Computer Based Documentation & Electronic Health Records

“Where are we headed...”

Jorge A. Ferrer, M.D., MBAMedical InformaticianVeterans Health Administration

Electronic Health Records• Computer Based Documentation (CBD)

– “Fully structured coded notes, for example, facilitate data collection for research and real-time decision support but can be cumbersome to use during patient encounters and may lack the flexibility and expressivity required for general medical practices.”

– “Handwritten notes, by contrast, are extremely flexible and permit a high degree of expressivity but may be limited in their legibility and accessibility for data processing and analysis.”

– Aspects of Electronic Health Record Systems. Chapter 14, Computer-based Documentation: Past, Present and future, Kevin B. Johnson and Trent Rosenbloom, 2nd ed. New York: Springer Science Business Media, 2006. p310. Print. Health Informatics Series. http://www.springer.com/public+health/book/978-0-387-29154-3

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Electronic Health RecordsBrainstorming about next-generation computer-based documentation: an AMIA

clinical working group survey.Johnson KB, Ravich WJ, Cowan JA Jr. Vanderbilt University Medical Center, 402 Eskind

Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232-8340, USA. Computer Based Documentation• “Computer-based software to record histories, physical exams, and progress or

procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. “

• “Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians.”

• “Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information. “

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Electronic Health Records• In Press: Rouse WB and Cortese DA, eds, Engineering the System

of Healthcare Delivery. Amsterdam: The IOM Press, 2009.Electronic Health Records, William W. Stead, M.D.

• http://courses.mbl.edu/mi/2009/pubs/Fall_Stead_EHR.pdf

• “A radical change in technical approach is needed to achieve electronic health records suitable to support an engineered system of healthcare.”

• “The failure of electronic health records to deliver on their potential is rooted in a mismatch between the conventional technical approach to their implementation and the nature of both the individuals those records are trying to describe and the clinical work they are trying to document (Stead, et al. 2000; Stead, 2007).”

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Electronic Health Records• Stead• “Healthcare information technology vendors, who sell enterprise solutions, compete

on how completely their system can automate the practices that make up the enterprise instead of competing on how well their systems work with data originating outside of them. This inward focus impedes progress towards the patient-centered health care society requires. “

• “To get the benefit of a complete record, the provider must either invest in costly excessively complex interfaces or rip out and replace pre-existing systems with a single vendor system that attempts to cover every current and future aspect of care and administration — even if most aspects of their pre-existing systems are doing a satisfactory job of their primary task of automating an aspect of the practice.”

• “In a time of paper records, diagnosis codes were developed to lump patients into

the common causes of mortality for easy tabulation, or into groups according to likely utilization of services to support prospective reimbursement. The full record was still available when needed for clarification. With the shift to electronic records, people commonly use the codes for diagnosis as if they were a more complete record despite the lack of clinical detail.”

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Electronic Health Records• Stead• “People’s roles, process and technology work together to

accomplish clinical work. Each has evolved together in response to changes in capability, patient mix, administrative requirements, etc. As problems surface, situation-specific work-arounds have been added. Take the paper order sheet as an example.”

• “The clinician writes a set of orders for care, diagnosis and treatment when a patient is admitted to the hospital. Thereafter, orders are added, stopped or changed one at a time. After the patient has been in the hospital for a short time, there is no one place where anyone can see all of the active orders for the patient. As a result, it has been common to require by policy that all orders be re-written on major transitions such as transfer of a patient from intensive care to intermediate care.”

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Electronic Health Records• Stead• “The processes from the paper world are used as a starting

point from which to develop requirements for new information technology. It is difficult to separate the purpose and essential steps of a work process from the related work-around.”

• “They are likely to judge the re-writing of orders as a requirement, and design a workflow within the order entry application to allow the clinician to carry out the task as quickly as possible. Despite their best effort, the computer entry task is likely to take the clinician more time than writing on paper.”

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Electronic Health Records• Stead• “Today’s predominant approach to implementing electronic health

records involves automating clinical workflow. One person enters data so that others can access the data later. They are encouraged to record findings and impressions using standard codes or terminologies.”

• “Clinical workflow and the clinician-patient interaction are interrupted by data entry. The detailed context and observations are lost. The information content of the record decays as advances in biology and healthcare result in changes to its codes and terminologies.”

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Electronic Health Records• Stead• “Consider a radically different approach to achieving the goal

of interoperable health information. “• “First, define interoperable data as data that can be

assembled and interpreted in the light of current knowledge, and re-interpreted as knowledge evolves. Re-interpretation requires access to an archive of “raw signal” (voice, image, text, biometrics, etc).”

• “Second, require data liquidity — the separability of data from applications so that other applications can use them.”

• “Third, limit the use of standard data, by which I mean data that can have only one interpretation, to situations where meaning is explicit and stable over time, e.g. drug ingredients, etc.”

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Electronic Health Records• Stead• “In this approach, data about the patient are captured from whatever sources, in

whatever form they are available in ways that minimize interruptions but clarify context. Computer algorithms and knowledge-bases work together to analyze this multi-source multi-mode set of “signals”.

• “As clinically significant patterns emerge, the computer presents possible interpretations to the clinician and/or the patient for confirmation or correction.”

• “This computer-human interpretation and annotation may take the form of the standard codes and terminologies that make up today’s electronic health record. However, now the annotations are additional “tags”.

• “ All of the “signals” and all of the contexts leading up to the interpretation are archived along with the tags. People move freely among levels of detail as they shift from exploring how a patient’s problems fit together to drilling down into the basis of one interpretation. As new signals become available, or as biological knowledge advances, the interpretations and annotations may be refreshed.”

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Electronic Health Records• Stead• “This shift breaks up the electronic health record into component parts.

Instead of attempting to have one record and practice management system that can be used for many purposes, the set of purposes is met through a set of frameworks for combining components.”

• “The scope of individual components are limited and matched to the breadth of coverage and to the depth of function supported by the component. As the breadth of coverage (number of circumstances supported) increases, the depth of functionality (number of features) is reduced so that the combination remains tractable”.

• “Limiting scope also achieves a degree of homogeneity among data handled by a component — providing implicit context for data fusion/mining algorithms. Within a framework, components are swapped out as requirements and technology change.”

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Electronic Health Records• Stead• “This shift in the paradigm for electronic health records makes

possible the flexibility to continually adapt people’s roles, process and the technology.”

• “It breaks the cycle of ripping out and replacing software to achieve data integration. It cuts the cost and time to implement electronic health records by an order of magnitude.”

• “Freedom from having to automate all clinical processes as the

means of assembling electronic patient records allows flexibility in sequencing the introduction of information technology.”

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Electronic Health Records• Hartzband P, Groopman J. Off the record — avoiding the pitfalls of

going electronic. N Engl J Med 2008;358:1656-1658. • http://content.nejm.org/cgi/content/full/358/16/1656?

ijkey=fc200e741c2f3508f5df950f14e2839e78801926&keytype2=tf_ipsecsha

• “The ultimate goal of the electronic medical record — a

technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies — is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient.”

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Electronic Health Records

• Hartzband• “As we have increasingly used electronic medical records in

our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted.”

• “Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians;

we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.”

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Electronic Health Records

• Hartzband• “This capacity to manipulate the electronic record makes it far too

easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong.”

• “Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems.”

• “Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny

for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.”

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Electronic Health Records

• Hartzband• “Writing in a personal and independent way forces us to think

and formulate our ideas. Notes that are meant to be focused

and selective have become voluminous and templated, distracting from the key cognitive work of providing care.”

• “Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be ‘efficient’ for the purpose of documentation but not for creative clinical thinking.”

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Electronic Health Records

• Hartzband• “Similarly, electronic medical records can reproduce all of a

patient's laboratory results, often dropping them in automatically.”

• “ There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems.”

• “Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.”

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Electronic Health Records

• Hartzband• “True, handwriting in charts is sometimes illegible and

can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand.”

• “But we have observed the electronic medical record

become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.”

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Electronic Health Records

• Hartzband• “The experience of many patients who, during their 15-minute clinic

visit, watch their doctor stare at a computer screen, filling in a template. This is perhaps the most disturbing effect of the technology, to divert attention from the patient.”

• “One of our patients has taken to calling another of her physicians "Dr. Computer" because, she said, "He never looks at me at all — only at the screen. “Much key clinical information is lost when physicians fail to observe the patient in front of them.”

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Electronic Health Records

• Hartzband• “The worst kind of electronic medical record requires

filling in boxes with little room for free text.” • “Although completing such templates may help

physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue.”

• “Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs.”

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Electronic Health Records• Hartzband• “Perhaps most important, we should be cautious in using templates

that constrain creative clinical thinking and promote automaticity.

We must be attentive to the shift in focus demanded by electronic

medical records, which can lead clinicians to suspend thinking,

blindly accept diagnoses, and fail to talk to patients in a way that allows deep, independent probing.”

• “The computer should not become a barrier between physician and patient; as medicine incorporates new technology, its focus should remain on interaction between the sick and the healer. Practicing "thinking" medicine takes time, and electronic records will not change that. We need to make this technology work for us, rather than allowing ourselves to work for it.”

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Electronic Health Records• Armijo D, McDonnell C, Werner K. Electronic Health Record Usability:

Interface Design Considerations. AHRQ Publication No. 09(10)-0091-2-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2009.

• http://healthit.ahrq.gov/portal/server.pt/gateway/

PTARGS_0_907505_0_0_18/09(10)-0091-2-EF.pdf • “An oft-cited limitation in the use of health information technology

(health IT) is the “usability” or more broadly, information design, of EHRs. Information design represents the art and science of preparing and conveying information so that it can be used by human beings with efficiency and effectiveness. Recent articles in peer-reviewed and popular literature have identified shortcomings in usability and information design as both contributing to the poor uptake of EHRs in the market as well as new categories of errors in care delivery.”

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Electronic Health Records

Armijo• “The usability of EHR systems, while recognized as critical for

successful adoption and meaningful use, has not historically received the same level of attention as software features, functions, and technical requirements (e.g., interoperability specifications).”

• “Recognizing the importance of usability, the Certification Commission for Health Information Technology (CCHIT) recently formed a Usability Workgroup; however, current CCHIT criteria do not assess EHR product usability.”

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Electronic Health RecordsArmijo• “At the time of this report, very little systematic evidence has been

gathered on the usability of EHRs in practice and the implications of their design on cognitive task flow, continuity of care, and efficiency of workflows.”

• “Further, the role of EHRs in patient care is evolving significantly as adoption is incentivized, health information exchanges operationalized, and new forms of comparative effectiveness codified and made available for clinical decision support. “

• “Given the significant Federal investment in EHR adoption, promoting improvements in EHR usability through fostering deliberations on the subject and furthering an action-based research agenda and policy recommendations are timely activities for the Agency for Healthcare Research and Quality (AHRQ).”

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Electronic Health Records

Armijo• “Various initiatives have sought to foster the adoption of technology including

the Institute of Medicine (IOM) which in 1991 called for paperless records in 10 years, the establishment of the Office of the National Coordinator for Health Information Technology with the goal of nationwide Electronic Health Record (EHR) use by 2014 and, more recently, EHR-related incentives and penalties introduced through ARRA.”

• “Despite these initiatives and the many successes achieved through EHR

implementations, physician adoption of clinical EHR systems is still estimated at less than 10 percent nationally.”

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Electronic Health Records

Armijo• “Usability has been cited as a major factor in both the

acceptance and effectiveness of EHRs in the clinical setting.” • “Examples describing potential negative impacts of EHRs on

efficiency, cognitive load, team collaboration, and medical errors can all be linked, at least in part, to issues directly related to usability and design.”

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Electronic Health RecordsArmijo• “The complexities of outpatient clinical environments are difficult to

replicate in laboratory settings, and ethical and privacy concerns may prevent some types of usability evaluations in clinical settings.”

• “This is further complicated by an inability or unwillingness of the vendor

community to invest heavily in usability constructed user acceptance testing, information design, and usability expert involvement in product development.”

• “The market’s inability or unwillingness to consistently pay for the level of implementation support required to appropriately incorporate technology into clinical practice (which can involve a level of process improvement beyond the change capital available in many practices) has also limited the quality of usability “evidence” available.”

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Electronic Health RecordsArmijo

• “Alignment of information displays (i.e., software interfaces) with physician cognition, workflows, and decision making in particular is an aspect of EHR design often cited as lacking in the current product market.”

• “Given the reality that multiple vendor systems, each having unique styles

and design constructs, coexist in the current health care environment, creating standard design elements and principles for EHR interfaces is an emerging need.”

• “In the user-interface (UI) design community this is partially addressed through the establishment of interactive patterns; a collection of building blocks that represent recurring solutions to common design problems.”

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Electronic Health RecordsArmijo• “There are strong indications that EHRs can dramatically improve

quality and lower cost; however, the majority of products in the market require far too much effort and skill to achieve those ends.”

• “The resource intensive planning and training necessary for effective EHR implementation has limited the realization of benefits expected from widespread adoption.”

• “While usability as defined by NIST is a broad concept, a particular

element of importance to health IT is intuitiveness or “learn-ability without teaching.” As tools offer more features and their relevance to clinical decisions grows, the ability to figure out how to accomplish a novel task without training grows in importance.”

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Electronic Health Records• Schiff, G. D., Bates, D. W. (2010). Can Electronic Clinical

Documentation Help Prevent Diagnostic Errors? NEJM 362: 1066-1069

• http://healthcarereform.nejm.org/?p=3217

• “We must ensure that electronic clinical documentation

works effectively to improve care if more benefits are to be

achieved. Yet many questions about it persist.” • “For example, can it be leveraged to improve quality

without adversely affecting clinicians' efficiency? Will the quality of electronic notes be better than that of paper notes, or will it be degraded by the widespread use of templates and copied-and-pasted information?”

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Electronic Health Records

Schiff, G. D., Bates, D. W.• “A fundamental part of delivering good medical care is getting the

diagnosis right. Unfortunately, diagnostic errors are common,

outnumbering medication and surgical errors as causes of outpatient malpractice claims and settlements. CRICO Harvard Risk Management Foundation. Diagnosis: 64% of claims from these four high-risk areas. (Accessed March 4, 2010, at http://www.rmf.harvard.edu/high-risk-areas/diagnosis/index.aspx.)”

• “EHRs promise multiple benefits, but we believe that one key selling

point is their potential for preventing, minimizing, or mitigating diagnostic errors. But we envision a redesigned documentation function that anticipates new approaches to improving diagnosis.”

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Electronic Health Records

Schiff, G. D., Bates, D. W.• “Systems developers and clinicians will need to

reconceptualize documentation workflow as part of the next generation of EHRs, and policymakers will need to lead by adopting a more rational approach than the current one, in which billing codes dictate evaluation and management and providers are forced to focus on ticking boxes rather than on thoughtfully documenting their clinical thinking.”

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Electronic Health RecordsSchiff, G. D., Bates, D. W.• “The first lies in filtering, organizing, and providing access to information.

Making accurate diagnoses has always depended on thoroughness in gathering the patient's history, findings from the physical examination, and other data.”

• “Because information from patients' previous clinical encounters and tests will be more readily available with electronic than paper records, shifting to electronic systems could substantially improve clinicians' knowledge about the patient.”

• “The problem of having too much information is now surpassing that of having too little, and it will become increasingly difficult to review all the patient information that is electronically available. However, one virtue of computerized systems is that they can display recorded information in various formats.”

• “Designers will need to leverage the "visual affordance" capabilities of EHRs to facilitate the aggregation, trending (of a patient's weight or renal function, for instance), and selective emphasis or display of data so as to facilitate rapid judgments.”

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Electronic Health RecordsSchiff, G. D., Bates, D. W.• “The second way in which EHRs can foster thoughtful assessment is by

serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions.”

• “Free-text narrative will often be superior to point-and-click boilerplate in

accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties.”

• “Documentation of clinicians' thinking must be facilitated by streamlined

text-entry tools such as voice recognition. Exam-room layouts, screen placement, and workflow should be redesigned to enable patients and physicians to work together on the same side of the screen. Follow-up questions should be documented in ways that facilitate tracking and sharing with future providers and consultants.”

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Electronic Health RecordsBlumenthal D. Stimulating the adoption of health information

technology. New England Journal of Medicine 2009;360:1477-147• “Spurring the adoption of EHRs and other HIT will probably require

more than financial carrots and sticks. Many physicians and

hospitals will need technical help to keep their systems working and to update them as technology improves.”

• “The law also authorizes grants to create regional technology extension centers to help providers install EHRs, funds to train a workforce to assist with HIT implementation, educational programs for medical students, and grants and loans to states to assist with adoption and interoperability.”

• “But perhaps its most profound effect on doctors and patients will result from its unprecedented $19 billion program to promote the adoption and use of health information technology (HIT) and especially electronic health records (EHRs).”

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Electronic Health RecordsPayne T. Transition from paper to electronic inpatient

physician notes. Journal American Medical Informatics Association 2010;17:108-111 doi:10.1197/jamia.M3173 – “The main barrier faced was the time required to enter notes,

which was addressed with data-rich templates tailored to rounding workflow, simplified login and other measures. After a 2-year transition, nearly all physician notes for hospitalized patients are now entered electronically, approximately 1500 physician notes per day.”

– “Remaining challenges include time for note entry, and the perception that notes may be more difficult to understand and to find within the EMR. In general, the transition from paper to electronic notes has been regarded as valuable to patient care and hospital operations.”

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Electronic Health Records• Simon SR, Kaushal R, Cleary PD, Jenter CA, Volk LA, Poon EG, Orav

EJ, Lo HG,Williams DH, Bates DW. Correlates of electronic health record adoption in office practices: a statewide survey. Journal American Medical Informatics Association. 2007 Jan-Feb;14(1):110-7. Epub 2006 Oct 26. PubMed PMID: 17068351; PubMed Central PMCID: PMC2215070.

• “The most frequently cited barriers to adoption were start-up financial costs (84%), ongoing financial costs (82%), and loss of productivity (81%). CONCLUSIONS: While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs.”

• “Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.”

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Electronic Health RecordsSequist TD, Cullen T, Hays H, Taualii MM, Simon SR, Bates DW. Implementation

and use of an electronic health record within the Indian Health Service. Journal American Medical Informatics Association. 2007 Mar-Apr;14(2):191-7. Epub 2007 Jan 9. PubMed PMID: 17213495; PubMed Central PMCID: PMC2213460.

• “ We evaluated the implementation of an EHR within the Indian Health Service (IHS), a federally funded health system for Native Americans. DESIGN: We surveyed 223 primary care clinicians practicing at 26 IHS health centers that implemented an EHR between 2003 and 2005.”

• “The survey instrument assessed clinician attitudes regarding EHR implementation, current utilization of individual EHR functions, and attitudes regarding the use of information technology to improve quality of care in underserved settings.”

• “Clinicians support the use of information technology to improve quality in underserved settings, but many felt that it was not currently fulfilling its potential in the IHS, potentially due to limited use of key functions within the EHR.”

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Electronic Health Records Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records

in U.S. hospitals. New England Journal of Medicine 2009;360:1628-1638.• “Among hospitals without electronic-records systems, the most commonly

cited barriers were inadequate capital for purchase (74%), concerns about maintenance costs (44%), resistance on the part of physicians (36%), unclear return on investment (32%), and lack of availability of staff with adequate expertise in information technology (30%).”

• “ Hospitals that had adopted electronic-records systems were less likely to cite four of these five concerns (all except physicians' resistance) as major barriers to adoption than were hospitals that had not adopted such systems.”

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Electronic Health RecordsShea, S., Hripcsak, G. (2010). Accelerating the Use of Electronic Health Records in

Physician Practices. New England Journal of Medicine 362: 192-195• “The cost–benefit calculus behind physicians' adoption of EHRs is also changing.

Financial incentives are one element. The prices of EHRs have come down as the volume of software licenses being sold has increased.”

• “A second factor is that the time investment associated with data entry, which has long represented a major obstacle to adoption, has been reduced as systems have

improved in performance and become more flexible with regard to individual preferences for data entry, including free text, templated data entry, dictation, speech recognition, and freehand graphic input. System usability has also improved, thanks to competition and customers' resistance to cumbersome products.”

• “ Third, the addition to EHR systems of capabilities beyond documentation,

including coding functions, the ability to create and export bills, the automated creation of consultation and patient letters, electronic prescribing, and task tracking, now translates into greater time savings for users. And a fourth factor is the increasing emphasis on quality of care, since payment for quality requires

documentation of quality.”

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Electronic Health Records

DesRoches CM, Campbell EG, Sao SR, et al. Electronic health records in ambulatory care -- a national survey of physicians. New England Journal of Medicine 2008;359:50-60.

• “Among physicians who did not have access to an electronic-records system, the most commonly cited barriers to adoption were capital costs (66%), not finding a system that met their needs (54%), uncertainty about their return on the investment (50%), and concern that a system would become obsolete (44%)”

• “Physicians with electronic health records tended to highlight

the same barriers but less frequently than did nonadopters.”

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Electronic Health Records

• How much more evidence do we need from the medical literature before we address the problem?

• Are we stimulating the right tools to improve the clinical capture of medical data?

• What if the medical data we are currently capturing was reusable, distributable and searchable?

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