Robust Electronic Health Record Research Articles

Design and Evaluation of a Computational Phenotype to Identify Patients With Metastatic Breast Cancer Within the Electronic Health Record.

Outcomes for patients with metastatic breast cancer (MBC) are continually improving as more effective treatments become available. Granular data sets of this unique population are lacking, and the standard method for data collection relies largely on chart review. Therefore, using electronic health records (EHR) collected at a tertiary hospital system, we developed and evaluated a computational phenotype designed to identify all patients with MBC, and we compared the effectiveness of this algorithm against the gold standard, clinical chart review. A cohort of patients with breast cancer were identified according to International Classification of Diseases codes, the institutional tumor registry, and SNOMED codes. Chart review was performed to determine whether distant metastases had occurred. We developed a computational phenotype, on the basis of SNOMED concept IDs, which was applied to the EHR to identify patients with MBC. Contingency tables were used to aggregate and compare results. A total of 1,741 patients with breast cancer were identified using data from International Classification of Diseases codes, the tumor registry, and/or SNOMED concept identifiers. Chart review of all patients classified each patient as having MBC (n = 416; 23.9%) versus not (n = 1,325; 75.9%). The final computational phenotype successfully classified 1,646 patients (95% accuracy; 82% sensitivity; 99% specificity). Hospital systems with robust EHRs and reliable mapping to SNOMED have the ability to use standard codes to derive computational phenotypes. These algorithms perform reasonably well and have the added ability to be run at disparate health care facilities. Better tooling to navigate the polyhierarchical structure of SNOMED ontology could yield better-performing computational phenotypes.

ESyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems.

Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available. As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes. eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts. eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

The influence of a Sprint optimization and training intervention on time spent in the electronic health record (EHR).

ObjectiveWe report the influence of Sprint electronic health record (EHR) training and optimization on clinician time spent in the EHR.Materials and MethodsWe studied the Sprint process in one academic internal medicine practice with 26 providers. Program offerings included individualized training sessions, and the ability to clean up, fix, or build new EHR tools during the 2-week intervention. EHR usage log data were available for 24 clinicians, and the average clinical full-time equivalent was 0.44. We used a quasi-experimental study design with an interrupted time series specification, with 8 months of pre- and 12 months of post-intervention data to evaluate clinician time spent in the EHR.ResultsWe discovered a greater than 6 h per day reduction in clinician time spent in the EHR at the clinic level. At the individual clinician level, we demonstrated a time savings of 20 min per clinician per day among those who attended at least 2 training sessions.DiscussionWe can promote EHR time savings for clinicians who engage in robust EHR training and optimization programs. To date, programs have shown a positive correlation between participation and subjective EHR satisfaction, efficiency, or time saved. The impact of EHR training and optimization on objective time savings remains elusive. By measuring time in the EHR, this study contributes to an ongoing conversation about the resources and programs needed to decrease clinician EHR time.ConclusionsWe have demonstrated that Sprint is associated with time savings for clinicians for up to 6 months. We suggest that an investment in EHR optimization and training can pay dividends in clinician time saved.

How Physician Perspectives on E-Prescribing Evolve over Time. A Case Study Following the Transition between EHRs in an Outpatient Clinic.

Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians' experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality. Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing. We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes. We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow. Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency.

Automated methods for the summarization of electronic health records.

Objectives This review examines work on automated summarization of electronic health record (EHR) data and in particular, individual patient record summarization. We organize the published research and highlight methodological challenges in the area of EHR summarization implementation.Target audience The target audience for this review includes researchers, designers, and informaticians who are concerned about the problem of information overload in the clinical setting as well as both users and developers of clinical summarization systems.Scope Automated summarization has been a long-studied subject in the fields of natural language processing and human–computer interaction, but the translation of summarization and visualization methods to the complexity of the clinical workflow is slow moving. We assess work in aggregating and visualizing patient information with a particular focus on methods for detecting and removing redundancy, describing temporality, determining salience, accounting for missing data, and taking advantage of encoded clinical knowledge. We identify and discuss open challenges critical to the implementation and use of robust EHR summarization systems.

Are Electronic Health Records Good for Health Care?

Are Electronic Health Records Good for Health Care?

System-level approaches to improving diabetes care: can asking simple questions improve exercise regimens for patients with diabetes?

Clin. Pract. (2014) 11(3), 243–245 ISSN 2044-9038 part of Physical activity is a cornerstone of the healthy lifestyle changes that most patients with Type 2 diabetes mellitus (DM2) must make to manage their condition [1,2]. Regular physical activity improves blood glucose control, blood pressure and quality of life, while lowering harmful cholesterol levels and decreasing cardiovascular events and mortality [1,3–5]. In a joint statement, the American Diabetes Association and American College of Sports Medicine recommend at least 150 min per week of moderate-to-vigorous physical activity (MVPA). MVPA should achieve approximately 40–60% of maximal aerobic capacity, which, for most people, is equivalent to brisk walking [1]. These recommendations, unfortunately, stand in stark contrast with the current reality in American society. Less than 10% of US adults achieve recommended levels of MVPA and over a third engage in no physical activity at all [6]. The twin epidemics of inactivity and overweight/obesity are directly responsible for over a fourth of US healthcare costs, a staggering US$700 billion dollars per year [7,8]. If the status quo remains, over 40% of Americans will be obese and over 50% will have diabetes or prediabetes by the year 2020 [9]. How then, does a modern health system address the daunting task of promoting physical activity in this current culture? Many middle-aged and older adults engage with the primary care setting on a regular basis (between four and eight clinical encounters per year), making this environment potentially highly suitable for implementing population-level programs focused on promoting physical activity [10,11]. Most primary care providers (PCPs), believing that physical activity is an important component of preventive health, report that they provide an integral role in engaging their patients to participate in regular exercise [12]. However, the lack of time and many competing demands during the typical primary care visit represent a significant barrier to adequately addressing physical inactivity. Moreover, despite the known importance of physical activity counseling in primary care, many providers still find it a challenge to provide detailed advice and less than a third of primary care visits include any exercise or lifestyle counseling at all [12–15]. As time constraints continue to tighten for most PCPs, new approaches are needed to help increase exercise levels in patients with diabetes. Clinicians and patients alike will need some assistance. With a prominent emphasis on and rewards provided for ‘meaningful use’ of electronic health records (EHRs) [16], health systems with robust EHRs can play an increasingly influential role in helping to address lack of physical activity. As these systems begin to share information across large populations, an electronic infrastructure is being developed to support clinicians and health systems interested in improving care. New approaches must now be developed and tested to leverage this electronic infrastructure. System-level approaches to improving diabetes care: can asking simple questions improve exercise regimens for patients with diabetes?

Readmission after hospitalization for heart failure among patients with chronic kidney disease: a prediction model

30-day readmission rates after hospitalization for heart failure (HF) approach 25%, and patients with chronic kidney disease (CKD) are disproportionately represented. A retrospective cohort study was conducted to develop a prediction tool for 30-day readmission after hospitalization for HF among those with non-dialysis dependent CKD. Geisinger primary care patients with Stage 3 - 5 CKD hospitalized with a primary discharge diagnosis of HF during the period July 1, 2004 through February 28, 2010 were eligible. Multivariate logistic regression was employed to build models from predictors of 30-day readmission, drawn from demographic, clinical, laboratory, and pharmaceutical variables in the electronic health record. Variables were manually removed to achieve a model with satisfactory goodness-of-fit and parsimony while maximizing area under the receiver operating characteristic curve (AUC). Internal validation was performed using the bootstrap resampling method (1,000 samples) to provide a bias-corrected AUC. 607 patients with CKD were admitted for HF during the study period; 116 (19.1%) were readmitted within 30 days. A model incorporating 23 variables across domains of medical history, active outpatient pharmaceuticals, vital signs, laboratory tests, and recent inpatient and outpatient resource utilization yielded an AUC (95% CI) of 0.792 (0.746 - 0.838). The bias-corrected AUC was 0.743. At an estimated readmission probability of 20%, the model correctly classified readmission status for 73% of the population, with a sensitivity of 69% and a specificity of 73%. A robust electronic health record may facilitate the identification of CKD patients at risk for readmission after hospitalization for HF.

ProvenCare lung cancer: A multi‐institutional improvement collaborative

Geisinger's ProvenCare™ Program (for elective coronary artery bypass surgery, total hip replacement, and others) has shown that the principles of reliability science, facilitated by a robust electronic health record and institutional commitment, allow the re-engineering of complicated clinical processes. This eliminates unwarranted variation and promotes the completion of evidence-based elements of care. It has not been established that ProvenCare can be generalized to other institutions. Now, under the auspices of the American College of Surgeons Commission on Cancer, ProvenCare has been adapted to a multi-institutional collaborative for the care of the patient with resectable lung cancer.

Nurses’ Information Management and Use of Electronic Tools During Acute Care Handoffs

Little evidence is available about nurses' use of electronic tools during handoffs. This qualitative study explored information management and use of electronic tools during nursing handoffs. The sample included 93 handoffs by 26 nurses on 5 medical/surgical units in 2 western hospitals with a robust electronic health record (EHR). Data collection included audiotaping handoffs, semi-structured interviews, observations, and fieldnotes. The dataset was inductively coded into 33 categories and 5 themes: good nurse expectations for handoffs, paper forms are best, information at a glance, only pertinent information please, and information tools that work. Two-thirds of the nurses abandoned use of the leadership-endorsed electronic handoff form, preferring personal paper forms. The findings suggest effective electronic solutions will require extensive contextually-based information, information integrated across EHR modules and portable, electronic support throughout shifts. This is a call to action for leaders and informaticists as they select and design future electronic tools.

Natural Language Processing Improves Identification of Colorectal Cancer Testing in the Electronic Medical Record

Difficulty identifying patients in need of colorectal cancer (CRC) screening contributes to low screening rates. To use Electronic Health Record (EHR) data to identify patients with prior CRC testing. A clinical natural language processing (NLP) system was modified to identify 4 CRC tests (colonoscopy, flexible sigmoidoscopy, fecal occult blood testing, and double contrast barium enema) within electronic clinical documentation. Text phrases in clinical notes referencing CRC tests were interpreted by the system to determine whether testing was planned or completed and to estimate the date of completed tests. Large academic medical center. 200 patients ≥ 50 years old who had completed ≥ 2 non-acute primary care visits within a 1-year period. Recall and precision of the NLP system, billing records, and human chart review were compared to a reference standard of human review of all available information sources. For identification of all CRC tests, recall and precision were as follows: NLP system (recall 93%, precision 94%), chart review (74%, 98%), and billing records review (44%, 83%). Recall and precision for identification of patients in need of screening were: NLP system (recall 95%, precision 88%), chart review (99%, 82%), and billing records (99%, 67%). Small sample size and requirement for a robust EHR. Applying NLP to EHR records detected more CRC tests than either manual chart review or billing records review alone. NLP had better precision but marginally lower recall to identify patients who were due for CRC screening than billing record review.

Electronic Health Record Adoption – Maybe It’s not about the Money

The slow adoption of electronic health record (EHR) systems has been linked to physician resistance to change and the expense of EHR adoption. This qualitative study was conducted to evaluate benefits, and clarify limitations of two mature, robust, comprehensive EHR Systems by tech-savvy physicians where resistance and expense are not at issue. Two EHR systems were examined - the paperless VistA / Computerized Patient Record System used at the Veterans' Administration, and the General Electric Centricity Enterprise system used at an academic medical center. A series of interviews was conducted with 20 EHR-savvy multiinstitutional internal medicine (IM) faculty and house staff. Grounded theory was used to analyze the transcribed data and build themes. The relevance and importance of themes were constructed by examining their frequency, convergence, and intensity. Despite eliminating resistance to both adoption and technology as drivers of acceptance, these two robust EHR's are still viewed as having an adverse impact on two aspects of patient care, physician workflow and team communication. Both EHR's had perceived strengths but also significant limitations and neither were able to satisfactorily address all of the physicians' needs. Difficulties related to physician acceptance reflect real concerns about EHR impact on patient care. Physicians are optimistic about the future benefits of EHR systems, but are frustrated with the non-intuitive interfaces and cumbersome data searches of existing EHRs.

Driving on Main Street: The Road to Widespread Physician EHR Use

TO THOSE OF US physicians who have long worked to encourage the use of electronic health record systems and other health information technology to improve care, what once felt like the frontier is feeling more and more these days like Main Street-during rush hour no less. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, with its time-limited funding to help offset the cost of implementing such systems, largely contributed to the recent surge in interest and activity in electronic health record (EHR) adoption and meaningful use. HITECH has also increased physicians' sense of urgency by drawing attention to looming healthcare payment reform, giving notice that organizations that lack qualified EHR systems containing data that prove and improve healthcare quality and value likely will suffer financially. Physicians newly interested in achieving EHR meaningful use may be reacting to different and transient forces than those of us who were out on the health information technology (IT) frontier. It is important to ensure that these physicians can align with the success principles that motivated leaders of successful EHR implementations in the days before HITECH, including those visionary CEOs who described their experiences in the feature articles. These correct principles are independent of any time-limited stimulus incentives and persist long after the EHR meaningful use incentive dollars are gone. MOTIVATING HOSPITAL AND HEALTH SYSTEM LEADERS The feature articles are replete with important rationales, insights, and advice from CEOs nationally recognized for their successful EHR system implementations. The authors' comments can serve as a useful reference for fellow CEOs leading their own boards, leadership teams, physicians, nurses, and other health professionals to work to achieve the health IT-enabled care transformation they see as essential to patient care quality and organizational excellence. M. Michelle Hood points out the critical importance of realizable, real-time, consequential exchange of information enabled by health IT, as well as the need to properly frame EHR implementations as transformative clinical care redesign initiatives rather than as IT projects. She also underscores the importance of responsiveness to business climate issues while promoting participative decisionmaking structures, communication, collaboration, process redesign, standardization, and frequent reporting on important processes and outcomes. Meanwhile, CEOs David Bernd and Peter Fine, who lead organizations nationally recognized for their successful implementation and productive use of advanced health IT systems, provide cautions regarding the unsustainable nature of the current healthcare delivery system, the precarious prospects for those who change too little or too slowly in the face of needed reform, and the capacity EHR systems possess to empower improved patient outcomes and costs when integrated into clinical practice. While their organizations are shining examples of the profoundly positive impact that successful EHR implementations can bring, Bernd and Fine are realistic in describing important barriers encountered on their EHR journeys and suggestions for reaching the next horizon. PHYSICIAN ENGAGEMENT: ONE KEY TO EHR SUCCESS Ultimately, no effort to achieve health ITenabled care transformation will succeed unless physicians - whose orders trigger most determinants of healthcare quality and costs - are meaningful users of robust EHR systems that support desired improvements in quality and value. While physicians on the whole have been slow to implement EHRs, we are not necessarily resistant to information technology in general or even to certain aspects of health IT use. Like other consumers, most of us increasingly use some combination of electronic technologies, such as digital cameras, ATMs, smart phones, digital media, GPS devices, social media, online reservation sites, airport check-in kiosks, and barcode scanners or credit card readers at grocery checkouts. …

Relationship Between Use of Electronic Health Record Features and Health Care Quality

Electronic health records (EHRs) are widely viewed as useful tools for supporting the provision of high quality healthcare. However, evidence regarding their effectiveness for this purpose is mixed, and existing studies have generally considered EHR usage a binary factor and have not considered the availability and use of specific EHR features. To assess the relationship between the use of an EHR and the use of specific EHR features with quality of care. A statewide mail survey of physicians in Massachusetts conducted in 2005. The results of the survey were linked with Healthcare Effectiveness Data and Information Set (HEDIS) quality measures, and generalized linear regression models were estimated to examine the associations between the use of EHRs and specific EHR features with quality measures, adjusting for physician practice characteristics. A stratified random sample of 1884 licensed physicians in Massachusetts, 1345 of whom responded. Of these, 507 had HEDIS measures available and were included in the analysis (measures are only available for primary care providers). Performance on HEDIS quality measures. The survey had a response rate of 71%. There was no statistically significant association between use of an EHR as a binary factor and performance on any of the HEDIS measure groups. However, there were statistically significant associations between the use of many, but not all, specific EHR features and HEDIS measure group scores. The associations were strongest for the problem list, visit note and radiology test result EHR features and for quality measures relating to women's health, colon cancer screening, and cancer prevention. For example, users of problem list functionality performed better on women's health, depression, colon cancer screening, and cancer prevention measures, with problem list users outperforming nonusers by 3.3% to 9.6% points on HEDIS measure group scores (all significant at the P < 0.05 level). However, these associations were not universal. Consistent with past studies, there was no significant relationship between use of EHR as a binary factor and performance on quality measures. However, availability and use of specific EHR features by primary care physicians was associated with higher performance on certain quality measures. These results suggest that, to maximize health care quality, developers, implementers and certifiers of EHRs should focus on increasing the adoption of robust EHR systems and increasing the use of specific features rather than simply aiming to deploy an EHR regardless of functionality.

Predictors of Physician Satisfaction among Electronic Health Record System Users

Electronic health records (EHRs) have experienced slow adoption rates but play an important role in improving ambulatory quality of care. Sustained use of EHRs is closely related to physician satisfaction, however little research exists on this issue. We focused on physician EHR users to determine factors that are related to satisfaction with the level of computerization in their office practice. After controlling for various factors, physicians with more robust EHRs, and those who adopted their system two or more years ago, were more likely to be satisfied. Lastly, several individual EHR functionalities were independently related to improved satisfaction.

“ProvenCareSM”

To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.

Achieving the Vision of EHR—Take the Long View

IN THIS SPECIAL issue of Frontiers of Health Services Management, Rosemarie Nelson and Michael Sachs discuss various themes pertaining to the adoption of electronic health records (EHRs) and the creation of the National Healthcare Information Infrastructure (NHII). These are exciting times for healthcare-the adoption of healthcare information technology (IT) will undoubtedly be a major part of the transformation of U.S. healthcare delivery. While the opportunity is vast, the challenges are many. It is wise for healthcare managers and leaders to take the long view on this journey. In this commentary, I comment briefly on the salient points made by Nelson and Sachs, and then offer my perspectives on key points in the adoption of health IT, and management perspectives critical for our collective success. Rosemary Nelson, an accomplished leader and change agent in healthcare, describes several key factors for successful adoption of health IT. First, dear objectives for IT adoption must be stated, and these measures of success-both clinical and financial-must be meaningful to all participants. Planning is critical, not only in defining IT requirements and selecting appropriate technology, but also in implementing and training people to use the new technology. is a change-management states Nelson-both when implementing the firsttime, and when using the technology as a platform for process redesign and care reengineering. Nelson would suggest that change management necessarily implies an incremental approach to technology adoption and process redesign. Finally, Nelson points out that the patient connection is critical not only for IT adoption but ultimately for the care redesign process as well. Michael Sachs, an accomplished healthcare strategist and visionary, describes several of the fundamental forces changing the nature of the U.S. economy and their potential impact on the U.S. healthcare delivery system. The World Wide Web (WWW) allowed creation of new approaches to business models-many fiscal and functional intermediaries were removed in the process of disintermediation, whereby the WWW allows more direct connections to occur between suppliers and potential customers. Mass customization allowed the hypersegmentation of consumer marketplaces essentially to the individual level-each person could customize his or her favorite web pages and get personalized recommendations for his or her online shopping. Sachs describes how modern medical technologies beyond IT are transforming medical practice, most notably the advances in medical imaging. However, the advances in our understanding of the human genome, and the relationships between our individual DNA maps and disease and treatment, are what will allow mass-customization to occur in healthcare in ways akin to what we have seen with the WWW. Sachs maintains that we are at the advent of a golden information age in healthcare as a result of the increased application of IT and the ability to personalize healthcare treatments based on the understanding of the human genome. ACHIEVING THE VISION OF ADOPTION Three key points need to be kept in mind when considering how to best achieve the vision of adoption and the transformation of healthcare in the United States. The evidence base is now overwhelming: using in clinical practice saves money for individual practitioners, key stakeholders in healthcare, and society as a whole. Functionality and Interoperability Savings only happen, however, when two things are true: (1) when a with appropriate features and functions (including clinical decision support) is used in practice, and (2) when systems can interface with other systems, or readily exchange clinical information with other caregivers providing patient care or services. A Robust First, therefore, EHRs must be implemented and used in practice. We have a dear understanding of a robust EHR from many sources. …