Building the Clinical Case for Electronic Health Records

By Edgar D. Staren, MD
10:05 AM

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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Finally, through capabilities such as electronic prescribing, allergy or drug-interaction checking, and remote chart access, EHRs are allowing for care opportunities simply not available to clinicians from paper charts. Particularly important given the increased time expectations placed upon modern clinicians, is the enhanced efficiency provided by EHRs which allow for more time to interact with patients rather than medical records. How can the EHR have such a substantial impact on patient care?  It does so through a number of means but especially, via improved documentation, access to data, and communication.

Clinical documentation which can be viewed in an EHR are quite comprehensive and includes: demographic information, clinical documents (e.g. notes, operative reports, problem lists), laboratory information (e.g. hematology, chemistry, microbiology, pathology, ABG's, PFT's, and EEG's), radiology reports and images (e.g. x-rays, CT, and MRI), and scheduling. The increased accuracy and legibility of clinical documentation and orders increases patient safety; this also has the effect of decreasing liability risk. Improved patient safety and timeliness of care is also accomplished through alerts and rules (e.g. being reminded of a drug interaction or allergy as a clinician writes a prescription) triggered by electronic documentation. These same alerts can be utilized to enhance continuing clinical education of staff by recommending evidence-based, cost-effective management options.

Clinical quality is improved by having more ready access to a comprehensive repository of clinical information at the time of the patient encounter. Off-site receipt of clinical alerts through mobile devices and electronic matching of the patient and order (e.g. medication) at the time and point of administration or point of care (e.g. bar code scanners checking for 5 "rights" - right patient, medication, dose, route, and time) can help to avoid just the types of errors described in the IOM report. The ability of the entire healthcare team to easily monitor and analyze individual patient outcome measures as well as the ability to trigger reminders of patients who are due for clinical tests and/or follow-up, greatly facilitates real-time care decisions and a coordinated care program.  Moreover, the EHR can provide a secure access to patient data thereby restricting confidential information to only those users appropriately authorized to access to them.

An EHR system can manage records from multiple offices as well as multiple types of records. Furthermore, the use of standard clinical care record (CCR) formats can allow for information to be shared between different healthcare organizations and EHR systems. All of this can facilitate increased collaboration and communication across departments and organizations leading to faster development of recommendations and treatment plans as well as decreased unnecessary and/or duplicative documentation and testing. The EHR allows for preparation of copies of records for electronic mailing to referring or affiliate physician files. The EHR greatly facilitates user-friendly presentation and analysis of clinical outcomes; it provides varieties of choices on ways to display the data (e.g. graphs, tables) thereby facilitating its review and analysis. Communication is further improved through electronic transfer of prescriptions directly to pharmacies, by personalized patient education instructions/handouts printed at the point of care, and by immediate availability of patient notes to multiple caregivers or the patients themselves, even at remote sites.

The EHR provides a foundation for better data mining because the operational data will exist in common, relational databases where data can be extracted to a data warehouse. Improved data mining can be used to identify patient groups who may be appropriate for preventive diagnostics and interventions, which can enhance quality of care and organizational revenue. Strategies for optimal clinical management can be evaluated retrospectively or prospectively as to their actual benefit. Current processes can be quantitatively measured; these outcomes may be compared over time using standard control charts, compared to other organizations, or established benchmarks. Reliable measurement and presentation of data often leads to decreased variation in practices by supporting organizational adoption of benchmarks and subsequent evidenced-based medical practice. Benchmark targets can be electronically communicated to departments, entire hospitals, or even systems. By reviewing the status of current processes through EHR associated measures and analytics, clinical guidelines can be established and monitored in an ongoing way so as to constantly update best practice modalities. Such a program of prospective analysis and implementation would be impossible without the availability of an EHR.

EHRs also provide a foundation for patient-centered portals which allow for secure internet access to parts of a patients own medical records and as such, information regarding their current medications, problem lists, and test results.  Patients may even be able to schedule/cancel appointments and complete forms prior to their visit. This and other components of the EHR may allow for quicker scheduling of diagnostic and therapeutic procedures and reduced turnaround time for orders and results. All of the above can substantially decrease non-value added time for the patient.

Long-term benefits that result from the immediate access to complete, accurate patient information afforded by an EHR extend beyond traditional, quantitative benefits.  As a result of carefully defining the various processes of one's business (e.g. process modeling) necessary for optimal EHR implementation, it is expected that healthcare organizations will identify ways to increase operating efficiencies, better utilize current staff and resources, and ultimately improve patient care and safety. The EHR assists the health care manager in justifying standardization of clinical pathways based on evidence-based practice thereby reducing variation in process across an organization. From this perspective, the EHR system becomes a tool for optimizing the way an organization does its business.