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Any analysis of the current Americanhealthcare system must acknowledge therole of the Affordable Care Act (“ACA”) asthe predominant legislative and regulatorycatalyst in our health services system.However, perhaps the earliest area ofprovider adaptation has come not as a re-sponse to the regulatory scheme of theAffordable Care Act, but rather as an effortto satisfy “Meaningful Use” requirements ofits precursor, the American Recovery andReinvestment Act of 2009 (“ARRA”).

THE ACT ARRA is known in common parlance as“the Stimulus.” As a response to the GreatRecession, Congress passed ARRA to address

a number of economic issues, includinghealthcare. Title XIII of ARRA is referred toas the Health Information Technology forEconomic and Clinical Health Act(“HITECH”) and was intended to addressmyriad healthcare issues including quality,information technology, and privacy. In fact,HITECH establishes an office within theDepartment of Health and Human Services(“DHHS”) to coordinate nationwide healthtechnology, ensure improvement of quality,and to generally increase efficiency. Indeed,in response to the efficiency requirements ofthe ARRA and ACA, burgeoning topics suchas population health management, account-able care organizations, and the network ofpatient-centered medical homes have been

regular topics of discussion in healthcaremedia and at conferences on effective gover-nance and management. Perhaps HITECH’s most notable effi-ciency requirement is the implementation ofthe Electronic Health Record (“EHR”). Atfirst mention, EHR is often viewed simply asmedical record digitization. However,HITECH empowers the DHHS NationalCoordinator, in conjunction with a standardscommittee, to answer the question: “Whatshould a viable EHR system look like?”Practically, the EHR systems implemented byproviders throughout the country will notonly digitize health records but will do muchmore. HITECH calls for the following: col-lection of population health data for internal

More Than JustDigitization

EFFECTS OF AN ELECTRONIC HEALTH RECORD ON QUALITY,PATIENT SATISFACTION AND PROVIDER OPERATIONS

Ryan Holt Sweeny, Wingate & Barrow, P.A.

U S L A W www.uslaw.org SPRING/SUMMER 2015

and external quality reporting, standardiza-tion of certain treatment with order sets forphysicians, assistance in determining preven-tative health care treatment for at-risk pa-tients, reduction of fragmented treatmentfor patients who visit multiple providers forchronic conditions, and reduction of the pa-perwork patients must complete at every visitto their providers. To encourage EHR implementation,ARRA creates “incentives for adoption andmeaningful use of certified EHR technol-ogy.” Hospital based physicians who satisfac-torily demonstrate meaningful use of EHRtechnology are eligible for these incentives,as are hospitals for inpatient services.Implementation of a viable EHR system oc-curs in stages. The Center for Medicare andMedicaid Services (“CMS”) has establishedobjectives for each of these stages, includingthe use of computerized entry of orders,maintenance of active medication and al-lergy lists for patients, inclusion of demo-graphic data, and notations on vital signsand smoking status. Implementation of theEHR, plus its meaningful use, will result inincentive payments.

IMPLEMENTATION PROCESSES The first step toward CMS incentivepayments is the implementation of an EHRprogram at the provider level. Again, be-cause EHR is more than simply scanningand digitizing patient medical records, im-plementation is easier said than done. EHRimplementation involves drastic – and ex-pensive – changes to provider software toensure that the EHR complies with the ob-jectives of the health information technol-ogy regulatory scheme. CMS has evenestablished an approved list of vendorswhose products meet the EHR require-ments. Writing in February 2013 for theHealthcare Financial ManagementAssociation in “The Total Cost of EHROwnership,” Steven Eastaugh observed thatEHR operation costs will exceed $2 millionfor the average 350-bed hospital. Originalcontract prices can be in the tens of millionsof dollars. Of course these costs are relatednot only to software licensing and upgrad-ing, but also to installation and trou-bleshooting. EHR installation has proved to be bothfinancially overwhelming and operationallydaunting. In an August 2014 piece forHealthcare IT News, Erin McCann profilesseven EHR implementation disasters whichresulted in medication errors, delays intreatment, budget deficits and resignationsof high-level hospital executives.

MEANINGFUL USE PAYMENTS HealthIT.gov reminds EHR partici-pants that early participation leads to maxi-mum incentive payments, and failure toparticipate will even result in financialpenalties beginning in 2015. CMS indicatesthat it will make up to $27 billion in EHRincentive payments, allowing thousands ofdollars in payments to eligible medical pro-fessionals and $2 million or more to hospi-tals. In its October 2014 report, the Officeof the National Coordinator of the DHHSreported that as of June 2014, 75% of pro-fessionals and 92% of hospitals had receivedincentive payments for implementation.

IMPLICATIONS ON HEALTHCARE The nascent spread of EHR raises thequestion of its full potential. As technologyimproves and providers pass the learningcurve associated with a paperless system, theopportunity for new uses of EHR is bound-less. The use of EHR for data collectionpresents new opportunities for analysis andbetter outcomes. Internally, this data min-ing will provide suggestions on how to im-prove procedural breakdowns. Practically,these analytics may help identify waste insupplies or pinpoint lags in emergencyroom response time. Data collection willalso help to pinpoint the frequency ofSerious Reportable Events, defined in theNational Quality Forum’s 2011 report as“unambiguous, largely preventable, and se-rious, as well as adverse, indicative of a prob-lem in a healthcare setting’s safety systems,or important for public credibility or publicaccountability.” This data will also improvepatient care. At the macro level, providerswill have a clearer picture of populationhealth, which may direct growth in certainpractice areas or help to reduce readmis-sions. At the micro level, holistic data on anindividual patient may help to predict oridentify certain risks. Once providers adapt to the significanttechnological changes which characterizeEHR, healthcare delivery is expected tochange further. EHR software allows practi-tioners to create “order sets” or importthose already developed by other profes-sionals. Order sets establish a pre-deter-mined method for specific procedures oreven basic, but frequent, tasks. For instance,one order set may prompt the administra-tion of one drug with the identification of aspecific condition. Another order set mayprovide suggested responses after entry of acertain symptom. The use of order sets stan-dardizes medicine and helps to reduceerror. Of course, the arrival of this new tech-nology has the potential for many unin-

tended consequences. For example, this stan-dardization may remove a practitioner’s priorinclination to analyze the single patient be-fore him or her and treat the unique healthconcerns presented. This can be remediedwith discipline and a flexible software thatpermits modification of order sets by eachprovider and the preservation of such ordersets in a bank available to the user. Perhaps the greatest, and yet un-formed, of these consequences is the im-pact order set usage will have onmalpractice standards of care. For instance,if physicians in a certain community aremore likely to use Order Set A for an appen-dectomy and defendant-doctor used OrderSet B, has he or she breached the standardof care? These are questions that courts willlikely answer in an EHR-dominated world. From a patient perspective, the adventof EHR increases the accessibility of medicalrecords. Providers and EHR software pro-ducers have created “patient portals,” whichallow patients to directly access records viaonline websites or handheld device applica-tions. A key aim of a viable EHR system, asstated by the Office of National Coordinatorin its October 2014 report, is the integrationof a patient’s medical record betweenproviders. The transferability and accessibil-ity of a patient’s record despite geographi-cal and organizational limitations appearsto end an era of hectic coordination be-tween patients, past providers, and currentproviders.

CONCLUSION While the present-day healthcare de-bate revolves around the ACA – both its re-quirements and its uncertain future –providers have already begun complyingwith earlier regulations from HITECH.Despite the cost of implementation, a com-plete EHR system presents unique opportu-nities to monitor quality of care, improvetreatment, and involve patients. More thanjust record digitization, EHR presents a rad-ical change to the healthcare industry andtime alone will tell its real impact.

Ryan Holt joined Sweeny,Wingate & Barrow, P.A.after a clerkship on SouthCarolina’s Circuit Court.He has litigated and triedcases on behalf of smallbusinesses as well as re-gional and national corpo-

rations. His community involvement includesserving as a board member for a health servicesdistrict anchored by a 400-bed hospital.