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Update on the Hospital Community EMR

Partner Institute: 
The Myers-JDC-Brookdale Institute, Jerusalem
Survey no: 
(14) 2009
Nurit Nirel, Arnon Cohen, Bruce Rosen, and Revital Gross
Health Policy Issues: 
New Technology, Quality Improvement
Reform formerly reported in: 
Update on the Integrated Hospital-Community EMR
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no


This innovation relates to a new information technology that integrates medical records and medical information from various care settings in the community and in hospitals. If regularly used by medical staff, the system was expected to assist in improving continuity and quality of care, avoiding dangerous medical mistakes, and reducing costs related to duplications. An evaluation study found that the new system had achieved some, but not all, of its objectives.

Recent developments

The linkage of electronic medical records across hospitals and community clinics sought to improve continuity and quality of patient care, avoid dangerous medical mistakes and reduce costs. The system developed by Clalit Health Services together with db motion consists of an information highway between the data creators and consumers in the organization that enables an information consumer to request and receive specific patient information automatically and quickly, without the need to install any program at the end user's station (by using a standard Internet browser), and without making any changes in the existing work processes or in the organization's structure. The solution provides available, up-to-date relevant medical information to each site of care while maintaining the highest level of information security, because each physician can only access the information about his patients. The described solution has been installed in all of Clalit Health Services' 14 hospitals and in all of its 2000 community clinics, and provides up-to-date information at the point of care.

The new integrated medical record system sought to improve patient care at the community and hospital levels by providing the needed relevant data at all sites of care; reduce the frequency of dangerous medical mistakes (related to contradicting medication, unknown sensitivity etc.); and reduce costs (related to duplications of tests, unnecessary procedures, unnecessarily long hospital stays and medical errors).

The Myers-JDC-Brookdale Institute has recently evaluated the extent to which the new system is used by physicians and how it has impacted medical service utilization and quality. This update focuses on the findings of that evaluation.

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal rather fundamental fundamental
Public Visibility very low low very high
Transferability strongly system-dependent system-neutral system-neutral
current current   previous previous

OFEK is very innovative, as it is one of the first systems worldwide to link information between hospital and community providers.  

At present, there is a great deal of consensus within Clalit that while OFEK still needs to undergo improvements, it makes an important contribution to patient care and to the workflow. (This is in contrast to the initial phases, where there was some physician and managerial resistance.)  

We have rated the structural impact as moderate, as even prior to the introduction of OFEK, all doctors already worked with electronic health records and computers.  

The general public, and patients, are unaware of the OFEK system. It improves their care through a "behind the scenes" effort.  

OFEK is highly transferable to other countries, and indeed similar systems have recently begun to be introduced in several locations in the U.S.

As was shown by our recent study, the use of OFEK assists in prevention of repeated blood tests and imaging. It also greatly speeds up the access of physicians to medical records and to the results of blood and imaging tests. Thus, it enhances the quality of care and increases the efficiency of medical treatment.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no

Initiators of idea/main actors

  • Providers: The OFEK system is deployed in Clalit Health Services.
  • Scientific Community: Myers-JDC-Brookdale is carrying out the evaluation; the evaluation is funded, in part, by the National Institute.

Stakeholder positions

The Myers-JDC-Brookdale Institute initiated the idea of evaluating the new information system, which is known officially as OFEK. Researchers at the Institute recognized that the new system was pioneering both in Israel and internationally. They realized that the system had great potential to influence both costs and quality, but also recognized that new information systems often do not realize their potential; that oftentimes the hopes and promises of the creators of new system do not materialize. Hence, they felt than a serious evaluation of the system's impact could contribute to managerial decisionmaking in Israel and abroad. This is consistent with the Institute's mission of helping improve healthcare services through applied research.

Clalit Health Services enthusiastically embraced the Institute's proposal to study its new system and a senior physician-manager from within the health plan even joined the study team as a co-investigator. Clalit understood that the study's findings could help them refine their efforts to use information technology to improve linkages between the hospital and community providers. Clalit has a clear interest in reducing unnecessary expenditures, improving quality of care, and maxmizing the payoff from its significant investment in information technology.

The National Institute for Health Policy and Health Services Research (NIHP) provided a significant part of the funding for the study, through its competitive grants program. Part of the mission of the NIHP is to facilitate and encourage research, surveys and professional expert opinion intended to evaluate health policies and services in Israel. The National Institute approved funding for this study because it believed that the study could contribute to that aim.

Actors and positions

Description of actors and their positions
Clalit Health Servicesvery supportivevery supportive strongly opposed
Scientific Community
Myers-JDC-Brookdale Institutevery supportivevery supportive strongly opposed
National Institute for Health Policy and Health Servics Researchvery supportivevery supportive strongly opposed
current current   previous previous

Actors and influence

Description of actors and their influence

Clalit Health Servicesvery strongvery strong none
Scientific Community
Myers-JDC-Brookdale Institutevery strongvery strong none
National Institute for Health Policy and Health Servics Researchvery strongvery strong none
current current   previous previous
Clalit Health Services, Myers-JDC-Brookdale Institute, National Institute for Health Policy and Health Servics Research

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Monitoring and evaluation

The objectives of the study were:

  1. To examine the intensity with which OFEK is used
  2. To examine how the introduction of OFEK has affected selected quality indicators and the utilization of medical services
  3. To examine the impact of extensive use of OFEK on quality indicators and the utilization of medical services 

The study methodology was as follows:

  1. The study team examined the frequency that OFEK screens were consulted, the information viewed on the screens and the correlations between physician characteristics/organizational unit and the extent that the system was used.
  2. The study team identified selected quality indicators and the utilization of medical services and examined OFEK's impact in community clinics at TO ("before" the third quarter of 2004) and at T1("after" introducing the system - the third quarter of 2005).
  3. In assessing the impact of OFEK's introduction on patterns of care in the community, we carried out three analyses at three levels. First, we analyzed the average impact on all clinics throughout the country. Second, we restricted the analysis to those clinics within the catchment areas of hospitals using OFEK (6 Clalit's hospitals and 2 government's hospitals), as these are the clinics most likely to benefit from the linkage of data between hospital and community. Third, we further restricted the analysis to those clinics within the catchment areas that used OFEK to the greatest extent (those in the upper quarter of screen consultations).
  4. For each of these analyses, we selected a control group that matched an experimental clinic across a broad range of characteristics. We found that at T0 the characteristics of the two groups were quite similar, though some differences were also found. To minimize the differences in the key background variables, we used the "nearest neighbor matching" method for the matching of the experimental and control groups. The difference between the change of outcome in the experimental group and the change in outcome for the same period in the control group was examined with the help of difference-in-difference analysis.
  5. In hospitals, the examination of "before" (the third quarter of 2003) and "after" (the third quarter of 2005 and 2007) applied to the general surgery, internal medicine and emergency departments at six CHS hospitals, in the experimental group - CHS members versus the control group - other patients.
  6. With regard to the hospitals, we carried out two levels of analysis. In the first, we considered all of the departments noted above. In the second, we restricted the analysis to those departments that used OFEK to a great extent (those in the upper quarter of screen consultations).
  7. As was the case for the community, here, too, we used the "nearest neighbor matching" method for the matching of the experimental and control groups, and carried out a difference-in-difference analysis.

 Study limitations

  • The limited time window opened by the study on the comparison of experimental and control clinics makes it difficult to estimate OFEK's long-term impact or apply the findings to other organizations using it.
  • There may be additional indicators of the system's impact, which were not examined in this study. Thus, the study may understate OFEK's benefits.

Expected outcome

The key findings of the evaluation (first in community clinics and then in hospitals) are as follows:  

A. In the community clinics

  1. OFEK utilization in clinics greatly increased between 2005 and 2006, and continued rising in 2007 and 2008. Use was greatest in clinics in catchment areas of hospitals with the OFEK system.
  2. Within those areas, and among clinics using the system extensively, OFEK reduced utilization of imaging services by 12% overall, with statistically significant decreases in 13 out of the 27 imaging tests considered.
  3. In those areas, OFEK did not have a statistically significant impact on total lab tests, and the impact on particular tests was mixed. There were  (statistically significant) decreases in 12 of the 38 tests considered, increases in 4 of them and no change in the other 22 tests.
  4. In those areas, OFEK was associated with improvements in 8 of the 17 quality measures considered to be influenced by data flow between hospitals and community clinics.
  5. Broadening the analysis to include all catchment area clinics, or all clinics in the study, weakened these effects regarding imaging and lab tests and quality of care.
  6. The use of OFEK by community-based clinics apparently did not have an effect on the total number of outpatient visits, visits to emergency, hospitalizations and medications given by a physician.

B. In the hospitals

  1. In hospitals, use of OFEK increased each year, but not as rapidly as in the community clinics.
  2. OFEK was associated with a 6% reduction in the total number of lab tests in internal medicine wards; no such association was found in surgical wards
  3. OFEK was not associated with a change in the frequency of imaging tests carried out, neither in internal medicine nor surgical words.
  4. OFEK was not associated with a decrease in ambulatory hospitalizations or repeat emergency hsopitalizations
  5. In internal medicine wards that used OFEK extensively, OFEK was associated with a large decrease (83%) in ambulatory hospitalizations and with a decrease in stomach sonar tests.
  6. Use of OFEK was not associated with a decrease in the rate of hospitalizations of patients presenting at emergency rooms.

Summary of findings and conclusions  

  1. In approaching the evaluation of OFEK, we encountered two contradictory claims:
    • That OFEK has a considerable impact on service utilization and quality of care;
    • That its impact is miniscule on the quality of care and the streamlining of services, whether because few physicians use it or because the information on what transpires in hospitals cannot truly contribute to what transpires in the community, and vice versa.
  2. The study findings were in between the two claims, showing a more complex picture. OFEK's introduction into community clinics and hospitals affected some of the outcome measures examined, though not others. For some of the parameters showing impact, the impact was considerable enough to be financially or medically significant, but in most cases, it was less significant. Moreover, OFEK was found to impact differently in community clinics and hospital departments.
  3. In addition, the accrued evidence of OFEK's impact on outcome measures yielded a clearer picture for the community than for hospitals; this may be connected to the different study designs used in the two settings.
  4. Also, because of the pace at which the system was introduced into the community, the time frame for comparing experimental and control clinics was relatively short.
  5. We found that the use of OFEK varied with time - both in the community and in hospitals, and that the impact in hospitals (where the system was examined for a longer period) increased with time. We also found that OFEK had a stronger impact in clinics that use it more. 
  6. Thus, when additional clinics increase their use of OFEK, the impact there too may be stronger (though this is unproven), augmenting its overall impact

Impact of this policy

Quality of Health Care Services marginal rather fundamental fundamental
Cost Efficiency very low neutral very high
current current   previous previous

When the previous report was filed, we did not yet have the results of the evaluation. At that time, we made the following tentative projections:  

  • Quality - The system will probably improve patient care at the community and hospital levels by increasing continuity and coordination of care. It may also reduce medical mistakes that are related to insufficient information on patients. The new technology will contribute to improving quality as it facilitates regular utilization.
  • Equity - This technology is expected to improve if information flow and is not dependent on the patient to pass the information from hospital to community and vice versa. Thus relevant information can be retrieved even when communication with the patient is difficult because of age, language and cultural barriers. Using the system is expected to especially improve their care.
  • Cost efficiency - The effect on costs is unclear. Cost savings related to duplications are likely to be achieved. However their extent is unknown and savings related to other aspects of care are not clear.

Our findings support some of these projections, run counter to others, and provide no new information on the rest, as follows:

  • Quality - Our findings are largely consistent with the projections, as we found signficant improvements in 8 of the 17 quality indicators considered. There was no expectation that OFEK would improve all elements of quality in Clalit; it was geared primarily to improve quality in those areas where improved hospital-community communication could improve health outcomes. The study did not examine the impact of OFEK on medical errors nor on several other significant dimensions of quality for which data were unavailable.
  • Equity - The evaluation study did not examine the effect of OFEK on equity. This could be a fruitful focus of future studies.
  • Cost efficiency - The study findings regarding the impact of OFEK on costs are mixed. In the community there appears to have been a greater impact on the use of imaging tests than on lab tests, while the opposite appears to have been the case within the hospitals.


Sources of Information

Sources of Information Personal communication with program officers Blondheim Orna. RHIO - from Vision to Reality, to be presented at the Healthcare Information and Management Systems Society, February 2006, San Diego CA.  

Author/s and/or contributors to this survey Nirel Nurit, Rosen Bruce, Gross Revital Myers-JDC-Brookdale; Cohen Arnon, Sherf Michael, Blondheim Orna Clalit Health Services  

Reform formerly reported in

Update on the Integrated Hospital-Community EMR
Process Stages: Implementation, Evaluation

Author/s and/or contributors to this survey

Nurit Nirel, Arnon Cohen, Bruce Rosen, and Revital Gross

Nurit Nirel is a senior researcher at the Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute.

Arnon Cohen is director of the department of quality measures and research at the general management of Clalit Health Services

Bruce Rosen is the director of the Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute.

Revital Gross is a senior researcher at the Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute and an Associate Professor at Bar Ilan University.

Suggested citation for this online article

Nirel, Nurit, Cohen, Arnon, Rosen, Bruce, and Revital Gross. "Update on the Hospital Community EMR". Health Policy Monitor, October 2009. Available at