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Are you using an EHR—really? Electronic health records can support patient care cost-effectively—but only if they're used as intended

Healthcare Financial Management, Nov, 2005 by Margret Amatayakul

The concept of electronic health records has been around for a while. When used as a fully integrated system, EHRs can support both patient care and the revenue cycle. But so far, their acceptance is slow in coming.

A commonly accepted definition of an EHR incorporates the idea of "collecting data from multiple sources and using them at the point of care to support clinical decision making." This definition has been around for at least the past decade. The Institute of Medicine has issued several reports specific to both EHRs (in 1991 calling the concept "computer-based patient record") and more recently to patient safety. The IOM describes a comprehensive system of reminders and alerts that would help improve decision making and reduce errors. The Healthcare Information Management and Systems Society has offered essentially this definition in position papers and journal articles.

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Nearly two years ago, Health Level Seven developed the EHR System Functional Model and Draft Standard for Trial Use that describes functions focused on capturing discrete data for improved documentation and patient care processes. The Office of the National Coordinator for Health Information Technology espouses the principles supported by this definition, even extending the definition to include health information exchange, personal health records, and beyond. Finally, the Certification Commission on Health Information Technology, which is developing an EHR product certification program (albeit for physician office products initially), has created use cases that call for the EHR to be an interactive system of documentation and support for patient care.

The Good Old Days Are Still Here

The definition of an EHR that incorporates clinical decision support at the point of fare implies a paradigm change in the way physicians and other clinicians use health information and how they document information about care rendered. In reality, this paradigm change is not occurring with many of the current implementations of what are being called EHRs.

What many hospitals today are calling an EHR is actually electronic document management. Paper forms are still being filled out by hand and then scanned into an electronic document repository, usually retrospectively. Notes are dictated into a digital dictation system with listening capability and ultimately transcribed into an electronic document. In some cases, speech recognition is good enough with some correction to result in an electronic document. Lab results and potentially some other data are COLD (computer output to laser disk) fed into the electronic document repository. These documents, however, are electronic images of print files.

In most hospitals, such electronic systems support improved access to information, but do not support improved documentation, let alone provide clinical decision support. The documents are available electronically, but have no individual data elements that can be processed by the computer. The electronic system cannot compare a medication order and a medication allergy for a potential contraindication. The system can make the allergy information available to view, but does not provide a reminder or alert concerning the allergy. Note that not all medication allergies have to be accepted.

The extent to which improved access to information for patient care is actually being used may be questioned. If much of the paper-based information is not made electronic until after discharge, its heightened availability affects only follow-up outpatient visits or subsequent admissions.

A Paradigm for All

The new paradigm, which does provide improved documentation and clinical decision support, is not only for physicians and other clinicians who are expected to use the system, but also for all who provide support or use medical record documentation in revenue cycle management. After all, the documentation of the patient's condition and care processes that have been administered initiates the revenue cycle. Without clearly documented conditions and processes, the health record cannot be coded accurately and completely, which will either delay the sending of bills or cause incomplete or incorrect bills to be sent. Bills are held after discharge to ensure that all charges are captured, but often documentation is insufficient to substantiate the charge or to support the medical necessity for the process being charged. If the revenue cycle is extended beyond coding, billing, collections, and denials, to access management, contract management, and disease management, the lack of documentation or inability to retrieve information cost-effectively from current paper-based medical records, even when they are available from an electronic system, is even more frightening.

The potential benefits of EHRs that support clinicians at the point of care are very important. In addition to making alerts and reminders feasible, they may provide more powerful and more subtle passive clinical decision-support mechanisms. A clinical guideline or protocol embedded in an EHR's documentation system that guides care and documentation ensures medical necessity and helps capture complete data--in real rime and in discrete form. Records don't need to be reviewed for documentation completion, because documentation, and the resultant directives for care, can't occur without the direction of the guideline. The presence of a reminder can be more powerful than an alert that blocks progress in documentation and care. Discrete data can be used to aid charge capture and code generation. Data can be extracted from the EHR for analysis that supports quality improvement, which can lead to better outcomes and pay-for-quality support.

Health Care Industry

Are you using an EHR—really? Electronic health records can support patient care cost-effectively—but only if they're used as intended

Healthcare Financial Management, Nov, 2005 by Margret Amatayakul

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