Electronic Health Records: Innovation and Adoption

Introduction

A digital version of a patient’s paper chart is an electronic health record (EHR). EHRs are real-time, patient-centered records that make information available to authorized users instantly and securely. While an EHR does contain patients’ medical and treatment histories, an EHR system is designed to go beyond standard clinical data collected in a provider’s office and can include a more comprehensive view of a patient’s care. EHRs are an important component of health IT because they can:

• Contains a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and lab and test results.
• Allow providers access to evidence-based tools for making decisions about a patient’s care.
• Provider workflow should be automated and streamlined.

One of the key features of an EHR is that authorized providers can create and manage health information in a digital format that can be shared with other providers across multiple health care organizations. EHRs are designed to share information with other health care providers and organizations, such as laboratories, specialists, medical imaging facilities, pharmacies, emergency rooms, and school and workplace clinics, so they include data from all clinicians involved in a patient’s care.

 

Comparison With Paper-Based Records

While there is still considerable debate about whether electronic health records are superior to paper records, the research literature paints a more realistic picture of the benefits and drawbacks. The adoption of electronic medical records may increase the ease with which they can be accessed by healthcare professionals, but it may also increase the amount of stolen information by unauthorized persons or unscrupulous users compared to paper medical records, as acknowledged by the increased security requirements for electronic medical records included in the Health Information and Accessibility Act. Security concerns contribute to the opposition to their adoption.

When users log in to the electronic health records, it is their responsibility to ensure that the information remains confidential, which they can do by keeping their passwords hidden from others and logging off before leaving the station.

Handwritten paper medical records may be difficult to read, contributing to medical errors. To improve the reliability of paper medical records, pre-printed forms, standardization of abbreviations, and penmanship standards were encouraged. Medication administration is one example of a possible medical error. Medication is an intervention that can quickly shift a person’s status from stable to unstable.

With paper documentation, it is very easy to fail to properly document medication administration, time given, or errors such as giving the “wrong drug, dose, form, or not checking for allergies,” which can have a negative impact on the patient. Because records are now online and require specific steps to avoid these errors, it has been reported that these errors have been reduced by “55-83%.”

Standardization of forms, terminology, and data input may be aided by electronic records. The digitization of forms makes data collection for epidemiology and clinical studies easier. However, standardization may pose difficulties for local practitioners. Those who used EMRs with automated notes and records, order entry, and clinical decision support had fewer complications, lower mortality rates, and lower costs overall.

It would be easier to coordinate health care delivery in nonaffiliated health care facilities if the ability to exchange records between different EMR systems was perfected (“interoperability”). Furthermore, data from an electronic system can be used anonymously for statistical reporting in areas such as quality improvement, resource management, and communicable disease surveillance in public health. However, removing data from its context is difficult.

Usefulness for Patients and Hospitals

Adoption of EHRs can have both positive and negative consequences for health care facilities and patients.

EHRs Make Life Easier for Patients

A person seeks treatment from practitioners and specialists at a dermatology clinic after recently relocating to a new state. When the individual attempts to schedule an appointment, a clinic administrator requests records and information from the organizations where she has previously received treatment. This requires the individual to make several phone calls and email requests over the course of two weeks in order to get officials from the previous clinics to forward their information to the new facility.

One of the advantages of EHRs is that they provide a centralized, widely adopted system in which multiple organizations share secure information about a patient, allowing patients to access and receive care more efficiently. Electronic health records make it easier to share information in situations where a patient needs to find information about a specific medication he has been prescribed in the past or a parent wants to ensure her child has received certain immunizations.

Improved Care Quality

In contrast to the notoriously bad handwriting of physicians, computerized records are easy to read. As a result, there is much less risk of misinterpretation or error in critical areas such as diagnosis and medical orders, which can have serious consequences for the patient’s health.

This improves care delivery on a variety of levels, including:

• Improve documentation accuracy, making diagnosis and claim submission easier and faster.
• Begin treatments right away, with automated alerts highlighting potential risks.
• Track and manage medications in one place, with drug-drug interaction alerts included.
• Make it easier to track and implement preventive care.
• Increase support for making point-of-care decisions.
• Integrate evidence-based clinical guidelines more easily and effectively.

EHRs also make it easier to store medical records and collect and analyze data. This includes producing reports more quickly, thoroughly investigating data trends, and more effectively controlling inventory.

Convenience and Efficiency

Office and medical staff no longer have to waste time sorting through mountains of paperwork to find the patient information they need. Instead, computerized records can be accessed much faster and more efficiently with just a few keystrokes. This, in turn, provides numerous benefits to both providers and patients.

EHRs Have the Potential to Increase Health-Care Utilization in Rural Areas

A person lives in a rural area with dozens of miles between the nearest medical facility or clinic. When the individual begins to exhibit symptoms of a common cold, he is hesitant to travel all the way to that facility. However, when the individual accesses his own PHR online, he discovers that these symptoms are also linked to one of his preexisting conditions. The individual visits the health clinic, and because the staff has access to data from the individual’s comprehensive health history via an EHR, he receives a more accurate diagnosis.

EHRs can assist such individuals living in rural areas by providing a more detailed snapshot of a person’s health history, determining whether that person requires specialized treatment, and making care more affordable. For example, if a person in a rural area has already received certain immunizations, an EHR can store that information and prevent her from receiving or having to pay for unnecessary services.

 

Technical Features

Although an EHR app is primarily intended for medical data management, viewing it solely as a repository for patients’ data is incorrect. EHRs not only pervade every step of the patient’s journey, from the clinic’s front desk to the drugstore to pick up medication, but they also use data analytics to provide valuable insights. Because the EHR software market is crowded, you can expect to find applications for every type of healthcare practice, large and small. However, the majority of these solutions share the following characteristics:

Front-Desk Staff

This unit assists administrative personnel and clinicians with day-to-day operations.

1. Scheduling That Is Automated

To keep the scheduling system up to date on the most recent appointments, the EHR app enters the information into it.

2. Monitoring The Condition Of Patients

The EHR software tracks patients’ movements and informs receptionists of their status. Personnel can use this feature to monitor peak times and send wait notifications.

3. Task management

In addition, the EHR system assigns work tasks, redirects and delegates them to other parties, and monitors their completion.

4. Creating documentation for support

Individual healthcare plans, guidelines, protocols, and other clinical documentation can be generated by EHR software.

5. Claims processing

The system processes client feedback to track their level of satisfaction, allowing a clinic to take timely measures to avoid reputation risks.

Doctors’ Assistance Unit:

This EHR system assists physicians in organizing patient records, tracking treatment progress, and much more.

1. Digital Graph

The EHR platform compiles all of a visitor’s information into an electronic chart. This record contains the patient’s treatment history, personal information, laboratory test results, medical images, and drug prescriptions and can be accessed quickly. It also keeps track of a person’s insurance and billing information.

2. Recognition of Voice and Handwriting

EHR applications allow doctors to enter patient data into a digital chart in a variety of ways, including filling out electronic forms, speaking into a microphone, and many solutions that recognize handwriting.

3. Report Generation

EHR solutions can generate reports based on a specific patient’s treatment plans, clinical notes, medication lists, and instructions. Physicians can create customized templates based on the patient’s current clinical needs and the type of visit.

4. Ingenious Prescriptions

The EHR sends the list of medications prescribed to the pharmacy. Furthermore, the system evaluates drug compatibility and suggests optimal dosages.

5. Notifications

The EHR sends a list of prescribed medications to the pharmacy. In addition, the system assesses drug compatibility and recommends optimal dosages.

6. Analytics of Data

The system identifies clients with the most dangerous health conditions and provides access to data that can assist in determining the best course of action.

7. Accountability

EHR systems can send data to public health registries to help them monitor the health of the population.

8. Data Categorization and Segmentation

To protect patients’ privacy, EHR apps can classify their data and share only parts of their medical chart.

Billing Unit

This EHR unit assists in managing the financial aspect of the patient’s treatment and provides financial information about the clinic.

1. Create Invoices

The EHR system generates invoices, compiles and sends claims to the patient’s insurance company, and handles denials, unpaid claims, and system exclusions after each visit.

2. Revenue and Expense Analysis

EHR systems provide information about how the medical practice is performing financially in comparison to other clinics, assist in monitoring revenue streams, and identify areas for restructuring and upgrades.

 

Implementation of Electronic Health Record System

The EHR implementation process can be difficult, especially given the risks of getting it wrong. As a result, organizations understandably have many questions about the process, particularly what it entails and how to approach it in a way that best positions them for success.

Implementation is a non-specific term that refers to integrating a software-based service or component into an organizational structure’s or an individual end-workflow. User’s As a result, EHR implementation refers to the process of planning and implementing EHR software and components in a healthcare organization.

Quality

Several studies have called into question whether EHRs improve care quality. One diabetes care study published in the New England Journal of Medicine in 2011 discovered evidence that practices using EHR provided better quality care.

EMRs may eventually aid in better care coordination. According to a trade journal article, because anyone using an EMR can view the patient’s full chart, it reduces guessing histories, seeing multiple specialists, smoothes transitions between care settings, and may allow for better emergency care. EHRs may also improve prevention by improving access to test results for doctors and patients, identifying missing patient information, and providing evidence-based recommendations for preventive services.

Cost

The high cost of adoption, combined with provider uncertainty about the value they will derive from it in terms of return on investment, has a significant impact on EHR adoption. In a survey conducted by the Office of the National Coordinator for Health Information, surveyors discovered that any gains in efficiency were offset by lower productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system. The Congressional Budget Office of the United States concluded that cost savings may occur only in large integrated institutions such as Kaiser Permanente, not in small physician offices. They questioned the Rand Corporation’s cost-cutting estimates.

“Office-based physicians, in particular, may see no benefit from such a product and may even suffer financial harm if they purchase it.” Despite the fact that the use of health information technology may result in cost savings for the health system, as a whole, many physicians may not be able to reduce their office expenses or increase their revenue sufficiently to pay for it.

Time

The implementation of EMR has the potential to reduce patient identification time upon hospital admission. According to a study published in the Annals of Internal Medicine, the use of EMR has resulted in a 65% reduction in time (from 46 to 130 hours).

Software Quality and Usability Deficiencies

The Healthcare Information and Management Systems Society, a large healthcare IT industry trade group in the United States, observed in 2009 that EHR adoption rates were declining “have been slower than expected in the United States, particularly when compared to other industries and developed countries. Aside from the initial costs and lost productivity associated with EMR implementation, one major reason is the inefficiency and usability of the current EMRs.” The National Institute of Standards and Technology of the United States Department of Commerce studied usability in 2011 and identified a number of specific issues raised by health care workers. The EHR used by the United States military, AHLTA, was reported to have significant usability issues.

Furthermore, studies like the one published in BMC Medical Informatics and Decision Making revealed that, while the implementation of electronic medical records systems has been a great help to general practitioners, there is still much room for improvement in the overall framework and the amount of training provided. It was discovered that efforts to improve EHR usability should be focused on physician-patient communication.

Hardware and Workflow Considerations

After a health facility has documented its workflow and selected a software solution, it must consider the hardware and supporting device infrastructure for end users. Throughout a patient’s stay and charting workflow, staff and patients will need to interact with various devices. Computers, laptops, all-in-one computers, tablets, mice, keyboards, and monitors are all examples of hardware devices. Other factors to consider include supporting work surfaces and equipment, wall desks, and articulating arms for end users to use.

Another important consideration is how all of these devices will be physically secured and charged so that staff can always use the devices for EHR charting when needed. Prior to implementation, the ability of the adopter to fully understand workflow and anticipate potential clinical processes is critical to the success of eHealth interventions. Failure to do so can lead to expensive and time-consuming service disruptions.

 

Governance, Privacy and Legal Issues

Privacy Concerns

The concept of a national centralized server model for healthcare data has been met with skepticism in the United States, the United Kingdom, and Germany. Concerns have been raised about privacy and security issues in such a model. In the European Union (EU), a new directly binding instrument, the General Data Protection Regulation, was passed in 2016 and will go into effect in 2018 to protect the processing of personal data, including that for health care purposes.

Threats to health care information are classified into three types:

• Employees or hackers are examples of human threats.
• Natural disasters and environmental hazards such as earthquakes, hurricanes, and wildfires
• Failures in technology, such as a system crash

Threats can be internal or external, intentional or unintentional. As a result, when discussing ways to protect patients’ health information, health information systems professionals will keep these specific threats in mind. It has been discovered that health care professionals in countries such as Spain have a lack of security awareness. The Health Insurance Portability and Accountability Act (HIPAA) has developed a comprehensive framework to mitigate the harm caused by these threats that is not so specific as to limit the options of healthcare professionals who may have access to different technology.

Legal Issues

Liability

In the 1990s and 2000s, legal liability in all aspects of healthcare was becoming increasingly problematic. The increase in the per capita number of attorneys in the United States, as well as changes in the tort system, increased the cost of every aspect of healthcare, including healthcare technology. Failure or damage caused during the installation or use of an EHR system has been feared as a legal threat. Similarly, it is critical to recognize that implementing electronic health records entails significant legal risks. This liability issue was especially concerning for small EHR system manufacturers. Because of the regional liability climate, some smaller companies may be forced to exit markets.

Larger EHR providers (or government-sponsored EHR providers) can withstand legal challenges better. While there is no doubt that electronic documentation of patient visits and data improves patient care, there is growing concern that such documentation may expose physicians to an increase in malpractice suits. Disabling physician alerts, using dropdown menus, and using templates can encourage physicians to skip a thorough review of past patient history and medications, resulting in missed data. Electronic time stamps are another potential issue. Many physicians are unaware that every time a patient record is updated, EHR systems generate an electronic time stamp.

If a malpractice claim is filed in court, the prosecution can request a detailed record of all entries made in a patient’s electronic record during the discovery process. Waiting until the end of the day to chart patient notes and making addendums to records after the patient visit can be problematic, as this practice may result in inaccurate patient data or indicate a possible intent to illegally alter the patient’s record. In some communities, hospitals try to standardize EHR systems by giving local healthcare providers discounted versions of the hospital’s software. This practice has been challenged as a violation of Stark rules, which prohibit hospitals from assisting community healthcare providers preferentially.

However, exceptions to the Stark rule were enacted in 2006 to allow hospitals to provide software and training to community providers, effectively removing this legal barrier.

Legal Interoperability

The issue of legal interoperability arises in cross-border use cases of EHR implementations. Different countries’ legal requirements for the content or use of electronic health records may differ, necessitating radical changes to the technical makeup of the EHR implementation in question. (Especially when there are fundamental legal incompatibilities) When implementing cross-border EHR solutions, it is often necessary to investigate these issues.

 

Medical Data Breach

The majority of European countries have developed and implemented a strategy for the development and implementation of Electronic Health Record Systems. This would imply that numerous stakeholders, including those from countries with lower levels of privacy protection, would have greater access to health records. The upcoming implementation of the Cross Border Health Directive, as well as the EU Commission’s plans to centralize all health records, are of particular concern to EU citizens, who believe that health care organizations and governments cannot be trusted to manage their data electronically, exposing them to additional threats.

The concept of a centralized electronic health record system was met with skepticism by the public, who are concerned that governments will use the system for purposes other than those intended. There is also the risk of privacy violations, which could result in sensitive health care information falling into the wrong hands. Some countries have enacted legislation requiring the implementation of safeguards to protect the security and confidentiality of medical information. These safeguards provide additional protection for electronically shared records and provide patients with important rights to monitor their medical records and receive notification of loss or unauthorized acquisition of health information. Medical data breach notifications are now required in the United States and the European Union.

Breach Notification

The goal of a personal data breach notification is to protect individuals so that they can take all necessary steps to limit the negative effects of the breach and to motivate the organization to improve the security of the infrastructure to protect the data’s confidentiality. The US law requires entities to notify individuals in the event of a breach, whereas the EU Directive currently requires breach notification only when the breach is likely to jeopardize an individual’s privacy. Because personal health data is valuable to individuals, determining whether the breach will cause reputational or financial harm or adverse effects on one’s privacy is difficult.

 

Technical Issues

Standards

• CONTSYS (EN 13940) promotes the standardization of continuity of care records.
• HISA is a services standard for inter-system communication in a clinical information environment (EN 12967).
• ASTM International Continuity of Care Record Standard for Continuity of Care Records
• NEMA sponsors DICOM, an international communications protocol standard for representing and transmitting radiology (and other) image-based data (National Electrical Manufacturers Association)
• HL7 (HL7v2, C-CDA) – a messaging and text communications protocol used between hospital and physician record systems, as well as practice management systems.
• FHIR stands for Fast Healthcare Interoperability Resources, a modernized HL7 proposal designed to provide open, granular access to medical information.
• ISO TC 215 develops international technical specifications for electronic health records. ISO 18308 describes EHR architectures xDT – a family of medical data exchange formats used in the German public health system.

The federal government of the United States has issued new rules for electronic health records.

Open specifications

• openEHR: an open community-developed specification for a shared health record with expert-created web-based content. Excellent multilingual ability.
• HL7’s proposed model for interacting with clinical decision support systems is known as the Virtual Medical Record.
• SMART (Substitutable Medical Apps, Reusable Technologies): an open platform specification that will serve as a foundation for healthcare applications.

Common Data Model (In Health Data Context)

A common data model (CDM) is a specification that describes how to combine data from multiple sources (for example, multiple EHR systems). A relational model is used by many CDMs (e.g., the OMOP CDM). A relational CDM specifies the names of tables and table columns as well as the valid values.

• Sentinel Common Data Model: Sentinel began in 2008 as Mini-Sentinel. The Food and Drug Administration’s Sentinel Initiative in the United States.
• The OMOP Common Data Model is a model that defines how electronic health record data, medical billing data, and other healthcare data from multiple institutions can be harmonized and queried in a unified manner. The Observational Health Data Sciences and Informatics consortium is in charge of its upkeep.
• PCORNet Common Data Model: Developed in 2014 and currently used by PCORI and the People-Centered Research Foundation.
• HMO Research Network coined the term “virtual data warehouse” in 2006. Health Care System Research Network has been conducting research on health care systems since 2015.

Customization

Each healthcare environment operates differently, often significantly so. It is difficult to design an EHR system that is “one-size-fits-all.” Many first-generation EHRs were designed to meet the needs of primary care physicians, leaving certain specialties dissatisfied with their EHR system. An ideal EHR system will have record standardization but interfaces that can be tailored to the needs of each provider. The modularity of an EHR system makes this possible. Many EHR providers use vendors to provide customization.

This can frequently be done so that a physician’s input interface closely resembles previously used paper forms. Simultaneously, they reported negative effects in communication, increased overtime, and missing records when using a non-customized EMR system. Customizing the software when it is released yields the greatest benefits because it is adapted for the users and tailored to the institution’s workflows. Customization can have drawbacks. Of course, the initial costs of implementing a customized system are higher. Both the implementation team and the healthcare provider must spend more time understanding the workflow requirements. The creation and upkeep of these interfaces and customizations may also result in higher software implementation and maintenance costs.

Long-Term Preservation and Storage Of Records

Planning for long-term preservation and storage of electronic health records is an important consideration in the development process. The field will need to reach an agreement on how long to keep EHRs, methods to ensure future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives.

Furthermore, long-term storage of electronic health records is complicated by the possibility that the records will be used longitudinally and integrated across sites of care one day. Multiple independent entities have the ability to create, use, edit, and view records. Primary care physicians, hospitals, insurance companies, and patients are among these entities. Individual electronic health record storage requirements will be determined by national and state regulations, which are subject to change over time. According to Ruotsalainen and Manning, the typical preservation time of patient data ranges between 20 and 100 years. While it is unclear how long EHRs will be kept, it is certain that the time will exceed the average shelf-life of paper records. Because of technological advancements, the programs and systems used to input information are unlikely to be available to a user who wishes to examine archived data. One proposed solution to the problem of future systems’ long-term accessibility and usability of data is to standardize information fields in a time-invariant manner, such as with the XML language.

Synchronization of Records

When care is provided at two different facilities, it may be difficult to coordinate the updating of records at both locations. To address this issue, two models were used: a centralized data server solution and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks). Synchronization programs for distributed storage models, on the other hand, are only useful after record standardization. A common software challenge is the merging of existing public healthcare databases. The ability of electronic health record systems to perform this function is a significant advantage that can improve healthcare delivery.

 

Challenges of Using Electronic Health Record

According to the Centers for Medicare & Medicaid Services, healthcare practices and providers are increasingly implementing electronic health record software. Since the program’s inception in 2009, 73 percent of eligible providers in the United States have registered for EHR Incentive Programs, totaling over 388,000 practices. However, while these cases of initial implementation were successful, initial usage is not always easy. It can be difficult to obtain the time, resources, and cooperation of the entire practice.

Here are a few potential challenges and roadblocks to EHR use. Learning about common roadblocks can help your practice manage them and set achievable goals.

1. The Usage Cost

EHRs and other advances in health information technology can be costly to implement and use. Finding the funds to invest in training, support, and physical infrastructure can be a challenge, particularly for smaller practices. Before making the decision to implement EHRs, it is critical to plan the funding. Make sure your practice’s location will make EHR implementation and usage a stress-free task for you.

2. Technical Expertise

According to the Morsani College of Medicine at USF Health, the ability of a computer to retrieve and send data throughout healthcare is affected by its age as well as other factors such as the location of the practice. Connecting to the system and the internet can be more difficult in a rural setting than in an urban setting.

3. Workflow Segmentation

One of the primary goals of implementing EHRs is to establish a consistent workflow in the practice. Unfortunately, according to Getting Paid, EHR implementation can completely disrupt a practice’s workflow if it is not properly customized to fit its purpose. To avoid this issue, ensure that your vendor provides you with a thorough demonstration of how the implementation will work in your practice.

4. The Instruction

Practices for training employees throughout the new and improved workflow process are recommended during EHR implementation. Unfortunately, this requires additional time, effort, and resources that some practices may not have. Before agreeing to implement EHRs, determine how much training will be required and only proceed if your practice is prepared to complete it. One of the most important aspects of successful EHR implementation is training.

5. Concerns About Privacy

Some healthcare providers and patients may be concerned about medical privacy when using EHRs, according to USF Health. Common concerns include data loss as a result of a natural disaster and cyber hacking. Ask questions about how strict privacy will be in your new system before implementing EHRs.

6. The Populace

Unfortunately, not everyone agrees on the importance of implementing and utilizing EHRs. There will be patients and providers who reject EHRs or quickly abandon them if there are initial technical problems. Consider the barriers you may face with patients and coworkers before implementing EHRs in your practice; you must be prepared to face every point of view.