Electronic Health Records

Electronic health records (EHRs) have been in development for decades. In the pre-Internet era, these systems were simply versions of electronic charting and resembled the paper office record. These early versions were called electronic medical records (EMRs) since they were limited to the physician’s office. “Electronic health record” implies that the record encompasses more than medical care, reflects the total health of the patient, and would be jointly “owned” by the physician and patient.

Electronic charting reflects a first generation of EHRs that were developed and produced from the 1970s to 1995. These records help the physician store and retrieve data, but they are not useful beyond the confines of the office. Some early EHRs were integrated with the patient billing system — a major advantage since electronic billing predated electronic records. During this early period, fewer than 5 percent of physicians had EHRs.

The coming of the Internet age, which began for the masses in 1995 with the development of Web browsers, marked a new period of development for electronic records. Second-generation EMRs became “Web enabled,” allowing transmission of all or part of the record over the Internet to the hospital, to consultants, and even to the patient. With the dot-com boom of the late 1990s, many hundreds of EHR companies came into being along with companies for specialized purposes such as electronic prescribing. The hopes that physicians would convert to EHR and other electronic systems en masse were not realized, and many companies went bust.

With the turn of the millennium, still only about 5 percent  of physicians were using EHRs. In November 1999, the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System1. Headlines across America described the 44,000 to 98,000 deaths that each year were attributable to medical errors. The IOM report called for the end of physician handwriting and the adoption of EHRs. A follow-up IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century in 2001, further promoted the adoption of EHRs, electronic prescribing, and clinical decision support using Internet sources2. Political pressure to improve the quality of healthcare in America continued to mount until the president, leaders in Congress, and a new health information technology czar, David Brailer, called for a decade of health information technology (HIT) in 2004. The movement toward EHRs and HIT picked up steam, and the diffusion of EHRs into medical practice is now gaining momentum.

The first-generation EMR was characterized by electronic charting, the second generation was Web enabled, but the third-generation EHR has added the important dimension of clinical decision support. If the patient data are synthesized into one place and can be connected to the world of knowledge on the Internet, this patient data should become intelligent and help guide the physician’s decision. With clinical decision support, physicians are able to consistently use best practice guidelines and be alerted to potential mistakes and complications at the point of care.
Electronic charting, Web-based communication, and clinical decision support form the triple convergence that truly revolutionizes the delivery of care. Any physician considering the purchase of an EHR system should look for all three dimensions in an EHR product.

Electronic Charting

Electronic records that look like paper records cause less confusion and intimidation. While such familiarity has some value, it should not be the overriding design issue. Electronic records should greatly improve medical record keeping, not just mimic paper records. The primary goal is to make patient information readily available. The functionalities of any good EHR include:

Single entry and multiple locations for critical information. For example, the patient’s vital signs are entered once and automatically become part of the day’s progress note and a vital-sign flow sheet. A diagnosis is entered once and is then automatically put on the patient’s problem list. A medication is entered once and is automatically put on a medication list.

A menu of important types or categories of patient information. The menu may include items such as a Problem List, Medication List, Chart Review of All Encounters by date, Preventive Services, Past History, Family History, Laboratory Review, Imaging Review, Consultant Reports, Hospitalizations, and Flow sheets.

Templates for easy entry of information in a consistent format. The record should come with many phrases and text bundles embedded in the record, with the capability for the physician to customize the information according to preference.

Multiple methods for data entry. Methods may include keyboarding, voice recognition, cutting and pasting, and scanning from outside sources.A messaging system for communication with patients and staff with automatic entry into the patient’s record. Functions such as prescription refills and laboratory review fit into this area. Letters or electronic messages to patients and consultants are developed using the record.

Web-based Communication

Web-based communication allows for patient care to extend beyond the office visit. Also, the asynchronous nature of this communication adds an element of mutual convenience that telephone communication does not have. Moreover, it is a self-documenting process. Having a portal for Web-based communication inside the EHR allows for automatically capturing the messages and incorporating them into the record. It also provides full patient information, allowing the physician to communicate in an informed manner. Web-based communication is especially helpful for:

• Communicating lab results and other reports
• Monitoring chronic illness
• Providing behavioral coaching for lifestyle change
• Providing reassurance and guidance for minor acute problems that do not require an office visit
• Allowing the patient to ask questions and obtain information outside of office visits.

Web-based communication provides a new platform for patient care that allows for a more selective use of office visits. Shifting care to this platform may allow for more available time when patients are seen in the office. Of course, a reimbursement model must be implemented that supports online communication in lieu of visits3,4.

A physician is well advised to select an EHR system that offers a portal for Web-based communication. Patients should have access to their health information and be able to provide updated information, which then becomes part of a unified and transportable health record. Appropriate privacy is provided through firewalls and encryption of messages, features that are part of any quality EHR product having a Web portal.

Clinical Decision Support

In the 1997 book by Michael Millenson, Demanding Medical Excellence, David Eddy, MD, calls for all physicians to begin using information technology for clinical decision support in order to provide consistent excellent care5. An article in the Wall Street Journal suggests that if physicians had access to clinical information at the point of care, as many as eight decisions would be made differently each day6. Most updated EHRs today have embedded clinical decision support functions. These will greatly improve in the next few years. Now or in the near future, look for the following functions:

Drug interactions. This is the oldest and most common decision support tool in EHRs and helps prevent medication complications.

Prevention reminders. Recommendations such as those of the U.S. Preventive Services Task Force can be embedded into the patient’s record and change as the patient ages. The physician should be able to customize these reminders.

Disease management guidelines. The EHR should help the physician provide current best practice by having clinical guidelines embedded in the record and accessible during the process of care. A common scenario is of a patient with diabetes and hypertension, and there is a choice of therapies. Another example would be of showing the indications for diagnostic testing given certain clinical signs and symptoms.

Drug formularies and allowable services. Both are usually specified by the patient’s insurance plan.

Embedded knowledge sources. These resources allow the physician to review information about a condition within the record while still seeing the patient.

Most clinical decision support today provides side-by-side information accessible at the point of care. In the near future, virtual intelligence programs will make the patient’s clinical information inherently intelligent and will guide patient care.

Financial Considerations

The greatest factor limiting the adoption of an EHR system is the expense. While EHRs have been shown to lower health care costs through providing better information and reducing repetition of unnecessary services, most of these savings go to the health plan, not the physician. With a price tag ranging from $5,000 to $30,000 per physician to set up an EHR system, most physicians are waiting for an imperative to change. That imperative may have arrived in the form of pay for performance (P4P) reimbursement.

The federal government, through Medicare and Medicaid, and private health insurance, through employers, have adopted P4P as the means to improve quality while controlling healthcare costs. While the formulas may be complicated, quite simply the payers will only provide reasonable reimbursement if certain quality parameters are met. Most likely, the only way a physician’s office will be able to report patient information to meet P4P requirements will be through EHRs. Reimbursement will drive almost universal EHR implementation within this decade.

Conclusion

Since physicians will need an EHR system to sustain their practice, they should get a good one. This means a third-generation EHR that provides not only electronic charting, but Web-based communication and clinical decision support. Select a vendor that will be around for a long time, so their upgraded software will easily fit into your practice. There are a variety of sources to get EHR information, and the annual conferences and exhibitions of Healthcare Information and Management Systems Society (HIMSS [http://www.himssanalytics.org/ASP/index.asp]) and the Medical Records Institute’s Towards the Electronic Patient Record (TEPR [http://www.medrecinst.com]) are good places to see many products. I recommend that primary care physicians use the Center for Health Information Technology at the American Academy of Family Physicians (AAFP)7. AAFP members get a discount, and all the vendors listed have made a commitment to improving the quality of primary care. For more information, refer to Transforming Care Using Information Technology.

This is a historic time for the practice of medicine. Some day, physicians will look back at this as the beginning of modern medicine. Old paper records are archaic, and the process of care based on using them is primitive in comparison to that which is facilitated by EHRs. It is commonly said “the Internet changes everything.” Medical practice has held out on this change for as long as it could, but that time is now past. All physicians should be in transition to a modern EHR system.