THE ELECTRONIC HEALTH RECORD

As previously discussed, patient medical records are used by health care organizations for documenting patient care, as a communication tool for those involved in the patient’s care, and to support reimbursement and research. Historically most patient records have been kept in paper form. Numerous studies have revealed the problems with paper-based medical records (Burnum, 1989; Hershey, McAloon, & Bertram, 1989; Institute of Medicine, 1991). These records are often illegible, incomplete, or unavailable when and where they are needed. They lack any type of active decision-support capability and make data collection and analysis very cumbersome. This passive role for the medical record is no longer sufficient in today’s health care environment. Health care providers need access to active tools that afford them clinical decision-support capabilities and access to the latest relevant research findings, reminders, alerts, and other knowledge aids. Along with patients, they need access to systems that will support the integration of care across the continuum. The health record of the future will likely become as critical to the accurate diagnosis and treatment of patients as the physician’s stethoscope has been to detecting heart murmurs and respiratory problems.

EHR Definition and Functions

What are electronic health records, and how do they differ from merely automating the paper record? In Chapter Four we introduced the concept of the EHR when we described the Institute of Medicine’s definition of the computer-based patient record (CPR) in its 1991 report titled The Computer-Based Patient Record: An Essential Technology for Health Care. Since this Institute of Medicine (IOM) report was first published, a variety of terms have been used in the literature to describe EHR-related systems. By the late 1990s, the term CPR had been generally replaced with the terms electronic medical record (EMR) or electronic health record (EHR). In 2008, after having sought widespread input and consensus, the National Alliance for Health Information Technology proposed standard definitions for the electronic medical record, the electronic health record, and the personal health record. Table 5.1 displays these definitions. It is common to find the terms EMR and EHR used interchangeably. The IOM defines the EHR as a system that can perform eight electronic functions (Table 5.2); the first four functions are considered the core of an EHR, although all are important elements to achieving meaningful use.

Table 5.1. Health information technology definitions

Source: National Alliance for Health Information Technology, 2008.

Electronic Medical Record	Electronic Health Record	Personal Health Record
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff in one health care organization.	An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.	An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Table 5.2. Functions of an EHR system as defined by the IOM

Source: Adapted from IOM, 2003.

Core Functions

Other Functions

Health information and data: includes medical and nursing diagnoses, a medication list, allergies, demographics, clinical narratives, and laboratory test results.
Results management: manages all types of results (for example, laboratory test results and radiology procedure results) electronically.
Order entry and support: incorporates use of computerized provider order entry, particularly in ordering medications.
Decision support: employs computerized clinical decision-support capabilities such as reminders, alerts, and computer-assisted diagnosing.

Electronic communication and connectivity: enables those involved in patient care to communicate effectively with each other and with the patient; technologies to facilitate communication and connectivity may include e-mail, Web messaging, and telemedicine.
Patient support: includes everything from patient education materials to home monitoring to telehealth.
Reporting and population health management: establishes standardized terminology and data formats for public and private sector reporting requirements.

An EHR can electronically collect and store patient data, supply that information to providers on request, permit clinicians to enter orders directly into a computerized provider order entry (CPOE) system, and advise health care practitioners by providing decision-support tools such as reminders, alerts, and access to the latest research findings or appropriate evidence-based guidelines. These decision-support capabilities make the EHR far more robust than a digital version of the paper medical record.

Figure 5.1 illustrates an EHR alert reminding the clinician that the patient is allergic to certain medication or that two medications should not be taken in combination with each other. Reminders might also show that the patient is due for a health maintenance test such as a mammography or a cholesterol test or for influenza vaccine (Figure 5.2).

c5-fig-0001 — **Figure 5.1.** Sample drug alert screen

*Source:* Partners HealthCare.

c5-fig-0002 — **Figure 5.2.** Sample EHR screen

*Source:* Partners HealthCare.

EHR Current Adoption and Use

How widely are EHR systems used in hospitals, physician practices, and other health care organizations? Up until most recently there have been few national studies to provide reliable estimates on the adoption rates of EHRs by U.S. physicians and hospitals, and estimates varied considerably. A number of professional organizations and researchers have attempted to estimate EHR adoption rates, yet accurately measuring adoption has been difficult for several reasons. First, no one definition for the EHR has been used consistently among researchers, and often convenience samples are used. Second, organizations may be in different stages of adoption. EHR adoption does not occur at a single moment in time, but rather evolves in stages over time. Further, the degree of usage and functionality can differ greatly from one organization to the next or even among divisions or departments in a single organization. It may not be clear whether health care providers use specific EHR functions such as decision support, even if they report having an EHR fully deployed.

The latest national survey of U.S. hospitals found that approximately 12 percent had either a basic or comprehensive EHR system (Jha, DesRoches, Campbell et al., 2009). A “basic system” was defined as including clinical documentation (demographics, physician notes, nursing assessments, problem lists, medication lists, and discharge summaries); lab, radiology, and diagnostic test results; as well as electronic ordering of medications. The comprehensive system included all of the basic system components in addition to advance directives, diagnostic images, consultant reports, computerized provider order entry, and decision-support functions such as drug alerts and clinical reminders. Larger hospitals, teaching facilities, and those located in urban regions are more likely to have EHRs than their small, public, and rural hospital counterparts (Jha, DesRoches, Campbell et al., 2009; Jha, DesRoches, Kralovec, & Joshi, 2010).

The adoption rates in physician practices range from an estimated 17 percent (DesRoches, Campbell, Rao et al., 2008) to 56.9 percent (Hsiao, Hing, Socey, & Cai, 2011), depending on the source and definitions used. As with hospitals, the larger the physician practice, the more likely the practice is to use an EHR system (DesRoches et al., 2008). A 2008 national survey of physicians found 4 percent of physicians report having an extensive, fully functional EHR, and 13 percent reported having a basic system (DesRoches, Campbell, Rao et al., 2008). Table 5.3 lists the differences between a basic system and a fully functional system as defined by these researchers.

Table 5.3. Functions defining the use of EHRs

	Basic System	Fully Functional System
Health Information Data
Patient demographics	X	X
Patient problem lists	X	X
Electronic lists of medications taken by patients	X	X
Clinical notes	X	X
Notes including medical history and follow-up		X
Order Entry Management
Orders for prescriptions	X	X
Orders for laboratory tests		X
Orders for radiology tests		X
Prescriptions sent electronically		X
Orders sent electronically		X
Results Management
Viewing laboratory results	X	X
Viewing imaging results	X	X
Electronic images returned		X
Clinical Decision Support
Warnings of drug interactions or contraindications provided		X
Out-of-range test levels highlighted		X
Reminders regarding guidelines-based interventions or screening		X

Less than 7 percent of solo or two-physician practices reported having either a basic or fully functional EHR (Rao, DesRoches, Donelan et al., 2011). Even among those who have adopted EHR systems, physicians from small practices are less likely to use certain features such as viewing and ordering radiologic tests, electronic prescribing, and maintaining clinical notes electronically.

Less is known about EHR adoption rates in settings other than hospitals and physician practices. The first and only study found of home health and hospice agencies reported that approximately 32 percent of home health agencies and 18 percent of hospice agencies are estimated to use computerized systems for record keeping, although it is not clear if these systems offer the level of functionality defined by the IOM (Pearson & Bercovitz, 2006). Data used in estimating these adoption rates come from the 2000 National Home and Hospice Care Survey, conducted before the latest IOM definition existed. Some states, such as California, have attempted to assess health information technology use in nursing homes and long-term care facilities (Hudak & Sharkey, 2007), but again, EHR functions can differ in these settings, and national estimates are nearly nonexistent. Most are qualitative studies examining the barriers to adoption in long-term care facilities (Cherry, Carter, Owen, & Lockhart, 2008) and experiences of early adopters (Cherry, Ford, & Peterson, 2011).

Factors Influencing EHR Adoption

Despite the relatively low rates of EHR use historically, a number of factors are driving demand. The extraordinary focus in recent years on health information technology at the federal level is a major factor. One of the primary goals of the HITECH part of the American Recovery and Reinvestment Act (ARRA) of 2009 is to improve the quality and value of health care through meaningful use of EHR systems. The law specifies that meaningful use includes electronic prescribing, health information exchange, and the reporting of quality measures. Providers participating in Medicare and Medicaid programs have the opportunity to receive incentive dollars for achieving meaningful use of EHR, or risk Medicare payment reductions if they fail to achieve meaningful use of EHR within a specified period of time. Health care payment reform initiatives require that health care providers and organizations are able to provide high-quality, coordinated, cost-effective care and report on quality indicators and outcomes. Trying to achieve these goals in a paper-driven environment, often laden with inefficient processes and duplicate tests, is nearly impossible.

In addition, over the years a number of empirical studies suggest that there is growing evidence that EHR-type systems help improve the quality and efficiency of care. Examples of this include the Veterans Health Administration (VA), which uses an EHR systemwide, so that any veteran treated at any VA hospital throughout the nation will have electronic access to his or her medical record. The VA has also been able to transform its health care system to one of the best in the world based upon quality measures (Jha, Perlin, Kizer, & Dudley, 2003). The Kaiser Permanente Health Plan is another example of an EHR adopter that has made significant improvements in the management and treatment of patients with chronic conditions through their systemwide EHR (Chen, Garrido, Chock, Okawa, & Liang, 2009). Since the early 1990s, Institute of Medicine has called repeatedly for the increased use of EHR systems in health care (1991, 2000, 2001), provided systems are safe and implemented appropriately (2011).

Health care leaders are becoming increasingly aware of the value of EHR systems to the patient, the provider, the organization, and the health care community at large in improving quality, managing population health, addressing patient safety concerns, and decreasing administrative costs. It is no longer a matter of if a health care organization will adopt and implement an EHR system; it is now a matter of when and how.

Value of EHR Systems

A number of studies over the past thirty years have demonstrated the value of using EHR systems and other types of clinical information systems within organizations. The potential benefits fall into three major categories: (1) quality, outcomes, and safety; (2) efficiency, productivity, and cost reduction; and (3) service and satisfaction. Following is a discussion of each of these major categories, along with several examples illustrating the value of EHR systems to the health care process. It is important to note, however, that not all studies have demonstrated positive outcomes. Some have shown no effect and others have shown possible safety issues associated with the introduction and use of features such as CPOE (Han et al., 2005; Koppel, Metlay, Cohen, Kimmel, & Storm, 2005) and other types of health information technology (Koppel & Kreda, 2009; Sittig & Singh, 2011; Sittig, Teich, Osheroff, & Singh, 2009). With the increased interest in and adoption of health IT, the Office of the National Coordinator for Health Information Technology (ONC) asked the IOM to establish a committee to investigate how private and public participants can make health IT–assisted care safer. In 2011, the IOM published its report Health IT and Patient Safety and outlined a number of key recommendations that are discussed more fully in Chapter Seven.

Quality, Outcomes, and Safety

Clinical information systems, including EHRs, can have a significant impact on patient quality, outcomes, and safety. Three major effects on quality are increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. For example, several early studies have shown that physicians who had access to clinical practice guidelines and features such as computerized reminders and alerts were far more likely to provide preventive care than were physicians who did not (Balas et al., 2000; Bates et al., 1999; Kuperman, Teich, Gandhi, & Bates, 2001; Ornstein, Garr, Jenkins, Rust, & Arnon, 1991; Teich et al., 2000). Other studies have found that computerized reminders used in an outpatient setting can have a significant effect on cancer prevention activities such as the performance of stool occult-blood tests, rectal examinations, breast examinations, smoking cessation counseling, and dietary counseling (Landis, Hulkower, & Pierson, 1992; McPhee, Bird, Fordham, Rodnick, & Osborn, 1991; McPhee, Bird, Jenkins, & Fordham, 1989; Yarnall et al., 1998). EHR-related systems have also been shown to improve drug prescribing and administration by providing clinicians with information on the appropriate use of antibiotics at the point of care (Berman, Zaran, & Rybak, 1992), to reduce adverse drug reactions (Bates & Gawande, 2003; Burke & Pestotnik, 1999), to improve the accuracy of drug dosing (Duxbury, 1982), and to reduce errors of omission such as failing to act on results or to carry out indicated tests (Bates & Gawande, 2003; Overhage, Tierney, Zhou, & McDonald, 1997). Bates and Gawande (2003) suggest that information technology can reduce the rate of medical errors by (1) preventing errors and adverse effects, (2) facilitating a more rapid response after an adverse event has occurred, and (3) tracking and providing feedback about adverse effects. Likewise, EHR systems can improve communication, make knowledge more readily available, require key pieces of information (such as the dose of the drug), assist with calculations, perform checks in real time, assist with monitoring, and provide decision support. If effectively incorporated into the care process, all of these features have the potential to improve quality, outcomes, and patient safety.

Efficiency, Productivity, and Cost Reduction

In addition to improving the quality of care the patient receives, some studies have shown that the EHR can improve efficiency, increase productivity, and lead to cost reductions (S. Barlow, Johnson, & Steck, 2004; Grieger, Cohen, & Krusch, 2007; Tierney, Miller, Overhage, & McDonald, 1993). It is not uncommon for clinicians who do not have EHR access to order a second set of tests because the results from the first set are unavailable, so one way EMR systems improve efficiency is by making test results readily available to clinicians (Bates, Kuperman et al., 1999; Tierney, McDonald, Hui, & Martin, 1988; Tierney, Miller, & McDonald, 1990). In addition, EHR features such as computerized reminders and alerts can reduce pharmaceutical costs by prompting physicians to use generic and formulary drugs (Bates & Gawande, 2003; Donald, 1989; Garrett, Hammond, & Stead, 1986; Karson et al., 1999; Levit et al., 2000). EHRs can also provide the infrastructure necessary to measure care processes and aid in continuous quality improvement efforts (Edwards, Huang, Metcalfe, & Sainfort, 2008).

The cost of EHR implementations can range from $15,000 to $50,000 per provider. A network of twenty-six primary care practices in north Texas recently conducted a study evaluating the hardware and software costs, as well as the time and effort invested in EHR implementation. The average cost per physician of implementing an EHR through the first sixty days of launch was $32,409 with an estimated 134.2 hours of staff time expended per physician (Fleming, Culler, McCorkle, Becker, & Ballard, 2011). Several studies have shown that the use of EHR systems can reduce costs related to the retrieval and storage of medical records. For instance, the Memorial Sloan-Kettering Cancer Center estimated that it realized space savings of two thousand square feet after implementing an EMR, equating to a savings of approximately $100,000 a year (Evans & Hayashi, 1994). Twenty-eight ambulatory care providers affiliated with the University of Rochester Medical Center found initial EHR costs were recaptured within sixteen months of implementation, with ongoing annual savings of $9,983 per provider (Grieger et al., 2007). Much of their savings was due to reductions in storage and retrieval costs. Savings have also been realized through the decreased use or elimination of transcription services (Zlabek, Wickus, & Mathiason, 2011). Others have reported that an EHR system has led to higher-quality documentation, resulting in improved coding practices and subsequently higher reimbursement (Barlow et al., 2004; Bleich, Safran, & Slack, 1989; Wager, Lee, White, Ward, & Ornstein, 2000) and also in savings from lower drug expenditures, reduced laboratory and radiology tests (Zlabek, Wickus, & Mathiason, 2011), and decreased billing errors (Wang et al., 2003). As to the impact of EHRs on clinician time, results are mixed. Nurses are more likely to realize time savings in using computer systems to document patient information than their physician counterparts are (Poissant, Pereira, Tamblyn, & Kawasumi, 2005). This may be due in part to the fact that nurses often document using standardized forms or care plans, whereas physicians rarely use standardized templates to document their notes. One recent time-motion study found it took twenty-five seconds longer to enter a prescription order using CPOE than to handwrite the order (Devine, Hollingworth, Hansen et al., 2010). However, the study did not examine time spent in interpreting the legibility of the handwritten orders or time spent in processing the orders. Investments in patient safety and quality of care may well be worth the investment in time.

Service and Satisfaction

The third category of potential benefits to be realized as a result of using EHR systems is improved service and satisfaction, from both the patient’s and the user’s perspectives. Patients whose physicians use EHR systems like the fact that their health information (health history, allergies, medications, and test results) is readily available when and where it is needed. Several early qualitative studies have shown that patients’ response to physicians using an EMR in the examination room is quite positive (Ornstein & Bearden, 1994; Ridsdale & Hudd, 1994). Patients in practices that use an EHR system view their physicians as being innovative and progressive. And even though some physicians initially expressed concern that using the EHR in the examination room might distance them from patients or impede the physician-patient relationship, the majority by far of the studies in this area have shown that EMR use has had no negative impact on the physician-patient relationship (Gadd & Penrod, 2000; Legler & Oates, 1993; Shield, Goldman, Anthony, Wang, Doyle, & Borkan, 2010; Solomon & Dechter, 1995; Wager, Ward et al., 2005) and can enhance it by involving patients more fully in their own care (Marshall & Chin, 1998). Both physicians and patients at Kaiser Permanente found the EHR can expand and strengthen the physician-patient relationship (Cochran, 2010).

In fact, a recent national study of U.S. hospitals found that those with EHRs had significantly higher patient satisfaction scores on items such as “staff always giving patients information about what to do for recovery at home,” “patients rating the hospital as a 9 or a 10 overall,” and “patients would definitely recommend the hospital to others” than hospitals that did not (Kazley, Diana, Ford, & Menachemi, 2011, p. 26). Yet the same study found that EHR use was not significantly associated with other patient satisfaction measures (such as having clean rooms) that one would not expect to be affected by EHR use. The patient’s perception of his experience and care is important, and EHRs may play an increasing role in facilitating communication.

EHR systems can also positively affect provider and support staff satisfaction. In a 2008 national survey of physicians, 90 percent of providers using EHRs reported that they were satisfied or very satisfied with them, and large majorities could point to specific quality benefits (DesRoches, Campbell, Rao et al., 2008). Those who have had systems in place for two or more years are more likely to be satisfied (Menachemi, Powers, Au, & Brooks, 2010). Physicians who have successfully implemented an EHR system in their practice have also reported that it has improved the quality of documentation, efficiency, and had a positive impact on their job satisfaction and stress levels (Wager et al., 2000, 2005, 2008). They are proud of the quality of their records and believe that their documentation is now more complete, accurate, and available and more useful in substantiating the diagnostic and procedural codes assigned for billing purposes. EHR users such as nurses and support staff have reported that the EHR has enhanced their ability to respond to patient questions promptly. Support staff who have historically been responsible for filing paper reports, pulling paper records, and processing bills tout the many benefits of having easy access to patient information through the use of an EHR system (Wager et al., 2000).

Limitations and Need for Future Research

Despite the promising work that has been done to date in evaluating EHRs, much more work is needed, particularly in studying the impact of such systems on organizations or communities that share patient data across organizational boundaries through a health information exchange. Until most recently, the majority of research on EHRs has been limited to four academic institutions that implemented internally developed systems over many years (Chaudhry et al., 2006). In addition, studies that have examined the impact of EHR systems on efficiency have tended to focus on the user level instead of the organizational level or, ultimately, the health system level (Poissant et al., 2005). Thus, an EHR might not save an individual physician time in documenting patient information, yet that information may be more complete and therefore may reduce unnecessary tests or improve the coordination of care, and so the process may save time or money in the long run. The “system-” level benefits such as impact on quality and cost reductions over time will be increasingly important to measure with health care reform. Some experts argue that to improve quality of care, merely implementing an EHR is not sufficient (Zhou et al., 2009). Long-term users are more likely to have relatively mature EHRs with well-designed clinical decision support and order entry management, and they may be more willing to use these features. Use of decision-support features has historically been quite low among EHR users, despite its availability (DesRoches, Campbell, Vogeli et al., 2010; Zhou et al., 2009).

Noteworthy EHR Implementations

There are many examples of health care organizations that have successfully implemented EHR systems and have realized the value that comes from using them. The following examples profile the 2011 Nicholas E. Davies Award recipients in the ambulatory care category and the community health organization category. The Nicholas E. Davies Award was established in 1994 by the Computer-Based Patient Record Institute (CPRI) to recognize organizations that have carried out exemplary implementations of EMR systems. (The Healthcare Information and Management Systems Society [HIMSS] has administered the Davies Award since 2002, the year that CPRI merged with HIMSS.)

PERSPECTIVE

2011 Davies Award Recipients: Ambulatory Care Category

The Reliant Medical Group (formerly known as the Fallon Clinic) was one of two winners in the ambulatory care category. Reliant Medical Group is a multispecialty group practice made up of 265 physicians and 92 advanced practitioners representing over 30 specialties that provides care for approximately 200,000 active patients. Their EHR journey began in 2001 when the CIO and medical director of informatics began discussing with staff at various sites which types of challenges they were facing, and a consensus emerged that an EHR would solve many of their problems. A multidisciplinary team was formed and the committee and organization identified the financial and nonfinancial benefits of EHR implementation, established a vision with objectives, and selected a vendor. They decided to use Epic and implemented the system in phases with breaks of time in between so all users could become comfortable with one change before tackling another.

The organization was also meticulous in the conversion from paper records to electronic, a lengthy process which included extensive mapping of terms and the utilization and creation of necessary interfaces. The result was a system that providers could log into and then immediately access all of the information on a patient for up to the past fifteen years. Reliant Medical Group supported their physicians by supplying them with typing courses, a note creation software for physicians who wanted to continue dictating notes, as well as demonstrations during Documentation Summits and Live Lunches. Extensive planning and coordination efforts, physician and nurse champions, thorough communication and training, and periodic EHR marketing to maintain positive momentum were some of the organization’s keys to success. The organization now utilizes almost every function offered by Epic and over the course of six years saw cost savings of nearly $20 million. Reliant Medical Group is now offering a level of quality care even higher than before and has also seen increases in physician, employee, and patient satisfaction.

2011 Davies Award Recipient: Community Health Organization Category

Hudson River Healthcare, Inc., (HRHCare) was the only winner in the community health organization category. The organization provides care to the underserved, uninsured, and underinsured population of Peekskill, New York, seeing nearly 64,000 patients through over 275,000 visits each year. HRHCare’s journey toward full EHR implementation was full of partnerships and collaborations with other organizations. Already valuing a robust clinical information system and data-driven decision making, the organization’s first EHR implementation in 1999–2000 was spurred by the desire to capture clinical information at the point of service. In 1999, HRHCare became a beta test site for a Windows-based EHR called Cliniflow and later changed vendors in order to better meet community needs. Over the years HRHCare found that the small size of their vendor company became a barrier and they found themselves doing a lot of double entry. The need for a system with greater capability became even clearer after they participated in Preventative Pilot Collaborative in 2004. In 2006, HRHCare developed a set of Strategic Aims and Measures to guide the organization that were based on the Institute of Medicine’s STEEP model and input from all levels of staff, from front-line caregivers to the Executive Team. These Strategic Aims and Measures provided the framework the organization uses to measure strategic planning success, and it was with that framework in mind that HRHCare decided to move to a new system, eClinicalWorks, in 2007. The organization has seen meaningful clinical, financial, and operational improvements and found that their ROI yield was approximately 5.23 to 1.

Source: Adapted from HIMSS, 2011.

OTHER MAJOR HCIS TYPES

In addition to EHR systems, several other clinical information systems or applications warrant discussion. The five we have selected to discuss are computerized provider order entry, medication administration, telemedicine, telehealth, and the personal health record (PHR), including providing patients with access to their health information through patient portals. We selected these systems because they have an enormous potential to improve quality, decrease costs, and improve patient safety or because they are being widely debated and are likely to be hot topics for the next few years—or because they possess both these qualities. In addition, we believe no respectable health information systems text would be complete without a discussion of them!

The first two, computerized provider order entry and medication administration systems, are applications used primarily in health care settings where tests and medications are ordered, performed, or administered. Telemedicine and telehealth are means of delivering services or communicating with patients at a distance. A personal health record is a record the patient creates, maintains, and controls. Its intent is to bring together the data and information that patients need to manage their health. The record can be maintained in paper or electronic form. Each of these information systems is described in the sections that follow, along with their current use and value to the patient care delivery process.

Computerized Provider Order Entry

One of the biggest concerns facing health care organizations today is how to keep patients safe. Several Institute of Medicine studies have brought to the forefront of people’s attention the fact that an estimated 98,000 patients die each year in U.S. hospitals due to medical errors (IOM, 2000, 2001). Medication errors and adverse drug events (ADEs) top the list and are common, costly, and clinically important issues to address. A medication error is an error in the process of ordering, dispensing, or administering a medication, whether or not an injury occurs and whether or not the potential for injury is present. An adverse drug event is an injury resulting from the use of a drug, a use that may or may not have involved a medication error. Thus, a medication error may lead to an adverse drug event but does not necessarily do so (Bates et al., 1999). Studies have shown that computerized provider order entry (CPOE) has the potential to reduce medication errors and adverse drug events (Bates et al., 1999; Bates & Gawande, 2003). In fact the Leapfrog Group has identified CPOE as one of three changes that it believes would most improve patient safety.

Many health care executives have taken steps to implement CPOE or are planning to do so in the near future. What is CPOE? How might it improve patient safety? How widely used are CPOE systems? We begin by defining CPOE and its major functions and then move on to discuss its current use and its potential value in improving patient safety and preventing medical errors.

Definition and Primary Functions of CPOE Systems

During a patient encounter the physician generally orders a number of diagnostic tests and therapeutic plans for the patient. In fact virtually every intervention in patient care—performing diagnostic tests, administering medications, drawing blood—is initiated by a physician’s order. Historically, physicians have handwritten these orders or called them in as verbal orders for a nurse or other health care professional to document. The ordering process itself is a critical step in the patient care process and represents a point where intervention can often prevent medication errors and improve adherence to clinical practice guidelines.

CPOE at its most basic level is a computer application that accepts physician orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians with decision-support capabilities at the point of ordering. For example, an order for a laboratory test might trigger an alert to the physician that the test has already been ordered and the results are pending. An order for a drug to which the patient is allergic might trigger an alert warning the physician of the patient’s allergy and possibly recommending an alternative drug. If a physician orders an expensive test or medication, the CPOE system might show the cost and offer alternative tests or drugs. CPOE systems can also provide other types of clinical decision support to the physician. For instance, if the physician is ordering a series of tests and medications for a common diagnosis, the computer can offer the use of a preprogrammed, institutionally approved set of orders to facilitate the process and can recommend drug therapy to aid the physician in following accepted protocols for that diagnosis (Metzger & Turisco, 2001) (Figure 5.3). The scope of CPOE functions and capabilities can vary considerably. The most advanced systems have sophisticated decision-support capabilities and can aid the provider in diagnosing and treating the patient by supplying information derived from knowledge-based rules and the latest research.

c5-fig-0003 — **Figure 5.3.** Sample CPOE screen

*Source:* Partners HealthCare.

Current Use of CPOE

Estimating the current use of CPOE systems is almost as difficult as assessing the use of EHR systems. A CPOE system is typically an integral part of a comprehensive clinical information system or EHR system and not a stand-alone application. It is estimated that only 8 percent of hospitals have fully implemented CPOE systems (Yu et al., 2009), although approximately 17 percent of hospitals report using CPOE to order medications and 20 percent to order laboratory tests (Jha, DesRoches, Campbell et al., 2009). Hospitals that use CPOE tend to be larger, nonprofit, teaching hospitals.

Why the relatively low usage rate? Part of it may be due to the fact that historically health care executives and vendors did not believe that physicians would be interested in computerized order entry, and consequently CPOE development lagged behind the development of other clinical information system components. Even among hospitals that have implemented a full or partial CPOE system, relatively few require physicians to use the system. We anticipate that this will change in the coming years as hospitals and physicians strive to achieve meaningful use of EHR systems (described more fully in Chapter Six).

Electronic prescribing (e-prescribing) has also surged in popularity since the passage of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which established a prescription drug benefit for Medicare beneficiaries (Part D) and required that Part D plans support an e-prescribing program should any of their providers or pharmacies choose to prescribe electronically (Friedman, Schueth, & Bell, 2009). Since then, payers, employers, pharmacies, state governments, and others are working to promote e-prescribing adoption through incentive payments and addressing standardization issues.

Value of CPOE

Despite the relatively low usage rates, CPOE systems can provide patient care, financial, and organizational benefits. Clearly, one of the fundamental reasons that CPOE has received so much attention in recent years is its potential to improve patient safety and, more specifically, reduce medication errors (Holdsworth et al., 2007; Kazley & Diana, 2011; Walsh et al., 2008). A review of CPOE studies found that 80 percent of studies report significant reductions in total prescribing errors, 43 percent in dosing errors, and 37.5 percent in adverse drug events when CPOE rather than handwritten orders is used (Shamliyan, Duval, Jing, & Kane, 2008). The use of CPOE is also associated with a 66 percent reduction in total prescribing errors for adults and a positive tendency in children. Niazkhani and colleagues (2009) examined the impact of CPOE on clinical workflow by developing a conceptual framework and conducting a literature review of CPOE evaluations between 1990 and 2007. The most frequently reported workflow advantages cited in fifty-one studies included legibility of orders, remote access, and shorter turnaround times. Disadvantages included time-consuming and problematic user-system interactions, and the enforcement of a predefined relationship between clinical tasks and providers (Niazkhani, Pirnejad, Berg, & Aarts, 2009).

Using CPOE systems in outpatient settings shows promise as well, but not as much research has been done in this area. Authors of two studies have found that CPOE can lead to better adherence to clinical protocols and improvements in the stages of clinical decision making—that is, initiation, diagnosing, monitoring and tracking, and acting (D. Johnston, Pan, Walker, Bates, & Middleton, 2003, 2004). They also found that CPOE can lead to improved patient outcomes by reducing medical errors, decreasing morbidity and mortality, and expediting recovery times. A report from the Agency for Healthcare Research and Quality (2001) substantiates the notion that CPOE systems can significantly reduce medication errors in outpatient settings and estimates that such systems may prevent 28 to 95 percent of adverse drug events.

Besides clinical benefits, CPOE systems can also provide financial benefits to a health care organization. For example, organizations that use CPOE systems may require fewer administrative clinical staff, improve the accuracy and timeliness of billing, and increase transaction processing rates (D. Johnston et al., 2004). Studies have also showed reductions in medication turnaround times, elimination of transcription errors, and improvements in countersigning orders (Ahmad et al., 2002; Jensen, 2006).

Despite growing evidence that CPOE systems have positive effects on patient safety, there have been studies that raised concerns. In 2005, researchers from an academic children’s hospital observed an unexpected increase in mortality after implementation of a vendor-acquired CPOE system (Han et al., 2005). Although some have challenged the methods used in this particular study, most would agree that CPOE technology is still evolving and requires ongoing assessment of systems integration and the effectiveness of the human-computer interface (Ash et al., 2007; Kilbridge, Classen, Bates, & Denham, 2006). A CPOE system does not operate in isolation. To function properly, it requires seamless integration within a strong and dynamic health information architecture (Han et al., 2005). Issues such as alert fatigue and the need for ongoing system enhancements are real, and without proper management, unintended consequences can occur. User training conducted by organizations should caution against providers blindly following or unreasonably ignoring alerts and should instead recommend that they use their best judgment in assessing the evidence; otherwise, there are real legal risks (Kesselheim, Cresswell, Phansalkar, Bates, & Sheikh, 2011).

In the late 1980s, the University of Virginia experienced a great deal of resistance to its CPOE initiative. Organizational leaders underestimated the impact of CPOE on clinical workflow as well as on physicians’ and nurses’ time and, in retrospect, did not invest sufficient resources in the effort. Many physicians, including residents, perceived the CPOE as an Information Systems Department initiative rather than as a clinician-led effort and felt it was forced upon them and offered little flexibility. Physicians complained that administration was trying to “turn them into clerks to save money.” Cumbersome interfaces and time-consuming ordering processes, along with the fact that the clinical care processes were never fully redesigned, contributed to the problems encountered (Massaro, 1993a, 1993b). In 2003, Cedars-Sinai Medical Center in Los Angeles experienced some of the same problems with its CPOE system implementation and ended up “pulling the plug” on the system, as the following case study describes. It is one of the most cited cases of all time. Since then, Cedars-Sinai has implemented a different CPOE system.

PERSPECTIVE
CPOE Implementation

Cedars-Sinai Medical Center developed and implemented a computer system known as Patient Care Expert (PCX) several years ago as part of a larger project to modernize the medical center’s computing infrastructure. The PCX system included a CPOE component and used browser-based technology, making the system accessible through any browser-enabled computer anytime, anywhere. Other performance criteria specified that

“The system needed to be highly flexible, allowing for rapid modifications of content and functionality.”
“The system needed to be fully integrated with all ancillary services, patient registration, and patient accounting.”
“The system needed to be user-friendly for large groups of users with a diverse range of familiarity and experience with computers” (Langberg, 2004).

After conducting an extensive review of existing products and obtaining broad input from administration, clinicians, and information technology experts, the Cedars-Sinai board of directors decided the organization should develop an in-house product in collaboration with Perot Systems. In August 2002, after nearly three years of development and testing, Cedars-Sinai launched a pilot program of the PCX system. This pilot involved obstetrical patients over a two-week period, during which approximately 400 patients were entered into the system. As part of the pilot, more than 140 physicians and 200 department staff members used the system to care for all obstetrical patients. Clinical staff tested the system with more than 20,000 orders. By October, more than 2,000 physicians had been trained and certified to use PCX. The pilot was felt to have been very successful, and minor changes were made to the PCX before rolling it out to other areas of the medical center. By January 2003, 700,000 orders had been placed for more than 7,000 patients—more than 10,000 orders per day. The system was operational for more than two-thirds of the medical center’s inpatients. However, in late January 2003, the system was suspended after hundreds of physicians complained that the system slowed down the ordering process and said they feared that orders were getting lost in the system. The medical center had worked with a forty-physician medical executive committee throughout the development and implementation process, and the administration believed that physicians were sufficiently involved throughout the project. However, rank-and-file physicians argued that the committee did not represent their views (Chin, 2003). One physician, for example, argued that the CPOE was very cumbersome and didn’t follow physician workflow. This same physician complained that to order an antibiotic, doctors had to go through three or four computer screens and wait six to eight seconds between screens (Chin, 2003). After receiving such complaints, the administration made the decision to take down the CPOE system. Those involved in the implementation reported that they found themselves managing two complex processes:

“Physician change management: Four months into ‘go-live’ physicians remained deeply concerned about the added time they reported in entering orders and their negative perception of the system’s ease of use. Further, [it was] believed that too many physicians … did not have an optimal working knowledge of the system’s functionality.
“Workflow change management: The procedures involved in hospital-based patient care are complex in any environment and need to be carefully and thoroughly understood in advance of automation. Additionally, CPOE will affect the workflow of all caregivers. [It was found that] far more operational workflow analysis and adjustment needed [to occur] after the ‘go-live’ than was initially anticipated” (Langberg, 2004).

Besides managing these two processes, the management team has instituted a number of system enhancements and has aggregated input from all users to enhance PCX and improve the implementation and workflow procedures. By intensifying training and support resources, and accelerating the system response time, management expects to improve physicians’ experiences.

Source: Adapted from Langberg, 2004.

We will discuss a host of issues related to the implementation of CPOE and other applications more fully in Chapter Eight. At this point, however, it is important to understand that CPOE systems can have a dramatic impact on physicians—how they spend their time, their work patterns, and the functions they perform. CPOE is an expensive and complex project that touches almost all aspects of the health care operation. It is not simply a niche computer system to replace handwritten orders. Rather, CPOE is a tool to aid the provider in order management. It can directly affect not only physician ordering but also physician decision making (through the decision-support features) and care planning, pharmacist decision making and workflow, nursing workflow and documentation, and communication with ancillary services. Just as automating the paper medical record is not the same as implementing an EHR system, automating the ordering process is not the same as implementing a CPOE system. Like an EHR system, a CPOE system provides decision support and can be a useful tool to the provider in managing the patient’s care more effectively.

Medication Administration Systems Using Bar-Coding Technology

Another clinical application that is being widely discussed in terms of its potential to improve patient safety is medication administration that uses bar-code verification technology within an electronic medication administration system, or bar-code e-mar. Like EHR and CPOE systems, bar-code e-mar systems have the potential to address many patient safety issues, particularly those relating to correctly identifying patients and medications.

Bar-coding technology is nothing new. It has infiltrated our lives, and we find it in grocery stores, hospitals, department stores, airports, and even in our own homes. In health care, bar-coding technology has been employed in areas such as materials management, supply inventory, and document management. However, medication administration using bar-coding, which has the potential to enhance productivity, improve patient safety, and ultimately improve quality of care, is still a relatively new area of emphasis. To be effective, medication administration bar-coding systems must be combined with decision-support capabilities and enable alerts and warnings designed to prevent errors. The goal is to ensure that the five “rights” of drug administration are met, meaning getting the right drug to the right patient through the right route at the right dose at the right time (Sakowski et al., 2005).

Most e-mar systems operate in essentially the same way. At the time of admission the patient receives an identification wristband with a bar code. This wristband correctly identifies the patient by name, date of birth, medical record number, and any other important identifying information. Correctly identifying the patient is the first step in seeing that the right patient gets the right medication. Next, the provider scans his or her own bar-coded identification band in order to log into the medication administration system. Bar-coding the provider or employee gives positive identification of the caregiver and ensures secure access to various information systems, according to the individual user’s privileges. It also produces an audit trail showing who has accessed what systems at what time and for what information. When the provider scans the patient’s bar-coded wristband, he or she has access to the physician’s orders and can view what currently needs to be done for the patient. When the caregiver scans a bar-coded item or medication, that code is compared with the order profile. If it does not match, the caregiver is alerted to the discrepancy, and a potential error is averted. The scanning process might also trigger real-time documentation and billing.

Studies have shown that about half of medication errors occur during the ordering process (Hatoum, Catizone, Hutchinson, & Purohit, 1986), but errors also occur in dispensing, administering, and monitoring medications (Kaushal & Bates, 2002; Poon, Cina et al., 2006). Medication administration systems that use bar coding can be highly effective in reducing all types of medication errors, wherever in the treatment cycle they occur (Paoletti et al., 2007; Poon, Cina et al., 2006; Sakowski et al., 2005). A recent prospective, before-and-after, quasi-experimental study compared transcription and medication error rates in units of a 735-bed academic medical center that were using bar-code e-mar technology with the rates in units that had not implemented it (Poon, Keohane et al., 2010). They found a 41.4 percent relative reduction in errors among units that used bar-coding e-mar systems.

A number of resources exist to aid health care organizations in implementing bar-coding systems. HIMSS (2003) developed a resource guide that outlines how bar coding works, describes clinical and administrative applications that can employ bar-coding technology, and offers strategies and tips for successfully implementing bar coding in health care organizations. The University HealthSystem Consortium (UHC) Bar-Coding Task Group has published recommendations for hospitals ranging from general recommendations to technology recommendations and implementation strategies (Cummings, Bush, Smith, & Matuszewski, 2005). In addition, the Department of Veterans Affairs (VA) has implemented bar coding in conjunction with its electronic medical record system used throughout its 163 medical centers. The VA has found that although bar-coding systems can lower medication administration errors, introducing bar coding also presents new challenges (Mills, Neily, Mims, Burkhardt, & Bagian, 2006). To address these challenges, it has employed a series of quality improvement strategies, using multidisciplinary teams to improve the safety and efficiency of the e-mar system. Others have found that it is important to identify and address the barriers to implementation by ensuring adequate training, providing continuous improvement, making certain of ample vendor involvement, acknowledging technology limitations, and providing clear channels of communication (Nanji et al., 2009).

Telemedicine and Telehealth

“Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status” (American Telemedicine Association, n.d.). It is a tool that enables providers to deliver health care services to patients at distant locations, and it is often promoted as a means of addressing the imbalances in the distribution of health care resources. Telemedicine systems have evolved over the past few decades, becoming most prevalent during the 1990s owing to major advancements in telecommunications technology and decreases in equipment and transmission costs. Telemedicine may be as simple as two health care providers discussing a case over the telephone or as sophisticated as using satellite technology and videoconferencing equipment to broadcast a consultation between providers at facilities in two countries. The first method is used daily by most health professionals, and the second is used by the military and some large medical centers. Telemedicine can also include the use of e-mail, smart phones, wireless tools, and other forms of telecommunications technology.

Health care literature often uses the terms telemedicine and telehealth interchangeably. We use telehealth to refer to a broader view of remote health care, one that does not always involve the provision of clinical services, which is generally the province of telemedicine. Telehealth includes the use of technology to access remote health information, diagnostic images, and education.

Current Status and Primary Delivery Methods

Most recent estimates suggest that there are over two hundred telemedicine programs throughout the nation, involving over 3,500 health care institutions (Eron, 2010). The types of telemedicine services may include everything from specialist referral services to patient consultations to remote patient monitoring. Two delivery methods can be used to connect providers to providers or providers to patients. The first is called store and forward. This technology is used primarily for transferring digital images from one location to another. For example, a digital image might be taken with a digital camera, stored on a server, and then sent (or forwarded) to a health care provider at another location upon request. Teleradiology and teledermatology are two telemedicine services that use store-and-forward technology. In the case of teleradiology, one provider might send radiological images such as X-rays, CT scans, or magnetic resonance imaging (MRI) results to another provider to review. In the case of teledermatology, a digital image of the patient’s skin might be sent to a dermatologist for diagnosis or consultation. Store-and-forward technology is generally used in nonemergency situations. These images can be sent using private point-to-point networks.

The second major delivery method is known as two-way interactive videoconferencing and is used when a face-to-face consultation is necessary. For example, a specialty physician in an urban tertiary care hospital might consult with a primary care physician in a rural community, using high-speed or dedicated Internet lines and real-time videoconferencing capabilities. This gives patients and providers in rural communities access to providers, particularly specialists, in urban areas without having to travel. In addition, a number of peripheral devices can be linked to computers to aid in interactive examination. For example, a stethoscope can be linked to a computer, allowing the consulting physician to hear the patient’s heartbeat from a distance. Remote monitoring of patients is also possible through closed-circuit television systems, and electronic monitoring of physiological vital signs can be done through electronic intensive care unit (eICU) patient monitoring systems.

A recent study by Berenson and colleagues examined the reasons hospitals chose either to adopt or not adopt telemedicine to support delivery of their intensive care units (Berenson, Grossman, & November, 2009), also known as eICUs. Some ICU directors felt it was a viable alternative to staffing given the shortage of intensivists and provided the backup and additional patient safety needed for continuous monitoring 24/7, while others preferred to have on-site staff and questioned its return on investment (Berenson, Grossman, & November, 2009). Approximately 10 percent of ICU beds in the United States are now part of eICUs.

Other uses of telemedicine can be found in the military and in university research centers. Robotic equipment is being used for telesurgery applications. Telesurgery can enable a surgeon in one location to remotely control a robotic arm to perform surgery in another location. The military have been developing and deploying this technology particularly for battlefield use, although some academic medical centers are also piloting telesurgery technology.

Telehealth is being used to capture and monitor data from patients at home. Examples of early telehealth efforts include capturing cardiac data from congestive heart failure patients at home, monitoring patient blood sugar levels through glucometers attached to cell phones, and conducting teledermatology visits with the aid of cell phone cameras. Home monitoring devices that transmit physiological data electronically to care providers are also being used in a variety of different ways (LeRouge, Hevner, & Collins, 2007; Shea et al., 2006).

Value of Telemedicine and Telehealth

Telemedicine can make specialty care more accessible to rural and medically underserved communities and can easily connect providers at distance locations. Kaiser Permanente conducted a study examining the impact of remote video technology on quality, use, patient satisfaction, and cost savings in the home health care setting. It found that the technology was well received by patients, capable of maintaining quality of care, and had the potential for cost savings if used as a substitute for some in-person caregiver visits (B. Johnston, Wheeler, Deuser, & Sousa, 2000).

Telemedicine has also shown promising results in improving access to care, quality, and outcomes for patients with chronic diseases (J. Barlow, Singh, Bayer, & Curry, 2007; Gambetta, Dunn, Nelson, Herron, & Arena, 2007). Researchers have found that videoconferencing can enhance the availability and use of psychiatric services for patients living in rural or remote communities (Modai et al., 2006; Spaulding, Belz, DeLurgio, & Williams, 2010). Remote surgery also has value. It could bring to local communities access to the top specialists in the world.

Electronic consultation (e-consultation) is another emerging use of technology that primary care clinicians may use to communicate with specialists about patients asynchronously instead of the typical pager, telephone call, or hallway conversation (Horner, Wagner, & Tufano, 2011). The process for conducting an e-consultation can vary depending on the technology but generally includes (1) requesting clinician poses a clinical question to a consultant electronically, (2) consultant reviews questions and accesses patient’s EHR or other clinical information systems, (3) consultant replies to the requesting clinician or they may correspond back and forth in consulting mode. The system may be web-based or available through a secure server. Since fewer primary care physicians are providing care in hospital settings where they used to interact frequently with specialists, e-consultations have been found to offer clinicians a number of benefits, including

Greater satisfaction owing to convenience and timely and helpful advice
Education transfer from specialist to primary care provider
Information exchange that does not interrupt workflow (it is less disruptive)
More appropriate specialty referrals
Improved information transfer between providers (Horner et al., 2011, p. 5)

Dr. Kendrick, a practicing physician at the University of Oklahoma School of Community Medicine, uses a Web-based e-consultation system called Doc2Doc that was designed to simulate the physician’s lounge culture when providers gathered, developed relationships, and discussed patient cases together (Horner et al., 2011). The Oklahoma Department of Corrections implemented the Doc2Doc system using the University of Oklahoma’s Medical School faculty for specialty referrals. To defray the overall cost of medical care by eliminating unnecessary referrals, the Department of Corrections paid $50 per e-consultation. Since implementing the e-consult system, they have reduced specialty visits by 50 percent and reduced costs (Horner et al., 2011). They have also conducted over 100,000 e-consultations and expanded the use of the system to Louisiana and Kentucky.

These are a few examples of the value of telemedicine. The possibilities for using telemedicine are endless. However, several major barriers must be addressed if telemedicine is to be more widely used and available. Concerns about provider acceptance, interstate licensure, overall confidentiality and liability, data standards, and lack of universal reimbursement for telemedicine services from private payers are barriers to the widespread use of telemedicine. Furthermore, its cost-effectiveness has yet to be fully demonstrated.

Personal Health Record and Patient Portals

With the advent of the Internet, including e-mail, web logs (blogs), and other web-based technologies, patients or consumers have assumed a much more active role in managing their own health care. To empower consumers in recent years, the concept of a personal health record (PHR) has emerged. Although a PHR could be in paper or electronic format, the vision is that the electronic PHR would enable individuals to keep their own health records, and they could share information electronically with their physicians or other health care professionals and receive advice, reminders, test results, and alerts from them. Unlike the EHR, which is managed by health care provider organizations, the PHR is managed by the consumer. It may include both health information and wellness information, such as an individual’s exercise and diet. The consumer decides who has access to the information and controls the content of the record. A patient portal is a secure web site through which patients can access their PHR or EHR. Portals often allow users to complete forms online, schedule appointments, communicate with providers, request refills on prescriptions, review test results, or pay bills (Emont, 2011). See Figure 5.4.

web_c5-fig-0004 — **Figure 5.4.** Sample patient portal

*Source:* Medical University of South Carolina. Used with permission.

What is the value of the PHR, and how does it relate to the EHR? Tang and Lansky (2005) believe the PHR enables individuals to serve as “copilots” in their own care. Patients can receive customized content based on their needs, values, and preferences. PHRs should be lifelong and comprehensive and should support information exchange and portability. Patients are often seen by multiple health care providers in different settings and locations over the course of a lifetime. In our fragmented health care system, this means patients are often left to consolidate information from the various participants in their care. A PHR that brings together important health information across an individual’s lifetime and that is safe, secure, portable, and easily accessible can reduce costs by avoiding unnecessary duplicate tests and improving health care communications.

PHRs may be particularly helpful to patients with chronic illnesses in enabling them to track their diseases in conjunction with their providers, prompting earlier intervention when they encounter a deviation or problem (Tang, Ash, Bates, Overhage, & Sands, 2006). In addition, PHRs may make it easier for caregivers to care for their loved ones by providing those caregivers with access to complete information. Research in this area is in its early stages; however, experts agree that the value of the PHR is greatest when the PHR is integrated with the provider’s EHR (Tang et al., 2006).

Currently, only 7 percent of adults in the United States report having a PHR (Undem, 2010). Six percent indicate they have looked at test results online and 8 percent have sent or received e-mails from their physicians. As EHRs are more widely deployed in the years to come, providing patient access to information will create many policy and technical challenges for health care organizations, payers, and employers, as well as great opportunity. Early adopters have found that a number of important considerations need to be addressed, such as what information (for example, problem lists, medications, laboratory and diagnostic test results, and clinical notes) should be shared with patients, how patients should be authenticated to access their records, what access minors should have, and whether the record should include secure clinician and patient messaging (Halamka, Mandl, & Tang, 2008; Wiljer, Urowitz, Apatu, Leonard, Quartey, & Catton, 2010). Kaiser Permanente’s patient portal and PHR, My Health Manager, is used by more than three million of its eight million members (Emont, 2011). A recent review of the literature on the use of patient portals suggests that they offer a number of potential benefits to providers including administrative efficiencies (such as reduced call volume), improved patient satisfaction, decreased utilization of health services, more effective care, and cost savings (Emont, 2011). In the future, demand for PHR and patient portal functionality will likely increase due to the need to meet meaningful use requirements, a greater emphasis on patient-centered care, and patients’ demand for access to information. Health care leaders will need to examine the extent to which they are equipped to meet consumer expectations.

OVERCOMING BARRIERS TO ADOPTION

What do the EHR, CPOE, e-mar, telemedicine, and many other clinical applications have in common? They all affect the ways providers deliver care to or communicate with patients, and they all confront the same barriers impeding their widespread adoption and use. Most of these barriers can be categorized as (1) financial, (2) organizational or behavioral, (3) technical, or (4) privacy and security. Financial barriers include lack of the capital or other financial resources needed to develop, acquire, implement, and support a health care information system. Organizational and behavioral barriers relate to provider use and acceptance of such systems and the workflow challenges associated with the introduction of new technology. And technical barriers include everything from the work needed to build system interfaces to a lack of adequate definitions and standards for data interchange. Privacy and security involve ensuring the confidentiality of the patient’s personal health information. Although all four types of barriers typically affect all clinical applications, the actual impact of any one barrier may vary considerably. For example, historically the lack of financial resources or of reimbursement for EHR systems has slowed their implementation but not stopped it. Conversely, the lack of financial resources or of reimbursement for telemedicine services has been devastating to telemedicine programs, and many programs have not survived these financial difficulties.

Financial Barriers

EHRs and related systems can be expensive to develop, implement, and support, and even with the EHR incentive funds now available through the Medicare and Medicaid programs, some providers are reluctant to invest in a system when they are unsure of the return on investment and uncertain about the future. Our fee-for-service payment system also does not currently financially reward the improved quality and efficiency that health information technology enables. The up-front investment necessary to acquire an EHR for the small physician practice is substantial. Seventy-eight percent of physicians in the United States practice in groups of eight or fewer, yet it is the small practice that is least likely to adopt an EHR system. As mentioned earlier, estimates of the cost of acquiring and installing an EHR system range from $15,000 to $50,000 (Baron, Fabens, Schiffman, & Wolf, 2005; Miller, West, Brown, Sim, & Ganchoff, 2005), with another amount equal to 15 to 20 percent of the acquisition cost needed to support the system. Physicians and hospitals have historically borne the cost of the EHR system, but the majority of the benefits are realized by patients, payers, and purchasers. Second, EHRs can negatively affect productivity, particularly during the initial months after implementation. One study found that practices experienced a 10 to 15 percent reduction in productivity for at least several months following EHR adoption (Gans, Kralewski, Hammons, & Dowd, 2005). Small physician practices tend to be highly risk averse and are fearful about the possibility of implementation failures. Thus, the misalignment of incentives is a huge barrier.

Beyond changes in reimbursement, in August 2006, the Centers for Medicare and Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) Office of the Inspector General expanded exceptions to the Stark and antikickback regulations, permitting hospitals to offer computerized health information systems (or access to such systems) to physician practices, potentially at a significantly greater discount than the practices could obtain if they purchased the systems individually. To meet requirements, any donated system must be “necessary and used predominately” to create, maintain, transmit, and receive electronic health record information (HHS, 2006).

Organizational and Behavioral Barriers

In addition to the financial barriers, many behavioral or organizational barriers impede the adoption of EHR systems and other clinical applications. These barriers can be equally difficult to overcome as the financial barriers. They include everything from lack of physician acceptance to changes in workflow to differences in state licensing regulations.

EHR and other clinical information systems may alter the way providers interact with patients and other team members and render patient care services. They often require that providers enter visit notes directly into the system, respond to system reminders and alerts, and give complete documentation. Studies have shown that the EHR, CPOE, and other clinical information applications can be difficult to incorporate into existing workflow processes and may require additional time (Devine et al., 2010; Poissant et al., 2005; Poon et al., 2004). When a system is initially implemented, it invariably adds time to the physician’s day. This may seem contrary to one of the reasons for implementing EHR systems, to save time. In truth, EHR systems require that physicians respond to reminders, alerts, and other knowledge aids—all of which can lead to better patient care but may also require more time. For instance, suppose a physician is treating a patient with diabetes mellitus. The EHR might remind the physician to follow clinical practice guidelines for treating diabetes, which include conducting an eye exam and checking the patient’s hemoglobin A1C levels—both of which take time. Without the EHR reminder, these tasks might have been forgotten.

This is not to say that all health care organizations have been unable to gain physician acceptance. Strong leadership support, initial and ongoing training, sufficient time to learn the intricacies of the system, and evidence that the system is well integrated with patient care workflow are all important factors in gaining physician acceptance and use. Physicians need to realize the value that comes from using the clinical application—or they simply won’t use it. This value may be improved patient services, improved quality of care, more highly satisfied patients, happier staff, or something more personal to the physician such as improved quality of documentation, less stress, and more leisure time. Factors leading to physician acceptance of clinical information systems will be discussed further in Chapter Seven.

When it comes to telemedicine and telehealth systems, things such as differences in state laws and in standard medical practice can affect physicians’ attitudes and impede adoption. Many states will not permit out-of-state physicians to practice in their state unless licensed by them. Some physicians are concerned about medical liability issues and the lack of hands-on interaction with patients. Many physicians still prefer to meet with the patient and conduct the examination in person for fear of litigation or of missing important information.

Technical Barriers

The third broad category of barriers to adopting EHR systems involves technology; health care organizations must implement the technologies necessary to support and sustain these systems. They must choose these technologies wisely—understanding how emerging technologies fit with existing technologies, and engaging in continuing development and refinement of standards and data definitions.

Getting your arms around health care information standards is not an easy task. Many of the standards issues in health care also exist for the general business community; others are specific to health care. One thing is clear—standards are what enable different computer systems from different vendors and different health care organizations to share data. We discuss standards that affect health care information systems and how these standards are developed in greater detail in Chapter Ten. In the context of the present discussion, what is important to understand is that inadequate standards combined with rapidly changing technologies can be a barrier to widespread EHR adoption and use. Standards, implementation specifications, and certification criteria for EHR technology have been adopted by the Secretary of the Department of Health and Human Services. EHR technology must be tested and certified by an Office of the National Coordinator (ONC) Authorized Testing and Certification Body (ATCB) in order for a provider to qualify for EHR incentive payments through the Medicare and Medicaid programs (ONC). The certified EHR product list is updated continuously on the ONC web site: onc-chpl.force.com/ehrcert. Preparing to exchange data electronically with other providers is not a simple task.

Significant work in standards development has occurred nationally in recent years. The Healthcare Information Technology Standards Panel (HITSP), established in 2005, has brought together experts from across the health care community—from consumers to physicians, nurses, and hospitals; from those who develop health care IT products to those who use them; and from the governmental agencies that monitor the U.S. health care system to those organizations that actually write the standards (www.hitsp.org). Although widespread interoperability remains a goal, all the right players seem to be working together toward its achievement.

Privacy and Security Barriers

The fourth major challenge impeding the widespread adoption and use of health IT stems from our concern about privacy and security of health information. Privacy and security have always been important issues, and they become increasingly important when we see examples of identity theft, health care fraud, and other breaches of personal information occurring far more often than we would expect. Personal health records (PHR) are not currently regulated or protected under the Health Insurance Portability and Accountability Act (HIPAA), which is an added concern.

Strategies for Overcoming Barriers

Despite these and other barriers to the widespread adoption of interoperable EHR systems, the desire to overcome them is extraordinarily strong. The biggest remedy to the financial barrier has been the federal government’s investment providing $27 billion in extra Medicare and Medicaid incentive dollars to health care professionals and hospitals that become meaningful users of EHRs (Blumenthal, 2011). Through public-private collaborations, vendors, researchers, educators, policymakers, clinicians, and industry leaders have been involved in various aspects of ensuring that providers and hospitals have the local technical assistance and resources they need to assist them on their journey, standards development is progressing, and privacy and security regulations and issues remain a priority. With collaboration between public and private sectors, the federal initiatives successfully implemented, and strong leadership, we expect that interoperable EHRs are achievable in the years to come.

LEARNING ACTIVITIES

Search the Internet and find five health care information system vendors that offer EHR products. Compare and contrast the functions and features of each product. How do these systems compare with the IOM’s definitions of the EHR?
Search the clinical management literature and find at least one article describing the adoption or use of (a) an EHR system, (b) a CPOE system, (c) a medication administration system using bar-coding technology, (d) a telemedicine system or telehealth system, (e) a PHR, or (f) another clinical information system or application. Summarize the article for your classmates and discuss it with them. What are the key points of the article? What lessons learned does it describe?
Visit a health care organization that uses one of the clinical applications described in this chapter. Find out how the application’s value is measured or assessed. What do providers think about it? Health care executives? Nurses? Support staff? What impact has it had on patient care?
Investigate what efforts are being made nationally and in your state (in both the public and private sectors) to further the adoption of EHR systems. How likely are these efforts to work? What concerns do you have about them? What else do you think is needed to further the adoption of EHR systems?
Four broad categories of barriers to health information technology are discussed in this chapter. Of these, which do you think is the greatest barrier and why? What other barriers do you see? What strategies are being employed to overcome these other barriers? Conduct a search of the literature to support your answers.

REFERENCES

Agency for Healthcare Research and Quality. (2001). Reducing and preventing adverse drug events to decrease hospital costs. Retrieved May 2004 from www.ahrq.gov/qual/aderia/aderia.htm

Ahmad, A., Teater, P., Bentley, T., Kuehn, L., Kumar, R., Thomas, A., & Mekhjian, H. S. (2002). Key attributes of a successful physician order entry system implementation in a multi-hospital environment. Journal of the American Medical Informatics Association, 9, 16–24.

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