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===Reduce healthcare costs===
===Reduce healthcare costs===
One of the major sources of rapid growth in healthcare costs comes from medical imaging. Medicare Part B spending on imaging rose from $6.80 billion in 2000 to $14.11 billion in 2006.<ref>{{cite web|title=Medicare Part B Imaging Services|url=http://www.gao.gov/new.items/d08452.pdf|publisher=United States government Accountability Office Report to Congressional Requesters|format=PDF}}</ref> Access to a patient's images in an EHR is an effective way to avoid duplicating expensive imaging procedures. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.
One of the major sources of rapid growth in healthcare costs comes from medical imaging. Medicare Part B spending on imaging rose from $6.80 billion in 2000 to $14.11 billion in 2006.<ref>{{cite web|title=Medicare Part B Imaging Services|url=http://www.gao.gov/new.items/d08452.pdf|publisher=United States government Accountability Office Report to Congressional Requesters|format=PDF}}</ref> Access to a patient's images in an EHR is an effective way to avoid duplicating expensive imaging procedures. Another high cost to healthcare is the printing and mailing of checks. If all medical payment transactions in the U.S. were handled electronically via direct deposit, America could save $11 billion annually<ref>IT's Role in Efficient Practice[http://www.nuesoft.com/media/Washington_Post_Healthcare_Tech.pdf]</ref>. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.


===Improve quality of care===
===Improve quality of care===

Revision as of 15:03, 27 July 2009

File:VistA Img.png
Sample patient record view from an image-based electronic health record (VistA)

An electronic health record (EHR) refers to an individual patient's medical record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a network. It may be made up of electronic medical records (EMRs) from many locations and/or sources. Among the many forms of data often included in EMRs are patient demographics, medical history, medicine and allergy lists (including immunization status), laboratory test results, radiology images, billing records and advanced directives.

EHR systems can reduce medical errors.[1] In one ambulatory healthcare study, however, there was no difference in 14 measures, improvement in 2 outcome measures, and worse outcome on 1 measure.[2]

EHR systems are believed to increase physician efficiency and reduce costs, as well as promote standardization of care. Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, less than 10 percent of hospitals as of 2006 have a fully integrated system.[3]

Overlap in Terminology

Multiple terms have been used to define electronic patient care records, with overlapping definitions.[4] Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some health informatics users assigning the term EHR to a global concept and EMR to a discrete localised record. EHR is defined by the Healthcare Information and Management Systems Society as:

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.[5]

For most users, however, the terms EHR and EMR are used interchangeably. An EHR system is also often abbreviated as EHR or EMR. Information in the section on EMRs electronic medical record may be more relevant to physician offices seeking a less expensive or comprehensive solution.

Health Information Technology is an even broader term that describes any computer-based electronic aid to healthcare delivery.

An electronic health record is a patient’s health record that has been compiled into a digital format.

Background

In his joint address to Congress in 2009, Obama stated that:

"Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down cost, ensure privacy, and save lives" [6]

The 2009 economic stimulus package (HITECH Act) passed by the US Congress aims at incenting more physician to adopt EHR. The act promises incentive payments to those who adopt and use "certified EHRs" and, eventually, reducing Medicare payments to those who do not use an EHR. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to also show "meaningful use" of an EHR system.[7]

Categories of information in a patient record

A patient record consists of 4 main categories of information. Some information requires digitization. Other forms of information are by nature digital but require an infrastructure designed for secure access through the EHR.

Textual information

Textual information in a patient record include notes and individual reports.

Data for Calculations

Data for calculations or graphing from laboratory reports are included in a patient record. This information is used for searching or decision support.

Multimedia

Multimedia information in a patient record such as diagnostic images are typically located in various departments in a healthcare facility. The large volume and disparate locations of this data make the electronic health record the only viable way for access.

Paperwork

Patient records include signed forms, hand drawn figures, photographs of wounds, and other various forms of paper-based documentation.

Advantages of electronic medical records

There are several benefits to wide scale usage of electronic health records.

Reduce healthcare costs

One of the major sources of rapid growth in healthcare costs comes from medical imaging. Medicare Part B spending on imaging rose from $6.80 billion in 2000 to $14.11 billion in 2006.[8] Access to a patient's images in an EHR is an effective way to avoid duplicating expensive imaging procedures. Another high cost to healthcare is the printing and mailing of checks. If all medical payment transactions in the U.S. were handled electronically via direct deposit, America could save $11 billion annually[9]. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.

Improve quality of care

An EHR system can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine enable proliferation of ongoing improvements in healthcare efficacy.

Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices.

These benefits may be realized in a realistic sense only if the EHR systems are interoperable and wide spread (e.g. national) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medial informatics must be deployed.[10]

EHRs also have the advantages of electronic medical records (EMR). In general, medical records may be on "physical" media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.

Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance.

In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic medical records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.[11][12]

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[13] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In contrast, EMRs can be continuously updated. The ability to exchange records between different EMR systems ("interoperability"[14]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[15]

Lack of adoption of EHRs in the United States

US medical groups' adoption of EHR (2005)

Outside of the Veterans Health Administration system and a few other major implementations of EHRs such as in the New York City Health and Hospitals Corporation, the vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s.

As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Less than 10% of American hospitals had implemented HIT,[16] while a mere 16% of primary care physicians used EHRs.[17] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.[2][18] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.[18] However, less than one-tenth of these physicians actually had a "complete EMR system" (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).[19]

The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.[20][21][22]

The reasons for the lack of adoption of EHRs in the United States include:

Costly investment for providers

The selection, implementation and usage of an EHR system is expensive, time-consuming and burdensome. The success of the system has a lot of dependencies such as quality IT leadership and product reliability.

Until recently, with the American Recovery and Reinvestment Act of 2009, providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.

Problems with EHR products on the market today

Physicians find available health IT software frustrating due to its poor usability.[23] Today's products lack interoperability and capabilities required to experience the benefits that outweight the risks.

Attempts to facilitate EHR compatibility in the United States

The Veterans Administration health care system in the United States, with over 155 hospitals and 800 clinics, represents one of the largest integrated healthcare delivery systems in the world. It relies on a single EHR system called the Veterans Health Information Systems and Technology Architecture (VistA), which has been in use for years. Data exchange is facilitated by a protocol called BHIE (Bidirectional Health Information Exchange), and the VA healthcare network is being expanded in 2007 to integrate the Department of Defense healthcare facilities using the BHIE networking protocol.

This EHR has been made publicly available for download and has been adapted for use in many non-VA hospitals and healthcare networks. As BHIE becomes more widely available, a national healthcare network will be facilitated.

Outside of the VA's EHR system, however, there are currently at least 25 major competing vendors of EHR systems, many selling software incompatible with competitors.

This lack of interoperability provides a significant barrier to a "National Health Information Network."[24] In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer. Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. The US Congress is currently working on legislation to increase funding to these and similar programs.

In response to this problem, the Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards.

Benefits of EHR standardization / National Healthcare Information Network

Improved billing accuracy

Although billing is now largely accomplished electronically in the United States, these claims often require additional documentation from a patient's medical record. This is a tedious task when records are in an electronic format not compatible with the billing program, or when the records are in paper format. An integrated electronic medical record / billing system, therefore, both expedites and makes billing more accurate.

Reduction in duplication of services

Duplication of lab tests, diagnostic imaging, work-ups, and other services can be prevented by good record-keeping of any type. However, because electronic records can be available at many locations at once, integration of services and awareness of duplication is facilitated.

Facilitation of clinical trials

Clinicians and researchers suggest benefits to integrating electronic health records with data collection and analysis in clinical trials.[25]

Improved access to medical records

Records, once a few years old are typically put into long-term storage as records must be kept for as long as 21 years. Electronic medical records enable health organizations to access old records instantly, thereby allowing them to be sent to another health organization in the event of an emergency. Many EHR systems now offer integrated Patient Portal or Personal Health Record systems which allow patients and 3rd parties to access medical records with a secure username and password.

Potential clinical trial participants may be more easily identified, administrative overhead costs may be lessened, data errors may be reduced, and adverse outcomes may be more rapidly identified.[25]

Some institutions have already been partially successful in implementing and integrating co-ordinated data collection and analysis systems. For example, the Shared Pathology Network (SPIN) of the National Cancer Institute has effectively established a web-based network for locating pathological tissue samples at various institutions across the nation.[26] The electronic nature of reports within the system allows the use of search engines to find specific text with the reports, facilitating analysis.[27]

Organizations to evaluate standardization proposals

Several models of standardization for electronic medical records and electronic medical record exchange have been proposed and multiple organizations formed to help evaluate and implement them.[28][29]

Organizations

  • AHIMA (Americal Health Information Management Association) - provides medical records professionals with educational resources and programs. The Association also administers the gold-standard for certification.
  • CHI (Consolidated Health Informatics Inititiative) - recommends nationwide federal adoption of EHR standards in the United States
  • CCHIT (Certification Commission for Healthcare Information Technology) - a federally funded, not-for-profit organization that evaluates and develops the certification for EHRs and interoperable EHR networks (USA)
  • IHE (Integrating the Healthcare Enterprise) - a consortium, sponsored by the HIMSS, that recommends integration of EHR data communicated using the HL7 and DICOM protocols
  • ANSI (American National Standards Institute) - accredits standards in the United States and co-ordinates US standards with international standards
  • Healthcare Information and Management Systems Society (HIMSS) - an international trade organization of health informatics technology providers
  • American Society for Testing and Materials - a consortium of scientists and engineers that recommends international standards
  • openEHR - provides open specifications and tools for the 'shared' EHR
  • Canada Health Infoway - a federally funded, not-for-profit organization that promotes the development and adoption of EHRs in Canada
  • World Wide Web Consortium (W3C) - promotes Internet-wide communications standards to prevent market fragmentation
  • Clinical Data Interchange Standards Consortium (CDISC) - a non-profit organization that develops platform-independent healthcare data standards
  • EHR-Lab Interoperability and Connectivity Standards (ELINCS) - run by the HL7 group to help provide lab data and other EHR interoperability

Standards

  • ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
  • CEN's TC/251 provides EHR standards in Europe including:
    • EN 13606, communication standards for EHR information
    • CONTSYS (EN 13940), supports continuity of care record standardization.
    • HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
  • Continuity of Care Record - ASTM International Continuity of Care Record standard
  • DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
  • HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
  • ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures

Barriers to deploying an EHR system

Difficulty in adding older records to an EHR system

Older paper medical records ought to be incorporated into a patient's electronic health record.

One method is to merely scan the documents and retain them as images. However, surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone rather than fully electronic data-based systems.[30] EHR systems with image archival capability (such as VistA Imaging) are able to integrate these scanned records (along with other types of image-based records) into fully electronic health records systems.

Another method to convert written records (such as notes) into electronic format is to scan the documents then perform optical character recognition. For typed documents, accurate recognition may only achieve 90-95%, though, requiring extensive corrections. Furthermore, illegible handwriting is poorly recognized by optical character readers.

Some states have proposed making existing statewide database data (such as immunization records) available for download into individual electronic medical records.[31]

Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the 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.

Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that “choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.”[32]

The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."[33]

In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that “the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."[34]

Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. This is a problem that plagues distributed computer records in all industries.

Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks).

In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.[35][36]

Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.

Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.[37][38][39]

Privacy

Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.[40] Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[41] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of implementation of these standards.

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[42]

Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.[43] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec.

Privacy and Security of the Electronic Health Record: As the ever-changing healthcare industry evolves, one key topic within the electronic health record (EHR) is privacy. The Federal government has set guidelines that all healthcare organizations will have to comply with in regards to electronic health transactions. Most supporters believe that the EHR will improve care and reduced costs, while transforming the health care system, but whether the privacy of the records will be upheld is yet to be determined. A successful partnership for administrative health data standards can promote the development of clinical data standards and their application in computer based patient record systems.[44]

One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. Former US president Bush called for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”[45]

The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while "hospitals keep careful tabs on who accesses the charts of VIP patients," they are powerless to act against "a meddlesome pharmacist in Alaska" who "looks up the urine toxicology on his daughter's fiance in Florida, to check if the fellow has a cocaine habit."[46] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the U.S. Supporters of EHRs have argued that there needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records if adoption of an EHR is to occur.[47]

According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client's knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes. Stanford had merged her notes with her general medical record, and the general medical record wasn't covered by HIPAA restrictions.[48]

Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[47] Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[45] So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.

Hardware limitations

Computer access is required to use an electronic health record system. A sufficient number of workstations, laptops, or other mobile computers must be available to accommodate the number of healthcare providers at any one facility.[49] EHR software ought to be backwards compatible with older technology so that existing technology infrastructure can be used. Furthermore, most healthcare facilities have at least some degree of existing computerization, whether in the lab or in billing services. EHR systems need to interface with existing systems, again mandating a modular approach.[50]

In the past, poor networking technology was a limiting factor in the adoption of EHR software. There are now solutions which profit from new networking and mobile technology.[51][52]

Cost Advantages and Disadvantages

Most practitioners and healthcare organizations will agree that both quality healthcare and medical error reduction take precedence over many other healthcare concerns. Common knowledge to most, the U.S. allocates a vast amount of funds towards the health care industry—more than $1.7 trillion per year.[53] Unfortunately, these distributed funds have not significantly improved the U.S.’s quality of healthcare. The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.[53] Of course, such savings will not occur overnight and will require EHR adoption by most healthcare businesses. Obviously, these savings can lead to healthcare quality promotion. In addition, these savings are not limited to businesses alone: If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.[53] Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.[54] Furthermore, If patients are aware of their opportunities, they are more likely to comply with their doctors’ recommendations; thus, reducing future hospital visits and saving money. Despite the advantages, many providers have not adopted EHR due to its expensiveness: The cumulative cost for 90 percent of hospitals to adopt an EHR system is $98 billion [and] $17.2 billion for physicians.[53] The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[55] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[55] Overall, physicians in the focus groups did not see any financial incentives for adopting an EHR. In other words, if providers do use an EHR system, not only do they have to pay for it, but they also have to pay for the maintenance of the system and classes to train staff. Moreover, technology is not perfect. On occasion, systems crash and experience technical difficulties, which is very costly to repair. Such issues make providers question if EHR is a step they are willing to take. Overall, EHR systems provide more benefits than disadvantages to patients and the economy. These systems can improve savings and the quality of healthcare to a superior level.

The U.S. Congressional Budget Office concluded that the cost savings may only occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product – and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." If a physician performs tests in the office, it might reduce his or her income. "Given the ease at which information can be exchanged between health it systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."[56]

Start-up costs and software maintenance costs

In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.[57] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).[58][59][60] Vendor costs only account for 60-80% of these costs.[61]

There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 – $7500/provider and $67 – $750/month per provider.[62]

Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.[63] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.[64]

Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.[65][66]

Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.[67]

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[68]

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems eventually retire.

Inertia

Most large organizations resist change. The institutional stress of implementing any new large-scale system must be anticipated by management. According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EHR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself.

The healthcare industry has more licensed professionals with advanced degrees than any other industry. However, systems analysis and computer science has not, until recently, been an integral part of healthcare training. Most health administrators also lack training in computer science.

Liability barriers

Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[69] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[70]

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[71]

This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[72] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.

In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[73] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[74][75]

Ownership of electronic records

HIPAA standards allow patients the right to review the content of their medical records.

When records are centralized, it is often difficult to determine whose responsibility it is to maintain the records. If a company agrees to manage and maintain records but goes out of business, how does that impact the healthcare provider whose ultimate responsibility it is for record maintenance?

If a healthcare provider retires or goes out of business, what arrangements to convert records to archival formats are available?

If an individual physician and a hospital system share a record database system but then the individual physician leaves that healthcare system, how does she separate her practice's records from the hospital's central database to take them with her for archival, as often required by law?

Who determines the frequency of "purging" of records?

A patient may store a portion of his/her health records online or with an independent storage service (in a health record trust), in which case that subset of records is no longer under the control of the healthcare provider. This transfers HIPAA liabilities to the databank that stores the records for the individual. Concerns about loss of data integrity and lessened HIPAA adherence arise, because these records are no longer part of the health record maintained by the healthcare provider.

Unalterability of records, spurious records, and digital signatures

Medical records must be kept in unaltered form and authenticated by the creator. However, simple mistakes often create spurious documents. How are spurious documents identified so that they do not clutter the medical record without altering or disposing of them illegally?

Most national and international standards now accept electronic signatures.[76] However, a database of electronic signatures must be created as an EHR system is implemented.

In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions.[77]

Customization

Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system.

An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.

This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.[78]

At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[79] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[80]

Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.[81][82]

These hurdles make customizations that can be made publicly available through an open source model more desirable.

Successful implementations of EHR systems

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.

The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.

As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT).[83]

Australia is dedicated to the development of a lifetime electronic health record for all its citizens. HealthConnect is the major national EHR initiative in Australia, and is made up of territory, state, and federal governments. MediConnect is a related program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[84]

The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.

Failures in Health Information Technology implementation

In 2002 at Cedars Sinai Medical Center in Los Angeles, physician dissatisfaction forced the administration to scrap a proprietary $34 million Central Physician Order Entry system that was developed within the medical center itself. Physicians were reported by nurses as being embarrassed by the number of errors the system caught and corrected, as well as being frustrated by the slow performance of the system.[85] It is notable that the system had never been used or tested outside of Cedars-Sinai.

As many as 30% of EHR implementation attempts have failed over the past few years, according to the National Health Information Network Co-ordinator, David Brailer.[85] Brailer's Santa Barbara County Care Data Exchange failed for a variety of reasons including poor project management, technical challenges, and a failure to create a compelling business model for the participants.[86]

Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. As of October 2006, CCHIT had certified 34 ambulatory EHR products.[87][88]

Software criteria of interoperability

The Certification Commission for Healthcare Information Technology (CCHIT) has developed an open-source program called Laika to test EHR software for compliance with CCHIT interoperability standards.

The Center for Information Technology Leadership described four different categories ("levels") of data structuring at which health care data exchange can take place.[89] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are:[90]

Level Data Type Example
1 Non-electronic data Paper, mail, and phone call.
2 Machine transportable data Fax, email, and unindexed documents.
3 Machine organizable data (structured messages, unstructured content) HL7 messages and indexed (labeled) documents, images, and objects.
4 Machine interpretable data (structured messages, standardized content) Automated transfer from an external lab of coded results into a provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation.

An unusual form of Health Information Technology is the VeriChip system, an RFID microchip that can be implanted under the skin to give instant access to a patient's records. The tiny electronic device, produced by Applied Digital Solutions Inc. of Delray Beach, Florida, transmits a unique code to a scanner that allows doctors to confirm a patient's identity and obtain detailed medical information from a database maintained by Applied Digital. Only the identification is provided by the implant, so the system remains limited to hospitals, doctors and patients having access to the scanner.[91]

See also

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Further reading

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