What is the purpose for having electronic or paper based filing systems in the medical office?

This article is an interpretive critical review essay aimed to critically assess the possible transition of a fictional health center from using a traditional paper-based record system to an electronic health record (EHR) system. This paper is constructed in two parts, the first identifies the benefits, general adoption and uses of the electronic health record from recent reports in current studies, with the aim to justify the need for its implementation and transition from the paper based system. The second part would review the challenges experienced during EHR implementation efforts as described in evaluatory studies.

Search Strategy

Articles for this review were sourced by searching GOOGLE SCHOLAR, PUBMED, AND ABI/INFORM GLOBAL databases from 31st of January 2018 to 7th of February 2018. The keywords used for the search were “EHR”, “Electronic Health record” AND “Uses” OR “Adoption” OR “benefits”; “EHR Challenges”; “EHR OR Electronic Health Records Implementation”. Search limits were placed on articles between 2010-2018, only articles written in English and original journal articles were considered.

Justification

Relevant primary sources for this review were selected using the approach as described by (Keshav, 2007). The review of articles for relevant content was done in four phases.

Phase 1. Search for relevant articles in the electronic databases listed above using the keywords indicated above.

Phase 2. Carefully reading the title, abstract, keywords and conclusion and determining relevance, articles not deemed to be relevant were discarded

Phase 3. More in-depth reading of the articles that were not eliminated in phase two, to grasp the content of the article, to determine its relevance and if the article should be added to the review.

Phase 4. Screening through the reference list of articles selected in phase 3, identifying possible studies that could be added to the review and screening them through phase 1 to phase 3 to ascertain relevance to the study.

Only primary sources that were written in English, published between 2010-2017 and which contained content relevant to the topic of electronic health records, its challenges, benefits, use, and adoption were used in this literature review.

PART 1: The Need for an Electronic Health record.

1. Introduction.

Transitioning from a traditional paper based system to a digital record system is difficult. (McAlearney, et al., 2014) (El Mahalli, 2015) suggested that the transition should be treated as a change project because of the complex organizational, social, legal, and technical factors involved and concluded that all associated stakeholders must be involved in all stages of the change process for implementation to be successful. Therefore, to ensure a seamless, successful and sustainable transition, leaders of the change process must consult and identify key findings from published literature of prior health information transition efforts, to plan and predict factors limiting or promoting adoption and the possible challenges they might face in implementation.

1.1.Background.

A medical record is an account of a patient that contains information regarding his/her presenting symptoms, with comments from the physician or other healthcare practitioners detailing their observations as well as discussions with the patient (Al-Aswad, et al., 2013). The history of medical records can be dated back to the ancient Egyptians were details of people’s medical history were carved on walls in hierographic, and more recently to the 5th Century B.C where Hippocrates kept a description of the first formal medical record (Al-Aswad, et al., 2013). Currently, information collected in a medical record includes demographic information, medical history, medication and allergies, immunization status, laboratory test results, radiology reports vital signs as well as billing information.

Traditional paper-based record system as the name implies involves recording patient’s health care information using physical means like paper, films, discs and storing this recorded information in physical storage facilities to be retrieved when needed. On the other hand, Electronic health records (EHR) which is sometimes used interchangeably in literature as Electronic medical records (EMR) or Electronic Patient record (EPR) is part of an evolving concept involving a wide range of information systems. It is a representation of the data that would have been originally found in the paper-based record in a digital or electronic format. An EHR is a longitudinal, cross-sectional, comprehensive and systematic collection of electronic health records of individual patient’s, created and gathered across more than one healthcare organization, managed and consulted by licensed clinicians and staff (Al-Aswad, et al., 2013) (Grossman, et al., 2016) (Slaveykov, et al., 2013).

The worldwide movement to switch from traditional paper records to Electronic Health Records(EHR) system is mostly driven by the many challenges experienced with paper-based systems, involving the storage of medical records (requiring large physical storage spaces to house the records, radiological films and reports), retrieval and transfer ( physical nature of these records presents challenges in retrieving or transferring records from one provider to another), safety, loss, destruction or deterioration of medical records, efficiency limiting, cost, environmental unfriendliness etc.

This transition to an electronic method of recording patient data was first seen in 1821 when the Massachusetts General hospital started recording admissions electronically, improvements continued in successive decades until the 1960’s when the first idea of an EHR was first introduced (Al-Aswad, et al., 2013) (Slaveykov, et al., 2013) and there has been successive growth and improvement in the systems capabilities since then (Chao, et al., 2013). Currently, an electronic health record system is seen as a means to improve quality, efficiency and safety, collect data and survey disease. For this reason, the American academy of paediatricians encouraged the use of EHR systems and state that its use is a “mark of professionalism” (Lehmann, 2015). However, despite the generally perceived role of EHR in improving the quality of clinical practice, there has however been a slow adoption of electronic health record system worldwide and understanding the reason for this is necessary for individual implementation efforts (Abramson, et al., 2012).

1.2. Electronic Health Records Systems Adoption.

Generally, there has been a slow but steady increase in the adoption of electronic health care systems around the world, though its rising popularity does not match its rate of adoption. Understanding these adoption rates and the factors associated with its decrease or increase is crucial to promoting further use.

In the United States of America(U.S.A), the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in 2009 to rapidly encourage the adoption and use of EHR systems, the Act authorized Medicare and Medicaid to provide incentives to healthcare providers that demonstrate they are meaningfully using certified EHR systems meeting certain objectives (Abramson, et al., 2012) (King, et al., 2014) (Gabriel, et al., 2014). Before the Act, several studies reported very low rates of EHR and other health information systems adoption across the country, (Yoon, et al., 2012) reported that in 2008 only 1.5% of acute care hospitals had a comprehensive EHR and just an additional 7.6% had a basic EHR, which is similar to what was reported by (Abramson, et al., 2012) that before this time only 11.9% of U.S.A hospitals had adopted an EHR system. After the Act, studies done in different regions in the U.S.A showed an increase in adoption rates, with (Hsiao & Hing, 2014) reporting a 336% increase in the percentage of physicians that reported having an EHR system that meets the criteria for a basic system from 2006 to 2013. This highlights the importance of government or federal initiatives in aggressively promoting EHR adoption by physicians.

Similarly, in the United Kingdom (U.K) after the NHS remarkably failed to meet the 2005 target to implement electronic medical records in all trusts across the U.K and realization that only 3% of all trusts had achieved this target by 2002, £2.7 billion was invested in a new national program for information’s technology (NpfIT)- the biggest I.T program in the history of the NHS- in response (Al-Aswad, et al., 2013). However, despite this, the NpfIT experienced several challenges in implementation and the National Audit Office described the NHS ambition as “unrealistic and complex” and failing to represent value for money, but despite the critics the Department of Health maintained that the project had the potential to deliver value for money. The patience paid off, because by 2012 about 97% of primary care physicians indicated that they now use electronic medical records ( Schoen, et al., 2012) .

In these two countries, visible improvement in adoption of health records systems was appreciated after federal interventions to improve adoption and use. However around the world, several studies have reported increasing rates of adoption and use with or without federal interventions which could be translated to mean that the improving adoption of EHR systems might just be due to the perceived benefits of its use and the evolution of healthcare service delivery, not particularly limited to federal initiatives or interventions (Al-Aswad, et al., 2013) (Abramson, et al., 2012) (Yoon, et al., 2012) ( Schoen, et al., 2012). Even though there is a visible rise in adoption rates around the world, this progress has been slow, and several factors have been reported to either limit or promote the adoption of electronic health records in medical service.

One important factor reported in literature is the purchasing price, coordination, monitoring, upgrade and governance costs involved in implementation (Abramson, et al., 2012) (Wang & Biedermann, 2012) (Ajami & Bagheri-Tadi, 2013). A common association seen was that anything that reduces the burden of the cost of implementation and maintenance ultimately improves the chance of adoption. For example, hospitals that had the support of a larger health system or where involved in group EHR purchasing program (where hospitals or practices pull together resources to purchase electronic systems from vendors, leading to a lesser price and increased ability to overcome the financial challenges) had higher adoption rates than hospitals who did not (Gabriel, et al., 2014), and were also associated with higher health information exchange because of their presence in a group network (Abramson, et al., 2012).

Also, non-profit hospitals and hospitals with >40% of public insurance were also more likely to adopt an EHR, this might be because non-profit hospitals have lower tax requirements and therefore more financial buoyancy to invest in health information systems (Gabriel, et al., 2014) (Lehmann, 2015). Furthermore, the size and the type of the hospital was also reported to be associated with the level of adoption, large hospitals, multi-speciality practices and health maintenance organizations were reported to have higher EHR systems adoption when compared to contrasting types like small hospitals or primary care physicians (Yoon, et al., 2012) (Lehmann, 2015) (Grossman, et al., 2016) (Menachemi, et al., 2011).

In a similar light, the uncertainty about return of investment after procurement and implementation of an EHR system is a factor reported in several studies regarding adoption levels, most providers are worried that the EHR system might just be a white elephant project too expensive to manage or maintain, and some are worried that even after implementation their system can become obsolete because of the rapid growth of technology, leading to a need to upgrade, integrate add-ons or even change systems all concluding into increased cost (Rao, et al., 2011) (Lehmann, 2015) (Yoon, et al., 2012).

In addition, sources (Menachemi, et al., 2011) (Grossman, et al., 2016) (Gabriel, et al., 2014) (Wang & Biedermann, 2012)show that the presence of hospitals in a rural environment also predisposes to lower adoption rates when compared to hospitals in urban or sub urban areas and this could also be due to the fewer available resources in rural areas (Wang & Biedermann, 2012) (Xierali, et al., 2013).

Another factor crucial to adoption is the user factor. Physicians are the chief users of EHR systems and they have a great impact on the overall level of adoption of this system. Characteristics involving, physician age, lack of skill to operate the system, perception of usefulness, have all been shown to affect the level of adoption in one way or the other. For example, reports show that younger physician have higher adoption levels than older physicians which might be due to the fact that they tend to be more technologically skilled/ savvy that their older colleagues (King, et al., 2014) (Menachemi, et al., 2011).

Finally, the design of the EHR system was a factor expressed in literature that could limit adoption rates. Most EHR vendors have been reported to use the “one size to fit all” strategy when producing an EHR system, but in cases of sub specialities like ophthalmology or paediatrics where specific system requirements are needed to record crucial information (like immunization status, growth chart, eye examination, etc.) which are not routinely captured in institution-wide EHR systems, they find it difficult to select an EHR system that is suitable or that meets the practice needs (Lehmann, 2015) (Yoon, et al., 2012) (Redd, et al., 2014) (Rao, et al., 2011).

1.3. Benefits of an Electronic Health Record.

The potential of an electronic health record system to improve quality, productivity and efficiency in the health care service system is well documented. However, with the relative ease to implement and maintain a paper-based records system and the smaller required cost to implement it, change leaders seeking to transition a hospital from a paper-based system to an electronic system need to assess the benefits and determine if the change would be positive to the growth of the organization. In fact, because of the immense cost to implement an EHR system, in many developing countries the EHR is seen as just a supporter of the paper-based system (Al-Aswad, et al., 2013).

However, despite the cost, the ability of an electronic health record to reduce errors and improve the quality of service provided to patients by ensuring and increasing patient safety is well reported in literature (Redd, et al., 2014) (El Mahalli, 2015). Furthermore, because patient’s clinical information, medication lists, demographic information etc. in traditional paper-based records are all documented by hand there is an increased risk of misinterpretation of the information written, in cases when the handwriting is not visible or even spelt right patients could receive the wrong medication or treatment or be given drugs that they are allergic to because it was not legible, leading to an adverse drug event. To emphasise, the Harvard medical practice study reported that 58% of adverse events were due to errors and were preventable, whereas just 19% were due to drug complications. Therefore, health information systems like EHR provides a more effective means of communicating and managing patient’s medical records, reducing errors and improving patient safety (Ajami & Bagheri-Tadi, 2013).

In addition, EHR systems eliminate the need for large storage houses needed to house paper records and films in the past (Chao, et al., 2013). Patient files and information can now be stored electronically in databases and assessed online by whoever is authorized to access the information. This capability of an electronic record system to record and store patient’s information online opens the door to many benefits, for example patient’s information can be accessed online at any point of the clinical pathway, clinicians now do not need to wait for the paper copy of lab results or radiological images before making decisions- this information can now be accessed online in a timely manner ensuring decisions are made quicker and more efficiently while also reducing the patients length of stay in the hospital.

Also, the EHR improves communication between departments and enhances multispecialty management of a patient, because the information is online multiple specialties can access the patient’s files at the same time. In addition, in comparison to paper-based records in terms of exchange or transfer of patient’s health information from one hospital to the other, the EHR allows for quicker, faster information exchange between hospitals instead of copying, duplicating and then transporting these records physically. Ultimately, the current drive for electronic health records is capable of providing patient’s the ability to access and possibly transfer their own medical information, allowing patients to be more involved in their own care and control of their medical data (Chao, et al., 2013) (King, et al., 2014) (Rao, et al., 2011) (Redd, et al., 2014).

Lastly, information documented by electronic health records most times is in a structured format, this allows researchers to easily extract data to carry studies, and also enables easier access to information for disease surveillance, which demonstrates the capability of EHR systems to improve the body of knowledge through research and promote public health surveillance (Chao, et al., 2013) (Grossman, et al., 2016) (Slaveykov, et al., 2013).

1.4.What are the reported uses of electronic health records?

The use of the available functionalities of EHR improves the quality of services offered to patients and reduces errors in medical practice, to ensure effective use of an EHR the system must be used meaningfully (El Mahalli, 2015). For this reason, the HITECH Act incentivises physicians through payment from Medicaid and Medicare for meaningfully using EHR while also penalizing practices not making meaningful use of EHR systems in their practice (Menachemi, et al., 2011). This Act gives a framework of what functionalities EHR systems should have and what they should be used for.

Firstly, medical practitioners can use the EHR system through the computerized provider order entry(CPOE) to order for patient medications, laboratory and radiological investigations electronically, without having to fill time wasting, laborious forms. Importantly, due to the electronic nature of the information the system can crosscheck prescribed medications with already documented patient allergies and medications, preventing drug adverse events. Also, the system can also perform sanity checks of the prescribed dosages of medications with what is required to ensure suitability and adequacy (Slaveykov, et al., 2013).

In addition, an EHR system records demographic information of patients making it possible to perform research involved in analysing the association of disease to these demographic factors. Also, in cases of epidemics an EHR system can help public health authorities identify the areas affected from the presenting patients and the specific groups associated with the disease (Slaveykov, et al., 2013).

Furthermore, the EHR system is also s provide decision support to clinicians, providing them with clinical guidelines to enable them to make faster and more accurate diagnosis of presenting cases. This capability has been shown to improve the efficiency and productivity of clinicians when applied to clinical practice (Slaveykov, et al., 2013) (He, et al., 2014).

Additionally, the EHR system can also be used as an administrative tool, monitoring patient admission and discharge while also recording treatment performed and necessary information for billing and disease-price coding. As a matter of fact, (Wang & Biedermann, 2012) reports that the finance functionality of EHR systems is the most utilized and administrative functions are more utilized than clinical functions.

Equally important, the EHR system has been shown to be used effectively as a safe communication network between physicians while also allowing communication between doctor and patients, enabling better physician-patient interaction and better quality of patient care (Blumenthal & Tavenner, 2010).

Finally, electronic health records can be used to compile disease specific lists or risk factor specific lists (e.g. smoking status) or intervention lists to be transmitted to the appropriate registries. For example, electronic data of immunization status of paediatric patients can be compiled and transmitted to immunization registries through the EHR system (Lehmann, 2015).

PART 2 of this literature review will be published in another article.

What is the purpose of having electronic medical record?

What is a benefit of using electronic medical records instead of traditional medical records?

Why is electronic health records better than paper?

Is it better to have paper or electronic health records?