FAP-Marketa Mashall Bumpus

1THE ELECTRONIC HEALTH RECORD, DO THE PROS OUTWEIGH THE CONS?

The College of St Scholastica

Duluth, Minnesota

THE ELECTRONIC HEALTH RECORD, DO THE PROS OUTWEIGH THE CONS?

by

Marketa M. Bumpus

Final Applied Project Advisor: Danika Brinda

Final Applied Project Committee:

Pamela K. Oachs, MA, RHIA

Amy Waters, MA, RHIA, FAHIMA

Ryan Sandefer, MA, CPHIT

Approved:

Submitted in partial fulfillment of the requirements for the degree of Master of Science in Health Information Management, The College of St. Scholastica, Duluth, Minnesota.


Thesis Problem Statement

Marketa M. Bumpus

Advisor: Danika Brinda, Final Applied Project

The Electronic Health Record, Do the Pros Outweigh the Cons?

Topic:

My Master’s Program will deal with “The Electronic Health Record, Do the Pros

Outweigh the Cons?” When hospitals and other healthcare facilities implement an EHR,

redundant waste is often eradicated. However, if the system is inconsistent, implementing new

technology can create more complications, and the results can be "damaging." It is crucial that

healthcare executives understand the benefits and challenges of EHRs and what can be done to

remove them. An EHR is only as good as the processes that it supports. If the technology is not

supported with well thought out processes, hospitals and other healthcare facilities may invest in

complex and costly technologies that create more waste in a system accompanied with

inefficiency.

Rationale

The electronic health record is very valuable to hospitals and other healthcare facilities

because EHRs make health information readily available to authorized health care providers

wherever and whenever a patient gets care. In addition, EHR’s improve the coordination and

continuity of care and promote informed decision-making. As a result, consumers can attain

more complete and correct information to informed decision-making about their own health care.


EHRs also help to reduce preventable medical errors and replication of treatments and

procedures. Overall, EHRs Lower administrative costs and decrease clerical errors, while

improving research. Lastly, EHRs reduces the time it takes to bring safe, effective products and

practices to healthcare providers.

Method

My thesis will discuss the pros and cons of electronic health records. First I will discuss

meaningful use criteria that an electronic health record can bring to hospitals and healthcare

organizations. Secondly, I will discuss the many problems that can arise in healthcare

organizations when using electronic health records as the only means of storing patient data. To

conclude I will provide information on how hospitals and healthcare systems can avoid these

issues.

To support my findings of EHR adoption I will present a bar graph depicting physicians,

hospitals, and healthcare facilities that have adopted the EHR. The bar graph will also display

the relevant age of physicians that have adopted the EHR and their overall satisfaction. Also, the

bar graph will display the types of physician practices that are more or less often to adopt the

EHR.


The Electronic Health Record, Do the Pros Outweigh the Cons?

Marketa M. Bumpus

The College of St. Scholastica


Abstract

This topic is important because the creation of the electronic medical records was

compelling. Healthcare became less expensive, more efficient, and the quality of patient care

greatly improved by making medical records accessible to all healthcare providers that treats a

patient. The idea of making medical records accessible to all healthcare providers was

surprisingly promoted by the Obama administration that spend an excess of $6.5 billion in

incentives, and hospitals and doctors have spent more to implement the accessibility of electronic

medical records to all healthcare providers (Becker& Sewell, 2004). But the adoption of the

electronic medical record has caused proven challenges with a potential for mix-ups that can be

costly and dangerous.


Improved Data Accessibility

Before EHRs, access to medical charts required a fair amount of physical labor. For

example, every time a patient visited the office or hospital, their file had to be physically pulled

from a storage space, transported, delivered (batch processing), stamped and sorted all in one

visit. As a result of this back and forth, there was a greater chance of human error and charts

would sometimes be missing information or be chronologically out of order. In my experience, it

was not unusual for five out of 15 charts for a clinic day to be unavailable at any given time,

which ultimately resulted in wasted time, space, motion and frequent defects to care (Burton, L.

C., Anderson, G. F., & Kues, I. W., 2004) .

EHRs, on the other hand, have eliminated the physical transporting, sifting and filing of

charts, making data available at all times. Additionally, for systems that allow remote access to

charts, clinicians can even be off site and still securely access patient files. Storage and inventory

is also reduced, freeing up physical space within the hospital or office, and allowing the

redeployment of human resources (Burton, L. C., Anderson, G. F., & Kues, I. W., 2004).

Unnecessary movement is eliminated, ultimately eliminating batch delivery and improving the

flow of patients and information. Most importantly, the culmination of the reduction in waste is

improved quality of care for the patient.

Computerized Physician Order Entry

CPOE allows physicians to place lab and imaging orders, prescriptions and other notices

electronically, reducing the error of hand-written orders and allowing the patient's other

physicians within the EHR network access to the order. That means, if a patient is prescribed a


drug from his/her cardiologist and they are on the same EHR, the primary care physician will

have access to the prescribing information. This not only reduces time, but also dramatically

reduces errors —such as duplicate prescriptions or drug interactions — and potential harm to the

patient (Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., ... &

Seger, D. L., 1998).

Charge Capture

Healthcare organizations keep track of ("capture") a patient's use of hospital resources,

such as equipment, medical supplies, diagnostic testing, medication and hospital staff. These

charges are recorded and then billed to patients and third-party payers. Often, the use of a

resource may be overlooked (Menachemi, N., & Brooks, R. G. (2006). The process behind

"charge capture" can be complex, making it very important that that a system is in place to

capture charges completely and correctly, maximizing the potential reimbursement for revenue.

With an EHR system, at least one diagnosis must be captured along with a level of

service that documents what was done for the patient at the end of every encounter. Additionally,

the EHR includes a list of selectable Current Procedure Terminology codes that allows for easy

input and helps reduces errors, ensuring the right code is used (Menachemi, N., & Brooks, R. G.

(2006).

Preventative Health


EHRs allow for prompts for preventative health screenings. During routine doctor or

urgent care visits, the physician has access to preventive health records conveniently in one

place. If the patient is due for a cancer screening (such as mammogram or colonoscopy), or

blood pressure testing, the doctor can set easily look this up via the EHR system and schedule an

appointment for the patient (Blumenthal, D., & Tavenner, M., 2010).

What's more is EHRs allow data analysts to mine the entire system for say, all patients

with diabetes who haven't had their hemoglobin A1C and cholesterol check within the past year.

From there, the analysts can provide the physician with a list that allows practice management to

contact the patients to schedule these preventative health appointments (Blumenthal, D., &

Tavenner, M., 2010). This type of data mining cannot be done through paper records.

Ease Sign Off for PAs and NPs

While this varies from state-to-state by law, physician assistants and nurse practitioners

are typically required to have their notes approved and signed off on by their supervising

physician. EHRs allow the revision and cosigning of notes to happen electronically as opposed to

physically moving and signing paper.

E-messaging Between Providers

As any physician can attest, telephone tag between providers can be common, and is a

big time-waster. With EHR software, physicians can e-message across practices. One situation

that benefits in particular from e-messaging is referrals. Rather than playing telephone tag to get

an appointment scheduled, the physician electronically send a message to schedule the

appointment.


Implementing the Electronic Medical Record

In recent years, Electronic Health Records (EHRs) have been implemented by an ever

increasing number of hospitals around the world. There have, for example, been initiatives, often

driven by government regulations or financial stimulations, in the USA, the United Kingdom and

Denmark. EHR implementation initiatives tend to be driven by the promise of enhanced

integration and availability of patient data, by the need to improve efficiency and cost-

effectiveness, by a changing doctor-patient relationship toward one where care is shared by a

team of health care professionals, and/or by the need to deal with a more complex and rapidly

changing environment.

Although the complete medical record does not completely exits, portions of the medical

record have been computerized for many years. The most heavily computerized aspects are the

administrative and financial portions. On the clinical side, the most common computerized

function has been the reporting of laboratory results, usually made easier with the installation of

automated equipment for laboratory specimen testing. As more information recording functions

become computerized, increasing proportions of the record are computerized as well. All

comprehensive EMR’s share several common traits (Becker & Sewell, 2004). First, they all

contain large data dictionaries that define their contents. Second, all data are stamped with time

and date so that the record becomes a permanent chronological history of the patient’s care.

Third, the systems have the capability to display data in flexible ways, such as flowsheets and

graphical views. Finally, they have a query tool for research and other purposes.

A number of successful EMR implementations have been in place for decades. One of

the earliest ambulatory care record systems was COSTAR (Computer-Stored Ambulatory


Record), developed at Massachusetts General Hospital in Boston (Becker& Sewell, 2004). It

allows patient registration and scheduling, storage and retrieval of clinical data, and financial

capabilities such as billing. The COSTAR system is in the public domain so the other vendors

and institutions can modify and enhance it (Becker& Sewell, 2004). This system evolved with

computer and network technology itself. Most systems initially consisted of dumb terminals

connected to mainframes or minicomputers, but have since evolved into microcomputer-based

networks embracing client-server architectures. Future technologies, such as voice recognition

or pen-based input, will likely cause further evolution of these systems.

Problems with Electronic Health Record

Implementation

The implementation of hospital-wide EHR systems is a complex matter involving a range

of organizational and technical factors including human skills, organizational structure, culture,

technical infrastructure, financial resources, and coordination. Implementing information

systems (IS) in hospitals is more challenging than elsewhere because of the complexity of

medical data, data entry problems, security and confidentiality concerns, and a general lack of

awareness of the benefits of Information Technology (IT). There are three reasons why hospitals

differ from many other industries, and these differences might also affect EHR implementations

(Meystre, Savova, & Kpper-Schuler, 2008). The first reason is that hospitals have multiple

objectives, such as curing and caring for patients, and educating new physicians and nurses.

Second, hospitals have complicated and highly varied structures and processes. Third, hospitals

have a varied workforce including medical professionals who possess high levels of expertise,

power, and autonomy.


Problems with the Electronic Medical Record

The problems identified with the EMR, is increased provider time, computer down time,

lack of standards, and threats to confidentiality. Electronic order increases the amount of time

physicians spend entering orders. Studies have proven that, 44 more minutes per day is needed

when using the computerized order entry (Burton, Anderson, & Kues, 2004). .

An additional concern with the EMR systems is computer down time. It recent years

computer down time was 1 hour. Today, approximated 10 minutes has been recorded for

computer down time (Meystre, Savova, & Kpper-Schuler, 2008). Most hospital computer

systems and the databases that run on them are being designed for non-stop usage (Burton,

Anderson, & Kues, 2004).

Lack of interoperability between information technologies/EHRs

With more accountable care organizations emerging across the U.S., technology plays an

essential role in developing an ACO, allowing primary care physicians to track and follow the

patient flow throughout the healthcare system. Part of the driving force behind the model

stemmed from the need to integrate EHRs throughout the health system and share information

with network of referring hospitals (Meystre, Savova, & Kpper-Schuler, 2008). However, this

sharing of information is often not possible. Finding a hospital partner that is willing to open the

lines of communication is critical to the success. For example, Simpler Consulting client Atrius

Health worked closely with Beth Israel Deaconess Medical Center and Epic Systems to develop

a web portal that allows the two provider organizations to access each other's EHR systems for

shared patients.1 If this planning and integration is not put into place, communication can


become a serious problem and result in additional follow up, time and waste (Meystre, Savova,

& Kpper-Schuler, 2008).

Cost of set-up and maintenance

The cost associated with EHRs is often a deterrent. Not only must the provider pay for

the physical hardware and/or software, the organization must also put forth a considerable dollar

amount for setup, maintenance, training, IT support and system updates. For many smaller

practices with lower cash flow, cost alone prohibits the ability to properly implement and

maintain the system.

Productivity

A study conducted by the University of California-Davis found a 25-33 percent drop in

physician productivity in the initial implementation phases of the EMR (Meystre, Savova, &

Kpper-Schuler, 2008). While ultimately the goal is to increase productivity in the office or

hospital, expect to see a significant drop in productivity, and ultimately revenue, in the first

several weeks, and perhaps longer.

Delays in Documentation

This may come as a shock to many, however, EHRs actually increases the physician

workload. With written notes, documentation tended to be briefer and straight to the point. With

EHRs, much more documentation is required of physicians before, during and after a patient

visit. This has its pros and cons (Meystre, Savova, & Kpper-Schuler, 2008). . For example, a

benefit of more robust documentation is that it provides additional information for the coders that

may justify a higher level of service being billed. On the negative, it can cause further delays and


errors as physicians often wait to close notes until the end of the day or, sometimes, days later

(Blumenthal, D., & Tavenner, M., 2010). Thus they rely on memory to enter correct information.

Additionally, if a patient is seeing a different provider, others will not be able to access this

updated information until the note is closed.

As with most systems, however, shortcuts can be built into and customized for the

physician to reduce some documentation. Standard work is needed to ensure provider support

and learning.

E-Messaging Between Providers

While e-messaging is listed above as a benefit, it can also be a drawback as it can result

in a lack of face-to-face or phone-to-phone conversation. With EHRs, there are no give-and-take

conversations or question-and-answer scenarios. There is no way to express emotion, nuances or

voice your concerns or fears. Rather, physicians must trust that the information they are

providing is what the other physician needs, interpreted without confusion and read at all

(Meystre, Savova, & Kpper-Schuler, 2008). This is not always the case.

Continuous Need for Updates and Lack of Accountability for Doing So

For every task large or small whether it's a basic wellness visit, a diagnosis, a procedure,

a treatment or a prescription the EHR system requires a corresponding update. For example,

when you have an active "problem list" for a patient (e.g., diabetes, hypertension, high

cholesterol, etc.) someone has to be responsible for updating his or her medication and keep the

problem list accurate (Blumenthal, D., & Tavenner, M. (2010).


However, in my experience, I've seen a significant lack of accountability for making

constant updates which needs to be addressed across all health systems. For example, when

patient has a surgical procedure, this needs to be added to the health record so that all those with

access to the EHR can see the work that has been done. The question is, however, who is

responsible for updating (Blumenthal, D., & Tavenner, M. (2010)? The primary care physician

or the surgeon? There needs to be a clear, communicated system between all of the patient's

doctors and nurses so that updates are made efficiently and by the right persons.

Lack of Standards

A lack of standards is another significant problem with EMR systems. While a number

of standards do exist to transmit pure data, such as diagnosis codes, test results, and billing

information, there is still no consensus in areas such as patient signs and symptoms, radiology

and other test interpretation, and procedure codes.

A related problem to standards is that a large proportion of clinical information is

“locked” in the form of narrative text (Meystre, Savova, & Kpper-Schuler, 2008). Although a

number of systems have been successful in limited domains, the technology for nature language

processing (NLP) is still unable to interpret narrative text with the accuracy required for research

and patient care applications (Mandl, Kohane, & Brandt, 1998). While NLP is difficult for well-

written published medical documents, it is even harder for medical charts that contain poorly

structured, highly elliptical language, with frequent misspellings to boot. Even if such language

could be parsed, the lack of an underlying framework makes it semantic interpretation more

difficult.


Final Concerns

A final concern about the EMR is the problem of security and patient confidentiality.

This problem, of medical information, abstracted from paper records, already exists in electronic

repositories. Well-known privacy experts have documented the threats that misuse of this

information has on personal privacy (Meystre, Savova, & Kpper-Schuler, 2008). The paper

record is no barrier to duplication, as medical records are routinely copied and faxed among

health care providers and insurance companies already. While some fear the EMR will

exacerbate this problem, others note that computer-based records, with appropriate security, are

potentially more secure and at a minimum leave a trail of documentation of those who access

them (Mandl, Kohane, & Brandt, 1998).

Empty Data Fields

While this issue varies by the proprietary nature of the system being used, many EHR

systems allow for auto-population of data for new records. While these shortcuts save some time

and effort on behalf of the physician, they can also result in inaccurate new records if the

previous auto-populated record is not current (Meystre, Savova, & Kpper-Schuler, 2008). For

example, if a patient went in for surgery in June and this was not or improperly documented, a

"no data available" empty data field error message or, even worse, inaccurate information could

be displayed. Once again, the creation of standard work and managing to these standards is

critical to prevent this type of problem.

Copy and Paste


Copy and paste is by and large the biggest ugly of all the shortcomings of EHRs. Because

documentation is more involved with EHRs, physicians may rely on the copy and paste function

as a shortcut, particularly for routine or follow-up visits. While this may save time for the

physician, this puts the patient's safety at risk and impairs quality of care as updates or changes

between visits can be overlooked or not documented properly.

The Future of the Electronic Medical Record

With the increased incentive to document and scrutinize the delivery of medical care, the

use of the EMR should continue to increase. For the EMR to be effective, it must be beneficial

to the user, the individual clinician who will be entering the data and using the results for patient

care decisions. Data entry must not be excessively time-consuming or otherwise difficult, while

obtaining information out must be similarly fast and easy. Clinician involvement is crucial for

successful implementation of EMR’s. The system must not compromise patient confidentiality.

Reasonable mechanisms must be implemented to insure patient information is not viewed by

inappropriate viewers and those who breach security are appropriately punished (Meystre,

Savova, & Kpper-Schuler, 2008). But security must not be so restrictive as to impede use of the

system by clinicians.

It is very likely that the clinicians of the future will interact heavily with computers. Not

only will processes of healthcare delivery become increasingly automated, but larger amounts of

non-patient information, such as the medical literature, will also be accessed electronically. This

future clinician will likely use a computer to enter findings and diagnoses, take advantage of

links that connect these with decision support modules and the medical literature, and

communicate with colleagues and others taking care of the patient.


Conclusion

The advantages of EHRs to the physician, hospital or physicians' office and patient alike

are considerable. That being said, the "bad" and the "ugly" can often outweigh the "good." To

avoid these issues, hospitals and healthcare systems must perform a thorough evaluation of the

EHR system before purchase and implementation. Unfortunately for many, this is a step often

overlooked. In fact, a recent Black Book Rankings survey mentioned above found that 79

percent of the 17,000 participants surveyed reported they did not sufficiently evaluate their needs

prior to selecting their EHR system.

Taking the time to evaluate new technology and implement a new process, such as Lean

management, to evaluate workflows and identify and eliminate waste before implementing a new

EHR system, will help improve implementation, foster communication, decrease non-value

added work and ultimately increase adoption.


Project Description

My final product will investigate the use of Electronic Health Records by the

visualization of bar graphs reported between 1996 and 2013. These bar graphs will evaluate

types of physician practices, hospitals, and other healthcare facilities that have adopted the

electronic health record. Overall, these graphs will show the increase in the amount of electronic

healthcare data that is being used by physicians and healthcare facilities. These graphs will

depict challenges with EHR adoption which will help researchers in the field of Health

Information Management who seek to understand the pros and cons of EHR adoption through

visualization techniques.


References

Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., ... & Seger, D.

L. (1998). Effect of computerized physician order entry and a team intervention on prevention of

serious medication errors. Jama, 280(15), 1311-1316.

Becker, M. Y., & Sewell, P. (2004, June). Cassandra: Flexible trust management applied to

electronic health records. In Computer Security Foundations Workshop, 2004. Proceedings. 17th

IEEE (pp. 139-154).

Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health

records. New England Journal of Medicine, 363(6), 501-504.


Burton, L. C., Anderson, G. F., & Kues, I. W. (2004). Using electronic health records to help

coordinate care. Milbank Quarterly, 82(3), 457-481.

DesRoches, C. M., Campbell, E. G., Rao, S. R., Donelan, K., Ferris, T. G., Jha, A., &

Blumenthal, D. (2008). Electronic health records in ambulatory care—a national survey of

physicians. New England Journal of Medicine, 359(1), 50-60.

Green, L. A., Fryer Jr, G. E., Yawn, B. P., Lanier, D., & Dovey, S. M. (2001). Ecology of

medical care. New England Journal Medicine, 344(2021), 5.

Häyrinen, K., Saranto, K., & Nykänen, P. (2008). Definition, structure, content, use and impacts

of electronic health records: a review of the research literature. International journal of medical

informatics, 77(5), 291.

Mandl, K. D., Kohane, I. S., & Brandt, A. M. (1998). Electronic patient-physician

communication: problems and promise. Annals of internal Medicine, 129(6), 495-500.

Menachemi, N., & Brooks, R. G. (2006). Reviewing the benefits and costs of electronic health

records and associated patient safety technologies. Journal of Medical Systems, 30(3), 159-168.


McInnes, D. K., Saltman, D. C., & Kidd, M. R. (2006). General practitioners' use of computers

for prescribing and electronic health records: results from a national survey. Medical Journal of

Australia, 185(2), 88.

Miller, R. H., West, C., Brown, T. M., Sim, I., & Ganchoff, C. (2005). The value of electronic

health records in solo or small group practices. Health Affairs, 24(5), 1127-1137.

Poissant, L., Pereira, J., Tamblyn, R., & Kawasumi, Y. (2005). The impact of electronic health

records on time efficiency of physicians and nurses: a systematic review. Journal of the

American Medical Informatics Association, 12(5), 505-516.

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