Critical factors for EMS systems success: Case Analysis
Adoption of Electronic Medical Record (EMR) system can provide benefits for hospitals and Clinic centers. Sometimes the lack of information or structure this system fails for some reasons. This paper present some cases of success and fails analyzing many EMS systems implemented over the years
THE adoption of Electronic Medical Record (EMR) systems is becoming a essential part for modernizing healthcare centers and lead to reduce costs and increasing quality for either patients and medicals professionals.
Health Information System (HIS) evaluation focus on the relationship among the system user, the technology and the medical environment ,. An Electronic Medical Records (EMR) system is a part of HIS, and a comprehensive, successful and highly acceptable EMR system will help healthcare professionals to improve efficiency, effectiveness, and reduce medical errors.
Hospitals and clinics tend to adopt EMRs seeking to reduce documentation requirements and redundant paperwork. Physicians can reduce excess staff, increase efficiency, eliminate transcription costs and include security data over information .
However, investing on EMR system is a costly process and failure to implement EMR systems could be attributed to developers ignoring stakeholder needs .
There are many EMR implementation failures in the literature [5, 6] and at least one in four projects ends in failure, mostly about budget and schedule .
Another important factor consideration about HIS is the care to be accepted by stakeholders' professionals; in addition, whether its use brings benefits in a real medical environment.
The paper is organized as follows. Section II presents the related work. Section III presents the main concepts of LEICA environment. Section IV describes the Asterisk PBX platform and some aspects of conferences creation and inclusion of new functionalities. Section V presents the architecture and implementation aspect of the CoCE. In section VI, is presented the integration of a Co-browser tool with conference support. Finally, section VII draws some conclusions and future work.
II. Literature Review
A. EMR Concepts
A general definition for EMRs systems can be found in the literature review , and a general consensus can be defined as an integrated software suite of healthcare process functionalities built around a common patient database. Some functionalities typically included in such systems are:
• Electronic Health Records
• Diagnostic Tools
• Patient Billing
• Electronic Prescribing
• Practice Management.
These systems usually working integrated and in a similar and architecturally way as Enterprise Resource Planning (ERP) systems. One of the most important functionality for such systems is retrieving and manipulates medical records data found at databases. Both systems aim on improving speed and accuracy of data sharing, reporting, and planning functions  as well systematize, integrate, and streamline business .
Sometimes terms like Electronic Health Records (EHR) and Computerized Patient Record (CPR) are used to describe a person's medical history for the same propose.
 suggests that healthcare information is a knowledge based on enterprise and as a result, academic research in healthcare systems has been minimal compared to other areas.
EMR systems has been considered relatively new in journals and articles relating to healthcare systems in particular and still emerging as a mainstream field in the academic literature according to  and moreover a turning point in the focus of healthcare organizations on the value and necessity of integrated information systems .
According to , the proper use of EMR systems is believed to potential improve the quality of medical care and save lives but as many systems, there are negatives factors that may direct to failures.
III. Effectiveness of EMR's Systems
Measure effectiveness of a EMR systems is a difficult and complex task to do as there is a clear criteria on which the effectiveness can be measured ,. Since hospitals may vary widely from size, urban/rural location, system membership and leadership can influence the factors for measure . In addition these systems also vary on capability, functions configuration and format .
IV. Case Analysis
This section covers the case analysis on several EMRs implementations over the literature exposing difficulties and results of practical use of healthcare systems on these organizations.
A. Qualitative studies to improve usability of an EMR
In  describe two qualitative studies to identify user task flows with a web based application. The study was focus on Longitudinal Medical Record (LMR) application that comprises management of patients' information, clinical messaging, methods of data entry and retrieval. Moreover, the main focus for the study was on Result Manager component that presents follow up tasks for patient laboratory tests as presented in Fig. 1.
Both studies were performed in four clinics located in USA being the first study conducted with 7 participants and the second one with 5 group sessions.
The first study combined a methodology that focuses attention on users and on their tasks and goals. The task analysis was to capture and identifying the communication among the user's needs when executing tasks.
The second study included separate focus group sessions that were open to physicians or internal residents whose work is in primary care practice. It was conducted in 5 sessions with 90 minutes each one.
The results were found comparing the similarities between the two qualitative studies allowing a new design proposed for the Result Manager component. The main points were: information design, navigation, user-centered design, ergonomic issues.
The findings of the studies are mostly focused in creating advises for futures EMR's system and was based only in one EMR system. The highlight is to deal with problems found it in many EMR's systems available overall.
B. Effectiveness EMR's through Composite Index for benchmarking
 propose a conceptual framework to generate a Composite Index (CI) for measuring, quantitatively, effectiveness of EMR systems. The framework involved used statistic and principal component analysis and the CI was developed summing up the scores of: system quality, information quality, use and user satisfaction.
The authors cited advantage of using CI to summarize complex constructs into a single unit, which represent a ‘big-picture' of the problem than trying to find a trend in many separate measures.
The tests were performed on 20 health institutions in Japan and five stakeholders (chief information officer (CIO), chief medical officers (CMO), chief nursing officer (CNO), doctors (DR) and nurses (NS)) were chosen based on whose works is the most affected by EMR's systems. All research was based on questionnaires submitted to stakeholders answered anonymously.
The results shown that mostly of hospitals performed well on system quality and use, but weakly on user satisfaction. The results point out that user satisfaction criteria was mostly related to the lack of knowledge and experience of end-users about computer applications in medicine.
A large cooperation was necessary to achieve all the data from the hospitals and clinics. From 20 institutions (1952 stakeholders) to generate the CI were necessary 41 hospitals.
Other limitations of this approach is only for benchmarking which is comparing one EMR's with another one across the hospitals.
C. Effectiveness EMR's through Composite Index for benchmarking
V. Conclusions and Future Work
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