Electronic Health Records
Information Problem
In this paper, I will be evaluating the system of ‘Paper health records’. My focus will be on identifying the limitations and challenges of ‘paper-based system’ from the perspective of a hospital which stores patient’s health records. Further, I will be evaluating how EHR (electronic health records) can be used to overcome these challenges. Evaluation of EHR will help us understand the strengths of EHR when compared with the paper-based system and potential weaknesses and threats of EHR.
Challenges of Paper Records
• Accessibility
Storing and maintaining every patient's file requires a lot of physical space. Additional each file will have multiple documents. The high volume of documents makes it difficult for the staff members to locate, sort and search for records. The inability or delayed access to important health records will affect the hospital’s services. This would mean lower quality of patient care, burdened staff and overlooked information. Additionally, the physical copies of health records can only be present at one place at a time, making it difficult to access them from outside the hospital.
• Productively
The limited access to the medical health records would mean different teams in the hospital cannot work in unison. If both the administration and the billing department want to access the patient records, they cannot do it at the same time. Hence one team will have to wait while the other team accesses the records. This reduces the productivity of the teams and the hospital as a whole. As discussed earlier, tasks like locating, sorting and storing patient’s records will require manual efforts which in turn increases the work burden of the staff.
• Security
While security threats would be a major concern when implementing Electronic health records, it seems paper-based records are more prone to breaches. According to the Department of Health and Human Services’ Office of Civil Rights website, 258 breaches were reported in 2015. Off these 71 were for paper-based records and only 16 were on electronic records. Hence paper-based records are not an ideal option when it comes to security and privacy. It is impossible to keep an accurate log of users accessing paper-based records and audit their use. Individuals can easily access paper records and make copies of them without anyone knowing.
Case Studies
On 27th November 2015, thousands of lab records were found in a dumpster in Ohio. The lab records may include patients’ names, physicians’ names, accession numbers, types of study, guarantor information, health insurance information, diagnoses, other clinical information, and in some instances Social Security numbers and driver’s license numbers etc. "Some documents were intended for a shredding vendor, while other documents were identified to be moved to a secure new off-site location. None of them were intended for a Dumpster” spokesman Dave Lamb said. The authorities are not certain if all the lab reports have been recovered and if the information on the lab reports was accessed by anyone.
A staff member of Prince of Wales Hospital lost about 100 medical records containing private information of hundreds of patients. The staff had accidentally left the papers in the taxi after taking them out of the office.
Electronic Health Records
An electronic health record is an electronic version of paper health record. Ideally an EHR contains a patient’s entire medical history and is maintained by the provider over time. A patient’s key clinical data such as demographics, progress notes, problems, medications, vital signs, immunization, laboratory test reports etc. are included in an EHR.
History of EHR
Prior to 1960, paper based system was the only method used to store patient’s medical records. All documents related to a patient like diagnoses, lad reports, visit notes and medication direction was written on papers and manually filled in the patient’s medical health record folder. In order to sort and search of patient’s records, labeling system based on patient’s last name, last digits of his SSN and other chart numbering systems were used. These records were stored on shelves inside a document’s room from where they would be accessed manually. In mid 1960s, Lockheed developed an electronic system to store medical records. This system was called as clinical information system and this was the first step towards EHR.
In late 1960s and early 1970s, many technology companies started developing clinical information system for hospitals. In the 1970s, the federal government using the electronic information system with the Department of Veterans Affairs implementation of vistA, originally known as Decentralized Hospital Computer Program(DHCP). They termed the electronic information system as Electronic Health Record. In 1980s focused efforts were made by the federal government to increase the use of EHR.
A study conducted by the Institute of Medicine(IoM) on paper record usage in mid 1908s, published the results in 1991, arguing EHR as one of the seven key recommendation to improve patient records, and proposed a means of converting paper to electronic records.
In 2004, the Office of the National Coordinator(ONC) of Health Information technology(IT) was created as an effort to convert medical records to EHRs. Shortly after, Health Information Technology of Economic and Clinical Health Act(HITECH) incorporated the EHRs by providing higher payments to health care providers that meaningfully use EHRs for relevant purposes. EHRs are now also a part of HIPAA regulations.
As of March 2017, 67% of all providers use EHR. EHR adaptation by office based physician has doubled from 42% to 87% since 2008.
Advantages of EHR
• Comprehensive view of the patient
EHRs track a patient’s health care over his lifetime. EHR is a single, continuous record of a patient’s health and hence provides a comprehensive overall view for better diagnosis and treatment.
• Better coordination of care
The digital and electronic nature of EHRs makes it easy to coordinate and track patients care across practices and facilities. Easy sharing of EHRs makes it possible for medical teams across different specialties and discipline to collaborate on a patient’s diagnosis and care as a team to ensure better care
• Sharing Information
EHRs can be shared across disciplines, specialties, pharmacies hospitals and emergency response teams easily. The ability to access records on demand through portable device like cell phones allow for better and timely decision making, particularly in critical situations.
• Streamlined workflows
EHRs reduces paperwork and hence increase productivity and efficiency. Clinicians can invest more time in patient diagnosis and treatment with reduced number of forms to handle. Wait time for appointments and pickups can be cut down because of the ability to share referrals and prescription quickly. Integration patient billing in EHRs would make insurance claims easier.
• The power of data
Health issues can now be tackled in a preventive manner since continuous medical history information is now available. By using the power of Big Data Analytics and aggregated patient data, larger health threats like outbreaks, epidemics can be predicted.
• Greater efficiency and cost savings
EHRs reduces the need for transcription, physical records storage, claims management as well as allows efficient coordination between various teams by reducing the time of hard copy communications. By reducing tasks and increasing efficiency, a significant amount of administrative cost is saved
• Reduced Error
EHR is a standardized documentation of a patient’s medical history and has the potential to reduce errors. Digital documents eliminate the risk of illegal handwriting in clinical notes or prescriptions. Drug integration and other indicators of potential harm can be flagged.
Electronic health records are a big step forward towards improving patient care. Reducing paperwork allows more time to be spend on treatments and diagnosis instead of tracking records. A comprehensive set of digital health data will allow healthcare providers to share information and detect patterns, enabling more effective cures.
Disadvantages of EHR
• Setup cost and maintenance
Implementing EHRs require a large initial capital investment. The hospital needs to pay for the hardware and the software. Post implementation maintenance costs towards IT support, system updates, training etc. are incurred. Cost factor would prohibit few medical institutes to adopt EHRs
• HIPAA violations
The easy access of EHR allows sensitive information to be accessed and used my unauthorized users. ‘Snooping’ or improper security measure may allow so. Additional features are needed for tracking the access and use of EHRs, which adds additional costs.
• Continuous need to update
For every task, the EHR system needs a corresponding update. Basic tasks like wellness visit, a diagnosis, a procedure, a treatment or a prescription would require an HER update. This adds to the workload of the doctor and the medical staff.
• Copy and Paste
Because EHR involves more documentation, even for basic tasks, physician may rely more on copy and paste for routine or follow-up visits. While this saves a medical team’s time, the patient’s life is at risk as changes between visits may be overlooked and not updates into the EHR system.
Paper Records vs EHR
• Paper records require human resources for storing, sorting and handling of large no of medical documents. EHR require lesser human efforts, lesser time and lesser physical space.
• Paper medical records require large physical space for storage. Not only do physical records take-up a lot of space but they are less environment friendly. Paper records tend to deteriorate with time whereas EHRs can be stored on a server can be stored safely on the server and backed up. Since many 3rd party cloud services are available, no physical space at the hospital is required.
• Most medical institutes keep only 1 copy of a medical documents. Loss or damage to that document would mean losing the data forever. Cloud Services often backup the data on their cloud, hence there is no risk of losing EHRs.
• Access to paper records from outside the host hospital would require the need to scan, fax and mail. This is more time consuming then to share a digital record. Also, digital records can be accessed from any electronic device on the go.
• Illegal penmanship of Paper records may lead to misinterpretation of inability to understand the information. Paper record provide limited space to add information. Standardized fonts of digital records make EHRs easy to read and interpret. Also, there is no restriction of space on EHR
• Paper based records are dispersed across different clinic, doctors and hospitals and are often incomplete. This may result in repetitive tests and treatments. EHR includes patient’s complete medical history and hence above scenarios can be avoided.
• In 2009, physician practices using EHR had $50000 greater annual total revenue that physicians using paper based system.
Challenges in Implementing Electronic System for storing and updating health records
While electronic records are meant to overcome the challenges posed by paper records, they too pose new challenges. Many hospitals have implemented and adopted the EMPI (Enterprise Master Patient Index) and EHR (Electronic Health Record) system.
A major challenge faced by the hospitals is misidentification of patients. Patient identification errors threaten to harm patient safety, impact revenue cycle efficiency, and reduce profit margin and market share. Here are 4 statistics that illustrate how patient identification errors have become a critical issue for hospitals:
• 7-10% of patients are misidentified when their EMPI and EHR records are being searched. AHIMA reports that 8-12% of EHR records are duplicates. Still, more patients may suffer medical errors due to missing health information in their records, or overlays that mingle multiple patients’ records together.
• Roughly 2.3 million Americans were victims of medical identity theft in 2014 and had to pay an average of $13,450 in out-of-pocket expenses. Medical identity theft is estimated to cost the healthcare industry over $30 billion a year.
• Traditional patient identifiers, such as oral demographic data, Social Security Numbers, and patients’ addresses, can be easily mistyped and cause preventable medical errors. Preventable medical errors are the third leading cause of death in the United States, causing an estimated 440,000 deaths per year.
• Cleansing inaccurate patient records can be costly for hospitals. The average cost to resolve a single duplicate medical record is $1,000. If 8% of a hospital’s records are duplicates, the costs to clean their EMPI database and EHR records increase exponentially.
The next major challenge with Electronic health records is the security of electronic health records. Because the records are stored on a server, there is a higher risk of illegal access of this information through hacking and other fraudulent activities. More than 25 million patient records were reportedly compromised as of October 2016. And then, in November, the cases spiked: There were 57 health data breaches—the most in any one month this year, according to the Protenus Breach Barometer. Thus, with an increase in the digitization of health record, there has been an increase in security breaches. Protecting the individual’s health information and preventing illegal access to them is a major challenge.
With implementing an electronic system to store every individual's health records, we also face an ethical conundrum. Should these records be made accessible to governments and other health facilities so that they can predict and prevent plagues, epidemics etc.? Are we violating people's privacy by doing so? Should we value people’s privacy more than their well-being?
Conclusion
The advantages of EHRs to physicians and hospitals are considerable. That being said EHRs do have few drawbacks and challenges. A thorough evaluation of EHR system before purchase and implementation is required to minimize the issues. A recent Black Book ranking survey found that 79% of the 17000 surveyed participants did not evaluate their needs prior to selecting and implementing the EHR system. This would lead to plenty issues and difficulties and would require many updates. Hence more resources and efforts are invested in overcoming issues rather than using EHRs to their maximum potential.
Taking the time to evaluate new technology and implement a new process, such as Lean management, to evaluate workflows and identity and eliminate waste before implementing a new EHR system will help improve implementation, foster communication, decrease non-value added work and ultimate increase adoption.