Electronic Health Records

1. Electronic Health Records

2. Definition of the term Electronic Health Record Electronic Health Record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization”. Electronic Medical Record: “An electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within one healthcare organization”. Personal Health Record: “An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared and controlled by the individual” .

3. • The EHR is the larger system that includes the EMR and PHR and interfaces with multiple other electronic systems locally, regionally and nationally • The EMR, on the other hand, is the electronic patient record located in an office or hospital • The PHR is a collection of health information by and for the patient. There is overlap between the EMR and the PHR, since the PHR can be part of the EMR as will be pointed out in the chapter on patient informatics

4. Electronic Health Record Adoption • Outpatient (Ambulatory) EHR Adoption. In 2006, The National Ambulatory Medical Care Survey, conducted by the Centers for Disease Control reported that 29% of respondents had a partial EHR but only 12% had a truly comprehensive EHR. A comprehensive EHR was defined as having computerized ordering of medication, test ordering, test results retrieval and clinical notes. • Inpatient EHR Adoption: The American Hospital Association reported on the 2006 use of EHRs with more than 1,500 community hospitals responding. They noted that 68% of the hospitals surveyed had implemented inpatient EHRs, but only 11% were fully implemented and these were mainly by large urban and/or teaching hospitals. The most of practice used HER where educational hospitals and health care hospitals

5. A HIMSS Analytics study looked at data from over 5000 hospitals to determine the actual level or degree of EHR adoption in 2008. The scale they used rated hospitals from 0, meaning hospitals with an EHR with no functionality installed, to 7 indicating a fully functional paperless system. As of March 2009, only two hospital systems in the US had attained level 7 adoption.

6. Why do we need Electronic Health Records? • The paper record is severely limited. • The need for improved efficiency and productivity. • Quality of care and patient safety. • Public expectations. • Public expectations. • Financial savings. • Technological Advances. • Older and more complicated patients require more coordinated care.

7. Example for Outpatient paper-based patient encounter form

8. Computerized Physician Order Entry (CPOE) CPOE is an EHR feature that processes orders for medications, lab tests, x-rays, consults and other diagnostic tests.

9. What CPOE can do? • Reduce medication errors. CPOE has the potential to reduce medication errors through a variety of mechanisms. Because the process is electronic, you can embed rules-engines that allow for checking allergies, contraindications and other alerts. The following advantages of CPOE compared to paper-based systems: • CPOE overcomes the issue of illegibility • Fewer errors are associated with ordering drugs with similar names • More easily integrated with decision support systems than paper • CPOE is easily linked to drug-drug interaction warnings • More likely to identify the prescribing physician • Able to link to adverse drug event (ADE) reporting systems

10. Able to avoid medication errors like trailing zeros • CPOE will create data that is available for analysis  • CPOE can point out treatment and drugs of choice • Has the potential to reduce under and over-prescribing • Prescriptions reach the pharmacy quicker • Reduce costs. Several studies have shown reduced length of stay and overall costs in addition to decreased medication costs with the use of CPOE. Tierney was able to show in 1993 an average savings of $887 per admission when orders were written using guidelines and reminders, compared to paper based ordering that was not associated with clinical decision support.

11. Reduce variation of care. One study showed excellent compliance by the medical staff when the drug of choice was changed using decision support reminders.42 Study conclusions should be interpreted with some note of caution. On the surface CPOE seems easy: just replace paper orders with an electronic format. The reality is that CPOE represents a significant change in work flow and not just new technology. An often repeated phrase is “it’s not about the software, dummy”, meaning, regardless which software program you purchase, it requires a change in the way you do business or work flow.

12. Clinical Decision Support Systems (CDSS) Traditionally, CDSS meant computerized drug alerts and reminders as part of computerized physician order entry (CPOE) applications. Most of the studies in the literature evaluated those two functions. However, according to Hunt, CDSS is “any software designed to directly aid in clinical decision making in which characteristics of individual patients are matched to a computerized knowledge base for the purpose of generating patient specific assessments or recommendations that are then presented to clinicians for consideration”

13. Some of the clinical decision support available today.

14. The Ten Commandments for effective clinical decision support: • Speed is everything—provide the information rapidly • Anticipate needs and deliver in real time—make it convenient and provide at the point of care • Fit into the users workflow—provide information in a screen that is logical and not in a separate standalone application • Little things make a big difference—subtle details may make or break CDSS • Recognize that physicians will strongly resist stopping—because of this some monitoring of clinicians who ignore important guidelines may be necessary

15. Changing direction is easier than stopping—a helpful reminder to make a minor change (like lower dose of med) is better accepted than a complete change • Simple interventions work best—guidelines should fit on a single screen • Ask for additional information only when you really need it—clinicians will object to having to find information that is not readily available • Monitor impact, get feedback and respond—suffice it to say that no system will work without getting feedback from the end user and tweaking it as needed • Manage and maintain your knowledge based systems—there is a need to update recommendations as new evidence appears

16. EHR Successes and Failures Duke University Medical Center • EHR developed in 1986 • Total time per patient visit was reduced by 13% • Pre-exam functions were reduced • Fewer overlooked problems • Fewer charting errors • Fewer prescription errors • Physician’s actual time with patient unchanged

17. Central Utah Multi-specialty Clinic • 59 physicians practicing in nine locations • Clinic used AllscriptsTouchworksHER • In first year they experienced $900,000 profit due to increased revenue and decreased expenses • They anticipate savings of $8.3 million over next 5 years University of Rochester • Implemented AllscriptsTouchworks EHR for three Internal Medicine Clinics, one Dermatology clinic and a Pediatric Endocrinology clinic • ROI occurred in 16 months with ongoing annual savings of almost $10,000 per physician • Reduction in chart pulls accounted for 63% of savings • Salary savings accounted for 23% of savings

18. Maimonides Medical Center • With a new EHR system medication discrepancies fell by 60% • 165,000 potential drug interactions were detected (unknown how many were truly serious) in one year resulting in 82,000 treatment changes • System used by 100% of medical staff Cincinnati Children’s Hospital Medical Center • Partial EHR based on Siemens software implemented at a cost of $14 million dollars • Medication ordering/dispensing errors reduced from 120 to 90 per month • Program reduced time to get drugs from pharmacy to bedside in half

19. Cedar-Sinai Hospital • $34 million CPOE system rolled out in 2003 • Shut down 3 months after implementation because: • System too slow and too many technical problems • o Poor physician inputo No phase-in. Mandated CPOE from the beginning

20. Barriers to Electronic Health Record Adoption • Financial Barriers. Although there are models that suggest significant savings after the implementation of ambulatory EHRs, the reality is that it is expensive. Surveys by the Medical Records Institute, MGMA and HIMSS report that lack of funding is the number one barrier to EHR adoption, cited by about 50% of respondents. • Physician resistance. In a monograph by Dr. David Brailer, lack of support by medical staff is consistently the second most commonly perceived obstacle to adoption, behind lack of resources.101 They have to be shown a new technology makes money, saves time or is good for their patients. None of these can be proven for certain for every practice.

21. Loss of productivity. It is likely physicians will have to work at reduced capacity for several months with gradual improvement depending on training, aptitude, etc. This is a period when physician champions can help maintain momentum with a positive attitude. • Work flow changes. Everyone in the office will have to change the way they route information compared to the old paper system. If planning was well done in advance you should know how your work flow will change. Initially, you will have to maintain a dual system of paper and electronic records. Work flow analysis will also determine where you will place computer terminals. • Integration with other systems. Hopefully, integration with other systems like the practice management software was already solved prior to implementation. Be prepared to pay significantly for programmers to integrate a new EHR with an old legacy system. An average cost is about $3-$15,000.104 Most office and hospitals have multiple old legacy systems that do not talk to each other. Systems are often purchased from different vendors and written in different programming languages.

22. Lack of standards. One can assume that an EHR purchased today will not communicate with other EHRs, although vendors are being pressured to make their products interoperable. The Department of Health and Human Services established the Certification Commission for Healthcare Information Technology (CCHIT) with the goal of certifying technologies such as EHRs. Twenty nine ambulatory EHRs have been certified using the 2008 standards. Certification will last for only two years and is expensive, about $35,000 for initial certification. Interoperability testing requires a vendor to receive lab results using the HL7 v.2.5.1 standard, test lab codes using LOINC and generate a continuity of care document. • Adverse legislation. There is concern that previously passed legislation will make it difficult for hospitals and physicians to combine forces and create information networks. The Stark Law prohibited a physician from referring Medicare patients to an entity if he/she had a financial relationship with the entity. The Anti-kickback Act made it illegal for an individual or entity to offer remuneration of any kind to another individual or entity for referring a patient. It is illegal to have to purchase or lease any covered item or service.

23. Inadequate proof of benefit. Although there is plenty of hype regarding the benefits of EHRs, the reality is we need better research. A systematic review by Hunt showed that the effects of clinical decision support systems, as an example, have not been adequately studied.46 Moreover, successful CDSS programs at a medical center where they have been in use for an extended period of time does not mean they will be successful at another medical center with no such track record .