Electronic health records (EHRs) replace the paper-based patient chart with an electronically based patient chart. At a minimum, EHRs must be able to:

• Produce an electronic encounter note effectively and efficiently. Many EHRs use the SOAP note format (subjective, objective, assessment, plan) and include checklists that allow the physician to record clinical findings. Most EHR products facilitate the entry of clinical notes that meet the evaluation and management documentation standards. EHRs accept the relevant billing information about a patient visit and send billing information to the medical billing system.

• Store a variety of information, including diagnostic reports, referral letters, lab results, and images. EHRs may store lab information as values in a table that can be reviewed and analyzed in graphs. Letters and documents received from outside parties are stored as images that can be accessed through the EHR; however, these files may not update EHR-based information. For example, an incoming image of a referral letter may not update the status of the referral order in the EHR.

• Keep track of messages and patient issues, such as planned treatment, scheduled surgery, and pending diagnostic tests that need to be addressed by physicians and staff. Clinicians and staff may need to address patient issues immediately or follow up on patient issues months or even years later.

There are no globally accepted standard definitions or EHR feature requirements, so each EHR vendor has developed their own version of solutions to these three basic requirements. For example, some EHRs allow you to attach images to a message, whereas other EHRs only accept a text message that is stored in a general to-do list. Some EHRs provide checklists and appropriate features for specific areas of medicine but may lack basic tools for other areas of medicine.

EHRs may differ dramatically in their design and capabilities owing to medical specialty, practice size, or technical aspects of the software. For example, primary care-oriented EHRs have outgoing referral features and immunization tools, but may not have surgery scheduling tools needed by general surgeons and orthopedists.

EHRs may have workflow tools to monitor patient flow in multiple offices and even pods within an office. Many EHRs do not address workflow issues for the larger practice.

Some EHRs use a third-party image management tool to present and support annotation of images. These tools are accessible from the EHR but may have a different look and feel from the basic EHR product.

Several EHR vendors use third-party patient portals to supplement the features of their EHR. That means that the patient portal may display information sent from the EHR, but it may not necessarily send information back to the EHR. In such cases, the patient portal would have separate software tools to view messages sent to the practice that are not available or noted in the EHR.

EHRs have many advantages over the paper chart, as well as certain limitations. For example, most EHR systems present a patient summary sheet with prescriptions, orders, and list of notes that is more accurate and easier to maintain than the face sheet of a paper chart. On the other hand, many physicians can get an overall picture of the patient's situation by fanning through the pages of a paper chart—which is not possible with many EHR products.

Why Are More Physicians Getting EHRs?

Originally, EHRs were used by physicians taking advantage of technology to improve operations and patient service. These early adopters were inspired by the positive effects that technology had on many other areas of business. Having seen how billing systems helped operations, many physicians believed that the positive impact on claims and collections would be replicated with EHRs.

Few physicians implemented all of the features of their EHRs, and few experienced results that were superior to those obtained with the paper chart. Indeed, by the end of 2008, approximately 42% of physicians were using an EHR. In most cases, the EHR was being used for basic dictation and record storage.

The Centers for Medicare & Medicaid Services (CMS) program for EHR meaningful use (discussed further in Chapter 2) triggered a dramatic increase in EHR installation and use because CMS offered cash incentives to use EHRs. Up to $44,000 could be earned through the Medicare program, whereas the Medicaid program offered up to $63,750. These incentives could offset a substantial portion of the cost of implementing the EHR required for meaningful use. By the end of 2015, over 80% of doctors were using an EHR.

Another factor in EHR adoption was the encouragement of integrated delivery systems (IDSs), physician hospital organizations (PHOs), and others that wanted to capitalize on technology to improve productivity and cut costs. To achieve systemic objectives, these larger healthcare organizations needed a technology base within practices to strategically support electronic exchanges of information. Such exchanges would help the IDS or PHO, but not necessarily the physician.

For example, PHOs wanted to use EHRs to support contracting with payers on clinical improvements and superior patient services across a variety of PHO members. A standard EHR would allow the PHO to gather information on performance and patient service. However, physicians may be challenged by the varying operational and EHR requirements by different PHOs. For example, a practice may belong to a PHO that requires the use of EHR "A," but the hospital near their practice may support only EHRs "B" and "C."

IDSs aimed to create more effective relationships with clinicians by enabling easier patient registration and delivery of reports to medical staff. Physician-based EHRs would allow the IDS to upload information on patients and download diagnostic results and procedure notes. However, physicians may be required to use EHRs that are not necessarily appropriate for their specialty. For example, an ophthalmology practice may be told to use an EHR that does not have ophthalmic checklists or interface with relevant diagnostic equipment.

Reference labs wanted to improve the flow and processing of samples for analysis as well as provide more useful results on a more reliable basis. For example, electronically delivered results could be loaded into an EHR-based flowsheet to monitor and track trends over time. Of note, several labs provided subsidies to offset the lab interface costs charged by EHR vendors.

Why Do So Many Physicians Have Problems With EHRs?

Healthcare has experienced a significant number of growing pains and challenges in using EHRs. These problems have included technical as well as compliance issues. For example, early EHRs lacked the ability to annotate images or even compare images on the same screen; in the paper-based world, that task required only some desk space and a pen.

The EHR checklists and features offered by vendors were also missing important aspects of patient services and clinical operations. Many EHRs lack surgery scheduling tools to track the variety of surgical administrative and clinical issues. Similarly, the EHR may have checklists for general orthopedics, but lack the details needed by a spine surgeon.

The evaluation and management note standards were programmed into many EHRs to help doctors meet the evaluation and management documentation standards. The EHRs encouraged (or forced) clinicians to fully document information that was not necessarily documented in the paper chart. For example, on paper charts, many physicians documented remarkable findings in detail and negative findings as "WNL" (within normal limits), but some EHRs forced the physician to provide more extensive documentation for unremarkable observations.

In addition to the technological challenges posed by EHRs, doctors also face difficult transitional issues from the paper charts:

• Paper charts contain important contextual information about the patient's medical history. In addition, medical and legal standards require keeping historical information from the paper chart. A physician may have an expensive and complex challenge in properly setting up the patient in the EHR and recording clinically important information from the paper chart. For example, a birth abnormality, previous procedure, abnormal lab result, or history of blood test results may be important for specific patients but not easily transferred from the paper chart to the EHR. Indeed, a significant amount of patient information may still be on a paper chart after the EHR is in use, or the practice may be faced with an expensive process to scan the previous paper chart into the EHR.

• The practice may own old diagnostic equipment that cannot be connected to the EHR. After conversion, the EHR becomes the location of the patient's designated record. In that case, the practice may have to incur the expense of diagnostic equipment that can work with the EHR, or have to scan and/or enter diagnostic images, readings, and information into the EHR.

• EHR tools dramatically affect the speed of information movement and the tracking of patient service in the practice. Important roles that exist in the paper world may disappear with an EHR, and jobs that don't exist in the paper-based office will become essential with an EHR. For example, paper chart prep staff are not needed with an EHR, but your practice may need an EHR support specialist.

• Flipping through a paper chart can easily give you a general impression of the patient. Many physicians can get an excellent overview of the patient's situation based on the pages documenting the frequency and type of tests, as well as other documents. Flipping through an electronic chart is more time-consuming because each image must be separately accessed.

• Many physicians document remarkable observations in paper charts that can concisely flag remarkable issues relevant to the patient's situation. EHRs collect much more data, which may be more difficult to review for the relevant remarkable information. For example, some doctors have encountered a 5- to 10-page office note from an EHR, whereas their previous notes consisted of a few paragraphs of relevant information.

In addition, doctors may have to dramatically change their patient service style to work with the EHR. The checklists in the EHR may differ from how the clinician previously collected information. In other instances, the clinician may have issues with the EHR's user interface. Any change to the doctor's treatment style could have ripple effects on patient flow and services. Adopting an EHR requires intense practice so that the physician doesn't experience a slowdown in productivity and patient services.

Because all information is in the EHR, all staff and doctors need to have constant access to it. Staff and physicians who are not comfortable with or skilled in using an EHR may end up with clinical and operational problems in the practice. And it is important for every practice to have adequate workstations, tablets, and computing power to effectively serve all staff and physicians at the same time.

An EHR brings a variety of benefits. However, a practice needs to overcome a substantial set of challenges to avoid having problems implementing or using an EHR.

Cloud vs In-House EHRs

In-house EHRs are based on a central system or server that is physically located in the practice. In contrast, cloud-based EHRs are supported from a computer center that is typically accessed through an Internet connection.

For in-house EHRs, the practice purchases the computer servers and software to support their EHR installation upfront. In most cases, these purchases are designed to meet the storage and processing needs of the practice for 18-36 months. This additional capacity is needed to avoid having to reconfigure the system at yet more expense. The practice must also buy the EHR software and licenses needed to use the system. So, starting on day one, you incur a substantial financial outlay for hardware and software that are not necessary with a cloud EHR.

Vendor charges for cloud-based EHRs are typically based on a cost per month per clinician. The monthly fee includes the central hardware in a remote location that serves many other practices as well as the software license and support fees. Cloud hardware is designed to allocate additional hardware capacity as the practice grows and it is needed, rather than paying to have the resources ready to be used with the in-house system. The dynamic resources of cloud-based EHRs are also more flexible for growing practices. For cloud-based EHRs, the practice also has to pay for Internet access for all users (which is not necessary when users are at the location of the in-house system).

A hybrid solution is also available: The practice buys the cloud services from any one of a number of vendors, and installs their purchased software on the cloud service. Regardless of the strategy, the practice will have to purchase the various workstations, printers, and other devices for users to access and use the EHR.

Many EHR vendors offer both in-house and cloud-based solutions. The key issues with cloud-based and in-house options include:

• Hardware: Cloud-based EHRs offer more flexible use of computer capacity and storage. In-house systems require purchasing hardware well in advance of when you may need the storage or computing power.

• Compliance with the Health Insurance Portability and Accountability Act (HIPAA): Cloud-based EHRs address several HIPAA security issues that are difficult for practices. From physically accommodating servers to managing backups, cloud-based EHRs require less work from the practice than in-house systems.

• Communication: Cloud-based systems typically require more communication capacity, because all practice sites need to have an Internet connection for all EHR users.

• License costs: In many cases, monthly cloud fees include software license fees, which are paid for as long as you use the cloud services. Typically, cloud fees are structured to pay for the license in 2-4 years. Most in-house EHR systems require purchasing the licenses upfront, plus an annual maintenance fee. Because EHRs are very difficult to change, most practices will keep their EHR for years and the cloud EHR fees will continue to include the license component. Over the life of the EHR, the practice could pay more in license fees than they would for an in-house system.

• Exit strategy: In the event that your practice moves to another EHR in the future, the practice will have to continue to pay the cloud EHR fees (in most cases) to maintain access to patient information. Because healthcare organizations are required to retain this information, they will probably need to find more acceptable cloud exit strategies. In-house systems can be maintained at minimal costs for as long as the practice needs to maintain the old EHR records. Whether using the cloud or an in-house system, the EHR contract should address the transition to a new system at the end of the useful life of the EHR that you are buying.