Electronic Health Records

The widespread adoption and use of electronic health records (EHRs) is a primary agenda item for a number of federal, state, and non-profit entities. EHR technology has shown to be effective in transforming the quality, safety, and efficiency of care in health care organizations that have implemented it successfully. However, successful implementation is not easy. Integration of EHR technology into clinical workflow, the adoption strategies used when implementing EHR technology, and technology upgrades and continuous quality improvement are all issues when seeking to implement and use EHRs to store and manage clinical information.

This page features profiles of and lessons from the AHRQ-funded projects working on implementing and measuring the impact of EHRs on the quality, safety, and efficiency of health care. Each project is contributing to the knowledge base around implementation of best practices and integration of technology into clinical practice.

First, we present the following lessons theorized in the literature and observed in practice through the many grants and contracts that make up the AHRQ health IT portfolio:

Adoption

  • Despite progress, widespread adoption of EHR systems remains an issue for small and medium-size physician practices. Nationally, less than one-fifth of physician practices currently use an EHR. One AHRQ grant surveyed practices within its state and found similar results. Furthermore, the grant found that more than half of those practices without an EHR had no plans to implement one.
  • To succeed at implementation, clinicians, including physicians and nurses, must accept and use the EHR. Otherwise, the project will fail. Acceptance can be gained - and sustained - by identifying at least one clinician champion who will speak positively about the system to fellow clinicians and help recruit other enthusiastic EHR supporters.
  • Do not underestimate the amount of training and support needed to help clinicians and staff make the transition from paper to electronic records. Successful grants have employed a combination of "super-users" (clinicians trained and deployed prior to and after go-live to support other clinicians in learning about and using the system), formal training sessions (Lunch and Learns, Brown Bags, classroom trainings), and 24/7 technical support teams. Education and training should be conducted during the planning, implementation, and post-implementation stages of an EHR project. 
    • EHRs in Massachusetts: Who Has Them and How Are They Using Them?
    • IT Successes and Challenges in Opening an All-Digital Hospital
    • Organizational Barriers and Enablers to Using Electronic Health Records

Project Management

  • A staged approach is often viewed as the ideal way to implement EHRs across multiple organizations or within a single large organization. However, AHRQ grants have found that an all-at-once or "Big Bang" approach is successful and may even be preferable to a staged approach.
  • Securing the right expertise to help in the design and implementation of an EHR project can be challenging, especially for rural and facilities for the underserved, such as community health centers. One AHRQ-funded health center got help from a local chapter of the Health Information and Management Systems Society (HIMSS). The HIMSS chapter provided volunteer industry experts who worked together to help the health center design its architecture and implementation plan. Prior to volunteer involvement, the health center received conflicting messages from various consultants and vendors it had engaged. The HIMSS chapter served as a neutral third party with which the health center could consult. Look for this type of in-kind service in your community, perhaps through a university or non-profit organization. 
    • EHR Roll Out: Learning from the Maine General Experience
    • IT Successes and Challenges in Opening an All-Digital Hospital
    • Genesis: Clinical Process Redesign
    • Moving Healthcare into the 21st Century

Return on Investment (ROI)

  • ROI will vary by hospital, depending on current medical record practices, but implementation of EHRs will produce measurable ROI that project leaders can demonstrate to stakeholders. Here are a few returns that AHRQ-funded projects have observed and measured: 
    • Improved compliance with Joint Commission standards for information management (IM 3.10)
    • Less time delivering records to health information management (HIM) coders; savings are greater if coders are off-site
    • Reduced numberof reported non-billable diagnosis codes
    • Fewer pharmacy call-backs
    • Reduced number of HIM work hours, FTEs
    • Less paper consumption
    • Reduced the volume of discharged not final billed (DNFB) patient accounts
    • Less need for physicians to physically come to the HIM department to sign charts; electronic signing can further improve HIM and physician efficiency in chart signing
      • Louisiana Rural Health Information Partnership
      • Trinity Health's Adoption of Health Care IT Shown to Improve Savings and Quality

Technical Architecture and Operations

  • Development of in-house expertise -- such as systems engineers, and informatics personnel --  reduces dependency on outside resources, like consultants, vendors, other IT contract services, and promotes sustainability.
  • Networks allow individual entities, such as clinics and physician practices, to access more sophisticated resources and take advantage of economies of scale. 
    • Moving Healthcare into the 21st Century

Workflow/Process Redesign

  • Implementation of health information technology (health IT) is one-third technology and two-thirds organizational culture and work process. Successful EHR implementations devote significant time and resources to planning efforts that examine and redesign clinical workflow. Analysis of current workflow helps an organization more easily integrate technology into care delivery processes. Process redesign does not require expensive consultants or software, but it does require significant staff time and effort. Investing in process redesign on the front end of EHR projects will significantly pay off in the end. 
    • Genesis: Clinical Process Redesign
    • Health Information Technology & Patient Safety
    • Workflow Redesign: The Challenge in Implementing an Electronic Medical Record

Second, we highlight the many projects in the AHRQ-funded health IT portfolio implementing and measuring the impact of EHRs on the quality, safety, and efficiency of health care: