ABSTRACT: The electronic health record (EHR) has the potential to improve the quality, safety, and efficiency of patient care when fully implemented, yet adoption of this tool has been slow. The advantages of the EHR include facilitating improved communication between health care providers; assisting with medication safety, tracking, and reporting; and promoting quality of care through optimized compliance with guidelines. Despite obstacles to widespread adoption and implementation, use of the EHR as a real-time, evidence-based support tool can help busy obstetrician–gynecologists improve the quality of the care they provide through improved care coordination, communication, and documentation.
The electronic health record (EHR) has the potential to improve the quality, safety, and efficiency of patient care when fully implemented (1). Use of the EHR can improve communication among health care providers and increase team effort among providers. Its use can assist with medication safety, tracking, and reporting and eliminate concerns about the legibility of paper medical records. Most importantly, its use has been shown to have an effect on quality of care through optimized compliance with guidelines (2). The use of preassembled ordering and documenting tools within an EHR may simplify the documentation process, although care must be taken when using templates to avoid importing previous notes without updating data, assessment, and plans. When using templates, the record must be reviewed and edited to ensure that it accurately documents the patient encounter. Record uniformity may reduce practice variations and can standardize health care, procedures, and follow-up (3). In addition, a more complete record can be created by offering staff additional questions, information, or alerts (4). However, like paper medical records, EHRs are only as accurate as the information entered into them. Electronic health records provide the benefit of improving the legibility of prescriptions, potentially reducing the risk of some medication errors. Health care providers have the benefit of accessing information from an online formulary, assuming that it is updated on an ongoing basis, as well as providing real-time medication alerts. It also can aid with medication reconciliation for each patient.
Electronic health records can also open communication with patients through online secure portals and reception area kiosks. These encourage patient partnering by allowing patients to enter personal or medical history information, make appointments, request refills on prescriptions, or obtain laboratory results. These kiosks and web portals can also be made interactive so patients may receive targeted education materials and other information (5).
Tracking and Reporting
The ability of an EHR to store and retrieve data makes it a logical tool to improve the quality of patient care. Using an EHR can consolidate patient information, such as diagnoses, medications, and test results, which may enable providers to deliver safer, more effective health care. Decision-making support, such as prompts and reminders when tests are due or when specific care does not meet guidelines, provides the clinician with a tool to provide quality care. The enhanced ability of a health care provider to clearly document all aspects of the encounter using an EHR may also ensure proper billing and coding to optimize reimbursement. Outside the patient encounter, EHRs may improve tracking for patient follow-up care, especially with missed appointments. They can also flag abnormal test results and store information about a patient's symptoms. In addition, a well-designed EHR will enable providers to search for specific patient populations to ensure that quality measures (such as mammograms, Pap tests, or hemoglobin A1C assessments) are up-to-date.
Improve Health Care Delivery and Office Efficiency
Office efficiency and the ability to streamline work-flow processes may improve with the use of EHRs because of timely access to medical records, especially to records at multiple or remote locations. This cross-over frequently occurs between inpatient and ambulatory care settings. Improved efficiency can translate into increases in direct patient care time, and in the accuracy, legibility, and completeness of the data entered into an EHR (6).
The improvement of office efficiency and the availability of legible documentation may also improve billing efficiency, generate referrals, and increase office revenue. This is possible because the system provides clear, timely, and legible documentation to support expanded clinical team initiatives (7).
Changes in Work Flow
Changes in work flow and redistribution of existing work have impeded the adoption of EHRs. Whether it is order entry or retrieval and viewing of information, these processes are more intricately related to the documentation process of physicians. The design of many vendor-provided EHRs adds structure to this process, which may not always be intuitive to the user. The system may be difficult to learn and the practice may be less productive as the new technology is assimilated, especially at the outset (8). Additional staffing resources may be necessary until the system is fully implemented.
The change of the clinician's focus from the patient to a machine is also a concern. This may even detract from the patient encounter and may, at least temporarily, result in a decrease in the number of patients seen. It may also have an effect on residents and students. This may reduce the learning potential of a patient encounter as residents become more focused on placing orders or typing notes rather than obtaining a detailed medical history and performing an adequate physical examination. It is important for all health care providers to understand that even the best EHRs are not a substitute for listening to patients. Appropriate placement of the computer screen during the patient encounter may also improve the communication process.
The Joint Commission's Sentinel Event Alert 42, Safely Implementing Health Information and Converging Technologies, outlines the effect technology can have on health care processes, work flow, and safety (9). Various technology-related adverse events already have been reported to the U.S. Food and Drug Administration, including medication errors, confusion between patient records, loss of information or corruption of data, and software incompatibility.
Keys to Implementation
A key to implementation is to identify champions or leaders among health care providers who can bridge the training programs from the vendors to the health care providers. These champions need to continuously engage in improving systems and related work-flow processes to make them more effective and efficient. There are few things that can undermine the use of EHRs faster than a system that is unreliable, slow, or unable to take advantage of new, powerful advances in health care information systems (10).
Acceptance of EHR implementation within an institution is facilitated when a single, specific program is installed across a network of computers, along with the establishment of an information technology support department provided by the organization. This allows uniformity of communication and a complete interface between group practices and the institution. More importantly, it allows the institution to provide an information technology support department, through partnership with a particular vendor. The members of the information technology department can meet with clinicians regularly to review usage, navigation, and updates to the system. Also, the information technology support department should be available, at any time, for immediate consultation to troubleshoot any system problems, such as retrieval of lost data due to power outages, or to assist the clinician in efficiently using the system. The efficiency of the department is dependent on how well it can train and assist clinicians, along with upgrading the system as problems or inefficiencies are discovered. Efficiency is maximized when the information technology support department includes vendor-supported personnel who are able to adapt the software for the institution.
Balancing Patient Privacy and Security and a Physician's Need for Patient Information
The American College of Obstetricians and Gynecologists holds patient privacy and the confidentiality of a patient's medical records in the highest regard and respects the fundamental right of an individual patient to make her own choices about her health care. Protecting patients' health information is of paramount importance. Electronic record keeping within a physician's office can make a patient's medical record more secure. Health information technology systems can block unauthorized viewers and keep track of when and by whom a record was viewed.
Health information technology systems should be compatible with the requirements of the Health Insurance Portability and Accountability Act and flexible enough to accommodate state privacy laws, a particular concern for adolescent care, assisted reproductive technology, and genetic testing. Health information technology systems must integrate these various rules.
There are compelling reasons why physicians should have access to shareable, complete medical records. But there are also compelling reasons, based on respect for patients' privacy and right to make their own health decisions, for limiting physician access to some patient medical information. In many cases, the clinical benefit derived from a physician's knowledge of sensitive personal health information may not be significant enough to outweigh the patient's need for confidentiality and privacy. At one end of the continuum, patients would have no control over the content of or access to their records, and all of the patient's physicians would have full access to all of the patient's medical information. At the other end, a patient may wish to block access to or delete important information from his or her medical record, leaving physicians with only some information.
The American College of Obstetricians and Gynecologists has strong concerns about allowing patients to delete information from their records entirely or to block provider access to any information in their records. The Health Insurance Portability and Accountability Act allows patients to request that inaccurate information be corrected, but not to demand changes for other reasons. Blocking access to selected information gives the patient significant control over her record, but could also hinder a physician's ability to provide the best patient care. The American College of Obstetricians and Gynecologists supports patients being active health care consumers but recognizes the importance of physician access to medical information for accurate diagnosis and treatment.
Because of the unique nature of the practice of obstetrics and gynecology, it is difficult to develop an EHR capable of following the flow of a prenatal record with its frequent encounters and timely laboratory testing, imaging, and counseling. All of these encounters need to be continually accessed most easily on a single screen within a problem-oriented chart that is automatically populated from multiple areas of care, including laboratory and radiology results, office visits, and labor and delivery. In addition, EHRs need to provide a safety net with clinical decision support to aid busy providers with alerts and guideline compliance assistance (11).
The use of health information technology may improve health care quality; however, more studies need to be conducted to examine the benefits of the EHR and its effect on improving patient safety and health care outcomes (4). Many of the analyses conducted to date are through single-site studies and national estimates are based on extrapolations from these single-site studies (12). As data demonstrating the benefits of EHR use become available, including improved communication across the continuum of care, improvements in patient outcomes, and reduction in medication errors or lower readmission rates, the need for health care information technology will become obvious (13). Using an EHR as a real-time, evidence-based support tool can help busy obstetrician–gynecologists improve the quality of the care they provide through improved health care coordination, communication, and documentation.
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