2, 2009. Unfortunately, five medical professionals who were initially contacted to participate in the study later declined to take part due to lack of understanding of the survey questions. As a result, different participants were contacted to replace the five individuals to make up the sample size.Since the researcher could not travel to Gambia to facilitate the survey, one of th e administrative officers at the hospital was contacted and helped to distribute hard copies of the questionnaire to all participants. Participants were requested to fill out the attached survey and return it in a sealed envelope to this person or the chief administrator. After three weeks, on February 23, 2009, a first reminder was mailed asking for their cooperation and the importance of returning the survey. A final reminder was sent out on March 9, 2009, to those who might have forgotten to return the survey. 8 3. 3. Data Analysis The 30 completed surveys were coded, sorted, and organized into themes. A spreadsheet was created in MS-Excel to enter all data for analysis. All responses were placed into themes and summarized. The survey responses and themes generated were used to determine result interpretation, recommendation, and future research direction. Despite initial difficulties to get volunteers to participate in the study, 30 out of the 50 surveys mailed were returned on March 16,2009, thus representing 60% response rate. 3. 4. Limitations of the studyDue to the difficulty of getting other hospitals in the area involved, the study was limited to RVTH only_ The findings represent views ofthat hospital alone. However, the research would have been more interesting and challenging if more professionals from other hospitals were involved in the study. Secondly, due to cost of air travel between the United States and Gambia, the researcher was not able to travel to Gambia to collect the necessary data for the study. The inability of participants to respond to some important questions on the survey skewed the data.Finally, due to the six hour time difference between Kansas and Gambia, it was hard to reach the participants at during business hours. Lack of high speed internet or sometimes no connection at all caused the delay in receiving all the responses on time. It was also really difficult to get people to cooperate because the survey was not on their l ist of priorities. 19 4. Results Based on the methodology, surveys were mailed to 50 participants at the RVTH in Banjul, The Gambia. Thirty completed surveys were received which included 15 questions.The results from all participants are as follows: The 30 respondents consisted of 17 males, 11 females and two people who did not indicate their gender. The age range of the group was 25-56. Table 2 presents the professional distribution of participants. No Response represents people who did not include their profession. The five students, however, included final year medical and dentistry students, as well as nursing, and medical laboratory students. Professional experience ranged between 1 and 20 years.Profession Surgeon Pharmacist Physician Radiologist Midwife Nurse Laboratory Technician Student No Response Total Table 2: List of Professiona is, RVTH 2009 Number 3 2 3 2 5 6 2 5 2 30 20 To analyze this result, key words such as computerized, storage and retrieval, were used to determi ne respondents' understanding of the concept of an EMR system. Subsequently, one-third of respondents (33. 3%) who included these three key words were marked as right. While nine people representing 20% who said it is a mechanism for storing patient medical record on a computer were classified as partially right and approximately half respondents (46. %) who just said the use of machine to keep patient medical data were classified as having an idea or understanding of the system. In addition, implementing and running a successful EMR system requires a number of key elements. Accordingly, 15 people identified technical elements such as (electricity, hardware, software, etc. ), 10 stated patient data, while four said adequate trained personnel, and one person indicated the need for money to train staff on EMR. Also availability of adequate infrastructure such as experts to support and train care providers on EMR is very crucial when implementing EMR system.However, more than half resp ondents agreed that enough infrastructures are not available in Gambia to support EMR implementation. On the other hand, 10 people believed that infrastructures are available, while four said available infrastructures are only few. Despite unavailability of infrastructures, 16 respondents reported there are enough computer experts in Gambia to train healthcare providers to use EMR. Seven reported experts are not available; six stated experts are available but too few to meet the demand and needed training requirement of the healthcare sector.Lastly, one person indicated he has no idea of the subject. Responses concerning how much developed nations are assisting less developed countries like Gambia with Health Information Management (HIM) system infrastructure 21 implementation showed diverse opinions. Nine people said developed countries are helping, 15 responded no. However, six indicated that â€Å"the help given from developed nations are not enough and sometimes electronic devi ces sent to less developed countries like the Gambia are inferior and lack quality†.Still others think â€Å"some form of assistance comes in to support the country on information management systems but not much is channeled towards the health sector†. Lastly, seven people reported they have no idea â€Å"if developed nations are helping† and one person did not respond to this question at all. This pie chart below shows the sources of funding and the amounts received for the year 2008. Sources of Funding 2% †¢ Gambia Government †¢ Patient User Charges †¢ Donation Fund †¢ Internally Generated Fund †¢ Global Fund Severe Malaria in African Children FundFigure 1: Sources of funding, RVTH 2008 22 The majority of funds come from the Gambia Government in the fonn of subvention received monthly or quarterly in advance. However, about 70% of the amount goes towards payment of salaries and allowances to approximately 1,200 staff. Other donations re ceived are in the fonn of drugs, equipment, supplies and services which made considerable contribution to the hospital. (RVTH) 4. 1. Reasons why EMR is not being used at RVTH Paper records are bulky and can take up costly space.Filing, retrieval of files, and the re-filing of paper records are very labor-intensive methods with which to store patient infonnation. Plus if a record is checked out for one department, another department cannot access the chart. The impact of not having immediate access to key infonnation in emergency situations can be serious. Paper medical charts also cannot be effectively searched and used to track, analyze, and/or chart voluminous clinical medical infonnation and processes. They cannot be easily copied or saved off-site.Also physician's orders and the corresponding results such as medications and labs can be issued and saved in a comprehensive EMR system. Our literature review and results have proven that paper records are costly, cumbersome, misinter preted, easily misplaced and cannot be used for any meaningful decision analysis. Unfortunately, RVTH does not have any EMR system in place to improve patient safety. As noted-by participants, â€Å"EMR software is not used at RVTH because administration keeps complaining of the lack of money. It looks expensive to them and also they are more used to the paper folder†.Nevertheless, four key issues were identified by participants as the main reasons why RVTH does not have an EMR system in use. 23 Overall, 36% of respondents attributed the problem to lack of resources in terms of personnel and infrastructure, 29% blamed it on lack ofleadership initiative and priority. While 18% reported cost in terms of equipment and training personnel, 15%, however, stated lack ofEMR importance or awareness and fear to change. Lastly, 2% respondents did not give any reason. 4. 2. Benefits and challenges of EMR There are both benefits and challenges to EMRs.Many argue that positive aspects of u sing an EMR system outweigh the challenges. Even though the investments in EMR systems are costly, most argue that over time this outset cost will result in greater savmgs. As well as cost saving, many agree that one advantage of EMR system is that they save space. Instead of keeping huge paper files on patients, all records are kept on computer files. Though someone must store these records in computers, this still represents a small percentage ofthe space required to store physical records. Along with saved space is reduction of paper used by hospitals.Although EMR systems do not render paper obsolete, but they certainly do reduce needed paper significantly. Another advantage of electronic medical records is the ability for all in a health care team to coordinate care in terms of monitoring and treating diseases. This helps avoid duplication of testing, prescribing medicines that in combination might be dangerous and the ability for anyone on the medical team to understand the app roaches taken to a condition. A person with complex health issues may see several specialists, and can easily become confused by overlapping or contrary advice.When specialists and primary care doctors use the same system for electronic medical records, then everyone on the team would be aware of all the other team members' actions and recommendations. Electronic medical records may save time as well. Though faxing and email may assist one doctor to get information from another doctor or a laboratory, there is generally a wait time to receive this information. When a doctor has instant access to all of a patient's information, including things like x-rays, lab tests, and information about prescriptions or allergies, he or she is ready to act right away, thus saving time.This may be particularly helpful in emergency situations where a patient cannot answer questions about medical history or allergies due to extreme illness or injury. Generally, doctors are often considered to have th e worst handwriting, though this is just a generalization, unclear writing can lead to misinterpretations and mistakes. Typed notes and prescriptions are more legible and less likely to create misunderstandings. However, electronic medical records do not rule out the occasional typo. One of the main disadvantages to EMR system is that start up costs is enormous.Not only must you buy equipment to record and store patient charts (much more expensive than paper and file cabinets), but efforts must be taken to convert all charts to electronic form. Patients may be in the transitional stage where old records haven't yet been converted and doctors don't always know this. Further, training on EMR software adds additional expense in paying people to take training, and in paying trainers to teach practitioners. In fact, one concern about the use of electronic medical records is that doctors may have a significant learning curve when these programs are first implemented.A poor 25 typist may a ctually take a long time to input information. Doctors often have to be their own medical clerks especially during an office visit, and a doctor distracted by confusing technology may not be as alert to a patient's symptoms or needs. There is no single electronic medical records source or system, so different hospitals and individual clinicians may not all be using the same program. This negates the possibility of instant information for all on the medical team, since one program may not communicate with another.Another concern is that electronic medical record systems might be hacked and exploited by others. Since one of the first considerations of medical treatment is confidentiality, it may remain a concern about how many people may have access to other medical records which they are not authorized to do so. Misuse of private medical information could create problems for people who have conditions they wish to keep private. Despite these concerns, it appears many hospitals are no w attempting to use EMR systems.It remains unclear how long it will take for hospitals to transition completely from the traditional paper-based systems to a complete paperless environment. As shown from the survey results, it is clear that many participants believe that implementation ofEMR will tremendously improve upon patient in the country. For instance, as noted by one respondent, â€Å"availability of patient past history in electronic format will enable health care workers have information about patients in seconds and with ease which will facilitate quick diagnosis and treatment hence reducing the rate of mortality. 26There is always some level of fear and resistance to change, especially in the healthcare industry. A question concerning the level of acceptability from the traditional paper-based system to EMR system shows that such change will be met with some difficulties. More than half of respondents said the process would be challenging initially, but eventually care providers will accept the system because it will improve patient safety and work performance. Although the majority may still prefer the paper-based system, â€Å"they will change when they see the importance or need for EMR† stated a participant.Others also believe it would be a â€Å"welcome idea†. The adequate protection of patient health record requires limitations at all levels, such as: collection, use, access, and disclosure. Therefore, development of privacy, confidentiality, and security principles is necessary to protect patients' interests against inappropriate access to their health data. Unfortunately, 14 respondents (47%) did not respond to this important question regarding measures necessary to maintain patients' privacy, security, and confidentiality at RVTH.However, 16 people representing (53%), did state that all health records must be securely protected by use of password, data encryption, and access restrictions to users. It is obvious from the surv ey results that effective implementation and utilization ofEMR can improve patient safety in developing countries. Considering training as one of the key elements to EMR success, a question was asked to determine length of time required to train care providers in Gambia on EMR.Almost 50% of respondents indicated it might take 6-18 months depending on â€Å"practitioners' ability to understand the concepts ofEMR as well as the user friendliness of the software†. Others believe â€Å"for 27 current medical students who are already computer literate may take about two weeks, but the older practitioners will take longer time (approximately over a year)†. Table 3, below shows the number of respondents that own a computer or has had some form of computer training in the past. Computer Training Profession Own a Computer 1 1 1 0 1 2 1 2 I Yes 1 1 1 0 2 3 1 7 16

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