Use Of Electronic Health Record Systems Research Articles

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions

Healthcare professionals develop workarounds rather than using electronic health record (EHR) systems. Understanding the reasons for workarounds is important to facilitate user-centered design and alignment between work context and available health information technology tools. To examine both paper- and computer-based workarounds to the use of EHR systems in three benchmark institutions. Qualitative data were collected in 11 primary care outpatient clinics across three healthcare institutions. Data collection methods included direct observation and opportunistic questions. In total, 120 clinic staff and providers and 118 patients were observed. All data were analyzed using previously developed workaround categories and examined for potential new categories. Additionally, workarounds were coded as either paper- or computer-based. Findings corresponded to 10 of 11 workaround categories identified in previous research. All 10 of these categories applied to paper-based workarounds; five categories also applied to computer-based workarounds. One new category, no correct path (eg, a desired option did not exist in the computer interface, precipitating a workaround), was identified for computer-based workarounds. The most consistent reasons for workarounds across the three institutions were efficiency, memory, and awareness. Consistent workarounds across institutions suggest common challenges in outpatient clinical settings and failures to accommodate these challenges in EHR design. An examination of workarounds provides insight into how providers adapt to limiting EHR systems. Part of the design process for computer interfaces should include user-centered methods particular to providers and healthcare settings to ensure uptake and usability.

Infection preventionists' awareness of and engagement in health information exchange to improve public health surveillance

Advances in electronic health record (EHR) systems and health information exchange (HIE) are shifting efforts in public health toward greater use of information systems to automate notifiable disease surveillance. Little is known about infection preventionists' (IPs) awareness, adoption, and use of these technologies to report information to public health. To measure awareness and engagement in EHR and HIE activities, an online survey of IPs was conducted in states with HIE networks. A total of 63 IPs was invited to participate; 44 IPs (69%) responded. The survey asked about the adoption and use of EHR systems, participation in regional HIE initiatives, and IP needs with respect to EHR systems and public health reporting. Over 70% of responding IPs reported access to an EHR system, but less than 20% of IPs with access to an EHR reported being involved in the design, selection, or implementation of the system. Just 10% of IPs reported that their organizations were formally engaged in HIE activities, and 49% were unaware of organizational involvement in HIE. IPs expressed a desire for better decision support, paperless reporting methods, and situational awareness of community outbreaks. Many IPs lack awareness and engagement in EHR and HIE activities, which may limit IPs ability to influence or utilize key information technologies as they are implemented in health care organizations.

Editorial

The American Recovery and Reinvestment Act of 2009 provided financial incentives to providers and hospitals to adopt, implement, and demonstrate meaningful use of certified electronic health records (EHRs). The criteria, objectives, and measures for EHR meaningful use are organized into three stages covering a five-year period. Stage 1, started in 2011, set the baseline for electronic data capture and sharing health information in a structured format. Stage 2 is building upon the first stage with a focus on data aggregation and quality improvement at the point of care. The final stage will focus on using data to affect outcomes. The Centers for Medicare and Medicaid Services' final rule, published in August, specifies stage 2 criteria for this EHR incentive program. The regulations were based on recommendations from the Department of Health and Human Services Health IT Policy Committee, which coordinates input from industry and providers. Beginning Oct. 1, 2013, eligible hospitals will be required to report clinical quality measures (CQMs) to qualify for incentive payments. Hospitals are required to report on 16 of 29 CQMs endorsed by the National Quality Forum, regardless of participation in stages 1 or 2. The CQMs chosen by hospitals must relate to at least three of six domains defined in the HHS National Quality Strategy (NQS). The clinical process and effectiveness domain includes the CQM Hearing Screening Prior to Hospital Discharge, a newborn hearing screening endorsed by NQF in August 2011. This measure was developed by the Centers for Disease Control and Prevention's Early Hearing Detection and Intervention (EHDI) program. The CDC, as the measure steward, will be responsible for maintaining and updating EHDI CQM electronic specifications. The stage 2 final rule for meaningful use outlines the process to submit CQM data electronically to reduce the burden of reporting. This rule requires that reporting EHDI CQM and other aggregate measures must be done using the Health Level Seven Category III Quality Reporting Data Architecture (QRDA), an XML format that humans and machines can read. This aggregate QRDA report will be generated and transmitted electronically by the hospital EHR via a CMS-designated transmission method. Beginning in 2015, hospitals that do not demonstrate meaningful use of EHR systems will be subject to a payment reduction for services provided, according to the EHR Incentive Program Final Rule. The final rule publication is available at http://bit.ly/FedRegRule. Read more about NQF's quality measure consensus process at: http://bit.ly/NQFprocess. Learn about CDC's EHDI program at http://bit.ly/CDCprogramEHDI. Click and Connect! Access the links in The Hearing Journal by reading this issue on our website or in our new iPad app, both available at thehearingjournal.com. Find us on Twitter at twitter.com/hearingjournal and Facebook at www.facebook.com/HearingJournal.

Hopes and Fears in Implementation of Electronic Health Records in Bangladesh

AbstractHealth is seen as a major key for development and many developing country governments invest in ICT‐based Health Information Systems (HIS). The purpose of this paper is to explore physicians’ hopes and fears for implementing Electronic Health Record (EHR) systems in Bangladeshi hospitals. Data was collected through interviews and observations at two Bangladeshi hospitals. We found very little use of EHR systems at the hospitals and many physicians were skeptical of using EHR systems. Whereas this skepticism could be seen as a symptom of backward thinking our analysis found much of this skepticism to be reasonable. In this way this research contributes to the ongoing debate on how to implement HIS in developing countries. We articulate and analyze users’ concerns beyond mere “attitudes” and “acceptance”. Our results show that the fears and concerns on the hospital floors are legitimate and should be taken into consideration when HIS projects are initiated.

Electronic Health Records

One goal of public-policy makers in general and health care managers in particular is the adoption and efficient utilization of electronic health record (EHR) systems throughout the health care industry. Consequently, this investigation focused on the effects of known antecedents of technology adoption on physician satisfaction with EHR technology and the continued use of such systems. The American Academy of Family Physicians provided support in the survey of 453 physicians regarding their satisfaction with their EHR use experience. A conceptual model merging technology adoption and computer user satisfaction models was tested using structural equation modeling. Results indicate that effort expectancy (ease of use) has the most substantive effect on physician satisfaction and the continued use of EHR systems. As such, health care managers should be especially sensitive to the user and computer interface of prospective EHR systems to avoid costly and disruptive system selection mistakes.

Electronic health records in small physician practices: availability, use, and perceived benefits

To examine variation in the adoption of electronic health record (EHR) functionalities and their use patterns, barriers to adoption, and perceived benefits by physician practice size. Mailed survey of a nationally representative random sample of practicing physicians identified from the Physician Masterfile of the American Medical Association. Measurements We measured, stratified by practice size: (1) availability of EHR functionalities, (2) functionality use, (3) barriers to the adoption and use of EHR, and (4) impact of the EHR on the practice and quality of patient care. With a response rate of 62%, we found that < 2% of physicians in solo or two-physician (small) practices reported a fully functional EHR and 5% reported a basic EHR compared with 13% of physicians from 11+ group (largest group) practices with a fully functional system and 26% with a basic system. Between groups, a 21-46% difference in specific functionalities available was reported. Among adopters there were moderate to large differences in the use of the EHR systems. Financial barriers were more likely to be reported by smaller practices, along with concerns about future obsolescence. These differences were sizable (13-16%) and statistically significant (p < 0.001). All adopters reported similar benefits. Limitations Although we have adjusted for response bias, influences may still exist. Our study found that physicians in small practices have lower levels of EHR adoption and that these providers were less likely to use these systems. Ensuring that unique barriers are addressed will be critical to the widespread meaningful use of EHR systems among small practices.

A student-centred electronic health record system for clinical education.

Electronic Health Record (EHR) systems are an increasingly important feature of the national healthcare system [1]. However, little research has investigated the impact this will have on medical students' learning. As part of an innovative technology platform for a new masters level program in medicine, we are developing a student-centred EHR system for clinical education. A prototype was trialed with medical students over several weeks during 2010. This paper reports on the findings of the trial, which had the overall aim of assisting our understanding of how trainee doctors might use an EHR system for learning and communication in a clinical setting. In primary care and hospital settings, EHR systems offer potential benefits to medical students' learning: Longitudinal tracking of clinical progress towards established learning objectives [2]; Capacity to search across a substantial body of records [3]; Integration with online medical databases [3]; Development of expertise in creating, accessing and managing high quality EHRs [4]. While concerns have been raised that EHR systems may alter the interaction between teachers and students [3], and may negatively influence physician-patient communication [6], there is general consensus that the EHR is changing the current practice environment and teaching practice needs to respond. Final year medical students on clinical placement at a large university teaching hospital were recruited for the trial. Following a four-week period of use, semi-structured interviews were conducted with 10 participants. Audio-recorded interviews were transcribed and data analysed for emerging themes. Study participants were also surveyed about the importance of EHR systems in general, their familiarity with them, and general perceptions of sharing patient records. Medical students in this pilot study identified a number of educational, practical and administrative advantages that the student-centred EHR system offered over their existing ad-hoc procedures for recording patient encounters. Findings from this preliminary study point to the need to introduce and instruct students' on the use of EHR systems from their earliest clinical encounters, and to closely integrate learning activities based on the EHR system with established learning objectives. Further research is required to evaluate the impact of student-centred EHR systems on learning outcomes.

Analysis of Free Text with Omaha System Targets in Community-Based Care to Inform Practice and Terminology Development

The Omaha system is one of the most widely used interface terminologies for documentation of community-based care. It is influential in disseminating evidence-based practice and generating data for health care quality research. Thus, it is imperative to ensure that the Omaha system reflects current health care knowledge and practice. The purpose of this study was to evaluate free text associated with Omaha system terms to inform issues with electronic health record system use and future Omaha system standard development. Two years of client records from two diverse sites (a skilled homecare, hospice, and palliative care program and a maternal child health home visiting program) were analyzed for the use of free text as a component of the intervention when structured targets for interventions were not identified. Intervention text entries very commonly contained duplicate "carry forward entries", multiple concepts, mismatched problem focus, or failure to identify an existing appropriate target. Our findings support the need to better address education gaps for clinicians. We identified additional suggested targets for Omaha system problems, and propose new targets for consideration in future Omaha system revisions.

The Regional Extension Center Program: Helping Physicians Meaningfully Use Health Information Technology

Many physicians face financial and organizational barriers that inhibit their adoption of electronic health record (EHR) systems. The 2009 Health Information Technology for Economic and Clinical Health Act included provisions to facilitate the transition from paper to electronic records, including Medicare and Medicaid incentive payments to support the adoption and meaningful use of EHR systems. It also created the Health Information Technology Regional Extension Center (REC) program to ease the barriers faced by primary care physicians and rural and critical-access hospitals seeking to implement EHRs. The 60 RECs will administer individualized assistance to primary care practices and rural and critical-access hospitals as they implement new EHR systems or upgrade existing ones. In aggregate, the RECs aim to help 100000 primary care physicians, physician assistants, and nurse practitioners to effectively implement EHR systems and qualify for incentive payments for meaningful use. This article describes the rationale for the REC program and describes how the 60 RECs promote the meaningful use of EHR systems.

Openness of patients' reporting with use of electronic records: psychiatric clinicians' views

Improvements in electronic health record (EHR) system development will require an understanding of psychiatric clinicians' views on EHR system acceptability, including effects on psychotherapy communications, data-recording behaviors, data accessibility versus security and privacy, data quality and clarity, communications with medical colleagues, and stigma. Multidisciplinary development of a survey instrument targeting psychiatric clinicians who recently switched to EHR system use, focus group testing, data analysis, and data reliability testing. Survey of 120 university-based, outpatient mental health clinicians, with 56 (47%) responding, conducted 18 months after transition from a paper to an EHR system. Factor analysis gave nine item groupings that overlapped strongly with five a priori domains. Respondents both praised and criticized the EHR system. A strong majority (81%) felt that open therapeutic communications were preserved. Regarding data quality, content, and privacy, clinicians (63%) were less willing to record highly confidential information and disagreed (83%) with including their own psychiatric records among routinely accessed EHR systems. single time point; single academic medical center clinic setting; modest sample size; lack of prior instrument validation; survey conducted in 2005. In an academic medical center clinic, the presence of electronic records was not seen as a dramatic impediment to therapeutic communications. Concerns regarding privacy and data security were significant, and may contribute to reluctances to adopt electronic records in other settings. Further study of clinicians' views and use patterns may be helpful in guiding development and deployment of electronic records systems.

QOPI, EHRs, and Quality Measures

We read with great interest the article by Neuss et al (“A Process for Measuring the Quality of Cancer Care: The Quality Oncology Practice Initiative”) in the September 1, 2005, Journal of Clinical Oncology, and the Quality Oncology Practice Initiative (QOPI) article from the January 2006 JOP. From the perspectives of an electronic health record (EHR) vendor and a practicing oncologist, we found the reports on the QOPI system timely and laudable, and the results are encouraging. That the indicators largely improved between the two survey rounds was encouraging, especially given that the project is in its infancy. What was disheartening, however, was that the capability for collecting quality indicators using EHR systems was entertained neither in the conception of the study nor in the associated article discussions. While this is understandable given the limited penetration of EHR systems, it neglects considerations for scaling and evolving the QOPI program. Oncology-specific EHR systems are currently available and are capable of providing a robust infrastructure for support of quality-improvement projects. These systems will likely render manual data abstraction and collection methods obsolete, and help reduce the $1,000 per-practice cost for the QOPI assessment—a cost that increases dramatically when applied to a nationwide system. Furthermore, the use of EHR systems in oncology will undoubtedly increase over time, and their costs can be offset by their potential for promoting efficiency, reducing medical errors, and enhancing quality care. Initiatives launched by the Office of the National Coordinator for Health Information Technology, the promotion of the Oncology Demonstration Programs by Centers for Medicare and Medicaid Services, and proposed legislation encouraging Pay for Performance, as well as patient demands, all suggest that widespread adoption of EHR systems by oncologists is imminent. Advantages of embedding quality measures into the core of an EHR system abound. Indicators can be “calculated” based on data entered during the course of routine care, and reports of quality could become routine. Quality for all patients, not just a random few, could be tracked and quantified in real time. Using EHR systems, aggregation across practices along with centralized collection, comparison, and analysis is more readily supported. The same may be true for methods of abstracting, reviewing, auditing, and identifying other leading and lagging quality indicators. By promoting and standardizing QOPI measures, data from disparate EHR systems could be compared, and otherwise leveraged in support of quality management. Perhaps most importantly, an EHR can help promote the very quality it is responsible for measuring, by enforcing rules such as “no chemotherapy administration unless a consent is present.” We believe that quantification of most of the 11 QOPI indicators is already possible using commercially available oncology-specific EHR systems. However, as the QOPI project evolves, the following EHR-specific criteria would add significantly to the “ideal and practical” criteria introduced by the authors: Coordination and standardization of indicators among all the stakeholders, including professional societies, insurers, payers, patient advocacy groups, governmental organizations, accreditation bodies, and the practices themselves Consideration for ease of “calculating” the indicator from measures already present in an EHR. For example, whether an explicit statement of the patient's staging has been entered is far easier to “calculate” and validate than whether there was appropriate use of chemotherapy and hormonal therapy for a subset of breast cancer patients It is vital that all stakeholders agree upon a standardized nomenclature, lest the field degenerate into a “Tower of Babel.” We agree with the authors that a process for gathering data concerning the quality of oncology care in individual practices needs to be expeditiously designed and implemented. The QOPI system may indeed allow rapid feedback of performance data for each of the selected indicators, but probably not as efficiently and rapidly as a QOPI-equipped EHR system. In an era where EHRs are coming of age, the time to incorporate indicators into the core of such systems is now. EHR vendors have an interest in collaborating in the development and adaptation of current indicators, but the responsibility of equipping EHRs to measure, track, and enhance quality in the oncology practice belongs to all of us.