Chapter 4: Electronic Health Records Robert Hoyt MD Vishnu Mohan MD After reading this chapter the reader should be able to: State the definition and history of electronic health records (EHRs) Describe the limitations of paper-based health records Identify the benefits of electronic health records List the key components of an electronic health record Describe the ARRA-HITECH programs to support EHRs Describe the benefits and challenges of computerized order entry and clinical decision support systems State the obstacles to purchasing, adopting and implementing an electronic health record Enumerate the steps to adopt and implement an EHR Learning Objectives 2 There is no topic in health informatics as important, yet controversial, as the electronic health record (EHR) In spite of fledgling EHRs being around for the past 35-40 years they are still controversial in the eyes of many Due to the federal government reimbursement programs for EHR use by physicians and hospitals, EHRs are now part of the healthcare landscape Some of the famous early EHRs are listed on the next slide Introduction The Problem Oriented Medical Information System (PROMIS) American Rheumatism Association Medical Information System (ARAMIS) Regenstrief Medical Record System (RMRS) Summary Time Oriented Record (STOR) Health Evaluation Through Logical Processing (HELP) Computer Stored Ambulatory Record (COSTAR) De-Centralized Hospital Computer Program (DHCP)—forerunner of VistA (Veterans Health Administration) Early EHRs Electronic Health Record: “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 healthcare organization” While the “experts” can debate the difference between EHR and EMR, we will not and will stick with EHR throughout the textbook and slides Definition Paper records are severely limited: less legible, more difficult to retrieve, store and share and unstructured data. Also, electronic records less likely to be missing and available 24/7 from multiple locations. Paper records do not permit clinical decision support Need for improved efficiency and productivity: clinicians are more productive if charts are available and retrieval of results is faster. EHR access from home while on call helps productivity Quality of care and patient safety: the factors already described in last two bullets plus clinical decision support, quality reports and secure messaging as part of an EHR Why do we need EHRs? Public expectations: EHRs may increase patient satisfaction through faster results, messaging, patient portals, electronic patient education, e-prescribing and online scheduling Governmental expectations: federal government considers EHR to be transformational and hence why they support reimbursement for u.

1. Chapter 4: Electronic Health Records
Robert Hoyt MD
Vishnu Mohan MD
After reading this chapter the reader should be able to:
State the definition and history of electronic health records
(EHRs)
Describe the limitations of paper-based health records
Identify the benefits of electronic health records
List the key components of an electronic health record
Describe the ARRA-HITECH programs to support EHRs
Describe the benefits and challenges of computerized order
entry and clinical decision support systems
State the obstacles to purchasing, adopting and implementing an
electronic health record
Enumerate the steps to adopt and implement an EHR
Learning Objectives

2. 2
There is no topic in health informatics as important, yet
controversial, as the electronic health record (EHR)
In spite of fledgling EHRs being around for the past 35-40 years
they are still controversial in the eyes of many
Due to the federal government reimbursement programs for
EHR use by physicians and hospitals, EHRs are now part of the
healthcare landscape
Some of the famous early EHRs are listed on the next slide
Introduction
The Problem Oriented Medical Information System (PROMIS)
American Rheumatism Association Medical Information
System (ARAMIS)
Regenstrief Medical Record System (RMRS)
Summary Time Oriented Record (STOR)
Health Evaluation Through Logical Processing (HELP)

3. Computer Stored Ambulatory Record (COSTAR)
De-Centralized Hospital Computer Program (DHCP)—
forerunner of VistA (Veterans Health Administration)
Early EHRs
Electronic Health Record: “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 healthcare organization”
While the “experts” can debate the difference between EHR and
EMR, we will not and will stick with EHR throughout the
textbook and slides
Definition
Paper records are severely limited: less legible, more difficult
to retrieve, store and share and unstructured data. Also,
electronic records less likely to be missing and available 24/7

4. from multiple locations. Paper records do not permit clinical
decision support
Need for improved efficiency and productivity: clinicians are
more productive if charts are available and retrieval of results is
faster. EHR access from home while on call helps productivity
Quality of care and patient safety: the factors already described
in last two bullets plus clinical decision support, quality reports
and secure messaging as part of an EHR
Why do we need EHRs?
Public expectations: EHRs may increase patient satisfaction
through faster results, messaging, patient portals, electronic
patient education, e-prescribing and online scheduling
Governmental expectations: federal government considers EHR
to be transformational and hence why they support
reimbursement for use
Why do we need EHRs?

5. 7
Financial savings: EHRs may save money by eliminating
transcription and improving coding. Decreased file room
storage and faster chart pulls and info retrieval may result in
cost savings
Technological advances: computers are much faster, the Internet
is more prevalent, wireless and mobile technologies are
ubiquitous; all supporting EHRs
Need for aggregated data: healthcare data must be electronic to
be shared, stored and analyzed. Research depends on large study
populations and data sets which EHRs can provide
Why do we need EHRs?
Need for integrated data: electronic data permits integration
with health information organizations, data analytics, public
health reporting, artificial intelligence and genomic information
EHR as a transformational tool: select organizations such as the
VA and Kaiser Permanente made huge investments in EHRs to
standardize care and transform delivery and analysis of
healthcare
Why do we need EHRs?

6. Need for coordinated care: with an aging population with
multiple physicians and medications, care coordination is
important. Sharing electronically has great potential, but
barriers exist as we point out in the chapter on health
information exchange
Why do we need EHRs?
Electronic Health Record Key Components
Clinical decision support
Secure messaging
Computerized physician order entry
Practice management
Manage care module
Referral management
Results retrieval
Prior encounter retrieval
Patient reminders
Electronic encounter notes

7. Multiple input methods
Access via mobile technology
Remote access from home
Electronic prescribing
Integration with images
Integration with physician and patient education
Public health reporting
Quality reports
Problem summary lists
Electronic Health Record Key Components
Ability to scan in data
Evaluation and management help
Ability to graph and track results
Ability to create patient lists
Ability to create registries
Preventive medicine tracking
Privacy/security compliance
Robust backup systems
Ability to generate summaries of care (CCD)
Support for client server or application service provider (ASP)
modes

8. CPOE is an EHR feature that processes orders for medications,
lab tests, imaging, consults and other diagnostic tests. It is not
the same as electronic prescribing
CPOE has many potential benefits (next slide)
CPOE has the potential to reduce medical errors but the
literature is mixed. Most early studies came from a select
number of academic institutions with home grown EHRs and
large IT departments
Computerized Physician Order Entry (CPOE)
Potential Benefits of CPOE
Koppel et al
Overcomes the issue of illegibility
Fewer errors associated with ordering drugs with similar
names,
More easily integrated with decision support systems than
paper,
Easily linked to drug-drug interaction warning
More likely to identify the prescribing physician,
Able to link to adverse drug event (ADE) reporting systems
Able to avoid medication errors like trailing zeroes

9. Creates data that is available for analysis
Can point out treatment and drugs of choice
Can reduce under and over-prescribing,
Prescriptions reach the pharmacy quicker
One study suggested cost savings from reduced length of stay,
compared to paper based orders
Some studies have shown improved standardized care with
EHRs, but this is not universal
CPOE is difficult to implement in hospitals because it disrupts
workflow and slows physicians down. They often don’t realize,
however, that CPOE benefits others on the team, such as nurses
and pharmacists
CPOE
With CPOE you can embed a variety of tools to assist in
decision making. Traditionally, this meant medication alerts and

10. patient reminders. In reality, any software that assists decisions
is a CDSS:
Knowledge support: programs embedded into the EHR that
educate clinicians or patients
Calculators: part of the EHR
Flow charts and graphs: to look at lab or vital sign trends over
time
Clinical Decision Support Systems (CDSSs)
CDSS (continued)
Order sets: inpatient clinical practice guidelines for specific
scenarios (e.g. pneumonia), standardizing care
Reminders: remind clinician or patient about pending tests, etc.
Differential diagnosis: software exists that helps clinicians
analyze symptoms and signs, to arrive at a diagnosis
Lab and Imaging decision support: what tests are indicated and
at what costs?
Public health alerts: primarily infectious disease alerts for new
outbreaks, e.g. MERS virus
Clinical Decision Support Systems (CDSSs)

11. Currently, the vast majoring of eRx occurs as part of an EHR
and not a standalone program
69% of office-based prescriptions are now electronic
93% of community pharmacies are connected to the Surescripts
network
The next slide lists the potential advantages of eRx over paper-
based prescriptions
Electronic Prescribing (eRx)
eRx Potential Benefits
Legible and complete prescriptions
Abbreviations+ unclear decimal points are avoided
The wait to pick up scripts shorter
Fewer duplicated prescriptions
Better compliance with fewer drugs not filled or picked up
Potential to reduce workload for pharmacists
Timely notification of drug alerts and updates
Ability to check formulary status and copays

12. Can interface with practice and drug management software
The process is secure and HIPAA compliant
Associated with CDDSs
Digital records improve data analysis of prescribing habits
Batch refills can save time
Better use of generic or preferred drugs
Details about drug allergies
Drug-drug interaction alerts
Formulary alerts to tell you drug is either not recommended or
not reimbursed
Alerts can exist to ask about pregnancy, kidney or liver function
and safety in the elderly
Dosing alerts can arise based on age or size of patient
eRx Clinical Decision Support
Alert fatigue: too many alerts result in deletions, some justified,

13. others not. Hot topic and area of much future research
Prescribing errors still occur with eRx but they are different;
wrong drug or wrong dose
There are still issues at the pharmacist’s end but these should
improve over time
Still not clear how many adverse drug events are prevented with
eRx; perhaps too soon to know
eRx Challenges
Chronic disease: track e.g. diabetes
Research registries: high volume allows research questions to
be answered
Safety registries: issues reported to e.g. FDA
Public health registries: immunizations, cancer and
biosurveillance
Quality: data could be stored in registry and later forwarded to
e.g. CMS
EHR Registries

14. Prior to EHR adoption, most medical practices used an
electronic PMS. Now most are part of their EHR
PMSs are essential to run any practice: for billing, dealing with
insurance companies, evaluating physician performance and
practice trends
Typical office workflow is shown in next slide
Practice Management Systems (PMSs)
EHR Adoption

15. The US has been behind many other “developed” countries up
until the HITECH ACT that included reimbursement for EHRs
Ambulatory EHR adoption (2015): roughly 86% have EHRs, but
some are much more advanced than others. Larger practices
adopt at a higher rate due largely to stronger finances
Inpatient (hospital) EHR adoption (2015): perhaps as many as
96% of US hospitals have EHRs and most are participating in
the Meaningful Use program. Smaller urban and rural hospitals
lag
Just because you own an EHR doesn’t mean you are maximizing
the features and benefits (next slide)
Very Few Practices Have Reached Stage 7 Sophistication
(HIMSS data second quarter 2017
Financial: in spite of government reimbursement, some
practices will gain and some will lose money. What will the

16. long term annual costs be after reimbursement ends? Will some
stop using EHRs?
Physician resistance: complying with meaningful use has been
onerous and may not result in any immediate and direct benefit
to clinicians and patients
Loss of productivity: there is almost always initial loss of
productivity and if the practice doesn’t change workflow habits
there will be a long term losses as well
EHR Challenges
Workflow changes: everyone must adapt to doing business
differently but some seek strange workarounds
Reduced physician-patient interaction: without careful
forethought and planning, there will be less eye contact and
interaction with patients
Usability issues: some EHRs are not user friendly and require
too many mouse clicks or illogical steps, impeding workflow
Integration with other systems: practices may need to build
expensive interfaces to communicate with HIOs, practice
management systems, etc.
EHR and Meaningful Use Challenges

17. Lack of interoperability: EHRs are not capable of
communicating with each other without additional technology,
thus an impediment to data sharing
Privacy concerns: hacking into EHRs could result in loss of
privacy for thousands, rather than a single paper chart
Legal: It is not known if EHRs will increase or decrease
malpractice over the long haul
Inadequate proof of benefit: in spite on many published studies,
there is not adequate proof that EHRs improve quality of care
EHR and Meaningful Use Challenges
Patient safety and unintended consequences: not only are
studies suggesting improved patient safety mixed, there is
evidence that new medical errors may occur (at least in the
short term) with EHR use. “E-iatrogenesis” means medical
errors due to technology
Situation worsened by alert fatigue, frequent software upgrades,
usability issues, stress to meet meaningful use objectives
Several sentinel failures of major EHRs in large healthcare
systems have highlighted EHR vulnerability
EHR and Meaningful Use Challenges

18. The US federal government (along with the IOM) has opined
that EHRs are an important part of healthcare reform
A program for reimbursement for EHR use by clinicians and
hospitals under Medicare and Medicaid (HITECH Act) was
established in 2009
Clinicians had to: (1) be eligible, (2) register for
reimbursement, (3) use a certified EHR, (4) demonstrate and
prove Meaningful Use, and (5) receive reimbursement.
As of December 2017, $24.8 billion was spent by Medicare and
$12.54 by Medicaid on EHR reimbursement to clinicians
HITECH ACT and EHR Reimbursement
Medicare defines EPs as doctors of medicine or osteopathy,
doctors of dental surgery or dental medicine, doctors of
podiatric medicine, doctors of optometry and chiropractors
Medicaid defines EPs as physicians, nurse practitioners,
certified nurse midwives, dentists and physician assistants
(physician assistants must provide services in a federally

19. qualified health center or rural health clinic that is led by a
physician assistant). Medicaid physicians must have at least
30% Medicaid volume (20% for pediatricians)
Eligible Professionals (EPs)
The goals of MU are the same as the national goals for HIT: (a)
improve quality, safety, efficiency and reduce health disparities;
(b) engage patients and families; (c) improve care coordination;
(d) ensure adequate privacy and security of personal health
information; (e) improve population and public health
EHRs must be certified by several organizations as capable of
meeting meaningful use objectives
Meaningful Use Goals
Users must meet required core measures and multiple menu
measures (textbook for more details). Quality measures are a
major part of meaningful use

20. There are penalties for hospitals or EPs that don’t comply with
Medicare Meaningful Use
Meaningful Use
Low cost that includes 3 month free trial
Fully featured and compliant with Meaningful Use
Available as a client or web based (ASP) model
Appeals to small practices, particularly primary care
Small EHR Example
Amazing Charts
Medium priced for medium sized practices of multiple
specialty types
More clinician and patient features to include mobile and a
health information exchange (HIE) solution
Medium EHR Example
eClinicalWorks

21. Intended for very large practices such as Kaiser-Permanente
Includes every aspect of Meaningful Use and numerous
innovations such as a comprehensive patient portal and several
mobile solutions
Large EHR Example
Epic
Develop an office strategy: why are you considering EHRs? Is
your entire staff onboard? Don’t do it just for reimbursement.
Plan, plan, plan
Do Research: take advantage of courses, books, articles, EHR
survey results, regional extension centers, HIT consultants, etc.
List features: be sure to include inputting methods, backup,
warrantees, mobile presence, etc.

22. Analyze and re-engineer workflow: consider all processes likely
to change when you transition from paper to electronic
Implementing an EHR Steps
Use project management tools: these will improve your
organization for tasks
Choose client versus ASP model: the web based model will be
easier with less of the need for in house IT support
Practice management system needs: should you purchase a
combination or build an interface?
Survey your hardware and network needs: will you need more
bandwidth? Wireless? How many computer stations and will
they require upgrades?
Implementing an EHR Steps

23. Develop a vendor strategy: create request for proposals (RFPs)
for vendors to outline all of your needs, to include price,
maintenance, etc. Obtain commitments in writing.
Select a vendor: develop a contract and have it reviewed by
legal
Develop a paper to EHR conversion strategy: it is likely you
will initially run a dual paper and electronic practice. Textbook
discusses this in more detail
Implementing an EHR Steps
Training: you can’t train to much and be sure to discuss the
details with your vendor early on
Implementation: decide whether you will phase in
implementation or have a “go live” date. Be prepared to
decreased productivity for several months and a new glitches
along the way
Implementing an EHR Steps

24. EHRs are felt to be critical for US healthcare reform
Paper based health records are severely limited
EHR reimbursement has greatly increased US adoption
In spite of many potential benefits of EHRs, multiple challenges
are associated with adoption
Planning, training and strategizing about EHRs is more
important than the actual EHR brand purchased
Conclusions