Return on investment in electronic health records in primary care practices: a mixed-methods study

Benefits, facilitators, and barriers of electronic medical records implementation in outpatient settings: A scoping review

This scoping review examined the breadth and depth of evidence on Electronic Medical Record (EMR) implementation benefits in outpatient settings. Following PRISMA guidelines for scoping reviews, five databases were searched, and 24 studies were retained and reviewed. Benefits, facilitators, and barriers to EMR implementation were extracted. Direct benefits included improved communication/reporting, work efficiency, care process, healthcare outcomes, safety, and patient-centredness of care. Indirect benefits were improved financial performance and increased data accessibility, staff satisfaction, and decision-support usage. Barriers included time and financial constraints; design/technical issues; limited information technology resources, skills, and infrastructure capacity; increased workload and reduced efficiency during implementation; incompatibility of existing systems and local regulations; and resistance from healthcare professionals. Facilitators included training, change management, user-friendliness and alignment with workflow, user experience with EMRs, top management support, and sufficient resources. More rigorous, systematic research is needed, using relevant frameworks to inform healthcare policies and guide EMR projects in outpatient areas.

Value of Electronic Health Records Measured Using Financial and Clinical Outcomes: Quantitative Study

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act of 2009 was legislated to reduce health care costs, improve quality, and increase patient safety. Providers and organizations were incentivized to exhibit meaningful use of certified electronic health record (EHR) systems in order to achieve this objective. EHR adoption is an expensive investment, given the resources and capital that are invested. Due to the cost of the investment, a return on the EHR adoption investment is expected.

OBJECTIVE

This study performed a value analysis of EHRs. The objective of this study was to investigate the relationship between EHR adoption levels and financial and clinical outcomes by combining both financial and clinical outcomes into one conceptual model.

METHODS

We examined the multivariate relationships between different levels of EHR adoption and financial and clinical outcomes, along with the time variant control variables, using moderation analysis with a longitudinal fixed effects model. Since it is unknown as to when hospitals begin experiencing improvements in financial outcomes, additional analysis was conducted using a 1- or 2-year lag for profit margin ratios.

RESULTS

A total of 5768 hospital-year observations were analyzed over the course of 4 years. According to the results of the moderation analysis, as the readmission rate increases by 1 unit, the effect of a 1-unit increase in EHR adoption level on the operating margin decreases by 5.38%. Hospitals with higher readmission payment adjustment factors have lower penalties.

CONCLUSIONS

This study fills the gap in the literature by evaluating individual relationships between EHR adoption levels and financial and clinical outcomes, in addition to evaluating the relationship between EHR adoption level and financial outcomes, with clinical outcomes as moderators. This study provided statistically significant evidence (P<.05), indicating that there is a relationship between EHR adoption level and operating margins when this relationship is moderated by readmission rates, meaning hospitals that have adopted EHRs could see a reduction in their readmission rates and an increase in operating margins. This finding could further be supported by evaluating more recent data to analyze whether hospitals increasing their level of EHR adoption would decrease readmission rates, resulting in an increase in operating margins. Hospitals would incur lower penalties as a result of improved readmission rates, which would contribute toward improved operating margins.

[Implementation of an electronic clinical decision aid to support quality of care for COPD in family medicine]

BACKGROUND

Electronic clinical decision aids (eCDAs) have the potential to improve the quality of chronic disease management (CDM) and; therefore, patient relevant outcomes. However, eCDAs are only sparsely implemented in primary care for chronic obstructive pulmonary disease (COPD). The aim of this pilot study was to develop and implement of an eCDA for COPD primary care in two Swiss primary care practices.

METHOD

Two primary care practices, each with five primary care physicians and their assistants participated in the study. The eCDA was developed in collaboration with one of the two GP practices (Practice 1) following a development cycle encompassing alpha- and beta-testing stages. Long-term testing for one year was conducted in both practices. The implementation of the eCDA was evaluated according to the RE-AIM framework counting occurrences as follows: Reach: the number of patients included in the CDM using the eCDA.

EFFECTIVENESS

the number of treatment processes initiated per patient. Adoption: practice utilization of the diverse functions featured in the eCDA. Implementation and Maintenance: health care professionals' attitudes towards the impact of the eCDA on the quality of care and their willingness to continue using the eCDA after long-term testing. Data were collected by the eCDA itself, which was programmed to track user data, and from practice staff using questionnaires.

RESULTS

Reach: After the long-term test, the number of patients recorded in the eCDA was 28 in practice 1, and 12 in practice 2.

EFFECTIVENESS

The number of evidence-based treatment processes per patient was 14 (IQR 6 to 22) in Practice 1 and 6 (IQR 5 to 8) in Practice 2. Adoption: The utilization profiles of the eCDA differed greatly between practices. Implementation and Maintenance: After the long-term test, respondents were more critical of the quality of the CDM for patients with COPD, and attitudes consistent with interprofessional care were more prevalent compared to baseline. Respondents were optimistic regarding both the potential of the eCDA to improve the quality of CDM and their motivation to continue using the eCDA after long-term testing.

CONCLUSION

This pilot study is a roadmap for future projects aiming to develop and implement eCDAs for the CDM of COPD in primary care. Future larger implementation studies in this domain should place greater emphasis on the measurement of structural practice characteristics as potential determinants of patient-relevant outcomes. The modifiable determinants should then be tested for their effects on patient-relevant outcomes in a randomized controlled design.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Digital Health Value Realization Through Active Change Efforts

Digital health has massive potential in health care but has been slow to evolve in comparison to other information-intensive industries, which have more readily taken advantage of new technology. One of the key barriers has been the complex relationship between the perceived return on investment for the investor and the resulting value to patients and caregivers. Those actors who pay for technologies do not always see an appreciable return for themselves, while those actors who must apply the technology to generate value are not always incentivized to do so. This misalignment across health system payers and administrators, clinicians and patients must be better understood and addressed to help accelerate digital health. This paper will examine this challenge through the clinician experience, using empirical case examples from Canada to illustrate opportunities for change. While many factors may influence digital health adoption, this paper specifically aims to explore the shifts in the balance of the perceived value of implementing digital health tools, vs. the efforts required to adopt them. It will explore two contrasting case examples: clinical adoption of EMRs in Canada from 2009 to 2015, and clinical adoption of virtual care technologies during the COVID-19 pandemic from 2020 to 2021. In 2006, Canada lagged peer countries significantly in the adoption of electronic medical records (EMR) in community-based care. Financial support and cooperation of multiple levels of government and clinical stakeholders were required to address the misaligned incentives, which led to significant uptake by care providers. The rapid adoption of virtual care in Canada in response to the pandemic provides another relevant example of the importance of alignment among the factors of clinical workflows, clinical appropriateness, technology integration and payment models. Experts have highlighted the need for standardization, regulation, and clear policy to ensure sustainable, high quality virtual care that complements in-person care. In both cases, the costs and effort of adopting new technologies outweighed direct clinician value, requiring change initiatives to catalyze progress. This imbalance could be unique to these examples in Canada, and may not be globally generalizable to the adoption of all digital health tools. However, how change efforts can be tailored to adjust to a rapidly evolving health care workforce, spanning diverse jurisdictions and stakeholder groups will be critical to the sustainability of virtual care adoption. Furthermore, what key elements must be considered to guide change initiatives for successful implementation, designed to influence change while adding value for patients, clinicians and Canada's health care systems? Using insights from successful change initiatives past and present, this paper aims to answer these questions to enable a smoother transition to digital health innovations of the future.

Economic Value of Data and Analytics for Health Care Providers: Hermeneutic Systematic Literature Review

BACKGROUND

The benefits of data and analytics for health care systems and single providers is an increasingly investigated field in digital health literature. Electronic health records (EHR), for example, can improve quality of care. Emerging analytics tools based on artificial intelligence show the potential to assist physicians in day-to-day workflows. Yet, single health care providers also need information regarding the economic impact when deciding on potential adoption of these tools.

OBJECTIVE

This paper examines the question of whether data and analytics provide economic advantages or disadvantages for health care providers. The goal is to provide a comprehensive overview including a variety of technologies beyond computer-based patient records. Ultimately, findings are also intended to determine whether economic barriers for adoption by providers could exist.

METHODS

A systematic literature search of the PubMed and Google Scholar online databases was conducted, following the hermeneutic methodology that encourages iterative search and interpretation cycles. After applying inclusion and exclusion criteria to 165 initially identified studies, 50 were included for qualitative synthesis and topic-based clustering.

RESULTS

The review identified 5 major technology categories, namely EHRs (n=30), computerized clinical decision support (n=8), advanced analytics (n=5), business analytics (n=5), and telemedicine (n=2). Overall, 62% (31/50) of the reviewed studies indicated a positive economic impact for providers either via direct cost or revenue effects or via indirect efficiency or productivity improvements. When differentiating between categories, however, an ambiguous picture emerged for EHR, whereas analytics technologies like computerized clinical decision support and advanced analytics predominantly showed economic benefits.

CONCLUSIONS

The research question of whether data and analytics create economic benefits for health care providers cannot be answered uniformly. The results indicate ambiguous effects for EHRs, here representing data, and mainly positive effects for the significantly less studied analytics field. The mixed results regarding EHRs can create an economic barrier for adoption by providers. This barrier can translate into a bottleneck to positive economic effects of analytics technologies relying on EHR data. Ultimately, more research on economic effects of technologies other than EHRs is needed to generate a more reliable evidence base.

Cultivating eHealth evaluation leadership

This article discusses eHealth evaluation leadership in terms of the need, key characteristics, and means to cultivate this leadership. It is well known that health leaders with technical informatics skills and prior eHealth adoption experience are more likely to commit to a long-term eHealth vision, are highly motivated, and can navigate through complex adoption issues. However, much less attention is paid to leadership when it comes to electronic health evaluation. The aim here is to engage the eHealth and broader health leadership communities in a dialogue about eHealth evaluation leadership in terms of its importance, the issues involved, and ways to build capacity in Canada and abroad.

A Framework for Contracted Health IT Performance Assessments

Limited research exists which aids in structuring health IT contracts in an era of performance-based payments. We provide an assessment of common approaches to contracting and measuring of performance in practice. We conducted a review of existing literature and compliment this approach with a survey of healthcare professionals directly involved with health IT systems to further understand and classify current approaches. We identified architypes for structuring healthcare IT performance contracts to include: (1) internal operations, (2) external evaluation and (3) joint agreement for the delivery of value-based care.

An Optimization Program to Help Practices Assess Data Quality and Workflow With Their Electronic Medical Records: Observational Study

Background

Electronic medical record (EMR) adoption among Canadian primary care physicians continues to grow. In Ontario, >80% of primary care providers now use EMRs. Adopting an EMR does not guarantee better practice management or patient care; however, EMR users must understand how to effectively use it before they can realize its full benefit. OntarioMD developed an EMR Practice Enhancement Program (EPEP) to overcome challenges of clinicians and staff in finding time to learn a new technology or workflow. EPEP deploys practice consultants to work with clinicians onsite to harness their EMR toward practice management and patient care goals.

Objective

This paper aims to illustrate the application of the EPEP approach to address practice-level factors that impede or enhance the effective use of EMRs to support patient outcomes and population health. The secondary objective is to draw attention to the potential impact of this practice-level work to population health (system-level), as priority population health indicators are addressed by quality improvement work at the practice-level.

Methods

EPEP’s team of practice consultants work with clinicians to identify gaps in their knowledge of EMR functionality, analyze workflow, review EMR data quality, and develop action plans with achievable tasks. Consultants establish baselines for data quality in key clinical indicators and EMR proficiency using OntarioMD-developed maturity assessment tools. We reassessed and compared postengagement, data quality, and maturity. Three examples illustrating the EPEP approach and results are presented to illuminate strengths, limitations, and implications for further analysis. In each example, a different consultant was responsible for engaging with the practice to conduct the EPEP method. No standard timeframe exists for an EPEP engagement, as requirements differ from practice to practice, and EPEP tailors its approach and timeframe according to the needs of the practice.

Results

After presenting findings of the initial data quality review, workflow, and gap analysis to the practice, consultants worked with practices to develop action plans and begin implementing recommendations. Each practice had different objectives in engaging the EPEP; here, we compared improvements across measures that were common priorities among all 3—screening (colorectal, cervical, and breast), diabetes diagnosis, and documentation of the smoking status. Consultants collected postengagement data at intervals (approximately 6, 12, and 18 months) to assess the sustainability of the changes. The postengagement assessment showed data quality improvements across several measures, and new confidence in their data enabled practices to implement more advanced functions (such as toolbars) and targeted initiatives for subpopulations of patients.

Conclusions

Applying on-site support to analyze gaps in EMR knowledge and use, identify efficiencies to improve workflow, and correct data quality issues can make dramatic improvements in a practice’s EMR proficiency, allowing practices to experience greater benefit from their EMR, and consequently, improve their patient care.

Measuring Electronic Health Record Use in Primary Care: A Scoping Review

BACKGROUND

Simple measures of electronic health record (EHR) adoption may be inadequate to evaluate EHR use; and positive outcomes associated with EHRs may be better gauged when varying degrees of EHR use are taken into account. In this article, we aim to assess the current state of the literature regarding measuring EHR use.

OBJECTIVE

This article conducts a scoping review of the literature to identify and classify measures of primary care EHR use with a focus on the Canadian context.

METHODS

We conducted a scoping review. Multiple citation databases were searched, as well as gray literature from relevant Web sites. Resulting abstracts were screened for inclusion. Included full texts were reviewed by two authors. Data from the articles were extracted; we synthesized the findings. Subsequently, we reviewed these results with seven EHR stakeholders in Canada.

RESULTS

Thirty-seven articles were included. Eighteen measured EHR function use individually, while 19 incorporated an overall level of use. Eight frameworks for characterizing overall EHR use were identified.

CONCLUSION

There is a need to create standardized frameworks for assessing EHR use.

The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study

Background

Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking.

Objective

The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization.

Methods

The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence.

Results

Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings.

Conclusions

EMR implementation allowed Ontario Shores Centre for Mental Health Sciences to use data analytics to identify and select appropriate quality improvement initiatives, supporting patient-centered, recovery-oriented practices and providing value at the clinical, organizational, and societal levels.

Stepping Up to the Plate: An Agenda for Research and Policy Action on Electronic Medical Records in Canadian Primary Healthcare

Building on a previous study, which identified gaps in primary healthcare electronic medical record (emr) research and knowledge, a one-day conference was held to facilitate a strategic discussion of these issues. This paper offers a multi-faceted research agenda and suggestions for policy actions as a way forward in bridging the gaps. one facet focuses on the need for research. The second facet focuses on harnessing the knowledge of primary healthcare emr stakeholders. finally, the third facet focuses on policy actions. this paper offers consensus-based suggestions with a view to improving the overall primary healthcare emr landscape in canada.

Designing an Electronic Patient Management System for Multiple Sclerosis: Building a Next Generation Multiple Sclerosis Documentation System

BACKGROUND

Technologies like electronic health records or telemedicine devices support the rapid mediation of health information and clinical data independent of time and location between patients and their physicians as well as among health care professionals. Today, every part of the treatment process from diagnosis, treatment selection, and application to patient education and long-term care may be enhanced by a quality-assured implementation of health information technology (HIT) that also takes data security standards and concerns into account. In order to increase the level of effectively realized benefits of eHealth services, a user-driven needs assessment should ensure the inclusion of health care professional perspectives into the process of technology development as we did in the development process of the Multiple Sclerosis Documentation System 3D. After analyzing the use of information technology by patients suffering from multiple sclerosis, we focused on the needs of neurological health care professionals and their handling of health information technology.

OBJECTIVE

Therefore, we researched the status quo of eHealth adoption in neurological practices and clinics as well as health care professional opinions about potential benefits and requirements of eHealth services in the field of multiple sclerosis.

METHODS

We conducted a paper-and-pencil-based mail survey in 2013 by sending our questionnaire to 600 randomly chosen neurological practices in Germany. The questionnaire consisted of 24 items covering characteristics of participating neurological practices (4 items), the current use of network technology and the Internet in such neurological practices (5 items), physicians' attitudes toward the general and MS-related usefulness of eHealth systems (8 items) and toward the clinical documentation via electronic health records (4 items), and physicians' knowledge about the Multiple Sclerosis Documentation System (3 items).

RESULTS

From 600 mailed surveys, 74 completed surveys were returned. As much as 9 of the 10 practices were already connected to the Internet (67/74), but only 49% preferred a permanent access. The most common type of HIT infrastructure was a complete practice network with several access points. Considering data sharing with research registers, 43% opted for an online interface, whereas 58% decided on an offline method of data transmission. eHealth services were perceived as generally useful for physicians and nurses in neurological practices with highest capabilities for improvements in clinical documentation, data acquisition, diagnosis of specific MS symptoms, physician-patient communication, and patient education. Practices specialized in MS in comparison with other neurological practices presented an increased interest in online documentation. Among the participating centers, 91% welcomed the opportunity of a specific clinical documentation for MS and 87% showed great interest in an extended and more interconnected electronic documentation of MS patients. Clinical parameters (59/74) were most important in documentation, followed by symptomatic parameters like measures of fatigue or depression (53/74) and quality of life (47/74).

CONCLUSIONS

Physicians and nurses may significantly benefit from an electronically assisted documentation and patient management. Many aspects of patient documentation and education will be enhanced by eHealth services if the most informative measures are integrated in an easy-to-use and easily connectable approach. MS-specific eHealth services were highly appreciated, but the current level of adoption is still behind the level of interest in an extended and more interconnected electronic documentation of MS patients.