Chapter Outline
Benefits and Barriers to Implementing Electronic Health Records
Health informatics (also known as health care informatics, health care informatics, medical informatics, nursing informatics, or biomedical informatics ) is a discipline at the intersections of information science, computer science, and health care. It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems.
Health information technology (HIT) consists of electronic methods used to manage people’s health and health care. Legislation requires the use of certified electronic health record (EHR) technology for exchange of health information to improve the quality of health care. The terms EMR and EHR are frequently interchanged. However, there is a difference. The electronic medical record (EMR) is simply an electronic version of the paper chart. The EHR shares health information across the continuum of services (e.g., physicians and laboratories). Information can follow the patient through different health care settings (e.g., clinics, hospitals, nursing homes, catastrophic events). Hurricane Katrina is an example of a catastrophic event after which medical information of displaced patients was retrievable.
The personal health record (PHR) extends the capabilities of what is being called the virtual chart. The PHR can stand alone or be interconnected to the EHR. Capabilities include prescription refills, appointments, insurance information, and patient education. Sharing of medical data in the PHR can be influenced by patients’ willingness to share their condition and sociodemographic variables, which include age, education, and severity of health and public health emergencies. Although safety-monitoring mechanisms are being implemented, patient trust will ultimately facilitate support sharing.
Development
The 2000 Institute of Medicine (IOM) report estimated 44,000 to 98,000 deaths occur annually in the United States because of errors. The IOM’s report “Crossing the Quality Chasm” emphasized that a redesign in health care should include a focus on information technology. The Leapfrog Group, a voluntary program focusing on the safety, quality, and affordability of health care, and The Joint Commission, an accrediting body for organizations and programs, promote the implementation of the EHR. However, they also agreed with the Food and Drug Administration that “consistency, reliability, and accuracy needed to be evaluated.”
In 2008, only 2% of the nonfederal general acute care hospitals had a comprehensive EHR, but 7.6% had a basic EHR. In 2013, basic EHR growth had increased fivefold. Larger hospitals and teaching hospitals had higher utilization of electronic record systems. Adoption rates did not differ among high- and low-indigent patient populations in hospitals known as the Disproportionate Share Index Hospitals (DSH).
Regional Health Information Organizations (RHIOs) were designed to enhance clinical data availability and provide Health Information Exchange (HIE). A federal initiative from the Office of the National Coordinator of Health Information Technology (ONCHIT) included the development of a functional health information infrastructure. The ONCHIT funded Health Information Technology Regional Extension Centers (RECs). The RECs provided assistance to primary care physicians, physician assistants (PAs), and nurse practitioners in the United States to develop their EHR system. The Health Information Technology Economic & Clinical Health Act (HITECH) provided an opportunity to expand the use of HIT with grants, loans, and financial assistance. HITECH funds mostly supported primary care and critical-access and rural hospitals with fewer than 50 beds.
Lewis notes that the decision to switch his office to an electronic system provided fantasies of a streamlined, technologically efficient, and almost functionless setting, which in reality was not the case. Practices and organizations need to use the EHR now to avoid penalties. Improved outcomes occur when emphasis is placed on better technology, integration, and privacy concerns. One should consider the implementation of an EHR system in an institution with 200 or more beds to take the same time as completion of construction on a new hospital building.
Meaningful Use
Recent federal initiatives include the American Reinvestment and Recovery Act (ARRA), for which “meaningful use” incentives were applied in order to meet performance metrics. Assisted by the Centers for Medicare & Medicaid Services (CMS), stage I and stage II of meaningful use requirements includes the “capturing of information and the exchange of information.” ARRA focuses on standards, quality needs, functionality, communication, and government program links. This also includes transmitting prescriptions to the pharmacy electronically and demonstrating the capability of the EHR to electronically exchange key information.
Beginning in 2016, penalties will be applied if meaningful use quality and efficiency criteria are not met. As each stage progressed, the ability to meet these criteria became more difficult. With stage III, in 2017, interoperability among different health care EMR systems will allow for greater sharing of information. The concern with the advent of ICD-10 (International Statistical Classification of Diseases and Related Health Problems—World Health Organization [WHO] medical classification) is that the degree of interoperability will become limited. Clinical information exchanges among different health care systems may not occur because of the higher requirement for mapping needed to ensure standardization in terminology. Many advisory organizations, including the American Medical Association, believe that more time is necessary to build these mechanisms so that “adoption and innovation” occur.
Implementation
Major EHR market vendors include Cerner, Eclipsys, EPIC, iMD Soft, McKesson Provider Technologies, MediTech, Misys Healthcare Systems, Philips Medical Systems, Picis, and Siemens. In 2004, the military implemented the Armed Forces Longitudinal Technology Application, which is the Department of Defense’s global health record.
When choosing a system, it is important to look at the success of the system in the marketplace. Ideally, you would speak with other institutions that have implemented the same system and discuss customer satisfaction. Workflow implications differ for various stakeholders within institutions. Approximately 30% of EHR implementations fail because of steep learning curves and loss of productivity. The development of a flexible navigation system, enhanced functionality, and the ability to complement your work will enhance usability.
It is essential to secure organizational commitment when EHR implementation is going to occur. A broad group of extrinsic and intrinsic stakeholders needs to be involved in the implementation process. Change is not an easy concept. Therefore, the existence of a change management organizational culture is essential. Intentional planning that is clear and consistent with the vision and principles of the organization must be present.
It is important that PAs become incorporated early in the process of EHR development. Factors that go beyond technology can hinder HIE. The cultural change is even more important than the challenge with technology. Work sessions need to be created to enhance training, develop workflows, and limit complaints during the process.
Many clinicians think that EMR is a direct extension of computerized physician order entry (CPOE) and that improvements in functionality, performance, learning curves, and technology have resulted. A selected group of subject matter experts (SMEs) should develop order set content. Integrating general admission order sets with disease-specific order sets improves outcomes. Selected PAs with subject matter expertise strengthen the integration process. PAs who use specific order sets can incorporate evidence-based links to enhance core-measure compliance. Development of order sets will increase utilization, time, and compliance in addition to eliminating discrepancies with handwriting, signature, dating, and timing in the EHR ( Fig. 22.1 ). A good example is in the recent development of the Surviving Sepsis Campaign Order Sets in which critical elements must be met with the first hour, third hour, and sixth hour of resuscitation (e.g., blood cultures, broad-spectrum antibiotics, lactate levels, crystalloids, possible vasopressors, and repeat lactate levels).
Mandatory elements in the EHR include a problem list, a medication list, vital signs, allergies, a smoking record, discharge documentation, a discharge summary, CPOE for medications, drug-to-drug and drug-to-allergy checks, the ability to electronically exchange key clinical information, decision support, security, laboratory test results, patient list of conditions, patient-specific education sources, and medication reconciliation. Critical value alerts can be incorporated into an EMR screening system for early recognition of potentially life-threatening outcomes. Additional functions include advanced directives, electronic surveillance, and the ability to submit electronic data to public health organizations. A dedicated integrity and clinical content team becomes essential in monitoring and recommending improvements within a system.
Functionality is incorporated across services and commonly occurs in laboratory data, radiology images, and radiology reports. Whereas laboratory data and reports are considered to be passive, writing progress notes and CPOE are considered to be active. Clinical information and data should be handled at “point of care” or in “real time.” Device integration allows bar coding and hemodynamic data to be immediately charted.
Physician assistant “champions” are integral in the necessary training and reinforcement during the EHR initiative. If hospital-wide implementation follows a big-bang initiative, then administrative recommendations are made to be 100% paperless. Other hospitals may want to start slowly with one service at a time being integrated into the paperless process. System failures have been noted when a paper backup is required. The prevention of workarounds is essential with both approaches to minimize safety flaws and incidents. When too much nonessential information is populated into a note, a condition called “note bloat” occurs. Attention to the body of the content becomes unfocused, with greater focus placed on only the assessment and plan and not the note itself. Copy and pasting or copy forwarding has resulted in inaccurate information being posted and ultimately can result in a sentinel event.
Benefits and Barriers to Implementing Electronic Health Records
Benefits to implementing an EHR immediately starts with improved legibility, dating, and timing. Greater emphasis on CPOE will perpetuate meaningful use implementation and best practice advisories. Improved encounter classifications enhance the ability to assess and review patient information with universal access in real time. Over a wide range of patient populations, the quality of personal performance responses is thought to improve.
Barriers to implementing an EHR immediately starts with cost, purchasing, implementation, and maintenance. The time involved in educational training and medical record keeping continues to become more involved. Failure can result if extrinsic and intrinsic stakeholders are not part of a strong interdisciplinary steering committee. The benefit to quality is still not clear, but other benefits such as “efficiency, patient engagement and health care information” are thought to exist. A reluctance to embrace new technology is evident. Current and precise information is essential; otherwise, the belief of “garbage in, garbage out” holds true.
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