FAP-Marketa Mashall Bumpus

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THE ELECTRONIC HEALTH RECORD, DO THE PROS OUTWEIGH THE CONS?
The College of St Scholastica
Duluth, Minnesota
by
Marketa M. Bumpus
Final Applied Project Advisor: Danika Brinda
Final Applied Project Committee:
Pamela K. Oachs, MA, RHIA
Amy Waters, MA, RHIA, FAHIMA
Ryan Sandefer, MA, CPHIT
Approved:
Submitted in partial fulfillment of the requirements for the degree of Master of Science in Health
Information Management, The College of St. Scholastica, Duluth, Minnesota.

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Thesis Problem Statement
Marketa M. Bumpus
Advisor: Danika Brinda, Final Applied Project
The Electronic Health Record, Do the Pros Outweigh the Cons?
Topic:
My Master’s Program will deal with “The Electronic Health Record, Do the Pros
Outweigh the Cons?” When hospitals and other healthcare facilities implement an EHR,
redundant waste is often eradicated. However, if the system is inconsistent, implementing new
technology can create more complications, and the results can be "damaging." It is crucial that
healthcare executives understand the benefits and challenges of EHRs and what can be done to
remove them. An EHR is only as good as the processes that it supports. If the technology is not
supported with well thought out processes, hospitals and other healthcare facilities may invest in
complex and costly technologies that create more waste in a system accompanied with
inefficiency.
Rationale
The electronic health record is very valuable to hospitals and other healthcare facilities
because EHRs make health information readily available to authorized health care providers
wherever and whenever a patient gets care. In addition, EHR’s improve the coordination and
continuity of care and promote informed decision-making. As a result, consumers can attain
more complete and correct information to informed decision-making about their own health care.

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EHRs also help to reduce preventable medical errors and replication of treatments and
procedures. Overall, EHRs Lower administrative costs and decrease clerical errors, while
improving research. Lastly, EHRs reduces the time it takes to bring safe, effective products and
practices to healthcare providers.
Method
My thesis will discuss the pros and cons of electronic health records. First I will discuss
meaningful use criteria that an electronic health record can bring to hospitals and healthcare
organizations. Secondly, I will discuss the many problems that can arise in healthcare
organizations when using electronic health records as the only means of storing patient data. To
conclude I will provide information on how hospitals and healthcare systems can avoid these
issues.
To support my findings of EHR adoption I will present a bar graph depicting physicians,
hospitals, and healthcare facilities that have adopted the EHR. The bar graph will also display
the relevant age of physicians that have adopted the EHR and their overall satisfaction. Also, the
bar graph will display the types of physician practices that are more or less often to adopt the
EHR.

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The Electronic Health Record, Do the Pros Outweigh the Cons?
Marketa M. Bumpus
The College of St. Scholastica

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Abstract
This topic is important because the creation of the electronic medical records was
compelling. Healthcare became less expensive, more efficient, and the quality of patient care
greatly improved by making medical records accessible to all healthcare providers that treats a
patient. The idea of making medical records accessible to all healthcare providers was
surprisingly promoted by the Obama administration that spend an excess of $6.5 billion in
incentives, and hospitals and doctors have spent more to implement the accessibility of electronic
medical records to all healthcare providers (Becker& Sewell, 2004). But the adoption of the
electronic medical record has caused proven challenges with a potential for mix-ups that can be
costly and dangerous.

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Improved Data Accessibility
Before EHRs, access to medical charts required a fair amount of physical labor. For
example, every time a patient visited the office or hospital, their file had to be physically pulled
from a storage space, transported, delivered (batch processing), stamped and sorted all in one
visit. As a result of this back and forth, there was a greater chance of human error and charts
would sometimes be missing information or be chronologically out of order. In my experience, it
was not unusual for five out of 15 charts for a clinic day to be unavailable at any given time,
which ultimately resulted in wasted time, space, motion and frequent defects to care (Burton, L.
C., Anderson, G. F., & Kues, I. W., 2004) .
EHRs, on the other hand, have eliminated the physical transporting, sifting and filing of
charts, making data available at all times. Additionally, for systems that allow remote access to
charts, clinicians can even be off site and still securely access patient files. Storage and inventory
is also reduced, freeing up physical space within the hospital or office, and allowing the
redeployment of human resources (Burton, L. C., Anderson, G. F., & Kues, I. W., 2004).
Unnecessary movement is eliminated, ultimately eliminating batch delivery and improving the
flow of patients and information. Most importantly, the culmination of the reduction in waste is
improved quality of care for the patient.
Computerized Physician Order Entry
CPOE allows physicians to place lab and imaging orders, prescriptions and other notices
electronically, reducing the error of hand-written orders and allowing the patient's other
physicians within the EHR network access to the order. That means, if a patient is prescribed a

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drug from his/her cardiologist and they are on the same EHR, the primary care physician will
have access to the prescribing information. This not only reduces time, but also dramatically
reduces errors —such as duplicate prescriptions or drug interactions — and potential harm to the
patient (Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., ... &
Seger, D. L., 1998).
Charge Capture
Healthcare organizations keep track of ("capture") a patient's use of hospital resources,
such as equipment, medical supplies, diagnostic testing, medication and hospital staff. These
charges are recorded and then billed to patients and third-party payers. Often, the use of a
resource may be overlooked (Menachemi, N., & Brooks, R. G. (2006). The process behind
"charge capture" can be complex, making it very important that that a system is in place to
capture charges completely and correctly, maximizing the potential reimbursement for revenue.
With an EHR system, at least one diagnosis must be captured along with a level of
service that documents what was done for the patient at the end of every encounter. Additionally,
the EHR includes a list of selectable Current Procedure Terminology codes that allows for easy
input and helps reduces errors, ensuring the right code is used (Menachemi, N., & Brooks, R. G.
(2006).
Preventative Health

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EHRs allow for prompts for preventative health screenings. During routine doctor or
urgent care visits, the physician has access to preventive health records conveniently in one
place. If the patient is due for a cancer screening (such as mammogram or colonoscopy), or
blood pressure testing, the doctor can set easily look this up via the EHR system and schedule an
appointment for the patient (Blumenthal, D., & Tavenner, M., 2010).
What's more is EHRs allow data analysts to mine the entire system for say, all patients
with diabetes who haven't had their hemoglobin A1C and cholesterol check within the past year.
From there, the analysts can provide the physician with a list that allows practice management to
contact the patients to schedule these preventative health appointments (Blumenthal, D., &
Tavenner, M., 2010). This type of data mining cannot be done through paper records.
Ease Sign Off for PAs and NPs
While this varies from state-to-state by law, physician assistants and nurse practitioners
are typically required to have their notes approved and signed off on by their supervising
physician. EHRs allow the revision and cosigning of notes to happen electronically as opposed to
physically moving and signing paper.
E-messaging Between Providers
As any physician can attest, telephone tag between providers can be common, and is a
big time-waster. With EHR software, physicians can e-message across practices. One situation
that benefits in particular from e-messaging is referrals. Rather than playing telephone tag to get
an appointment scheduled, the physician electronically send a message to schedule the
appointment.

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Implementing the Electronic Medical Record
In recent years, Electronic Health Records (EHRs) have been implemented by an ever
increasing number of hospitals around the world. There have, for example, been initiatives, often
driven by government regulations or financial stimulations, in the USA, the United Kingdom and
Denmark. EHR implementation initiatives tend to be driven by the promise of enhanced
integration and availability of patient data, by the need to improve efficiency and cost-
effectiveness, by a changing doctor-patient relationship toward one where care is shared by a
team of health care professionals, and/or by the need to deal with a more complex and rapidly
changing environment.
Although the complete medical record does not completely exits, portions of the medical
record have been computerized for many years. The most heavily computerized aspects are the
administrative and financial portions. On the clinical side, the most common computerized
function has been the reporting of laboratory results, usually made easier with the installation of
automated equipment for laboratory specimen testing. As more information recording functions
become computerized, increasing proportions of the record are computerized as well. All
comprehensive EMR’s share several common traits (Becker & Sewell, 2004). First, they all
contain large data dictionaries that define their contents. Second, all data are stamped with time
and date so that the record becomes a permanent chronological history of the patient’s care.
Third, the systems have the capability to display data in flexible ways, such as flowsheets and
graphical views. Finally, they have a query tool for research and other purposes.
A number of successful EMR implementations have been in place for decades. One of
the earliest ambulatory care record systems was COSTAR (Computer-Stored Ambulatory

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Record), developed at Massachusetts General Hospital in Boston (Becker& Sewell, 2004). It
allows patient registration and scheduling, storage and retrieval of clinical data, and financial
capabilities such as billing. The COSTAR system is in the public domain so the other vendors
and institutions can modify and enhance it (Becker& Sewell, 2004). This system evolved with
computer and network technology itself. Most systems initially consisted of dumb terminals
connected to mainframes or minicomputers, but have since evolved into microcomputer-based
networks embracing client-server architectures. Future technologies, such as voice recognition
or pen-based input, will likely cause further evolution of these systems.
Problems with Electronic Health Record
Implementation
The implementation of hospital-wide EHR systems is a complex matter involving a range
of organizational and technical factors including human skills, organizational structure, culture,
technical infrastructure, financial resources, and coordination. Implementing information
systems (IS) in hospitals is more challenging than elsewhere because of the complexity of
medical data, data entry problems, security and confidentiality concerns, and a general lack of
awareness of the benefits of Information Technology (IT). There are three reasons why hospitals
differ from many other industries, and these differences might also affect EHR implementations
(Meystre, Savova, & Kpper-Schuler, 2008). The first reason is that hospitals have multiple
objectives, such as curing and caring for patients, and educating new physicians and nurses.
Second, hospitals have complicated and highly varied structures and processes. Third, hospitals
have a varied workforce including medical professionals who possess high levels of expertise,
power, and autonomy.

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Problems with the Electronic Medical Record
The problems identified with the EMR, is increased provider time, computer down time,
lack of standards, and threats to confidentiality. Electronic order increases the amount of time
physicians spend entering orders. Studies have proven that, 44 more minutes per day is needed
when using the computerized order entry (Burton, Anderson, & Kues, 2004). .
An additional concern with the EMR systems is computer down time. It recent years
computer down time was 1 hour. Today, approximated 10 minutes has been recorded for
computer down time (Meystre, Savova, & Kpper-Schuler, 2008). Most hospital computer
systems and the databases that run on them are being designed for non-stop usage (Burton,
Anderson, & Kues, 2004).
Lack of interoperability between information technologies/EHRs
With more accountable care organizations emerging across the U.S., technology plays an
essential role in developing an ACO, allowing primary care physicians to track and follow the
patient flow throughout the healthcare system. Part of the driving force behind the model
stemmed from the need to integrate EHRs throughout the health system and share information
with network of referring hospitals (Meystre, Savova, & Kpper-Schuler, 2008). However, this
sharing of information is often not possible. Finding a hospital partner that is willing to open the
lines of communication is critical to the success. For example, Simpler Consulting client Atrius
Health worked closely with Beth Israel Deaconess Medical Center and Epic Systems to develop
a web portal that allows the two provider organizations to access each other's EHR systems for
shared patients.1 If this planning and integration is not put into place, communication can

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become a serious problem and result in additional follow up, time and waste (Meystre, Savova,
& Kpper-Schuler, 2008).
Cost of set-up and maintenance
The cost associated with EHRs is often a deterrent. Not only must the provider pay for
the physical hardware and/or software, the organization must also put forth a considerable dollar
amount for setup, maintenance, training, IT support and system updates. For many smaller
practices with lower cash flow, cost alone prohibits the ability to properly implement and
maintain the system.
Productivity
A study conducted by the University of California-Davis found a 25-33 percent drop in
physician productivity in the initial implementation phases of the EMR (Meystre, Savova, &
Kpper-Schuler, 2008). While ultimately the goal is to increase productivity in the office or
hospital, expect to see a significant drop in productivity, and ultimately revenue, in the first
several weeks, and perhaps longer.
Delays in Documentation
This may come as a shock to many, however, EHRs actually increases the physician
workload. With written notes, documentation tended to be briefer and straight to the point. With
EHRs, much more documentation is required of physicians before, during and after a patient
visit. This has its pros and cons (Meystre, Savova, & Kpper-Schuler, 2008). . For example, a
benefit of more robust documentation is that it provides additional information for the coders that
may justify a higher level of service being billed. On the negative, it can cause further delays and

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errors as physicians often wait to close notes until the end of the day or, sometimes, days later
(Blumenthal, D., & Tavenner, M., 2010). Thus they rely on memory to enter correct information.
Additionally, if a patient is seeing a different provider, others will not be able to access this
updated information until the note is closed.
As with most systems, however, shortcuts can be built into and customized for the
physician to reduce some documentation. Standard work is needed to ensure provider support
and learning.
E-Messaging Between Providers
While e-messaging is listed above as a benefit, it can also be a drawback as it can result
in a lack of face-to-face or phone-to-phone conversation. With EHRs, there are no give-and-take
conversations or question-and-answer scenarios. There is no way to express emotion, nuances or
voice your concerns or fears. Rather, physicians must trust that the information they are
providing is what the other physician needs, interpreted without confusion and read at all
(Meystre, Savova, & Kpper-Schuler, 2008). This is not always the case.
Continuous Need for Updates and Lack of Accountability for Doing So
For every task large or small whether it's a basic wellness visit, a diagnosis, a procedure,
a treatment or a prescription the EHR system requires a corresponding update. For example,
when you have an active "problem list" for a patient (e.g., diabetes, hypertension, high
cholesterol, etc.) someone has to be responsible for updating his or her medication and keep the
problem list accurate (Blumenthal, D., & Tavenner, M. (2010).

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However, in my experience, I've seen a significant lack of accountability for making
constant updates which needs to be addressed across all health systems. For example, when
patient has a surgical procedure, this needs to be added to the health record so that all those with
access to the EHR can see the work that has been done. The question is, however, who is
responsible for updating (Blumenthal, D., & Tavenner, M. (2010)? The primary care physician
or the surgeon? There needs to be a clear, communicated system between all of the patient's
doctors and nurses so that updates are made efficiently and by the right persons.
Lack of Standards
A lack of standards is another significant problem with EMR systems. While a number
of standards do exist to transmit pure data, such as diagnosis codes, test results, and billing
information, there is still no consensus in areas such as patient signs and symptoms, radiology
and other test interpretation, and procedure codes.
A related problem to standards is that a large proportion of clinical information is
“locked” in the form of narrative text (Meystre, Savova, & Kpper-Schuler, 2008). Although a
number of systems have been successful in limited domains, the technology for nature language
processing (NLP) is still unable to interpret narrative text with the accuracy required for research
and patient care applications (Mandl, Kohane, & Brandt, 1998). While NLP is difficult for well-
written published medical documents, it is even harder for medical charts that contain poorly
structured, highly elliptical language, with frequent misspellings to boot. Even if such language
could be parsed, the lack of an underlying framework makes it semantic interpretation more
difficult.

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Final Concerns
A final concern about the EMR is the problem of security and patient confidentiality.
This problem, of medical information, abstracted from paper records, already exists in electronic
repositories. Well-known privacy experts have documented the threats that misuse of this
information has on personal privacy (Meystre, Savova, & Kpper-Schuler, 2008). The paper
record is no barrier to duplication, as medical records are routinely copied and faxed among
health care providers and insurance companies already. While some fear the EMR will
exacerbate this problem, others note that computer-based records, with appropriate security, are
potentially more secure and at a minimum leave a trail of documentation of those who access
them (Mandl, Kohane, & Brandt, 1998).
Empty Data Fields
While this issue varies by the proprietary nature of the system being used, many EHR
systems allow for auto-population of data for new records. While these shortcuts save some time
and effort on behalf of the physician, they can also result in inaccurate new records if the
previous auto-populated record is not current (Meystre, Savova, & Kpper-Schuler, 2008). For
example, if a patient went in for surgery in June and this was not or improperly documented, a
"no data available" empty data field error message or, even worse, inaccurate information could
be displayed. Once again, the creation of standard work and managing to these standards is
critical to prevent this type of problem.
Copy and Paste

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Copy and paste is by and large the biggest ugly of all the shortcomings of EHRs. Because
documentation is more involved with EHRs, physicians may rely on the copy and paste function
as a shortcut, particularly for routine or follow-up visits. While this may save time for the
physician, this puts the patient's safety at risk and impairs quality of care as updates or changes
between visits can be overlooked or not documented properly.
The Future of the Electronic Medical Record
With the increased incentive to document and scrutinize the delivery of medical care, the
use of the EMR should continue to increase. For the EMR to be effective, it must be beneficial
to the user, the individual clinician who will be entering the data and using the results for patient
care decisions. Data entry must not be excessively time-consuming or otherwise difficult, while
obtaining information out must be similarly fast and easy. Clinician involvement is crucial for
successful implementation of EMR’s. The system must not compromise patient confidentiality.
Reasonable mechanisms must be implemented to insure patient information is not viewed by
inappropriate viewers and those who breach security are appropriately punished (Meystre,
Savova, & Kpper-Schuler, 2008). But security must not be so restrictive as to impede use of the
system by clinicians.
It is very likely that the clinicians of the future will interact heavily with computers. Not
only will processes of healthcare delivery become increasingly automated, but larger amounts of
non-patient information, such as the medical literature, will also be accessed electronically. This
future clinician will likely use a computer to enter findings and diagnoses, take advantage of
links that connect these with decision support modules and the medical literature, and
communicate with colleagues and others taking care of the patient.

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Conclusion
The advantages of EHRs to the physician, hospital or physicians' office and patient alike
are considerable. That being said, the "bad" and the "ugly" can often outweigh the "good." To
avoid these issues, hospitals and healthcare systems must perform a thorough evaluation of the
EHR system before purchase and implementation. Unfortunately for many, this is a step often
overlooked. In fact, a recent Black Book Rankings survey mentioned above found that 79
percent of the 17,000 participants surveyed reported they did not sufficiently evaluate their needs
prior to selecting their EHR system.
Taking the time to evaluate new technology and implement a new process, such as Lean
management, to evaluate workflows and identify and eliminate waste before implementing a new
EHR system, will help improve implementation, foster communication, decrease non-value
added work and ultimately increase adoption.

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Project Description
My final product will investigate the use of Electronic Health Records by the
visualization of bar graphs reported between 1996 and 2013. These bar graphs will evaluate
types of physician practices, hospitals, and other healthcare facilities that have adopted the
electronic health record. Overall, these graphs will show the increase in the amount of electronic
healthcare data that is being used by physicians and healthcare facilities. These graphs will
depict challenges with EHR adoption which will help researchers in the field of Health
Information Management who seek to understand the pros and cons of EHR adoption through
visualization techniques.

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Becker, M. Y., & Sewell, P. (2004, June). Cassandra: Flexible trust management applied to
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IEEE (pp. 139-154).
Blumenthal, D., & Tavenner, M. (2010). The “meaningful use” regulation for electronic health
records. New England Journal of Medicine, 363(6), 501-504.

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Burton, L. C., Anderson, G. F., & Kues, I. W. (2004). Using electronic health records to help
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McInnes, D. K., Saltman, D. C., & Kidd, M. R. (2006). General practitioners' use of computers
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Miller, R. H., West, C., Brown, T. M., Sim, I., & Ganchoff, C. (2005). The value of electronic
health records in solo or small group practices. Health Affairs, 24(5), 1127-1137.
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American Medical Informatics Association, 12(5), 505-516.

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