Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an integrated health care delivery system. Most physicians and institutions view the widespread use of EMRs to be inevitable. But the transformation has not been painless. Many have questioned whether the substantial investment in electronic health records has really been justified by improved patient outcomes or quality of care. This article describes historical and recent efforts to use EMRs to improve the quality of patient care, and provides a roadmap of EMR uses for the foreseeable future.
Key points
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Recent legislation has incentivized American hospitals and providers to rapidly adopt electronic medical records (EMRs) and demonstrate meaningful use of them. This implementation will drive quality improvement for the next 5 to 10 years.
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EMRs allow numerous surgical quality initiatives to be implemented efficiently: examples are the Joint Commission’s Surgical Care Improvement Program (SCIP), surgical timeout, and care hand-offs. Such quality initiatives are otherwise difficult or impossible to realize with paper processes.
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Successful implementation of EMRs requires considerable time and money. Patients can be harmed when EMRs are poorly implemented.
Introduction
Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an integrated health care delivery system. For the purposes of this article, an EMR is defined as a systematic collection of digital health information that theoretically can be shared across different health settings and is designed to accurately capture the state of the patient (or population) at all times. Most physicians and institutions view widespread use of EMRs to be inevitable. But the transformation has not been painless. Many have questioned whether the substantial investment in EMRs has really been justified by improved patient outcomes or quality of care. Despite these concerns, widespread adoption of EMRs is currently a national priority: in 2009 Congress and the Obama administration enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH act provided unprecedented incentives and penalties for meaningful use of EMRs. This article describes historical and recent efforts to use EMRs to improve the quality of patient care, and provides a roadmap of EMR uses for the foreseeable future.
Introduction
Widespread adoption of electronic medical records (EMRs) in the United States is transforming the practice of medicine from a paper-based cottage industry into an integrated health care delivery system. For the purposes of this article, an EMR is defined as a systematic collection of digital health information that theoretically can be shared across different health settings and is designed to accurately capture the state of the patient (or population) at all times. Most physicians and institutions view widespread use of EMRs to be inevitable. But the transformation has not been painless. Many have questioned whether the substantial investment in EMRs has really been justified by improved patient outcomes or quality of care. Despite these concerns, widespread adoption of EMRs is currently a national priority: in 2009 Congress and the Obama administration enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH act provided unprecedented incentives and penalties for meaningful use of EMRs. This article describes historical and recent efforts to use EMRs to improve the quality of patient care, and provides a roadmap of EMR uses for the foreseeable future.
Early efforts
In the 1970s and 1980s, early informatics experts envisioned computers as intellectual amplifiers that could help doctors diagnose disease. Automated history-taking, combined with statistical associations of diseases with physical and laboratory findings, could alert the physician to the most probable diagnosis, and suggest the most appropriate, safest course of action. Such assistance could free up the physician to perform tasks that are uniquely human, such as bedside skills or managing emotional aspects of a patient’s illness. Some experts envisioned that entire specialties, such as primary care or anesthesia, could be largely regulated to computerized automation. These predictions never came to pass.
At the same time, simple computer systems were developed to automate discrete departments or processes within the hospital or clinic. Software to handle coding or billing, laboratory results, simple text reports (eg, microbiology, pathology, or radiology), or radiographic images (PACS: Picture Archiving and Communication System) became commonplace. Unfortunately, the data structures and formats of these systems were typically proprietary and protected by the vendor. This made integration between software packages difficult or impossible. In 1987, a protocol named Health Level-7 was founded to provide data standards and definitions to allow for sharing of health information. Health Level-7 was accredited in 1994 by the American National Standards Institute and created a “common language” for health systems to be able to talk to one another.
In 1999, the Institute of Medicine published “To Err is Human: Building a Safe Health System,” which reported that up to 98,000 Americans died annually as a result of preventable medical errors. Examples included adverse drug events, improper transfusions, wrong-site surgery, falls, pressure ulcers, and mistaken patient identities. Lack of integration within the US health care system was cited as a major contributor to these errors. Shortly thereafter, systems engineering principles were applied to patient safety and medical informatics to address many of the Institute of Medicine’s listed causes of patient harm. Health information systems were recognized to be more than a digital reproduction of the paper chart. Rather, they were recognized to be major actors that interact with humans to form a complex adaptive system. The EMR is not an adjunct to the system of care, it creates the system of care .
Quick wins
By the early 2000s, computerized order entry systems (CPOE) were developed to address several errors reported by the Institute of Medicine. CPOE systems could eliminate handwriting errors, reduce incomplete orders, eliminate ambiguous abbreviations, force proper units, and standardize orders within an organization almost overnight. When combined with automated clinical decision support (ie, automated weight or body-surface-area dosing, drug-drug or drug-allergy interaction, order sets, and other rule-based alerts) or bar-coded medication administration (right drug, right formulation, right dose, right patient, right time), many medical errors were avoided. One study reported that such systems could reduce nonintercepted serious medication errors by 81%. As a result, CPOE was heralded as a hospital “best practice” in medication safety and a litmus test of safe care. Many payors and advisory groups, such as the Leapfrog Group, pushed CPOE systems heavily in the mid-2000s.
Unintended consequences
Although CPOE systems could overcome many of the obvious problems associated with paper-based orders, sometimes their implementation actually harmed patients. One hospital reported a doubling of the hospital mortality rate after a commercially sold CPOE system was implemented. The increased mortality was attributable to usability and workflow issues: physicians could not write orders until patient arrival and registration (delaying care), no order sets were built, less provider time was spent at the bedside, and there was less communication between doctors and nurses. The designers of these systems did not anticipate the complexity of care processes within the hospital. Many physicians also pointed out the poor usability of EMR systems. Alert fatigue (defined as alerts so frequent that the physician ignores or overrides the result) was recognized as a major limitation to CPOE and decision support systems. Many hospitals did not commit adequate resources to successfully understand their own internal processes to implement EMR systems.
Despite these growing pains, by the late 2000s, most reports in the literature showed that incorporation of health technology resulted in an overall improvement in access to care, patient satisfaction, provider satisfaction, effectiveness of care, and efficiency of care. By 2010, more than 50% of American office-based practices had incorporated EMRs.
The Health Information Technology for Economic and Clinical Health Act of 2009
The 2008 presidential election made health care reform a major debate in the United States. After taking office, the Obama administration and Congress passed the HITECH Act under Title XIII of the American Recovery and Reinvestment Act of 2009. Under the HITECH Act, the US Department of Health and Human Services was budgeted up to $27 billion to promote and expand the adoption of health information technology. Under the act, individual provider incentive payments of up to $44,000 through Medicare and up to $63,750 through Medicaid were made available, provided clinicians could demonstrate meaningful use of EMRs in addition to simple EMR implementation. In 2010, the Department of Health and Human Services proposed meaningful use requirements and solicited public comment. The meaningful use measures were chosen to maximize individual patient safety and quality, improve care coordination, and improve public and population health, while ensuring privacy and security for personal health information.
The meaningful use objectives were divided into three stages, phased in over 5 years. These measures are listed in Table 1 . Stage 1 objectives focus on simple electronic data capture and patient access. Stage 2 added objectives that focus on more advanced clinical processes: usage of clinical decision support, generating reports (ie, lists) of patients for quality improvement or outreach, or submission of digital health data to registries. Stage 3 objectives have yet to be defined, but will focus on improved patient outcomes (as opposed to processes). In the next 5 years, widespread implementation of EMRs to meet meaningful use objectives will drive health care organizations and dominate patient safety efforts.
| Objective | Measure |
|---|---|
| Provide clinical summaries for patients for each office visit | Clinical summaries provided to patients within 1 business day for more than 50% of office visits |
| Use clinical decision support to improve performance on high-priority health conditions |
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| Use CPOE for medication, laboratory, and radiology orders directly entered by any licensed health care professional who can enter orders into the medical record per state, local, and professional guidelines | More than 60% of medication, 30% of laboratory, and 30% of radiology orders created during the EHR reporting period are recorded using CPOE |
| Automatically track medications from order to administration using assistive technologies in conjunction with an eMAR | More than 10% of medication orders created by authorized providers of the eligible hospital’s inpatient or emergency department during the EHR reporting period for which all doses are tracked are tracked using eMAR |
| Generate and transmit permissible prescriptions electronically | More than 50% of all permissible prescriptions written by the EP are compared with at least one drug formulary and transmitted electronically using certified EHR technology |
| Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach | Generate at least one report listing patients with a specific condition |
| Incorporate clinical laboratory test results into certified EHR technology as structured data | More than 55% of all clinical laboratory tests results ordered during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data |
| Perform medication reconciliation between care settings | Medication reconciliation is performed for more than 50% of transitions of care |
| Record the following demographics: preferred language, gender, race, ethnicity, date of birth, and date and preliminary cause of death in the event of mortality in the eligible hospital or CAH | More than 80% of all unique patients have demographics recorded as structured data |
| Use certified EHR technology to identify patient-specific education resources and provide those resources to the patient if appropriate | Patient-specific education resources identified by certified EHR technology are provided to patients for more than 10% of all unique patients seen during the EHR reporting period |
| Use secure electronic messaging to communicate with patients on relevant health information | A secure message was sent using the electronic messaging function of certified EHR technology by more than 5% of unique patients seen during the EHR reporting period |
| Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care | Use EHR to identify and provide reminders for preventive/follow-up care for more than 10% of patients with two or more office visits in the last 2 y |
| Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities | Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a) (1), including addressing the encryption/security of data at rest and implement security updates as necessary and correct identified security deficiencies as part of its risk management process |
| Record smoking status for patients 13 y old or older | More than 80% of all unique patients 13 y old or older have smoking status recorded as structured data |
| Capability to submit electronic data to immunization registries or immunization information systems and actual submission except where prohibited and in accordance with applicable law and practice | Successful ongoing submission of electronic immunization data from certified EHR technology to an immunization registry or immunization information system for the entire EHR reporting period |
| Provide summary of care record for patients referred or transitioned to another provider or setting | Summary of care record is provided for more than 50% of patient transitions or referrals Summary of care record is provided electronically for more than 10% of patient transitions or referrals Conduct an electronic summary of care exchange with either another EHR or with CMS |
| Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available |
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| Record and chart changes in vital signs: height, weight, blood pressure (age 3 and older), calculate and display BMI; plot and display growth charts for patients 0–20 y, including BMI | More than 80% of all unique patients have blood pressure (for patients age 3 and older only) and height and weight (for all ages) recorded as structured data |
| Menu selection objectives and measures (any three are required) | |
| Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through certified EHR technology | More than 10% of all scans and tests whose result is an image ordered for patients seen during the EHR reporting period are incorporated into or accessible through certified EHR technology |
| Record whether a patient 65 y old or older has an advance directive | More than 50% of all unique patients 65 y old or older admitted to the eligible hospital’s or CAH’s inpatient department during the EHR reporting period have an indication of an advance directive status recorded as structured data |
| Provide structured electronic laboratory results to ambulatory providers | Hospital laboratories send structured electronic clinical laboratory results to the ordering provider for more than 20% of electronic laboratory orders received |
| Capability to identify and report cancer cases to a state cancer registry, except where prohibited, and in accordance with applicable law and practice | Successful ongoing submission of cancer case information from certified EHR technology to a cancer registry for the entire EHR reporting period |
| Record electronic notes in patient records | Enter at least one electronic progress note created, edited, and signed by an EP for more than 30% of patients seen during the EHR reporting period |
| Generate and transmit permissible prescriptions electronically | More than 10% of hospital discharge medication orders are compared with at least one drug formulary and transmitted electronically using certified EHR technology |
| Record patient family health history as structured data | More than 20% of all unique patients seen during the EHR reporting period have a structured data entry for one or more first-degree relatives or an indication that family health history has been reviewed |
| Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice | Successful ongoing submission of specific case information from certified EHR technology to a specialized registry for the entire EHR reporting period |
| Capability to submit electronic syndromic surveillance data to public health agencies and actual submission except where prohibited and in accordance with applicable law and practice | Successful ongoing submission of electronic syndromic surveillance data from certified EHR technology to a public health agency for the entire EHR reporting period |
Related posts:
Quality Improvement in Neurosurgery
The Relationship Between National Health Care Policies and Quality Improvement in Neurosurgery
Quality Improvement Tools and Processes
Technology and Simulation to Improve Patient Safety
Using Clinical Registries to Improve the Quality of Neurosurgical Care
Comanagement Hospitalist Services for Neurosurgery
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