Electronic Health Records: The Good, the Bad and the Ugly

With passage of the Patient Protection and Affordable Healthcare Act, electronic health records have been widely adopted across healthcare organizations large and small. While there are many benefits to EHRs — improved accessibility to patient data, increased charge capture and improved preventative health — there are inherent problems in adopting this technology.

An EHR is only as good as the processes that it supports. If the technology is not supported with well-thought processes, hospitals may invest in complicated and expensive technologies that create more waste in a system already fraught with inefficiency.

When adopting new technology, vendors and healthcare providers from the early stages of EHR planning need to identify and eliminate waste in processes that involve the use of EHRs to ensure positive outcomes before making large investments. Lean management in healthcare is a valuable tool way to meet this objective as it educates hospital executives, clinicians and staff to seek out and eliminate waste.

When an EHR is implemented, unnecessary waste is often eliminated. However, if the system is flawed, implementing new technology can create more problems, and the results can be "bad," or worse, "ugly." It is imperative that healthcare executives understand the benefits and challenges of EHRs and what can be done to eliminate them.

Let us begin on a positive note and take a look at the "good" EHRs can offer practices and health systems alike to start. I've outlined from my experience the six main benefits.

The good

1. Improved data accessibility
Before EHRs, access to medical charts required a fair amount of physical labor. For example, every time a patient visited the office or hospital, their file had to be physically pulled from a storage space, transported, delivered (batch processing), stamped and sorted all in one visit. As a result of this back and forth, there was a greater chance of human error and charts would sometimes be missing information or be chronologically out of order. In my experience, it was not unusual for five out of 15 charts for a clinic day to be unavailable at any given time, which ultimately resulted in wasted time, space, motion and frequent defects to care.

EHRs, on the other hand, have eliminated the physical transporting, sifting and filing of charts, making data available at all times. Additionally, for systems that allow remote access to charts, clinicians can even be off site and still securely access patient files. Storage and inventory is also reduced, freeing up physical space within the hospital or office, and allowing the redeployment of human resources. Unnecessary movement is eliminated, ultimately eliminating batch delivery and improving the flow of patients and information. Most importantly, the culmination of the reduction in waste is improved quality of care for the patient.

2. Computerized physician order entry
CPOE allows physicians to place lab and imaging orders, prescriptions and other notices electronically, reducing the error of hand-written orders and allowing the patient's other physicians within the EHR network access to the order. That means, if a patient is prescribed a drug from his/her cardiologist and they are on the same EHR, the primary care physician will have access to the prescribing information. This not only reduces time, but also dramatically reduces errors — such as duplicate prescriptions or drug interactions — and potential harm to the patient.

3. Charge capture
Healthcare organizations keep track of ("capture") a patient's use of hospital resources, such as equipment, medical supplies, diagnostic testing, medication and hospital staff. These charges are recorded and then billed to patients and third-party payers. Often, the use of a resource may be overlooked. The process behind "charge capture" can be complex, making it very important that that a system is in place to capture charges completely and correctly, maximizing the potential reimbursement for revenue.

With an EHR system, at least one diagnosis must be captured along with a level of service that documents what was done for the patient at the end of every encounter. Additionally, the EHR includes a list of selectable Current Procedure Terminology codes that allows for easy input and helps reduces errors, ensuring the right code is used.

4. Preventative health
EHRs allow for prompts for preventative health screenings. During routine doctor or urgent care visits, the physician has access to preventive health records conveniently in one place. If the patient is due for a cancer screening (such as mammogram or colonoscopy), or blood pressure testing, the doctor can set easily look this up via the EHR system and schedule an appointment for the patient.

What's more is EHRs allow data analysts to mine the entire system for say, all patients with diabetes who haven't had their hemoglobin A1C and cholesterol check within the past year. From there, the analysts can provide the physician with a list that allows practice management to contact the patients to schedule these preventative health appointments. This type of data mining cannot be done through paper records.

5. Ease sign off for PAs and NPs
While this varies from state-to-state by law, physician assistants and nurse practitioners are typically required to have their notes approved and signed off on by their supervising physician. EHRs allow the revision and cosigning of notes to happen electronically as opposed to physically moving and signing paper.

6. e-messaging between providers
As any physician can attest, telephone tag between providers can be common, and is a big time-waster. With EHR software, physicians can e-message across practices. One situation that benefits in particular from e-messaging is referrals. Rather than playing telephone tag to get an appointment scheduled, the physician electronically send a message to schedule the appointment.

The Bad

1. Lack of interoperability between information technologies/EHRs
With more accountable care organizations emerging across the U.S., technology plays an essential role in developing an ACO, allowing primary care physicians to track and follow the patient flow throughout the healthcare system. Part of the driving force behind the model stemmed from the need to integrate EHRs throughout the health system and share information with network of referring hospitals. However, this sharing of information is often not possible. Finding a hospital partner that is willing to open the lines of communication is critical to the success. For example, Simpler Consulting client Atrius Health worked closely with Beth Israel Deaconess Medical Center and Epic Systems to develop a web portal that allows the two provider organizations to access each other's EHR systems for shared patients.1 If this planning and integration is not put into place, communication can become a serious problem and result in additional follow up, time and waste.

2. Cost of set-up and maintenance
The cost associated with EHRs is often a deterrent. Not only must the provider pay for the physical hardware and/or software, the organization must also put forth a considerable dollar amount for setup, maintenance, training, IT support and system updates. For many smaller practices with lower cash flow, cost alone prohibits the ability to properly implement and maintain the system.

3. Productivity
A study conducted by the University of California-Davis found a 25-33 percent drop in physician productivity in the initial implementation phases of the EMR.2 While ultimately the goal is to increase productivity in the office or hospital, expect to see a significant drop in productivity, and ultimately revenue, in the first several weeks, and perhaps longer.

4. Delays in documentation
This may come as a shock to many, however, EHRs actually increases the physician workload. With written notes, documentation tended to be briefer and straight to the point. With EHRs, much more documentation is required of physicians before, during and after a patient visit. This has its pros and cons. For example, a benefit of more robust documentation is that it provides additional information for the coders that may justify a higher level of service being billed. On the negative, it can cause further delays and errors as physicians often wait to close notes until the end of the day or, sometimes, days later. Thus they rely on memory to enter correct information. Additionally, if a patient is seeing a different provider, others will not be able to access this updated information until the note is closed.

As with most systems, however, shortcuts can be built into and customized for the physician to reduce some documentation. Standard work is needed to ensure provider support and learning.

5. e-Messaging between providers
While e-messaging is listed above as a benefit, it can also be a drawback as it can result in a lack of face-to-face or phone-to-phone conversation. With EHRs, there are no give-and-take conversations or question-and-answer scenarios. There is no way to express emotion, nuances or voice your concerns or fears. Rather, physicians must trust that the information they are providing is what the other physician needs, interpreted without confusion and read at all. This is not always the case.

6. Continuous need for updates and lack of accountability for doing so
For every task large or small — whether it's a basic wellness visit, a diagnosis, a procedure, a treatment or a prescription — the EHR system requires a corresponding update. For example, when you have an active "problem list" for a patient (e.g., diabetes, hypertension, high cholesterol, etc.) someone has to be responsible for updating his or her medication and keep the problem list accurate.

However, in my experience, I've seen a significant lack of accountability for making constant updates which needs to be addressed across all health systems. For example, when patient has a surgical procedure, this needs to be added to the health record so that all those with access to the EHR can see the work that has been done. The question is, however, who is responsible for updating? The primary care physician or the surgeon? There needs to be a clear, communicated system between all of the patient's doctors and nurses so that updates are made efficiently and by the right persons.

The Ugly

1. HIPAA violations
Since EHRs allow for easier access to sensitive information, there is an increased risk of privacy violations. These may include intentional "snooping" or may be accidental by using improper security measures. Thankfully, many systems have implemented a forensics piece to track what files are accessed when and by whom.

2. Empty data fields
While this issue varies by the proprietary nature of the system being used, many EHR systems allow for auto-population of data for new records. While these shortcuts save some time and effort on behalf of the physician, they can also result in inaccurate new records if the previous auto-populated record is not current. For example, if a patient went in for surgery in June and this was not or improperly documented, a "no data available" empty data field error message or, even worse, inaccurate information could be displayed. Once again, the creation of standard work and managing to these standards is critical to prevent this type of problem.

3. Copy and paste
Copy and paste is by and large the biggest ugly of all the shortcomings of EHRs. Because documentation is more involved with EHRs, physicians may rely on the copy and paste function as a shortcut, particularly for routine or follow-up visits. While this may save time for the physician, this puts the patient's safety at risk and impairs quality of care as updates or changes between visits can be overlooked or not documented properly.

In closing
The advantages of EHRs to the physician, hospital or physicians' office and patient alike are considerable. That being said, the "bad" and the "ugly" can often outweigh the "good." To avoid these issues, hospitals and healthcare systems must perform a thorough evaluation of the EHR system before purchase and implementation. Unfortunately for many, this is a step often overlooked. In fact, a recent Black Book Rankings survey mentioned above found that 79 percent of the 17,000 participants surveyed reported they did not sufficiently evaluate their needs prior to selecting their EHR system.3

Taking the time to evaluate new technology and   implement a new process, such as Lean management, to evaluate workflows and identify and eliminate waste before implementing a new EHR system, will help improve implementation, foster communication, decrease non-value added work and ultimately increase adoption.

1 Atrius Health. “Atrius Health, Beth Israel Deaconess Medical Center Working to Create New Health Care Model.” Nov. 2009. http://www.atriushealth.org/news/AH%20and%20BIDMC%202009.asp
2 University of California—Davis. “UC Davis study finds e-medical records have varying effects on productivity.” Dec. 2010. http://www.news.ucdavis.edu/search/news_detail.lasso?id=9665
3 Dolan, Pamela Lewis. “Many dissatisfied physicians to switch EHR vendors.” Amednews.com. Web. 12 Mar. 2013 http://www.amednews.com/article/20130312/business/130319987

George Palma, MD, is the medical director at Simpler Consulting.

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