Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

An Examination of Factors in the Healthcare Environment that Halt Adoption of Electronic Health Records - Matthew Lee

Electronic health records, also known as electronic medical records, are patient health records stored in digital format. Typically, electronic health records contain past and current medical information of the individual as well as medical referrals, treatments, and medically-related administrative information. Data in electronic health records can come from patient medical records, third-party health information providers, lab results, hospital information, as well as medical insurance information. Widespread use of electronic health records can potentially improve public health by limiting medical error, duplication of diagnostic tests, reduce paper work, and reduce health care costs. Slow adoption of electronic health records by the medical establishment and inertia of practice changes by medical practitioners raises healthcare costs, lowers the standard of medical care in America, and contributes to fragmentation of the US health care system.
Promise of EHR
Use of electronic health records can help improve overall patient care. In some areas of medicine, electronic health records are already being used to supplement clinical decisions regarding specific medical issues. The Australian General Practice Model has already shown significant improvements in falls prevention among elderly patients and the physically disabled (1). A recent survey showed that some of the most important perceived benefits of electronic health records were improving ambulatory/outpatient capabilities and making optimal use of emerging medical technologies (2). Healthcare providers view electronic health records as buttressing the quality of care they can provide for patients, which is welcome news to all consumers of healthcare. Electronic health records are also helping to shift the focus of healthcare towards prevention, which can help prevent disease or mitigate the severity of disease symptoms (3).
Patient safety incidents, including wrong site surgeries, medication errors, and other errors by health care providers, in the United States continue to rise with an increasing disparity between higher quality care and lower quality care. A recent study found that from 2003 to 2005, Medicare-related patient safety incidents rose by 3% with approximately 250,000 preventable deaths (4). Electronic health records would help prevent many of these medical errors by providing information to the health care provider such as appropriate medication doses and pertinent medical history when needed. In addition, unified electronic health record information systems would help curb unnecessary medical tests that are being performed in the United States, because of the lack of continuity of care. Widespread adoption of electronic health records that are communicable from inter-network health information systems would help alleviate the ordering of redundant tests.
One of the major complaints among practicing health care providers is the enormous amount of paper work that constantly needs to be completed during each working day. Administrative duties, referrals, insurance claims filing, medical history, and lab results, all contribute to the enormous time and space that health care providers waste filing paper work. Having all the information compiled into one electronic health record would simplify the process of information accrual as well as medical insurance claim filing.
The benefit of electronic health records extends beyond the patient care realm with the possibility of monetary savings. With ballooning health care costs, the price of public health is an increasingly heavier burden that the United States cannot afford to ignore. In 2001, at $5,021 per capita the United States led all developed nations in health care spending, nearly doubling its nearest competitor, Switzerland at $3,322 (5). An estimated $81 billion of overall health care spending can be saved with efficient electronic health record implementation and networking (6). These savings could be passed directly on to patients, healthcare providers, employers, and payers alike. Although a savings of $81 billion is relatively small compared with the approximately $2 trillion in overall health care spending, it is still a substantial savings.
Diffusion of innovations social science model
Electronic health records and other aspects of medical informatics are still emergent technologies. Innovators and early adopters represented by major academic medical institutions, HMOs, and certain small group practices are currently using the technology. An estimated 28% of United States health care practitioners use some type of electronic health record in their practice or through their institution. This is far below the use of other developed nations, such as the 95% in the Netherlands, 90% in New Zealand, and 87% in the United Kingdom (7). Applying Everett Rogers’s theory, adoption of electronic health records are still in the lower tail of the technology diffusion S curve, and may be stuck at the decision stage of the diffusion of innovation theory (8).
The diffusion of innovations is a social science model that applies to the lack of adoption of electronic health records in the United States. The dissemination of innovation focuses on three basic clusters of influence that, in descriptive studies, correlate with the rate of spread of a change: (1) perceptions of the innovation; (2) characteristics of the people who adopt the innovation, or fail to do so; and (3) contextual factors, especially involving communication, incentives, leadership, and management (9).
Perceptions of the innovation depend upon perceived benefits of the change, compatibility of the innovation to the values and needs, and complexity of the proposed change to the adopter. Many physicians have heard of electronic health records, especially those working in hospitals or large institutions. However, the perceptions of electronic health records still remain negative over issues, such as tedious information entry, adequacy of training, and general work flow issues (10-12). More widespread adoption of electronic health records by health care providers requires changes in the overall perception of this technology and the benefits as well as limitations inherent in using it.
Dearth of role models and insufficient knowledge of benefits
When it comes to new medical techniques, new methods in practice management, and adoption of medical technology, many medical practitioners observe and model the behaviors, attitudes, and emotional attitudes of other medical practitioners. Since there is a prevailing attitude of wait and see for new technology and practice changes, the adoption of innovations is limited. Innovators in the medical community are often limited to academics and those in HMO practices that are either helping to push along the innovation or have incentives to do so. Widespread use of electronic health records faces a similar barrier to adoption.
Similar to other innovations in health care, buy-in by opinion leaders within the health care provider community, incentives, and clear communication of its benefits are required for greater adoption of electronic health records. An opinion leader is one who is held in high esteem by those who accept their opinions (13). In health care, opinion leaders could be well-known nurses or physicians who are reputable in their specific area of medicine. For years, pharmaceutical companies have paid health care opinion leaders salaries, covered travel expenses, purchased expensive gifts, and treated them to expensive meals. They have essentially bribed health care providers into advocating their products (14). Although this is not a healthy approach to increasing adoption of electronic health records, the success of the pharmaceutical companies in increasing health care provider awareness and use of their products points to the effectiveness of selling the innovation to the end users.
Technical Obstacles
Current technological limitations have also inhibited more widespread adoption of electronic health records among healthcare providers. The overall patient records architecture presents challenges to the development of an efficient and useful electronic health record. Once an architecture has been developed, the data contained within must be searchable and instantly accessible to the physician. Further, the health care provider needs to be able to enter clinical information quickly, so the electronic health record should be able to recognize clinical terminology. In addition, often the healthcare provider does not work alone, so different systems need to be able to communicate with each other using interoperability standards. Overshadowing all of these surmountable technical issues is the worry of security of the patient data.
A major technical hurtle in the development of electronic health records is interoperability of different systems. Every major application vendor that produces electronic health record systems created their programs using a coding standard that may or may not be able to communicate with other health information systems. In any given clinical setting, too many different types of information inherent in health care pose a challenge in developing information architecture capable of handling the data. For example, in a hospital emergency room admission discharge and billing as well as nurse triage, laboratory systems, pharmacy systems, and intensive care monitoring all need to contribute information to the patient health care record (15). Standard terminologies are an essential part of preserving inter-system semantics, and set language standards to address this issue have been developed. For example, the Logical Observation Identifiers Names and Codes database is a set of universal identifiers for laboratory and other related clinical observations (16). Logical Observation Identifiers Names and Codes terminology is a simple enumeration of the observations about the patient that does not create concepts about the results of the coded observations, but others, such as SNOMED-CT® do (17). A single or defined set of standards needs to be defined before electronic health records can be more widely adopted.
In addition to the dearth of an accepted architectural standard in electronic health records is the diversity of clinical terminology employed by health care providers. Many physicians and nurses employ shorthand in their clinical notes in patient charts, necessitating the need for standard clinical semantics. Although international classification of diseases 9 (ICD-9) codes have become a de facto standard due to health insurance reimbursements, they are difficult to memorize and cumbersome to use. This limits their utility and the speed in which medical information is added to a patient’s electronic health record. Having a codified, searchable programming language is an adjoining technology barrier that has been recently been overcome with the development of XML (18). It will take time for this new technology to diffuse and become more widely adopted in the industry.
Security of patient information remains a challenge for electronic health records. A private practice physician typically sees one patient at a time. However, in a hospital setting a patient may see an entire team of physicians in different departments, have medical diagnostic tests performed, and associated administrative or insurance information to fill out (19). Securing patient information in such complex workflow situations becomes that much more difficult. With the passing of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, patient confidentiality takes on even greater importance. The development of Internet applications to handle electronic health records has proven to be both a benefit and curse. Technical issues, such as updating software and other similar problems with electronic health records are largely eliminated with Internet applications. The application service providers handle most of the upgrades by updating the software on the server hosts for the Internet applications (20). With an Internet interface, electronic health records are more readily accessible for both patients and healthcare providers alike. However, the difficulty of securing the data so that only the intended user can view the information increases exponentially with greater access.
Economic obstacles
One of the primary concerns of health care providers in implementing any new technology or technique is the cost of the innovation. A radiologist spending $100,000 for new x-ray equipment can more easily justify the cost of that investment compared with the estimated $40,000 initial set-up costs and additional $10,000 per year maintenance fees required to install an electronic health record system. This is especially true when there is no immediate financial gain from the investment (21). Although practicing physicians are estimated to gain $86,000 over 5-years with the implementation of electronic health records, the time and resources required to learn a new system of clinical care information recording remains a barrier to wider use (22). Physicians have very few alternate financial incentives to improve their standard of care, which is reflected in the lack of adoption of new technology such as electronic health records (7). The creation of federal and state subsidies for healthcare providers, institutions, and payers to implement electronic health record systems would help spur greater investment in this field. Increased investment and greater adoption of electronic health records would increase competition among electronic health record application developers and lower prices for the end users.
An ancillary cost tied to current technological limitations comes from the issue of storage. Physician’s offices, clinics, and hospitals are notorious for their massive space concerns because of paper patient records. With electronic health records, physical space is all but eliminated. However, finding economical and efficient means of storing the digital information has become a growing concern. Affordable storage solutions access data slower, while faster data access is generally accompanied with high costs. These storage solutions can range in cost from $65 per gigabyte to $15 per gigabyte (23). With the average hospital capable of accumulating up to 500 terabytes of information, there are significant financial costs that electronic health records are creating. Until digital storage advances, healthcare providers will have to make compromises to data access and the types of medical information that can be stored in digital format.
Future steps
Several steps need to be taken to make the promise of electronic health records a reality. Perhaps the largest technical obstacle is the adoption of an architecture standard for electronic health records and other clinical information systems. This is a technical hurdle that is surmountable, but will require greater cooperation within the sphere of the medical informatics community before it can be standardized. Another issue is the dispersed hodgepodge of private, public, and semi-public institutions, private practices, and small medical practices (24). Without a national healthcare system to unify efforts, the deployment of technology such as electronic health records relies on market forces and individual adoption of the technology, which is haphazard in the diverse market that comprises the US healthcare system.
Better organization of the national healthcare system will have to wait for sufficient political and corporate impetus, but standards in the adoption of electronic health records can be accomplished now. Leading the development of standards are two federal organizations, including the Office of the National Coordinator for Health Information Technology (ONCHIT) and the American Health Information Community (AHIC) (25). These two federal organizations are responsible for federal contractors to private-sector organizations. It is unclear yet if the ONCHIT and the AHIC will be able to help build the infrastructure and manage cooperation in the private sector to enable more rapid and widespread adoption of electronic health records.
A widely adopted architecture standard for the syntax used to create electronic health record programs is necessary to enable communication of electronic health record systems with each other. The success of small-scale electronic health records projects may help encourage development of a national standard. Limiting the project to one aspect of health records, such as medication errors would facilitate bringing together health care providers, payers, employers, patients, governmental agencies, as well as information technology vendors to implement standards. For example, the nonprofit organization Vermont Information Technology Leaders (VITL) is working towards the development of a comprehensive medication history (26).
HL7 was conceived as a standard that would permit an affordable interfacing of heterogeneous systems to create an integrated hospital information system (27). It is both a standards developing organization and collection of published protocols that has gained widespread usage in the health care industry and is rapidly becoming a recognized international standard (28). HL7 compiles the data to be exchanged between systems into messages. The messages can be a response to a query or simply an update of information. For example, a query might be as simple as one system requesting the lab system to send all lab results for a specific patient. This would be useful for transmitting more complex data, such as medical image scans. HL7 version 3 also uses extensible markup language (XML) for health care, which is also known as clinical document architecture (29). XML documents are machine readable, allowing the document to be parsed and searched electronically. A major impact of adoption of the HL7 reference information model standard in family practice and other primary care providers on public health is the ability to link electronic health records in these clinics with other medical networks to ensure continuity of care. The development of the HL7 reference information model standard can contribute to more widespread adoption of clinical guideline standards through electronic clinical decision support tools. A review of a test model already being developed would be useful in understanding the obstacles in implementing clinical guideline decision-support tools in clinical information systems.
Widespread adoption of electronic health care records can reduce healthcare administrative costs and improve overall patient care. However, the current state of electronic health records has limited adoption of this new technology. The diffusion of innovations model of social behavior helps frame the issues related to electronic health record adoption through misperceptions of the technology from lack of role models and knowledge of benefits of this technology, technical limitations, and economic obstacles. Electronic health records will not become more prevalent or gain greater penetration within the fabric of public health until technical standards and implementation standards are truly created and regulated by national or state/regional bodies. Once these standards are developed and adopted, public health stands to benefit from the promise of electronic health records.
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