The following content comes from Dr. Robert E. Hoyt’s authoritative textbook, Health Informatics: A Practical Guide (the 6th edition). Dr. Hoyt is an internal medicine physician with extensive expertise in health informatics and clinical research. He is the head of the Medical Informatics program at the University of West Florida.
Need for Electronic Health Records (EHR)
The following are the most significant reasons why our healthcare system would benefit from the widespread transition from paper to electronic health records.
Paper records are severely limited
Much of what can be said about handwritten prescriptions can also be said about handwritten office notes. Figure 4.2 illustrates the problems with a paper record. In spite of the fact that this clinician used a template, the handwriting is illegible and the document cannot be electronically shared or stored. It is not structured data that is computable and hence shareable with other computers and systems. Other shortcomings of paper: expensive to copy, transport and store; easy to destroy; difficult to analyze and determine who has seen it; and the negative impact on the environment. Electronic patient encounters represent a quantum leap forward in legibility and the ability to rapidly retrieve information. Almost every industry is now computerized and digitized for rapid data retrieval and trend analysis. Look at the stock market or companies like Walmart or Federal Express. Why not the field of medicine?
Figure 4.2: Outpatient paper-based patient encounter form
With the relatively recent healthcare models of pay-for-performance, patient centered medical home model and accountable care organizations there are new reasons to embrace technology in order to aggregate and report results in order to receive reimbursement. It is much easier to retrieve and track patient data using an EHR and patient registries than to use labor intensive paper chart reviews. EHRs are much better organized than paper charts, allowing for faster retrieval of lab or x-ray results. It is also likely that an EHR will have an electronic problem summary list that outlines a patient’s major illnesses, surgeries, allergies and medications. How many times does a physician open a large paper chart, only to have loose lab results fall out? How many times does a physician re-order a test because the results or the chart is missing? It is important to note that paper charts are missing as much as 25% of the time, according to one study.10 Even if the chart is available; specifics are missing in 13.6% of patient encounters, according to another study.11 Table 4.1 shows the types of missing information and its frequency. According to the President’s Information Technology Advisory Committee, 20% of laboratory tests are re-ordered because previous studies are not accessible.12 This statistic has great patient safety, productivity and financial implications. Table 4.1: Types and frequencies of missing information
|Information Missing During Patient Visits
|History and physical exams
EHRs allow easy navigation through the entire medical history of a patient. Instead of pulling paper chart volume 1 of 3 to search for a lab result, it is simply a matter of a few mouse clicks. Another important advantage is the fact that the record is available 24 hours a day, seven days a week and doesn’t require an employee to pull the chart, nor extra space to store it. Adoption of electronic health records has saved money by decreasing full time equivalents (FTEs) and converting records rooms into more productive space, such as exam rooms. Importantly, electronic health records are accessible to multiple healthcare workers at the same time, at multiple locations. While a billing clerk is looking at the electronic chart, the primary care physician and a specialist can be analyzing clinical information simultaneously. Moreover, patient information should be available to physicians on call so they can review records on patients who are not in their panel. Furthermore, it is believed that electronic health records improve the level of coding. Do clinicians routinely submit a lower level of care for billing purposes because they know that handwritten patient notes are short and incomplete? Templates may help remind clinicians to add more history or details of the physical exam, thus justifying a higher level of coding (templates are disease specific electronic forms that essentially allow a user to point and click a history and physical exam). A study of the impact of an EHR on the completeness of clinical histories in a labor and delivery unit demonstrated improved documentation, compared to prior paper-based histories.13 Lastly, an EHR provides clinical decision support such as alerts and reminders, which will be covered later in this chapter.
Need for improved efficiency and productivity
The goal is to have patient information available to anyone who needs it, when they need it and where they need it. With an EHR, lab results can be retrieved much more rapidly, thus saving time and money. It should be pointed out however, that reducing duplicated tests benefits the payers and patients and not clinicians so there is a misalignment of incentives. Moreover, an early study using computerized order entry showed that simply displaying past results reduced duplication and the cost of testing by only 13%.14 If lab or x-ray results are frequently missing, the implication is that they need to be repeated which adds to this country’s staggering healthcare bill. The same could be said for duplicate prescriptions. It is estimated that 31% of the United States $2.3 trillion dollar healthcare bill is for administration.15 EHRs are more efficient because they reduce redundant paperwork and have the capability of interfacing with a billing program that submits claims electronically. Consider what it takes to simply get the results of a lab test back to a patient using the old system. This might involve a front office clerk, a nurse and a physician. The end result is frequently placing the patient on hold or playing telephone tag. With an EHR, lab results can be forwarded via secure messaging or available for viewing via a portal. Electronic health records can help with productivity if templates are used judiciously. As noted, they allow for point and click histories and physical exams that in some cases may save time. Embedded clinical decision support is one of the newest features of a comprehensive EHR. Clinical practice guidelines, linked educational content and patient handouts can be part of the EHR. This may permit finding the answer to a medical question while the patient is still in the exam room. Several EHR companies also offer a centralized area for all physician approvals and signatures of lab work, prescriptions, etc. This should improve work flow by avoiding the need to pull multiple charts or enter multiple EHR modules. Although EHRs appear to improve overall office productivity, they commonly increase the work of clinicians, particularly with regard to data entry. We’ll discuss this further in the Loss of Productivity section.
Quality of care and patient safety
As previously suggested, an EHR should improve patient safety through many mechanisms: (1) Improved legibility of clinical notes, (2) Improved access anytime and anywhere, (3) Reduced duplication, (4) Reminders that tests or preventive services are overdue, (5) Clinical decision support that reminds clinicians about patient allergies, correct dosage of drugs, etc., (6) Electronic problem summary lists provide diagnoses, allergies and surgeries at a glance. In spite of the before mentioned benefits, a study by Garrido of quality process measures before and after implementation of a widespread EHR in the Kaiser Permanente system, failed to show improvement.16 To date there has only been one study published the authors are aware of that suggested use of an EHR decreased mortality. This particular EHR had a disease management module designed specifically for renal dialysis patients that could provide more specific medical guidelines and better data mining to potentially improve medical care. The study suggested that mortality was lower compared to a pre-implementation period and compared to a national renal dialysis registry.17 It is likely that healthcare is only starting to see the impact of EHRs on quality. Based on internal data Kaiser Permanente determined that the drug Vioxx had an increased risk of cardiovascular events before that information was published based on its own internal data.18 Similarly, within 90 minutes of learning of the withdrawal of Vioxx from the market, the Cleveland Clinic queried its EHR to see which patients were on the drug. Within seven hours they deactivated prescriptions and notified clinicians via e-mail.19 Quality reports are far easier to generate with an EHR compared to a paper chart that requires a chart review. Quality reports can also be generated from a data warehouse or health information organization that receives data from an EHR and other sources.20 Quality reports are the backbone for healthcare reform which are discussed further in another chapter.
According to a 2006 Harris Interactive Poll for the Wall Street Journal Online, 55% of adults thought an EHR would decrease medical errors; 60% thought an EHR would reduce healthcare costs and 54% thought that the use of an EHR would influence their decision about selecting a personal physician.21 The Center for Health Information Technology would argue that EHR adoption results in better customer satisfaction through fewer lost charts, faster refills and improved delivery of patient educational material.22 Patient portals that are part of EHRs are likely to be a source of patient satisfaction as they allow patients access to their records with multiple other functionalities such as online appointing, medication renewals, etc.
EHRs are considered by the federal government to be transformational and integral to healthcare reform. As a result, EHR reimbursement is a major focal point of the HITECH Act. It is the goal of the US Government to have an interoperable electronic health record by 2014. In addition to federal government support, states and payers have initiatives to encourage EHR adoption. Many organizations state that healthcare needs to move from the cow path to the information highway. CMS is acutely aware of the potential benefits of EHRs to help coordinate and improve disease management in older patients.
The Center for Information Technology Leadership (CITL) has suggested that ambulatory EHRs would save $44 billion yearly and eliminate more than $10 in rejected claims per patient per outpatient visit. This organization concluded that not only would there be savings from eliminated chart rooms and record clerks; there would be a reduction in the need for transcription. There would also be fewer callbacks from pharmacists with electronic prescribing. It is likely that copying, faxing and mail expenses, chart pulls and labor costs would be reduced with EHRs, thus saving full time equivalents (FTEs). More rapid retrieval of lab and x-ray reports results in time/labor saving as does the use of templates. It appears that part of the savings is from improved coding. More efficient patient encounters mean more patients could be seen each day. Improved savings to payers from medication management is possible with reminders to use the drug of choice and generics. It should be noted that this optimistic financial projection assumed widespread EHR adoption, health information exchange, interoperability and change in workflow.23 EHRs should reduce the cost of transcription if clinicians switch to speech recognition and/or template use. Because of structured documentation with templates, they may also improve the coding and billing of claims. It is not known if EHR adoption will decrease malpractice, hence saving physician and hospital costs. A 2007 Survey by the Medical Records Institute of 115 practices involving 27 specialties showed that 20% of malpractice carriers offered a discount for having an EHR in place. Of those physicians who had a malpractice case in which documentation was based on an EHR, 55% said the EHR was helpful.24
The timing seems to be right for electronic records partly because the technology has evolved. The internet and World Wide Web make the application service provider (ASP) concept for an electronic health record possible. An ASP option means that the EHR software and patient data reside on a remote web server that users can access via the internet from the office, hospital or home. Computer speed, memory and bandwidth have advanced such that digital imaging is also a reality, so images can be part of an EHR system. Personal computers (PCs), laptops and tablets continue to add features and improve speed and memory while purchase costs drop. Wireless and mobile technologies permit access to the hospital information system, the electronic health record and the internet using a variety of mobile technologies. The chapter on health information exchange will point out that health information organizations can link EHRs together via a web-based exchange, in order to share information and services.
Need for aggregated data
In order to make evidence based decisions, clinicians need high quality data that should derive from multiple sources: inpatient and outpatient care, acute and chronic care settings, urban and rural care and populations at risk. This can only be accomplished with electronic health records and discrete structured data. Moreover, healthcare data needs to be combined or aggregated to achieve statistical significance. Although most primary care is delivered by small practices, it is difficult to study because of relatively small patient populations, making aggregation necessary.25 For large healthcare organizations, there will be an avalanche of data generated from widespread EHR adoption resulting in “big data” requiring new data analytic tools.
Need for integrated data
Paper health records are standalone, lacking the ability to integrate with other paper forms or information. The ability to integrate health records with a variety of other services and information and to share the information is critical to the future of healthcare reform. Digital, unlike paper-based healthcare information can be integrated with multiple internal and external applications:
- Ability to integrate for sharing with health information organizations (another chapter)
- Ability to integrate with analytical software for data mining to examine optimal treatments, etc.
- Ability to integrate with genomic data as part of the electronic record. Many organizations have begun this journey. There is more information in the chapter on bioinformatics 26
- Ability to integrate with local, state and federal governments for quality reporting and public health issues
- Ability to integrate with algorithms and artificial intelligence. Researchers from the Mayo Clinic were able to extract Charlson Comorbidity determinations from EHRs, instead of having to conduct manual chart reviews 27
EHR is a transformational tool
It is widely agreed that US Healthcare needs reform in multiple areas. To modernize its infrastructure healthcare would need to have widespread adoption of EHRs. Large organizations such as the Veterans Health Administration and Kaiser Permanente use robust EHRs (VistA and Epic) that generate enough data to change the practice of medicine. In 2009 Kaiser Permanente reported two studies, one pertaining to the management of bone disease (osteoporosis) and the other chronic kidney disease. They were able to show that with their EHR they could focus on patients at risk and use all of the tools available to improve disease management and population health.28-29 In another study reported in 2009 Kaiser-Permanente reported that electronic visits that are part of the electronic health record system were likely responsible for a 26.2% decrease in office visits over a four year period. They posited that this was good news for a system that aligns incentives with quality, regardless whether the visit was virtual or face-to-face.30 Other fee-for-service organizations might find this alarming if office visits decreased and e-visits were not reimbursed. Kaiser also touts a total joint registry of over 100,000 patients with data generated from its universal EHR. As a result of their comprehensive EHR (KP HealthConnect) and visionary leadership they have seen improvement in standardization of care, care coordination and population health. They also have been able to experience advanced EHR data analytics with their Virtual Data Warehouse, use of artificial intelligence and use of computerized simulation models (Archimedes). In addition they have begun the process of collecting genomic information for future linking to their electronic records.31-32
Need for coordinated care
According to a Gallup poll it is very common for older patients to have more than one physician: no physician (3%), one physician (16%), two physicians (26%), three physicians (23%), four physicians (15%), five physicians (6%) and six or more physicians (11%).33 Having more than one physician mandates good communication between the primary care physician, the specialist and the patient. This becomes even more of an issue when different healthcare systems are involved. O’Malley et al. surveyed 12 medical practices and found that in-office coordination was improved by EHRs but the technology was not mature enough to improve coordination of care with external physicians.34 Electronic health records are being integrated with health information organizations (HIOs) so that inpatient and outpatient patient-related information can be accessed and shared, thus improving communication between disparate healthcare entities. Home monitoring (telehomecare) can transmit patient data from home to an office’s EHR also assisting in the coordination of care. It will be pointed out in a later section that coordination of care across multiple medical transitions is part of Meaningful Use.
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