Electronic health records: just around the corner? Or over the cliff?

Trends in primary care clinician perceptions of a new electronic health record

BACKGROUND

Clinician perceptions of a newly implemented electronic health record play an important role in its success or failure.

OBJECTIVE

To measure changes in primary care clinician attitudes toward an electronic health record during the first year following implementation.

DESIGN

Longitudinal survey.

PARTICIPANTS

86 primary care clinicians surveyed between December 2006 and January 2008.

MEASUREMENTS

Perceived impact on overall quality of care, patient safety, communication, and efficiency at 1, 3, 6, and 12 months following implementation.

RESULTS

Response rates for months 1, 3, 6, and 12 were 92%, 95%, 90%, and 82%, respectively. The proportion of clinicians agreeing that the EHR improved the overall quality of care (63% to 86%; p < 0.001), reduced medication-related errors (72% to 81%; p = 0.03), improved follow-up of test results (62% to 87%; p < 0.001), and improved communication among clinicians (72% to 93%; p < 0.001) increased from month 1 to month 12. During the same time period, a decreasing proportion of clinicians agreed that the EHR reduced the quality of patient interactions (49% to 33%; p = 0.001), resulted in longer patient visits (68% to 51%; p = 0.001), and increased time spent on medical documentation (78% to 68%; p = 0.006). Significant improvements in perceptions related to test result follow-up were first detected at 6 months, while those related to overall quality, efficiency, and communication were first identified at 12 months.

CONCLUSIONS

Primary care clinicians report increasingly positive perceptions of a new electronic health record within 1 year of implementation across a spectrum of domains of care.

How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings

Background

Adoption of EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation.

Discussion

The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process.

Summary

The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties.

The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature

OBJECTIVE

This paper presents the results of a systematic literature review and a formal analysis of the scientific quality of empirical research on computerized provider order-entry (CPOE) applications.

DESIGN

Formal, systematic review techniques were used to search the literature, determine study relevance, and evaluate study quality.

MEASUREMENT

A search of multiple databases from 1976 through mid-2007 yielded a final set of 46 articles. Relevance criteria included: (1) a direct comparison of a CPOE system with a non-CPOE system; (2) implementation in a clinical setting; and (3) clinically relevant outcomes.

RESULTS

Study quality varied widely. Three major areas were identified for improvement in future studies: (1) internal validity, especially in terms of study designs, blinding, and instrumentation bias; (2) construct validity of the phenomenon of CPOE itself; and (3) measurement strategies, including reliability and validity assessments.

CONCLUSIONS

The evidence for the impact of CPOE needs to be improved to support scientific generalizability. Several common confounds are found in this literature. Future researchers will want to address them to improve the strength of the inference between CPOE and clinical outcomes. Discussion focuses on methods to improve future CPOE research.

Health Information Technology in Nursing Homes

This study describes nursing homes' use of Minimum Data Set (MDS) software and identifies features that are available in the most commonly used software packages. Data came from the On-line Survey, Certification and Reporting system and a national survey of nursing home administrators ( N = 2,899) conducted in 2005. Results show that 2,397 (82.7%) of nursing homes used third-party MDS software, and more than 85% of those facilities purchased the software from one of five vendors. Advanced features in the software were available to most (87% to 98%) of the facilities; however, most features were not being used all the time. Findings are instructive in showing the use of health information technology in nursing homes. Nursing homes are often viewed as technologically impaired. With respect to MDS software, many nursing homes are using quite advanced health information technology.

Health information technology will shift the medical care paradigm

The current paradigm of medical care depends heavily on the autonomous and highly trained doctor to collect and process information necessary to care for each patient. This paradigm is challenged by the increasing requirements for knowledge by both patients and doctors; by the need to evaluate populations of patients inside and outside one's practice; by consistently unmet quality of care expectations; by the costliness of redundant, fragmented, and suboptimal care; and by a seemingly insurmountable demand for chronic disease care. Medical care refinements within the old paradigm may not solve these challenges, suggesting a shift to a new paradigm is needed. A new paradigm could be considerably more reliant on health information technology because that offers the best option for addressing our challenges and creating a foundation for future medical progress, although this process will be disruptive.

An effort to improve electronic health record medication list accuracy between visits: Patients’ and physicians’ response

OBJECTIVE

To evaluate the efficacy of a secure web-based patient portal called Patient Gateway (PG) in producing more accurate medication lists in the electronic health record (EHR), and whether sending primary care physicians (PCPs) a clinical message updating them on the information their patients provided caused physicians to update the EHR medication list.

METHODS

We compared the medication list accuracy of 84 patients using PG with that of 79 who were not. Patient-reported medication discrepancies were noted in the EHR in a clinical note by research staff and a message was sent to the participants' PCPs notifying them of the updated information.

RESULTS

Participants were taking 665 medications according to the EHR, and reported 273 additional medications. A lower percentage of PG users' drug regimens (54% versus 61%, p=0.07) were reported to be correct than those of PG non-users, although PG users took significantly more medications than their non-user counterparts (5.0 versus 3.1 medications, p=0.0001). Providing patient-reported information in a clinical note and sending a clinical message to the primary care doctor did not result in PCPs updating their patients' EHR medication lists.

CONCLUSIONS

Medication lists in EHRs were frequently inaccurate and most frequently overlooked over-the-counter (OTC) and non-prescription drugs. Patients using a secure portal had just as many discrepancies between medication lists and self-report as those who did not, and notifying physicians of discrepancies via e-mail had no effect.

Organizational and environmental determinants of hospital EMR adoption: a national study

The recent focus on health care quality improvement and cost containment has led some policymakers and practitioners to advocate the adoption of health information technology. One such technology is the Electronic Medical Record (EMR), which is predicted to change and improve health care in the USA. Little is known about factors that influence hospital adoption of this relatively new technology. The purpose of this paper is to determine the national prevalence of EMR adoption in acute care hospitals while examining the organizational and environmental correlates using a Resource Dependence Theoretical Perspective. Significant predictors of hospital EMR use may indicate barriers to use for some hospitals and can be used to guide policy. This study uses a non-experimental cross sectional design to examine hospital EMR use in 2004. A logistic regression approach is used to determine the correlations between hospital EMR use and organizational and environmental characteristics. Hospital EMR use was identified using the HIMSS Analytics data. Organizational and environmental variables were measured using data from the AHA, CMS (financial and case mix) and ARF. Hospital EMR adoption is significantly associated with environmental uncertainty, type of system affiliation, size, and urbanness. The effects of competition, munificence, ownership, teaching status, public payer mix, and operating margin were not statistically significant. Significant predictors of hospital EMR adoption represent barriers that may prevent certain hospitals from obtaining and using EMRs. These hospitals include those that are smaller, more rural, non-system affiliated, and in areas of low environmental uncertainty. Since EMR adoption may be an organizational survival strategy for hospitals to improve quality and efficiency, hospitals that are at risk of missing the wave of implementation should be offered services and incentives to enable them to implement and maintain EMR systems.

Electronic health records in specialty care: a time-motion study

BACKGROUND

Electronic health records (EHRs) have great potential to improve safety, quality, and efficiency in medicine. However, adoption has been slow, and a key concern has been that clinicians will require more time to complete their work using EHRs. Most previous studies addressing this issue have been done in primary care.

OBJECTIVE

To assess the impact of using an EHR on specialists' time. DESIGN Prospective, before-after trial of the impact of an EHR on attending physician time in four specialty clinics at an integrated delivery system: cardiology, dermatology, endocrine, and pain.

MEASUREMENTS

We used a time-motion method to measure physician time spent in one of 85 designated activities.

RESULTS

Attending physicians were monitored before and after the switch from paper records to a web-based ambulatory EHR. Across all specialties, 15 physicians were observed treating 157 patients while still using paper-based records, and 15 physicians were observed treating 146 patients after adoption. Following EHR implementation, the average adjusted total time spent per patient across all specialties increased slightly but not significantly (Delta = 0.94 min., p = 0.83) from 28.8 (SE = 3.6) to 29.8 (SE = 3.6) min.

CONCLUSION

These data suggest that implementation of an EHR had little effect on overall visit time in specialty clinics.

Correlates of electronic health record adoption in office practices: a statewide survey

OBJECTIVE

Despite emerging evidence that electronic health records (EHRs) can improve the efficiency and quality of medical care, most physicians in office practice in the United States do not currently use an EHR. We sought to measure the correlates of EHR adoption.

DESIGN

Mailed survey to a stratified random sample of all medical practices in Massachusetts in 2005, with one physician per practice randomly selected for survey.

MEASUREMENTS

EHR adoption rates.

RESULTS

The response rate was 71% (1345/1884). Overall, while 45% of physicians were using an EHR, EHRs were present in only 23% of practices. In multivariate analysis, practice size was strongly correlated with EHR adoption; 52% of practices with 7 or more physicians had an EHR, as compared with 14% of solo practices (adjusted odds ratio, 3.66; 95% confidence interval, 2.28-5.87). Hospital-based practices (adjusted odds ratio, 2.44; 95% confidence interval, 1.53-3.91) and practices that teach medical students or residents (adjusted odds ratio, 2.30; 95% confidence interval, 1.60-3.31) were more likely to have an EHR. The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%).

CONCLUSIONS

While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

It Ain't Necessarily So: The Electronic Health Record And The Unlikely Prospect Of Reducing Health Care Costs

Electronic health record (EHR) advocates argue that EHRs lead to reduced errors and reduced costs. Many reports suggest otherwise. The EHR often leads to higher billings and declines in provider productivity with no change in provider-to-patient ratios. Error reduction is inconsistent and has yet to be linked to savings or malpractice premiums. As interest in patient-centeredness, shared decision making, teaming, group visits, open access, and accountability grows, the EHR is better viewed as an insufficient yet necessary ingredient. Absent other fundamental interventions that alter medical practice, it is unlikely that the U.S. health care bill will decline as a result of the EHR alone.

Working off the record: physicians' and nurses' transformations of electronic patient record-based patient information

BACKGROUND

Electronic patient records (EPRs) are increasingly being used in health care, but little is known about how EPR-based patient information is used in daily care activities, nor about its potential influence on novice training.

METHOD

Seventy-two physicians and nurses participated in an eight-month study on a single pediatric ward. Eighty hours of nonparticipant observations and 20 interviews were conducted. Data were analyzed using constructivist grounded theory and visual rhetoric.

RESULTS

Three main features of participant interactions with EPR-based information were identified: (1) EPR-based information was routinely transformed into paper documents; (2) these transformations were organized by profession-specific guiding principles; and (3) transformation strategies were learned through an informal curriculum.

CONCLUSIONS

This study describes how and why health care professionals work around EPR-based patient information, and suggests that an EPR's visual organization may be incompatible with professional activities. The study addresses the socializing implications of these activities, and highlights their educational potential.

Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial

BACKGROUND

To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting.

METHODS

A prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups.

RESULTS

Randomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3-19.6)), folic acid counseling (7.5 (2.7-20.8)), fecal occult blood testing (6.7 (1.9-24.1)), smoking cessation counseling (3.9 (2.2-7.2)), tetanus immunization (3.0 (1.7-5.2)), history of alcohol intake (1.33 (1.2-1.5)), history of smoking habits (1.28 (1.2-1.4)) and blood pressure measurement (1.05 (1.00-1.10)).

CONCLUSION

This simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms are accessible in English and French at the College of Family Physicians of Canada web site.

Evolution of health information management and information technology in emergency medicine

The implementation of information technology will continue to have important effects on the practice of emergency medicine. Patient registration and tracking systems, telemedicine electronic order entry systems, and the advent of electronic health records are some examples of applications that influence patient care in emergency departments. We review the literature regarding information technology advances in emergency medicine and outline the important role that emergency physicians play in developing and implementing a national health information technology strategy.

Physicians, patients, and the electronic health record: an ethnographic analysis

PURPOSE

Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that influence the manner by which physicians use the EHR with patients.

METHODS

This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offices in the Pacific Northwest; individual interviews with 52 patients, 12 office staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus-group interviews with physicians and computer advocates. The main outcome measures were factors that influence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data.

RESULTS

This study identified 14 factors that influence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial--effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational--perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational--issues of developing physicians' proficiency with and improving patients' understandings about EHR use; and (4) structural--institutional and technological forces that influence how physicians perceived their use of EHR.

CONCLUSIONS

This study found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.