Building the Clinical Case for Electronic Health Records

In previous articles we have introduced several steps which are critical to optimizing the successful implementation of electronic health records. Part of this process necessitates buy-in from organizational leadership (e.g. Board and senior administration) followed by clinical staff and other organizational membership.

Despite national efforts encouraging EHR adoption, including the new administrations efforts to attach such support as part of the economic stimulus package, it is not a given that any of the above constituents will embrace the substantial commitment of time, resource utilization, and change in process let alone the cost expenditure. As such, this article attempts to help the initiators of an EHR implementation build the clinical case for same. A future article will focus in more detail on building the business case.

It is truly remarkable that despite a history of quality improvement endeavors in the business community dating to the mid-1900's, it was only just prior to the turn of the century that substantial attention was given to the evident deficits in the quality of the United States healthcare system. Much of the impetus for this resulted from a series of reports which drew attention to the considerable opportunities for improvement therein.

These reports reached a crescendo with the year 2000 publication of To Error Is Human (Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. [eds.] To Err is Human: Building a Safer Health System. Washington, D.C., National Academies Press, 2000.). Shortly thereafter, the release of Crossing the Quality Chasm (Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C., National Academies Press, 2001.), focused laser-beam attention on strategies to improve the quality of healthcare in the United States.

Central to this plan was the notion that healthcare would be improved by attending to a number of measurable aims (i.e. safety, effectiveness, efficiency, timeliness, patient-centeredness, and equity) all of which could be observed through quantifiable metrics.

With this concept in mind, clinicians and providers are increasingly challenged to monitor an apparently limitless array of measures while at the same time being expected by patients, payers, and regulatory bodies to spend more time documenting the care they deliver. These often conflicting expectations have necessitated a means to address this dichotomy; electronic health records have been proposed as just such a means.

Much of the background for this recommendation comes from another report by the Institute of Medicine, (Dick, R.S. and Steen, E.B. [eds.], The Computer-Based Patient Record: An Essential Technology for Health Care, Washington, D.C., National Academy Press, 1991.), years before the seminal "Crossing..." article; since then a number of reports have provided further support for this role for EHRs.

For example, computer physician order entry has been proposed to be an important component in reducing the incidence of adverse drug reactions and particularly those which might result in patient death. In fact, a number of reports have demonstrated a greater than 50 percent reduction in medication errors related to the use of CPOE.

As documented by the HIMSS EHR adoption model, CPOE corresponds to a considerable functional evolution in EHR capabilities (stage four of a seven stage model) as it represents progression from clinicians passively reviewing electronically provided data to clinicians actively interacting with the electronic record. Even then, CPOE initially focused primarily on converting relatively straightforward order writing processes that were paper-based to electronic-based processes in combination with alert-focused decision support. Recently, CPOE has further progressed in sophistication to become a principal component of a comprehensive data repository that has the capacity to integrate information from varieties of applications.

Initial proponents of EHRs assumed that there would be a positive correlation between the quality of healthcare and the use of EHRs; this however, was difficult to confirm let alone quantify. Recent data is beginning to demonstrate the validity of this relationship. In 2005, Hospitals and Health Networks reported that its' list of the "100 most wired hospitals and health care systems" had on average a 7.2 percent lower risk-adjusted mortality rate as compared with other hospitals. Even more recently, a multi-hospital study from 12/2005-6/2006 demonstrated a 15 percent drop in mortality among 41 Texas hospitals going from paper-based to electronic health records (Amarasingham R et al, Arch Int Med 2009;169:108-114). In addition, hospitals with increased CPOE adoption recorded decreased overall complications and decreased cost-per-admission.

It should come as no surprise that since healthcare has been so slow to adopt routine quality of care endeavors into standard practice, that it would be similarly slow to utilize electronic capabilities in the form of EHRs to facilitate adoption of quality management tools. One may rightly ask nonetheless, why is it that now, nearly 20 years after the initial impetus toward EHR, that it is finally starting to gain traction among providers? One explanation has been that the related technology has finally become sufficiently sophisticated so as to have enhanced its user-friendliness. Moreover, the increased speed and portability of current computers, the availability of high speed networks (including wireless), the availability of mobile technology such as smart-phones, improved scanning capability, and significant reductions in cost, have created an environment where information can typically be managed electronically substantially faster and more cost effectively than it could be manually. In like manner, "point-and-click" technology, increasingly sophisticated templates and care plans, integration of dictation with templates, augmented voice-recognition capabilities, and others have increased clinician comfort level and contributed substantially toward EHR adoption.

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