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Barothy Road Custer, MI 49405 July 15, 2010 Helen Johnson Vice President of Nursing Services Memorial Medical Center of West Michigan 1 Atkinson Drive Ludington, MI 49431 Dear Helen: The push for organizations to convert to electronic health records (EHRs) has been a large issue in the healthcare field recently. In some instances, EHRs may be required as part of healthcare reform. Please find enclosed the research report on the integration of electronic health records, created as per the discussion on June 10, 2010. To meet the discussed requirements from that day, I have identified the main points regarding an organizational transition to electronic healthcare records. This report includes the importance of bringing improved technology to this organization as well as information regarding pros, cons, and necessities to fulfill such a transition. The information provided will offer a comprehensive overview of the initiation, implementation, and integration of electronic health records. The purpose of this report is to identify the need to comply with the ongoing push to increase technology within healthcare organizations. It is crucial that we are involved in this trend by initiating such a program at our facility. The research provided implies that such a transition at our corporation can only improve patient care and outcomes. I would recommend a continued discussion regarding this report as well as the initiation of a plan to move forward with this process. My only concern regarding this transition would be the research provided about employee resistance when attempting to initiate technological change. I would recommend moving forward with caution and adequate communication in order to convince employees that this transition will be an improvement over the current process. Sincerely,

Jennifer R. Williams Case Management Specialist Enclosures (1)

Abstract Within the ever-changing world of healthcare, yet another challenge is upon those organizations that choose to remain competitive in the field. With the initiation of healthcare reform, there has been a motivation for healthcare organizations to transition away from paper and improve their medical record technology. Integration of electronic health records is the first step in the direction of improving patient outcomes and maintaining a comprehensive care standard. The utilization of paper to document and store medical information will soon be the past. As this field transitions into an improved healthcare system, it is apparent that other alterations need to be addressed. How will the integration of electronic health records into healthcare organizations affect patient care and outcomes?

Williams 1 Jennifer R. Williams Professor Reynolds English 325 15 July 2010 Organizational Transition to Electronic Health Records Electronic health records (EHRs) have the potential to advance the quality of health care by providing timely access to patients health information, tracking patients over time to ensure that they receive guideline-recommended care and offering decision-support mechanisms to reduce medical errors (BMed et al. 457). Organizational transition from paper to electronic health records is one of the newly found ways to improve the delivery of care for patients. The National Institutes of Health (NIH) and National Center for Research Resources, identifies electronic health records (EHR) as the ability to automate and streamline clinical workflow while generating a complete record of the patients encounter, activities and outcomes (NIH 1). The need for continued and constant transition to EHRs is essential to the small health care organization. Patient care trends rely on the need to maintain technology upgrades as required by healthcare reform. HISTORY OF HEALTH RECORD DOCUMENTATION Hippocrates, in the fifth century B.C. identified two main goals for documenting medical records; a reflection of accurate course of the disease and indication of the cause of disease (NIH 1). Although still appropriate, electronic health records can also provide additional functionality to documentation than can be accomplished with paper-based systems (NIH 1). The history of the health record purpose essentially remains the same; however technology creates an incorporated way to keep track of patient health goals in a complete and comprehensive way.

Williams 2 Electronic health records are not a new idea. Pioneers began writing programs to store and retrieve patient records in 1958 (Stead, 1989). Many organizations continue to utilize paper programs while scanning information for storage only. EHRs however are an improved technology that allows healthcare workers to complete documentation in a computer format. In addition, orders, history and much more healthcare information can be controlled without the utilization of paper sources. It is important that health care institutions look at the impact that this type of technology could have on patient care and outcomes. The personal health record is an individuals collection of information about their health, health related activities and healthcare. Personal health records have the potential to allow the individual to aggregate a complete picture of their health related activities and control that can access that view of them (Stead 22). The health care field has been offered a new way to monitor a patients overall needs as well as protect their interests. EHRs are a part of a great initiative to enhance patient care through technology. FAVORABLE VIEWS OF UTILIZATION The value of integrated clinical systems is that they enable the capture of clinical data as part of the overall workflow (NIH 3). Currently within organizations without EHRs, paper documentation has to be stored, sorted, and forwarded in order to provide the comprehensive care possible to deliver exceptional healthcare. EHRs enable all disciplines to analyze the efficiency of treatment in patients with co-morbidities, giving each department a complete picture of a patients condition (NIH 3). This can be accomplished by giving each department appropriate department free access to any medical information needed to provide care to the patient.

Williams 3 The utilization of EHRs in complex clinical environments incorporates a higher level of detail for presenting clinical involvement and delivery (NIH 3). Also, the integration of computerized physician order entry (CPOE) permits clinical providers to electronically order laboratory, pharmacy, and radiology services (NIH 7). With utilization of paper orders, nurses and other healthcare disciplines have to rely on their interpretation of the physicians writing as well as a time consuming data entering process. This long process can be avoided with CPOE programs. The NIH emphasizes that only four percent of U.S. hospitals report that they are using CPOE systems (7). This is an extremely low number which puts a great emphasis on the need for health care systems to take a good look at how EHRs can assist in providing safer and more effective care. EHRs have several advantages of over conventional paper records; the cost of physically storing paper records and centralizing them in a convenient location are highly minimized when and EHR solution is implemented (Hristidis 18). In addition poor legibility and medical errors can be reduced from the utilization of handwritten medical records (Hristidis 18). Computerized provider order entry and other clinical information systems can help reduce medical errors, promote practice standardization, and improve the quality of patient care(Campbell 94). The importance of avoiding medical errors through interpretation is essential in patient care delivery. In addition to prevention of error, there can be improved interaction between physicians and patients. Finally, the implementation of EHR systems improves the availability, timeliness, accuracy, and completeness of medical documentation (Hristidis 21). ASSUMPTIONS AND EXPECTATIONS The assumption of the slow distribution rate of the use of this technology is identified as clinician skepticism about the value of electronic records and clinical decision support (NIS 7).

Williams 4 The process of changing a system that has been in place for so long can be difficult for organizations. On the other hand, Institutions implementing EHRs have reported immediate rewards, intervening pain and successes (NIH 12). The idea of creating a better environment and recovery for patients is a necessity for any healthcare organization. In addition to improved patient care, EHR applications can support more efficient and accurate collection, storage, analysis, and distribution of data that current paper or manual operations can accomplish (NIH 12). This statement reveals an obvious picture of complete access of medical records at healthcare workers fingertips. Additionally, costs could be diminished related to the decrease in paper, supplies, and alternative storage related to paper use. The initiation of electronic programs can only enhance processes that may already be in place. The expectation of new technology to include communication and integration of automated clinical record systems includes improvement of clinic care as systems mature and as users become more involved with their use (NIH 12). This statement expresses expectations, which are assumed in an environment that has no or little technology currently present. EHR systems are more time efficient and allow clinicians to have much greater access to other automated information regarding the disease process (NIH 13). As busier and more complicated health care needs are upon the healthcare system, automated systems could be the simplicity needed to improve current care delivery. The decrease in workforce and increase in workload related to the healthcare field is concerning to current organization. Also, the simplification of job descriptions by initiating improved technology can in turn promote employee interest in longevity. Implementation of EHR must coincide with workflow redesigns to ensure increased efficiencies, to generate improvements in quality of care, and to realize the maximum benefits of an automated environment (NIH 13).

Williams 6 Full charting capabilities for nurses and clinicians are a major advancement for inpatient EHRs (Carter 12). Documentation can be time-consuming portion of healthcare routines. To improve quality of care, it is becoming increasingly clear that implementing an electronic record is not sufficient and this tool needs to be coupled with other system supports such as registry functions, and care delivery transformations such as team-oriented approaches (BMed 463). Creating a team-oriented environment that will assist in the case management process allows for complete and comprehensive care. The Institute of Medicine identified the computer-based record as an essential technology for healthcare in 1991 (Stead 1). The failure of electronic health records to deliver on their potential is rooted in a mismatch between the conventional technical approach to their implementation and the nature of both the individuals those records are trying to describe and the clinical work they are trying to document (Stead 3). On the other hand, these system approaches have been found to improve the overall work environment. Healthcare delivery has become increasingly dependent on information technology to computerize almost all aspects of patient care, as evidenced by the proliferation of systems ranging from billing and accounts management to computerized provider order entry (CPOE) to sophisticated image-guided surgery systems(Campbell et al. 94). Institutions that do not begin to implement such programs are beginning to be considered behind the times. EHRs are very complex to install, and they often are rolled out gradually (NIH 14). Therefore, it is important to begin the process as soon as possible to prevent a delay in improvement. Technology is the prime force in initiating social change, and the introduction of new technology fundamentally shifts work activities, resulting in transformations of individuals and their social interactions as well as organizations in which they work (Campbell et al. 94). This

type of environment can improve not only patient care but the work environment as well. Improve interaction between workers should in turn improve overall patient care and satisfaction. CONCERNS AND SOLUTION OF INTEGRATION Issues with system unavailability are one of the issues that may be related to concerns about patient safety when initiating the utilization of a complete electronic health system (Campbell et al. 95). It would be essential to create a backup plan for times when the electronic system may be unavailable. Campbell et al. also stresses that system unavailability can create chaos for both users and the organization (95). The planning and initiation of appropriate protocol to follow during these times will prevent negative repercussions of system downtime and decrease the chance for medical error and patient harm. It is important that an overdependence on technology is not developed with such a transition to the total electronic health system (Campbell et al. 98). Resistance is typically based on lack of familiarity and the need for physicians and other healthcare workers to become more proficient with technology (Hristidis 21). The low levels of the adoption of electronic health records in the U.S. hospitals suggest obstacles to the achievement of the healthcare performance goals that depend on health information technology (Jha et al. 1628). The adoption o f electronic health records has the potential to improve the efficiency and effectiveness of health care providers (Jha et al. 1629). The following table will show physician utilization and compliance with EHR functions. Table 1. Among Physicians with EHRs, Availability and Usage of EHR Core Functions over Time. The length of each bar indicates the percentage of physicians who have each function available in their system. The component segments of each bar reflect the percentage of physicians using each function most or all of the time, some of the time, or not at all (BMed 461).

Williams 7

(BMed 461) With the implementation with new technology, it will be important to identify needed features and useful tools to encourage continued use of the product. Most identified factors regarding the delay of the implementation of EHRs were lack of capital budget. Larger institutions were more apt to identify and implement the utilization of this technology (Jha et al. 1636). On the other hand, data suggest that financially vulnerable institutions may flourish from the implementation of the appropriate electronic health record system (Jha et al. 1636). In addition, it was recommended that hospitals that choose to implement this type of system may benefit from incentives or increase reimbursement relate to the utilization of this technology (Jha et al. 1636). In deducing the cost and return on investment of the initiation of electronic health systems, most research focuses on the qualitative benefits of EHRS including the following (NIH 18): Improved quality of patient care

Williams 8 Efficient tracking of patients and costs Benefits to the business of healthcare Better documentation and improved audit capabilities Avoidance of repeating expensive tests and more time spent with patients. Privacy is another significant process that needs to be addressed in the implementation of electronic health records. Can individuals be persuaded to change their attitudes and adoption decisions toward electronic health records In the presence of significant privacy concerns associated with use (Angst 340)? Then again, a growing body of literature confirms the value of electronic health records (EHRs) in improving patient safety, improving coordination of care, enhancing documentation, and facilitating clinical decision-making and adherence to evidencebased clinical guidelines (Chen 323). STATISTICS Regardless of certain issues regarding integration, the proportion of clinicians agreeing that the electronic health record improved quality of care increased (El-Kareh et al. 466). Clinicians increasingly agreed that the electronic health record reduced medication-related errors (72% to 81%, p = 0.03) and improved follow-up of test results (62% to 87%, p < 0.001) during the 12 months following implementation (El-Kareh et al. 466). The vast majority of clinicians (92%) felt that the electronic record improved access to clinical information (El-kareh et al. 466). Virtually all clinicians (92%) reported immediate improvement in this measure at study baseline, which has important implications for clinical efficiency, where lack of access to information often results in redundant test ordering and the resultant substantial cost implications (El-Kareh et al. 466). In addition, it was found that while clinicians may perceive some initial problems

Williams 9 with a new electronic health record, they become significantly more receptive to it within 1 year of implementation (El-Kareh et al. 467). Table 2 Changes in Primary Care Clinician Perceptions of the Electronic Health Record Months since implementation Proportion agreeing, n (%) Overall quality Improves overall quality of care Patient safety Reduces medication-related errors Improves follow-up of test results Communication Improves communication among clinicians Decreases quality of patient interactions Efficiency Improves access to clinical information Patient visits take longer Spend more time on medical documentation outside of clinical sessions 73 (92) 54 (68) 62 (78) 77 (95) 55 (68) 66 (81) 71 (93) 44 (58) 58 (76) 64 (93) 35 (51) 47 (68) 0.68 0.001 0.006 57 (72) 39 (49) 61 (75) 39 (48) 61 (80) 34 (45) 64 (93) 23 (33) <0.001 0.001 57 (72) 49 (62) 57 (70) 46 (57) 59 (78) 61 (80) 56 (81) 60 (87) 0.03 <0.001 50 (63) 55 (68) 56 (74) 59 (86) <0.001 1 (n = 79) 3 (n = 81) 6 (n = 76) 12 (n = 69) Trend p value*

*Indicates statistically significant trend in proportion after adjusting for clinician characteristics p < 0.0167 for comparison to proportion at baseline (1 month). This threshold represents a Bonferroni correction for multiple testing (El-Kareh et al. 466).

Williams 10 ORGANIZATIONAL CONCIDERATIONS It will be important to consider a radically different approach to achieving the goal of interoperable health information. First, define interoperable data as data that can be assembled and interpreted in the light of current knowledge, and re-interpret additional need as knowledge evolves(Stead 9). There will be different needs at organizations regarding set up of EHRs related to the stage of electronic systems available. Examples of different scales include: records of healthcare entities such as integrated care delivery systems; regional data exchanges, such as regional health information organization; personal health records, and population databases (Stead 12). Todays predominant approach to implementing electronic health records involves purchasing an information system to automate, or script care processes. It would be appropriate to interview many vendors prior to purchasing this type of product. If a previous system were in place, a program that is compatible would need to be identified previous to the final decision on the vendor. Typically the vendor may provide a starter set but commonly the healthcare provider has to build its pick lists to support data capture, its decision or communication support logic, etc. (Stead 4). A comprehensive team of healthcare members could essentially assist in the process of determining which program is the best fit for the organization. PROCESS OF INTEGRATION The processes from the paper world are used as a starting point from which to develop requirements for new information technology. It is difficult to separate the purpose and essential steps of a work process from the related work-around (Stead 7). A plan for a specified implementation process will be needed in order to integrate the new technology related to the

Williams 11 electronic health record. The organization will need to work together in a thorough matter in order to pull this off. Particularly in the case of an EHR, a comprehensive communication plan is essential to maintain the organization focus and motivation (Walker, Bieber, and Richards 7). Communication in the healthcare field is a needed component to accomplish any new task. Healthcare workers often rely on each other for informational purposes when it comes to the patients. In this case, workers will need to rely on each other in order to implement a new system. Complete and knowledgeable teams can only assist in making this process a smoother one. Once the decision is made to implement, a plan to communicate the decision to the employees of the organization should be initiated (Walker, Bieber, and Richards 8). Especially in healthcare, it is important to communicate issues with tact and appropriateness. Their will most likely be individuals that will be resistant to the idea of change. The need to communicate the change with a positive nature will be essential to prevent opposition from employees that will be involved. EHR implementation is not easy, but it can transform your organization (Walker, Bieber, and Richards 8). As previously mentioned, resistance is often a natural response to change. Employees will need to be convinced via appropriate communication that the changes in technology will not only improve their work environment but also make their jobs simpler and allow them to provide the best care possible for their patients. The initiation of a good EHR program will create opportunity resulting in more efficient patient care operations (Walker, Bieber, and Richards 8). Cooperation of employees will be a crucial need to accomplish this task.

Williams 12 After choosing an EHR program and notifying staff about the implementation, a team should be composed to create goals regarding integration and education of the program (Walker, Bieber, and Richards 10). A project manager should then be chosen and kept appraised of the schedule in order to keep implementation on track. It is expected that those with project management experience should be utilized to make the process flow without excessive issues. Once the best plan is determined for the best workflow optimization, venders should be notified of the needed software to complete the organizations needs (Walker, Bieber, and Richards 12). An organizational needs assessment will be the foundation of the success of EHR implementation (Walker, Bieber, and Richards 14). Essentially, organizational teamwork as well as appropriate software discovery will be needed in order to have a successful implementation of this type of technology. CONCLUSION A successful computer system for the medical field requires thoughtful business planning, a clear understanding of organizational function and workflow, and reasonable knowledge about computer hardware and software (Carter 51). Implementation of new technology within a workplace can be a difficult task, however with the appropriate process and issue trouble shooting there should be a positive change associated with the initiation of EHRs. Understanding the strengths of new technologies will assist organizations in the delivery of better care (Carter 51). It is essential that appropriate research and technology design be considered during this important time. Our slow progress on electronic health records should act as a call to action. An electronic health record system with access for everyone family physicians, consultants, pharmacists, hospitals, managers and researchers will save lives and improve health outcomes (McGrail 535).

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McGrail, K. "No more dithering on e-health: lets keep patients safe instead." CMAJ. N.p., 6 Apr. 2010. Web. 10 July 2010. <www.ncbi.nlm.nih.gov/pmc/articles Stead, W. "Electronic health records." IOM press. N.p., 13 May 2009. Web. 12 July 2009. <courses.mbl.edu/mi/2009/pubs Walker, J, E Bieber, and F Richards. Implementing an Electronic Health Record System (Health Informatics). 1st ed. 2004. 2nd printing. ed. New York: Springer, 2006. Print.