Background |  Current Activities |  Emerging Lessons |  Projects Funded by AHRQ |  Topics for Discussion | 

Electronic medical record (EMR) systems, defined as "an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization," [1]  have the potential to provide substantial benefits to physicians, clinic practices, and health care organizations. These systems can facilitate workflow and improve the quality of patient care and patient safety. Despite these benefits, widespread adoption of EMRs in the United States is low; a recent survey indicated that only 4 percent of ambulatory physicians reported having an extensive, fully functional electronic records system and 13 percent reported having a basic system. [2]

Among the most significant barriers to adoption are:

• High capital cost and insufficient return on investment for small practices and safety net providers.
• Underestimation of the organizational capabilities and change management required.
• Failure to redesign clinical process and workflow to incorporate the technology systems.
• Concern that systems will become obsolete.
• Lack of skilled resources for implementation and support.
• Concern that current market systems are potentially not meeting the needs of rural health centers or federally qualified health centers (FQHC).
• Concern regarding negative unintended consequences of technology.

Recognizing the role that EMRs can play in transforming health care, in 2003, the Institute of Medicine issued a group of eight key functions for safety, quality, and care efficiency that EMRs should support.

• Physician access to patient information, such as diagnoses, allergies, lab results, and medications.
• Access to new and past test results among providers in multiple care settings.
• Computerized provider order entry.
• Computerized decision-support systems to prevent drug interactions and improve compliance with best practices.
• Secure electronic communication among providers and patients.
• Patient access to health records, disease management tools, and health information resources.
• Computerized administration processes, such as scheduling systems.
• Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts.

[1] The National Alliance for Health Information Technology (NAHIT)
[2] DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care – a national survey of physicians. N Engl J Med  2008 Jul 3;359(1):50-60.

Traditionally, the EMR vendor community has created systems that conform only to proprietary database formats, making it difficult for them to send and receive data from other (potentially competing) products. The medical informatics community has realized the need for interoperability and thus has created standards for data coding and communication. Recently, the Office of the National Coordinator for Health IT (ONC) announced several major initiatives to harmonize standards and create a certification process for EMRs so that different products can interoperate better and be easily and objectively compared. This will enable decision-makers to adopt EMRs more easily.

In 2006, the U.S. Department of Health and Human Services (HHS) recognized initial criteria for certification of ambulatory EHR systems as recommended by the Certification Commission for Healthcare Information Technology (CCHIT). These criteria will help reduce barriers for ambulatory providers to adopt EHR systems by ensuring confidence in purchased products. CCHIT certified products also meet requirements set forth by HHS in final physician self-referral law and Antikickback statute rules, providing access to external means of implementing EHR systems.

Many small practices and community health centers (CHCs) realize that the cost of adopting a traditional EMR (that is hosted within the practice) is too excessive at this stage and are evaluating ASP (application service provider) models. These are "subscription-based" models for EMRs, whereby the application runs on the computer system (server) of an ASP provider (a company that hosts the EMR). This approach substantially reduces the cost for the practice. In addition, the risks associated with security and privacy protection are undertaken by the host company and not the practice. Some practitioners dislike this approach because their data then reside with the host company.

One of the many projects funded by AHRQ, HIT-based Regional Medication Management Pharmacy System, employs a community-based ASP to deploy health IT solutions across a 14 critical access hospital (CAH) network. The ASP was formed by the CAHs in order to pool resources and work collaboratively to achieve a shared vision. The CAHs span a large geographic region in Minnesota, and together they have been able to achieve more than separate small, rural providers.

For lessons emerging from AHRQ-funded EMR/EHR projects, click here.

The Agency for Healthcare Research and Quality (AHRQ) has funded organizations across the country that are implementing and evaluating electronic medical and health record systems. Some of these include:

Title: CCHS-East Huron Hospital CPOE Project
Primary Investigator: Michael Waggoner
State: OH

Title: Collaborative EHR Implementation to Bridge the Continuum of Care in Rural Iowa
Primary Investigator: Sylvia Getman 
State: IA

Title: Connecting Healthcare in Central Appalachia
Primary Investigator: Polly M. Bentley
State: KY

Title: Creating an Evidence Base for Vision Rehabilitation
Primary Investigator: Cynthia Stuen 
State: NY

Title: Crossing the Quality Chasm in Eastern Rural Kern County
Primary Investigator: Kiki Nocella
State: CA

Title: Electronic Records to Improve Care for Children
Primary Investigator: Richard Shiffman
State: CT

Title: Enhancing Patient Safety through a Universal EMR System
Primary Investigator: Thomas H. Johnson
State: PA

Title: Enhancing Quality in Patient Care (EQUIP) Project
Primary Investigator: Fred Rachman
State: IL

Title: Holomua Project-Improving Patient Hand-Offs in Hawaii
Primary Investigator: Christine Sakuda
State: HI

Title: Impact of Health Information Technology on Clinical Care
Primary Investigator: John Hsu
State: CA

Title: Implementing an Ambulatory Electronic Medical Record and Improving Shared Access
Primary Investigator: Michael DeLuca
State: IL

Title: Improving Health Care Quality via IT
Primary Investigator: Robert A. Pezzulich
State: VT

Title: Improving HIT Implementation in a Rural Health System
Primary Investigator: Daniel B. Mingle
State: ME

Title: Improving Patient Safety/Quality with HIT Implementation
Primary Investigator: John G. Reiling
State: WI

Title: IT Systems for Rural Indian Clinic Health Care
Primary Investigator: Susan L. Dahl
State: CA

Title: Louisiana Rural Health Information Technology Partnership
Primary Investigator: Paul A. Salles
State: LA

Title: Metro DC Health Information Exchange (MeDHIX)
Primary Investigator: Thomas L. Lewis
State: MD

Title: Nursing Home IT: Optimal Medication and Care Delivery
Primary Investigator: Susan D. Horn
State: UT

Title: Project InfoCare
Primary Investigator: Peggy Esch
State: MO

Title: Rural Community Partnerships-EMR Implementation Project
Primary Investigator: R'Nee Mullen
State: ID

Title: Rural Iowa Redesign of Care Delivery with EHR Functions
Primary Investigator: Don Crandall
State: IA

Title: Santa Cruz County Diabetes Mellitus Registry
Primary Investigator: F. Wells Shoemaker
State: CA

Title: HIT Service Integration
Primary Investigator: Craig Mathews
State: LA

Title: Statewide Implementation of Electronic Health Records
Primary Investigator: David W. Bates
State: MA

Title: Taconic Health Information Network and Community THINC
Primary Investigator: John A. Blair III
State: NY

Title: The Chronic Care Technology Planning Project
Primary Investigator: John M. Branscombe
State: ME

Title: Tulare District Hospital Rural Health EMR Consortium
Primary Investigator: Paul D. Galloway
State: CA

EHR project leaders and managers are concerned with Participation, Functionality, Performance, and Quality (from Dan Mingle, Improving HIT Implementation in a Rural Health System). Participation involves project management, vendor selection, and user acceptance (buy-in). Functionality is getting the EHR to work technically, including any interfaces to other health IT systems or networks and implementation of proper privacy and security components. Performance involves integrating the EHR system into workflow in addition to ensuring that the system is performing at optimal levels. Quality focuses on clinical practice transformation, including user training/acceptance, impact on clinical outcomes, and ROI.

Because all of these concerns are important to the success of an EHR system, implementation requires significant time and resources no matter the size of the organization. This is why quality, especially ROI and impact on clinical outcomes, is so important. EHR systems must be worth the investment before small and medium-sized organizations can risk scarce resources.

One well-cited study shows a positive ROI of $86,400 in year 5 per provider for a full implementation within an ambulatory setting. Another study shows a positive ROI of $1.1 million in year 1. Analysis on a national level shows a net savings to physicians of almost $10 billion when efficiency and safety improvements are considered. Another national study looking at standards-based health information exchange (HIE) implementations estimates a $77.8 billion annual savings (commentary on that conclusion can be found here).

However, other analyses paint a different picture. A Markle Foundation workgroup recently found that implementation of an interoperable EHR in small practices would result in a net lossof $20,000 per doctor per year. So the value equation is very complex and depends on several variables including geographic region and vendor.