Proper Use of Electronic Health Records Could Enhance Patient Care

If properly utilized, Electronic Health Records (EHR) could increase the quality of care for Medicare’s beneficiaries and lower program costs. EHRs provide the possibility of easy transfer of information between providers, and better patient access to important information. This can mean that clinicians are apprised of changes in health status, with access to information regarding hospital, Intensive Care Unit (ICU), and Skilled Nursing Facility admissions.

EHR also have the potential to highlight and prioritize patient needs and preferences. For example, the goals expressed by a patient through a Physician Order for Life-Sustaining Treatment (POLST), or in an Advanced Directive, that are accessible in her EHR, can inform an emergency first responder as well as an ICU physician. Further, a well-designed EHR has the potential to assist a care team as it coordinates treatments and plans to meet the patient’s goals.

Each year, hospitals, primary care physicians and specialists are more likely to have Certified Electronic Health Records Technology (CERHT).  The extent to which these systems are accessed, however, is unclear.[1] Although providers are increasingly likely to record the results of an annual wellness exam, for instance, on a patient’s online portal, many patients are either unaware of these electronic records or do not know how to access them.

Additionally, the EHR goals of providing accurate, accessible information are only effective if the technology is properly used. The Centers for Medicare & Medicaid Services (CMS) recently proposed rules that define the extent to which clinicians must engage with their CERHT in order to keep Medicare payments in the future. The Center for Medicare Advocacy commented on the proposed regulation, expressing concern that CMS set such a low bar for the utilization of EHRs that physicians could do the bare minimum to satisfy CMS’s standards.[2]

While some clinicians and patients are understandably concerned about the security and accuracy of EHRs, available data should allay some of these concerns. Although CMS is proposing a very low bar for utilization, the possible benefits outlined above, and the discussion below regarding the accuracy and security of EHRs may influence more patients and providers to utilize these systems. While EHR systems are still relatively new, greater adoption of Electronic Health Records has the promise of enhancing health outcomes.

Electronic Health Record Security

Given the number of data breaches in recent years, more needs to be done to secure Medicare patients’ Electronic Health Records.[3] There are a few areas of concern and optimism:

Concern:

• In a survey that included respondents from hospitals, clinics and ambulatory health centers, IT leadership, and health care executives, Health IT Outcomes found that addressing health IT security was the top priority of those surveyed (42% percent of those surveyed).[4]

Cautious Optimism:

• It is unclear how recent data breaches are affecting the public’s perception of health IT privacy and security. The Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology (ONC) released data that showed the public’s confidence in the security of health IT grew from 2012 to 2014. The number of surveyed persons who said they were very or somewhat concerned with the privacy of medical records dropped from 77% in 2012 to 58% in 2014. The number of persons who said they were concerned with the security of medical records dropped from 72% in 2012 to 52% in 2014.[5]

Electronic Health Record Accuracy

Medicare beneficiaries may also have concerns that their electronic health records may not be accurate or up to date.  There is evidence, however, that EHR can create an accurate record in even the most fast-paced and stressful environments. Many of the problems regarding record accuracy could be significantly addressed if providers were required to do more than the bare minimum to participate in the upcoming MIPS program, and if patients themselves took greater initiative to check and, when appropriate, update their medication records.

Concern:

• In April 2016, Leapfrog Group, an organization that rates hospitals on patient safety, surveyed 1,800 hospitals and found that 40% of potentially harmful drug orders were not flagged by electronic health systems. These included medication orders for the wrong dosage or for the wrong condition. Moreover, Leapfrog discovered that EHRs missed 13% of particular kinds of errors that could have resulted in patient deaths.[6]
• A 2013 American College of Emergency Physicians report highlighted mistakes in the emergency room such as the ordering of the wrong medications in patients’ EHR. The study surmised that these mistakes were likely a result of a poorly designed record.[7]
• A 2010 Medical Care Research and Review literature review of 35 studies concerning EHR accuracy found “significant errors of omissions” in medication lists. Errors in retention of previously discontinued mediations were present anywhere between 13 and 29% of the time. In two studies, a high proportion of patients (81 and 95%) reported errors in their mediation lists.[8]
• A 2008 International Journal of Medical Informatics study highlighted that 54% of users of an EHR lacked up-to-date information in their health records concerning their over-the-counter medications. Around three times more over-the-counter drugs than prescription drugs were missing from patient records. The study further found that a patient’s emailing a provider in an effort to try to update his or her records rarely resulted in the updating of this information by providers.[9]

Cautious Optimism:

• A 2015 Journal of Biomedical Informatics article discussed an emergency department simulation that involved comparing the accuracy of entering records by hand to those entered electronically. A “comparison of diagnostic accuracy with and without access showed that accessing the EHR led to an increase in the quality of the clinical decisions.”[10] In the case of esophageal spasms, muscle pain, and diverticulitis, for instance, the preliminary diagnosis matched the final diagnosis when an EHR was used, but the preliminary and final diagnosis varied significantly when an electronic health record was not used.[11] The variation present when an EHR was not used may have something to do with the fast-paced environment of an ER in which ER providers take notes on papers that can be easily lost. A Modern Healthcare article had this to say about the drawbacks of not using electronic health records in an ER: “A triage nurse who is attending to multiple patients at once might scribble each individual’s details on the back of a piece of paper—ducking away later to enter the information into the computer system. That can make it easier to confuse patient records.”[12]
• A study conducted in the first half of 2012 by the National Opinion Research Center at the University of Chicago gave the roughly 200,000 patients enrolled in the MyGeisinger Health System that served central and northeastern Pennsylvania the option of indicating which medications they were no longer taking. The information was then presented to a pharmacist via the EHR and the pharmacist then reviewed the new data and had the option to contact the patient and the patient’s physician. In 89% of these cases in which forms were completed, patients requested changes to their medication record regarding such things as the frequency of their medication dosage. Out of a sample of 107 patient forms, pharmacists made updates to patients’ medication records reflecting the new information patients provided 68% of the time. Additionally, patients who were contacted by pharmacists found this follow up discussion reassuring.[13] The MyGeisinger pilot demonstration showed that increased patient-pharmacist communication can lead to a more accurate patient electronic health record when this communication occurs within a built-in communication tool.

Conclusion

Electronic Health Records are a work in progress.  Better patient and provider utilization of EHRs is the best means of ensuring that patient records are accurate and helpful. With CMS’s push for interoperability of patient records, providers have strong incentives to fix many of the growing pains that have caused concern. Given the benefits outlined above and the reported progress toward more secure and accurate EHRs, these systems hold promise for enhancing patient care.

July 13, 2016 – M. Hubbard.