The implementation of electronic health record
Only 4 percent of U.S. doctors are using an electronic medical record system (EHR) because of a diverse range of barriers and perceptions involved with implementing an EHR system. The health care portion of the American Recovery and Reinvestment Act (ARRA) called Health Information Technology for Economic and Clinical Health or HITECH promotes the "Meaningful Use" of information technology in the form of EHR systems for every American by 2014 (Hoffman, 2009). Just having an EHR system is not enough; "meaningful use" means the system must improve the quality, efficiency, security, access, and communication in the delivery of health care among other functions. The United States government has provided $17 billion in available incentives to assist physicians and health care facilities implement certified EHR systems that meet Federal qualifications by the year 2014 (Blumenthal, 2009). This important health care issue affects everyone in this country because of the nature of private health information. The U.S. government mandate for the implementation of electronic health records presents a wide variety of issues for and responses by physicians who want to retain their diversity relating to the way they practice medicine, while meeting the "Meaningful Use" requirements that will positively affect their investment and efficiency.
"Meaningful use" depends on interoperability, which means that physicians systems will be able to communicate with each other for information exchange. Currently some physicians may have systems that are interoperable, but some may have invested in software that does not provide that function. Numerous vendors often market more than one type of system. Currently, estimates of physicians using a complete, fully functional EHR system are only at four percent (DesRoches, et al., 2008). This leaves the majority in need of researching software systems, purchasing, and implementing an EHR system to meet the "Meaningful Use" requirements. The practice of medicine is a highly individualized field where every physician has their own ways to provide for their patients. A general practitioner will have different software needs than a surgeon or obstetrician. An issue the physicians have to address is that they have to choose a certified EHR system that will provide the functions they need for their particular practice of medicine. Many physicians are starting with a basic system and customizing it to fit their practice needs (Baron, et al, 2005). HITECH will need to certify systems that provide functions that the physicians require with enough flexibility to meet the diverse needs of every type of practice. Some EHR systems are designed for primary care practices or large hospitals and may not meet the needs of a specialist. Physicians will have to choose a certified system that will have the required functions as well as those his practice will require.
Whichever system a physician chooses will require training in order to benefit from the functions the software can provide. A basic knowledge of computer use is a skill many physicians do not even have. In fact, some physicians have technophobia when it comes to computers in their practice (Hayes, 2009). Statistics have shown that younger physicians are more apt to have a positive outlook on the EHR systems. Younger physicians also appear to have earlier adoption of an EHR system because of their prior exposure to computers. In-depth training to learn the functions and processes of the system are necessary to prevent severe disruptions in the workflow of the office. Many offices will train a few employees to be "Super Users" to be a resource for others in the office who have had less training. "Super Users" will be able to adjust the work processes when needed. Some physicians' offices close for a period of days to bring the system online and prepare the office for going live. The diversity in computer abilities and comfort levels will affect the complexity, price, and amount of training required for each physician and his office staff for the chosen system.
Cost is the biggest issue in the adoption of EHR systems. Cost estimates are between $12,000 and $24,000 to implement a fully functional EHR system (Baron, 2005). The equipment, software, training and one year of support can cost $140,000 or more (Baron, 2005). The HITECH incentives will cover some, but not all the cost of the conversion from paper to electronic records. Incentive payments can total $18,000 in the first year, for physicians implementing in 2011 and 2012 and will continue for 5 years at reducing amounts. The available incentive amounts will decline each year and end completely in 2016. In other words, physicians who adopt in 2011 could collect $44,000 over the five-year period while physicians who adopt in 2013 would receive $27,000 in incentive payments over 3 years (Blumenthal, 2009). The incentives will provide more funding for physicians that implement early. Surveys indicate that the incentives are a facilitator for approximately 55 percent of physicians who see the incentives as a reason to make the transition now, and receive maximum financial benefit (Blumenthal, 2009). The diversity in size of practices will affect how the physicians perceive capital costs.
Due to the diversity in the types and ways physicians practice, issues that need to be considered and addressed, and the many solutions available, physician's attitudes and opinions on EHRs and "Meaningful Use" vary from very enthusiastic to resentful and wary. Studies have shown that physicians who have already adopted an EHR system are generally satisfied with their system and the benefits it provides. However, although the physicians will be the ones assuming approximately 89 percent of the cost of the system, they will not receive much of a return on their investment (Hoffman, 2009). The insurance companies will save money on reduced testing, streamlined billing, and overall efficiency. The government will save money on the same things as well as have a medium for monitoring fraud. Physicians will save some money on record storage, employee salaries previously paid for filing and transcribing records, and paper office supplies, but in comparison to the cost of the system, savings are minimal. Physician concern over return on investment is 50 percent for physicians who do not have an electronic system but only 33 percent for physicians who are already using an electronic system (DesRoches, 2008). The results may reflect Medicare and Medicaid patient numbers, size of the physician practice or perhaps the diverse perceptions physicians have over the dollar value versus the benefits to their actual income.
Seemingly, the biggest numbers of implementers are the larger practices who are often better able to absorb the large investment than a small practice or single physician office. Statistics show that large primary care practices are more apt to implement EHR systems than other types of practices. These large group practices of fifty or more physicians were four times more likely to have a fully functional system than with physicians in practices of three or less physicians (DesRoches, 2008). The increased cash flow from a large practice makes the large capital expense less detrimental to the practice. This diversity in the size of physician practices is a significant basis for EHR implementation.
EHR implementation itself will not provide for full Medicare and Medicaid reimbursement. In order for a physician to receive full reimbursement from Medicare and Medicaid, an EHR system must meet the "Meaningful Use" requirements. Physicians who do not have an EHR system that meets the "meaningful use" requirements will see penalties in the form of reduced Medicare payments. The reduction of payments will start at one percent in 2015, increase to two percent in 2016, and increase again to three percent in 2017 (Blumenthal, 2009). Physicians with large amounts of Medicare and Medicaid patients will have a significant reason to implement a system that meets the" Meaningful Use" guidelines. This issue will not affect all physician practices and some physicians do not feel it is a significant impediment to their practice income to warrant the large expense involved with implementing an EHR system. The diversity in the types of patients a physician or practice routinely cares for will have an effect on their financial return and willingness to implement an EHR system.
For those who may not see a financial return there are many other benefits to adopting an EHR system for patients, insurance companies, and the government, and to some degree physicians. One benefit for physicians is a more efficient and streamlined insurance claims process, which will aid in cash flow. Physicians will also be better able to provide for their patients because the patient record will be able to go where the patient goes, including to hospitals and specialists, resulting in better coordination of the patient's care. The EHR will provide a reduction in clinical errors because of the ability of the EHR to provide clinical decision support and monitor medication dosing and contraindications, and allergies. However, a group of physicians feel that this is questioning their judgment and do not want the interference in the way they practice medicine. Of physicians who are using a fully functional EHR system 86 percent appreciate the avoidance of medication error function that their system provides. The diversity in the physicians' response to clinical decision support may be due to age of the physician, the number of years he or she has been in practice or any number of reasons including the personality of the physician.
Along with those benefits, there is disruption of the office workflow. This is a significant cause for physician concern (DesRoches, 2009). The learning curve for an EHR system slows down all the processes in the office. Some physicians are better able to deal with the chaos that ensues while converting to an electronic system. Everyone within the practice has to relearn his or her job processes. All the office procedures of the practice have to be redesigned to work with the EHR system and the practice requirements. There is a period even after implementation of changes and adjustments that must be made to customize the system to the practice. Physician practices have reduced their patient load as much as fifty percent during implementation to try to reduce the waiting time for patients (Braon, et al., 2005). This essentially means a reduction in revenues until everyone can perform their jobs smoothly and handle the normal patient load again. Estimates are anywhere from four to six months before normal patient load is fully resumed. Physicians have reported losing patients because the wait time to see the physician was too long during the early stages of implementation (Baron, 2005). This is a major barrier for 41 percent of physicians in making the switch to electronic records (DesRoches, 2008). Physicians are very busy by nature and a slowdown in the office creates a diverse level of frustration that has caused some physicians to put off implementation or even to reverse the work already done in adopting an EHR system and return to their paper system.
Those who do make the switch from paper to electronic records will have to consider HIPAA requirements for security of an EHR system. EHR systems require the secure storage of EHRs, which contain patient's private health information and interoperability requires secure access to patient EHRs. Some physicians will choose to be on an encrypted network to share information with their local hospital, laboratories, and other health care providers. A verification process will be required to allow authorized physicians access to patient's private health information and to deny access to unauthorized persons. Security of patient records is a concern for many physicians. Some physicians feel this is something that needs more regulation before they will expose their patients to the risk of a breach. The diversity in the EHR systems in operation now creates issues for secured patient PHI with system interoperability.
With all the diversity involved in implementing an EHR system, physicians perceive the challenges of the U.S. government mandate for the implementation of electronic health records in different ways. Some feel there are too many barriers to address before implementation of an EHR and others feel the benefits outweigh the barriers. There are as many opinions on the issues of switching to an EHR system as there are physicians themselves. Addressing issues such as cost, security, training without a major loss in cash flow, which stems from disruption to the workflow of the office, will all stress the doctor patient relationship at least for a time. This is important because it will effect how and when the physicians adopt and use the nationwide system. The diversity in the way physicians practice medicine is individualized and the approved EHR systems will have to be flexible enough to allow for that individuality. The one thing all physicians want is to practice medicine they way they always have and meet the required mandate for "Meaningful Use" so they may recoup some of their investment.
Baron, R. J., Fabens, E. L., Schiffman, M., & Wolf, E. (2005, August 2). Electronic health records: Just around the corner? Or over the cliff? Annals of Internal Medicine, 143(3), 222-226. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=17875478&site= ehost-live
This article is written by physicians in a 4-internist practice describing the processes involved with converting from traditional paper medical records to electronic medical records. Baron and colleagues address the problems and issues involved, and how they worked through them. Some topics of interest include both planned and unexpected finances, training, workflow and accommodations and the overall office environment. The article describes the realized benefits and lacking areas of standardization and interoperability. I chose this source for its overall description of actual process of implementing an electronic records system. This article also addresses computer skills and requirements.
Blumenthal, D. (2009, April 9). Stimulating the adoption of health information technology. New England Journal of Medicine, 360(15), 1477-1479. doi:10.1056/
This article describes the portions of the American Recovery and Reinvestment Act of 2009 (ARRA) that pertains to health information technology. The article addresses barriers physicians have for implementing the mandated electronic medical record. Financial issues including incentives, costs and financial penalties are of adopting the mandate are covered. Other areas to promote and ease the transition, such as support systems, state and regional medical information exchanges, education initiatives, and extended HIPAA guidelines with regard to electronic records and transmissions are included in this article. This article explains the incentives for implementing the electronic records system. I chose this article to explain the diversity involved in the governments promotion for adopting an electronic health record system.
DesRoches, C. M., Campbell, E. G., Rao, S. R., Karen, D., Timothy, F. G., Jha, A., . . . Blumenthal, D. (2008, July 3). Electronic records in ambulatory care: A national survey of physicians. New England Journal of Medicine, 359(1), 50-60. doi:10.1056/
This article is a summary of statistics and results compiled from a survey of physicians in the US regarding the adoption of electronic health records. Documented in the survey are physician statistics and opinions in areas of usage, implementation, and satisfaction with the electronic health record systems. Issues addressed are quality of care, age groups of physicians who have adopted an electronic system and size of practices more apt to adopt electronic health records. The positive effects on practice processes, barriers that hinder adoption of electronic health records, incentives for and reservations with switching to electronic health records are included in the survey. I chose this source because it provides actual statistics of the usage of electronic health record systems as well as the diversity in physicians' perceptions of the process, the systems, the benefits, and problems associated with compliance.
Hayes, F. (2009, February 2). No Rx for ROI. Computer World, 43(5), 40. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=36487540&site=ehost-live
In this article, the senior news columnist addresses the issue of "return on investment" (ROI) for the adoption of electronic health records. The definition of ROI is given and how it applies to aspects of electronic health record adoption for physicians and hospitals is examined. Risks to, benefits of, and improvements needed regarding electronic health records are noted. The author confirms that those assuming the expenses for electronic health records will not be the ones reaping the benefits. I chose this article because it covers reflects my opinion one of the most important reasons for physician resistance to implementing the government mandated electronic health record system.
Hoffmann, L. (2009, November). Implementing electronic medical records. Communications of the ACM, 52(11), 18-20. Retrieved from http://search.ebscohost.com/.aspx?direct=true&db=a9h&AN=45021143&site=ehost-live
In this article, a basic history of George W. Bush's goals for every American to have an electronic health record is presented along with the progress of the government in making those goals real. Usage of electronic records is briefly mentioned. The article focuses on some major barriers and concerns of physicians for implementation and usage. The article also addresses some of the positive aspects for electronic health records. I chose this article because it provides concise overall answers to who, what, when, where, and why answers to the implementation of the electronic health record and health information technology.
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