Regulations, advantages, and implementation of electronic health records

The health information technology for economic and clinical health act and meaningful use

The HITECH Act provides financial incentives for the meaningful use of certified EHR technology to achieve health and efficiency goals. It was incorporated into the ARRA to promote the adoption and meaningful use of health information technology.

Sidenote

HITECH and HIPAA

Remember, HIPAA was created in large part to simplify administrative processes using electronic devices.

Meaningful use, defined simply, means that providers must show that they are using EHR technology in ways that can be measured significantly in quality and quantity. If providers meet the meaningful use requirements, they will qualify for incentive payments.

Three main components of meaningful use can be identified, including:

• Use of certified EHR in a meaningful manner, such as e-prescribing
• Use of certified EHR technology for electronic exchange of health information to improve the quality of healthcare
• Use of certified EHR technology to submit clinical quality reports, procedure and diagnosis codes, surveys, and other measures

Criteria for meaningful use were designed to be implemented in three stages:

• Stage 1 (2011 and 2012): Electronic data capture and sharing
• Stage 2 (2014): Advanced clinical processes
• Stage 3 (originally projected for 2016, but ultimately finalized in 2015 for optional use in 2017 and required use in 2018): Improved outcomes

In Subtitle D of the HITECH Act, privacy and security concerns related to the electronic submission of health information are addressed. Several provisions strengthen the civil and criminal penalties of the HIPAA rules, most of which became effective in February 2009. More of the provisions will become effective over the next few years, subject to future lawmaking.

Included in the February 2009 modifications of HIPAA were:

• Establishment of categories of violations that reflect increasing levels of culpability
• Requirements that penalties be determined based on the nature and extent of the violation and the nature and extent of the harm resulting from the violation
• Establishment of tiers of increasing penalty amounts that determine the range of and authority to impose civil monetary penalties

HITECH’s four culpability tiers set the civil penalty range for a HIPAA violation:

• Did not know of the violation (and by reasonable diligence would not have known)
• Reasonable cause, but not willful neglect
• Willful neglect, corrected within 30 days of discovery
• Willful neglect, not corrected within 30 days of discovery

For example, a business associate who knew about a security gap, ignored it, and still hadn’t fixed it months later falls into the highest tier: willful neglect, not corrected.

Advantages and disadvantages of the EHR

According to a 2014 survey done by the National Ambulatory Medical Care Survey (NAMCS), 82.8% of providers in office-based practices use full or partial EMR systems. This is up from 18% in 2001.

Advantages

The EHR has several advantages over a paper health record, which fall into a few broad categories:

• Accuracy and legibility: the EHR can reduce medical errors by keeping prescriptions, allergies, and other information organized, and it can reduce costs by preventing duplicate tests. Because information is entered with a keyboard, the record is far less likely to be illegible than a handwritten one - typed copy stays easier to read than handwriting even years later.
• Storage and backup: compared with walls and file cabinets full of paper records, the EHR requires far less physical storage space, and files can be backed up regularly and stored off site - a thumb drive kept somewhere other than the healthcare facility can meet HIPAA’s backup requirements.
• Accessibility: information can be accessed in a variety of locations, and more than one person can see the record at any given time. Patient information is available quickly in an emergency, even when the patient is not in his or her hometown, and the provider and medical assistants can reach progress notes, test results, and other information - including patient education and appointment no-shows - from a smartphone or tablet.
• Data retrieval: the patient database usually allows various types of statistical information to be recalled, which lets staff compile data across all patient files rather than pulling charts one at a time.
• Staffing and throughput: staffing needs may be reduced, because fewer personnel are needed to manage an EHR system, and once the provider and staff become familiar with the system, they may be able to see more patients in a day than when paper records were used.

EHR systems require individual user names and passwords, which help secure the system from unauthorized users.

Files can also be backed up and stored off site to meet HIPAA’s requirements. Federal retention periods for Medicare and Medicaid records depend on the situation: 5 years for hospital records and cost reports, 7 years from the date of service for providers and suppliers enrolled in Medicare, and 10 years for Medicare Advantage. State law often sets its own period, so each record is kept for whichever required period is longest.

Sidenote

Data storage

More facilities are using cloud storage to protect the EHR content.

All of these advantages lead to cost savings and more efficient patient care.

Disadvantages

However, the EHR system is not without disadvantages. Studies show that lack of capital is the most significant obstacle to adoption of the system; another stumbling block is the reluctance of employees in providers’ offices to make such substantial changes and to learn a new computer system. Employees who are not very familiar with computers may fear that they will not be able to learn the system or that an EHR may mean that they no longer will have a job. Providers may have the same fears of learning a new system and wonder about how much more time it will take them to do their job. Employees may not be the only individuals resistant to a changeover to electronic records; patients often are fearful that their private health information will be available to unauthorized individuals, and they often assume that their records will be posted on the Internet.

The most significant obstacle to EHR adoption is often the high cost of implementation and training.

The startup costs of conversion to an EHR system usually are quite high, although most providers realize that the system eventually will be worth the cost. One widely cited study estimated roughly $162,000 in startup costs and $85,500 in first-year maintenance costs for a five-provider practice, plus hundreds of hours of implementation and end-user training (Fleming et al., 2011).

Both the provider and staff require extensive training in the EHR system and must be receptive to even more training to use the system to its full capacity. Training is time-consuming and takes the provider and staff away from treating patients for certain periods. Because not all computer systems are user friendly, care must be taken to choose a system that has technologic support, both live and online, that is available during the hours the healthcare facility is operating. Space for the equipment can be an issue, although usually less space is required than for a paper record system. Finally, security and confidentiality are major concerns of both the healthcare professionals and the patients.

Successful conversion to an electronic health record system

The following strategies can help make an EHR conversion more successful:

• Get the entire facility “on board” with the change and provide clear leadership throughout the process.
• Invest in thorough training for providers and staff, since unfamiliarity with the system is a leading cause of resistance.
• Use good people management skills with employees who resist the change - many who are initially averse to a conversion later say they can’t imagine working without the EHR.
• Work as a team, using each employee’s strengths and maintaining strong customer service throughout the transition.