Electronic Health Records: A Guide for Clinicians and Administrators

Abstract

Patient information plays a key role in the manner in which healthcare services are delivered and the quality of those services. Of equal importance however is the manner in which the information is recorded and stored. Traditionally, patient information was recorded manually in the form of paper and stored in files and folders. This is a cumbersome method because it implies that any organization has to have numerous files for all their patients.

Besides being cumbersome, this method of documentation and storage limited the physical space of the organization. It is based on these and other disadvantages of paper records that electronic health records have been and are still advocated for. But like every other thing, the electronic health records are not without their own demerits. This paper examines the advantages and disadvantages of using electronic health records in place of paper health records.

Background Information

During the past decades, systems have been created to enhance the running of healthcare organizations by speeding up the services being offered and improving the quality of care. Until lately, healthcare organizations especially hospitals, have been in the forefront in the design and creation of information systems. This has been attributed to a number of elements. First and foremost, the substantial costs involved in the installation and implementation of such systems made it impossible for small-scale organizations to adopt them.

Secondly, the pressure faced by healthcare organizations to adhere to stringent regulatory and economic obligations made it difficult for them to adopt the technology-based systems. Carter (2008) argues that “Hospital information systems (HIS) usually have, as their central component, an Admission, Discharge, and Transfer (ADT) system that manages census and patient demographic information,” (p. 5). The system also incorporates packages used in billing and accounting as its major constituents. In majority of the community hospitals, the HIS system comprised of the financial, ADT systems and Laboratory Information Systems (LIS).

Nevertheless, the past two decades have seen a growing interest by many healthcare organizations in the development of information systems solutions through the incorporation of systems of organizations’ units with the central HIS. Despite the growing interest approximately 20% of healthcare organizations lack electronic systems in their main subsidiary systems (Carter, 2008).

Departmental systems have shifted from concentrating on administrative chores to more health-based tasks. These systems were created chiefly for utilization by employees working in these departments rather than by the health care workers. Therefore, information concerning drug interaction was accessible only to pharmacists and their employees but not directly to physicians and nurses.

Clinical information systems were given that name due to the fact that they were used in fields that aided clinical services, and not because they were meant to be utilized chiefly by physicians. Carter (2008) argues that “of all the systems that fall under the rubric of clinical information systems, only a few are designed primarily for use by health care providers: intensive care units, picture archiving and communication systems, computerized physician order entry systems and the electronic health records,” (p. 6).

At the present times, information systems of healthcare organizations are influenced mainly by issues of quality, patient safety, and cost, as well as business and operational concerns. The focus in healthcare organizations has moved towards availing information systems that assist the healthcare professionals in the course of offering care. This has led to the introduction of computerized physician order entry CPOE systems and electronic health records. The electronic health record is viewed as the objective which health information systems have tried to achieve ever since they were introduced. Nevertheless, EHR systems are still uncommon in many healthcare organizations. Carter (2008) argues that “fewer than 3% of American hospitals have robust EHR systems, while fewer than 15% of physicians use EHRs on a regular basis” (p. 6).

The Development of Electronic Health Records

There has been an increasing interest in EHRs which has gone hand in hand with a rise in the number of efforts made towards providing definitions of the term. The confusion surrounding the definition of electronic health records is evidenced by the numerous terms given to them by large number of published studies. In the past decades, various names have been used to describe EHRs which include: electronic medical record, electronic patient record, computer-stored patient record, ambulatory medical record, and computer-based medical record.

Unluckily, these definitions are only conceptual in nature and offer little help in giving a technical, engineering, or scientific view of EHRs that could prove useful for either designing systems or reviewing products. Even though there lacks a formal model or standard design for EHRs, the original systems offered a fundamental model for the present-day EHRs that are used in hospitals and other healthcare centers and which have been imitated by the new products (Hamilton, 2010). This paper examines the advantages and disadvantages of EHRs.

Advantages of Electronic Health Records

Electronic health records have enormous advantages when compared with paper medical records hence the reason why their adoption has largely been encouraged. The advantaged of electronic systems are very significant and have led the American government to introduce the Health Information Technology Initiative whose objective is to create interoperable electronic health records by the year 2014 (Govindan, 2009).

Accessibility

Paper records have always been used as the main technique of organizing all available information related to the progress of patients as well as their diagnosis and treatment at a particular place. This compressed storage system is expedient but is rife with numerous demerits which have been addressed by the electronic system. Even if paper records can be duplicated, maintaining many copies of a single record is cumbersome due to limited storage space and the need to keep updating all health records. As a result, the single-record system availed by the electronic health record system enables multiple providers to gain access to the records.

The system also makes it possible for providers who are geographically constrained to access the records. This is impossible in the case of paper records. For instance, if a patient is in a different town from his physician, the physician would be forced to travel to where the patient’s records have been kept. On the other hand, in the case of the electronic health record, the physician is just required to log in to his computer and access the record.

In addition, for the healthcare providers to access their patients’ medical records, they have to borrow the records from where they are kept. If a healthcare provider loses a paper medical record, it becomes almost impossible to replace it and thus the whole process of obtaining the information begins. This may increase the risk of medical errors through inaccurate information pertaining to the patients’ diagnosis and medication.

This is different from the electronic medical records. It is impossible for an electronic health record to be lost unless the computer crashes. However, in most cases, the electronic health records are usually stored in different locations of the computer such as the main location, the hard drive and external storage facilities such as flash disks. It is thus easy to replace an electronic health record if the computer system crashes (Govindan, 2009).

Interface

Gaining access to a paper health record is tedious and entails going through a number of pages that have the outcomes of the tests done on the patient and notes on other information that is relevant to the patient’s health and medical condition such as medications given to him. The situation is worse when it comes to dealing with many patients because it implies that the health provider has to sort a number of files for the different patients.

Paper records also make it difficult for providers to obtain a specifically ordered result for instance chronological order of the patient’s tests and treatments. This challenge is easily solved by electronic health records in that the healthcare provider can easily make use of special tools, software and applications in the computer which would give him the outcome he is interested in.

In addition, electronic health records make it possible for the users of the records to create visual presentation of the records which in turn enable the users to further analyze, manipulate and respond to the information obtained. As a result, electronic records save the users the time taken to create mental pictures and write notes on the information. Moreover, the electronic records can be formatted in different formats such as videos which make it more interesting and convenient to use (Govindan, 2009).

Documentation and data collection

Entering information in a paper record is constrained to hand written notes and printed files. This process is thus tedious and consumes a lot of time. On most occasions, he process is also incomplete because of the nuisance involved. On the other hand, electronic records offer the benefit of allowing numerous techniques of recording the information which include direct typing, dictation, and voice recognition, which make the data entry process simpler and hastier and aids documentation.

Moreover, the ability to copy and paste or make use of shortcuts in computers makes it possible to repeat significant information without necessarily making reference to a different part of a document. The shortcuts availed by computerization can also retrieve information from specific segments and insert it into the document automatically, thereby reducing the time it takes to record the data as well as minimizing the probability of inaccurately omitting data (National Research Council, 1997).

In the healthcare sector, the issue of patient safety has always been a major concern due to the numerous errors and omissions that have been reported. Errors and omissions often lead to adverse effects such as incorrect diagnosis and thus inappropriate medication and other interventions. The end result is easy to imagine. Patients have been amputated, others have experienced deteriorated health condition and in extreme case, the errors and omissions have led to loss of lives. Unsafe patient care also affects the concerned healthcare organization for instance through poor reputation and loss of money in lawsuits.

Thus, it is imperative for healthcare organizations to reduce errors and omissions. In a paper record system, errors and omissions are encouraged due to illegibility of the handwritten notes. Although electronic health records cannot completely eradicate the medical errors, these records reduce the errors substantially for instance through the ability of the computer to check for spellings, eradication of unfamiliar abbreviations and making it mandatory for certain data to be entered into the record.

Another disadvantage of a paper health record is that it is practically impossible to identify who made changes to the record and when the changes were made in cases where a change is required in the paper. In such situations, users of the paper record have to go through a lengthy and manual process of identifying these issues for instance by asking around the organization for this particular information. This can take days or even months thus hindering the usability of the record. This is different from an electronic record. It is very easy for a user of an electronic health record to identify who made the changes and when the changes were made because such information is always saved in the record automatically by the system. Thus, the user of an electronic health record can follow up on the patient based on the new changes.

The ability of the electronic health record to keep a record of the changes made also avoids fraudulent use of the record because the users can easily enquire about the reasons behind the new changes made to a record. Most importantly, a paper record makes it impossible for the people responsible for the record to have one record containing all the information related to a patient. This is so especially when new information is received about the patient. The users of the record have to make other records that contain the new information because the information cannot be incorporated into the old record.

This is not the case in electronic health record. In EHRs, new information pertaining to a patient can easily be incorporated into the existing file by inserting the information where it is appropriate. Thus, this ensures that only one comprehensive record is maintained for each patient. This prevents the loss or misplacement of patients’ records. It is also convenient for the keepers and users of the health records (National Research Council, 1997).

Privacy

The confidentiality of patient information is a major concern in the healthcare sector. Indeed, it is one of the ethical standards governing the delivery of healthcare services. The standard states that patient information should only be used by the persons directly responsible for the patient’s care. With paper records, confidentiality of a patient’s information is highly impossible especially if it needs to be relocated from the central storage place.

Anyone can easily access such records. This is different in the case of electronic health records. One of the reasons behind this is that computers keep track of all the times the records have been accessed thus making it easy to identity violations of the confidentiality standard. Second, computers have security options through the creation of passwords which allow users to restrict access to the records only to authorized persons.

Moreover, the computers make it possible to define the rights to access by different personnel. This means that although patient records have different types of information used by different personnel, it is possible to restrict the users to obtain only the information that is relevant to them. This implies that different users can access the patient records but not all the information will be available to them. The National Research Council states that “the evolution of HIPAA compliance in health care institutions has underscored the unexpected enhancement to privacy through the HER” (National Research Council, 1997, p. 56).

Safety

As discussed earlier, patient safety is a major concern for patients. Electronic health records eliminate the probabilities of medical errors by eradicating the illegibility of paper records. Because electronic records are legible, users of the records can give treatments based on the information presented in the records thus reducing errors in medical prescriptions (Govindan, 2009).

Easy manipulation of data

Information that is saved and organized in electronic form can be utilized to achieve chores that are impossible to carry out if it is in the paper format even in a situation of high accessibility rate. For instance, information saved in computer can be restructured and presented in a different manner according to the requirements of the clinicians. National Research Council (1997) argues that “electronic health data can be manipulated by computer-based tools, so that knowledge about standards of care can be used to generate alerts, warnings, and suggestions,” (p. 36).

These abilities of the electronic health information are “known variously as real-time quality assurance, decision support systems, critiquing engines, and event monitors,” (Carter, 2008, p. 13). The abilities of the electronic health data to be manipulated are valuable in minimizing the difference between the quantity and the quality of health services offered to a diverse clientele. Electronic health records have also been proven to enhance the quality of clinical research. Presently, much of the information regarding the efficiency of experiments or interventions is hidden in huge volumes of paper files that are impossible to assess economically.

Health information and data that are stored in electronic form make it easier for clinicians to analyze through the systems’ search and recovery abilities as well as the existence of numerous data analysis tools. All these tools make the analysis of the health information not only easier but also hastier (National Research Council, 1997).

Risk management tool

Electronic health records also act as a management tool by availing information that can be used to enhance risk management and evaluation results. Presently, compensation is dependent on results and thus healthcare organizations need to find creative means of enhancing the quality of care they provide as well as the results while at the same time minimizing the costs. An electronic health record can minimize the time taken to record information as well as the errors incurred in the process of documentation, thus enhancing the efficiency of healthcare employees. In addition, while paper records increase the probability of medical errors due to illegible notes, electronic records minimize such errors because the records are in a manner that is legible.

The elimination or minimization of medical errors is one of the major concerns of clients when it comes to receipt of health and medical care. Patient safety is advocated for not only by the public but also by civil organizations, health care providers and governments and the implementation of electronic health records is a step in the right direction towards the achievement of patient safety (Govindan, 2009).

Disadvantages of Electronic Health Records

As seen in the discussion above, the electronic health records have numerous benefits not only to the patients but also to the healthcare providers as well as healthcare organizations. Despite these benefits, very few healthcare organizations and even fewer healthcare providers make use of EHRs. The reason for the underutilization of EHRs mainly can be explained by the disadvantages of the system as well as the challenges they present in their implementation.

Start up costs

One of the major disadvantages of electronic health records is the substantial startup costs required to install and implement them. At the moment, healthcare organizations are facing mounting pressures to cut down their costs due to cuts in budgetary allocations. As a result, shifting financial resources to advanced technologies remains a big problem to healthcare organizations. Nevertheless, many people believe that an electronic health record has the potential of minimizing costs and at the same time enhancing the quality of care provided by the organizations.

This is so because EHRs enhance the information available to providers and patients, get rid of reproduction testing, and enhances the coordination of treatment provided by numerous healthcare professionals. A good illustration of the cost efficiency of an EHR is the antineoplastic agent. Young (2000) argues that, “out-of-range lab values, which instantly appear at a pharmacy workstation and the chemotherapy infusion center, can prevent the mixing of expensive antineoplastic agents should the patient’s counts prevent infusion on that day,” (p. 32). Even if healthcare providers may be worried about the return on investment of EHRs, they should recognize that the long-term benefits emanating from EHRs are in enhancing the safety and quality of patient care and efficiencies and not mere physical and quantifiable monetary gains.

Extensive training requirement

Another demerit of an electronic health record is that it requires extensive training of the employees. EHRs cannot be run without basic technical knowledge and skills. Faced with mounting pressure to cut down on costs, majority of healthcare organizations got rid of clerks and the clerks’ tasks are currently being done by the clinicians. The clinicians however lack technical skills and knowledge. Thus, before any organization installs and implements an EHR, it should train its clinicians on how to use the system. National Research Council (1997) argues that “one of the more challenging issues confronting EHRs is the fact that physicians must be the users of the system, performing data entry as well as information retrieval, if they are to realize the benefits of interactive on-line decision support,” (p. 27).

This therefore raises the issue of usability which can be a chief challenge facing organizations that want to install and implement an EHR. Initially, designers of EHR did not take into account the needs of the users when developing the systems. It is only recently that usability of the system is being given serious thought by the designers. There should be tools and instruments that make it easy for the healthcare providers to obtain and comprehend the data that is appropriate for their decision-making responsibility. Put differently, “systems must be user friendly; otherwise these systems will not be easily accepted, nor will they be used to their fullest capacity,” (Govindan, 2009, p. 2943).

Even though moving from a paper and pen system to a computer-controlled system entails a major cultural shift, healthcare providers soon recognize the merits of a readily accessible and organized patient information, improved communication among the professionals, enhanced risk management, and immediate outcome tracking and reporting capacity.

Confidentiality and security issues

Many arguments have been given regarding these two issues and even if the patient information must be guarded, patients should also realize that their information needs to be available to the providers who utilize their information to offer medical and health services. Laws should not be too strict to the extent that they disallow the accessibility of the records by the professionals who have a legal right to the records.

Nevertheless, issues of illegal access cannot be ruled out. In order to prevent such incidences, there should be security technologies available to ensure that only authorized individuals gain access to patients’ health records. Young (2000) states that “some of these technologies include firewalls, passwords and properly designed and monitored audit trails can enhance user accountability by detecting and recording unauthorized access to confidential information,” (p. 34).

In addition, the designers of such systems should take into account how individual health records can be shielded and at the same time fulfill the regulatory preconditions instituted by regulatory bodies. Even though rigorous security measures should be put in place to protect the privacy of health information, it is also in the best interest of the patient for the EHR to be available to the authorized personnel for proper and lawful utilization.

Portability of the hardware

The installation of EHRs also raises the issue of the placement of the hardware which in turn raises issues of the portability of the equipment. Because the introduction of an EHR system in an organization will definitely alter the workflow in the organization, the management should determine beforehand on who will have the authority of entering the data and running the systems. In addition, the organization should amend the documentation forms so as to accommodate the changes (Govindan, 2009).

Lack of a common vision and definition of EHR

The introduction and implementation of an electronic health record in an organization requires the change of organizational vision. In essence, the organization needs to have a vision that supports patient safety and quality of healthcare provided. Thus, the lack of a clear and common vision is another challenge inherent in EHRs. The lack of a common vision is related to the lack of a common definition of the term electronic health record. As discussed earlier, this term is understood differently by different healthcare providers and organizations. It is also given different definitions by different organizations and providers.

Because of a common definition of EHR, different organizations develop different visions which adversely affect the implementation of EHRs. Young (2000) argues that “since there are multiple interpretations of what exactly an EHR is, and what the EHR requirements are, users are unable to identify their current and future needs,” (p. 35). Therefore, the lack of a clear understanding makes the users of the technology to experience difficulties in choosing systems that will address their needs. It also creates challenges for the vendors in terms of procuring the appropriate systems. In choosing systems that support their needs, organizations should take caution to ensure that they do not choose a temporary and limited system because it would hinder them from moving towards a universal system. Nevertheless, such universal systems are currently unavailable.

Lack of standardized terminology

Govindan (2009) argues that “another enormous obstacle in the implementation of an EHR is the lack of standardized terminology, system architecture, and indexing,” (p. 2943). A standard language and terminology is important in ensuring that the system can be shared. This also necessitates the development of a unique health identifier. Presently, many vendors exist each with a different software application promising different results.

Hence, it is impossible for data to be shared unless a common interface is created. Regrettably these interfaces are often inaccurate and unreliable. The inclusion of a standardized EHR platform will enable healthcare providers to utilize a variety of the top notch medical applications all of which have a common standard EHR design. The development of a standard language will provide systems with a greater flexibility and the capacity for the varied prerequisites of the diverse healthcare fields. Even though progress has been made in creating individual coding sets for data constituents, none of these standards has come about as a complete standard.

Healthcare providers also need to feel satisfied and comfortable with the standard language. Without this, the healthcare providers will find it difficult to use it to key in data. Because the final objective of an EHR is to enable the organization/healthcare providers to share the data across the organization’s departments, an exceptional health identifier is needed. Unfortunately, the development of this identifier has been both sluggish and challenging. Thus, leadership is crucial in this regard.

Summary and Conclusion

Electronic health records embrace the new and advanced information and technology systems. The adoption of EHRs has been advocated for extensively but the trend remains disappointingly low. EHRs offer numerous advantages for clients, users and organizations in terms of time saving, improved organization, improved communication, privacy, safety, accessibility, risk and financial management.

Nevertheless, EHRs are not without their demerits which include high startup costs, problems with usability, extensive training requirements, lack of a common vision and definition of the term as well as lack of a standard language. In conclusion, although the disadvantages of EHRs are credible, the benefits that organizations reap from implementing EHRs far outweigh the demerits. Moreover, the challenges and obstacles facing EHRs’ implementation can easily be overcome by improving the systems. Organizations should thus focus on the long-term benefits of EHRs rather than their short-term costs.

Reference List

Carter, J. (2008). Electronic health records: a guide for clinicians and administrators. New York: ACP Press.

Govindan, R. (2009). DeVita, Hellman, and Rosenberg’s cancer: principles & practice of oncology volume 1. New York: Lippincott Williams & Wilkins.

Hamilton, B. (2010). Electronic Health Records. New York: McGraw-Hill.

National Research Council. (1997). For the record: protecting electronic health information. New York: National Academies Press.

Young, K. (2000). Informatics for healthcare professionals. Philadelphia: F.A. Davis.

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