Barriers to Implementing an Electronic Health Record (EHR) system

Barriers to implementing an EHR system
Beleow is a list of ten things that are true barriers for most health care organizations today. Please review the list and decide which barrier your organization is facing. The first step is to acknowledge the issue(s) and then you can tackle them head on. Good luck.

#1 Difficulty in adding older records to an EHR system

Today there are organizations that pick a start date and then implement their new EHR system but older paper medical records ought to be incorporated into a patient’s electronic health record. One method of doing this is to merely scan the documents and retain them as images. However, surveys suggest that 22-25% of physicians are less satisfied with records systems that use scanned documents alone rather than fully electronic data-based systems. The reason is that they are hard to read. EHR systems with image archival capability are able to integrate these scanned records into fully electronic health records systems. This method makes the record more complete. Another method is 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. This means that there might be some records that are hard to read. Some states have proposed making existing statewide database data (such as immunization records) available for download into individual electronic medical records. This would make this process easier and more beneficial for the health care provider and the patient.
#2 Long-term preservation and storage of records

Most organizations do not really think of preservation of the EHR record. An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives. Considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.
While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language.
#3 Synchronization of records
When care is provided at two different facilities, it may be difficult to update records at both locations in a coordinated fashion. This is a problem that plagues distributed computer records in all industries. Standardization needs to occur first with medical documents. Synchronization programs for distributed storage models are only useful once record standardization has occurred.
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.
#4 Privacy

Privacy concerns in healthcare apply to both paper and electronic records. Today records can be exchanged over the Internet and they are subject to the same security concerns as any other type of data transaction over the Internet. The Health Insurance Portability and Accountability Act (HIPPA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of implementation of these standard. As the ever-changing healthcare industry evolves, one key topic within the electronic health record (EHR) is privacy. The Federal government has set guidelines that all healthcare organizations will have to comply with in regards to electronic health transactions. Most supporters believe that the EHR will improve care and reduced costs, while transforming the health care system, but whether the privacy of the records will be upheld is yet to be determined. A successful partnership for administrative health data standards can promote the development of clinical data standards and their application in computer based patient record systems.
One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. President Bush calls for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.
According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client’s knowledge or permission.
Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector. Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it. The private sector knows the importance of privacy and the security of the systems and continues to advance well ahead of the federal government with electronic health records.
#5 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. 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. In the past, poor networking technology was a limiting factor in the adoption of EHR software. There are now solutions which profit from new networking and mobile technology.
#6 Cost Advantages and Disadvantages
Most practitioners and healthcare organizations will agree that both quality healthcare and medical error reduction take precedence over many other healthcare concerns. Common knowledge to most, the U.S. allocates a vast amount of funds towards the health care industry. Unfortunately, these distributed funds have not significantly improved the U.S.’s quality of healthcare. The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality. This type of savings will not occur overnight and will require EHR adoption by most healthcare businesses. Obviously, these savings can lead to healthcare quality promotion. In addition, these savings are not limited to businesses alone: If patients are aware of their opportunities, they are more likely to comply with their doctors’ recommendations; thus, reducing future hospital visits and saving money. Despite the advantages, many providers have not adopted EHR due to its expensiveness: The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption. One of disadvantages is that systems crash and experience technical difficulties, which is very costly to repair. Such issues make providers question if EHR is a step they are willing to take. Overall, EHR systems provide more benefits than disadvantages to patients and the economy. These systems can improve savings and the quality of healthcare to a superior level. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR’s cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example, the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians.” If a physician performs tests in the office, it might reduce his or her income. “Given the ease at which information can be exchanged between health it systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used.
#7 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. 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. Vendor costs only account for 60-80% of these costs.
Some proponents of EHR systems suggest that startup costs will be recouped within 3 years. Some physicians 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.
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.
In the United State there a few recently-trained medical professionals but they will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems probably will retire.

#8 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.
#9 Legal barriers
[Liability barriers
Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorney and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception. Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.
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. Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.
In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital’s software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers. In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.
Ownership of electronic records
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? This is an issue that has to work out with a policy and procedure in place to follow.. 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? Another question that often arises is who determines the frequency of “purging” of records?
A patient may store a portion of his/her health records online or with an independent storage service in which case that subset of records is no longer under the control of the healthcare provider. This transfers HIPAA liabilities to the databank that stores the records for the individual. Concerns about loss of data integrity and lessened HIPAA adherence arise, because these records are no longer part of the health record maintained by the healthcare provider.
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. However, a database of electronic signatures must be created as an EHR system is implemented.
#10 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 or you can hire an outside consultant to assist you.
This customization can often be done so that a physician’s input interface closely mimics previously utilized paper forms.
At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized. Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.
Customization can have its disadvantages. There are higher costs involved in implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

Electronic Health Record Insider

EHR Blog

I decided to start this blog because I haven’t found one that addresses the concerns that I have.  My background is in Health Information Management.  I am a Registered Health Information Technician. (RHIT)  Most people have addressed the profession by what they remember when they go to pick up their health records and most people remember us as the Medical Records custodian or keeper of the medical record.  I actually like later title of health information specialist better because we are definitely health information managers.  Health care infromation comes in all shapes and sizes today. The filed is really complex. It takes a person with a great deal of experience to really understand every element  of the business. I have been around medical records all my career life. I love working with medical records.  I have seen the profession change but we are still concerned about quality.

 

I am now seeing the beginning of the transition to the electronic health record (EHR).  I have seen the numbers for implementation slowly increase from the provider’s side but the numbers are still low.  I know that we have a mandate from our former president to have this all in place by 2014.   I know that we are ALL working in the right direction but here are some of things that still surprise me as a health information management specialist.

 

 

• Lack of staff adequately trained to work with an Electronic Health Record  (EHR)
• Lack of education on documentation for providers in order to bill.
• Lack of knowledge on selecting an EHR/EMR

 

Let me address them one by one.  I will start out with the need for more adequately trained staff to work with an electronic health record.  Most people will blame the small numbers of qualified personnel on the fact that true implementation hasn’t taken place yet. The fact is we do not have to learn this skill on the job.  The skill to use electronic health record software should be taught now in colleges and universities across American and not just in a health infromation management program.  Nurses and Doctors need to know how to find their patients on the computer and document in their record online.  Not all nursing programs are offering this type of course.  They are not including online medical records training.  I have not seen a solid curriculum that addresses the issue.  Most colleges do not even allow their students the clinical experience because of the privacy issues and the students would have to go through training at the facility where they are doing the clinical and they are not really there long enough to warrant the extra training.  The onsite instructors still use the paper record for training purposes.

 

There is still a heavy need for education among health care providers (clinicians) for regulatory reasons and billing issues.  I am finding so many facilities delinquent with their paper records or on the issue of having duplicate medical records.  The medical records department has to be cleaned up before successful implementation of an electronic health record can take place.  Training current staff and offering ongoing training is a full time job.  Training doesn’t just begin with the implementation of the electronic health record.  It has to be an ongoing activity. Training is needed with reference to the quality of the documentation, regulatory agency compliance and for billing compliance.  Most large hospitals will have a compliance department but it is really everyone’s responsibility. 

 

The last issue to address is that most medical records directors are not considered an expert at selecting or recommending an Electronic Health Record.  Some of the Health Information Management (HIM) managers have been around long enough to remember when the card system on a conveyor belt was the only way to find out who was in the hospital but that doesn’t mean they are comfortable with computers.  I might add that not every electronic health record vendors is educated to all the processes of a health information department.  It is a challenge to find an HER vendor that is unbiased in their approach.  If they represent the EHR Company and their product, it is hard to be impartial. If you the CEO or the HIM director and you are serious about selecting an EHR/EMR there are different lists of criteria available on the internet on how to select an EMR/EHR but the list is hard to follow when you are responsible for so many aspects of the hospital or HIM department.  If you tangle that element (lack of time) to the element of an aggressive EHR salesperson you might end up with things you did not need at a price the hospital should not be responsible for.  It really means a great deal to do your research, have everyone involved in the process and to have everyone on board when the implementation takes place.

EHR moves forward

Most have heard that Obama’s set the audacious goal of full digital health records by 2014. This is the original target year because President Bush set the original target point.  Will we make it?  I look around and I see so many physicians still using paper records.  I am starting to notice some clinics heading towards the electronic health record but the ones that I see seem to be affiliated with a larger network.  Will the solo practitioner be left out of the loop or the last to come on board with implementing the electronic health record? Transitioning to the electronic health record (EHR) is expensive.  I am not just talking about the cost of the equipment and software but also all of the training that is needed.  Health care practices have a high employee turnover rate to begin with so that means even if the vendor does the initial training that there is still a lot of training left to be done.   The sad point of this is the fact that most employees are not coming equipped to handle the EHR when they walk through the door. They are not trained by a vocational school, college or from a previous employer because the technology is so new. Most employees with go through training on the job.  This training gets watered down from employee to employee over time.  This makes for errors.  Most employees are not really trained on all the functions of the electronic health record system thus leaving a big gap for a decrease in the return on the investment for the organization.

 

Most clinics and hospital employees are so thrilled when they hear that their facility is transitioning to the electronic health record. It is not long after the initial training is complete that most of the staff has lost its zest for the experience.  There is a great deal to consider before transitioning to the electronic health record.  Most managers are not even aware of everything that they need to consider before suggesting or implementing the change to an EHR.  I see so many times especially in small practices and clinics the mentality that the EHR will be the cure for all that ails them inside the facility.  This is not the case.  The EHR is a tool and only a tool. If you currently have physicians that are not completing their records in a timely manor then you will probably have physicians that will still continue to disregard the medical record policies unless they are trained thoroughly.   The physicians and staff will need to overcome a hurdle of resistance and procrastination and build a new healthy habit and appreciation for health information management in its place.  We all struggle with change even though we say we want it.  The top rule for the new manager or champion physician in charge of implementing the EHR is to talk about the change long before arrives.   The success rate will double if everyone is comfortable with the technology and supportive of the concept.  Remember the EHR is a tool so if the census is up, revenue is down and the physicians are not on board, it is probably not a good time to implement a new tool such as an EHR. 

 

Having a background in human resource really helps to understand the dynamics of resistance and how we all react to change.  Not everyone learns by hearing.  Not everyone learns in a formal class room.  Not everyone learns by reading a manual.  Not everyone learns by being shown once or twice.  Everyone learns differently and it is so important to take that into consideration.  Most EHR vendors have a customized and specific way of implementing the electronic health record but are their methods the best way for your organization?  What does the EHR vendor do with those individuals that do not learn the ways others do?  This is where a project manager or physician liaison can come in useful.  I have seen some organizations use the train the trainer approach.  This is a good method unless the person leaves then all the knowledge leaves with them.

 

Yes it is true, our new president will probably take the goal and make sure it is implemented but there are so many questions left unanswered.  I am not just speaking of funding and interconnectivity and interoperatability.  We all know that we need health information standards in place and with that we will probably see new laws proposed but more importantly we all need to be trained. First of all, products have to be thoroughly developed and then tested.  Where do you go to find a good product?  We all know that the vendors claim that there product is the best.  Where can you find an unbiased opinion?  Where can you find a consultant to offer you guidance to the entire process? The next step is that a training assessment needs to be done at your facility.  What are your needs?  Who is going to train the employees on the new software?  What is the skill level at your facility?  You do not always have to rely on the vendor for training. Where can you turn for help?   I hope I have provoked some thought on how to get moving on the transition to the electronic health record.  Good luck.