Electronic Health Record Implementation Research Articles

MHealth Security.

With the implementation of Electronic Health Record (EHR), the patients' health information will reside on the network of computers that can be accessed through a variety of techniques and technologies. One of the widely used present-day communication technology is the mobile/cell phone that has great potential in the healthcare delivery and management as the healthcare providers can remotely access electronically stored health information of patients from anywhere anytime. One of the greatest advantages of the mobile health technology is convenience of time-independent communication from geographically distant places with the healthcare centers and patients that enhances healthcare quality at reduced cost. However, its equally great disadvantage lies in sending and receiving the health information wirelessly through atmosphere which can be easily intercepted, eavesdropped, interjected, modified or even destroyed.

Electronic Health Records: Design, Implementation, and Policy for Higher-Value Primary Care

Ideas and Opinions20 May 2014Electronic Health Records: Design, Implementation, and Policy for Higher-Value Primary CareChristine A. Sinsky, MD, John W. Beasley, MD, Greg E. Simmons, MA, and Richard J. Baron, MDChristine A. Sinsky, MDFrom Medical Associates Clinic and Health Plans, Dubuque, Iowa; University of Wisconsin School of Medicine and Public Health and MetaStar, Madison, Wisconsin; and American Board of Internal Medicine and ABIM Foundation, Philadelphia, Pennsylvania.Search for more papers by this author, John W. Beasley, MDFrom Medical Associates Clinic and Health Plans, Dubuque, Iowa; University of Wisconsin School of Medicine and Public Health and MetaStar, Madison, Wisconsin; and American Board of Internal Medicine and ABIM Foundation, Philadelphia, Pennsylvania.Search for more papers by this author, Greg E. Simmons, MAFrom Medical Associates Clinic and Health Plans, Dubuque, Iowa; University of Wisconsin School of Medicine and Public Health and MetaStar, Madison, Wisconsin; and American Board of Internal Medicine and ABIM Foundation, Philadelphia, Pennsylvania.Search for more papers by this author, and Richard J. Baron, MDFrom Medical Associates Clinic and Health Plans, Dubuque, Iowa; University of Wisconsin School of Medicine and Public Health and MetaStar, Madison, Wisconsin; and American Board of Internal Medicine and ABIM Foundation, Philadelphia, Pennsylvania.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M13-2589 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Electronic health records (EHRs), and the policies and workflows around them, are inconsistently aligned with the needs of primary care patients and physicians. This results in substantial waste of physician and support resources, high rates of burnout (1, 2), and a decrease in primary care capacity precisely at the time when our nation needs a stronger primary care foundation (3).We propose a set of principles (Table) directed toward vendors, institutional leaders, policymakers, and physicians to support higher-value primary care. These principles draw on our expertise in patient care, quality assurance, industrial and systems engineering, and policy and EHR implementation. ...

Does it get easier to use an EHR? Report from an urban regional extension center.

Little is known about whether more experience with an electronic health record (EHR) makes it easier for providers to meaningfully use EHRs. To assess whether the length of time that small practice providers have been using the EHR is associated with greater ease in performing meaningful use-related tasks and fewer EHR-related concerns. We administered a web-based survey to 400 small practice providers in medically underserved communities in New York City participating in an EHR implementation and technical assistance project. We used logistic regression to estimate the association between the length of time a provider had been using the EHR (i.e., "live") and the ease of performing meaningful use-related tasks and EHR-related concerns, controlling for provider and practice characteristics. Compared to providers who had been live 6 to 12 months, providers who had been live 2 years or longer had 2.02 times greater odds of reporting it was easy to e-prescribe new prescriptions (p < 0.05), 2.12 times greater odds of reporting it was easy to e-prescribe renewal prescriptions (p < 0.05), 2.02 times greater odds of reporting that quality measures were easy to report (p < 0.05), 2.64 times greater odds of reporting it was easy to incorporate lab results as structured data (p < 0.001), and 2.00 times greater odds of reporting it was easy to generate patient lists by condition (p < 0.05). Providers who had been live 2 years or longer had 0.40 times lower odds of reporting financial costs were a concern (p < 0.001), 0.46 times lower odds of reporting that productivity loss was a concern (p < 0.05), 0.54 times lower odds of reporting that EHR unreliability was a concern (p < 0.05), and 0.50 times lower odds of reporting that privacy/security was a concern (p < 0.05). Providers can successfully adjust to the EHR and over time are better able to meaningfully use the EHR.

Developing and evaluating a machine learning based algorithm to predict the need of pediatric intensive care unit transfer for newly hospitalized children

BackgroundEarly warning scores (EWS) are designed to identify early clinical deterioration by combining physiologic and/or laboratory measures to generate a quantified score. Current EWS leverage only a small fraction of Electronic Health Record (EHR) content. The planned widespread implementation of EHRs brings the promise of abundant data resources for prediction purposes. The three specific aims of our research are: (1) to develop an EHR-based automated algorithm to predict the need for Pediatric Intensive Care Unit (PICU) transfer in the first 24h of admission; (2) to evaluate the performance of the new algorithm on a held-out test data set; and (3) to compare the effectiveness of the new algorithm's with those of two published Pediatric Early Warning Scores (PEWS). MethodsThe cases were comprised of 526 encounters with 24-h Pediatric Intensive Care Unit (PICU) transfer. In addition to the cases, we randomly selected 6772 control encounters from 62516 inpatient admissions that were never transferred to the PICU. We used 29 variables in a logistic regression and compared our algorithm against two published PEWS on a held-out test data set. ResultsThe logistic regression algorithm achieved 0.849 (95% CI 0.753–0.945) sensitivity, 0.859 (95% CI 0.850–0.868) specificity and 0.912 (95% CI 0.905–0.919) area under the curve (AUC) in the test set. Our algorithm's AUC was significantly higher, by 11.8 and 22.6% in the test set, than two published PEWS. ConclusionThe novel algorithm achieved higher sensitivity, specificity, and AUC than the two PEWS reported in the literature.

Health-oriented electronic oral health record: development and evaluation.

This study aims to develop and evaluate a new Health-oriented Electronic Oral Health Record that implements the health-oriented status and intervention index. The index takes the principles of holistic oral healthcare and applies them to the design and implementation of the Health-oriented Electronic Oral Health Record. We designed an experiment using focus groups and a consensus (Delphi process) method to develop a new health-oriented status and intervention index and graphical user interface. A comparative intervention study with qualitative and quantitative methods was used to compare an existing Electronic Oral Health Record to the Health-oriented Electronic Oral Health Record, focusing on dentist satisfaction, accuracy, and completeness of oral health status recording. The study was conducted by the dental staff of the Inter-country Center for Oral Health collaborative hospitals in Thailand. Overall, the user satisfaction questionnaire had a positive response to the Health-oriented Electronic Oral Health Record. The dentists found it easy to use and were generally satisfied with the impact on their work, oral health services, and surveillance. The dentists were significantly satisfied with the Health-oriented Electronic Oral Health Record compared to the existing Electronic Oral Health Record (p < 0.001). The accuracy and completeness values of the oral health information recorded using the Health-oriented Electronic Oral Health Record were 97.15 and 93.74 percent, respectively. This research concludes that the Health-oriented Electronic Oral Health Record satisfied many dentists, provided benefits to holistic oral healthcare, and facilitated the planning, managing, and evaluation of the healthcare delivery system.

Informatics support for clinical decisions

The utilization of Clinical Decision Support (CDS) systems is increasing with implementation of Electronic Health Record (EHR) systems across the USA. One of the first and most studied CDS applications has been computerized provider order entry (CPOE), particularly CPOE related to medications. Many EHR systems check drug dosage, allergies, and drug-drug interactions as clinicians enter their orders, and issue alerts as needed. However, alert overriding in CPOE systems is common practice. Nanji et al ( see page 487 ) reports that over 50% of alerts are overridden at a particular academic health center and proposes how to decrease unintended CPOE effects on workflows and communications ( see page 481 ). Related to workflows, Coiera ( see page 414 ) offers a model to study workspaces in which critical communications among clinicians occur. Many articles in this issue focus on medication management, including three systematic reviews that address barriers and facilitators …

Workflow Optimization

This article is the second in a series that highlights the role of the clinical nurse specialist in electronic health record implementation. Analyzing clinical workflows and processes is a critical step in the successful implementation of information technology. This article highlights the expertise of the clinical nurse specialist in this process and provides an example to illustrate the process.

Evidence-based management of ambulatory electronic health record system implementation: An assessment of conceptual support and qualitative evidence

ObjectivesWhile electronic health record (EHR) systems have potential to drive improvements in healthcare, a majority of EHR implementations fall short of expectations. Shortcomings in implementations are often due to organizational issues around the implementation process rather than technological problems. Evidence from both the information technology and healthcare management literature can be applied to improve the likelihood of implementation success, but the translation of this evidence into practice has not been widespread. Our objective was to comprehensively study and synthesize best practices for managing ambulatory EHR system implementation in healthcare organizations, highlighting applicable management theories and successful strategies. MethodsWe held 45 interviews with key informants in six U.S. healthcare organizations purposively selected based on reported success with ambulatory EHR implementation. We also conducted six focus groups comprised of 37 physicians. Interview and focus group transcripts were analyzed using both deductive and inductive methods to answer research questions and explore emergent themes. ResultsWe suggest that successful management of ambulatory EHR implementation can be guided by the Plan-Do-Study-Act (PDSA) quality improvement (QI) model. While participants did not acknowledge nor emphasize use of this model, we found evidence that successful implementation practices could be framed using the PDSA model. Additionally, successful sites had three strategies in common: 1) use of evidence from published health information technology (HIT) literature emphasizing implementation facilitators; 2) focusing on workflow; and 3) incorporating critical management factors that facilitate implementation. ConclusionsOrganizations seeking to improve ambulatory EHR implementation processes can use frameworks such as the PDSA QI model to guide efforts and provide a means to formally accommodate new evidence over time. Implementing formal management strategies and incorporating new evidence through the PDSA model is a key element of evidence-based management and a crucial way for organizations to position themselves to proactively address implementation and use challenges before they are exacerbated.

Surveillance of Suicidal and Nonsuicidal Self-Injury in the New York City Jail System

Suicide and nonsuicidal self-injury represent significant causes of morbidity and mortality in jail settings. The New York City Department of Health and Mental Hygiene instituted a database of suicidal and nonsuicidal self-injuries in 2007. Between 2007 and 2011, there were eight deaths by suicide and 2,514 acts of self-injury, with the annual rate of self-injury increasing significantly throughout this time period. The most frequent methods of self-injury were lacerations (816), ligature tied around the neck (569), attempted overdose (501), and swallowed foreign objects (372). This review led to improvements in surveillance as well as improvement of the newly implemented electronic health record.

Why Clinical Change Leadership Is Essential for Project Success

This is the first in a 4-part series where we will explore the role of the clinical nurse specialist (CNS) in the project lifecycle for effective technology adoption. The CNS is often called upon during major projects, such as the implementation of a new electronic health record, to play a key role in the project team. The CNS brings clinical knowledge and skills to the project team, with a particular focus on patient-centered workflows and the maintenance or improvement of the quality of care. However, CNSs may find it challenging to balance their role as members of the leadership group with the role they play in staff development and support.

Meaningful use: Floor or ceiling?

BackgroundIn 2011, federal incentive payments for meaningful use of electronic health records (EHRs) began. This study evaluates the impact of the program on hospitals and EHR vendors, identifying how it affects EHR planning and development. Specifically, it assesses whether vendors and Chief Information Officers (CIOs) are viewing the meaningful use requirements as a floor – the minimally acceptable level of implementation, upon which development continues – or as a ceiling – the upper-bound on EHR development and implementation. MethodsThe study combines interviews with EHR vendors and hospital CIOs with EHR adoption data from American Hospital Association surveys. Results from interviews with 17 hospital and system CIOs (representing 144 individual acute-care hospitals) and 8 EHR development executives (representing two-thirds of installations) are detailed. Furthermore, it compares adoption of two key EHR functions, BCMA and CPOE, which are treated differently under stage 1 of the incentive program. ResultsThree key findings emerge from the study. First, meaningful use requirements can serve as either a floor or a ceiling, depending on the abilities of institutions implementing EHRs. Second, the increasing focus on achieving meaningful use across both hospitals and vendors risks missing the forest of health care system change through the trees of meeting discrete requirements. Third, while the meaningful use incentive program has accelerated the development and implementation of some key functions, it has also slowed development of others. ConclusionsPolicy makers should craft subsequent stages of the incentive program to ensure smaller facilities and additional features necessary for health care system change are not left behind.

Electronic Health Record Training in Undergraduate Medical Education

While electronic health record (EHR) use is becoming state-of-the-art, deliberate teaching of health care information technology (HCIT) competencies is not keeping pace with burgeoning use. Medical students require training to become skilled users of HCIT, but formal pedagogy within undergraduate medical education (UME) is sparse. How can medical educators best meet the needs of learners while integrating EHRs into medical education and practice? How can they help learners preserve and foster effective communication skills within the computerized setting? In general, how can UME curricula be devised for skilled use of EHRs to enhance rather than hinder provision of effective, humanistic health care?Within this Perspective, the authors build on recent publications that "set the stage" for next steps: EHR curricula innovation and implementation as concrete embodiments of theoretical underpinnings. They elaborate on previous calls for maximizing benefits and minimizing risks of EHR use with sufficient focus on physician-patient communication skills and for developing core competencies within medical education. The authors describe bridging theory into practice with systematic longitudinal curriculum development for EHR training in UME at their institution, informed by Kern and colleagues' curriculum development framework, narrative medicine, and reflective practice. They consider this innovation within a broader perspective-the overarching goal of empowering undergraduate medical students' patient- and relationship-centered skills while effectively demonstrating HCIT-related skills.

APhA salutes federal pharmacists

The 15th annual APhA Federal Pharmacy Forum will welcome approximately 100 pharmacists and pharmacy technicians from the U.S. Army (USA), Navy (USN), Air Force (USAF), Coast Guard (USCG), Public Health Service (USPHS), Indian Health Service (IHS), Bureau of Prisons, and Department of Veterans Affairs (VA). Supporting industry partners will have more than 18 exhibition spaces, and additional industry partners will attend.

A qualitative study identifying the cost categories associated with electronic health record implementation in the UK

We conducted a prospective evaluation of different forms of electronic health record (EHR) systems to better understand the costs incurred during implementation and the factors that can influence these costs. We selected a range of diverse organizations across three different geographical areas in England that were at different stages of implementing three centrally procured applications, that is, iSOFT's Lorenzo Regional Care, Cerner's Millennium, and CSE's RiO. 41 semi-structured interviews were conducted with hospital staff, members of the implementation team, and those involved in the implementation at a national level. Four main overarching cost categories were identified: infrastructure (eg, hardware and software), personnel (eg, training team), estates/facilities (eg, space), and other (eg, training materials). Many factors were felt to impact on these costs, with different hospitals choosing varying amounts and types of infrastructure, diverse training approaches for staff, and different software applications to integrate with the new system. Improving the quality and safety of patient care through EHR adoption is a priority area for UK and US governments and policy makers worldwide. With cost considered one of the most significant barriers, it is important for hospitals and governments to be clear from the outset of the major cost categories involved and the factors that may impact on these costs. Failure to adequately train staff or to follow key steps in implementation has preceded many of the failures in this domain, which can create new safety hazards.

Exploring the sociotechnical intersection of patient safety and electronic health record implementation.

The intersection of electronic health records (EHR) and patient safety is complex. To examine the applicability of two previously developed conceptual models comprehensively to understand safety implications of EHR implementation in the English National Health Service (NHS). We conducted a secondary analysis of interview data from a 30-month longitudinal, prospective, case study-based evaluation of EHR implementation in 12 NHS hospitals. We used a framework analysis approach to apply conceptual models developed by Sittig and Singh to understand better EHR implementation and use: an eight-dimension sociotechnical model and a three-phase patient safety model (safe technology, safe use of technology, and use of technology to improve safety). The intersection of patient safety and EHR implementation and use was characterized by risks involving technology (hardware and software, clinical content, and human-computer interfaces), the interaction of technology with non-technological factors, and improper or unsafe use of technology. Our data support that patient safety improvement activities as well as patient safety hazards change as an organization evolves from concerns about safe EHR functionality, ensuring safe and appropriate EHR use, to using the EHR itself to provide ongoing surveillance and monitoring of patient safety. We demonstrate the face validity of two models for understanding the sociotechnical aspects of safe EHR implementation and the complex interactions of technology within a healthcare system evolving from paper to integrated EHR. Using sociotechnical models, including those presented in this paper, may be beneficial to help stakeholders understand, synthesize, and anticipate risks at the intersection of patient safety and health information technology.

University of Michigan Comprehensive Cancer Center Opportunities for Improvement Project

The University of Michigan Comprehensive Cancer Center (UMCCC) Opportunities for Improvement project involved a detailed patient-level medical record review, feedback to medical providers and clinical leadership, and discussion of potential predictors of discordant or delayed care. The medical record review revealed that reasons for discordant or delayed care were well documented by clinical providers, and medical comorbidity was the most common predisposing factor. Another common theme was the difficulty in obtaining treatment records for patients who received a portion of their care outside UMCCC. The project provided a valuable opportunity to examine established processes of care and data collection and consider how the newly implemented electronic health record might support future efforts aimed at improving efficiency and communication among providers.

The Effect of Electronic Health Record Implementation on Community Emergency Department Operational Measures of Performance

We study the effect of an emergency department (ED) electronic health record implementation on the operational metrics of a diverse group of community EDs. We performed a retrospective before/after analysis of 23 EDs from a single management group that experienced ED electronic health record implementation (with the majority of electronic health records optimized specifically for ED use). We obtained electronic data for 4 length of stay measures (arrival to provider, admitted, discharged, and overall length of stay) and 4 measures of operational characteristics (left before treatment complete, significant returns, overall patient satisfaction, and provider efficiency). We compared the 6-month "baseline" period immediately before implementation with a "steady-state" period commencing 6 months after implementation for all 8metrics. For the length of stay measures, there were no differences in the arrival-to-provider interval (difference of -0.02 hours; 95% confidence interval [CI] of difference -0.12 to 0.08), admitted length of stay (difference of 0.10 hours; 95% CI of difference -0.17 to 0.37), discharged length of stay (difference of 0.07 hours; 95% CI of difference -0.07 to 0.22), and overall length of stay (difference of 0.11 hours; 95% CI of difference -0.04 to 0.27). For operational characteristics, there were no differences in the percentage who left before treatment was complete (difference of 0.24%; 95% CI of difference -0.47% to 0.95%), significant returns (difference of -0.04%; 95% CI of difference -0.48% to 0.39%), overall percentile patient satisfaction (difference of -0.02%; 95% CI of difference -2.35% to 2.30%), and provider efficiency (difference of -0.05 patients/hour; 95% CI of difference -0.11 to 0.02). There is no meaningful difference in 8 measures of operational performance for community EDs experiencing optimized ED electronic health record implementation between a baseline and steady-state period.

Real-time database drawn from an electronic health record for a thoracic surgery unit: high-quality clinical data saving time and human resources

The aim of the present study was to verify whether the implementation of an electronic health record (EHR) in our thoracic surgery unit allows creation of a high-quality clinical database saving time and costs. Before August 2011, multiple individuals compiled the on-paper documents/records and a single data manager inputted selected data into the database (traditional database, tDB). Since the adoption of an EHR in August 2011, multiple individuals have been responsible for compiling the EHR, which automatically generates a real-time database (EHR-based database, eDB), without the need for a data manager. During the initial period of implementation of the EHR, periodic meetings were held with all physicians involved in the use of the EHR in order to monitor and standardize the data registration process. Data quality of the first 100 anatomical lung resections recorded in the eDB was assessed by measuring the total number of missing values (MVs: existing non-reported value) and inaccurate values (wrong data) occurring in 95 core variables. The average MV of the eDB was compared with the one occurring in the same variables of the last 100 records registered in the tDB. A learning curve was constructed by plotting the number of MVs in the electronic database and tDB with the patients arranged by the date of registration. The tDB and eDB had similar MVs (0.74 vs 1, P = 0.13). The learning curve showed an initial phase including about 35 records, where MV in the eDB was higher than that in the tDB (1.9 vs 0.74, P = 0.03), and a subsequent phase, where the MV was similar in the two databases (0.7 vs 0.74, P = 0.6). The inaccuracy rate of these two phases in the eDB was stable (0.5 vs 0.3, P = 0.3). Using EHR saved an average of 9 min per patient, totalling 15 h saved for obtaining a dataset of 100 patients with respect to the tDB. The implementation of EHR allowed streamlining the process of clinical data recording. It saved time and human resource costs, without compromising the quality of data.

A Multi-Case Investigation of Electronic Health Record Implementation in Small- and Medium-Size Physician Practices

The American healthcare system has undergone significant changes as health information technology (HIT) has evolved. As part of the American Recovery and Reinvestment Act (ARRA), the Health Information Technology Economic and Clinical Health (HITECH) Act was created to incentivize the use of Health Information Technology (HIT) programs. While there have been multiple studies on HIT impact on large hospitals, very few studies address electronic health records (EHRs) within small- and medium-size physician practices (SMPPs). The two goals of this study are first to examine EHR implementation within SMPPs and provide recommendations on how to successfully implement an EHR system within a small practice, and secondly to examine the impact of EHR implementation on quality within the SMPP. For the five SMPPs and their implementation of EHR systems studied, findings show that, with sufficient training and appropriate use of a project champion, an SMPP can have a successful EHR implementation. Also shown are the different ways in which an EHR can positively impact an SMPP. This study promotes an understanding of how these small organizations tackle the challenges of implementing an EHR and provides practical guidelines for EHR implementation in SMPPs.

The ongoing evolution of the core curriculum of a clinical fellowship in pathology informatics

The Partners HealthCare system's Clinical Fellowship in Pathology Informatics (Boston, MA, USA) faces ongoing challenges to the delivery of its core curriculum in the forms of: (1) New classes of fellows annually with new and varying educational needs and increasingly fractured, enterprise-wide commitments; (2) taxing electronic health record (EHR) and laboratory information system (LIS) implementations; and (3) increasing interest in the subspecialty at the academic medical centers (AMCs) in what is a large health care network. In response to these challenges, the fellowship has modified its existing didactic sessions and piloted both a network-wide pathology informatics lecture series and regular “learning laboratories”. Didactic sessions, which had previously included more formal discussions of the four divisions of the core curriculum: Information fundamentals, information systems, workflow and process, and governance and management, now focus on group discussions concerning the fellows’ ongoing projects, updates on the enterprise-wide EHR and LIS implementations, and directed questions about weekly readings. Lectures are given by the informatics faculty, guest informatics faculty, current and former fellows, and information systems members in the network, and are open to all professional members of the pathology departments at the AMCs. Learning laboratories consist of small-group exercises geared toward a variety of learning styles, and are driven by both the fellows and a member of the informatics faculty. The learning laboratories have created a forum for discussing real-time and real-world pathology informatics matters, and for incorporating awareness of and timely discussions about the latest pathology informatics literature. These changes have diversified the delivery of the fellowship's core curriculum, increased exposure of faculty, fellows and trainees to one another, and more equitably distributed teaching responsibilities among the entirety of the pathology informatics asset in the network. Though the above approach has been in place less than a year, we are presenting it now as a technical note to allow for further discussion of evolving educational opportunities in pathology informatics and clinical informatics in general, and to highlight the importance of having a flexible fellowship with active participation from its fellows.