Running Head: IMPACT OF ELECTRONIC HEALTH RECORDS ON HEALTH CARE 1

Impact of Electronic Health Records on Health Care:

Improving patient outcomes, safety, and treatment plans

Sarah Armenio

HCIN 540

University of San Diego

IMPACT OF ELECTRONIC HEALTH RECORDS ON HEALTH CARE 2

Abstract

Since the publication of To Err is Human: Building a Safer Health System (Institute of

Medicine, 1999) and Crossing the Quality Chasm (Institute of Medicine, 2001) a dialog

around medical errors and how they can be overcome has engaged the healthcare space.

Electronic health records (EHR) have sought to improve patient safety and outcomes and

the enactment of the HITECH Act has sped adoption of such technology. By making visit

information more readily available, through active monitoring of medication and human

errors, and by providing physician decision support, EHRs take a step toward achieving

their goals. By analyzing these factors and the impact of EHRs, it is determined that

EHRs are successful in their goals even though they are costly.
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Introduction

In 2009, the Health Information Technology for Economic and Clinical Health

(HITECH) Act, was enacted as part of the American Recovery and Reinvestment Act (ARRA)

(U.S. Department of Health & Human Services, 2013). Through the HITECH Act, the adoption

of meaningful use of health information technology by healthcare providers was promoted and

rewarded by the federal government. The intention of the act was to promote and advance

technology in healthcare while also stimulating the economy and supporting job growth.

HITECH created a number of stages of requirements to ease adoption of technology and ensure

compliance with the new regulations. The first stage was for health care providers to adopt an

electronic health record (EHR). Failure to do so beyond a set date could result in fines for the

organization. These new regulations caused a rapid expansion of adoption and meaningful use of

technology and EHRs at health care providers throughout the United States. This expansion

created new jobs in the health care information technology space and related fields—a primary

objective of the ARRA.

While EHRs were being adopted prior to HITECH, the rapid and forced adoption of

meaningful use has transformed the health care industry. EHRs are impacting the health care

industry in many ways. As we continue to be more integrated with technology in the health care

space, it is crucial to understand this impact so that we can measure the success and failure of

such systems. There is a significant cost to implementing EHRs and other technologies. Thus,

recording the positive and negative contributions of EHRs is important so that these costs can be

justified and that areas where improvement is needed are revealed.

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Broadly, EHRs can improve quality and coordination of care, access to care, and lower

the costs of healthcare among a suite of other benefits. This paper will narrow the focus using

published literature and studies to demonstrate how EHRs are impacting the health care industry

by making visit information more readily available to improve patient outcomes and speed

diagnoses, improving patient safety through active monitoring of medication and human errors,

and revealing more effective treatment plans through the use of natural language processing and

other technologies to examine data or provide decision support. Reviewing these contributions

and impact will help determine if the cost of EHRs are justified.

EHRs have the ability to put a wealth of information at a clinician’s fingertips. However

that information is only valuable if it is available in a timely manner. Previous to EHRs and HIT,

visit information was documented in paper format and required additional processing causing

delays in the availability of the information. The adoption of HIT and EHRs has allowed the data

to become electronic and quickly available either during the patient visit or shortly thereafter. As

observed by Bardach, Huang, Brand, and Hsu (2009), in early 2004, 85% of office visits used

paper to document the patient visit and diagnoses. Only basic HIT was available and used in

16% of visits. This resulted in delays of the diagnoses being entered and available in the system.

Often the paper record of a diagnoses had to be entered by a clerk days after the visit. Using this

rudimentary method, only 10% of visits had the diagnoses entered on the same day of the visit.

However, by the end of 2006, 98% of office visits were using some form of HIT for visit

information and entering diagnoses. This caused a dramatic reduction in the time between the

visit and the diagnosis being entered and available for that visit. Indeed, by the end of the study

and close to 30 million visits later, 95% of the visits had a diagnoses for that visit available on
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the same day. This increased availability of diagnoses helps subsequent treatment of the

individual.

In addition to speeding the availability of diagnoses, EHRs can also speed the process of

making a diagnosis. According to the American Cancer Society (2017), early detection and

diagnosis of cancer can have a positive impact on patient outcomes. Often there are delays in

diagnoses due to missed triggers or “’red flags” by providers. Patients are also transitioning

through the health care setting and may have care coordinated between multiple sites or

specialties. The lack of a comprehensive review of the patient or missed red flags can result in

delays in diagnosis. However, according to Singh et al. (2013) when HIT with EHRs are

designed to identify triggers and other suspicious results, patients that are at higher risk can be

identified more successfully and thus improve patient follow-up.

In Singh’s study, the research group used data mining of an EHR for triggers of cancer

diagnoses to identify patients that were at risk of a delayed diagnosis. They then used targeted

communication to notify the primary care physicians (PCP) of the potential diagnosis and

prompt a follow-up for the study group of the patients that had been identified. The physicians

for the control group did not receive the targeted communication for identified at risk patients.

Those in the study group had improved time to follow-up with 70.4% receiving a follow-up

action after EHR-intervention and communication to the PCP as opposed to the control group

where only 58% of identified at risk patients received a follow-up action. The study showed that

not only can EHRs be used to develop triggers or “red flag” monitoring tools to identify patients

that are at risk of a delayed cancer diagnosis, but they can also be used to intervene with the

patient care and communicate findings to PCPs so that diagnoses are not delayed and appropriate

follow-up action is taken.

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Similar to triggers or other passive monitoring for red flags for patients, EHRs also have

the ability to alert clinicians to potential medication interactions and human errors. The ability

for EHRs to catch such errors can greatly improve patient safety. The application and process of

electronically entering prescription medications for patients within a clinical setting is known as

computerized physician order entry (CPOE) (Dixon & Zafar, 2009, p. 1). This replaces the

traditional methods of written or verbal orders for medication and other procedures. The benefits

of such a system is that medication orders are accurately recorded between the physician and the

staff administering the order, ensuring that the order is legible and dosages are correct.

Additionally, as orders are entered, rules and checks are automatically run to ensure that the

order is safe, will not interfere with other prescribed medication, and adheres to proper

guidelines for compliance to regulations. Indeed, studies have shown that CPOE can improve

patient safety by reducing serious medication errors by 55% (Bates et al., 1998).

However, CPOE is not without issue. Often clinicians will experience “alert fatigue”

when there are critical alerts along with a large number of alerts of lesser importance (Dixon &

Zafar, 2009, p. 14). Clinician become desensitized to the alerts as many are frivolous or have

minor consequences and begin to ignore all alerts—including the critical ones. In these cases,

minimal risk alerts or alerts for commonly known interactions can turned off. Feedback and

adjustments on any HIT system, including CPOE, is crucial to ensure adoption throughout the

organization. CPOE is also only a part of the order workflow. Once the order has been entered

and transcribed, a medication must be dispensed and administered to the patient. It is crucial that

nurse administer the right medication, of the right dosage, to the right patient at the right time.

However, errors in dispensing medication exist and the rate of occurrence varies among health
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organizations. According to Strickland and McCarthy (2014), “Each hospital experiences a

medication error every 22.7 hours and every 19.73 admissions.”

Barcodes can help to reduce these errors. By barcoding the dispensed medication along

with requiring patients to wear barcoded wristbands, nurses can use scanners to scan the

medication and the patient’s wristband to ensure that the right medication is being given to the

right patient. Nurses are alerted if there is an error in the medication that they are about to give

and these “near misses” are tracked so that errors can be corrected and avoided in the future

(Oehlers, 2007). In addition, a permanent record and timeline of the patient’s medication history

is recorded within the EHR when such a system is deployed.

One final aspect of EHRs that improves patient safety is the ability to provide a complete

patient record as the patient transitions from outpatient to inpatient. Having an integrated system

between inpatient and outpatient allows for existing conditions that were known during

outpatient stays to also be known immediately as the patient transitions to an inpatient stay.

Knowing these conditions allow for better patient care, a reduction in duplicate tests and cost,

and even a reduction in infant mortality rate. In a study by Jeanne-Marie Guise et al., group B

streptococcus (GBS) for a pregnant women is the leading infectious cause of neonatal death and

it status woman is often determined prior to her arriving at an inpatient unit during labor (2009).

However, the results of the test and stats of GBS is sometimes unknown upon arrival due to

disparate systems between outpatient and inpatient care. This can cause the inpatient clinician to

administer penicillin treatment as safeguard even if it is unnecessary to ensure the health of the

newborn. In the study, a paper-based system had a rate of unknown GBS status of 10.3%. As an

integrated outpatient-inpatient EHR was adopted the rate dropped to 7.7%. Adding decision

support to the system by setting up reminders to check for GBS status during pregnancy further
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reduced the rate to 5.6%. This is significant decrease which can improve patient safety and cut

costs.

As EHRs evolve more decision support is being built into these systems. As we have seen

with targeted communication for delayed diagnoses of at-risk patients and reminders to check for

GBS status, EHRs are starting to automatically monitor patients and provide assistance to

clinicians so that the best treatment can be given to patients. While cutting costs and improving

patient safety are benefits of EHRs, the main object of health care and EHRs is to improve the

treatment of patients and their outcomes. To this end, advances in natural language processing

(NLP) tools can be used to review patient charts, record treatments and outcomes, and present

them in a way to physicians so that the best treatment is given to future patients. Such analysis

can even reveal bias in treatment based on gender or insurance coverage (Turchin et al., 2010).

In Turchin et al.’s report, NLP tools were developed to analyze physician notes on the

treatment of patients with diabetes and their glucose and lipid levels. According to Turchin et al.

“…there is strong evidence to support the benefit of glucose and lipid control in reducing

diabetes complications. Despite this evidence, recommended glucose and cholesterol levels are

not achieved in the majority of patients” (p. 4). It is theorized that achieving acceptable blood

glucose and lipid levels can help in the treatment of diabetes and lead to a shorter time to a

proper A1c target. However, such theories have been difficult to track and test.

The NLP tool in Turchin et al.’s study was designed to examine electronic and

handwritten notes and extract how often and when medication intensification to treat

hyperglycemia and hyperlipidemia began and also the subsequent glucose and lipid levels of the

patient (2010). From this data, a link between medication intensification and those levels can be
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established and analyzed. After analyzing 14,292 charts and adjusting for race, age, sex,

language, income, and insurance, the results of such analysis showed that when medication was

intensified more rapidly, normalized glucose and lipid levels were achieved much sooner. When

medication to treat hyperglycemia was intensified once per year, proper glucose levels were

generally achieved after 1,708 days. By comparison, target blood glucose levels were achieved in

147 days when medication was intensified every 3 months. Similarly, LDL cholesterol levels

were normalized in 1,408 days when medication was intensified once per year versus being

normalized in 89 for patients that had medication intensified every 3 months.

Furthermore (and perhaps more revealing), was that the probability that medication for

treatment would be intensified was strongly associated with patients that were already

undergoing a treatment of insulin. However, patients that were female or that were covered by

government insurance were less likely to receive an intensification of medication for treatment of

hyperglycemia and hyperlipidemia. More frequent intensification of medication was shown to

lead to targeted glucose and lipid levels quicker and improve the treatment of diabetes. However,

certain innate biases exist which can effect clinical decisions for the treatment of diabetes. Such

revelations would not be possible without the use of NLP to analyze the mass of patient records

and physician notes in the ERH.

CONCLUSION

In a relatively short time, EHRs have taken the health care industry by storm. Since the

enactment of the HITECH act, health care providers have scrambled to adopt HIT and EHRs.

While the threat of government penalties and the lure of monetary gains for achieving
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“meaningful use” have pushed the industry down this path (whether organizations wanted to go

or not), the main question that has to be asked is: Has it been worth it?

Adopting an EHR and other technology is no marginal task. Significant investment of

time and resources must be devoted and continue to be devoted by any organization willing to

take on such a project. Additional money must be devoted to maintenance and clinicians and

patients can become frustrated and dissatisfied with the service as they learn a new system.

Physicians can experience alert fatigue and even errors in electronic record keeping pose a risk to

the treatment of the patient. All of these reasons and more can make HIT seems daunting and

even detrimental for clinicians trying to “do their job” and treat the patient.

However, careful analysis has demonstrated that the impact of EHRs and HIT on

healthcare is far more positive than negative. It is the primary goal of physicians and health care

providers everywhere to provide the best possible treatment for patients. However, every

clinician makes mistakes. By assisting with diagnoses, prompting follow ups, and flagging

potential medication errors, EHRs are significantly improving patient safety and outcomes by

catching these potential mistakes and near misses. Computer analysis can reveal better treatment

plans and even human bias can be shown through NLP of diabetes patients. This shown

statistical improvement in care and treatment of patients demonstrates the positive impact of

adopting an EHR, regardless of the cost and time to implement such systems. Such error and

bias detection or proven improved treatment plans would not be possible without an EHR or

similar HIT.

Given the rapid adoption of such systems, it is not surprising that organizations and

technology companies have struggled to adopt and implement HIT. It has largely been a learning
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experience for all parties involved to deploy such vast and encompassing systems within a

relatively short time frame. Many HIT companies have found themselves and the technology

trying to “catch up” to the demands of their users and the health care industry. However, now

that EHRs are accepted and expanding in use, future efforts can be made towards data mining

and artificial intelligence to assist even more in the treatment of patients. It is truly an exciting

time to be a part of such a movement and witness each advancement unfold.

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Annotated Reference

American Cancer Society (2017). Cancer Prevention & Early Detection

Facts & Figures 2017-2018. Retrieved from https://www.cancer.org/content/dam/cancer-

org/research/cancer-facts-and-statistics/cancer-prevention-and-early-detection-facts-and-

figures/cancer-prevention-and-early-detection-facts-and-figures-2017.pdf. This is a

yearly report published by the American Cancer Society that summarizes current

information regarding cancer and the data about rates of cancer and known carcinogens.

It is used in this paper to demonstrate that earlier that cancer is detected and a patient is

diagnosed, the better patient outcomes are. Early and diagnoses are a benefit of EHRs.

Bardach, N.S., Huang, J., Brand, R., Hsu, J., (2009, July 17). Evolving health information

technology and the timely availability of visit diagnoses from ambulatory visits: A

natural experiment in an integrated delivery system. BMC Medical Informatics &

Decision Making, 9. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2731742/. This article published the

results of a study from 2004-2006 at Kaiser Permanente Norther California that recorded

when a diagnoses was made available in a patient’s record. The study compared the

results of basic, intermediate, and advance HIT as time and HIT advanced and an EMR

system was implemented. As HIT advanced, diagnoses were available in the patient chart

much sooner.

Bates D.W., Leape L.L., Cullen D.J., Laird, N., Petersen, L.A., … Seger, D.L., (1998, October,

21). Effect of computerized physician order entry and a team intervention on prevention

of serious medication errors. JAMA, 280, 1311-16. Retrieved from

http://jamanetwork.com/journals/jama/fullarticle/188074. This article published the

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findings of HIT intervening to prevent serious medication errors. The study compared a

group using computerized physician order entry (CPOE) alone and a group using CPOE

with intervention when adverse drug events were detected to a baseline group that was

not using CPOE. The results were that CPOE (with or without intervention) reduced

medication errors by 55%.

Dixon, B. E., Zafar A. (2009, January). Inpatient Computerized Provider Order Entry (CPOE):

Findings from the AHRQ Portfolio. Agency for Healthcare Research and Quality.

Retrieved from https://healthit.ahrq.gov/ahrq-funded-projects/emerging-

lessons/computerized-provider-order-entry-inpatient/inpatient-computerized-provider-

order-entry-cpoe. This is a report prepared by the AHRQ National Resource Center for

Health Information Technology. It describes and summarizes the findings of various

studies on the effects of CPOE in health care. It is used to define CPOE and observed

negative effects in this paper.

Guise, J-M., Kraemer, D., O’Haire, C., Greenlick, Campbell, E., M., Morris, C., … Osterweil, P.

(2009, August, 2009). Improving Safety and Quality Integrated Technology. The Agency

for Healthcare Research and Quality. Retrieved from https://healthit.ahrq.gov/ahrq-

funded-projects/improving-safety-and-quality-integrated-technology. This report was

funded by the AHRQ with the aim to demonstrate the value of a HIT system that is

integrated between inpatient outpatient settings. In the study, the rate of unknown GBS

status was tracked for pregnant women as they entered inpatient settings for labor and

delivery. EHR can provide reminders and alerts to check for GBS with the intention that

tests are completed and the results of that test are available as the women enters the

hospital for labor and delivery.

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Institute of Medicine (1999, November 29). To Err is Human: Building a Safer Health System.

Retrieved from

http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/1999/To-Err-is-

Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf. This report

revealed a suspected high number of patient deaths and other complications due medical

errors. Previous to this report, medical errors were known, but the severity was never

documented at such a level. The report discusses the causes of such errors in the

healthcare system and potential changes to help address the issue.

Institute of Medicine (2001). Crossing the Quality Chasm. Retrieved from

http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-

the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. This report

discusses the need for change and the types of changes necessary to improve patient

safety and quality of care. It is intended for hospitals, policy makers, and regulators as a

guide on the causes of the quality gap and current practices that are impeding progress.

Analysis of current methods results in suggested approaches to broad organization and

structural changes to the current healthcare system to close the gap.

Oehlers, R. (2007). Bar Coding for Patient Safety in Northern Michigan. Agency for Healthcare

Research and Quality. Retrieved from https://healthit.ahrq.gov/ahrq-funded-projects/bar-

coding-patient-safety-northern-michigan. This is the summary of a project to install a bar

coding application and use bar codes in the medication administration process at five

partnering hospitals in norther west lower Michigan. While CPOE systems can ensure

that the right medication and dosage is ordered, bar codes can help ensure that the right

medication is given to the right patient and reduce other medication administration errors.
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Singh, H., Murphy, D. R., Forjuoh, S. N., Laxmisa, A., Parikh, R., Reis, B. A., … Meyer, A.,

(2013, July 13). Using Electronic Data to Improve Care of Patients with Known or

Suspected Cancer. Agency for Healthcare Research and Quality. Retrieved from

https://healthit.ahrq.gov/sites/default/files/docs/publication/r18hs017820-singh-final-

report-2013.pdf. This project studied the use of HIT and EHRs to identify patients that

have a delay in a diagnosis of cancer. Usually these delays are due to a physician missing

the signs of cancer and not order the appropriate follow-ups when warning signs are

detected. The study tracked patients and detected if they were at risk of a delayed cancer

diagnosis. Subsequent actions and the rate of follow-up was tracked between two groups:

one group where physicians were notified of the detection and another group where the

physician was not notified. The studied show that HIT intervening and communicating to

the physician that the patient was at risk of a delayed diagnoses showed a higher rate of

follow-up.

Strickland, J., McCarthy, K., (2014, September 30). Medication Errors and Patient Safety:

Lessons Learned from Tragedy. Retrieved from

http://www.freece.com/files/classroom/programslides/42a5e3e6-aa6b-4618-8463-

889fe3bb2c2c/mederrorhk.pdf. This report compiles a wide range of information and

studies regarding medication and dispensing errors. It is meant to help educate

pharmacists on the types and rate of errors. It is used in this paper to discuss the

prevalence of medication errors and the steps that can be taken to avoid them.

Turchin, A., Atlasevich, Y., Goldberg, S., Babcock, K., Kramer, M., Breydo, E., … Delgado, A.,

(2010, September) Monitoring Intensification of Treatment for Hyperglycemia and

Hyperlipidemia. Agency for Healthcare Research and Quality. Retrieved from

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https://healthit.ahrq.gov/ahrq-funded-projects/monitoring-intensification-treatment-

hyperglycemia-and-hyperlipidemia. This project developed an NLP engine to read

physician notes from paper documentation and extract information regarding glucose and

lipid levels and intensification of medication. Thousands of records for patients with

diabetes were scanned and analyzed by the NLP engine. It was determined the more rapid

intensification of medication for a patient resulted in quicker target glucose and lipid

levels. Achieving such targets can help reduce complications and other side effects from

diabetes. The project also accounted for the patient’s sex, age, socio-economic status, and

insurance. It found that women and those supported by government insurance were less

likely to have their medication intensified at a more rapid pace (intensification once per

year rather than once every three months). The NLP engine was able to reveal these

innate biases in the treatment of patients by scanning and analyzing thousands of records

that would other be impossible without HIT.

U.S. Department of Health & Human Services. (2013, July 26). HITECH Act Enforcement

Interim Final Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/special-

topics/HITECH-act-enforcement-interim-final-rule/. This webpage is a summary of the

HITECH Act and its enactment as a part of the American Recovery and Reinvestment

Act. It describes what was enacted including broad definition of the violations and

penalties of the Act. It is used in the paper to give historical reference for the adoption of

HIT and EHRs.