Note: The vast majority of commercial EHR products have met the standards needed to support meaningful use and are referred to as "certified electronic health record technology." This course will focus on certified EHRs.

Electronic health records (EHRs) are critical tools to support patient care and services. Proper use of the right EHR tool will produce good results; in contrast, improper EHR use or use of the wrong EHR tool will mostly frustrate and confuse doctors, staff, and patients.

Your practice needs to effectively use and maintain technology because the healthcare industry is committed to using EHRs to improve patient adherence and cut costs. Right, wrong, or indifferent, payers are attaching more of your income to the effective use of technology. The 2015 repeal of the Medicare sustainable growth rate and the increasing linkage between payments and performance by commercial payers presents a complex strategic challenge to every practice and healthcare organization.

Many practices adopt EHR systems and continue to use the same workflows that were used with the paper chart. Wherever paper flows, the computer system is sure to follow. For example, some practices continue to route incoming paper reports to the staff and doctors until the document is signed off on. Then the document is scanned into the EHR. Similarly, many practices still route paper message forms and scan the form into the EHR after the patient has been contacted. Sometimes, administrative staff types the message and the doctor's response into the EHR.

However, there's a major difference between EHR-based patient records and paper charts. EHRs provide instant access to a patient's chart to as many people as necessary at any time. Instantaneous access changes everything, because no one is tethered to a paper chart and no one controls access by holding onto a patient chart. Practices need to change the workflow and processes to capitalize on EHRs and meet patient service requirements that are difficult or impossible with a paper chart.

For example, patient care items can be viewed easily on the EHR patient summary screen, but finding these same items on a paper chart would require a time-consuming manual search to find the patient orders, and yet more searching to determine whether the care items had been completed. Indeed, practices continue to struggle with tracking the location and disposition of paper messages and documents.

Too often, practices defer key decisions on strategies and tactics to the technology vendor and trainers. These parties, however, are not well positioned to focus on the needs of your practice, organization, and patients. To achieve the efficiencies possible with an EHR, the practice needs to design policies and procedures that take advantage of the EHR. Consider the following factors when designing and using your EHR:

EHR Capabilities

To support the practice, the EHR requires certain key baseline capabilities. However, not all EHR products are created equal. Indeed, some of the most important features needed to run your practice are not included in the meaningful use-focused EHR requirements. For example, some EHR products do not include workflow routing tools to monitor the flow of patients by office, modality, doctor, and group. These tools are useful, but not included in meaningful use.

CAUTION: If the EHR does not have all of the capabilities that you need to meet these requirements, contact your EHR vendor to design workarounds, and articulate your needs to get changes on the vendor's development program.

The key capabilities that you need to verify are:

• Workflow. Workflow tools manage and monitor patients as they move through the service process. For example, you can document the patient's location (eg, lab, treatment room) and status (eg, ready for treatment, waiting for doctor).

• Patient services. Patient service features accept and manage the various lab, treatment, diagnostic test, and other services needed to heal patients or maintain their health. Patient service tools manage the presentation of relevant services as well as the practice's activities to reinforce care recommendations.

• Charting services. EHRs need appropriate checklists, forms, and documentation tools to address the clinical record-keeping needs of the appropriate area of medicine. For example, the treatment management and documentation needs of a spine surgeon are very different from those of a sports medicine practice.

If your EHR has the appropriate functionality, your staff and clinicians must consistently use the system as designed to produce appropriate results. The processes for recording and managing patient information should be performed consistently throughout the practice. Failure to maintain consistency can distort results and information. For example, if some doctors base the severity of a condition on a scale of 1 to 3 yet other doctors use a scale of 1 to 5, then reports and health maintenance items may not trigger as expected because the selection criteria would have to differentiate between the two scales.

EHR Access and Availability

Before considering any changes to the workflow, you'll need to make some important decisions about the technology that will be used by staff and doctors. For example, a hospital used computers on wheels to support nursing staff and doctors. There were not enough computers for everyone working on a patient. Staff and doctors had to wait for another user to finish up and then sign on each time they wanted to review a patient record or document care. In many cases, the doctors decided to move on and enter the patient order later. Such a situation delays care and wastes everyone's time.

The reality is that if the EHR is going to be used for patient record access, patient flow management, and messaging, then all clinical staff and doctors will require constant access to support patient services. They will need a dedicated workstation, tablet, or laptop at all times. Without a dedicated device, the user cannot monitor his or her incoming messages and issues, or see where the next patient to be seen is.

Note: Providing designated tablets or laptops to all staff and clinicians solves many Health Insurance Portability and Accountability Act that (HIPAA) security issues that may occur when each staff member does not have his or her EHR. For example, shared computers require signing off the computer whenever a staff person leaves the room or another staff member is going to use the system. Sometimes, staff may not sign off to save time for the next person. In many practices or organizations, workstations are signed on in the morning and used throughout the day by various people. And in yet other cases, staff and doctors share workstations and other devices using the same user ID. Each of these situations is not compliant with the HIPAA security rules and leads to a distorted audit trail.

The solution to all of these issues is a separate tablet, laptop, or workstation for each provider and staff person. Note that workstations can be used by staff and clinicians who are stationary while performing their job. For example, the triage staff may be able to use a workstation. Staff and doctors who are on the move need a portable tablet or laptop. Using a portable device may improve flexibility and productivity. For example, a doctor may be able to review some incoming tests or patient information between patients.

A wide array of cost-effective tablets and laptop computers are available, which may be helpful in providing individual devices for all staff and doctors.

The Importance of Posting Information Into the EHR as Soon as Possible

Once information is in the EHR, you can track and manage it. For example, the process of scanning in a radiology report and assigning it to a doctor can be monitored and tracked in the EHR. A paper report on a desk is not known to the EHR or traceable in the practice.

Whenever possible, discrete information should be posted to the EHR. For example, posting lab results with an electronic connection to the lab is superior to scanning a lab report. Discrete information can be presented in a lab flowsheet, which can be graphed by many EHR products.

Note: Some EHR systems have a designated area to enter the physician's interpretation of the results as well as the appropriate follow-up activity.

The key objective is to scan or enter information into the EHR as soon as practical and work on the review and approval process within the EHR, as follows:

• Scan all incoming paperwork at the front desk into the EHR and assign the paperwork to the proper provider or resource.

• Electronically download information from labs, hospitals, diagnostic centers, and other clinicians.

• Work with other clinicians to establish electronic connections to exchange information. For example, the hospitals and diagnostic centers with which the practice or healthcare organization (HCO) does a lot of work should be exchanging electronic information, including orders, results, and summary of care records with the practice.

• Monitor the review and completion of all documents and incoming information within a timeframe that is appropriate to the patient and situation. For example, positive results may require a phone call within 4 hours of receipt, whereas negative results may be communicated by secure message through the patient portal.

Tip: If a key outside practice or organization will not establish electronic exchanges, ask them to fax information instead of sending paper. The faxed images should be routed to a fax server that will be monitored by appropriate staff to file the image in the EHR chart and assign the proper resource for review. The fax server maintains an audit record of the received document.

To make your use of the EHR most efficient, it's important to continually review how the EHR affects your practice, and how aspects of your practice affect how you use the HER. For example, the physical layout of the office may complicate the flow of patients, and the flexibility of staff to monitor and facilitate patient flow using the EHR.

To analyze use, consider the following issues:

• What EHR features are not being fully used, or are not used at all? Why? For example, the practice may use the office workflow feature only to note that a patient has arrived, but not to track the patient as he or she moves between the lab and treatment rooms. You may decide that this is not an important feature for you. As another example, perhaps the doctors may be entering follow-up orders, but overdue order reports are not being reviewed.

• What paper documents are managed outside of the EHR? Why? For example, many surgery schedulers maintain a shadow patient record outside of the EHR because the surgery forms are not scanned into the EHR.

• Where are there operational bottlenecks? How could the EHR help? For example, diagnostic testing equipment may be a bottleneck because orders are not being entered into the EHR.

• For new situations, has the practice developed a standard that incorporates appropriate EHR functions and practice procedures to address the change? For example, a new doctor may provide services that require new clinical content.

• What does the practice need from the EHR to improve operations and patient service? For example, the EHR may not have sufficient filter options for managers to monitor workflow throughout the day.

• What do reports indicate about patient service and response to patient issues? For example, the reports may show excessive wait times to complete messages or review incoming information.

Tip: If the practice or organization changes any clinical aspect, you should review EHR use to determine how to best use the EHR to support the change. For example, the purchase of a new piece of diagnostic equipment, establishment of a new relationship with another practice or HCO, and addition of a new service should be evaluated in light of the EHR.

Tip: Changes to the practice should be structured so that they strategically align with the EHR as appropriate. All things being equal, strategic convergence of a diagnostic equipment purchase with the EHR currently in use is desirable, when possible. Similarly, when negotiating to work with other practices or organizations, it may be wise to include a contractual item that requires beneficial interfaces with the EHR.

CAUTION: Changes to your practice may warrant changes to existing services and working practices. For example, if you open an urgent care center, you may need to rework tracking of patient calls, scripting of the triage line, and message priorities to ensure that the new services are managed within the other practice activities.

After reviewing current use of the EHR, the practice or organization should evaluate the unused or underused capabilities of the EHR against the practice or organization operation and see where it makes sense to change EHR use.

Upgrade to an EHR-Based Workflow

Changes to practice operations are always a challenge, for many cultural and operational reasons. From a procedure that has been used for years to a lack of computer resources, making changes to workflow and documentation standards is difficult. However, failure to make changes to take advantage of the EHR will inhibit your practice and may undermine the integrity of your patient records. For example, if an abnormal result is not recorded in the clinical note, the appropriate clinical intervention may not be flagged.

The key challenge is to strategically align your workflow with the EHR. In some cases, you are better off designing the workflow from scratch without considering the paper-based standard. In other cases, you only need to make some minor changes to produce big results. For example, electronic receipt of information eliminates scanning steps and workflow problems. Similarly, if all information is in the EHR, staff and doctors will not have to go around the office checking on information outside the EHR that they know about.

CAUTION: Using an EHR-based workflow does not mean that the EHR should drive the practice or influence care. The issue is that many practices try to graft on the paper process to the EHR.

If the EHR does not properly accommodate an aspect or service of the practice, then you may need to work around the problem outside of the EHR while the vendor works on a more appropriate EHR-based strategy. For example, many systems lack a serum mixing tool for allergists. Trying to document serum mixing without the right EHR-based tool could be difficult and awkward.

Similarly, the EHR-based solution may be poorly designed or inappropriate. For example, a poorly designed order management tool may prevent you from properly tracking outgoing referral assignments and status. In any case, your practice/HCO should be careful to maintain a balance between the capabilities of the EHR and the needs of your practice.

Being open to a new look at how you manage care and operate will be healthy for the practice or HCO and help you capitalize on your EHR investment. In contrast, adopting the EHR solutions without a critical eye could lead to ridiculous and inefficient processes that do not help your practice or patients. For example, separate EHR functions for images and findings may be less effective than just scanning in the report from the radiologist.

If an EHR-friendly process is not in place, clinicians and staff will do what they need to do to get their job done. For example, if disease-focused order sets are not established in the EHR, doctors will continue to enter dictated notes and free-form text patient orders. Similarly, if a function for surgery scheduling remains disabled in the EHR, the surgery schedulers will maintain their own records of this process in a notebook and not enter this information into the EHR.

To upgrade your workflow, you need to formally analyze it and document a new design. The workflow design should address the following issues:

• How can I most effectively use the EHR features within the practice or organization?

• What procedures and tasks are possible with the EHR that are not being done today?

• What tasks and positions are eliminated with effective use of the EHR?

• Who will manage the various patient service steps and record information in the EHR?

• Does the change in workflow affect signage, location of staff, and areas where patients are served?

• Are doctors and staff using the EHR according to the workflows that were set up by the practice?

• Have staff and doctors been properly trained on using the EHR?

• Are there any paper forms or messages still in use that can be improved through the EHR?

• If an EHR workaround is needed owing to missing or inappropriate functionality, how will the necessary patient service and clinical information be reflected in the EHR?

Note: You need to enlist patients and other clinicians to help optimize your workflow. For example, sending patient information and messages through the patient portal is efficient, but patients need to access their messages. Similarly, exchanging electronic information with other practices in your provider network is more effective and accurate than relying on standard mail and faxes.

Tip: Monitor response and workflow results periodically to ensure optimal EHR use, as well as to make changes that will improve operations and EHR use.

On the basis of the information gathered, you should document the workflow along with the capabilities of the EHR. That way, the final document frames the use of the EHR and specifies what functionality staff and doctors need to know to do their tasks. Using the new workflow design, the practice should train staff and doctors on the new workflow and relevant EHR functionality.

Note: Changes to the EHR may generate changes to the patient records that should be noted and used to train users. For example, if the practice starts using the immunization log in the EHR rather than a text note, then staff will need to maintain immunization inventory as well as deal with the missing immunization information from the EHR immunization log.