EHR: ADVANTAGES – WEAKNESSES / THREATS - FUTURE1

EHR: Advantages – Weaknesses / Threats - Future

Leslie LaStofka, Matt Reid, Terry Davis: MMI 401-DL 55

Northwestern University

June 3, 2011

Abstract

Electronic health record systems are a key part of the next generation in health care. To help highlight the pros and cons with such anintegral part of the health system we have used a modified SWOT analysis approach to investigate the advantages, weaknesses, future and threats to EHR systems. We have found that EHR systems can improve the quality of care and safety of patients while also providing cost savings and improved productivity. However, the cost of implementation along with the potential workflow disruptions can pose a burden to physician practices that are not equipped with sufficient IT personnel or training. Patients are also weary for the security of their personal medical information stored in EHR systems. With the influx of data entered into EHR systems, the secondary use opportunities are just starting to become apparent to the public and private sectors for both business opportunities and public health initiatives.

Advantages of the Electronic Health Record

The electronic health record (EHR) offers significant advantages when compared to the traditional paper medical record. The key advantages of an EHR can be categorized into the following general areas:

  1. Improved quality of care and patient safety
  2. Improved productivity,financial effectiveness and cost savings
  3. Improved end-user job satisfaction
  4. Improved patient satisfaction
  5. Improved ability to meet regulatory agency requirements

Improved quality of care and patient safety, the most important of the advantages, can be achieved with an EHR as attested to through numerous studies. Kaiser Permanente has determined the following through the implementation of KP HealthConnect:

“Benefits of the System
KP HealthConnect's built-in treatment guidelines are helping the organization improve the management of common/chronic conditions such as diabetes and hypertension. Kaiser Permanente is also enhancing patient care by increasing the accessibility of the patient medical record. Doctors and caregivers have data at their fingertips to identify what treatments and protocols work best.

Industry studies show that paper medical records are unavailable up to 30 percent of the time for patient office visits and are almost never available for patient care in an emergency room. Kaiser Permanente's electronic health record is available when and where it is needed. Having electronic health information that is integrated into Kaiser Permanente's services helps the organization's doctors care for its patients in ways never experienced before. With a patients' lifetime health record at their fingertips, doctors and other clinicians are improving care and services.

In addition, because KP HealthConnect includes more comprehensive patient information, it is helping caregivers address multiple problems or the provision of multiple services in a single visit, reducing the need for additional follow-up appointments. And Kaiser Permanente's new online features found at kp.org (secure e-mail to your doctor's office) have brought members unprecedented access to Kaiser Permanente care. Over time, it is expected these changes will bring measurable improvements to the quality, patient safety and service experienced by Kaiser Permanente members each and every day.”

(Kaiser Permanente HealthConnect™: Transforming Medical Care and Service, (2007, February 15) Retrieved from May 9, 2011)

With an EHR, clinical and demographic patient information can be accessed quickly and by multiple end-users simultaneously at the point-of-care. Critical clinical decisions rely on a patient’s medical history and previous treatment which is documented within the medical record. If providers are hindered from having access to this information when needed, patient safety and quality of care can be compromised. In the paper medical record world, there may be a delay in locating a previous admission or perhaps key documents such as dictation, lab, pathology or radiology results have not yet been filed within the medical record. With the EHR, the documents are either created directly within the application or received via a real-time interface from other source systems that collect the information. This allows care providers to reference key clinical information while treating the patient as well as conference with other providers who can see the same information from a remote location.

In addition, with an optimally configured health information exchange process, a patient’s health care information can be immediately available across the continuum of care, in a longitudinal format, to ensure that the treating professional has global access to all clinical information before rendering a care decision. This type of efficient exchange is not available in the paper record world which can impact the quality of care delivered and safety of the patient.It also eliminates the need to order duplicate diagnostics tests when either the results cannot be located or the ordering physician is unaware that the test has already been completed.

Another key set of factors that improve the quality of care and patient safety is computerized provider order entry (CPOE), medication management and access to decision support tools, such as the latest medical literature regarding a condition as well as best practices that are believed to contribute to improved quality of care. In addition, EHRs promote evidence-based medicine that allows the availability of vast amounts of clinical information for research which can quicken the knowledge level related to effective clinical practices. CPOE assists greatly in medication error reduction and cost-savings through use of standardized order sets and other electronic controls.As noted in Health Affairs, “CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.”(R. Hillestad, et al. Health Affairs). Also, medication management “expert knowledge” or EHR “intelligence” tools provide immediate “alerts” to ordering providers if there is any counter-indication to the use of a particular medication or combination of medications when considering the patient’s medical diagnoses. The alerts are also designed to flag abnormal diagnostic test results and other critical information that the care provider needs to make the best care decision. Having prompt knowledge of this kind of information allows the appropriate remediation to take place quickly which improves care and reduces the possibility of adverse outcomes. With the paper medical record, these kinds of benefits cannot be achieved.

The legibility of entries, a long-standing and significant problem with paper medical records, is no longer an issue with the EHR. This, in and of itself, has been proven to reduce medication errors in particular.

“Medication errors are among the leading causes of preventable errors, with a reported inpatient incidence of 5.7% (Kaushal, Bates, Landrigan, et al., 2001). Bates reports that preventable medication errors cost approximately $5,000 per event, with a projected annual cost of $2.8 million dollars for a 700-bed hospital (Bates, Spell, Dullen, et al., 1997). In To Err Is Human, the Institute of Medicine stated that the highest priority for healthcare organizations is medication safety (2000, pg. 27).

Medication errors are frequently the result of illegibile physician orders. A large healthcare system in the southeastern United States conducted a study on medication safety and discovered the following as related to the legibility of physician orders:

“Legibility of physicians' medication orders did not meet expectations in any of the hospital units. The percentages by unit were as follows: 13% legibility in the NICU, 53% in ICU, and 28% in telemetry. One medical surgical unit had 80% legibility, and the remaining medical surgical units ranged between 50% and 60%.” (Ettel, D. et al)

Improved productivity and financial effectiveness is another advantage the EHR affords the organization. Records can be accessed instantaneously without requiring staff to identify, retrieve, and refile hard copy charts. In addition, the cost to store an EHR is no where near the cost to maintain on-site and off-site storage areas for the paper medical records. The thoroughness and accuracy of ICD-9-CM and CPT code assignment is often times much improved because of the availability and timeliness of more comprehensive diagnostic information from the complete care team. A more thorough and accurate set of code assignments may lead to a higher level of reimbursement. Eliminating the legibility issue is also a key promoter of improved productivity and financial effectiveness. In addition, billing staff can immediately retrieve the clinical documents required for billing which enhances staff productivity as well as the efficient production of bills for quicker payment by third party payers.

Many studies have demonstrated the financial benefits of EHRs as reflected in Virtual Medical Worlds article entitled “Value Measurement and Return On investment for EHRs”

“To-date benefits of health information technology have been quantified and documented in a number of areas, e.g. Electronic Health Records (EHR) and Health Information Exchange (HIE) solutions. These benefits have been estimated at a global level, but there are some documented case studies that show benefits achieved by specific organizations. The following points highlight some global level benefits that have been observed in the United States:

  • Health Information Exchange & Interoperability
  • Reduction in redundant tests, reduction in delays and cost associated with paper-based ordering and reporting would result in $31.8 billion benefits per year
  • Savings from avoided tests and improved efficiencies - $26.2 billion per year
  • Medium-size hospital would accrue $1.3 million benefits per year with improved efficiency in transactions with providers, ancillaries, payers and pharmacies
  • Benefits of Health Information Technology - A recent GAO Study focusing showed:
  • 40 percent decrease in radiology tests resulting in $1 million in savings among the pilot group;
  • Reduction in staff with automation of manual processes resulting in savings of over $700,000;
  • Savings of $4 million in automated claims processing without manual intervention.

The actual benefits can be summarized as follows:

  • EHR Systems
  • It is estimated that over 5 years, EHR benefits will be $86,400 per provider and the benefits will be accrued by several stakeholders such as physician practices, ancillary services, pharmacies and most importantly patients
  • Ohio State University Health System reduced the time for getting medication to patients by 65 percent from 5.28 hours to 1.51 hours. They also reduced Radiology turnaround from 7.37 hours to 4.21 hours
  • Maimonides Medical Center reported 30.4 percent reduction in average length of stay from 7.26 to 5.05 days. They also realized organizational efficiencies by preventing duplicate ancillary tests
  • Heritage Behavioral Health experienced 70 percent reduction in cost of clinical documentation with EHR
  • University of Illinois at Chicago Medical Center gained significant benefits in reallocation of nursing time from manual documentation to direct care - estimated to be $1.2 million
  • e-Prescriptions
  • Many errors occur because of handwritten prescriptions that can be easily misunderstood and can result in adverse drug events or complications. More than 3 billion prescriptions are written annually and according to an eHI report, medication errors account for 1 out 131 ambulatory care deaths and many deaths in acute care are also attributed to medication error.
  • Studies indicate that the national savings from universal adoption could be as high as $27 billion annually
  • Computerized Provider Order Entry (CPOE)
  • The Center for Information Technology Leadership (CITL) estimates that implementing advanced ambulatory CPOE systems would eliminate over 2 million drug events per year; avoid nearly 13 million physician visits, 190,000 admissions and over 130,000 life-threatening adverse drug events per year and save $44 billion per year.
  • Brigham and Women's Hospital in Boston reported 55 percent reduction in serious medication errors and 17 percent reduction in preventable Adverse Drug Events (ADE) - average cost of an ADE was $2,595, resulting in projected savings of $480,000 per year. They estimated net savings from $5 million to $10 million per year.
  • Maimonides Medical Center in New York realized 55 percent decrease in medication discrepancies and 58 percent reduction in problem medication orders. They also eliminated pharmacy transcription errors.
  • Children's Hospital of Pittsburg has eradicated handwriting transcription errors completely and cut harmful medication errors by 75 percent.”

(Value Measurement and Return on Investment for EHRs. Retrieved from VM-08-06-19.html May 11, 2011)

Lastly, the time spent charting by health care professionals is reduced due to the efficiency of drop-down menus, document templates that support box check-marks, and other electronic documentation tools, including spell-check. Of note, the following results were cited in the Journal of the American Pediatrics – 2010:

"Children at intervention sites were more likely to have hada visit during the study period in which their ADHD was assessed.The ADHD template was used at 32% of visits at which patientswere scheduled specifically for ADHD assessment, and its usewas associated with improved documentation of symptoms, treatmenteffectiveness, and treatment adverse effects."

(Journal of the American Pediatrics – 2010).

A reduction in transcription costs can also be realized since the EHR supports the use of direct-entry templates that contain clinical information that would be dictated in the paper medical record world. Lastly, in the physician office, all of the previously mentioned benefits can be realized as well as improved efficiency when re-filling prescriptions and communicating with the pharmacy.

Improved end-user job satisfaction is evident when using an EHR because of the eliminating and/or reduction of tedious tasks such as loose filing of documents and the copying of paper documents for release of information requests. Information within an EHR, when properly organizedduring initial design sessions, is much easier and quicker to locate. In response to a request for information, the EHR content may be transmitted to a secure server or burned to a CD. In addition and as previously cited, the record can be accessed by multiple users at one time so there is no longer the need to wait for the single hard-copy record to be available. In light of the number of uses involving the medical record, including patient care, peer review, quality management studies, basic processing for deficiencies and coding, medical information release, research studies, internal and external agency auditing, this is a great advantage.

Patients are also more satisfied with the use of an EHR. When properly configured, they can have direct access to their medical record and personal health record(PHR) through a patient portal or other similar mechanism.

There is a much improved method of delivering patient education materials that pertain to their specific conditions and necessary patient/physician follow-up. There is an improved overall continuity of care due to the availability of their clinical information to their physicians in various healthcare delivery settings. No longer does the patient have to retrieve a hard-copy of their medical record from a provider in order to present to the next physician he/she is scheduled to see. Lastly, hospitals and physician offices that have an EHR tend to run more efficiently and cost-effectively which leads to enhanced satisfaction for the patient.

“"Patients are very amazed, especially ones that go over to urgent care and they say, "Oh, you already have my records?' On the flip side, if they go in to see the doctor, the doctor already knows the patient went in to urgent care. For the doctor to know that real-time is very impressive to patients."
— Beth Lopez, RN Manager, Kaiser Permanente Southern California

"I know that when I see a member, the chart is available...I can see all the pertinent information, write my notes, order labs and medications, and feel secure that the next provider who sees this member will have all this information as well."
— Nancy Goler, MD, The Permanente Medical Group, Kaiser Permanente Northern California

"KP HealthConnect is my lifeline. Everything is on it from my schedule to my patients to my phone calls to patient history. I don't know how I survived with the paper chart."
— Linda Ramirez, medical assistant, Kaiser Permanente Northwest”

(News Release—Kaiser Permanente Makes Major Gains in Online Medicine: Retrieved from May 9, 2011)

The EHR also assists the healthcare delivery system in adhering to external regulatory agency requirements. In the realm of privacy and data security, the EHR is designed in a manner that demonstrates high level information security through implementation reliable and industry standardized IT controls. The privacy of the information can be assured through the required use of unique logons and passwords by authorized individuals who must attest, in some environments, to their reason for accessing the electronic record. In addition, end-user access logs are maintaining within the EHR system that tracks the date and time an individual viewed or modified the record, and from what location. This is extremely critical data to have should there be a suspected breach of confidential patient information. This is not functionality that is available with the paper medical record.