Electronic Health Records (EHR) is a HIT (Healthcare Information Technology) that is becoming increasingly popular among health care organizations. In its essence, EHR functions as an electronic version of a patient’s medical history that includes critical clinical data relevant to a particular person. However, EHR is not limited by standard clinical data since it provides a broader view of a patient’s care.
According to the Office of the National Coordinator for Health Information Technology (ONC, 2019), one of the key EHR features is creating and sharing health information across multiple health care organizations. As a result, an EHR can potentially contain valuable information from various health care providers and organizations, such as laboratories, pharmacies, specialists, and clinics. Moreover, accurate and complete information is instantly and securely available to authorized users, allowing quick access for more efficient care.
These features make EHR a convenient solution for hospitals that strive to provide a better quality of services for their patients. Larsen et al. (2018) stated that many health care providers became reliant on EHR for viewing records, ordering medications, and receiving support for guiding the care process. Lin et al. (2018) revealed that the adoption of EHRs has a positive impact on mortality rates, although it takes time to realize the beneficial effects. Nevertheless, hospitals represent a type of health care organization with the most extensive experience in developing and implementing EHR technology.
Based on the nature and key features of the EHR, that HIT has a strong potential for a twofold practical application. First of all, an EHR system fulfills a clinical purpose since it helps the hospital staff to diagnose patients more effectively, reduce medical errors, and provide safer care (ONC, 2019). Furthermore, EHRs enhance the quality and safety of prescribing in comparison to paper-based clinical records. According to Larsen et al. (2018), alerts of possible allergic reactions to medications or negative drug interactions are becoming standard in EHRs, and clinicians increasingly use them during prescribing. Overall, the EHRs serve as auxiliary information technology for nursing personnel, assisting them in clinical performance and enhancing the quality and safety of provided care.
Secondly, EHRs provide important administrative support for the hospital’s staff. Graber et al. (2017) highlighted the following administrative advantages of the EHR: access to care, information gathering and access, and organization of information. Most importantly, the EHRs allowed to broaden the site of care; the patient can contact the hospital’s staff without visiting the facility. This feature of the EHR improves communication between the patient and the health care provider, allowing to detect the new health-related issues as they arise.
In addition, EHR created an administrative possibility for innovative care models such as team-based care, in which different clinicians can contribute to clinical documentation (Graber et al., 2017). Previously, such cooperation was not technically viable, and the patient’s care was tied to paper-based health records and a limited number of specialists. Lastly, the EHRs provided the health care workers with an opportunity to organize and display clinical data in more meaningful ways (Graber et al., 2017). The EHR enables hospital personnel to customize documentation or display the data as a graph instead of traditional text. As a result, the EHRs reduce paperwork, introduce new functionalities, and allow immediate and reliable access to all relevant clinical documentation.
An interview with a chief nursing officer (CNO) of one of the local hospitals has been conducted in order to get a better insight into the practical implementation of the EHR technology. According to their words, the health care organization decided to adopt the EHR several years ago. The CNO mentioned several reasons for the EHR development; however, the key arguments for the EHR implementation were the following:
- Quality of care improvement. The hospital leadership deemed it necessary that their organization shows its commitment to the well-being of patients. The EHR allowed to streamline the diagnosis process and aid the staff in prescribing. In addition, EHR provided readily available access to the complete records, thus enabling the staff to check the history of medical interventions;
- Administrative support for the personnel. With time, the staff realized that the EHR is an inherently more convenient system than the old paper-based records. The nursing personnel appreciated the reduction of paperwork and the ability to work at a faster pace. In addition, the EHR created an opportunity for better communication between the clinicians and the patients, shrinking the grounds for misunderstanding.
- Demands of time. The hospital leadership considered that a significant amount of health care organization across the country has already implemented the EHR systems in one or another variant. As a result, the leadership decided to follow the growing trend in order to not fall behind the competition. Therefore, the EHR implementation was a step forward undertaken to hold the current position and uphold an image of a respectable health care organization;
The CNO gave the most credit for the EHR development and implementation to the nursing leaders of their organization — the informatics nurses. The initiative belonged to the CNO, who gave the green light for the project; however, the informatics nurses developed a proposal for the hospital administration based on the relevant research data. Throughout the EHR implementation process, they served as a link between the line nursing personnel and the hospital leadership.
The informatics nurses assessed the situation, identified the issues, and shared their knowledge with their colleagues. The CNO themselves acted as an overseer and manager, while the informatics nurses handled the technical aspects. Overall, the needs for the EHR implementation were determined by analyzing the daily working experience of the line personnel and accessing the pre-existing researches on that account.
The use of workflows and staff opinions was crucial for conducting the assessment. As with any HIT, the eventual success of the EHR implementation depended on the support of the line nursing personnel. Therefore, the informatics nurses had to create a roadmap for the EHR development and convince the line staff to support the changes. The CNO determined several people among the personnel who were appointed to the key positions of the EHR implementation team.
In addition, the key stakeholders were defined, primarily from the hospital staff members and the various organization’s departments. By the CNOs initiative, the informatics nurses headed by the Chief Nursing Informatics Officer (CNIO) prepared surveys and organized the brainstorming sessions for the initial gathering of information from the key stakeholders. It was necessary to determine why to use the EHR, who exactly will be using it, who will require access, and if there is a need for extra functionality.
After gathering the information from the key stakeholders, the chief analyst selected from the ranks of informatics nurses prepared a detailed report that contained a list of needs expressed by the personnel. According to those needs, the CNO deemed it necessary to proceed with the EHR implementation. The personnel showed a general dissatisfaction with the amount of paperwork in the care process. That notion served as a deciding factor in favor of the EHR. Most commonly, the clinician stakeholders wanted to improve communication with their colleagues and limit the amount of time spent on working with documentation, especially for obtaining the relevant information from the health records.
The functionality of the EHR system seemed to be an effective and modern solution for these problems. In addition, the existing empirical evidence of the EHR practical application helped determine its usefulness for clinical purposes. Finally, the growing presence of the EHR technology in American health care organizations determined the need for implementation from the hospital’s image point of view.
Currently, the key stakeholders and beneficiaries of the implemented EHR system are the members of the line nursing personnel who use it on a daily basis. However, the EHR management is conducted by the representative of the so-called actor’s schema — the Electronic Health Records manager. The EHR manager is an informatics nurse working under the supervision of the CNIO, who in turn reports to the CNO. Their primary working tasks include overseeing work activities of the medical records department, supervising the release of information in accordance with security regulations, and training of staff in EHR use. In addition, the EHR manager works in close connection with the billing department, assisting with budget planning and financial reporting.
The technical aspects of the EHR support and management are left for the IT services company since the annual in-house maintenance cost of the EHR is quite significant. Moreover, the IT professionals possess a much greater experience in technical support of the EHR systems, so the hospital leadership decided to use their expertise and leave only the day-to-day operation for the personnel. Informatics nurses know how the EHR works and share it with the line nursing staff; however, they do not take responsibility for the ongoing technical maintenance. According to the hospital’s CNO, the external IT partners offer “a valuable speed and stability by providing timely support, security and data backup.” Besides, the hospital leadership did not want to add extra tasks to the already difficult job of the informatics nurses.
Overall, the hospital uses a combination of local resources and external partnerships for managing the implemented EHR system. The hospital’s Department of Informatics handled the purchasing and implementation of the EHR. The informatics nurses oversee the daily operation of the EHR system and train the line nursing personnel on how to use it. However, the technical support and maintenance duties have been outsourced to the IT services company since that was the most cost-efficient course of action in terms of finances and professional experience. An easy and downtime-free operation was one of the biggest concerns expressed by the key stakeholders, which was addressed mainly by cooperation with experienced IT specialists.
In general, the hospital leadership paid significant attention to the wishes, demands, and requirements mentioned by the predetermined key stakeholders. According to information from the hospital’s CNO, the personnel of the Department of Informatics identified four major groups of stakeholders whose decisions meant the difference between success and failure of the EHR performance. Therefore, the opinions of those people had to be considered during the system’s implementation.
The clinician stakeholder group included physicians and nurses — the frontline personnel of any health care organization. Since these people were expected to work with the EHR daily, it was extremely valuable to receive their positive input and support. According to Laukka et al. (2020), supporters represent the most common and important part of decision-makers. In that regard, the hospital’s CNO made a wise choice by showing their interest in the clinician’s needs. The hospital’s leadership could have forced the changes from above; however, such a forceful implementation could have faced a silent resistance and decreased the EHR effectiveness. Instead, the attentive approach swayed the clinicians in favor of the EHR and made them more welcoming to the changes.
The considerations applied to the clinician stakeholder group were also extrapolated on the office staff. These people were deemed important since they are responsible for filling the patients’ contact, billing, and demographic information. Therefore, the CNO decided to obtain feedback from them, as this stakeholder group could provide additional support for the EHR implementation and offer an insight into improving the EHR in various regards. As it turned out, the office staff was eager to reduce the amount of time spent entering the information and channeling the patients to clinicians.
The Billing Department was a vital stakeholder since it is responsible for dealing with payment for services and insurance claims. Therefore, the CNO included the billing staff in the focus group for surveys. In return, the Billing Department decided to support the EHR, which would consist of specific workflows, such as real-time data access, electronic claim submission, verification, rejection, and payment tracking. The Billing Department was willing to receive assistance in its daily operations, and the implications of the EHR implementation looked promising in that regard.
After gathering support from the three key stakeholder groups mentioned before, the CNO addressed the last but probably the most important stakeholder — the Administration. They had to carefully present the evidence in favor of the new EHR system since the Administration had the deciding role in management and finances. In that regard, the support from the Billing Department was especially valuable since it equipped the CNO with promising information on the potential Return on Investment (ROI) in EHR. In addition, the CNO approached Administration before making the final selection of the EHR and provided several options with regard to other stakeholder’s opinions. By doing that, the CNO showed Administration that their judgment is highly respected and valued.
Therefore, the end-users of the EHR technology were directly involved in its implementation. Moreover, end-user stakeholder’s opinions and decisions were crucial for the eventual success since their input allowed the CNO to conduct a preliminary selection and present the meaningful results to the Administration. Due to support from the majority of stakeholders, the CNO managed to achieve a critical mass and convince the most influential decision-maker in the chain. The CNO’s leadership was essential; however, it would have been difficult to succeed if other stakeholders were neglected.
Regardless of the reasons behind the EHR implementation, this technology has become a standard attribute of modern health care organizations. By 2017 80,5% of the American hospitals had adopted at least a basic EHR system (Adler-Milstein et al., 2017). Therefore, the ability to operate the EHR logically became one of healthcare workers’ most critical professional competencies. Nursing specialists create special guidelines for avoiding malpractices or adverse events during the use of the EHR. For example, Balestra (2017) provided a comprehensive list of recommendations for nursing practitioners, which includes the following key tips for navigating an EHR, among the many others:
- Completion of a basic training course and participation in all training updates;
- Advocating for regular staff meetings for discussing the issues with the HER;
- Requesting a basic written manual for the use of the system;
The hospital’s CNO confirmed that the informatics nurses are responsible for training the clinicians and billing staff in using the EHR. Sharing the knowledge on how to operate the system properly has become one of their essential tasks. The Department of Informatics has developed an internal user manual for the staff. In addition, the informatics nurses regularly oversee that all staff members who operate the EHR are fully aware of possible liabilities and know how to work with the system as it was intended. The lack of knowledge and comprehension can lead to undesirable consequences for the patients, EHR users, and healthcare organizations. Therefore, the Department of Informatics pays special attention to incorporating recommended practices in the day-to-day EHR operation.
The EHR demands accuracy and knowledge from the users to facilitate in achieving the needs of the organization. However, the EHR technology poses unique concerns in terms of cybersecurity due to the large concentration of valuable personal health information. In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which stressed the importance of patient privacy and protection of sensitive information (McDermott et al., 2019).
The spread of EHR required health care organizations to implement three measures to safeguard patient information: administrative policies, restriction of physical access, and technical safeguard (Kruse et al., 2017). These measures were meant to prevent cybercrime in healthcare, which was increasing at a rapid rate. According to McDermott et al. (2019), in the first half of 2015 alone, health care organizations reported 187 security breaches that compromised the personal data of eighty-four million patients. Therefore, the EHR demands addressing security issues along with the general training of personnel in day-to-day operation.
The hospital CNO admitted that security concerns remain one of the crucial aspects of EHR operation. The hospital leadership strives to protect patient information from all three major sources of threat. Administrative measures include periodic IT audits, the development of clear administrative policies regarding security threats, and training of staff members in security matters. Physical security is addressed by properly disposal of paper documents and keeping track of personal devices such as laptops and phones.
Finally, the possible technical security breaches are handled by the Department of Informatics and IT service company that maintains the hospital’s EHR. The IT professionals educate line personnel in computer competency, identification of possible cyber-attacks, and reaction to them. Overall, the combination of these three steps creates a framework for legally sound health care.
Implementation of the EHR technology in the USA went quite differently from the rest of the world. Initially, the US health care adopted a “bottom-up” approach, where each local organization transforms or develops information systems (Fragidis & Chatzoglou, 2018). However, that approach had been gradually switched to a “middle-out” approach, where local providers adapt their systems to comply with new national standards (Fragidis & Chatzoglou, 2018). Nevertheless, the transformation from paper-based health records to the EHR was funded from the hospital’s resources since the U.S. health care system is financed privately, except for Medicare and Medicaid programs.
All EHR budget-related matters, such as funding of its maintenance and updates, are managed by the key stakeholder — Administration, with the assistance of the Billing Department. The Administration has the final word in allocating funds; however, the costs of EHR technical support are calculated by the specialists from the Department of Informatics. Those staff members prepare reports for the hospital’s CNIO and CNO, which are presented for the Administration subsequently. After that, the Administration decides what amount of funding is available for the EHR needs and which issues should be prioritized.
In addition to possible errors caused by the lack of knowledge or human factor and cyber-security issues, the EHR demands s special attention in case of planned or unplanned downtime. Larsen et al. (2019) noted that downtime events could have varying impacts on an organization’s performance, from barely noticeable to completely disruptive. According to the hospital’s CNIO, the organization has not faced an unplanned or total EHR downtime yet; however, planned partial downtimes happened several times as a part of a system update.
Due to close cooperation with the EHR vendor and hospital’s IT partners, the organization had developed a set of arrangements in case of downtime. Firstly, the organization introduced a comprehensive EHR downtime response act for the staff members, which ensured care delivery regardless of the EHR condition. Secondly, the administration ran several EHR downtime simulations in order to evaluate personnel readiness. Lastly, the hospital’s leadership had developed a downtime contingency plan to ensure the continuity of operations on all organizational levels.
Since the EHR updates often result in downtime, the hospital developed a plan to schedule and conduct the upgrades. The main purpose of this plan is the reduction of downtime period and prevention of workflow interruptions. First of all, the update starts with the formulation of tangible and measurable goals used to identify the needed functionalities. The hospital does not try to be among the pioneers. On the contrary, the Department of Informatics learns from the experience of organizations that upgraded their EHR before. After that, the informatics nurses identify possible risks related to the update and develop a plan of action. Finally, the Department of Informatics creates two checklists: a downtime checklist that informs the staff what will happen during the update, and a restart checklist, which describes what needs to be done after restart. Overall, the hospital leadership prefers a smooth operation of the EHR and does not make updates for the sake of making them.
The EHR technology has significantly evolved due to changes in health care legislation. The initial pace of EHR adoption was slower than desired, which resulted in the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Passed by Congress in 2009, this act created incentives for the Meaningful Use of the EHR (Rathert et al., 2019). The Meaningful Use program encouraged health care organizations not simply to adopt the EHR systems but utilize them meaningfully. According to Wani and Malhotra. (2018), the Meaningful Use program includes the following key concepts:
- Electronic capturing of patient information in a standardized format;
- Using patient information for tracking key clinical conditions;
- Integrating and utilizing the decision support tools;
- Communicating with health care providers with a purpose of care coordination;
- Reporting the key clinical quality measures;
- Using the gathered information to engage the patients and their families in the care process.
In addition to these first stage requirements, the health care organizations were obliged to reach certain numbers in EHR performance. For instance, the hospitals were required to maintain diagnoses, medication, vital statistics, and drug checks electronically for at least 80% of the patients (Wani & Malhotra., 2018). In addition, the hospitals were supposed to provide electronic copies of health records and discharge instructions for at least 50% of patients (Wani & Malhotra 2018).
As a result, the EHR systems in health care have become increasingly sophisticated and challenging in implementation and operation. By 2014, only 2% of U.S. hospitals could meet the Meaningful Use criteria (De Angelis, 2014, as cited in Rathert et al., 2019). The financial incentives promised by the government were sufficient only to promote the adoption of the basic EHR forms.
Given the complicated situation around adopting the EHR Meaningful Use, the related legislation could be amended to assist the health care organizations. Rathert et al. (2019) suggested several options for improving the pace of Meaningful Use implementation. Firstly, the legislation could provide the EHR vendors an incentive to enhance the interoperability of their products. According to Rathert et al. (2019), the lack of interoperability was the key negative element in EHR operation.
Secondly, the legislation should take into account the feedback from the clinicians who use the EHR every day. Finally, the legislators could study workarounds utilized by the frontline EHR users in their practice. Studying the workarounds could be challenging since personnel would be reluctant to share them without feeling safe (Rathert et al., 2019). However, the focus on workarounds as a learning tool could potentially make the EHR safer and provide an insight into the unwillingness of the proper EHR use shown by the hospitals and their staff.
The EHR tailored to the basic compliance with the Meaningful Use program utilizes several innovative applications. Wani and Malhotra (2018) provided a list and description of EHR elements needed for Meaningful Use:
- Clinical Data Repository (CDR): this application stores real-time data on demographics, hospitalization history, problem list, medication, and allergy list;
- Clinical Decision Support (CDS): used for generating recommendations for patient care according to evidence-based guidelines;
- Computerized Physician Order Entry (CPOE): enables clinicians to change medications and lab tests or access notes left by the colleagues;
- Electronic Medication Administration Record (eMAR): coupled with the CDS, this application ensures that a patient is given the correct medication in a correct dose at the right time;
- Nursing Documentation: used for keeping track of nursing interventions and communication with other care providers;
- Ancillary applications: stores patient information related to radiology, laboratory, and pharmacy
Widespread use of electronic applications defines the innovative nature of the EHR. However, the Meaningful Use implies a full-scale EHR assimilation rather than implementation, which could be challenging for smaller organizations. As a result, not every hospital goes beyond installing the basic applications. The hospital’s CNIO admitted that their organization had not implemented a complete set of the Meaningful Use EHR components due to financial considerations. Nevertheless, eventual compliance with the Meaningful Use guidelines is set as a strategic goal of the nearest future.
The legislative push for EHR assimilation would likely become more robust in the upcoming years since the government already put a significant effort into accelerating HIT adoption. Considering the information obtained from the hospital’s CNO and CNIO, it seems reasonable to recommend staying on the current path and gradually adjust the organization’s EHR to the Meaningful Use requirements. So far, the organization has shown a careful, logical, and strategic approach to implementing and upgrading the EHR. Therefore, the progressive pursuit of eligible professional objectives set by the Centers for Medicare & Medicaid Services (CMS, 2020) would be a recommended course of action. Following that way would allow meeting the Meaningful Use requirements without disrupting the hospital’s activity.
Overall, the hospital’s use of the EHR technology seemed to be quite efficient. While staying within a reasonable budget, the hospital leadership did not neglect the EHR implementation. However, since the organization has not fulfilled all the Meaningful Use requirements, it seems appropriate to formulate a nursing report before implementing the remaining components of the EHR. According to McBride et al. (2017), nurses play a critical role in shaping the HIT. Therefore, a proper assessment and report conducted by the Department of Informatics would greatly assist in upgrading the hospital’s EHR system. Meeting the Meaningful Use criteria would eventually improve the quality of provided care and the hospital’s reputation, which in turn could result in greater commercial efficiency.
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