Top 10 Reasons

Top 10 Reasons Why We Top 10 Reasons Why We Need EHRs & Need EHRs &

Why They Should Be Open-Why They Should Be Open-SourceSource

Bob Hoyt MD FACPCo-Director Medical Informatics Program

University of West Florida

EHRs: Not a panaceaEHRs: Not a panacea

BackgroundBackground

• EHRs are associated with a significant amount of vendor and academic hype, as well as mixed reviews in the medical literature

• Many of the earlier studies reported came from the same 4 large academic institutions, not representing the average small office or hospital

• What, therefore, are the facts about EHRs?

Why we need EHRs #1Why we need EHRs #1

• Paper records are grossly inadequate:• Dangerous because they may be illegible or

missing • Difficult to share • Expensive to copy • Expensive to retrieve ($5-$7/pull) and store • Unable to data mine or easily generate quality

reports because they contain non-computable data

Paper-based templatePaper-based template


• Vital information is frequently missing:• 25% of paper charts are missing at the time of the

visit• When charts are present, they still have missing

information 14% of time• Without e-prescribing: no prior medication

histories• Bottom line: decisions are made with incomplete

information and about 20% of tests are repeated unnecessarily


• Faster retrieval times:• Previous patient notes, lab results, x-rays and

medication histories much faster to retrieve using an EHR compare to a paper chart

• Permits better trend analysis• Permits graphs and flow charts of important

results, like PSA, weight, blood pressure, etc• Computable data and associated with data

standards such as HL7, DICOM and LOINC

OpenEMR Vital SignsOpenEMR Vital Signs


• EHR is available from the office, hospital or home if web based or using VPN

• How many clinicians take call at home at night with the inability to access records on patients they are not familiar with?

• How many clinicians make rounds on a patient at the hospital without office records?

• These are patient safety and quality of care issues


• Electronic record can be viewed by medical and non-medical staff simultaneously and 24/7 (Not possible with paper)

• If on the same system, a consultant can view the record remotely, as can billing personnel, etc

• Can access records after-hours and on weekends• Other team players like pharmacists and social

workers could have access


• EHRs are a building block of regional health information organizations and the Nationwide Health Information Network (NHIN)

• It is pointless to spend billions on creating health information organizations and the NHIN if the adoption rate for EHRs stays in the 10% range


• EHRs can save money, compared to paper by:• Reducing transcription costs by using templates

and voice recognition• Upcoding encounters because the note is more

complete• Reducing pharmacy call backs by using e-

prescribing• Reducing FTEs and record storage space• Reducing mailing and faxing costs


• EHRs support patient (consumer) informatics. There is a trend to allow patient access via a web portal to the electronic health record for:

• Lab results• Online appointing• Med refills and renewals• E-visits• Secure messaging with office staff or clinicians


• Data mining is far easier with electronic records:• American medicine is very late in digitizing its records so

aggregated patient information can be analyzed• We need comparative effectiveness research so we know

what the best treatments are, but we can’t do that with paper records

• AI and NLP will help when data is not structured• This is why Google, Microsoft and IBM are jumping on

board the electronic data ship


• Electronic disease registries are far superior to paper registries

• Compare an auto-populating electronic disease registry with a manual populating disease registry

• You can build in alerts, reminders, rules engines, auto-e-mails and text messages to patients, etc

• Also important for pay-for-performance programs

EHR DiseaseEHR Disease R Registry Useegistry UseLee BJ BMJ 2009;339:b2395Lee BJ BMJ 2009;339:b2395

• Kidney doctors (6) who work for Kaiser-Permanente (largest non-profit system in US) in Hawaii wanted to improve the early care of patients with chronic kidney disease with earlier referrals from the 110 generalists

• Their population base is 214,000 patients, 10,000 have known decreased kidney function based on accessing lab results

• K-P has Epic® EHR so they could estimate kidney function in all patients and place abnormals in disease registry

Electronic disease registryElectronic disease registry

• Because all patients are in the same EHR they could also access medications and clinical notes

• Kidney doctors notified generalists by secure e-mail about any patient with decreased kidney function


• Bottom Line: Kidney docs either made treatment recommendations or referred patients to themselves (unsolicited referrals). The rate of late referrals dropped from 32% to 12%

• Is this a logical step for population health and disease management?

• This will work for other diseases


• This is an intelligent human-machine hybrid clinical decision support initiative

• Why not do this for several years as generalists come on board and slowly work towards computer generated alerts?

• Simple tool for all EHRs to include open-source

Why no mention of improved Why no mention of improved patient safety and quality?patient safety and quality?

• E-prescribing reduces costs because of fewer call backs and increased use of generics

• E-prescribing reduces a few medication errors but not many adverse drug events and we are seeing new errors due to e-prescribing

• Clinicians tend to ignore drug alerts• Clinicians often ignore guideline

recommendations as part of the EHR

Why do Open-Source EHRs Why do Open-Source EHRs make sense to me? #1make sense to me? #1

• They are usually developed from the bottom up, with the end-user in mind

• Compare the DOD’s AHLTA and the VA’s VistA to note the extreme differences in usability and clinician satisfaction


• Private EHR vendors are not willing to create and share a training database for students or prospective clients.

• We need hands-on experience for all healthcare workers, including medical students, who want EHR training

• OpenEMR is being used by University of West Florida students as we speak for teaching purposes


• Much more cost effective • Still require implementation, support, upgrades

and backup but cost likely to be about 10% of proprietary cost to purchase and maintain

• No haggling with the vendor for best deal

What does the literature What does the literature say?say?

Why do Open-Source EHRs Why do Open-Source EHRs make sense to me?make sense to me?


• 60-70% of US primary care medicine is practiced by very small (1-3 clinicians) groups that are often rural

• They don’t have the capital for upfront expenses• They have no in-house IT support• They may have no physician champion• Initial decreased productivity is a hardship


• There are multiple other communities that could benefit from low cost EHRs, besides typical outpatient medical offices:

• Public health• Nursing homes• School nurses• Home health• Community clinics


• They are customizable, unlike proprietary EHRs

• Modifications can be made to match workflow or other requirements

• Modifications can be shared with others


• Open-source EHRs have a long track record in the business

• More than 10 FOSS EHRs available• Example is VistA which has been around for

about 15 years• Has been improved multiple times from input

from VA physicians and is not available in many flavors


• Open-source in healthcare is on the rise


•Open-source in healthcare is on the rise


• FOSSs are reliable and secure• “FOSS systems can meet, or even exceed, the

quality of their proprietary counterparts” and “FOSS-developed systems have a distinct advantage in their ability to respond to security threats (Boulanger, A 2005)

ConclusionsConclusions

• Electronic Health Records do have unequivocal benefits over paper records

• FOSS is here to stay in the healthcare field• Open-source EHRs are unique and a very

good fit for many medical communities

Health & Medicine

Top 10 Reasons