One of the biggest changes taking place in the world of healthcare is the transition from paper records to Electronic Health Records (EHR).
According to the Centers for Medicare and Medicaid Services, more than $21 billion in incentive payments were made to healthcare providers between 2011 and 2015 for EHR implementation through the government’s Meaningful Use (MU) initiative. (1) The program was created to spur the adoption of health technology nationwide, and a late 2015 data brief from the Office of the National Coordinator for Health Information Technology (ONC) showed that more than 80 percent of physicians and 90 percent of hospitals had adopted EHRs by 2014. (2) Physicians who do not use EHRs or fail to meet their MU goals can be penalized under the program.
It has not been an easy transition for everyone. A $764 million EHR implementation in New York City’s hospital system has been 18 months behind schedule and has led to “significant crew turnover,” (3) while the EHR implementation at Boston’s Brigham and Women’s Hospital went $27 million over budget, with about half of that being the result of lower reimbursements caused by coding issues related to the project. (4)
Beyond the expensiveness, there are other problems affecting the EHR industry. Another major concern has been interoperability, or the ability for different systems to communicate with each other to accurately share patient information. With hundreds of different agencies creating a wide range of EHR programs that use different file formats and templates, transferring records from one system to another has proven to be a large-scale issue. The Government Accountability Office (GAO) conducted a review of 18 nonfederal EHR initiatives in 2015 and concluded that they remained “works in progress.”(5) The GAO determined five obstacles to full interoperability, which were insufficiencies in health data standards, variation in state privacy laws, difficulties in accurate patient matching, the costs involved, and the need for “governance and trust” between EHR developers. There have also been accusations that many EHR vendors are engaging in “data blocking” by either making their systems difficult to access from the outside or by charging fees for information exchanges.
The major goals of EHRs are to improve efficiency so that physicians can provide better and more focused care for their patients, and so that patients can have more control over their health records. Unfortunately, many physicians are instead finding the process to be a headache, with more time spent on data entry than on patient care. Technology consultant Software Advice reported that 59 percent of buyers who contacted them in 2015 were existing users looking to replace their old EHR systems, with 24 percent saying that their EHR was too cumbersome or faulty. (6) Advocacy for physicians against the Meaningful Use initiative has appeared in many forms, most notably with the American Medical Association’s “Break the Red Tape” campaign and EHR vendor Athenahealth’s “Let Doctors Be Doctors” campaign. In January 2016, 31 healthcare organizations signed a letter to Health and Human Services Secretary Sylvia Burwell urging the reconsideration of MU Stage 3 requirements. (7)
There has been some relief already. Congress passed a bill in December that will allow CMS to grant blanket hardship exemptions for providers and hospitals who did not meet their MU goals. That was followed by CMS Administrator Andy Slavitt stating that MU was going to be phased out and replaced by initiatives that focused on quality of care instead of technology usage. (8) Still, there has been no official timeline for when that change will happen, and physicians who have not made the switch or who are disappointed with their current system may find themselves navigating murky water as they try to find the right one.
Due to the elaborate requirements of installing an EHR system, it is difficult to choose the best system for your practice, but with smart planning and patience, the process can be made much less painful.
One early step that can help you avoid mistakes is to lay out a detailed list of the features that you want from your EHR system, including the types of hardware used. Desktop, laptop and tablet computers each have their own pros and cons.
Desktops are relatively cheap to purchase and maintain. They have a wide range of compatible software and available accessories, and the risk of theft is much lower due to their size. Since they cannot be carted around, desktops have to be installed in every exam room, and attention must be paid to room layout so that they accommodate the provider’s contact with the patient. A good setup should include a way to rotate the monitor to allow for patient education opportunities.
Laptops have much of the same functionality as desktops. They add the convenience of being small enough to be carried from room to room, and in most cases physicians can set the laptop between themselves and their patients without obstructing face-to-face interaction. The cons of laptops are that they have batteries that will require occasional charging, and the physicians may get tired of carrying around a 5-7 pound computer to every exam. Special attention should be given to security, because laptops can be easily misplaced or stolen, jeopardizing any personal information that may be stored on them. Connecticut’s Hartford Hospital and a contractor, EMC, learned this lesson to the sum of $90,000 recently when they agreed to pay that sum and improve security measures after a stolen laptop exposed the records of nearly 9,000 patients. (9)
Tablet computers can be extremely useful due to their small size, touchscreen features and the large market of affordable and free applications that can be quickly installed on them. In a medical setting, tablets can be a perfect all-around tool for a fast-paced environment, allowing physicians to pull up drug interaction charts, decision support and e-prescribing instantly, sometimes all in one app. Depending on the tablet, it may also be possible to add other useful tools like a portable ECG recorder. The touchscreen on a tablet can be coupled with handwriting recognition software to allow physicians to take fast, accurate notes. However, as with laptops, tablets present a higher risk of being lost or stolen. And since the screen on a tablet is much smaller, physicians who want to show information to patients may choose to have a monitor in each exam room that is set up to connect to the tablet.
When budgeting for an EHR system, it is important to remember that hardware costs extend beyond the basics. Basic hardware like scanners and printers may need to be upgraded. Accessories such as routers, cables, microphones, cameras and faster Internet connections can quickly add to the expense. Printers will be a necessity as well, and physicians may opt to either have a single printer in a central location that can be used by the entire staff or install smaller printers in each exam room for faster, more convenient printing.
Another crucial part of the budgeting process is determining staffing needs. Training on the new system and adjusting to a new workflow will take time and may require extra staff hours. Furthermore, inputting paper records or migrating records from one system to another can put a heavy strain on workflow, and HIPAA regulations limit who is allowed to access these records. Most EHRs allow records to be scanned in, but manual interaction will be needed as well. The transition period may require hospitals and practices to temporarily reduce their patient volume, which will of course reduce reimbursements. It may also be necessary to hire additional staff to help with the transition, or providers may choose to hire an independent contractor to handle the heavy lifting and allow staff to focus on patient care. Performing a workflow analysis prior to shopping for an EHR system can save time and prevent future complications.
Before contacting EHR vendors, consider what types of services should be added besides basic EHR functions. Different systems offer practice management functionalities that can increase productivity and even extend convenience to patients. E-prescribing is a common feature that can generate prescriptions, warn of potential adverse reactions, check the availability of generics, and transmit scripts to a pharmacist. EHRs can often be integrated with other systems to ensure more accurate billing and scheduling. Another recommended feature to consider is secure direct messaging, which can allow physicians to communicate with specialists, office staff and even patients without the use of a phone or fax machine. It is also possible to set up a system through a website or other platform to allow customers to remotely access their records.
Having a clear plan in place can help speed up the vendor selection process by filtering out vendors who do not meet your needs. Providers can start their research by contacting one of the ONC’s Regional Extension Centers or by simply visiting the websites of potential vendors. Another valuable resource is the ONC’s Certified Health IT Product List, which is accessible online and can be sorted for either ambulatory or inpatient practices.
Once the list of vendors is pared down, the next step is to prepare and submit a Request for Information (RFI) to each prospective vendor. The request can include basic information like costs, support, training, certification and interoperability. Be sure to pay attention to whether you will be purchasing the system or leasing it from the company and if there are any additional costs for training and support. Ask if the contract is all-inclusive, or if the vendor charges more for interfaces that may need to be developed. If the vendor requires the purchase of licenses to use their software, find out what that cost will be and if there are additional charges should more licenses need to be acquired in the future.
After responses from the vendors are gathered and the field is narrowed down to a select few, the next step is to explore the vendors’ systems more thoroughly. This can often begin with a demonstration video provided by the vendor or by using an interactive trial version of their software. Demonstrations can also be requested from the vendor, at which time they physician may want to run a few sample cases to see how the system works. The final step in the trial process is to schedule an on-site demonstration with a client who uses the vendor’s system to see how it is used in real time.
During demonstrations, pay attention to the system’s overall usability. Make sure the interface is cleanly designed and easy to navigate. Watch out for systems that are bogged down by pages of excessive, unnecessary information. Many physicians complain of “alert fatigue,” which happens when an EHR system issues too many common alerts. (10) This can quickly become frustrating, and without the right system can lead to a physician overlooking an important alert.
It is also valuable to remember that EHRs can create additional liability exposures. Many systems may offer a form of computer-assisted documentation that aims to improve accuracy and workflow by automatically filling in required fields. This can reduce data entry time, but no software is guaranteed to be 100 percent accurate. Failure to catch mistakes made by a software program could potentially cause risk to patient health and open up the practice to the threat of a malpractice claim. The same can happen when a physician or staff member attempts to copy and paste information rather than entering each line manually.
EHR systems record metadata that can be subpoenaed in the event of a malpractice claim. This includes data about what information was accessed, when it was accessed and by whom, as well as any changes that may have been made to records. This can show where any mistakes may have been made in entering records or viewing decision support information. It may also be possible to prove that important information was accessed but ignored, leading to injury.
As mentioned earlier, security is a concern for EHRs. Liability can result from a HIPAA violation, whether it comes from hacking, hardware theft or even accidental release of information. A record $4.8 million fine was handed out in 2014 for a data breach that occurred when a physician was trying to deactivate a personal computer server and unintentionally exposed the information of more than 6,800 patients. (11) Avoiding HIPAA violations requires diligence on the part of all who have access to protected health information. Use a secure network system with security codes approved under HIPAA and make sure that any Internet portals use secure encryption to prevent hacking. This extends to any use of web-based cameras or other communication systems.
Any external storage devices like hard drives or flash drives should also be encrypted. Laptops and tablets that contain patient information or have access to the system should be kept secure with reliable antivirus software and a strong password. Fingerprint identification systems are available for laptops and tablets as well and can add an extra layer of security. Any hardware devices containing patient information should be kept in sight or locked up where they cannot be stolen or misplaced.
Before signing a contract with a vendor, read it thoroughly or have it checked out by legal counsel if necessary. Although the vendor is creating and supplying the software, they will typically not want to accept any liability should a software glitch or a security failure occur. If a physician or other staff notices an issue with the system, it should be reported to the vendor immediately, no matter how small it may seem.
Finally, it is worth considering potential insurance implications resulting from the use of an EHR system. Consult with your liability insurance provider to make sure that you are fully covered for any liabilities stemming from EHR use, and consider adding cyber security insurance so that all of your bases are covered.
- Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-guidance/legislation/EHRIncentivePrograms/DataAndReports.html
- Heisey-Grove, Dawn, M.P.H.; Patel, Vaishali, Ph.D., M.P.H. Any, Certified, and Basic: Quantifying Physician EHR Adoption through 2014. The Office of the National Coordinator for Health Information Technology. https://www.healthit.gov/sites/default/files/briefs/oncdatabrief28_certified_vs_basic.pdf September 2015. Accessed January 2016.
- Gonen, Yoav. 4th official leaves amid hospital system’s improper billing probe. The New York Post. August 18, 2015. http://nypost.com/2015/08/18/4th-official-leaves-amid-hospital-systems-improper-billing-probe. Accessed January 2016.
- Bailey, Melissa. Hospitals face budget woes with switch to electronic records. Stat News. December 07, 2015. http://www.statnews.com/2015/12/07/brigham-budget-electronic-health-records. Accessed January 2016
- Nonfederal Efforts to Help Achieve Health Information Interoperability. Government Accountability Office. http://www.gao.gov/assets/680/672585.pdf. Accessed December 2015.
- Loria, Gaby. EHR Software Buyer Report 2015. Software Advice. http://www.softwareadvice.com/resources/ehr-software-buyer-trends-2015. Accessed January 2016
- Halamka, John D., MD, MS. The Future of Meaningful Use Stage 3. Life as a Healthcare CIO. January 14, 2016. http://geekdoctor.blogspot.com/2016/01/the-future-of-meaningful-use-stage-3.html. Accessed January 2016.
- Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Conference, Jan. 11, 2016. The CMS Blog. http://blog.cms.gov/2016/01/12/comments-of-cms-acting-administrator-andy-slavitt-at-the-j-p-morgan-annual-health-care-conference-jan-11-2016. Accessed January 2016.
- Levin Becker, Arielle. AG: Hartford Hospital, contractor to pay $90,000 in 2012 data theft. The Connecticut Mirror. November 06, 2015. http://ctmirror.org/2015/11/06/ag-hartford-hospital-contractor-to-pay-90000-in-2012-data-theft. Accessed January 2016.
- Miliard, Mike. How one hospital tweaks its EHR to fight alert fatigue. Healthcare IT News. September 18, 2015. http://www.healthcareitnews.com/news/how-one-hospital-tweaks-its-ehr-fight-alert-fatigue. Accessed January 2016.
11. McCann, Erin. Hospitals fined $4.8M for HIPAA violation. Government Health IT. May 09, 2014. http://www.govhealthit.com/news/hospitals-fined-48m-hipaa-violation. Accessed December 2015.To contact the author, call 800-457-7790 and ask for William Bateman.