Electronic Health Records

The development of the electronic health record (EHR) is a potential bright spot in the future of health care. EHRs may offer an opportunity for better care by streamlining evaluations and documentation at substantially less cost. EHRs can improve communication, improve screening, facilitate care transitions, minimize adverse drug events, provide decision support, and facilitate overall quality improvement. Overall, EHRs have the potential to revolutionize the practice of medicine.

Advantages of EHRs

Expected advantages of an EHR system are numerous and include the following:

• Reduce error
  

• Eliminate illegibility of poor or “hurried” handwriting
  

• Provide electronic prescriptions directly to the pharmacy, decreasing transcription errors
  

• Minimize the loss of medical records
  

• Eliminate duplication of data entry
  Mandated documentation requirements often call for the same information to be available in different environments and on several different forms. An EHR system can eliminate redundant exercises in information entry by filling in the same information that is needed on numerous forms, such as admission history forms, physical examination forms, discharge summaries, etc.
  

• Automate completion of various forms
  Information can be downloaded from an EHR onto standard forms such as the Medical Eligibility Review Form (3871), which must be completed for any nursing home admission covered by Medical Assistance.
  

• Allow access to health information anywhere an internet connection exists
  Patient information could flow seamlessly via Web access from office to hospital to nursing home and back to the office as a patient’s setting changes. Having all patient information available across the continuum of care can also reduce adverse events.
  

• Improve ability to maintain comprehensive records, leading to improved regulatory compliance
  EHR systems can potentially facilitate regulatory compliance and minimize associated redundancies in the documentation required in the administration of medical care. This issue is particularly prominent in long-term care and for physicians working in nursing homes or other institutional settings.
  

• Automate and improve billing and coding
  With reimbursement integrally tied to documentation, EHRs may offer the only reasonable solution for individual practitioners. Larger organizations and institutions will also appreciate the ease at which discharge summaries and other information can be provided and accessed.
  

• Facilitate data collection and analysis for quality improvement
  

• Allow for real-time decision support and screening or monitoring tools
  For example, many EHR systems allow access to medical information Web sites while working in the patient record. Institutional guidelines and treatment recommendations can be provided automatically. Inappropriate drugs and potential drug-drug interactions can be more easily identified.
  

• Eliminate costly paper medical record storage and dictation services
  

• Improve patient communication
  Providing patient instructions and patient educational material electronically can lead to increased compliance. Patients and family members who have authorization can potentially review information from recent patient interactions as well as ask questions electronically in a secure fashion. Clinicians who participate in oversight electronically may also be able to be reimbursed for such clinical contact.

Experts agree that physician offices and most major healthcare systems will have to adopt EHRs to survive as pressures to balance budgets lead to reduced reimbursement. The improved efficiency and billing opportunities from EHR systems offer financial survival in addition to the merits of improved patient care. Perhaps most exciting is the prospect of being able to spend more time with patients and less time with paper!

Potential Disadvantages of EHRs

Despite the obvious benefits of an EHR system, only a small percentage of physicians currently use EHRs in their practices. What are some of the reasons?

• Upfront purchase cost
  Initial costs to set up an office EHR system vary widely, and many physicians are leery of making any substantial outlay of capital without a clear understanding of the return.
  

• Equipment cost
  Many EMR packages require purchase or lease of hardware and/or network software.
  

• Lack of technical personnel
  Inadequate technical expertise within the office setting and, particularly in the long-term care setting, is often a concern.
  

• Training of office staff
  Many packages are complex and may not be easily incorporated into an established practice. Training various levels of office staff is often not practical. Unfortunately, large EHR companies with complex packages may not be able to provide the personal oversight that most practices would need. The result could be fewer patients seen and additional clinician hours spent trying to resolve issues.
  

• Changes in technology
  Once the initial investment is made, will technological changes render the system obsolete?

• Privacy and security issues
  Protecting patient records is of paramount importance. While most EHR systems are more secure than old-fashioned paper charts, this concern must be addressed within each EHR system.

Unquestionably, the biggest obstacle is that most physicians have had little exposure to EHRs, so there is little knowledge of systems that are available to avoid the problems listed above. Reviewing the following list of twenty questions can help you make a decision on switching to an EHR system.

Twenty Questions to Consider Before Purchasing an EHR System

1. Can the system be accessed when off site?
   Ideally, the system would be Web-based with no excess hardware or software costs, no IT personnel requirements, and no need to transfer information between computers or offices. Multiple physicians could have access in multiple sites when authorized. More sophisticated systems could also allow consultants temporary access to needed records.
   

2. Are the templates flexible and can they be adapted for specific needs?
   Can the system be adapted to individual preferences and modified rapidly on a large scale rapidly as medical knowledge advances?
   

3. Are menus and templates used excessively?
   If the system that is overly dependent on use of templates and algorithms, writing routine notes may take an excessive amount of time. Ideally, a system would incorporate rich text fields with templates to allow for both efficient information entry and a smooth transition for future notes.
   

4. Are prescriptions and treatment plans automated?
   Choosing a diagnosis should be followed by automated suggestions of prescriptions and treatment plans. Pop-up alerts should notify the clinician about appropriate screening or alarming test results. The clinician should be able to modify these easily as appropriate. Most desirable is a system that “learns” from prior input.
   

5. Can the system be adapted for personal and specialty preferences?
   Templates and treatment protocols should be able to be modified easily to accommodate specialty or personal preferences.
   

6. Is the Web accessible while working in a patient record?
   Ability to access the Web (eg, for assistance based on personal preferences) without leaving the medical record should be part of the standard package.
   

7. Does the EHR system perform calculations automatically and support graphing to identify clinically relevant changes or trends?
   These functions can help identify changes so that potential problems can be anticipated. For example, creatinine clearance can be easily calculated based on information in the patient records. The system should be able to provide this information and alert the clinician when levels drop below a predetermined threshold.
   

8. Is E&M coding automated?
   Automatic calculation of the bill improves reimbursement (with less “undercoding”) and reduces the chance of inadvertent fraud.
   

9. Is access secure?
   Currently, only a few EMR systems provide increased ease of compliance with Health Insurance Portability and Accountability Act (HIPAA) and role-specific access/authorization. Those that do ensure a more secure environment than hard copy records.
   

10. Can the system be integrated into other data systems?
    An integrated system will reduce errors in prescriptions and other medical information because handwriting is no longer an issue. Coordination with laboratory databases will allow for direct entry into the medical record. Even basic vital signs collected by medical assistants should be instantly accessible.
    

11. Does the system actually reduce space requirements?
    Most Web-based systems take very little office equipment or space. However, a few client-based systems require enough additional equipment and update storage that the benefit to file space savings in a very small office practice is almost lost.
    

12. Is the system sufficiently automated to also reduce transcription costs?
    While most current voice-activated systems leave much to be desired, the technology will continue to improve and can provide many benefits. Thinking ahead, the EHR system should blend well with voice activation systems and use templates that are flexible enough so that information can be downloaded from existing records in a way that verbal dictation is essentially eliminated. Most physicians, especially those who have not grown up with computers want to keep the amount of typing to a minimum.
    

13. Can the system search information rapidly?
    Are data queries simple enough so they can be performed rapidly, while still satisfying quality improvement and reporting requirements? Such systems should be able to improve both quality assurance and research potential. Rapid analyses of guideline compliance and patient screening should be available.
    

14. Can the system download old record information and modify templates without leaving a patient record?
    Many systems require labor-intensive “cut and paste” techniques. Some even require leaving a record to make changes or to obtain previous information.
    

15. Can patients or authorized family members access the system securely?
    This feature can help reduce requests for patient records, save staff time for finding and copying records for patients, and help keep caregivers informed of treatment changes and other recommendations.
    

16. Are there excessive or hidden costs after the initial purchase?
    Usually there is a monthly or annual maintenance fee. These fees are usually similar to a monthly cell phone bill, but they can be considerably more. If updates must be installed on every computer for a client-based system or if onsite staff must perform data backups every day, the cost associated with personnel time must be included.
    

17. Will system upgrades be compatible with other systems currently in use (eg, prescription, laboratory), and will upgrades have an additional cost?
    One physician complained that when his system was upgraded, it lost compatibility with all other interfacing and took days of support time to correct. Even then, his old records were not completely assimilated into the new system!
    

18. Will there be additional charges for initial set-up and training and ongoing support/help?
    This is usually part of a maintenance fee.
    

19. Is support/help available 24 hours a day?
    

20. Can support/help also be provided onsite or only via phone?

Specific Practice Considerations

Before choosing an EHR system, it is essential to consider the specific needs of the practice as a group and determine whether each feature is essential, a nice option, or not necessary. Unnecessary features can increase the upfront cost, while too few features can limit optimal use of an EHR system. For example, some EHR systems include billing, scheduling, and e-prescribing all in one system. Many practices already have some or all of these features. Rather than pay for an expensive all-inclusive system, it may make more sense to find a less expensive system that can easily interface with office systems currently in place.

The following table can assist you in determining the specific needs of your practice.

Features of an Electronic Health Record System

*Geriatric Care of Nevada for internal evaluation of available EMR products and other requirements.

Remaining Challenges for EHR Systems

• With information being filled in automatically on various forms and sent to other locations, an initial error in data entry can proliferate and become widely disseminated. Nonetheless, the Medicare Modernization Act of 2003 established incentives that may be enough to encourage physicians to embrace e-prescribing as happened years ago when reduced turnaround time pushed physicians to incorporate electronic billing systems into their practices.

• Another important issue that has not been well addressed (and that is usually not in the minds of potential purchasers of EHR systems) is how the EHR system will access information from other systems (eg, laboratories, imaging centers, hospitals) that are not designed for this exchange of information. For example, if a patient is seen in a private office and then goes to a VA hospital, information cannot be easily transferred from one system to the other. Despite efforts to create common coding for such exchanges, this area of health information technology presents one of the greatest obstacles to reliable, valid, and secure health information exchange.

• Finally, more research using high quality study designs and solid outcome measures associated with EHRs is needed. EHRs are likely to change the office paradigm. Gathering and documenting information, and intellectualizing medical information in the physicians’ mind, can all be accomplished in less time. Some care will likely take place in the cyber environment with fewer office appointments. The time actually spent with patients may improve, and a return to “high touch” medicine may prove to be more satisfying for all involved.