Gul 2014 charles ho paper

Implementation of Electronic Medical Records in Turkey and the United States Charles Ho 4/25/2014

Created for Global Urban Lab Rice University: School of Social Sciences & Kinder Institute for Urban Research

Executive Summary Electronic medical records can greatly enhance the delivery of healthcare by facilitating information exchange among healthcare providers. They can also make healthcare treatments more efficient by providing decision support for physicians and shortening documentation time.

Both the United States and Turkey have demonstrated strong interests in the complete implementation of electronic medical records, since both have made major healthcare policies that were indented to stimulate electronic medical record adoption. Despite these benefits and efforts, utilization of electronic medical records has not yet reached its full potential.

This report is a comparative study between the health care systems of the United States and Turkey with respect to the adoption of electronic medical records. The goal is to identify the major factors that may have greatly influenced the implementation process. In order to so, this study examines the fundamental structure of each nation’s healthcare system by reviewing literature on this issue as well as interviewing healthcare experts in both nations.

The major findings from this research suggest government policies designed to increase electronic medical record adoption, such as incentive programs, and investment in information technology development are important factors when considering future directions for electronic medical record implementation.

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Table of Contents Executive Summary....................................................................................................................................... 1 Table of Contents .......................................................................................................................................... 2 Introduction .................................................................................................................................................. 3 The Issue ....................................................................................................................................................... 4 Research Methodology ................................................................................................................................. 5 Findings ......................................................................................................................................................... 6 Discussion.................................................................................................................................................... 11 Conclusion ................................................................................................................................................... 14 Works Cited................................................................................................................................................. 15 Acknowledgments....................................................................................................................................... 18

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Introduction Effective documentation of medical information is important for clinicians to provide successful care. On the individual level, a comprehensive medical record provides the clinical staff, as well the patient, the essential facts and information on the patient’s health status. This gives the opportunity to develop the best treatment possible. From a broader perspective, a practical medical record also allows healthcare managers to evaluate their institution’s current treatment strategies by giving them a better ability to oversee their institution’s care and outcomes.

An electronic medical record (EMR), as opposed to paper-based systems, provides a much needed enhancement in medical documentation. While computer-based record platforms have been conceived as early as 1978 (Barnett 1978), recent advancements in the information technology field have made EMRs more practical and feasible to implement. This is good news, since limitations in outdated paper-based systems have caused errors in medical care and frustration among medical staff since information was hard to find and exchange (Joe 2014).

Figure 1. An example of the electronic medical record (EMR) user interface.1 Benefits of EMRs are numerous. They facilitate communication among members of the clinical staff in order to craft an optimized treatment plan for the patient. Since access to information is near instant, the time to obtain key patient information is greatly reduced. This helps make patient care much more efficient. EMRs also can serve as a vital resource for clinical decision making (Jha 2009). For instance, the electronic record can alert the physician if the prescribed drug has adverse interactions with other drugs the patient is currently taking. The benefits also extend beyond individual patient care. These electronic records allow physicians’ work and decisions to be accounted for and clinical performance can be more effectively 1

Image source: http://www.ehrmarket.com/blog/wp-content/uploads/NextGen_mainview_large.jpg

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evaluated by healthcare managers, as more data can be quickly recorded and analyzed. Clinical research can also be greatly enhanced since more data is available for clinical investigators to analyze. This expands the opportunity to make important findings about clinical outcomes of certain diseases and treatments.

While the benefits are impressive, the implementation of EMRs is currently not universal. EMRs are not a perfect product and needs continuous adjustment to best tailor to the medical setting. In fact, there are several obstacles that must be overcome in order for physicians and other healthcare professionals to usefully utilize digital means of medical records. For example, the electronic systems may be complicated to use. Some clinicians may not be convinced of the practicality of the system. Also, initial starting costs as well as maintenance expenses can be costly and not feasible for certain healthcare practices (Jha 2009).

The Issue Due to the promising enhancements that are associated with electronic medical records, health care systems worldwide have been interested in implementing these digital systems (Iakovidis 1998, Fuad and Hsu 2012, Aminpour, Sadoughi and Ahamdi 2014). Because healthcare spending in the United States has consistently been the highest among all nations worldwide (Anderson et al. 2006), it is reasonable to assume implementation of EMR systems in the United States would be one of the highest in the world. However, that is not the case.

Studies have reported that only about half of American primary care physicians use an electronic health system while certain countries in Europe have near complete participation in such systems by primary care physicians (Gray et al. 2011). Thus, further investigations into this issue need to be conducted in order to identify and better understand the factors involved in integrating electronic records into the health care system.

The importance of this issue extends to national policy making. In the United States, there has been a great deal of motivation for increased EMR implementation. President George W. Bush, in his 2004 State of the Union address, declared that a major objective for future healthcare reform was for every patient in the U.S. to have an EMR by 2014 (A New Generation of American Innovation n.d.). Subsequently, funding for healthcare information technology development was doubled in 2005. Then, by 2007, federal entities such as the Office of the National Coordinator for Health Information Technology (ONC) and the American Health Information Community (AHIC) were established to enhance these policy efforts (Simborg 2008). In 2011, in conjunction with the American Recovery and Reinvestment Act of 2009, the HITECH (Health Information Technology for Economic and Clinical Health) act was implemented to stimulate the adoption of interoperable EMRs (Blumenthal 2010).

To better understand the contributing factors of EMR implementation, a comparison with another nation’s healthcare system that is also undergoing reform would be insightful. In Turkey, there is also an ongoing effort to reform the nation’s healthcare system, which is known as the Health Transformation Program (Akdag 2010). Like the United States, one major 4|Page

aspect of this healthcare reform entails advancements in healthcare information technology.

For instance, the Ministry of Health (the governing body for Turkish healthcare) has required all “secondary and tertiary care providers” to submit EMRs (Akdag 2010). While similar goals have been declared, American and Turkish health care are structured very differently, with Turkish healthcare being relatively more centralized, though privatization has become a recent trend in Turkey (şentürk, Terzi, and Dokmeci 2011) Because of the similarities and differences associated with EMR implementation between healthcare in United States and Turkey, a comparative study and analysis between the health care systems of these two nations may provide deeper understanding of the major determinants for successful adoption of EMRs. The goal of this paper is to compare EMR implementation policy made in the United States and Turkey. Implications of this comparison may provide some insight into how certain changes may affect the implementation process, which may provide useful information for future policy decisions on this issue.

Research Methodology In order to compare electronic medical record adoption between the United States and Turkey, a review of literature of EMR implementation for the United States as well as for Turkey was conducted. This review focused on government policies made by the respective nations with regard to healthcare information technology as well as the structure of the general health care systems.

To supplement the investigation of the Turkish healthcare systems, two structured, open-ended interviews were conducted, lasting approximately thirty minutes each. Both of these interviews were recorded. The first was done with Dr. Ali Sarper Taskiran, MD, a psychiatrist and faculty member at Koç University in Istanbul, Turkey. The second interview was with Dr. Zenyel Mungan, MD, professor of gastroenterology at the American Hospital in Istanbul, Turkey. These interviews focused on gaining knowledge of the government’s role in Turkey’s healthcare system as well as how Turkish physicians utilize EMR in their practice.

This study also involves a more specific comparison between the two systems by focusing on two prominent healthcare groups in two major global cities in the United States and Turkey. In this case, a comparison is made between the Kelsey-Seybold Clinic (Houston, United States) and the Acibadem Healthcare Group (Istanbul, Turkey). A structured, openended interview lasting one hour was conducted with Dr. Robert Turner, DO, the Physician Champion of Electronic Medical Records for Kelsey-Seybold. A site visit to the Acibadem Hospital Kadikoy in Istanbul was also performed, where a one-hour open-ended discussion was done with Arda Bozoglu, the Information Technology System Management Supervisor at the Acibadem Hospital. The goal for these discussions was to directly compare how the two practices compare and contrast with respect to the integration of EMRs in their own network of clinics.

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This study is qualitative in nature, where general trends and perceptions are identified to help understand the similarities and differences between the American and Turkish healthcare systems. Conclusions will be made based upon an evaluation on relevant information that can portray the fundamental factors driving EMR implementation in each nation’s healthcare system.

Findings The findings and observations for this comparative study will be described by comparing Turkey and the United States with respect to the following four major topics.

I. II. III. IV.

Government role in EMR implementation Structure of national healthcare system Usage of EMRs within clinics and hospitals Case study between Acibadem Hospital (Istanbul) and Kelsey-Seybold Clinic (Houston)

I. Government role in EMR implementation In the recent decade, both Turkey and the United States have proposed major changes in their respective health care systems. In Turkey, the major movement for healthcare change was outlined in their Health Transformation Program in 2003. In the United States, major landmark reforms in healthcare include the Affordable Care Act in 2011. Both of these influential programs have included measures for increasing electronic medical record adoption.

This was a goal that has been considered by both nations since the mid-2000s, where Turkey declared this in 2003 and the United States government acknowledging this goal in 2004.

However, this was much later than that of other developed countries. For instance, policy makers in Germany have been working on this implementation process as early as 1993 (Anderson et al. 2006).

As a means of achieving that goal, the government must allocate a portion of their budget to invest in implementing this modern technology in existing hospitals and clinics. The United States has made large efforts to fulfill this. One example is associated with the highlypublicized American Recovery and Reinvestment Act of 2009, also known as the “stimulus package” following the recent economic recession. Part of this large-scale policy was the Health Information Technology for Economic and Clinical Health (HITECH) act, which outlined the investment of $36 billion for the creation of an integrated electronic health record system (O’Harrow 2009). Based on the estimated $2.5 trillion of U.S. healthcare expenditures (Fleming 2010), this calculates to about 1.5% of total healthcare spending dedicated to information technology updates. On the other hand, Turkey is relatively less financially invested in strengthening its healthcare information technology, since they devote “much less than 1% of total investment in healthcare” to information technology (Turan and Palvia 2014).

In terms of the actual implementation process, the Turkish Ministry of Health has made several concrete plans to establish a nationally integrated electronic health record system. The overall plan is called the National Health Information System (NHIS). In their Health 6|Page

Transformation Program (Akdag 2010), a nationwide program called “Saglik-Net”, which is part of their overarching NHIS initiative, is a centralized record database where the governing body of health can collect data from individual patients. This system also claims to facilitate the sharing of electronic health records between healthcare providers across the country. Another major component is the development of the Hospital Information System, which attempts to computerize the hospitals under the Ministry of Health’s domain, facilitating transmission of EMRs to the government database. These efforts are not currently seen in the United States, where the EMR systems are not integrated between healthcare providers in the nationwide spectrum and there do not seem to be any explicit programs currently in progress regarding the integration of EMRs in the U.S. The government can also play a significant role in the implementation process by influencing healthcare providers to adopt this new technology. The United States government has recently applied an incentive program to increase EMR participation among American physicians. This is done through Medicare reimbursements, which is the U.S. government’s method of paying for uninsured or low-income citizens. These reimbursements represent a significant part of a healthcare provider’s revenue. In order to receive these benefits, physicians must demonstrate Meaningful Use, a term used to refer to the defined set of usage criteria.

Furthermore, penalties may be incurred for lack of effective usage by withholding of reimbursement funds (U.S. Department of Human and Health Services n.d.). In Turkey, the motivation for healthcare providers to use EMRs is similar. Since the Ministry of Health controls much of the healthcare programs in Turkey, the Social Security Institution is the primary mean for covering healthcare expenditures (World Health Organization 2013). Thus, when the government implements a program and requires healthcare providers to participate, they must do so in order to continue receiving funds from the Social Security program. The difference between this method of garnering EMR adoption seems to be that Turkey has a more control over healthcare processes while in the United States, hospitals and clinics can pursue other means of funding if they do not meet the government’s requirements for reimbursements.

II. Structure of national healthcare system In order to analyze how EMRs are implemented into a nation’s healthcare scheme, its composition should be taken into consideration. The composition of public and private healthcare institutions greatly differs between Turkey and the United States. American healthcare spending has significant resources from the private sector. With the recent healthcare reform policies, the public sector share of expenditures is rapidly rising, but is still only half of health spending in 2012 (Truffer et al. 2010). On the other hand, Turkish healthcare costs are primarily covered by public programs, where 73% of spending in 2011 is accounted for by the social security funding program as well as other government resources (Tatar et al.

2011). However, the private sector has been becoming a larger role in Turkish healthcare in recently years (Çaha 2007). With regards to usage of EMRs, interviews have portrayed the notion that, in Turkey public institutions’ records systems are not as effective as those seen in private institutions. The records completed by public-based physicians are more basic and contain less useful information (Taskiran 2014).

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The amount of centralized control the Turkish government has seems greater than that seen in the United States. A fact learned from interviews was that the Ministry of Health can control how many and where physicians are allocated, depending on how the government evaluates the regions that are in most need for increased healthcare access. Physicians are required to receive approval from the government in order to practice (Taskiran 2014). This seems to be a stricter criterion than that for American physicians, where the main factors in where physicians practice are not typically due to government influences and decisions. This observation relates to this comparison EMR implementation since it is another instance where the Turkish government has a great degree of influence over healthcare processes. This can affect EMR implantation by providing an additional dimension to motivate physicians to use EMRs. III. Usage of EMRs within clinics and hospitals The manner by which clinics and hospitals utilize their EMRs can vary between the two countries. Based on personal observations, physicians in the U.S. who are legitimately utilizing the EMR system are directly interfacing with the computer system as they are making clinical observations and interacting with the patient. However, in Turkey, clinicians claiming to utilize an EMR seem to indirectly use the computer only to obtain and store information. While Turkish physicians use the electronic system to order prescriptions, the usage of decisionsupport tools and information sharing appears to be currently limited. Furthermore, interviews have indicated that relying on the electronic system during patient consultations may negatively interfere with the patient-physician relationship (Mungan 2014). Instead, these clinicians write their notes and observations by hand, which are then scanned into the electronic system.

The integration of medical records in the national sense is a major consideration. One of the promising benefits of the EMRs is the potential to link all patient records in a nation for easy sharing of information and reduction of errors due to missing information. In Turkey, as mentioned previously, there have been large efforts to implement this type of system through its nationwide Saglik-Net initiative. However, the sharing of information across all hospitals is neither consistent nor firmly established as of now. Based on visits to hospitals in Istanbul, there is a general consensus that gathering patient information across different healthcare institutions is not yet a digital process. A similar scenario is present in the United States. The electronic health records are not integrated between most medical providers. This is dependent on the system on which the particular institution’s electronic system is based on. For instance, numerous U.S. hospitals utilize an EMR produced by Epic, one of several private, commercial companies devoted to developing healthcare information technology solutions. Hospitals under this particular system can freely exchange and access patient records. However, there is a plethora of different EMR systems. These distinct platforms are not currently interconnected.

Finally, current statistics regarding EMR implementation and adoptions need to be mentioned to evaluate the current progress in this important healthcare initiative. In Turkey, 8|Page

the Ministry of Health reports that 85% of healthcare institutions participate in the nationwide “Saglik-Net” electronic system. Also, they report that all of their public hospitals under the Ministry of Health’s jurisdiction are using the Hospital Information System (Akdag 2010), where nearly 1.5 million EMRs are submitted per day (Dogac 2010). Furthermore, the NHIS system has experienced 99% participation by public hospitals and 71% participation by private and university hospitals in Turkey (Dogac et al. 2011). In the United States, as of 2013, about 50% of physicians have demonstrated Meaningful Use of EMRs in their practice (Doctors and Hospital’s Use of Health IT More than Doubles since 2012 n.d.). Over the past few years, particularly in 2012, there has been a drastic increase in EMR adoption (Figure 2). This number of can be expected to further increase in the next few years (Xierali et al. 2013).

Figure 2. Physician usage of electronic health records have rapidly increased in 2012 (U.S. Department of Health & Human Services)2.

IV. Case study between Acibadem Hospital (Istanbul) and Kelsey-Seybold Clinic (Houston) To provide a more specific comparison between two specific global cities, two major private healthcare groups in each global city are examined. In Houston, United States, the Kelsey-Seybold clinic is a multi-specialty practice with over 20 clinics, and is one of Houston’s largest outpatient clinic systems (Figure 3). In Istanbul, Turkey, the Acibadem Healthcare group is a major practice in Turkey, with multiple clinics through Istanbul as well as internationally (Figure 3).

One observed difference between the usages of EMRs was how physicians recorded their information into the computer system. At Kelsey-Seybold, the clinician directly interfaces with the computer system while making the medical observations of the patient. The physicians are also able to utilize the numerous tools and applications available to them through the EMR in order to provide better treatment for the patient. For instance, the electronic system 2

Image source: http://www.hhs.gov/news/press/2013pres/05/20130522a.html (U.S. Department of Human and Health Services.

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reminds the physicians to perform certain tests and procedures based on the patient’s previous conditions. On the other hand, in the Acibadem Hospital in Turkey, the physician interaction with the computer system seems to be more limited. Based on observations in the radiology department of this hospital, the physician records the clinical findings by verbally dictating into an audio-recording device. This audio file is then transferred to a human transcriber clerk, who types up the audio record into a word processed document that is added to the patient EMR.

Figure 3. Healthcare institutions observed in this research study. (left) Kelsey-Seybold Clinic, Houston, Texas, United States3. (right) Acibadem Hospital Kadikoy, Istanbul, Turkey.4 While integration with healthcare institutions outside their immediate domain is not fully developed, both Kelsey-Seybold and Acibadem enjoy efficient integration of medical records within hospital and clinics in their same respective systems. Since both are relatively large clinic systems, their adoption of EMRs has been met with more approval, since this system allows all of the clinics to be better integrated. Furthermore, it was interesting to note that both health care systems place a high emphasis on patient confidentiality and data security (Turner 2014, Bozoglu 2014), indicating that this is an important aspect of EMRs that must be addressed before they can be accepted for usage.

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Image Source: http://upload.wikimedia.org/wikipedia/commons/a/a0/KelseySeybold_Clinic_Main_Campus_Holcombe_Ave.jpg 4 Image Source: http://www.acibademlazerepilasyon.com/images/kadikoy_acibadem_hastanesi.jpg

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Discussion In this discussion, the previously mentioned findings are evaluated with respect to the following major themes: I. II. III. IV.

Lack of consistent definition of electronic medical records EMR presence in public and private healthcare practices Monetary investment in EMR development Limitations of current study and considerations for future research

I. Lack of consistent definition of electronic medical records An interesting, perhaps surprising, finding was that the statistics associated with EMR adoption rates seemed to be much higher in Turkey than in the United States. However, such a strict comparison should be evaluated with caution due to a number of factors.

First of all, this direct comparison assumes that the definition of EMR usage is the same in both countries. However, based on the findings of this study, this does not seem to be the case. Because of the high numbers reported by the Ministry of Health with regards to health information technology adoption, it was expected that there would be an overarching notion that Turkish clinicians are regularly using EMRs during their treatment of patients. However, when interviewing the Turkish healthcare experts and visiting the hospitals in Istanbul, it was discussed that was not necessarily the case.

A true EMR system should not only allow physicians to store clinical information in an efficient manner but should also enhance clinical care by providing decision support and easy sharing capabilities with other healthcare professionals essential for the patient’s treatment.

Literature review indicated that the successful implementation of the Saglik-Net system has allowed hospitals to easily interconnect with each other. However, in the visits to the Istanbul hospitals, there was a general perception that hospitals did not engage in this type of information sharing. Moreover, many physicians have mentioned that the implementation of Saglik-Net was still a work in progress. A factor for this discrepancy is the tendency for the Ministry of Health to impose policy changes without first establishing a legislative framework (Turan and Palvia 2014). Indeed, it seems that in this case, Turkish healthcare policy makers seem to be quick in approving changes but leave it up to the implementation process to work out the details. Thus, the implementation process encounters problems since the issues are not addressed beforehand. This contrasts with American policymaking, where policies are generally deliberated for relatively long periods of time before implementation can occur. Therefore, the rate of technology updates being made in Turkey may be overstated, but at least an explicit effort is being made.

The observation that EMRs were not as implemented as expected also seems to imply that the data and conclusions presented by the Ministry of Health should be interpreted differently and may not be strictly comparable to data for the U.S. implantation process.

Previous authors have hinted at this potential issue (Kilic 2014). In this case, the variation may 11 | P a g e

be attributed to fundamentally different definitions of an EMR system by both nations. It is possible that the statistics reported by the Ministry of Health only reflect the prevalence of a very basic EMR system where only medication orders and basic doctor’s notes are recorded into the computer. If this is the case, such a usage standard is much different from the criteria set forth by the Meaningful Use program in the United States, the program where physicians are granted additional funds through Medicare reimbursements when they demonstrate proficient usage of EMRs. The Meaningful Use program includes a rigorous set of standards to motivate physicians to utilize the functions of a more sophisticated EMR system as well as keeps clinicians accountable with regard to their EMR usage. An interesting study for the future would be to apply the United States’ Meaningful Use criteria to the EMR usage in Turkey and see if the proportion of Turkish healthcare institutions utilizing an effective EMR system remains high or drops significantly. However, one should be careful in extending these findings to policy decisions, since setting the criteria for meaningful usage of EMRs can backfire, where physicians may stop using EMRs since the requirements become too overwhelming to handle (Jha 2010).

II. Public and private healthcare practices One factor that should be considered between these two research sites is whether EMR implementation differs between public and private healthcare institutions. This comparison may help policy makers decide where to better allocate resources in terms of development of EMRs. Based on discussions with Turkish physicians, public hospital’s EMR systems are not as effective or comprehensive than those seen at private institutions (Taskiran 2014). On the other hand, in the United States, there does not seem be major differences in EMR quality between public and private hospitals and clinics (Turner 2014). For example, the Veterans Health Administration, a public hospital system, is renowned for its effective and integrated electronic health record system (Asch et al. 2004).

A further complication to this public-private comparison, with regard to the Turkey’s situation, is that contradictory information appears in published reports. According to a study (Dogac 2011), 99% of public hospitals participate in the NHIS (National Health Information System) while 71% of private and university hospitals do so. Due to both the discrepancy both between the U.S and Turkey and also within Turkey with regards to this public-private institutional comparison, it is difficult to make a conclusion as to whether a different strategy is needed when addressing EMR implementation in public and private health institutions.

Instead of simply the designation of public and private hospitals and clinics, other factors, such as size and location of the medical practice may more predictive of the effective usage of EMRs. Independent private practices are not as receptive to utilizing EMRs since they do not perceive the immediate benefits of EMRs (Turner 2014). It is not vital for these clinics to have EMRs since their volume of patients is small enough for paper-based system to sustain. A similar case can be made for rural medical practices, since they do not feel the need to integrate with other clinics that are too far away to make a meaningful communications. In Turkey, a similar perspective prevails. Outpatient clinics not directly linked to the large hospital 12 | P a g e

practices are not as receptive to using EMRs while inpatient clinics are more likely to integrate EMRs into their practice. Therefore, determinants such as funding, size, location and type of the medical practice are likely to be more crucial to EMR adoption.

III. Monetary investment in EMR development Another major aspect of the health care systems which needs to be examined is the amount of spending involved in EMR implementation. In this case, there does indeed seem to be a correlation between the amount of spending and adoption rates. Both Turkey and the United States have increased spending on healthcare information technology during their respective reform policies. For the case of the United States, the Meaningful Use incentive program seems to play a significant role in the increased proportion of physicians using the appropriate EMR systems, since the large rise in 2012 followed closely after the start of the Medicaid meaningful use incentive program.

One reason why Turkey’s EMR implementation is not as strong as expected is because the amount of money invested in this process may not be sufficient (Turan and Palvia 2014).

Indeed, as mentioned previously, Turkey has invested a smaller proportion of their health budget to healthcare information technology relative to that of the United States. One interesting observation made at Acibadem Hospital was that the management emphatically showcased their usage of ultra-modern technology. For instance, their hospital system employs the use of three da Vinci Surgical Systems, which are well known for their high costs. Although this finding was at a private hospital, the implication here is that the available spending seems sufficient, but rather the allocation of the available resources should be the basis of investigation. It may be possible for Turkey to not value the novelty and benefits of EMRs as much as other types of medical technologies.

Since the initiative set for by the HITECH act included large investments in health information technology seems to have had an impact of EMR adoption, increased spending in the implementation process can be suggested to be a large contributing factor. However, the argument for increased spending to improve EMR adoption may be countered with the notion that higher spending does not necessarily relate to better outcomes. For instance, the United States by far leads the world in healthcare spending. However, certain parameters measuring healthcare access, such as physician per capita, are lower than other countries that spend drastically less amounts of money (Reinhardt, Hussey and Anderson, 2004). Thus, the relationship between investment spending and success of EMR implementation should be considered in more depth in order to evaluate this being suggested in this comparison.

IV. Limitations of current study and considerations for future research One purpose of this comparative study was to demonstrate that there are many factors that must be considered when investigating the implementation of EMRs. This study could be extended by conducting additional site visits to Turkish healthcare institutions. In particular, although this paper implies that there is not much difference between public and private 13 | P a g e

healthcare institution’s EMR adoption, public Turkish hospitals need to be evaluated. This is one aspect that was not performed in this current study. Information from this additional component would be helpful, since it can either confirm or deny the claim that there is not much difference between public and private hospitals. Also, since public hospitals are directly under the domain of the Ministry of Health—the source of the statistics considered in this paper—studying these public hospitals would allow a better understanding of what the Ministry of Health means by their claims of high EMR usages.

Furthermore, it should be mentioned that this research report is not focused on identifying the fundamental obstacles to EMR adoption, in the sense of the intrinsic usage of EMRs. This includes the potentially confusing interface physicians may encounter when using the system as well as interference with the doctor-patient interaction (Friedberg, Crosson, and Tutty 2014). As with most upcoming technology, time is needed to optimize usability. Instead of analyzing these types of EMR implementation obstacles, this paper focuses on more general themes of the American and Turkish healthcare systems which may play a role in explaining the implementation process. Thus, a potential extension to this investigation would be to evaluate the scientific and developmental progress in updating the EMR to better suit the clinical setting, since this can also be a major factor in EMR implementation not considered here.

Additionally, the generalized implications made in this analysis may be met with skepticism of the analysis performed by this paper may be that this study was based on only a literature review and a series of interviews with select healthcare experts. A future research study may utilize a survey of large amount of healthcare providers in order to better assess the situation at a wider scale, rather than a simple case study of two selected clinics performed here. Nevertheless, the analysis and discussion here should provide motivation for further investigations that can help both healthcare providers and policymakers better understand the implications of EMRs.

Conclusion The implementation of electronic medical records in a nation’s healthcare system is a crucial issue in current healthcare agenda, as indicated by the inclusion of this issue in many recent healthcare reform policies. Both the United States and Turkey are two such examples of this case. While both have similar goals in achieving complete EMR adoption in the near future, both nations have encountered unique challenges in EMR implementation. The similarities as well as the differences surrounding this issue between the U.S. and Turkey provide contrasting arguments that help better understand these challenges. By making a comparison between the U.S. and Turkey, some possible factors that may be associated with the two nations’ differing EMR usage situations are health information technology investments, government incentives and the defined EMR usage standards. While further study is needed to better understand these relationships, healthcare management professionals as well as related policy makes should consider these factors when moving forward with EMR implementation.

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Works Cited.

Barnett, G Octo, NS Justice, ME Somand, et al.

1979 COSTAR—A Computer-Based Medical Information System for Ambulatory Care.

Proceedings of the IEEE 67(9): 1226–1237.

Joe, John 2014 A Decade of Healthcare IT; No Pain No Gain? Rice Medical Speaker Conference, Rice University, February 8.

Jha, Ashish K, Catherine M DesRoches, Eric G Campbell, et al.

2009 Use of Electronic Health Records in US Hospitals. New England Journal of Medicine 360(16): 1628–1638.

Iakovidis, Ilias 1998 Towards Personal Health Record: Current Situation, Obstacles and Trends in Implementation of Electronic Healthcare Record in Europe. International Journal of Medical Informatics 52(1): 105–115.

Fuad, Anis, and Chien-Yeh Hsu 2012 High Rate EHR Adoption in Korea and Health IT Rise in Asia. International Journal of Medical Informatics 81(9): 649–650.

Aminpour, Farzaneh, Farahnaz Sadoughi, and Maryam Ahamdi 2014 Utilization of Open Source Electronic Health Record around the World: A Systematic Review. Journal of Research in Medical Sciences 19(1).

Anderson, Gerard F, Bianca K Frogner, Roger A Johns, and Uwe E Reinhardt 2006 Health Care Spending and Use of Information Technology in OECD Countries. Health Affairs 25(3): 819–831.

Gray, Bradford H, T Bowden, I Johansen, and S Koch 2011 Electronic Health Records: An International Perspective on“ Meaningful Use”. Issue Brief (Commonwealth Fund) 28: 1–18.

A New Generation of American Innovation N.d. http://georgewbushwhitehouse.archives.gov/infocus/technology/ economic_policy200404/chap3.html, accessed April 7, 2014.

Simborg, Donald W 2008 Promoting Electronic Health Record Adoption. Is It the Correct Focus? Journal of the American Medical Informatics Association 15(2): 127–129.

15 | P a g e

Blumenthal, David 2010 Launching HIteCH. New England Journal of Medicine 362(5): 382–385.

Akdag, Recep 2010 Turkey Health Transformation Program Evaluation Report (2003-2010). şentürk, Tuğba, Fatih Terzi, and Vedia Dokmeci 2011 Privatization of Health-Care Facilities in Istanbul. European Planning Studies 19(6): 1117–1130.

O’Harrow, Robert 2009 The Machinery Behind Health-Care Reform. The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/ AR2009051503667.html, accessed April 16, 2014.

Fleming, Chris 2010 2009 U.S. Health Spending Estimated At $2.5 Trillion – Health Affairs Blog. Health Affairs. http://healthaffairs.org/blog/2010/02/04/2009-u-s-health-spending-estimated-at-25-trillion/, accessed April 16, 2014.

U.S. Department of Human and Health Services N.d. Are There Penalties for Not Using an EHR in a Meaningful Way? http://www.hrsa.gov/healthit/toolbox/HealthITAdoptiontoolbox/MeaningfulUse/ aretherepenalties.html, accessed April 16, 2014.

World Health Organization 2013 Country Cooperation Strategy, Turkey.

Truffer, Christopher J, Sean Keehan, Sheila Smith, et al.

2010 Health Spending Projections through 2019: The Recession’s Impact Continues. Health Affairs 29(3): 522–529.

Tatar, Mehtap, Salih Mollahaliloglu, Bayram Sahin, et al.

2011 Turkey, Health System Review. Health Systems in Transition 13(6). Çaha, Havva 2007 Service Quality in Private Hospitals in Turkey. Journal of Economic & Social Research 9(1).

Taskiran, Ali Sarper. Interview by Charles Ho. Koç University, Istanbul, Turkey, March 5, 2014 Mungan, Zenyel. Interview by Charles Ho. American Hospital, Houston, TX, March 7, 2014

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Dogac, Asuman, Ünal Hülür, Ali Kemal Çaylan, Mustafa Yuksel and Jess Heywood.

2010 eHealth Strategies. Country Brief: Turkey. European Commission. Information Society and Media Doctors and Hospitals’ Use of Health IT More than Doubles since 2012 N.d. U.S. Department of Health & Human Services. http://www.hhs.gov/news/press/2013pres/05/20130522a.html, accessed April 7, 2014.

Xierali, Imam M, Chun-Ju Hsiao, James C Puffer, et al.

2013 The Rise of Electronic Health Record Adoption among Family Physicians. The Annals of Family Medicine 11(1): 14–19.

Turner, Robert. Interview by Charles Ho. Kelsey Seybold Clinic Main Campus, Houston, TX, USA February 26, 2014 Bozoglu, Arda. Interview by Charles Ho. Acibadem Hospital Kadikoy, Istanbul, Turkey March 6, 2014 Turan, Aykut H, and Prashant C Palvia 2014 Critical Information Technology Issues in Turkish Healthcare. Information & Management 51(1): 57–68.

Kilic, Bulent 2014 Health-Care Reform in Turkey: Far from Perfect. The Lancet 383(9911): 28–29.

Asch, Steven M, Elizabeth A McGlynn, Mary M Hogan, et al.

2004 Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample. Annals of Internal Medicine 141(12): 938–945.

Dogac, A, M Yuksel, A Avci, et al.

2011 Electronic Health Record Interoperability as Realized in the Turkish Health Information System. Methods of Information in Medicine 50(2): 140.

Reinhardt, Uwe E., Peter S. Hussey, Gerald F. Anderson 2004 U.S. Health Care Spending In An International Context. Health Affairs 23(3): 10-25.

Friedberg, Mark, Francis J. Crosson, and Michael Tutty 2014 Physicians’ Concerns About Electronic Health Records: Implications And Steps Towards Solutions – Health Affairs Blog. Blog. Health Affairs. http://healthaffairs.org/blog/2014/03/11/physicians-concerns-about-electronic-healthrecords-implications-and-steps-towards-solutions/, accessed April 23, 2014.

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Jha, Ashish K. 2010 Meaningful Use of Electronic Health Records: The Road Ahead. The Journal of the American Medical Association 304 (15): 1709-1710.

Acknowledgments I thank Dr. Robert Turner, Dr. Ali Sarper Taskiran , Dr. Zenyel Mungan and Arda Bozuglu for their generous time in offering personal interviews which have contributed to this report. I would also like to thank Dr. Tan Atila (American Hospital) and Dr. Korel Goymen (Istanbul Policy Center) for helpful discussions about the Turkish healthcare system. Major considerations must be given to Ipek Martinez and Abbey Godley for organizing a successful and memorable international experience in Istanbul. As the academic faculty advisor, Dr. Nia Georges must be acknowledged for helpful discussions and instruction regarding the formulation of this research study.

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