The implementation and sustainability of electronic health records

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by Stephanie Sheridan, MSN, RN, ANP-C, CNN-NP


Sheridan, S. (2012).  The implementation and sustainability of electronic health records. Online Journal of Nursing Informatics (OJNI), 16 (3), Available at http://ojni.org/issues/?p=1992


Electronic health records are a vital part of the transition to computerized documentation. The purpose of this article is to discuss the implementation and sustainability of the electronic health records. The digital wave must be embraced to improve the healthcare disparities of Americans. Congress is enforcing the initiation of electronic health records by 2014 for all United States citizens; unfortunately, there is resistance from health care providers, largely because of the lack of knowledge of electronic technology. To address the future of health care in the 21st century, the utilization of electronic health records is imperative and will lead to better quality outcomes for the patients.


Comparative effectiveness, electronic health records, health information  technology, meaningful use, Office of the National Coordinator for Health Information Technology


            Health care costs in the United States are astronomical, and comparative effectiveness research (CER) has shown there are often inexpensive medical alternatives that have not been utilized by health care providers (Hoffman & Podgurski, 2011). Currently 64% of health care facilities still use paper-based documentation; these units will have to convert to electronic health records in the near future or face penalties (Kelley, Brandon, & Docherty, 2011). “Electronic health record (EHR) is defined as the computer application that electronically stores individuals’ identifiable health data” (Layman, 2008, p. 165). The EHR is supposed to benefit the patient’s overall health care outcomes from several different aspects such as improved quality care, reduced cost, and the resolution of medication errors (Linder, Ma, Bates, Middleton, & Stafford, 2007).

As technology continues to progress into the health care realm, the EHR will explode and boost efficiency of customer services (Choi et al., 2010). Unfortunately the evidence to support EHR sustainability has not yet been proven; the purpose of this paper is to analyze the application and endurance of EHR (Kelly et al., 2011). For the EHR to succeed, the transition must yield successful outcomes.  These improved outcomes may be easily accomplished by invoking better treatment choice for the providers using EHRs.  For the EHR to achieve sustainability, the patients must be convinced that their security will be protected.  If this privacy is jeopardized the patient’s trust will be compromised and lost forever (Layman, 2008).


In 2004, President George W. Bush began a 10-year initiative to promote the EHR, this concept of electronic documentation was also a major priority to President Obama’s agenda (Madison & Stagger, 2011). Our current administration believes the induction of the EHR is essential to achieve better care for the citizens of the United States (Ericksen, 2009).The Office of the National Coordinator for Health Information Technology (ONC) and Center for Medicare and Medicaid (CMS) are leading endeavors to reduce health care disparities for Americans, because over fifty percent of Americans do not receive adequate health care due to the increasing cost of medical care (Linder et al., 2007). As patient safety is an ongoing challenge for clinicians, it satisfying to know that the government is working to resolve health care inconsistencies in the United States (Ericksen, 2009).

Federal policy is proposing that all Americans have computerized medical records by 2014 (Hebda & Calderone, 2010). The ONC has a plan to implement health information technology (HIT) nationwide in public and private sector (Thede & Sewell, 2010). HIT is the management of medical records through electronic networks with interoperational

benefits.  HIT is necessary to support the management of the EHR system and it is also challenged with the responsibility of improving health care quality and reducing medical errors. HIT will aid the providers by reducing the workload and the paperwork (Jamal, Mckenzie, & Clark, 2009)

The ONC is responsible for establishing the principles necessary to maintain the standards for HIT. Technology-based system has proven evidence of reducing human errors, thus reductions have been seen in non-health care models such as banking and aviation (ONC, 2010). In areas were HIT was unsuccessful, lack of knowledge was the major problem. Other barriers to EHR are lack of training provided in educational programs. In the United States there is minimal education of the EHR. With this federal mandate for EHR, the government has mandated appropriate training for physicians and hospitals (Borycki, Armstrong, & Kushnirik, 2009).). Appropriate training for the clinicians will be necessary to understand the EHR system. The goal is for health providers to exchange health care information between providers with hopes of developing nationally interoperational communication for all HIT (Orlova et al., 2005).

To motivate providers to support these new initiatives the American Recovery and Reinvestment Act of 2009 (ARRA) is promoting $27 billion in financial incentives to health care providers utilizing HIT to improve quality of care for patients (Hoffman & Podgurski, 2011). Congress also allocated $1.1 billion of funding for Patient-Centered Outcomes Research Institute to oversee the CER. CER is responsible for protecting the health of the general population (Hoffman & Podgurski, 2011).


For the objectives of EHR to be accomplished, ONC is implementing the

meaningful use term, which is defined by specific ONC criteria for improving quality of care. To preserve the standards of care the outcomes must be reported to CMS for providers to receive the financial incentives (Madison & Staggers, 2011). It is imperative to clarify the objectives of the meaningful use term. The four objectives are:

  • Improve quality, safety, and efficiency and reduce health disparities.
  • Engage patients and families in patient care.
  • Improve care coordination.
  • Ensure privacy and security of protected health information (Madison & Staggers, 2011, p.58).

These initial rules were very strict and required physicians to use computerized physician order entry (CPOE) for at least 80% of their orders. CMS also required 80% of demographics information be entered on all patients seen. The hospitals were required to have at least one CPOE medication entry order, and 80% of all patients over the age of 13 that smoked required documentation. In the final plans the guidelines were not as stringent as initially proposed; the measures were only required by providers accepting Medicare and Medicaid (Madison & Stagger, 2011).

ONC allowed specific agencies to oversee the clinical operation for EHR. For providers to achieve financial rewards the standards were enforced. The goal is to allow all health agencies to view and exchange data between facilities. For financial incentives to be received there are three stages of implementation necessary to receive the funds. The first stage requires proper documentation and standardized outcomes. Secondly, the provider and patient must communicate electronically, and the last stage monitors the electronic data for improvement. If all these stages occur then there is a maximum incentive of $44,000 per provider from 2011 through 2015. Unfortunately there are rules that must be followed, such as only collecting from Medicare or Medicaid, not from both agencies (Madison & Staggers, 2011).


EHR sustainability will require more than the physicians to survive. Nurses and Advanced Practice Nurses (APN) will play a vital role in the management of health care records. APNs will move into the new roles of nursing informatics, these APNs will specialize in computer technology and utilize their past clinical expertise to bridge the gap of computer and clinician. These specialists will make an overwhelming contribution to the medical profession, by translating reports and assisting the physician and hospital administration in the meeting the requirements of improved quality care (Goodman, 2010).

Today the majority of nursing programs have incorporated nursing informatics classes for future graduates (Murphy, 2011). Nursing Informatics Specialists (NIS) are an important piece of the sustainability puzzle, because nurses provide the largest amount of documentation in health care. Nurses use their skills to assess, plan, intervene, and evaluate their patients. Nurses are concerned about the time the EHR will require. The nurses fear that the EHR may take valuable patient–care time from their patients (Kelley et al., 2011). Nurses must understand the boundaries and capabilities of the EHR to assist their clinical colleagues with the necessary help for successful implementation of the EHR system. This is where the NIS is essential to explain the benefits of EHR and its cost effectiveness for the patients, and how the EHR will reduce errors and create a mutual relationship between the provider and the patient. Nurses will guide the development of EHR guidelines and assist the physicians with the transition from paper to computer (Kelley et al., 2011).

Improved care and less medication errors are very important to the sustainability of EHR, but the protection of patient’s privacy is just as important. Placing millions and millions of citizens’ private health information in one location creates risky operations. The Health Insurance Portability and Accountability Act (HIPAA) has established standards of privacy to protect health information (PHI) of patients. So any health care facility that stores, receives, or transmits electronic PHI must comply with HIPAA security. Any breaches will result in great fines that will be imposed by the federal government. As EHR grows with the 2014 initiative, so will the HIPAA regulation to protect the patients’ rights to privacy (Madison & Staggers, 2011).

ARRA has specific sections that document the expansion of patients’ rights in the Health Information Technology for Economic and Clinical Health (HITECH) Act.  HITECH expanded the patient’s rights, which now, entitles the patients to receive a portion of the government fines. HITECH now rewards the patients from state and federal agencies. HITECH Act is now required to report any breach of information to the patient. The guidelines are different according to the amount of individuals involved in the breach. If the breach is more than five hundred records, it must be reported to the media and security of United States Department of Health and Human Services. The Clearinghouse website is available to report and investigate other HIPAA violations (Madison & Staggers, 2011).


With this new wave of electronics in society, the healthcare community would be foolish not to utilize the personal device assistants and smartphones to provide better quality care for their patients. Communication is as simple as a text message or an email. Unfortunately, there are only 8% of the 5000 hospitals in the United States that are using computerized documentation (Ericksen, 2009). For the EHR to work successfully the barriers must be established and conquered by the providers.

HIT and EHR have tools to improve communication and documentation and health care outcomes. Protecting the privacy of patients will require health care agencies to mandate and follow HIPAA guidelines. If these policies are not enforced the health care facility and the provider will receive harsh penalties. HIPAA must be monitored and researched for efficiency for EHR to sustained (Madison & Staggers, 2011).

Another important need for sustainability is public health documentation, which will definitely require the interoperability to transfer electronic data from provider to facility (Orlova et al., 2011). A prototype has been designed to test and demonstrate the feasibility of EHR in the public health system, but the outcomes are pending (Orlova et al., 2011).

The true sustainability is more provider education. By providing more training this will impact the outcome of the EHR. There is current documented research that indicates a promising approach to informatics for providers with expanded education of the EHR system (Borycki et al., 2009).  As more evidence-based documentation is available this will direct policy towards usage of these computer-based systems for better patient care outcomes (Jamal, McKenzie, & Clark, 2009). Evidence will show that the EHR is economical and will force the patient to take a spirited part in their care (Madison & Staggers, 2011). Medical facilities will have to realize the importance of the EHR and investigate the widespread evidence and decide if the EHR is beneficial and if so, to whom? It could be beneficial, the patient, the physician, or the healthcare facility; beliefs are that every party involved is a winner with the EHR system, but the barriers of knowledge must be identified and conquered for sustainability to occur (Borycki et al., 2009). Research suggests that organization design, project management, and economic evaluation are necessary for the EHR system to be sustained. The stakeholders will require proper orientation of the EHR system to maximize the investment of this computerized system.


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Author Bio

Stephanie Sheridan, MSN, RN, ANP-C, CNN-NP

Ms. Sheridan is employed at the Dialysis Clinic Inc., as a Nurse Practitioner. She is currently pursuing her DNP at the University of Tennessee in Chattanooga School of Nursing. Ms. Sheridan is a member of the Scenic City Chapter of America Nephrology Nurse Association. Correspondence should be addressed to Stephanie Y. Sheridan, Dialysis Clinic Inc., 1425 East Third Street, Chattanooga, TN 37404. E-Mail: stephanie.sheridan@dciinc.org.

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