Design and Evaluation of Information Systems
All electronic health records (EHRs) systems are not the same. The vendor has a valid argument in promoting that his EHR system could, in fact, improve the quality of care and patient outcomes but only if his system can prove that his system is superior to the existing system in place. In order to properly consider his product first, we must understand what this product is and how it should be utilized.
EHRs are defined in Guide to Health Informatics by Enrico Coiera as, “A general term describing computer-based patient record systems. It is sometimes extended to include functions such as order entry for medications and tests, among others” (Coiera, 2015, p. 576). EHRs are typically more comprehensive than electronic medical records (EMR) and electronic nursing records (ENR) which are more geared towards the sole use of doctors and nurses.
If the facility is currently using a paper records system or even an EMR there is probable chance that his EHR system would, in fact, meet his claims. While there are some benefits to a paper records system they are slight in comparison to the benefits gained from utilizing an ERH system. An EHR system can collect a vast amount of data and be stored in a relatively small amount of space in comparison to storing traditional bulky paper records. Another advancement is “the ability to create duplicate copies easily and cheaply, for example, as back-ups, for security reasons” (Coiera, 2015, p. 133). Some argue they like the informality of using a paper system. They like being able to jot down thoughts and notes on paper and feel that this cannot be achieved electronically. There have been advancements made to the ERH technology that now allows this informality to transition over to the normally more rigid electronic system. Now it is possible to express thoughts and notes to be recorded in the EHR either by voice recordings or even handwriting data and converting it into electronic text. One of the most valuable attributes of an EHR is its portability and availability. EHRs can be accessed across networks and to some extent even to the patient’s personal devices. No longer does one have to wait or request access to records simply because they are in use elsewhere or misplaced. While EHRs are not infallible and do succumb to some risks those risks are minimal compared to the risks associated with the traditional fragile paper systems. EHRs are backed up and encrypted and stored in multiple locations thus making it harder to lose the valuable information they contain. Paper systems are at risk of being lost to fires, floods, theft, deterioration, and negligence much more easily than the electronic systems. Once the paper record is lost or destroyed it is difficult and time-consuming to recreate if it is even possible at all.
As I mentioned earlier all EHRs are not the same. As with any product or service, the quality and functionality can be greatly influenced by cost and manufacturer. I was speaking to a friend who owns a very small home health facility in a small town. She has owned this facility for many years and has fully transitioned to using an EHR system. She made the claim that she like the improved functionality and ease of use of the electronic systems but wishes she had invested in a more advanced system over the base model she selected. She has since been able to interact with the more desirable systems and feels some of the features her system lacks would greatly improve the quality of care she can provide to her patients. With that knowledge, this confirms my thoughts that even with EHRs you get what you pay for.
The article I chose to discuss is Electronic Health Records and Clinical Decision Support Systems Impact on National Ambulatory Care Quality by Romano & Stafford in a JAMA Internal Medicine Journal, May 23, 2011. The basis of the article is to discuss how the implementation of EHRs can be a solution to low-quality care reported due to physicians sometimes inability to provide adequate outpatient care. It is believed that EHRs can improve the quality of health by “Clinical practices implementing outpatient EHRs self-report improved clinical decisions and resulted in easier communication with other providers and patients, faster and more accurate access to medical records, and avoidance of medication errors” (Romano & Stafford, 2011).
“Due to the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Reinvestment and Recovery Act of 2009, the usage of EHRs has increased substantially. However, there is little evidence that indicates improved quality of care in association with the usage of EHRs and improved quality of care” (Romano & Stafford, 2011). Romano and Stafford claim that the less than favorable outcomes for linking quality of care with EHRs is the misuse or lack of use of the EHR function clinical decision support (CDS) which is “a feature that alerts, reminds, or directs health care providers according to clinical guidelines” (Romano & Stafford, 2011). Romano and Stafford go on to utilize federally collected data from 2005-2007 to conclude “that CDS functionality is associated with higher-quality outpatient care compared with EHR use without CDS” (Romano & Stafford, 2011).
The article appears uncertain whether EHRs show a significant quality of health improvement, however, the article was written in the early stages of the introduction to EHRs. It makes claims that feature such as CDSs are making slight improvements but more utilized in the west (41%)than in any other regions and then utilized more by women than men (54% vs 58%) yet those numbers are fairly close.
Regardless of the suboptimal findings Romano and Stafford found in this study they concluded that the study may have been too broad and that the study may have been conducted too early in the EHRs life to indicate a true assessment of its ability to improve quality of care. They have concluded that with despite promises of a better quality of care and more desirable clinical benefits that EHRs and CDSs just are not evident as quality indicators but they remain optimistic since the American Reinvestment and Recovery Act stimulus bill funded to promote HIT use in the United States. HITECH funding will raise reimbursement rates for programs such as Medicare and Medicaid services only if delivered with ‘meaningful EHR use’. This will raise the numbers using EHRs and thus a more thorough empirical study can be performed linking EHR usage to the quality of care and the more favorable results might be revealed that are still anticipated.
Coiera, E. (2015) Guide To Health Informatics, Third Edition, CRC Press, Taylor & Francis Group, New York, NY. ISBN 9781444170498
Romano, M. J., & Stafford, R. S. (2011). Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives Of Internal Medicine, 171(10), 897-903. doi:10.1001/archinternmed.2010.527