Feliciano B. Yu, MD
Department of Medicine
Division of Preventive Medicine
Medical Advisor for Clinical Informatics, HSIS Applied Informatics Group
University of Alabama at Birmingham

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the activity.

The boards of nursing in many states, including Alabama, recognize Category 1 continuing medical education courses as acceptable activities for the renewal of license to practice nursing.

You have probably heard about the EHR by now. Chances are you may already know one or two colleagues that are using electronic medical record (EMR) systems in their practice. Perhaps, you may have experienced it first hand during residency training and now you are seriously considering implementing one for your office.

You are not alone. Physician interest in the EHR is on the rise. As of 2003, about 17% to 21% of all physicians were already interacting with an EMR system and at least 71% considered implementing.[1,2] There is growing evidence that EMR systems positively impact physician performance and patient outcomes.[3] In fact, the federal government, the Institute of Medicine and a number of medical specialties have highlighted the advantages EMRs and have now advocated for its universal adoption.[4,5] In a recent survey by the Alabama Quality Assurance Foundation (AQAF), about 19% of the 204 surveyed physicians reported having an EMR system and 48% were either already implementing or were planning to implement within the next 2 years.

You may not really care much about the subtle differences in the terminologies, but it may be best to understand the differences between an EMR and EHR. An EMR is a computer application that allows you to create, store, edit, retrieve and organize your patient records electronically via a computer. It often mimics the function of your paper medical record system; however, it can do more. The term EMR has been previously referred to as the computerized medical record, computerized patient record, and computer-based patient record. The EHR or electronic health record is a more robust version of the EMR. Its advanced functionality allows the EHR system to link to other sources of information, combining data from and interoperate with several different computer applications and databases (i.e., laboratory, radiology, public health registries, prescription order entry systems, etc).[6] This robust capability of the EHR allows access to a vast pool of information for better and more efficient use of clinical information.

So, if you are new to the world of EHRs or especially if you do not have much computer experience, you may find this decision to be unlike anything you have ever encountered. The EHR is not just a software package that you can buy off the shelf like any other computer programs. It does not come with a manual that provides step-by-step instructions on how to run it successfully. Most of the time, you will be dealing with a vendor, or a company that develops and maintains the EHR system.

Much of the apprehension lie on the fact that we know little about the technology and how it can help us navigate through our daily patient care activities.[7] In this online course we are going to try to detail some of the reasons why an EHR might benefit your practice.

When would be a good time to buy an EHR for my practice, you might ask? This is a question that is probably easier answered today than a few years back. As you know, the technology has changed tremendously over the past several years and that a number of vendors are now offering systems with more robust functionalities. Most of us are probably reluctant to decide on an EHR simply because we do not know when is the best time to jump in. We want to know what type of system to choose, which vendor to trust, and most of all, how much it will eventually cost.

A better question to ask might be – how will my practice benefit from an EHR system? In this regard, now would be a good time to invest in an EHR because the market is ripe for such a move. The software and hardware systems are now more affordable. The vendors have now matured and the applications are more robust. We now have a choice of excellent vendors that have survived and grew over the past decade. Plus, the number of colleagues who have transformed their offices with EHRs is on the rise. They often provide invaluable insight to their own experience with their EHR system.

More importantly, the advantages of EHRs are already broadly accepted by the industry so that ignoring its benefits may limit your practice to provide the expected quality and efficiency of care that you deliver to your patients. Patients, third-party payors and the federal government have favorable perceptions and expectations from practices with EHRs.

Implementing an EMR system in your practice does require an upfront investment, but it can help pay for itself over time when properly implemented. Return on investment is often realized through reductions in transcription and paper costs, improved staff efficiency, accurate coding through proper documentation, timely reimbursement, and enhanced office workflow and physician productivity. It is estimated that for a 3-physician practice, each physician is expected to invest an average of $4,000 to $7,200 per year over 3 years, depending on the type of EHR system.[8] In a recent cost-benefit study of EHRs in the ambulatory setting, Wang et al estimated that a physician can experience a net benefit of about $85,000 over 5-years of using an EMR. The positive financial gains were due to savings accrued with enhanced utilization of medical tests, appropriate prescription process, improved coding and decreased errors in billing.[9]

Properly implemented EHR systems assist physicians in ways paper-based medical record systems can not even begin to match. Most EHRs are flexible and customizable enough that it will be able to fit well in your office's routine workflow. Basically, an EHR system helps your office to bypass a number of processes by incorporating the workflow into the software design. As a result, your office becomes more efficient with time management, documentation and patient services. There are no more lost charts, illegible handwriting, or missing records or documents. Table 1 provides a brief list of the benefits of EHR.

Table 1 - Benefits of an Electronic Medical Record System

Source: Carolyn Hartely and Edward Jones. EHR Implementation: A step-by-step guide for the medical practice. AMA Press. 2005.

EHR systems are capable of storing different types of patient data. They can store laboratory, radiologic, photographic and other digital files such as scanned paper documents. When patient records are stored or archived electronically, a single 650 megabyte CD-R disc can contain over 10,000 pages of scanned paper records. This is equivalent to a regular 4-drawer filing cabinet stuffed with paper records. A DVD-R disc on one hand can store about 4,700 megabytes (4.7 gigabytes), giving you room for at least 70,000 paper records. So in terms of archiving or storing records, you can already save up a lot of resources in storage space (not to mention that a single disc now cost less than a dollar a piece!). With very inexpensive memory, it will not cost much to have multiple back-up copies of your practice data.

EHR systems can also help automate mundane office tasks such as filing, searching, and storing a patient’s medical record. With regards to paper record management, the Gartner group estimated that a typical office staff spends about 8 hours per week just managing paper records (creating, finding, storing, etc). A study by Cooper and Lybrant also estimated that about 7.5% of the paper documents are lost and about 3% are misfiled. Just imagine the time and resources wasted in these unnecessary activities. Table 2 gives us a brief summary of the benefits of electronic storage compared to the current paper-based system.

Table 2 - Comparing Paper-based Medical Record System and EHR

Some EHR systems can connect directly with your hospital information system. By doing so, you now have an integrated view of your patient's information both in the ambulatory and inpatient setting. Some EHRs even link or interface to other computers across a specific geographic area or across regions, pooling your patient data with others for a more comprehensive collection of clinical data. They are able to link or interface with other computer systems such as you hospital, external laboratory, and immunization registries, to name a few. By doing so, the input and transmission of data to and from your computer are done automatically without any human intervention.

Built into the EHR functionality may be the following decision support tools. By using special software programming, the EHR system can assist the physician with important patient safety interventions such as safe prescribing and preventative medicine or improve productivity with coding and reimbursement functionalities. Specific examples are described below.

ePrescribing
Most EHRs now incorporate prescribing tools that assist the clinician during this important process. The drug or medication information can now be linked to other data elements within the EMR such that it can automatically detect drug to drug, allergy, laboratory, formulary, or diagnosis interactions that can impact patient safety.[10] The prescription process can also be automated so that one can easily fax or print the patient’s prescription in a timely manner.

CPT coding assistance
Most EHRs have incorporated this functionality to help clinicians navigate through the complexity of CPT and E/M coding. This added functionality is a boon to busy clinicians by enhancing the accuracy and appropriateness of the coding process.[11] The software can also provide automated charge capture and coding reminders ensuring proper reimbursement.

Access to electronic Medical References
Clinicians frequently have a number of unanswered questions about their patients during a typical clinic day.[12,13] With EHRs, readily available electronic medical references such as medical textbooks and specialty-specific journals, access to Medline or local libraries, or even patient-focused educational materials are often just a click away. The system can also help automate the printing of predetermined patient education and disease management materials that you frequently use in the office.

Clinical event monitors
Clinical event monitors are computer programs that are designed to be sensitive to changes in clinical data. Alerting mechanisms can be triggered based on predetermined “rules” so that, for example, when a critical laboratory or radiologic result is captured or stored in the computer, the software can send alerts or report the critical information to the clinician in a timely manner.[14] The same functionality can be extended to changes in other data elements that are already in your EHR system such as vital signs, diagnoses, problem lists, to name a few.

Anticipatory guidance recommendations
Using the event monitors, this functionality can further help clinicians identify patients who are eligible for preventative interventions. For example, it can help send reminders for vaccination, screening tests, counseling and anticipatory guidance improving the quality of care that is delivered to your patients.[15]

Diagnostic Support tools
The software may also have built-in tools that can help provide diagnostic support or assistance. Elements from the EHR’s clinical data (i.e., history, physical exam, review of systems, laboratory results) can be used as input to the program and is used to trigger diagnostic suggestions or differential diagnoses.[16] This functionality is very helpful, not only as a tool to improve our diagnostic capability, but also as a timely educational tool in a busy practice.

Automated practice guidelines
Some EHR systems may also have incorporated programs that provide automated practice guidelines. Once triggered, these programs assist the clinician by presenting patient-applicable protocols making it easy for the clinician to follow clinical practice guidelines.[17,18]

With an EHR you can also view patient information in several ways. You can view relevant patient information such as diagnosis, laboratory or vital sign values longitudinally or crossectionally. You can even view groups of patients and look at specific trends or patterns in your practice on the fly. Try doing that with a paper medical record system!

More importantly, by having an EHR, you now have the ability to monitor the quality of care you provide to your patients without extensive paper chart reviews. Previously limited only to insurance companies and practice oversight agencies, you may now proactively monitor the care that you deliver to your patients. For instance, using predefined reports, you can look up the number of patients in your office that may need certain medical interventions like vaccinations, medication recall, health checks and follow-ups.

Deciding on an EHR may not be easy. However, the benefits to you and your practice are remarkable. Once implemented, it may take some time to get used to the new workflow, but on the other hand, the end results are worth the extra effort. These are just a few of the benefits of the EHR. If you are interested in learning more about EHRs, you can access the following resources as a start.

1. The Paperless Medical Office: Digital Technology's Potential for the Internist - http://www.acponline.org/hpp/paperless.pdf
2. Electronic Medical Records for the Physician's office - http://www.rheumatology.org/products/coding/emr_whole2.pdf
3. Special Requirements for Electronic Medical Record Systems in Pediatrics - http://aappolicy.aappublications.org/cgi/reprint/pediatrics;108/2/513.pdf
4. AAFP's Center for Health Information Technology - http://www.centerforhit.org/
5. Doctors' Office Quality - Information Technology (DOQ-IT) - http://www.doqit.org
6. HL7's Electronic Health Record System Functional Model and Standard, Draft Standard for Trial Use - http://www.h17.org/ehr/downloads/index.asp
7. Key Capabilities of an Electronic Health Record System - http://www.iom.edu/report.asp?id-14391
8. The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition (1997) Institute of Medicine - http://books.nap.edu/books/0309055326/html/