Presented by Jennifer Miller and Pat Tincher
The business of health care is constantly changing,
with information technology being a significant factor in this change. We are now at a point where continuous cost management,
patient safety, and consumer driven health care are paramount to our
success. While we are able to provide
quality patient care and excellent outcomes, we need to take the next
step. This involves a significant
financial and human resource investment, involving our patient care staff,
physicians and significant IT resources.
This next step is the electronic health record(EHR).
As described in the following pages, the EHR will
allow us to electronically document all activity regarding a patient’s visit,
as well as having physicians provide orders electronically. Depending on security levels, this
information can be shared with providers across the country. It will also allow us to provide our patients
with an electronic health record that contains all of the relevant information
regarding their treatment.
This relatively new technology will also provide us
the ability to evaluate trends and activities on a real-time basis and provide
information that currently takes significant review to obtain. While it may appear that we have a choice in
this technology today, the Federal Government and the JCAHO have set goals for
universal implementation of the electronic health record.
This technology will also aid in reducing medical
costs, as physicians who treat our patient after they visit us will be able to
review the electronic records and possibly reduce the amount of testing that
they would normally do, thus saving the patient money and providing more
timely, accurate medical advice. While
there will be cost savings to implementing this technology, these savings will
be primarily realized by the patient and the insurance company, as there should
be less diagnostic testing performed and improved treatments.
Besides the electronic health record and the data
repository that will be necessary, we will also need to consider additional
technologies to include computerized physician order entry and digital imaging(PACS)
for radiology exams. These technologies
will provide us with state-of-the-art information technology that will support
us and our patients for the foreseeable future.
These technologies will not come without significant
costs, both financially and in personnel, but they are necessary to provide our
patients with the utmost in safety, convenience and cost effective care. Due to this, we will also want to make sure
that we have the appropriate individuals, including physicians, clinicians and
IT staff involved in the evaluation, decision making and implementation of this
technology.
The health care industry includes several different
disciplines, with hospitals, physicians, nursing homes and home care services
being some of the primary providers. In
total, there are approximately 5,000 hospitals, 690,000 physicians, 6,000
nursing homes, and 7,500 home health care providers. In addition, there are a wide variety of
other providers, including outpatient surgery and imaging centers, durable
medical equipment providers, and pharmacies.
In the industry, there is a significant deviance in the size of
organizations, with large systems that may have upwards of 100 hospitals, 1,000
physicians, and other health care services being the extremely large
providers. At the same time, there are
providers who operate a single company, whether it be a hospital, nursing home,
or a physician office. The information
systems utilized in these organizations are as diverse as the size of the
organizations, with some organizations being essentially paperless, while some
organizations provide only manual billing and outsourcing the majority of their
backoffice functions.
With this wide diversity, there are significant
issues in the communication of medical information, its accuracy and the
overall safety of the patient. The communication issue includes:
1.
Timeliness
2.
Completeness
3.
Portability
With our current paper-based medical record system,
each provider has only their portion of the medical record for the services
that they provide for the patient. These
records are unavailable to other providers, unless the patient requests that
the records be released to that specific provider. These requests take time and, if several
providers are involved, requests need to be made to each provider.
The concerns with accuracy relate to the manualness of the paper record. Whether it is a note provided by a physician
or a nurse, or a prescription being ordered for a patient, handwritten notes
have significant error possibilities.
This can impact the patient in a negative way, as evidenced by the
The Answer
An emerging information technology that may address
these issues is the electronic medical record.
While it was developed in the late 1970’s(Advisory Board, 1999), it has
been implemented in a relatively small number of organizations. Concerns with cost, physician acceptance and
the lack of a universal language delayed widespread implementation of
electronic medical record systems.
The need for improved accuracy, patient safety,
convenience and a national focus on health care information have been the
primary reasons for the increase in popularity of these systems.
The
Technology
The technological requirements include hardware,
software, a well organized infrastructure, top-rate security features and
proper training to use the new technology.
The hardware would include all computer and
workstation equipment and servers. These
computers will include wireless technology options, to include PDA’s, laptops,
and Tablet PC’s.
There are many different software options being
developed by different vendors. Some
programs offer single resources for specific departments such as billing or
scheduling. Other programs include all
departments to create an integrated system.
Other value adding programs allow for more functionality to a currently
running system, such as a program that condenses a patient’s record and creates
a master page.
The infrastructure is one of the most important
components to the technological side of EHR’s, since that creates the ability
to communicate across departments and from different locations in the
Security features are essential to a successful EHR
system. Complying with HIPAA requires
extensive security measures to protect patient’s rights. Tools often used to increase security are
encryption, authentication and Extensible Markup Language (XML). XML is a useful way to create the health
record, because it is an open format that doesn’t tie the information to a
proprietary system. This will make it
easier for the data to be easily transferred to other systems with
accuracy. The U.S. Department of
Health and Human Services(HHS) is working with HIPAA to create specific
guidelines for EHR systems. This will
make it easier for system designers to ensure that all federal regulations are
being followed.
Once the system is chosen and implemented, extensive
training needs to take place to ensure that all users understand how the system
works. With the EHR system being such a
huge investment, proper training is critical to increasing ROI. Planning and training are key components of
a successful installation and long-term viability of the system.
Strengths
and Limitations to Technology
The HHS goal is an EHR system being implemented
across the country with in the next 10 years.
They have worked with the
Another major strength of the EHR system is that
electronic records are actually more secure than paper records, since there is
an audit trail left behind to track all that view a patient’s record. Paper records can be more easily lost, can
have missing information that needs to be researched on other documents and can
be illegible. An EHR system would solve
those problems and also would allow reminders to automatically pop up to ensure
proper follow up care. It also allows
for more quality control efforts, since all data is in one place. Metrics can be established to ensure that
procedures are being followed across departments or at different
facilities. While electronic records may
be more secure than paper records, any of these systems will also be exposed,
especially those utilizing the internet, to attacks and unauthorized access. Vigilance and common sense, with regards to
security will be the core safeguards for making the internet safe for health
data (Goedert, 2004).
The Health Insurance Portability and Accountability Act provide the
standards for health organizations to utilize in protecting the privacy,
security and integrity of health information.
These standards will need to be understood and implemented as part of
the implementation of the HER.
There are many limitations to the technology that
revolves around the EHR system.
Currently only 5% of
Another limitation is the huge price tag attached to
implementing these systems. Mike Kappel,
senior vice president of strategic planning at McKesson Corp (a pharmaceutical
distributor and health care IT provider), predicts the cost of developing a
national EHR system could cost up to $10 billion. The federal government has
only budgeted $50 million this fiscal year and $100 million next year for
health care IT. (Berwin, 2004) This
means most of the cost will fall on doctors and hospitals.
The commitment to change over from paper to
electronic records requires time. In
small clinic settings, doctors may not be able to give the proper amount of
time with out sacrificing patient care.
The high costs may be seen as more useful to invest in other
technologies, because they will see a faster rate of return.
Additional limitations are the buy-in of all
necessary partners. This is especially
true of physicians, who may see the EHR as a time wasting task and will need to
be part of the process on the front-end, so they will be able to understand the
purpose behind the EHR and will be able to be part of the selection process and
actively promote it. An excellent
example of this is a the Marshfield Clinic, where a small number of
participants evaluated Tablet PC’s to be utilized for point-of-care computing
in October, 2002. Within a year, formal
testing began, and in July, 2004, the process of distributing the PC’s began,
with 50 clinicians receiving their PC’s.
The Clinic is distributing 30 Tablet PC’s per week through 2006, until
roughly 2,000 physicians, physician assistants, nurses, and other are
equipped. While not all physicians are
necessarily ecstatic about the change, they are now able to wirelessly connect
to the EHR, find historical data, update a patient’s chart, write electronic
prescriptions, and even show a patient and parents an X-ray.(Goedert, 2004).
To deal with these limitations, a clearly thought out
plan needs to be established. This plan
needs to include the following points; how to decide what system will best fit
current and future needs, who to involve in the process, how will the
installation take place, and how training will take place. Some recommendations include installing a
system in increments to ensure that each piece of the puzzle is fully
integrated and everyone is fully trained.
This breaks the big project into more manageable pieces. Since EHR’s require large hardware, software
and training investments it is critical that the plan includes clear management
of the process, to ensure that there is the possibility of ROI.
Other things to take into consideration when choosing
an EHR system include how the product is licensed. Licensing is usually offered through
unlimited usage per facility at one price or a specific charge per user. It is also important to look at the technical
support the vendor can provide.
Questions to ask are what kind of technical support is available, when
is it available and who will be providing it.
Sometimes the technical support is included in the usage fees, but more
extensive support is usually offered at an extra cost.
Industry Impacts
The biggest impact will be
the cost savings across the board.
Health and Human Services secretary Tommy Thompson predicts that a
nationwide EHR system could lower the country’s annual health care bill of $1.7
trillion dollars by 10%(Brewin, 2004).
The use of electronic health records in the U.S. health care industry
will allow care-givers from multiple locations to view the same exact
data. This will improve patient care
through more uniform diagnoses. It will
also speed up the health care process, since a doctor does not have to wait for
a fax or mailing of a patient’s records from another doctor. There will also be cost savings with the
reduction of repeat tests and procedures due to lack of full patient
information. This will also cut costs of
copying, faxing and storage of medical records. There will be increased efficiency in
creating, reading and accessing patient’s records. The integration with departments from billing
to scheduling will reduce labor hours needed and increase revenues. Many insurance companies are willing to give
5 to 10% discounts to EHR system users.
A second impact is the
ability to utilize patient information in researching how to improve the health
care that is being provided. Medical
records can be identified via I.D. numbers, and eliminating any personal
information. This will allow researchers
to track patients with certain ailments across a period of time at different
locations with in the
Recommendations
While there may be some rationale to delaying
implementation of the EHR system, in the interest of patient safety, clinical
efficiency and improvements in quality of care, we recommend that
Additionally, the EHR system has the potential to
create major costs savings across the health industry. Our early entry into this system will give us
the time and experience to fully utilize this system when the nationwide system
is in place. Early entry will also allow
us to take adequate time to plan and implement this system. Our ability to see a return on investment
will increase if we have a clear plan for management of the process. Our patients will see the results of this
investment of money, time and effort.
A team approach is necessary in implementing this, to
include the clinicians, physicians, IT staff and others who may be impacted by
this technology. It may also be wise to
include our partners, including physicians and area hospitals, to determine if
there are opportunities to implement a single solution that will work for all.
The team designated to head up this challenge needs
to closely follow the HHS recommendations.
Their database of terminology and model patient record will help to ensure
that our system’s infrastructure is fully compatible to nationwide system. Following their recommendations will also
open the door to financial help from the limited government grants. Outsourcing our infrastructure is the optimal
choice for us, since we can eliminate the set-up and maintenance costs. Our criteria should include the expectation
that this service provider follows HHS and HIPAA recommendations and
guidelines. They need to provide
extensive training and technical support.
The extra costs will increase our ability to fully integrate and utilize
the EHR system.
While we are not prepared to provide an estimate of the financial ramifications of this proposal, we expect that the total cost will be at least $2 million for a facility our size.
Bibliography
Abrahamsen, Cathie, “Patient Safety: Take the informatics challenge” Nursing Management, Apr 2003, Vol. 34, Issue 4
Bethke, Walter, “What’s New in Electronic Medical Records”, Review of Ophthalmology, Nov 2000, Volume 7, Issue 11
Brewin, Bob,
“Claims technology will save money, but upfront IT costs likely will be steep”,
Computerworld,
Brewin, Bob,
“Feds Push Standards for Health Care IT”, Computerworld,
Darr, Kurt, “Electronic Medical Records: The Future- At Some Point”, Hospital Topics, Winter 98, Vol. 76
Jonietz, Erika, “Paperless MedicineTechnology Review”, Apr 2003, Volume
106, Issue 3, p59-64
Leventhal, Walter D., “Four tips for EHR Integration”, Family Practice Management, Jul/Aug 2001, Vol. 8, Issue 7
Meyers, Jaymi S., “ 10 Questions I Didn’t Know to Ask”, Family Practice Management, Mar2001, Vol. 8, Issue 3, p 29
Radosevich,
Lynda, “Health Care Uses XML for Records”, InfoWorld,
“Top Health Care Technology Trends”, Health Care Advisory Board, May, 1999
Goedert, Joseph, “For
Goedert, Joseph, “Making the Internet Safe for Health Data”, Health Data Management, November, 2004, Volume 12, Number 11, p. 62-68