Practice Management
Electronic Health Records: Time to Take the Plunge
Gluck PA
The Female Patient. 2011;36(1):39-42

The benefits of electronic health records (EHR) are now clear, but the consequences of making the wrong decisions are significant. Armed with the right information, clinicians must begin the process of EHR implementation.

EHR encompasses a wide range of systems and capabilities. Some current information systems only store patient data. Robust, fully functional systems store many data components, including medications (allergies), history, physical examination, problem lists, and health maintenance, and allow simultaneous access by diverse health care professionals. The most robust systems have analytical capabilities and clinical decision support systems (CDSS) based on current guidelines. Also, EHR systems may be used for secondary purposes beyond direct patient care, such as quality assessment and improvement, as well as health policy planning.1

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The National Ambulatory Medical Survey excluded information systems used only for financial management, such as billing. The most recent survey included 3,200 inperson (phone) interviews and 2,000 mail surveys (64% response rate). Based on its data, there has been a significant increase in uptake of basic EHR systems, with a more modest increase in fully functional systems, as described in Table 1.2,3

A 2007 survey of 1,144 physicians in Massachusetts (79.4% response rate) reported an increase in use of EHR from 23% in 2005 to 35% in 2007. The individual component demonstrating the most significant increase was e-prescribing.4 Even if the EHR had the capability for e-prescribing, 25% of providers used this feature only occasionally or not at all.5

Overall, the penetration of EHR, especially fully functional systems, in the outpatient environment is exceedingly slow. Factors associated with increased rates of adoption include primary care specialties, younger practitioners, availability of information technology (IT) support, large group or hospital-based practice, Western states, urban location, and teaching programs.2,6,7

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There are 3 major components to the ideal EHR: (1) clinical records, (2) e-prescribing with advanced features, and (3) CDSS with frequent updates.

Aside from the overall requirements for fully functional EHR, an ObGyn practice presents special challenges for system architecture. A general ObGyn practice encompasses both primary and specialty care. Care settings include the office, ambulatory surgery center, and hospital.

Obstetric care with frequent visits presents a unique set of EHR challenges. There must be rapid data capture, ability to plot maternal trends (eg, weight and blood pressure) and fetal trends (eg, growth curves), as well as storage of nondata elements such as ultrasound images and nonstress tests.

Obstetric information and concerns can change rapidly during pregnancy, such as adjustment of estimated due date. Ideally, prompts will remind providers of the appropriate screening test at each stage of pregnancy. Simultaneous, remote access to data in multiple locations is especially critical. Contemporaneous exchange of information (eg, for group B streptoccocus status) between the hospital and the office or clinic is critical and mandates a high degree of interoperability.

Gynecology also requires storage of nondata elements such as ultrasound and colposcopy. In addition, there should be prompts for health maintenance and agespecific screening. Many of the special needs in an ObGyn practice are not currently part of the certifying process for EHR systems.8

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Gynecology also requires storage of nondata elements such as ultrasound and colposcopy. In addition, there should be prompts for health maintenance and agespecific screening. Many of the special needs in an ObGyn practice are not currently part of the certifying process for EHR systems.8

Prompts reduce the risk of drug allergies, drug interactions, and critical lab alerts, while increasing preventive care. Prompts also improve clinical decisions, communication with patients, accuracy and efficiency of prescription refills, and compliance with chronic disease guidelines.2 When compared to EHR, paper admission records to labor and delivery were more likely to miss key clinical information, such as contraction frequency, membrane status, vaginal bleeding, and fetal movement, as well as prenatal labs, eg, HIV status.10

From a meta-analysis, 23 of 25 studies showed that computerized provider order entry (CPOE) significantly reduced medication errors, as well as potential and actual adverse drug events.11

Without EHR, the labor costs to retrieve, review, and analyze medical information in support of quality improvement programs would be prohibitive.12


Financial Benefits

Financial benefits and return on investment from an EHR are more difficult to quantify, because of the indirect costs and savings. The initial software costs range from $15,000 to $45,000 per provider. Added to that, however, are the hardware costs, initial reduced efficiency, annual IT support, and transitioning records from a paper to an electronic environment. On the other hand, there is increased revenue from improved charge capture and reduced billing errors.

EHR reduced costs by decreasing waste through lower supply and printing costs, more efficient test review and patient notification, lower transcription costs, fewer chart pulls, increased productivity through easy access to records, and less employee turnover. Often these efficiencies resulted in a reduction in the number of employees.

Financial benefits of e-prescribing include fewer pharmacy recalls because of formularies, legibility, or dosing issues. Medication refills are more efficient and accurate.

In addition to the other costs, CDSS requires physician time for development and continual review of complex clinical algorithms. The financial benefits of CDSS include shorter hospital stay, reduced drug costs, improved preventative care, and prompt ordering of appropriate treatments.13

Even more difficult to assess is the reduced liability risk that results from improved safety and quality, improved coordination of care, and improved patient satisfaction. Using a logistic regression comparison in Massachusetts, a direct link was shown between use of EHR and fewer malpractice claims and payments.14

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The biggest and most consistent barrier preventing wider dissemination of EHR is concern about costs, both initial and ongoing, and uncertain return on investment. Other significant barriers include physician resistance to change, implementation problems, lack of IT support, loss of productivity during the transition, and maintenance of patient confidentiality and security.2 Nothing will set back EHR adaptation more than poorly designed systems and inadequate training in which "institutions will convert complex paper-based systems to expensive digital chaos."15

Clinician decision makers are also standing on the sidelines, concerned that the system they buy today will be obsolete tomorrow because of interoperability concerns and noncompliance with meaningful use criteria.

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Under the auspices of the Center for Medicare and Medicaid Services (CMS), meaningful use criteria was proposed to improve the quality of care, increase efficiency, enhance CDSS, expand research opportunities, reduce costs, and incentivize EHR adoption. The initial proposal was modified to facilitate compliance.

To qualify for provider "bonuses" of up to $44,000 for Medicare patients or $63,750 if certain Medicaid thresholds are met, the EHR system must meet all 15 core criteria, along with 5 other criteria selected from a menu of 10 by October 2011.16 The remaining 5 criteria must be implemented by October 2012.

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EHR will improve efficiencies, reduce medical errors, and eventually result in a positive return on investment. The question is not if clinicians should convert to a robust EHR system but when and how.

The author reports no actual or potential conflict of interest in relation to this article.

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  2. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care—a national survey of physicians. N Engl J Med. 2008;359(1): 50-60.
  3. Hsioa CJ, Beatty PC, Hing ES, Woodwell BA, Rechtsteiner EA, Sisk JE. Electronic medical record/ electronic health record use by office-based physicians: United States, 2008 and preliminary 2009. Available at: ehr/emr_ehr.pdf. Accessed September 21, 2010.
  4. Simon SR, Soran CS, Kaushal R, et al. Physicians' use of key functions in electronic health records from 2005 to 2007: a statewide survey. J Am Med Inform Assoc. 2009;16(4):465-470.
  5. Grossman JM. Even when physicians adopt e-prescribing, use of advanced features lags. Issue Brief Cent Stud Health Syst Change. 2010;(133):1-5.
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  8. McCoy MJ, Diamond AM, Strunk AL. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol. 2010;116(1):140-143.
  9. Elders NC, McEwen TR, Flach F, Gallimore J, Pallerla H. The management of test results in primary care: does an electronic medical record make a difference? Fam Med. 2010;42(5):327-333.
  10. Eden KB, Messina R, Li H, Osterweil P, Henderson CR, Guise JM. Examining the value of electronic health records on labor and delivery. Am J Obstet Gynecol. 2008;199(3):307.e1-e9.
  11. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5): 585-600.
  12. Wachter RM. Expected and unanticipated consequences of the quality and information technology revolutions. JAMA. 2006;295(23):2780-2783.
  13. Menachemi N, Brooks RG. Reviewing the benefits and costs of electronic health records and associated patient safety technologies. J Med Syst. 2006;30(3): 159-168.
  14. Virapongse A, Bates DW, Shi P, et al. Electronic health records and malpractice claims in office practice. Arch Intern Med. 2008;168(21):2362-2367.
  15. Kadry B, Sanderson IC, Macario A. Challenges that limit meaningful use of health information technology. Curr Opin Anaesthesiol. 2010;23(2):184-192.
  16. Centers for Medicare and Medicaid Services. Medicare & Medicaid EHR Incentive Program Final Rule: Implementing the American Recovery & Reinvestment Act of 2009. July 20, 2010. Available at: /EHRIncentivePrograms/Downloads/EHR_Incentive_ Program_Agency_Training_v8-20.pdf. Accessed September 24, 2010.


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