Beverly Bell
Kelly Thornton

Realizing the benefits of an EHR requires specific steps to establish goals, involve physicians and other key stakeholders, improve processes, and manage organizational change.

At a Glance  

  • Implementing an electronic health record (EHR) can transform the clinical process and patient care among other positive outcomes.  
  • Hospitals can help physicians adopt the new technology by showing how it can enhance patient care and improve outcomes.  
  • An EHR implementation project should be a multidisciplinary coordinated effort.  

The attention currently focused on electronic health records (EHRs} is largely driven by the financial incentives promised by the HITECH provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) for the "meaningful use" of an EHR by 2015. Although these financial incentives provide a business driver to implement EHR technology, the end result will be improved patient care along every important parameter (quality, safety, effectiveness) while simultaneously improving a hospital's operational efficiencies and fiscal bottom line.

EHR implementations are often driven by four major factors:

  • Improving overall patient care and efficiency
  • Integrating the enterprise to provide seamless access to both ambulatory and inpatient records
  • Supporting key market changes in payer requirements
  • Meeting consumer expectations

Consequently, the scope of many large EHR implementations includes not only inpatient and ambulatory clinical applications but also revenue cycle and clinical data applications. Once these applications are in place, organizations often consider implementing patient portals and standalone data repositories to further support greater patient involvement in their own care and data reporting.

It's important to clarify the use of two important terms-EHR and computerized provider order entry (CPOE). In this article, the use of the term EHR includes both ambulatory (the physician's office) and inpatient (the hospital) settings. The term CPOE refers not only to physician order entry, but also order entry by advanced practitioners, including nurse anesthetists, advanced practice nurses, physicians' assistants, and midwives.

Transforming the Clinical Process

When Fletcher Allen Health Care, a community hospital in Vermont, recently implemented an EHR system as part of its PRISM (Patient Record and Information Systems Management) initiative, the hospital saw a 60 percent decrease in near-miss medication events, a 20 percent increase in completion of daily fall assessment, and a 25 percent drop in the number of patient charts needing to be pulled for signing orders and dictated reports, which translated to providers having access to information in real time, among other positive outcomes.

This is an illustration of the wide-ranging impact an EHR implementation can have on the clinical process and patient care, including:

  • Access to clinical information across the continuum of care to support provider decision making
  • Real-time clinical decision-support prompts and alerts to physicians, which directly lead to better patient care and a reduction in medical errors
  • Increased medication safety and fewer adverse drug events
  • Standardization of care to improve patient outcomes, notably through the use of standard order sets, based on evidence-based medicine, for major medical conditions
  • Better preventive care through improved communications between physician and patient as well as proactive patient reminders

CPOE, as a core component of EHR, has been proven to decrease delays in order completion, reduce errors related to handwriting or transcription, provide error checking for duplicate or incorrect doses/tests, and simplify inventory and posting of charges.

Many of the positive outcomes identified above also have a positive impact on a hospital's fiscal bottom line, in the form of cost reductions, cost avoidance, top-line revenue growth, and cash-flow increases. Based on the size of the health system and the scope of the implementation, benefits for a large hospital can range from $37 million to $59 million over a five-year period following an EHR implementation. This revenue is in addition to the incentive payments earmarked in ARRA and includes benefits primarily from length-of-stay (LOS) reduction, readmission rate reduction, emergency department (ED) revenue reimbursement, ambulatory revenue reimbursement, and drug cost reduction.

Helping Physicians Adopt the EHR/CPOE

In our experience, physicians are almost always willing to adopt a new system if it is shown to enhance patient care and improve outcomes. Although an organizational change such as EHR/CPOE requires a change in the way physicians, nurses, and almost everyone else involved in patient care think and work, the transition can be eased through a combination of organizational vision and effective change management, physician involvement in the EHR design process, and-most critical-initial as well as ongoing training and support.

Organizational vision involves making the EHR a top hospital priority, with demonstrable leadership and sponsorship commitment. It also involves developing a clear vision and implementation strategy, backed by a detailed communications plan, to outline the benefits of the new system for physicians and their patients. It is important to engage credible, well-respected physician and nurse champions in every aspect of the design, functionality, and workflow of the new EHR/ CPOE system. These champions should have a deep understanding of both the technology and the clinical requirements necessary to support success of the EHR/CPOE system. Having champions involved in the design process will ensure that the system is intuitive and easy to use, and that it allows physicians and nurses seamless access to critical information (such as laboratory/test results).

Finally, sustained training and support can play a crucial role in shortening the learning curve and helping physicians understand and use the new system. Initial training should be followed by multiple methods of just-in-time training and backed by ongoing support coverage (available 24 hours a day during the initial go-live period) to provide the guidance physicians will need for a change of this magnitude.

The following strategies have proven to be helpful:

  • After initial training, organize brief, five-minute "tricks of the trade" sessions in the physicians' lounge or other physician-friendly places during designated times.
  • Develop user-friendly feedback loops for physician suggestions/concerns at the point of discovery.
  • Provide physician incentives for adoption of the new EHR/CPOE system (for example, if x number of orders entered electronically in x period of time, the physician will be eligible for drawing of an "in demand" item).
  • Build trust and win credibility through a track record of highly responsive support and system changes to meet physician needs.

How Automating Clinical Documentation and Orders Affects the Revenue Cycle

One area where the financial benefits of an EHR/CPOE system are visible is in a health system's revenue cycle. Because standardized data and complete documentation are central both to timely filing of claims and to minimizing lost revenue due to denial of claims, automating clinical documentation and orders can affect the revenue cycle positively in many ways.

The first benefit to the organization's revenue cycle process is an enhanced ability to meet important regulatory requirements such as the Physician Quality Reporting Initiative (PQRI), which gives financial incentives to healthcare professionals to participate in a voluntary quality reporting program. An EHR/CPOE implementation that leverages clinical decision support makes it easier to meet PQRI as well as other federal/state reporting requirements by alerting physicians to complete key regulatory data elements and by building key quality measures into their workflow.

Hospital and professional billing systems integrated with an EHR can provide for automated charge capture and reduce the time and resources needed for manual charge entry, which can lead to more accurate billing and a reduction in lost charges. An EHR can also result in a reduction in charge lag days, which refers to the time it takes for charges to enter a system following the performance of a service. Because charges can be automatically triggered in an EHR system the moment a provider closes the encounter, charge lag days, as well as vendor/insurance denials associated with late filing of charges, can be significantly reduced.

Another benefit relates to the EHR system's ability to embed charge review edits in clinical documentation, so that a physician can be alerted if, for example, a test can be performed only at a certain frequency, or if a patient has been wrongly classified as a new patient when, in fact, he or she is an established patient. Charge edits related to Medicare regulations, such as the requirement for advance notice to a beneficiary before performing certain procedures, can also be embedded in an EHR. This can help minimize claim denials and lost charges related to Medicare procedures performed without such Advance Beneficiary Notice.

Payers will continue to follow the government's lead in developing reimbursement arrangements based on how well these providers deliver care. To meet these requirements and obtain maximum reimbursement, having electronic documentation and orders in place will be key.

Implementing an EHR System to Accomplish Your Organizational Vision

It is a mistake to regard an EHR implementation as an IT project. In reality, implementing an EHR is a huge operational change project that directly affects how patient care is delivered. It is, therefore, critical to work toward an EHR as a coordinated effort rather than as a series of disparate efforts. Begin by setting up an executive steering committee that includes clinical/operational executives and strong physician leaders as members. The committee will provide leadership for the project vision, backed by clear goals and metrics. This strategic vision will become the guiding principle for the implementation, while the metrics-for example, 10 percent of physicians using CPOE on Day 1-will determine the rollout plan and project focus. The metrics identified up front will provide guidance to the design and a benchmark to evaluate project success following go-live. The next step is governance. A strong project governance model, with multidisciplinary teams contributing to the governance structure, is essential to expedite the decision-making process and ensure that decisions are made at the appropriate level inside the organization. At this stage, a communications plan should be drafted to identify target audiences and the mode and frequency of communications.

After the visioning sessions and the finalization of the governance model, the design phase begins. Design and development are closely guided by the visioning principles and project goals. During design, it is imperative that organizations work closely with physicians, nurses, and other user groups to ensure that the redesigned workflow is modeled on their needs and has the functionality, features, and ease of use that are important to the healthcare provider community.

The design phase is followed by organizational adoption, where there are collaborative, multidisciplinary meetings to work with the healthcare professionals to give them a better understanding of the direct impact to their daily work. Typically, much of the physicians' daily paper ordering and documentation tasks will now transition to the EHR. Extensive training and support are both indispensable at this stage, to ensure the new system is being used as intended and brings the planned benefits.

Throughout EHR/CPOE implementation, the metrics review board is usually held accountable for baseline metrics collection as well as monitoring the metrics to measure progress. Following the successful go-live, there should be a stabilization period to ensure the new processes and workflows are working as intended. At approximately 90 days after go-live, metrics outcomes are measured again by the metrics review board to ensure that the outcomes align with the initial project goals. In our experience, post-implementation metrics collection and reporting are essential activities to address design functionality and feature gaps, to fit in workflow workarounds, and to ensure project success.

Leveraging the EHR Across the Continuum of Care

When we look across the continuum of care-at a patient who needs to move from a primary care physician to a specialist to an ED and then to an inpatient setting-the advantages of an EHR over paper records become most apparent.

Better integration among providers;improved information sharing. In a paper world, it's virtually impossible to share or transfer patient information, which remains isolated in silos. In contrast, EHRs can promote a truly integrated ambulatory-ED-inpatient solution, with a single record, on one screen, that is easily accessible to every caregiver. This integration of patient information, in turn, promotes improved information sharing and better communication among caregivers that can dramatically reduce the potential for errors, redundant testing, adverse drug interactions, and many other problems in care caused by critical gaps in patient information.

Viewable medication and allergy lists. Unlike paper documentation that cannot travel across care settings, an EHR makes it easy to electronically view all the recent (and even historical) medication taken by a patient. With an EHR, allergy and problem lists are also much easier to maintain, standardize, consolidate, and access on a single screen. This cuts down on "chart chasing" and chart pulls, reduces errors, and allows multiple users to use a chart simultaneously. Even more important, it allows easy checking of drug-to-drug and drug-to-allergy interactions. All of these can positively affect a hospital's cost bottom line.

Order entry at point of care or off site. CPOE allows a physician to enter an order either at point of care or remotely using a portal or handheld device. It also reduces the turnaround time for medication refills.

Standardization of data. A major disadvantage of paper records is the lack of standardization and the large amount of variability that can occur based on the care setting. By ensuring that structured data are captured during the care delivery process, an EHR/CPOE system makes the process of accessing and using the data more efficient and seamless. Standardization of orders sets and care plans help implement common treatment of patients using evidence-based medicine, thus improving patient outcomes and improving compliance with hospital-based formularies and standards.

Access to experts for rural healthcare providers. By automating information, an EHR system makes comprehensive patient data as well as best practices available for sharing by hospitals and physicians in remote and rural areas. EHR systems can also support distant, rural areas, which are typically lacking in specialized care, through telemedicine, which can greatly enhance the ability to treat patients remotely. The availability of order sets in CPOE also supports high-quality, standardized care to patients in such areas, at much lower costs to the patient as well as the

Population management. The utilization of standardized data across large populations enables a segment of the population with particular disease entity or symptom to be evaluated over time. Data can be trended to evaluate treatment and outcome to better manage patients in the future. Preventive alerts can be put in place in the documentation tools as reminders to improve care standards in areas such as immunization and the evaluation of chronic diseases that are not the primary reason for the patient visit. Long term, the combination of preventive medicine and evaluation of treatment and outcomes can be leveraged to improve the health of the population.

Disease management. Because of the availability of an EHR that both physician and patient can access, chronic disease management becomes more convenient, simpler, and faster. To give just one example, hypertensive patients can enter their blood pressure and other key indicators from home, and their physician can assess these indicators and change the medication or dosage-all remotely, without the need for an appointment.

These are only a small sample of the most crucial benefits that an EHR/CPOE system offers across the continuum of care. There are countless others that go to the heart of better patient care and improved cost efficiencies.

EHR: The Right Thing to Do

Over the years, we have worked with hospitals of all sizes and descriptions on various aspects of EHR implementation-whether building readiness, planning, implementing, or optimizing. Consistently, we have seen that although the up-front dollar investment is considerable, the ROI, both tangible and intangible-in the form of improved patient outcomes and better satisfaction rates among both physicians and patients, improved staff productivity and lower administrative costs, reduced redundant and duplicate testing, fewer adverse drug and clinical events, lower infection rates and reduced incidence of complications, reduced LOS, and lower readmission rates-almost always makes up for the scale of the effort required to implement and use an EHR meaningfully.

In the final analysis, then, the reason for an EHR implementation is simple: It is the right thing to do for patients and a must for the hospital's future.

Beverly Bell, RN, MHA, CPHIMS, FHIMSS,is the director of EHR Implementation Practice, CSC, Columbus, Ohio (

Kelly Thornton is a principal in CSC's Healthcare Group, Broken Arrow, Okla. (

Publication Date: Tuesday, February 01, 2011

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