Electronic Health Record Implementation Research Articles

The long-term financial impact of electronic health record implementation.

To examine the financial impact of electronic health record (EHR) implementation on ambulatory practices. We tracked the practice productivity (ie, number of patient visits) and reimbursement of 30 ambulatory practices for 2 years after EHR implementation and compared each practice to their pre-EHR implementation baseline. Reimbursements significantly increased after EHR implementation even though practice productivity (ie, the number of patient visits) decreased over the 2-year observation period. We saw no evidence of upcoding or increased reimbursement rates to explain the increased revenues. Instead, they were associated with an increase in ancillary office procedures (eg, drawing blood, immunizations, wound care, ultrasounds). The bottom line result-that EHR implementation is associated with increased revenues-is reassuring and offers a basis for further EHR investment. While the productivity losses are consistent with field reports, they also reflect a type of efficiency-the practices are receiving more reimbursement for fewer seeing patients. For the practices still seeing fewer patients after 2 years, the solution likely involves advancing their EHR functionality to include analytics. Although they may still see fewer patients, with EHR analytics, they can focus on seeing the right patients. Practice reimbursements increased after EHR implementation, but there was a long-term decrease in the number of patient visits seen in this ambulatory practice context.

Studying the impact of interoperable electronic health records on workflow in ambulatory care

Many of the proposed benefits of health information systems, particularly those regarding efficiency, are assumed to be caused by changes in clinical provider and staff workflow. Assessing the extent to which electronic health records (EHRs) are having the expected effects and identifying barriers to anticipated improvements requires a detailed understanding of how such systems affect day-to-day work activities. This study utilized interviews and observations to develop prototypical workflow models of day-to-day activities in ambulatory practices, allowing activity changes due to the implementation of EHRs with varying levels of interoperability to be identified. Primary and specialty care practices from a multi-county region were sampled. Results showed that EHRs did not consistently improve efficiency, but variously reduced, added, or simply changed work tasks. The impact depended on the work process, level of interoperability, and type of provider involved, as well as aspects of the user interface design. Additionally, implementing EHR systems did not eliminate the use of paper from work processes. Implications for successful implementation and design of EHR systems are provided. Relevance to industryEffectively designing and implementing health IT systems in clinical settings requires an understanding of how the IT system will impact, and be integrated with, existing work activities, and how these impacts may depend on the level of interoperability achieved by the IT system.

The impact of electronic health record implementation on emergency physician efficiency and patient throughput

Background: In emergency departments (EDs), the implementation of electronic health records (EHRs) has the potential to impact the rapid assessment and management of life threatening conditions. In order to quantify this impact, we studied the implementation of EHRs in the EDs of a two hospital system. Methods: using a prospective pre–post study design, patient processing metrics were collected for each ED physician at two hospitals for 7 months prior and 10 months post-EHR implementation. Metrics included median patient workup time, median length of stay, and the composite outcome indicator "processing time." Results: median processing time increased immediately post-implementation and then returned to, and surpassed, the baseline level over 10 months. Overall, we see significant decreases in processing time as the number of patients treated increases. Conclusions: implementation of new EHRs into the ED setting can be expected to cause an initial decrease in efficiency. With adaptation, efficiency should return to baseline levels and may eventually surpass them. Implications: while EDs can expect long term gains from the implementation of EHRs, they should be prepared for initial decreases in efficiency and take preparatory measures to avert adverse effects on the quality of patient care.

Hospital rounding--EHR's impact.

The purpose of this paper is to understand the time spent on various tasks during physician inpatient rounds and to examine the new electronic health records (EHRs) impact on time distribution. Trained observers shadowed hospital physicians to record times for various tasks before and after EHR implementation. Electronic records did not improve efficiency. However, task times were redistributed. Physicians spent more time reviewing patient charts using time saved from miscellaneous work. The study focusses solely on work distribution and the changes it underwent. It does not include quality measures either on patient results or physician satisfaction. As EHR provides rich information and easier access to patient records, it motivates physicians to spend more time reviewing patient charts. Hospital administrators seeking immediate returns on EHR investment, therefore, may be disappointed. Unlike previous work, this study was conducted in a non-teaching hospital, providing a task-time comparison without any educational and team factor influence. The result serves as a benchmark for many community hospital managers seeking to address the same issue.

"Big data" and the electronic health record.

Implementation of Electronic Health Record (EHR) systems continues to expand. The massive number of patient encounters results in high amounts of stored data. Transforming clinical data into knowledge to improve patient care has been the goal of biomedical informatics professionals for many decades, and this work is now increasingly recognized outside our field. In reviewing the literature for the past three years, we focus on "big data" in the context of EHR systems and we report on some examples of how secondary use of data has been put into practice. We searched PubMed database for articles from January 1, 2011 to November 1, 2013. We initiated the search with keywords related to "big data" and EHR. We identified relevant articles and additional keywords from the retrieved articles were added. Based on the new keywords, more articles were retrieved and we manually narrowed down the set utilizing predefined inclusion and exclusion criteria. Our final review includes articles categorized into the themes of data mining (pharmacovigilance, phenotyping, natural language processing), data application and integration (clinical decision support, personal monitoring, social media), and privacy and security. The increasing adoption of EHR systems worldwide makes it possible to capture large amounts of clinical data. There is an increasing number of articles addressing the theme of "big data", and the concepts associated with these articles vary. The next step is to transform healthcare big data into actionable knowledge.

Impact of electronic health records on the patient experience in a hospital setting.

The impact of electronic health records (EHRs) and their effects on optimizing the patient experience has been debated nationally. Currently, there is a paucity of data in this area, and existing research offers conflicting results. Since 2006, the Assessing Residents' CI-CARE (ARC) program has evaluated the physician-patient interaction of resident physicians at University of California, Los Angeles (UCLA) Health utilizing a 20-item questionnaire administered through facilitator-patient interviews. To evaluate the impact of EHR implementation on the patient experience. Retrospective cohort study. Two academic medical campuses: Ronald Reagan UCLA Medical Center and UCLA Medical Center, Santa Monica. A total of 3417 surveys, spanning December 1, 2012 to May 30, 2013, were assessed. This included patient representation from 9 departments within UCLA Health. Surveys were analyzed to assess physician-patient communication. Statistical comparisons were made using χ analysis. All 16 questions assessing physician-patient communication received better responses in the 3 months following EHR implementation, compared to the 3 months prior to implementation. Of these, 9 questions illustrated statistically significant improvement, whereas the improvement in the remaining 7 questions was not statistically significant. These results suggest that EHRs may improve physician-patient communication. The ARC infrastructure allowed for observation of this trend; however, future research should aim to further validate and understand the etiologies of this improvement.

Electronic health record (EHR) projects in Canada: participation options for Canadian health librarians

Research question: What are the major issues in the implementation of electronic health record (EHR) systems in Canada and what competencies can Canadian health librarians bring to their participation in these projects? Data sources: Health informatics and library science databases were searched for EHR literature. Grey literature was located at Canada Health Infoway's website, on provincial and federal government websites, and by searching online news websites. Study selection: The data sources were searched for journal articles, reviews, newspaper articles, government publications, interviews, grey literature, dissertations, editorials, and discussions. Data extraction: Data were extracted from the data sources using search strategies and keywords outlined in Appendix A. Due to the scope and focus of this paper, search terms were selected to emphasize a Canadian context; in particular, a British Columbian perspective in regards to EHR implementation. Results: This paper draws on a body of evidence to discuss EHR implementation issues and health librarian involvement in Canada. There is a growing body of research in the American biomedical literature about health librarian participation in EHR implementation but little in the Canadian health literature. Conclusion: This is the first paper of its kind that proposes new roles for Canadian health librarians in EHR implementation. Health librarians’ expertise in organizing and retrieving information makes them ideally suited for providing evidence-based medicine or consumer health information embedded directly in EHRs. Further research is needed to demonstrate the value of health librarians on EHR project teams.

Development of a tool to measure user experience following electronic health record implementation.

The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives. Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation. The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support. Validation efforts included content validity assessment, a pilot study, and analysis of 606 nurse respondents. The revised tool was sent to randomly sampled EHR nurse-users in 11 acute care facilities. A total of 1,301 nurses responded (37%). Internal consistency of the survey tool was excellent (Cronbach's α = .892). Survey responses including 1,819 open comments were used to identify and prioritize improvement efforts in areas such as education, support, optimization of EHR functions, and vendor change requests. The Baylor EHR UX survey was a valid tool that can be useful for prioritizing improvement efforts in relation to EHR implementation.

Understanding process change management in electronic health record implementations

Electronic health record (EHR) implementations involve changes to core organizational processes, and management of these changes is critical to the success of such implementation efforts. This rese...

Meaningful Use of Electronic Health Records

The concerns on patient safety and quality improvement in health care are increasing. There is growing use of technology in health care, particularly use of the electronic health record (EHR). As this occurs, the health care system is transforming. The federal government has become involved in EHR implementation, encouraging improved health care. The Centers for Medicare & Medicaid Services are implementing the Meaningful Use (MU) Incentive Program for Medicare- and Medicaid-eligible providers. As EHR implementation and MU Programs grow, it is important for the nurse practitioner (NP) to be aware of the MU Program. As NPs become engaged in using EHRs, MU will have an impact on changing health care systems and implications related to clinical practice and improved outcomes.

Implementation of Electronic Health Record (EHR) System in the Healthcare Industry

The purpose of this research is to demonstrate the efficiency of the Electronic Health Record (EHR) software that is adopted in the healthcare industry to provide better patient care. The authors examine the impact of EHRs on the efficient delivery of healthcare services. More specifically, they detail the origin of EHR, its significance in modern healthcare delivery along with the selection and implementation criteria for EHR software. They present a survey on the extent of adoption of EHR by clinicians. They also highlight the challenges and barriers faced by organizations in adopting EHR software such as cost, workflow impact and data security. Finally, the authors contemplate the future of EHR, its role in the implementation of health information exchange and its implementation in the cloud. They conclude that the implementation of EHR in the cloud is an important step towards better health management across the population with the end-goal of better health outcomes.

Improvement in Quality of Care Metrics Through The Implementation of Electronic Health Records (EHR) in Renal Transplant Patient Management.

Objective: Present our experience with Electronic Health Records (EHR) in Clinical Decision Support (CDS), Computerized Physician Order Entry (CPOE), and Health Information Exchange (HIE) in renal transplant care. Methods: Apply EHR for standardized post transplant care A)Implement protocols and flow sheets 1) Establish unified template note and flow sheets (TX chemistry, TX anemia, Tx CVD risk, Tx virology, TX HLA) 2) Establish clinical pathways with CDS to detect allograft dysfunction, drug levels, DSA's, viral surveillance and protocol biopsies. 3) Manage CDC high risk organs recipients with viral monitoring. 4) Manage post-transplant viral infections (CMV, BKV) to reduce treatment variability and improve outcomes. B) Communication: Implement HIE to improve communication between patients and staff, immediate availability of lab results and medication refills through E-prescribing. Lab results download into patient charts with critical alerts. Patients received results via secure health track emails. C) Patient care: Improved monitoring for compliance with lab testing, medication refills and follow up. Periodic reports for “at risk patients” allowed focused interventions. D) Established a standardized note to reduce variability, decrease error, and improved the quality of care. Results: At our center we performed 192 kidney alone transplants in 2013 and achieved 100% compliance with chemistry testing monitoring, 90% BKV screening, and 78% protocol biopsy. We have unified patient care for BKV infection and acute allograft rejection. We noticed an improvement in 1-year actual allograft survival (Figure) with 6m allograft survival of 98% (transplanted in 2013). Conclusion: Adopting a unified approach to patient care using EHR resulted in improvement in quality metrics via protocols and flow sheets, monitoring of compliance and better communications. The use of EHR has been associated with effective patient care with a trend towards better outcome.Figure: No Caption available.

Electronic health records and technical assistance to improve quality of primary care: Lessons for regional extension centers

BackgroundIn 2009, the American Recovery and Reinvestment Act apportioned $643 million for a Health Information Technology Extension Program, which established Regional Extension Centers (RECs) to support the implementation and use of electronic health records (EHRs). ProblemLittle is known, however, about how RECs should assist in EHR implementation and how they should structure ongoing support. GoalsThe purpose of this paper is to describe physicians' experiences with the Primary Care Information Project (PCIP), an REC run by the New York City Department of Health and Mental Hygiene. StrategyWe interviewed 17 physicians enrolled in PCIP to understand the role of the EHRon quality of care and their experience with technical assistance from PCIP. ResultsAll physicians stated that they felt that the EHR improved the quality of care they delivered to their patients particularly because it helped them track patients. All the physicians found technical assistance helpful but most wanted ongoing assistance months or years after they adopted the EHR. Implications•Physicians believe that both the EHR and ongoing technical assistance are important determinants of quality improvement.•RECs should consider models that provide ongoing technical assistance at regular intervals.

Topics in Neonatal Informatics: Meaningful Use: Implications for the Neonatologist

Meaningful use is promoting rapid spread and implementation of the electronic health record in hospital systems and practices of eligible providers. Meaningful use criteria are directed at supporting policy priorities for health outcomes. The staged timeline began in 2010 and extends to 2021 with final incentive payments. Specific objectives and clinical quality measures must be met in order for hospitals or providers to be eligible for the incentives. Neonatologists can benefit from understanding meaningful use and advocating for systems and measures that meet the workflow and clinical needs of the neonatal care providers and patients.

The impact of electronic health record implementation and use on performance of the Surgical Care Improvement Project measures.

To examine the impact of electronic health record (EHR) deployment on Surgical Care Improvement Project (SCIP) measures in a tertiary-care teaching hospital. SCIP Core Measure dataset from the CMS Hospital Inpatient Quality Reporting Program (March 2010 to February 2012). One-group pre- and post-EHR logistic regression and difference-in-differences analyses. Statistically significant short-term declines in scores were observed for the composite, postoperative removal of urinary catheter and post-cardiac surgery glucose control measures. A statistically insignificant improvement in scores for these measures was noted 3months after EHR deployment. The transition to an EHR appears to be associated with a short-term decline in quality. Implementation strategies should be developed to preempt or minimize this initial decline.

Factors related to health information exchange participation and use.

This study examines factors facilitating and delaying participation and use of the Health Information Exchange (HIE) in Louisiana. Semi-structured qualitative interviews were conducted with health care representatives throughout the state. Findings suggest that Meaningful Use requirements are a critical factor influencing the decision to participate in the HIE, specifically the mandate that hospitals be able to electronically transfer summary of care documents. Creating buy-in within a few large hospital networks legitimized the HIE and hastened interest in those markets. Fees charged by electronic health record (EHR) vendors to develop HIE interfaces have been prohibitive. Funding from the federal incentive program is intended to offset the costs associated with EHR implementation and increase the likelihood that HIEs can provide value to the population; however, costs and time delays of EHR interface development may be key barriers to fully integrated HIEs. State HIEs may benefit from targeted involvement of state health care leaders who can champion the potential value of the HIE.

Requirements for Integrating End-to-End Security into Large-Scale EHR Systems

Electronic Health Records (EHR) are becoming a growing trend in the healthcare industry. Especially when applied across healthcare organizations, EHRs provide benefits such as financial incentives and a more complete view of a patient’s history. However, they also face security issues regarding the confidentiality and privacy of the patients’ data, especially when the EHRs are stored at third-party providers or in the cloud. In general,confidentiality can be ensured by using cryptographic mechanisms or access control. Unfortunately, both techniques diminish the usability of the EHR if they are applied straightforwardly. Privacy and confidentiality have to be ensured in a way that does not restrict usability as it reduces the benefits of the EHR. This paper presents experiences from a requirements analysis we made during ongoing projects. We summarize the requirements for integrating end-to-end confidentiality into large-scale EHR systems in a usable fashion. In particular, show(i)which data granularity is useful to been crypted without interfering with access control, (ii) requirements for an authorization mechanism to access encrypted data, (iii) a privacy classification of typical metadata in EHRs, and (iv) interoperability issues that must be solved to allow for secure and usable EHR implementations.

Perceptions of Electronic Health Record Implementation: A Statewide Survey of Physicians in Rhode Island

ObjectivesAlthough electronic health record use improves healthcare delivery, adoption into clinical practice is incomplete. We sought to identify the extent of adoption in Rhode Island and the characteristics of physicians and electronic health records associated with positive experience. MethodsWe performed a cross-sectional study of data collected by the Rhode Island Department of Health for the Health Information Technology Survey 2009 to 2013. Survey questions included provider and practice demographics, health record information, and Likert-type scaled questions regarding how electronic health record use affected clinical practice. ResultsThe survey response rate ranged from 50% to 65%, with 62% in 2013. Increasing numbers of physicians in Rhode Island use an electronic health record. In 2013, 81% of physicians used one, and adoption varied by clinical subspecialty. Most providers think that electronic health record use improves billing and quality improvement but has not improved job satisfaction. Physicians with longer and more sophisticated electronic health record use report positive effects of introduction on all aspects of practice examined (P < .001). Older physician age is associated with worse opinion of electronic health record introduction (P < .001). Of the 18 electronic health record vendors most frequently used in Rhode Island, 5 were associated with improved job satisfaction. ConclusionsWe report the largest statewide study of electronic health record adoption to date. We found increasing physician use in Rhode Island, and the extent of adoption varies by subspecialty. Although older physicians are less likely to be positive about electronic health record adoption, longer and more sophisticated use are associated with more positive opinions, suggesting acceptance will grow over time.

Going Live

This study evaluated the immediate effects of implementing an electronic health record (EHR) system on physician workflow in the emergency department. Two sets of observations were conducted in one emergency department. The first set of observations, the baseline period, was completed in the 22 days prior to the implementation of a new EHR. The second set of observations, the go-live period, was completed during the seven-day period immediately after the EHR go-live date. A comparison across four task-based categories revealed that during the go-live period there was a decrease in the proportion of time physicians spent in patient rooms and engaged with paper-based tasks, and an increase in the proportion of time physicians spent at computer stations and working with other people. In addition, physicians engaged in more information seeking behaviors during the go-live period than during the baseline period. The impact of these shifts in tasks and behaviors is discussed with a focus on the importance of fully understanding the EHR go-live process.

Importance-satisfaction analysis for primary care physicians' perspective on EHRs in Taiwan.

The Taiwan government has been promoting Electronic Health Records (EHRs) to primary care physicians. How to extend EHRs adoption rate by measuring physicians’ perspective of importance and performance of EHRs has become one of the critical issues for healthcare organizations. We conducted a comprehensive survey in 2010 in which a total of 1034 questionnaires which were distributed to primary care physicians. The project was sponsored by the Department of Health to accelerate the adoption of EHRs. 556 valid responses were analyzed resulting in a valid response rate of 53.77%. The data were analyzed based on a data-centered analytical framework (5-point Likert scale). The mean of importance and satisfaction of four dimensions were 4.16, 3.44 (installation and maintenance), 4.12, 3.51 (product effectiveness), 4.10, 3.31 (system function) and 4.34, 3.70 (customer service) respectively. This study provided a direction to government by focusing on attributes which physicians found important but were dissatisfied with, to close the gap between actual and expected performance of the EHRs. The authorities should emphasize the potential advantages in meaningful use and provide training programs, conferences, technical assistance and incentives to enhance the national level implementation of EHRs for primary physicians.