Institute of Medicine’s Vision for EHRs
The history and significance of the Institute of Medicine (IOM) is detailed in chapter 1. They have published multiple books and monographs on the direction US Medicine should take, including The Computer-Based Patient Record: An Essential Technology for Health Care. This visionary work was originally published in 1991 and was revised in 1997 and 2000.6 In this book and their most recent work Key Capabilities of an Electronic Health Record System: Letter Report (2003) they outline eight core functions all EHRs should have:
- Health information and data: In order for the medical profession to make evidence based decisions, clinicians need a lot of accurate data and this is accomplished much better with EHRs than paper charts; if you can’t measure it, you can’t manage it.
- Result management: Physicians should not have to search for lab, x-ray and consult results. Quick access saves time and money and prevents redundancy and improves care coordination.
- Order management: CPOE should reduce order errors from illegibility for medications, lab tests and ancillary services and standardize care.
- Decision support: Should improve overall medical care quality by providing alerts and reminders.
- Electronic communication and connectivity: Communication among disparate partners is essential and should include all tools such as secure messaging, text messaging, web portals, health information exchange, etc.
- Patient support: Recognizes the growing role of the internet for patient education as well as home telemonitoring.
- Administrative processes and reporting: Electronic scheduling, electronic claims submission, eligibility verification, automated drug recall messages, automated identification of patients for research and artificial intelligence can speed administrative processes.
- Reporting and population health: Healthcare needs to move from paper-based reporting of immunization status and bio-surveillance data to an electronic format to improve speed and accuracy.35
Electronic health record key components
Many current EHRs have more functionality than the eight core functions recommended by IOM and this will increase as time goes by. The following components are desirable in any EHR system. One of the advantages of certification for Meaningful Use is that it helped standardize what features were important. The following are features found in most current EHRs:
- Clinical decision support systems (CDSS) to include alerts, reminders and clinical practice guidelines. CDSS is associated with computerized physician order entry (CPOE). This will be discussed in more detail in this chapter and the patient safety chapter.
- Secure messaging (e-mail) for communication between patients and office staff and among office staff. EHRs will likely include messaging that is part of the Direct Project, explained in the chapter on health information exchange. Telephone triage capability is important.
- An interface with practice management software, scheduling software and patient portal (if present). This feature will handle billing and benefits determination. This will be discussed further in another section.
- Managed care module for physician and site profiling. This includes the ability to track Health plan Employer Data and Information Set (HEDIS) or similar measurements and basic cost analyses.
- Referral management feature
- Retrieval of lab and x-ray reports electronically
- Retrieval of prior encounters and medication history
- Computerized Physician Order Entry (CPOE). Primarily used for inpatient order entry but ambulatory CPOE also important. This will be discussed in more detail later in this chapter.
- Electronic patient encounter. One of the most attractive features is the ability to create and store a patient encounter electronically. In seconds one can view the last encounter and determine what treatment was rendered.
- Multiple ways to input information into the encounter should be available: free text (typing), dictation, voice recognition and templates.
- The ability to input or access information via a smartphone or tablet PC
- Remote access from the office, hospital or home
- Electronic prescribing discussed in a section to follow
- Integration with a picture archiving and communication system (PACS), discussed in a separate chapter
- Knowledge resources for physician and patient, embedded or linked
- Public health reporting and tracking
- Ability to generate quality reports for reimbursement, discussed in the chapter on quality improvement strategies
- Problem summary list that is customizable and includes the major aspects of care: diagnoses, allergies, surgeries and medications. Also, the ability to label the problems as acute or chronic, active or inactive. Information should be coded with ICD-9/10 or SNOMED CT so it is structured data.
- Ability to scan in text or use optical character recognition (OCR)
- Ability to perform evaluation and management (E & M) determination for billing
- Ability to create graphs or flow sheets of lab results or vital signs
- Ability to create electronic patient lists and disease registries. Discussed in more detail in the chapter on disease management
- Preventive medicine tracking that links to clinical practice guidelines
- Security and privacy compliance with HIPAA standards
- Robust backup systems
- Ability to generate a Continuity of Care Document (CCD) or Continuity of Care Record (CCR), discussed in the data standards chapter
- Support for client server and/or application service provider (ASP) option 36
Computerized physician order entry (CPOE)
CPOE is an EHR feature that processes orders for medications, lab tests, imaging, consults and other diagnostic tests. The majority of articles written about CPOE have discussed medication ordering only, possibly giving readers the impression that CPOE is the same as electronic prescribing. The reality is that CPOE has a great deal more functionality as will be pointed out later in this and other chapters. Many organizations such as the Institute of Medicine and Leapfrog see CPOE as a powerful instrument of change. There is limited evidence that CPOE will reduce medication errors, cost and variation of care. This is discussed in the following sections.
Reduce medication errors
CPOE has the potential to reduce medication errors through a variety of mechanisms.37 Because the process is electronic, users can embed rules (clinical decision support) that check for allergies, contraindications and other alerts. Koppel et al. lists the following advantages of CPOE compared to paper-based systems for patient safety: overcomes the issue of illegibility, fewer errors associated with ordering drugs with similar names, more easily integrated with decision support systems than paper, easily linked to drug-drug interaction warning, more likely to identify the prescribing physician, able to link to adverse drug event (ADE) reporting systems, able to avoid medication errors like trailing zeroes, creates data that is available for analysis, can point out treatment and drugs of choice, can reduce under and over-prescribing, prescriptions reach the pharmacy quicker.38
This functionality was recommended by the IOM in 1991. Most studies so far have looked primarily at inpatient CPOE and not ambulatory CPOE. A 1998 study by David Bates in JAMA showed that CPOE can decrease serious inpatient medication errors by 55% (relative risk reduction). This frequently cited article did not show reduction of potential adverse drug events (ADEs), however.39 Many of the studies showing reductions in medication errors by the use of technology were reported by a limited number of academic institutions with a home grown EHR and robust technology support. Other hospital systems with commercial EHRs are unlikely to experience the same optimistic results. A 2008 systematic review of CPOE with CDSS by Wolfstadt et al. only found 10 studies of high quality and those dealt primarily with inpatients. Only half of the studies were able to show a statistically significant decrease in medication errors, none were randomized and seven were homegrown systems, so results are difficult to generalize.40 With the inception of CPOE new errors that result from technology have arisen. A 2005 article reported that the mortality rate increased 2.8%-6.5% after implementing a well-known EHR.41 In a 2006 article, also from a children’s hospital implementing the same EHR, they found no increase in mortality; perhaps due to better planning and implementation. One of the authors stated that the CPOE system eliminated handwriting errors, improved medication turnaround time and helped standardize care.42 Nebeker reported on substantial ADEs at a VA hospital following the adoption of CPOE that lacked full decision support, such as medication alerts.43 On the other hand, another inpatient study showed a reduction in preventable ADEs (46 vs. 26) and potential ADEs (94 vs. 35) compared to pre-EHR statistics.44 To summarize, clinicians and staff must be properly trained in CPOE; otherwise errors will likely increase, at least in the short term.
Americans made 906.5 million outpatient visits in the year 2000. By sheer numbers there is more of a chance for a medication error written for outpatients. According to an optimistic report by the Center for Information Technology Leadership, adoption of an ambulatory CPOE system (ACPOE) will likely eliminate about 2.1 million ADEs per year in the USA. This could potentially prevent 1.3 million ADE-related visits, 190,000 hospitalizations and more than 136,000 life-threatening ADEs.23 However, a systematic review by Eslami was not as optimistic as he concluded that only one of four studies demonstrated reduced ADEs and only three of five studies showed decreased medical costs. Most showed improved guideline compliance, but it took longer to electronically prescribe and there was a high frequency of ignored alerts (alert fatigue).45 Kuo et al. reported medication errors from primary care settings. He concluded that 70% of medication errors were related to prescribing and that 57% of errors might have been prevented by electronic prescribing.46
Several studies have shown reduced length of stay and overall costs in addition to decreased medication costs with the use of CPOE.47 Tierney was able to show in 1993 an average savings of $887 per admission when orders were written using guidelines and reminders, compared to paper-based ordering that was not associated with clinical decision support.48
Reduce variation of care
One study showed excellent compliance by the medical staff when the drug of choice was changed using decision support reminders.49 Study conclusions should be interpreted with some note of caution. Many of the studies were conducted at medical centers with well-established health informatics programs where the acceptance level of new technology was unusually high. Several of these institutions such as Brigham and Women’s Hospital developed their own EHR and CPOE software. Compare this experience with that of a rural hospital trying CPOE for the first time with potentially inadequate IT, financial and leadership support. It is likely that smaller and more rural hospitals and offices will have a steep learning curve. On the surface CPOE seems easy, just replace paper orders with an electronic format. The reality is that CPOE represents a significant change in work flow and not just new technology. An often repeated phrase is “it’s not about the software, dummy,” meaning, regardless which software program is purchased, it requires change in work flow and extensive training. Adoption of CPOE has been slow, partly because of cost and partly because inputting is slower than scribbling on paper.50 Although physicians have been upset by new changes that do not shorten their work day, many authorities feel EHRs greatly improve numerous hospital functions. There has been less resistance traditionally in teaching hospitals with a track record of good informatics support. Also, young house staff who work in teaching hospitals and who write the majority of orders are more likely to be tech savvy and amenable to change. It does require great forethought, leadership, planning, training and the use of physician champions in order for CPOE to work. According to some, CPOE should be the last module of an EHR to be turned on and alerts should be phased in to bring about change more gradually. Others have recognized nurses as more accepting of change and willing to teach docs one-on-one on the wards. For more information on CPOE readers are referred to a monograph “A Primer on Physician Order Entry” and an article “CPOE: benefits, costs and issues.”51-52
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