From the Physician’s Corner

Preparing for Electronic Health Records (EHRs)

By Henry Tulgan, M.D. FACP

Part of President Barack Obama’s proposed $634 billion reserve fund to overhaul the American health care system includes implementation of electronic health records by 2015.  The plan also includes incentives for physicians whose EHR systems are in place by 2011.  While EHRs have existed for a full generation, adoption of them has been limited to date. In 2005, the National Center for Healthcare Statistics (NHSC) estimated that less than 10 percent of private practices use a “complete” electronic records system, though institutional practice usage is higher.

EHRs, which are sometimes called electronic medical records (EMRs), are intended to increase physician and institutional efficiencies in the long run, reduce costs and promote standardization of care.  In addition to individual electronic medical records, EHRs also include such things as Computerized Physician Order Entry (CPOE), e-prescribing, laboratory results, radiology and cardiology images. They may also contain insurance, billing and other demographic information. They are computer accessible over networks.

What are some of the potential advantages of EHRs?  First, EHRs allow for the elimination of physical space and records, which leads to a huge savings, along with minimizing paper copies and faxes.  The reduction in handwritten notes as a result of e-prescribing is also likely to reduce medical errors.
Second, readily available EHRs are likely to reduce repetitive laboratory and imaging studies and minimize unnecessary hospitalizations.
Expanding the use of electronic records will also improve quality, clinical trials research, and communicable disease tracking, in addition to billing security.
Are there potential barriers to implementation?

Cost
One obvious barrier is that EHR software costs more than $10,000 per doctor to install and support may cost $1,500-2,000 annually on top of that. It’s still unclear how the government will pay for these costs, estimated to be well over $100 billion across the country.  The federal American Recovery and Reinvestment Act of 2009 allocated $20 billion toward this effort. These funds will go to the states, which will provide additional matching funds.

Finding a System Provider
Another concern is that there are hundreds of systems commercially available, some of which may not survive competition.

Interoperability
Interoperability – the means for systems to communicate with each other – is yet another concern. However, this concern may be alleviated by the development of common IT standards, as well as new network and mobile technology solutions.

To address these concerns, the Office of the National Coordinator for Health IT (ONC) funded initiatives to create a certification process to harmonize standards for EHR products and interoperability.
The Certification Commission for Healthcare Information Technology (CCHIT), established in 2006 by the U.S. Department of Health and Human Services (HHS), recommended minimum criteria for the certification of ambulatory EHR systems.  Qualifying EHR systems are listed on the CCHIT website at http://www.cchit.org/products/Ambulatory.

Converting Paper Records
Converting paper records to electronic ones can be difficult.  Conversion can be done in a number of ways, including manual data entry, scanning or electronic conversion. Many practices choose a blended approach for converting their paper medical charts to an EMR system.

Retaining Records
Another concern will be how long and where EHRs should be retained. This issue will have to be resolved by federal and state law changes. 

Privacy and Security
To protect privacy and ensure security of electronic records systems as required by the Health Insurance Portability and Accountability Act (HIPAA) and state law, secure passwords and other protections will need to be developed for all users.

Record Review by Patients
If records are maintained in a central repository, who will be responsible when a patient requests to review his or her records? If a physician employed by a health system leaves, who will be the responsible custodian?

Successful EHR Models
Until a decade ago, the VA health care system was in deplorable condition. But implementation of an EHR, the Veteran’s Health Information Systems and Technology Architecture (VistA), has linked all its 155 hospitals and 800 Outpatient Clinics and, despite a recent computer glitch, has revolutionized care. The success of this system has led to expanding the program to The Indian Health Service and The Department of Defense.  Also, in 2006, the United Kingdom National Health Service began to introduce EHRs and expects to cover 60 million people by 2010. Several Canadian provinces are also utilizing EHRs. While this will be a difficult program at the start, the benefits of EHRs will clearly outweigh the startup costs and limit the spiraling cost of health care in the U.S. Physicians need to be ready for this major change.

Risk Management Strategies

• Pay close attention to the details of the contract with your EHR software provider to determine if it is also providing the installation services.
• Insure that your EHR system complies with state and federal privacy rules.
• Confirm that your EHR system is interoperable and can communicate and connect with other provider offices and hospital systems.

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