State Of EHR Adoption


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Whether the designation is electronic
medical records (EMR) or electronic
health records (EHR), there is widespread
consensus that the costs and difficulties
associated with system adoption are surpassed
by the benefits to be gained by all stakeholders. In
addition to providing more efficient and cost-effective
care delivery workflows, EHRs offer opportunities
to standardize care delivery processes, reduce
medical errors, and speed reimbursements.

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State Of EHR Adoption

  1. 1. The State of EHR Adoption:On the Road to Improving Patient SafetySPONSORED BY
  2. 2. VMWare ■ THe STaTe of eHR adopTIonW hether the designation is electronic a broad range of improvements that range from medical records (EMR) or electronic amendments to HIPAA’s privacy and security rules health records (EHR), there is wide- to construction. Of particular interest to health-spread consensus that the costs and difficulties care information technology professionals are theassociated with system adoption are surpassed ARRA provisions, known as the Health Informa-by the benefits to be gained by all stakeholders. In tion Technology for Economic and Clinical Healthaddition to providing more efficient and cost-ef- Act (HITECH).fective care delivery workflows, EHRs offer oppor-tunities to standardize care delivery processes, re- Signed into law in February 2009, ARRA’s HITECHduce medical errors, and speed reimbursements. provisions provide funding for acquisition of HIT systems and adoption incentives for healthcareThe consensus around the need to move forward provider organizations. In addition, money hasto implement EMRs/EHRs across the healthcare been earmarked for the development of a nation-system has gained steady ground over the past wide health information technology infrastruc-several years to the point where there is no longer ture to support the use and exchange of electronicany question among all stakeholder groups about health information. The organizational EHR is anthe theoretical value of EMRs/EHRs. Yet adoption essential element in this proposal, and its adop-and implementation continue to face significant tion by care providers is critical to transformingchallenges. and modernizing the business of healthcare. In short, the government remains committed to theDespite being identified as an essential tool to goal of the utilization of an EHR for each person insupport quality care initiatives, improve patient the United States by 2014, and has added to its callsafety and reduce healthcare costs, electronic to action both guidelines and funding for adop-medical and health record (EMR/EHR) systems tion of the technology.have been stuck in a slow growth cycle. Financialcosts, changes to traditional workflow, and an- Further, the ARRA defines certified EHR technol-ticipated productivity losses have restricted in- ogy as a “qualified EHR” that meets certain stan-vestments and adoption by many care providers. dards that define the type and functional capabili-However, now the pressure on caregivers to make ties of the system. Core functions include patientthose changes needed is continuing to mount. demographic and clinical health information, such as: medical history and problem lists; clinicalMost efforts to increase EHR adoption have come decision support; electronic order entry, includingthrough federal guidelines, regulations, and fi- computer-based provider order entry and e-pre-nancial incentives. And so they continue. EHRs scribing; health information exchange; and dataare an important and high profile component in collection and query to support healthcare qualityCongress and in the Obama administration’s na- initiatives.tional policy agenda. Included in the billions tagged for healthcare pro-Whereas a key focus within the Administrative viders are incentives, which are aimed at luring re-Simplification provisions in Title II of the Health calcitrant physicians and hospitals into the digitalInsurance Portability and Accountability Act of age by using a classic carrot-and-stick strategy. For1996 (HIPAA) was to streamline back-end admin- physicians who demonstrate “meaningful use”1istrative functions by standardizing identifiers of electronic health record (EHR) technology andand formats for transactions and code sets, the performance during the payment year’s reportinghealthcare component of the American Recovery period, Medicare and Medicaid reimbursementsand Reinvestment Act of 2009 (ARRA) focuses on will increase. Those who do not adopt the technol-2 Healthcare Informatics Research VMWare
  3. 3. THe STaTe of eHR adopTIon ■ VMWareogy are threatened with penalties in the form of involved in EHR adoption and implementationreduced payments, which are scheduled to begin projects, executives are usually the ones whoin 2015. spearhead the initiatives—a leadership role seen across all types of care provider organizations.Factors Driving EHr implEmEntation Most hospital IT departments (81%) are deeply in-Improved safety, quality, and efficiency are the volved and provide key support for adoption andmain business drivers for EHRs at organizations implementation of EHRs—as they should be.that have implemented or plan to implement anEHR. Although differences between inpatient- However, smaller hospitals are also more likelyand outpatient- based care providers are minimal, than average to have physicians in charge of thesehospitals are more likely to identify the goal of im- projects. And, as would be expected, physiciansproving safety and quality, whereas non-hospital-based organizations are somewhat more likely tosay the goal to improve efficiency and operationsis the bigger driver.When respondents were asked to identify addi-tional key factors that are important drivers forEHR implementation, nearly all (99%) countedbusiness cases—including competitive strategy,essential to adding efficiency, streamline opera-tions, and improve safety and quality—as the pri-mary drivers for EHR adoption overall. At largerhospitals, competitive strategy is particularly im-portant whereas at hospitals that are not part oflarge networks and non-hospital-based business-es, incentive programs are the most important.lEaDErsHipWhile CIOs and their IT departments, along withphysicians and nurses, are reported to be closelyVMWare Healthcare Informatics Research 3
  4. 4. VMWare ■ THe STaTe of eHR adopTIonare also more likely to be the leads at non-hospi- Far fewer satisfy requirements for a fully function-tal-based businesses where they often function as al EHR based on 17 functions of clinical decisionde facto CEOs. support, health information and data, order entry and management, and results management. Only 9% of hospitals and 5% of non-hospitals currentlytHE currEnt statE oF EHr implEmEntation operate with such a robust EHR.The first deadline, set in 2004, provided a 10-yearwindow in which to establish a national EHR sys- Among the organizations that report no plans totem. Although there has been some progress to- implement an EHR, cost is the single most com-ward that goal, most advances have been psycho- mon reason. The few respondents who work atlogical. Most care provider organizations are now organizations where EHRs are not on the agendacommitted to the transition to electronic health speculate that their organization might considerrecords, and expect the benefits of automation to EHR adoption with access to more affordablesupport long-standing patient safety and quality products and/or access to money to implement.goals. The effect of the Department of Health and Hu-Overall, the majority of survey participants report man Services’ rules granting exceptions to exist-that their organization has either implemented ing Stark Physician Self-Referral Exceptions andsome type of an EHR or has plans to do so. Hos- Anti-Kickback Safe Harbor rules that allowedpitals continue to be the most aggressive in mov- donations and acceptance of interoperable EHRing to EHRs. Larger hospitals, as well as those that technology has not been a major force in extend-are part of a network and those located in urban ing EHR adoption and interoperability. Largerareas, are the most likely to have implemented an hospitals continue to be the most likely donors.EHR. And nearly all of those represented here areengaged in some phase of implementation. improvEmEnts crEDitED to EHrs Asked to identify the single most important im-Among those organizations that have implement- provement that can be attributed to adoption ofed an EHR or component, the factors that drove EHRs, it is clear that the EHR is achieving its de-the project closely align with the benefits theyhave realized. Healthcare Informatics ResearchPanelists with EHRs report that the EHR has en- Organizational Bene ts of EHRsabled them to meet their goals of improved safety,quality, and efficiency—results consistently citedacross all care provider types, sizes, and commu-nity settings.Most organizations remain short of fulfilling evenbasic levels of EHR functionality. When comparedagainst a basic set of six functions—which includeclinical notes and documentation; computer-based orders for prescriptions and laboratorytests; electronic transmission of prescriptions;and the ability to view diagnostic laboratory andimaging results—only 21% of hospitals and 20% ofnon-hospital based businesses meet the criteria.4 Healthcare Informatics Research VMWare
  5. 5. THe STaTe of eHR adopTIon ■ VMWaresired benefits. Respondents are about equally di- Although fewer than one in ten identified benefitsvided between organizational and patient-related to operational efficiency as the single most impor-benefits—both of which are tied to improved safe- tant benefit, two in three of those say revenue cyclety and quality. There are few differences across dif- improvements have been beneficial to the organi-ferent types and sizes of organizations. zation. Nearly all of the improvements are associ- ated with primary attributes typically associatedOne in three providers says the adoption of EHRs with EHR use, that is, more complete documen-is part of their organization’s strategy to improve tation that supports higher coding levels (39%);safety and quality. And nearly one in five says that improved charge capture/faster billing (35%); re-safety and quality, which is supported by quicker duced costs related to transcription (36%); storageaccess to information, are the number one pa- space for paper-based charts (32%); and reducedtient benefit. Other organizational benefits focus costs for paper (31%). Text-based responses detailon adding efficiencies and improving operations. two other important attributes:Very few of those surveyed (3%) did not perceiveany benefits—and these were confined to non-hos- • “Increased efficiency by [the] decrease in time pital-based care providers. from order to care delivery.” • “Too many to list: improved efficiency, improved Many respondents credit the EHR with improved data for research, improved patient throughput.”safety and quality through access to a patient’s con-solidated medical record and legible documentation Few report benefits associated with supplementaryand orders. Other important attributes identified in- revenue associated with increased reimbursementsclude evidence-based clinical decision support (7%) for demonstrating higher quality of care throughand structured data collection (2%). Some of those pay-for-performance premiums (12%) or cost sav-surveyed itemized specific examples of improve- ings through reduced malpractice insurance ratesments that included increased pediatric immuniza- (8%).tion rates, reductions in adverse drug events, andclinical reminders to improve vaccination rates, Although few respondents (8%) rate staff benefitsscreening rates, and other safety measures. associated with EHR adoption as most important, Patient Bene ts of EHRs Sta Bene ts of EHRsVMWare Healthcare Informatics Research 5
  6. 6. VMWare ■ THe STaTe of eHR adopTIonthree out of four recognize their importance as Most hospital IT departments (81%) are deeply in-part of the bigger picture. Primarily, efficiency and volved and provide key support for adoption andworkflow improvements are noted, with about implementation of EHRs—as they should in three citing the role of digital signaturesin speeding the chart authentication process. However, smaller hospitals are also more likelySlightly fewer noted ease of use and quality of life than average to have physicians in charge of theseimprovements. Most of the “other” staff-related projects. And, as would be expected, physiciansbenefits focused on access—better, quicker, ubiq- are also more likely to be the leads at non-hospi-uitous data entry, and access to documentation tal-based businesses where they often function asand information for all members of the care team, de facto CEOs.from remote locations and for simultaneous ac-cess by multiple users in multiple locations. One EHrs in tHE clouDrespondent reports, “improved pride in work and As care providers move to EHRs, Web-based sys-in organization.” And another says the organiza- tems offer attractive alternatives, particularly fortion was able to eliminate one and one-half full- physician practices in small offices. But for manytime employees with the system. physicians in small offices, the cost advantages are not enough to overcome concerns regardinglEaDing EHr aDoption the security of their patients’ personal health dataWhile CIOs and their IT departments, along with when stored off-site. Indeed, this group shows aphysicians and nurses, are reported to be closely higher percentage of records stored onsite wheninvolved in EHR adoption and implementation compared to hospitals.projects, executives are usually the ones whospearhead the initiatives—a leadership role seen When considering the text-based responses foracross all types of care provider organizations. those who indicated that storage was something6 Healthcare Informatics Research VMWare
  7. 7. THe STaTe of eHR adopTIon ■ VMWareother than onsite or Web-based, many clarified conclusionthe various types of models possible. Among those Given the goals of ARRA-HITECH, EHR imple-in use by this group of organizations are: ASP with mentations in healthcare organizations across thelocal thin-client; central data center serving mul- country are all but certain. When asked to sharetiple hospitals; a combination of onsite and ven- advice with others planning an EHR implementa-dor-hosted storage; corporate data centers; local tion, one-third of healthcare organizations whodata exported daily to a larger [storage] site; and had already implemented any EHR componenta remote storage site owned by the organization. said that “Obtaining buy-in” was the singlemostMany combine local and off-site storage. important piece of advice they had to offer. They also cautioned others to ensure adequate funding, integrate the EHR with the current systems, em- phasized the importance of testing and communi- cation, and to choose a system wisely.mEtHoDologyA total of 491 online interviews were conducted with members of the Healthcare Informatics Research Panel. Withinthis group, 317 members represented hospital-based care providers and 141 represented non-hosptial-based providersincluding physician offices and ambulatory care centers with the remaining 33 representing health plans. Responseswere collected from January 13, 2009 to January 28, 2009. The data was then tabulated, analyzed, and objectivelyreported by Healthcare Informatics Research.VMWare Healthcare Informatics Research 7