Electronic health record

An electronic health record (EHR) refers to an individual patient's medical record in digital format. Electronic health record systems co-ordinate the storage and retrieval of individual records with the aid of computers. EHRs are usually accessed on a computer, often over a network. It may be made up of electronic medical records (EMRs) from many locations and/or sources. A variety of types of healthcare-related information may be stored and accessed in this way.

EHR systems can reduce medical errors.^[1] In one ambulatory healthcare study, however, there was no difference in 14 measures, improvement in 2 outcome measures, and worse outcome on 1 measure.^[2]

EHR systems are believed to increase physician efficiency and reduce costs, as well as promote standardization of care. Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, less than 10 percent of hospitals as of 2006 have a fully integrated system.^[3]

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Overlap in Terminology

Multiple terms have been used to define electronic patient care records, with overlapping definitions.^[4] Both electronic health record (EHR) and electronic medical record (EMR) have gained widespread use, with some health informatics users assigning the term EHR to a global concept and EMR to a discrete localised record. For most users, however, the terms EHR and EMR are used interchangeably. An EHR system is also often abbreviated as EHR or EMR.

Health Information Technology is an even broader term that describes any computer-based electronic aid to healthcare delivery.

An electronic health record is a patient’s health record that has been compiled into a digital format. This record may contain information about the type of treatment that a patient has received from a healthcare provider, such as the patient’s medical history, lifestyle, prescribed medication, test results, etc. Usually the patient’s healthcare provider has access to these records, however, insurance companies, government agencies, other healthcare providers, such as nurses, and the medical information bureau may also have access to the patient’s records upon request. In the United States, the HIPAA privacy act protects the patient from having their record distributed amongst other healthcare providers without the patient’s consent.

Types of data stored in an electronic medical record

An electronic medical record might include:

• Patient demographics.
• Medical history, examination and progress reports of health and illnesses.
• Medicine and allergy lists, and immunization status.
• Laboratory test results.
• Radiology images (X-rays, CTs, MRIs, etc.)
• Photographs, from endoscopy or laparoscopy or clinical photographs.
• Medication information, including side-effects and interactions.
• Evidence-based recommendations for specific medical conditions
• A record of appointments and other reminders.
• Billing records.
• Advanced directives, living wills, and health powers of attorney

Advantages of electronic medical records over paper records

A medical record includes any of an individual's health documents of the types listed above. Medical records may be on "physical" media such as film (x-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces.

Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage.

When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant.

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.^[5]. However, no scientific report has linked EHR to a reduction in malpractice suits—they find only that hospital risk managers are "looking" for such a reduction to occur .^[6] Numerous major physician malpractice insurers have not reduced malpractice premiums due to EHR implementation. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input.

Electronic records keeping and order entry were found to reduce errors associated with handwritten documents and were recommended for widespread adoption.^[1][7]

Lack of adoption of EHRs in the United States

  Outside of the Veterans Administration Healthcare system, the vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s.

As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Less than 10% of American hospitals had implemented HIT,^[8] while a mere 16% of primary care physicians used EHRs.^[9] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.^[2][10] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.^[10] However, less than one-tenth of these physicians actually had a "complete EMR system" (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).^[11]

The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.^[12]

EHR adoption in the US has been hampered by a number of factors including high software costs and complex installation and technical requirements.

Research studies also indicate that adoption of Electronic Health Records strongly correlate with practice size and payer mix. Adoption rates seem to be lower in smaller practices, those not affiliated with hospitals and those that do not teach medical students or residents. In addition, findings also imply that privately insured patients in physician’s practices influence EHR adoption.^{[13] [14]}

In 2005, The Department of Ambulatory Care and Prevention of Harvard Medical found that of the 45% of physicians using Electronic health records in Massachusetts, 52% of practices consisted of 7 or more physicians compared to 14% of solo practices.^[15] Results from a study conducted by Florida State University College of Medicine had similar findings. Of 756 Florida licensed family physicians, EHR use was related to large practice, urban location and young physician age.^[16] Noticing the significant difference between small practice verses large practice EHR use, it is suggested that barriers to adoption for solo practices are due to start-up financial costs.^[17] Thus, in order to expand EHR use financial barriers must be minimized specifically among smaller practices.

Despite of agreement on the benefits resulting from the integration of Electronic Health records, many legal challenges to sharing of the EHR exist. The main concerns involve:

• HIPAA's privacy and security regulations.
• A Federal provider Anti-Kickback law, the Stark Anti-referral rules.^[18]

Other most significant barriers to adoptation of the EHR are:

• Lack of national information standards and code sets.
• Lack of available funding, trained staff, and high start and operating costs for providers.
• Concerns about physicians' hesitation for usage.^[19]

Ideal characteristics of an electronic health record (EHR)

• Information should be able to be continuously updated.
• The data from an electronic health records system should be able to be used anonymously for statistical reporting for purposes of quality improvement, outcome reporting, resource management, and public health communicable disease surveillance.^[20]

• The ability to exchange records between different electronic health records systems ("interoperability"^[21]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities.

Attempts to facilitate EHR compatibility in the United States

The Veterans Administration health care system in the United States, with over 155 hospitals and 800 clinics, represents one of the largest integrated healthcare delivery systems in the world. It relies on a single EHR system called VistA, which has been in use for years. Data exchange is facilitated by a protocol called BHIE (Bidirectional Health Information Exchange), and the VA healthcare network is being expanded in 2007 to integrate the Department of Defense healthcare facilities using the BHIE networking protocol.

This EHR has been made publicly available for download and has been adapted for use in many non-VA hospitals and healthcare networks. As BHIE becomes more widely available, a national healthcare network will be facilitated.

Outside of the VA's EHR system, however, there are currently at least 25 major competing vendors of EHR systems, many selling software incompatible with competitors.

This lack of interoperability provides a significant barrier to a "National Health Information Network."^[22] In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer. Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. The US Congress is currently working on legislation to increase funding to these and similar programs.

In an attempt to continue to attack the interoperability problems with EHR’s, in December 2006, it was announced that HL7 will adopt and maintain the EHR-Lab Interoperability and Connectivity Standards (ELINCS). The overall goal of ELINCS is to develop a standard that provides vendor plug-and-play interoperability with regards to linking lab system codes and pharmacy codes with those established by individual providers.^[23] According to the California Healthcare Foundation, the creation and adoption of this type of national standard will simplify the use of electronic health record systems. It is anticipated that physician practices could reap tangible benefits early in the implementation phases of an EHR as well as reduce costs associated with the installation and configuration of such system. ELINCS has worked closely with the following organizations to ensure acceptance of the standard: Certification Commission of Health Information Technology (CCHIT), Connecting for Health (Markle Foundation), eHealth Initiative (eHI), DOQ-IT (Centers for Medicare and Medicaid Services), Integration the Healthcare Enterprise (IHE), and Public Health Information Network (CDC/PHIN). ^[24]

Benefits of EHR standardization / National Healthcare Information Network

Improved billing accuracy

Although billing is now largely accomplished electronically in the United States, these claims often require additional documentation from a patient's medical record. This is a tedious task when records are in an electronic format not compatible with the billing program, or when the records are in paper format. An integrated electronic medical record / billing system, therefore, both expedites and makes billing more accurate.

Reduction in duplication of services

Duplication of lab tests, diagnostic imaging, work-ups, and other services can be prevented by good record-keeping of any type. However, because electronic records can be available at many locations at once, integration of services and awareness of duplication is facilitated.

Facilitation of clinical trials

Clinicians and researchers see benefits to integrating electronic health records with data collection and analysis in clinical trials.^{[citation needed]}

Potential clinical trial participants can be more easily identified, administrative overhead costs can be lessened, data errors can be reduced, and adverse outcomes more rapidly identified.^{[citation needed]}

Some institutions have already been partially successful in implementing and integrating co-ordinated data collection and analysis systems. For example, the Shared Pathology Network (SPIN) of the National Cancer Institute has effectively established a web-based network for locating pathological tissue samples at various institutions across the nation.^[25] The electronic nature of reports within the system allows the use of search engines to find specific text with the reports, facilitating analysis.^[26]

Organizations to evaluate standardization proposals

Several models of standardization for electronic medical records and electronic medical record exchange have been proposed and multiple organizations formed to help evaluate and implement them.^[27][28]

Organizations

• CHI (Consolidated Health Informatics Intitiative) - recommends nationwide federal adoption of EHR standards in the United States
• CCHIT (Certification Commission for Healthcare Information Technology) - a private, not-for-profit organization that evaluates and develops the certification for EHRs and interoperable EHR networks (USA)
• IHE (Integrating the Healthcare Enterprise) - a consortium, sponsored by the HIMSS, that recommends integration of EHR data communicated using the HL7 and DICOM protocols
• ANSI (American National Standards Institute) - accredits standards in the United States and co-ordinates US standards with international standards
• Healthcare Information and Management Systems Society (HIMSS) - an international trade organization of health informatics technology providers
• American Society for Testing and Materials - a consortium of scientists and engineers that recommends international standards
• openEHR - promotes open source EHR guidelines
• Canada Health Infoway - a private, not-for-profit organization that promotes the development and adoption of EHRs in Canada
• World Wide Web Consortium (W3C) - promotes Internet-wide communications standards to prevent market fragmentation
• Clinical Data Interchange Standards Consortium (CDISC) - a non-profit organization that develops platform-independent healthcare data standards

Standards

• HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
• DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
• ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
• CEN - CONTSYS (EN 13940), supports continuity of care record standardization.
• CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
• ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures
• CEN's TC/251 provides EHR standards in Europe
• CEN - EHRcom (EN 13606), communication standards for EHR information in Europe

Barriers to implementing an EHR system

Difficulty in adding older records to an EHR system

Older paper medical records ought to be incorporated into a patient's electronic health record.

One method is to merely scan the documents and retain them as images. Surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone, however, rather than fully electronic data-based systems.^[29] EHR systems with image archival capability (such as VistA Imaging) are able to integrate these scanned records (along with other types of image-based records) into fully electronic health records systems.

Another method to convert written records (such as notes) into electronic format is to scan the documents then perform optical character recognition. For typed documents, accurate recognition may only achieve 90-95%, though, requiring extensive corrections. Furthermore, illegible handwriting is poorly recognized by optical character readers.

Some states have proposed making existing statewide database data (such as immunization records) available for download into individual electronic medical records.^[30]

Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion. This is a problem that plagues distributed computer records in all industries.

Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks).

In the United States, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.

Synchronization programs are only able to be adapted once record standardization occurs.

Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.^[31][32][33]

Privacy

Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.^[34] Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.^[35] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.

Privacy: Privacy is a concern for both health organizations, patients and the healthcare as a whole. In an article published in Public Medicine the author looks into whether HIPPA is really doing what it was designed to do. HIPAA the Health Insurance Portability and Accountability Act of 1996 was passed by Congress with two formidable tasks, “to reform the insurance market, and to simplify the healthcare administrative processes (Banks, p45)”. The author goes on to say that recent surveys indicate that many providers and payers are not fully compliant with the security and privacy regulations mandated by HIPAA. Even though HIPPA does not promise a more efficient and effective means of sharing important healthcare information. Many experts have concerns that the implementation and maintenance of HIPAA standards and policies will become a financial burden for many in the healthcare industry. In another article published in AAOHN, the author takes a deeper look into “Privacy.” He finds that information can be release to a third party without the consent of the patient. “a covered entity may disclose PHI to a health care oversight agency such as the Office of the Inspector General without first obtaining client authorization (Shuren p501)”. He also says that many organization records will not be protected under the HIPAA Privacy Rule because employers are not covered entities and few occupational health professionals meet the criteria of being considered a covered entity. Nevertheless, occupational health professionals need to be knowledgeable about the application of HIPAA in the occupational health care setting.

United States 

Electronic healthcare data ("Personal Healthcare Information (PHI)") access is regulated by the Department of Health and Human Services (DHHS) under the Health Insurance Portability and Accountability Act (HIPAA), and often by local laws as well. As a response to the public concern over the potential misuse of health information, HHS issued Standards for Privacy of Individually Identifiable Health Information, known as the Privacy Rule, on April 14, 2003.^[36] A major goal of the Privacy rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public health. HIPAA security implementation standards require organizations to authenticate protected electronic health information as a means of ensuring data integrity, including data at rest and transmitted data. Common standards mandated by HIPAA to protect the privacy and security of electronic medical records include:

• Authorizing - granting access to the appropriate persons who should have access to the EHR based on their role or function
• Authenticating - a process to verify the identity of all persons accessing the EHR
• Access control - setting limits appropriately to authorized persons
• Auditing - assurance the patient data has not been inappropriately accessed.

Europe 

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.^[37]

Hardware limitations

Computer access is required to use an electronic health record system. A sufficient number of workstations, laptops, or other mobile computers must be available to accommodate the number of healthcare providers at any one facility.^[38] EHR software ought to be backwards compatible with older technology so that existing technology infrastructure can be used. Furthermore, most healthcare facilities have at least some degree of existing computerization, whether in the lab or in billing services. EHR systems need to interface with existing systems, again mandating a modular approach.^[39]

Start-up costs and software maintenance costs

In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.^[40] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).^{[41] [42]} Vendor costs only account for 60-80% of these costs.^[43]

Some proponents of EHR systems suggest that startup costs will be recouped within 3 years. ^[44] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.^[45]

Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.^[46]

The federal government made justification to its regulations which allowed decreasing the cost of EHR implementation to enhance physicians’ adoption of EHR. ^[47] The average implementations can cost between $14,500 and $63,600 per full-time provider, with a median of approximately $45,750; median annual maintenance costs are approximately $7,200 per full-time provider, and practices average 2.5 years to reach a positive return. ^[48] However, many groups of physicians resist embracing this technology because they still assume that quality and revenues from using it is still not proved. ^[49]

Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.^[50]

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.^[51]

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the VistA electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems eventually retire.

Tommy Thompson, the former Health and Human Services Secretary once said that the most incredible feature of 21st-century medicine is that it is held together with 19th-century paperwork.^[52] In a time of booming medical advances, there is no reason that an effective tool such as EHRs are not used throughout the nation. In fact, many healthcare providers still rely on handwritten notes for communication and recordkeeping, and some still use typewriters to prepare patients’ bills.^[52] One reason that many healthcare providers have not adopted EHRs is the concern over high costs. In actuality, the results of using 19th-century technology in a 21st-century healthcare system are higher costs, increased errors, and decreased quality of care.^[52] Physicians informed lawmakers in March 2007 that a combination of higher Medicare reimbursement, tax credits, grants and loans would be needed to offset the costs of implementing health IT and to better ensure the use of electronic medical records across the nation’s patchwork of physician offices.^[53] Although the initial costs are high for EHRs, it is still imperative that they be implemented because of the amount of money that it will save hospital systems long-term. Also, the quality of care will increase dramatically.

Evaluating the costs of electronic health records is an involved and lengthy process. The cost of implementing electronic medical record systems involves not only investment in the software and hardware needed, but also potential added temporary staff and decreased productivity.^[54] The staggering upfront costs can be blinding to physicians and others looking to implement electronic health records. However, cost-benefit analysis studies show that over time a net benefit does result with implementation of electronic health records. One analysis from Wang et al demonstrates an estimated net benefit of electronic records of $86,400 per provider in a primary care setting over a five year period.^[55] Although these figures are sensitive to a number of factors, it clearly shows a potential cost savings in the long term.

The problem of temporary workers

Increasingly, a substantial portion of healthcare is provided by mobile, temporary workers, from physicians and nurses to administrative support personnel. Unless there is some standardization of electronic health record systems, there will be new training requirements for temporary workers each time they encounter a new EHR system.

Inertia

Most large organizations resist change. The institutional stress of implementing any new large-scale system must be anticipated by management. According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EHR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself.

The healthcare industry has more licensed professionals with advanced degrees than any other industry. However, systems analysis and computer science has not, until recently, been an integral part of healthcare training. Most health administrators also lack training in computer science.

Legal barriers

Liability barriers

Legal liability in all aspects of healthcare in the 21st century was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys^[56] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.^[57]

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.^[58]

This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.^[59] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted to improve the portability of health care insurance for persons leaving jobs. A section of the act encourages the use of electronic communications for health care claims adjudication, mandates the use of new standard code sets and transaction sets, and establishes the need for regulations to protect the security and privacy of individually identifiable health care information.^[60] Specifically, HIPAA prohibits the disclosure of patient health information except as permitted. Covered entities must follow the Rule's mandates for consent when disclosing patient health information. Patient electronic data includes transmissions via telephone, fax, Internet or storage disks. Violations of HIPAA can result in civil or criminal liability. Civil sanctions include a fine of no more than $100 per violation for any individual, but not organization, who fails to comply with the Rule. This fine cannot exceed $25,000 per violation of one Rule requirement involving any one person in one calendar year. Criminal liability can result in fines ranging from $50,000 to $250,000 and imprisonment of 1 to 10 years. Despite these harsh sanctions, a recent survey results by Phoenix Health Systems and the Health Information and Management Society (HIMSS) indicate many providers and payers are not fully compliant with the security and privacy regulations mandated by HIPAA.^[61] Many experts have concerns that the implementation and maintenance of HIPAA standards and policies will become a financial burden for many in the healthcare industry. While it may take several years before the industry is able to realize any true cost savings from administrative simplification, HIPAA does offer the promise of a more efficient and effective means of sharing and disseminating vital healthcare information.

Ownership of electronic records

Responsibility for patient records (no matter what their form) belongs to the creator and custodian of the record, usually a health care practice or facility. There are state and federal requirements for how long medical records must be preserved. HIPAA standards allow patients the right to review the content of their medical records.

When records are centralized, it is often difficult to determine whose responsibility it is to maintain the records. If a company agrees to manage and maintain records but goes out of business, how does that impact the healthcare provider whose ultimate responsibility it is for record maintenance?

If a healthcare provider retires or goes out of business, what arrangements to convert records to archival formats are available?

If an individual physician and a hospital system share a record database system but then the individual physician leaves that healthcare system, how does she separate her practice's records from the hospital's central database to take them with her for archival, as often required by law?

Who determines the frequency of "purging" of records?

In a health record trust (also known as a health record data bank), the patient owns the electronic health record.

Unalterability of records, spurious records, and digital signatures

Medical records must be kept in unaltered form and authenticated by the creator. However, simple mistakes often create spurious documents. How are spurious documents identified so that they do not clutter the medical record without altering or disposing of them illegally?

Most national and international standards now accept electronic signatures.^[62] However, a database of electronic signatures must be created as an EHR system is implemented.

Customization

Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system.

An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.

This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.^[63]

A survey of hospitals regarding the effectiveness of EMR found that more than half the respondents had improvements in efficiency, speed, accuracy, and development of nursing plans but at the same time they reported that the system caused a negative effect in communication, increased overtime, and more missing records^[64]. Customizing the software when it is released^[65] yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution. Success markers for the customization are that there is adequate training, buy-in from the intended users, commitment to overcome obstacles, vendor support that enables reasonable expenditure of costs and time, and ultimately a return on investment.^[66]

Customization can have its disadvantages. A shortage of investment capital, lack of vendor understanding of the unique complexity of community health centers (CHCs) in comparison with standard model group practices: complex funding, complex reporting requirements and complex regulatory environments require many special considerations in EH implementation in the CHC environment.1

Based on their funding requirements some CHCs provide more than medical care to their clients. Services may include mental health therapies and substance abuse counseling, medical adherence and nutritional counseling, and case management services. CHCs need an EHR that would allow them to capture all treatment data in a single, electronic record, and enable them to satisfy some very specific reporting requirements mandated by their funders. Many CHCs are rely heavily on state and federal funding.

The lack of vendor understanding of the challenges of this unique environment increases the need for the development of interfaces with legacy and other systems, and some degree of software customization to enable needed functionality. Simply redesigning workflows would not compensate for the absence of some functionality.

Development and maintenance of these interfaces and customizations can lead to higher software implementation and maintenance costs. Increased costs include the time both the customer and the vendor must spend to understand the requested change, to write new code to accomplish and test the customization, to modify training material and procedures to address information about the added customization, and ongoing maintenance and testing required after each new software release to address incompatibilities between the base product and the customization.^[67][68]

Successful implementations of EHR systems

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture or VistA. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, x-rays, patient care nursing orders, diets, and laboratory tests.

The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.

As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT). ^[69]

The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.

Failures in Health Information Technology implementation

In 2002 at Cedars Sinai Medical Center in Los Angeles, physician dissatisfaction forced the administration to scrap a proprietary $34 million Central Physician Order Entry system that was developed within the medical center itself. Physicians were reported by nurses as being embarrassed by the number of errors the system caught and corrected, as well as being frustrated by the slow performance of the system.^[70] It is notable that the system had never been used or tested outside of Cedars-Sinai.

As many as 30% of EHR implementation attempts have failed over the past few years, according to the National Health Information Network Co-ordinator, David Brailer.^[70] Brailer's Santa Barbara County Care Data Exchange failed for a variety of reasons including poor project management, technical challenges, and a failure to create a compelling business model for the participants.^[71]

Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. As of October 2006, CCHIT had certified 34 ambulatory EHR products.^[72][73]

Personal Health Records (PHR)

A personal health record is medical information that is in the possession of an individual patient (or patient's non-professional caregiver). The format may be either paper (or similar types of) documents, electronic media, or a combination of both. Any of the types of data listed above may be included. It may also include information that a doctor may not have, such as exercise routines, dietary habits, herbal or nonprescription medications, or results of home testing (such as home blood pressure or blood sugar readings).

Organizations such as the American Health Information Management Association (AHIMA) encourage individuals to keep their own complete PHR.^[74] According to AHIMA, 42 percent of US adults surveyed said they keep some form of a personal health record. Personal health information storage is offered online at several internet sites.

Veterans Administration patients are able to access their personal health records, called Personal Health Journals, through HealtheVet,^[75] an online service linked to the VistA electronic health record system.

Continuity of Care Records (CCR)

The Continuity of Care Record (CCR) is meant to represent a brief synopsis of recent healthcare encounters, to include only significant data. It is meant to enable a rapid assessment of the patient's overall health and recent visits to healthcare providers. CCRs may be transmitted in paper or electronic form.

Almost all electronic health record systems have a CCR function built in (often called the cover sheet or health care summary). If a patient receives care in a healthcare setting using the same electronic health record system, the CCR can usually be instantly accessed. However, if the patient visits a healthcare setting that uses paper records or a different or non-compatible type of electronic health record system, the data may not be transferrable.

For this reason, a standard format for the CCR has been proposed.^[76]

If standardized, the CCR could be transferred directly (over a network connection, for example) or could be stored in a Personal Health Record storage device, such as a portable flash drive or smart card that the patient can bring from location to location.

Software criteria of interoperability

The Center for Information Technology Leadership described four different categories ("levels") of data structuring at which health care data exchange can take place.^[77] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.

The four levels are^[78]:

Related and supporting technologies

An unusual form of Health Information Technology is the VeriChip system, an RFID microchip that can be implanted under the skin to give instant access to a patient's records. The tiny electronic device, produced by Applied Digital Solutions Inc. of Delray Beach, Florida, transmits a unique code to a scanner that allows doctors to confirm a patient's identity and obtain detailed medical information from a database maintained by Applied Digital. Only the identification is provided by the implant, so the system remains limited to hospitals, doctors and patients having access to the scanner.^[79]

See also

• Certification Commission for Healthcare Information Technology
• Continuity of Care Record
• Electronic medical record
• European Institute for Health Records (EuroRec)
• Good European Health Record (GEHR)
• Health informatics
• Health information management
• Health Level 7
• MUMPS
• Veterans Health Information Systems and Technology Architecture (VistA)
• List of open-source Electronic Health Record systems

References

Further reading

• Murphy, G. F. et al. (1999), Electronic Health Records: Changing the Vision (ISBN 0-7216-7386-4), W.B. Saunders Company (Elsevier), Philadelphia, Pennsylvania, p.5.
• A State Policy Approach: Promoting Health Information Technology in California. California Legislative Analyst Office (February 2007).