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April 19, 2012

The Concept of a medical record was initiated by Hippocrates B.C. and it was designed to serve two main objectives: 1) Description of the presentation of the disease process in the patient and 2) the most likely course of illness (Bemmel, J., 1997). Since that time there have been further developments in the documentation process and information included about the patient, went hand in hand with the advancement of the medical field.

EHR past and present During the 20th century there has been significant advances in computer and information technology affecting so many sectors of society. Areas ranging from online degrees to business transactions have become much more efficient and productive for both the general population and industries. The healthcare system in the United States has been experiencing a concerning lag in keeping up with these changes especially over the last 10 years. It is time for a change and the United States is evolving the landscape of its healthcare sector by implementing an all electronic health record (EHR) system replacing the current paper system.

The early computerized systems to maintain medical records were called clinical information systems and were initially developed in the 1960s at the University of Utah and Massachusetts. They were called Health Evaluation through Logical Processing (HELP) and Computer Stored Ambulatory Record (COSTAR) respectively (Atherton, 2011). From the 1970s until now the EHR has gradually evolved to become more complex and comprehensive in nature. Some of the current softwares include VistA (used by the VA), Epic, and WizErd. The current paper based system of handling medical records has multiple disadvantages in comparison with EHR. The most significant being the inefficiency with transfer of information between healthcare professionals in a timely and accurate manner. Having the ability to retrieve the complete history of the patient including past hospitalizations, visits, allergies, medications

and consultations at any point by any health care provider aids in the quick decision making process and the reduction of errors associated with relaying information from one person to another. Consider a scenario where the on call physician is contacted to make decisions regarding a new admission. Having all the information available visually via EHR would make it much easier for an accurate assessment and management decisions rather than solely relying on verbal report by the house staff.

Since the change to EHR is necessary, the Government has stepped in to accelerate full integration by instituting laws and policies specific to the portability and privacy of medical records. The Health Information Technology for Economic and Clinical Health Act (HITECH), which is considered a part of the American Recovery and Reinvestment Act of 2009 (ARRA), is pushing for all medical providers to convert to an all electronic system. The Office of the National Coordinator for Health Information Technology (ONCHIT) is responsible for setting minimum standards and composing the infrastructure of HIT and incentives have been put in place for providers to adopt the new criterion. Some examples of these programs are the EHR incentive program and HITECH.

In 2009, Congress began to improve the privacy and security rules under the Health Insurance Portability and Accountability Act (HIPAA). HIPPA regulations are considered and enforced with the process to maintain the patient's privacy as health information technology evolves.

EHR Implementation to improve Safety and Patient OutcomesA Position Paper

Nicole Firsich, Nadia Kamagate, and Robin Bowen RN

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In light of the recent advancements in information technology along with the disadvantages of the traditional paper based method we fully support the implementation and application of EHR. This will result in a substantial improvement in the outcomes of patients and efficiency as well as cost effectiveness of the healthcare system. Unfortunately, there have been some obstacles to EHR fulfillment due to high initial start up costs and a potential threat to patients’ information privacy and misuse for research purposes. The supportive reasons to propel the HITECH Act and develop EHR are: 1) reduction in medical errors due to increased efficiency. 2) lower long-term costs, and 3) Improved patient outcomes and reduced mortality rates due to accurate and efficient transfer of patient information.

Exorbitant Initiation Costs Impede EHRThe current push for EHR is causing

skepticism for many. The leading reasons that deter companies from the conversion of EHR are due to the initial start up cost, patient privacy and secondary uses of medical information.

The start-up costs vary depending on the equipment and training needed and can translate into loss of productivity and revenue. A research study estimated the projected cost of a seven year EHR installation program to be around 19 million US dollars in an acute care hospital (Schmidt & Wofford, 2002). Research conducted in an outpatient setting shows the initial cost was between $50,000 and $70,000 dollars per physician (Agrawal, 2002).

As a result of the significantly high setup costs, many healthcare providers have been resistant in applying EHR into their practice. While this has been an obstacle, most providers did not appreciate the long term financial benefits. Utilizing EHR in a healthcare organization or group has been shown to markedly reduce medical errors including wrong treatments, unnecessary imaging studies and

lab tests. Furthermore, it greatly enhances efficiency in communication and accessibility between healthcare personnel reducing time spent by patient per visit. At a national level, savings have been projected to be around $81 billion annually for both inpatient and outpatient care if compliance with electronic records is at the 90% mark (Hillestad et al., 2005). These savings are directly related to the efficiency of data storage and transmission and the reduction of errors produced.

Compromising Patient Privacy Causes Hesitancy in Using EHR A major concern arising is how patient privacy will continue to be protected when all health records become electronic. Those who oppose the transition to EHR fear that “entrusting our most private and potentially compromising information to ‘black boxes’ and opening ourselves up to privacy breaches” (Jacques, 2011). Patient privacy has always been important to healthcare providers, and the potential of records becoming more accessible is a major concern. With new technology comes software that must be updated and professionals who must be trained to operate the systems. If issues with the system transpire, physicians and other providers will have to turn to computer technicians to fix the problem. This exposes information to people who may not fully respect patient privacy.

Another issue with electronic records is the demand to publish for secondary use, such as medical research (Fengiun, Xukai, Peng, & Chen, 2011). One study found how some patients were not comfortable with their health information on a computer.

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Some felt as though this makes it easier for anyone to look up their information, therefore, paper records seemed safer (Shield, Goldman, Anthony, Wang, Doyle, & Borkan, 2010). Surveys have also found that patients seem more accepting of a transition to EHR if they can be more proactive in the role of ownership of their records (Berk, Cohen, Callaly, & Lauder, 2008). Considering the fact that more people could have access to EHR, patients are more comfortable with the notion of knowing who sees their medical information.

The Government is aware of the fears associated with patient privacy and security and have been working to add provisions to privacy policies. In 2009, Congress began to improve the privacy and security rules under HIPAA. Congress realized that for the medical industry to switch from paper to EHR, new enforcement mechanisms must be enacted for ensuring the records’ privacy and security (Health and Human Services [HHS], 2009). According to Health and Human Services (HHS), the HITECH Act, in Title XIII of the ARRA was created to make changes to the HIPAA privacy policies. These amendments to HIPAA intend to make protected electronic health information “unusable, unreadable, or indecipherable to unauthorized individuals” (Jacques, 2011). Provisions found in subtitle D of the HITECH Act aim to support the enforcement of HIPAA privacy regulations concerning EHR (HHS, 2009). Subtitle D establishes four categories of violations and sets penalty amounts for each tier. Healthcare lawyers believe that along with the HITECH Act, enforcement of privacy policies will increase causing healthcare providers to prioritize patient privacy protection. With rigorous laws and regulations being set forth for EHR, patient privacy should not become a risk associated with the transition to EHR.

Accuracy and Efficiency in Transfer of Information

Technology has advanced but in healthcare the systems used became archaic. Everything was kept separate and records were stockpiled. It took weeks and even months to transfer records from facility to facility. With the execution of the HITECH act companies can upgrade to a stealthy system that has enhanced efficiency and functioning.

Electronic records allow all patient information to be kept together, so that the whole patient could be seen and treated, rather than bits and pieces. EHR allows the development of a comprehensive database of structured patient information including all active medical problems and diagnoses, hospitalizations, office visits, admission and discharge summaries, as well as lists of current medications and allergic reactions. All this information is stored in chronological order preventing confusion and mistakes when data is interpreted. In addition, any lab tests or imaging studies are uploaded electronically and can be accessed from any location. The primary advantage of this is the high accuracy in relaying the information between healthcare professionals. For example, a primary admitting physician could be discussing findings on a CT scan with a surgical consultant while in completely different locations. Information could also be accessed at bedside or the physician's home via computer which leads to prompt updates and no lag in the care process.

A qualitative prospective intervention study was conducted to investigate the benefits of EMR implementation at the private practice level. The study involved the introduction of EMR in six private practices,which were subsequently followed over a sixteen-month period.

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Data was collected qualitatively using a survey questionnaire method. The main advantages that were reported include ease of accessibility and organization of patient information, as well as efficiency with transfer and documentation. Additional functions readily available with the electronic system is the ability to plot and monitor trends in health (Goldberg, Kuzel, Feng, Deshazo, & Love, 2012).

As a result, recent research has shown that the ease in medical record transfer has increased the quality of care by decreasing mortality rates. With increased proficiency in the workplace, a reduction of errors seem to occur as evidence exists to support a significant reduction in mortality rates in hospitals that utilize EHR compared to hospitals that have not. A correlational study involving multiple hospitals in Texas was conducted to examine the relationship between computerization of medical information and risk of complications, costs, and mortality rates. This was compared with the traditional method of organizing medical information. Forty one hospitals were assessed on a numerical scale for level of computerization using the Clinical Information Technology Assessment Tool. Amongst all medical conditions there was a 15% decline in odds of fatal hospitalizations associated with a 10-point increase in computerization of records. Furthermore, the odds of developing complications with all causes of hospitalizations decreased by 16% using EHR (Amarasingham, R. et. al. 2009).

EHR Decreases Errors The transfer to EHR is very similar to

that of electronic prescriptions. In recent years, the use of electronic prescription of medication has become quite popular in many healthcare facilities, replacing the outdated handwritten process. The introduction of this new system was believed to have the potential to improve beneficiary health outcomes by means of reducing errors, and assist in providing quality and efficient care to patients (Trenkle, 2007).

The overall argument stemmed from the fact that the old handwritten system was prone to mistakes and confusion when transferred over to pharmacists, where an estimated thirty percent of all written prescriptions required callbacks from pharmacies to physicians for confirmation (Trenkle, 2007). This resulted in big delays in processing, which was a time-consuming inconvenience to both the patient and the pharmaceutical provider.

According to a recent study, the transfer to an electronic prescribing system improved the speed of primary care physicians in creating prescriptions in the first three months (Tamblyn et al., 2006). These physicians were not only able to write new prescriptions and review patient’s drug profiles in record time, but they were also able to review all possible drugs available for treatment.

If electronic prescriptions can succeed, then why can’t EHR? The two system updates are almost one in the same because it makes use of the same logic and technology that will in turn give similar results. Just as the transfer to electronic prescribing presented a cost effective and efficient method in caring for patients, EHR would convey very similar if not the exact same results (Corley, 2003). The move to a completely electronic system would eliminate most misunderstandings such as, confusing handwriting and show a total improvement in patient care. This will guarantee that patients will be provided with a legible and highly accessible record, which will ensure that each patient receives the best care. It will also improve the quality of care by decreasing the time it takes to complete charts and decreasing mistakes in the process, allowing more time with the patient.

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Promoting Health Care SavingsThough the high start up cost may put

a burden on the transition to EHR, people must keep in mind the lowered healthcare cost that will take place because of EHR. Physicians are constantly ordering imaging and lab tests along with prescribing medications. Many tests that are ordered are unnecessary and have already been done on patients, therefore may not be required again. With EHR every physician will have access to the past imaging and lab tests a patient has undergone. This will decrease the amount of unneeded tests and in turn save money. Overtime this will diminish the length of hospital stays, reduce the use of drugs in hospitals and the use of drug and radiology usage in the outpatient setting (Hillestad et al., 2005). It is estimated that the improvement in efficacy as a result of EMR can eventually save more than $81 billion annually (Hillestad et al., 2005).

Lowered health care cost will also result from computerized physician order entry (or electronic prescriptions). A randomized controlled trial found that electronic prescriptions result in lower inpatient costs and length of stay (Wu, 2007). Electronic prescriptions are much like EHR, which prove that if health care costs can be lowered by using electronic prescriptions, the same should come from using EHR.

Most research concerning the lowered health care cost from EHR in the United States is prospective. But studies of Europe’s e-health (health technologies including EHR) concluded that initial spending to implement e-health are more of an investment. A study found that in Europe it takes an estimated five years for the benefits of e-health to exceed the costs (Stroetmann, Jones, Dobrev, & Stroetmann, 2007). Though these studies were not done on the transition to EHR in the United States, it provides a logical piece of information concluding that the transition is an investment. Although decreased healthcare costs may not

occur right away, it will be a significant benefit to the future of U.S. healthcare.

Performing only necessary imaging and lab tests will not only condense healthcare costs but also improve the quality of care received by patients (HHS, 2011). Patients will receive the better care at a quicker time. Lower costs will also make quality care affordable, and available to more people resulting in improved health to more of the population.

Moving Forward with EHRAlthough some barriers are apparent

in the transfer to EHR, we support the full utilization of EHR because of the prospective benefits. By approving EHR throughout the health care system there will be an upswing in the accuracy and transfer of records between physicians, an expansion in the ease and safety in providing electronic prescriptions which leads to an overall decline in health care costs. All together, there will be an advancement in the quality of care that all patients receive. In order to successfully phase in EHR, the drawbacks of initial start up costs and the possibility of decreased patient privacy must be addressed.

Complete adoption of EHR in healthcare organizations is a very demanding process and should take place gradually. Leadership of this change should be comprised of multiple political authorities including the Federal and State Governments and other healthcare associations, such as American Medical Association (AMA) and American Nurse Association (ANA), that possess a strong political momentum. A huge component of the EHR initiative efforts should be dedicated to overcoming the barriers or perceived disadvantages making it more favorable for healthcare organizations to adopt. In addition, a categorization system should be devised by the Government to identify healthcare organizations adopting EHR as more superior than their counterparts.

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Finally, a realistic global deadline should be set by the Federal Government by which all healthcare organizations should eventually transition to complete electronic healthcare records.

Given that the major hurdle impeding healthcare organizations from adopting EHR is the significantly high initial startup costs, financial incentives should be created by the Federal and State Government to dampen the costs and make it more feasible for installment of EHR. Examples include, grant subsidies or loan programs to provide partial coverage for startup costs, and defined repayment plans based on generated profit and compliance with minimum quality standards regarding the use of EHR . Prioritization efforts should be enforced for small private practices and hospitals that face the most financial difficulty in adopting EHR. Additionally, tax breaks on expenses related to setting up EHR and professional training would be appropriate incentives to help with the cost. These financial stimuli should be conditional on meeting specific objectives and criteria that reflect appropriate and effective utilization of EHR in compliance with current standards of care.

An example illustrating a financial incentive based system to support full EHR transition is the Medicare stimulus grant. This grant is in accordance with the ARRA, and the Government has set aside $19.2 billion in incentives for medical institutions (Jacques, 2011). In order to receive these incentives, medical institutions must meet the “meaningful use” requirements (Hoggle, Yadrick, & Ayres, 2010). Upon meeting the objectives they will receive $44,000 in stimulus money from Medicare (Lee & Smith, 2011). The stimulus money will be paid to healthcare organizations in tapered installments over five years which will help offset the cost and ensure that minimum “meaningful use” objectives are used. To further propagate the incorporation of EHR we suggest that hospitals and other healthcare organizations should receive greater Medicaid and Medicare reimbursements that are directly

proportional to the usage of EHR. As previously discussed “meaningful use” is defined by fulfilling minimum criteria of core clinical competencies and objectives that utilize EHR. The more objectives completed above the minimum, the greater the financial reward.

As EHR is becoming a standard of care, we suggest that healthcare organizations should be categorized by the JCAHO (Joint Committee on Accreditation of Healthcare Organizations) based on usage of EHR. Grade A reflects full compliance with EHR standards. Grade B reflects partial integration of EHR standards. Grade C reflects no EHR capabilities. This grading system segregates healthcare organizations based on quality of care on a public level in order for patients can make their own decisions regarding the facility. In addition Grade B organizations should be offered recommendations to improve towards a goal of obtaining Grade A status. Grade C organizations would be at risk for losing their accreditation status from JCAHO.

Finally, a global deadline has already been set by the Government for full transition to EHR in all healthcare facilities. It is intended to be accomplished by 2014 after which penalties exist in the form of incremental reimbursement reductions from Medicare, which we fully support.

Conclusion EHR is necessary to use as technology advances and demands for increased patient safety continues. The Government has enacted laws to give the US a push to improve the efficiency and accessibility of patient records that will in turn provide better outcomes and lower mortality in patients.

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