1. Chapter 2 Electronic Health Records

2. Learning Objectives After reading this chapter the reader should be able to: • State the definition and history of electronic health records • Describe the limitations of paper based health records • Identify the benefits of electronic health records • List the key components of an electronic health record • Describe the 2009 Medicare and Medicaid reimbursement for electronic health records • Describe the benefits of computerized order entry and clinical decision support systems • State the obstacles to purchasing and implementing an electronic health record

3. There is no universally accepted definition of an EHR
There is no universally accepted definition of an EHR. As more functionality is added the definition will need to be broadened. Importantly, EHRs are also known as electronic medical records (EMRs), computerized medical records (CMRs), electronic clinical information systems (ECIS) and computerized patient records (CPRs).

4. The definition of EHR
An electronic health record (EHR) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across different health care settings. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

7. Electronic Health Record Adoption
Outpatient (Ambulatory) EHR Adoption: In 2008 a study was conducted to rate the adoption of EHR in outpatient clinics. In this study a sample of 5000 physicians was selected. The return rate of the survey was just over 60%. The most significant finding was that only 4% of respondents reported using a comprehensive EHR (order entry capability and decision support), whereas 13% reported using a basic EHR system. The adoption rate was higher for large medical groups or medical centers. Given the fact that most experts believe only comprehensive EHRs will impact patient safety and improve the quality of medical care, the 4% adoption rate is disturbing

8. Inpatient EHR Adoption: In March 2009 an article about inpatient EHR adoption. They surveyed all members of the American Hospital Association and had a return rate of 63% (3049 hospitals). Their results showed that 7.6% of the respondents reported a basic EHR system and only 1.5% reported a comprehensive EHR. Again, large urban and/or academic centers had the highest adoption rates. 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.

10. Many physicians believe that purchasing an EHR is not their responsibility and therefore someone else should pick up the tab. Others are concerned that they will purchase the wrong system and waste money and others are simply overwhelmed with the task of implementing and training for a completely different system. As a group, physicians are not noted for embracing innovation. In their defense, new technologies should be shown to improve patient care, save time or money, in order to be accepted. There are over three hundred EHR vendors but only about ten to twenty seem to be consistently successful in terms of a large client base. If the selection and purchase of EHRs was easy they would already be universal.

11. The Stimulus Package and EHR Reimbursement
In order to be reimbursed there must be “meaningful use” that, at a minimum, means that an EHR: • Must include e-prescribing • Provides the electronic exchange of information (interoperability) • Is capable of producing quality reports • Must be certified

12. Relationship between EHR, PHR and EMR
The consensus is that: • 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.

14. In May 2008 the National Alliance for Health Information Technology released the following definitions in an effort to standardize terms used in HIT: 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”. 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”. 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”.

15. Why do we need Electronic Health Records?
• The paper record is severely limited

17. • The need for improved efficiency and productivity
• The need for improved efficiency and productivity. • Quality of care and patient safety. • Public expectations • Governmental expectations. • Financial savings. • Technological Advances. • Older and more complicated patients require more coordinated care.

18. Electronic Health Record Key Components
The following components are desirable in any EHR system. The reality is that many EHRs do not currently have all of these functions.
• Clinical Decision Support Systems (CDSS) to include alerts, reminders and clinical practice guidelines. CDSS is associated with computerized physician order entry (CPOE).
• Secure messaging ( ) for communication between patients and office staff and among office staff. Telephone triage capability is important
• An interface with practice management software, scheduling software and patient portal (if present). This feature will handle billing and benefits determination.
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19. Computerized Physician Order Entry (CPOE)
CPOE is an EHR feature that processes orders for medications, lab tests, x-rays, consults and other diagnostic tests. Reduce medication errors. Reduce costs. Reduce variation of care.

20. Clinical Decision Support Systems (CDSS)
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” Therefore, CDSS should have a broader definition than just alerts and reminders.

21. EHR Successes and Failures

22. Electronic Health Record Examples
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