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Efficacy of Electronic Health Records  I am a practicing OR nurse, an AORN member, and a CNOR. Two hospitals at which I have worked, including my current one, have adopted an electronic health record (EHR) for charting in the OR during my employment. Following my hospital's adoption of an EHR last year, I requested and received from AORN a list of published articles addressing the efficacy of the EHR. A recent, well-written article by J. Roeder1 and an equally detailed predecessor article by L. Saletnik et al2 are of great interest to me. The Roeder and Saletnik articles, respectively, describe the implementation of an EHR by Department of Veterans Affairs (VA) health care facilities and by The Johns Hopkins Hospital, Baltimore, Maryland. The thoughtful descriptions of the pre- and postimplementation issues surrounding the EHR in those institutions have been valuable to me. However, neither article meaningfully addresses what I consider to be the two main issues underlying the very expensive EHR:
1.Does it help patients?
2.Does it reduce costs?
The Roeder article makes some claims in those regards, but none of them are based on empirical evidence. For example, she states,
The old-style chart is a stack of papers. The [electronic health record] screens provide the same information in organized tabs, allowing nurses to provide optimal perioperative care.1(p677)
She also quotes David Brown of The Washington Post:
computer accessible records have the potential to save … billions of dollars. … 1(p680),3(pHE01)
and an article by Kilbridge and Classen:
Computer and information systems can make important fundamental contributions toward creation of safe systems through … increasing vigilance. … 1(p685),4(p398)
Regarding the improved patient care assertion, there is, in my and others' reviews of the literature, no data to support it. The best article I have read appeared in The Wall Street Journal opinion section on March 12, 2009.5 The authors are J. Groopman, MD, and P. Hartzband, MD, staff members of the Harvard Medical School, Boston, Massachusetts. In addition to their own and their fellow Harvard staff members' lack of findings of either cost savings or improved patient outcomes from use of the EHR, they report:
•A 2008 study of 15,000 cardiology patients published in Circulation concluded that “current use of electronic health records results in little improvement in the quality of health care compared with paper-based systems.”5(pA15)
•A study of 1.8 billion ambulatory care visits conducted by physicians from Harvard, Stanford, and Brigham and Women's Hospital concluded “as implemented, electronic health records were not associated with better quality ambulatory care.”5(pA15)
•A 2009 Canadian review of 3,700 published papers on the use of EHRs in primary care delivered in seven countries “found no solid evidence of either benefits or drawbacks accruing to patients.”5(pA15)
Regarding the recent nationally touted cost and patient care benefits of the EHR, the authors concluded: “We need the president to apply real scientific vigor to fix our health-care system rather than to rely on elegant exercises in wishful thinking.”5(pA15) My own experience is anecdotal, but it seems to me that the extensive time OR nurses spend with their “heads in the computer” cannot help the patient. Neither of the institutions where I have seen the EHR instituted asserted that costs had been reduced after the data were in. In my view, the study has yet to be conducted and the article has yet to be written that will demonstrate a reduction in infections, wrong site surgeries, other surgical complications, or any other measurable patient outcome indicators we use in the OR. Unless and until these data become available, our professional organization, AORN, has a duty to stop cheerleading and to start seriously analyzing the EHR. Response from AORN We acknowledge Mr Van Winkle's concerns, especially regarding the impact that the EHR has on patient care. The pursuit of measurable and meaningful data that allow for the evaluation of care is an area that needs to be developed; this can be accomplished by learning from past mistakes in implementing EHRs. Current EHRs allow for great customization, which does not provide standardized data collection. As a result, data cannot be evaluated across institutions. To make documentation more meaningful and less time consuming, the data collected should be used to evaluate interventions used in providing care either through quality improvement projects or research studies. Standardized data should decrease the time necessary to document care. Syntegrity™, a project initiated by AORN and developed in collaboration with CSC, builds upon the Perioperative Nursing Data Set, a standardized nursing language. In addition, to the standardized language, Syntegrity includes standardized data points necessary for reporting to regulatory and accrediting agencies. Unlike previous EHR efforts, Syntegrity uses patient outcomes as a focus of documentation. We realize that EHR use is a developing field. With the continued use and refinement of documentation systems and standardized data elements, the ultimate goal of delivering quality and effective care in an efficient manner can be achieved. Response from Jacqueline Roeder It is important to remember that the adoption of an interoperable EHR is in its infancy. The interoperable EHR is but one aspect of health care reform designed to improve a very fragmented record-keeping system, which will likely result in the reduction of health care costs as well as better patient outcomes. In a 2006 Business Week article, author Catherine Arnst states,
while studies show that 3% to 8% of the nation's prescriptions are filled erroneously, the VA's prescription accuracy rate is greater than 99.997%. … 1
The article attributes this accuracy to use of the EHR. Estimates of cost savings in the literature vary as real-time, national data have yet to be collected and analyzed. Studies are currently underway through the Agency for Healthcare Research and Quality.2 The RAND Corp, a group whose mission is to help improve policy and decision making through research and analysis, concluded from a computer-simulated study in 2005 that
if 90 percent of doctors and hospitals successfully adopt health information technology and use it effectively, resulting efficiencies would save $77 billion annually. The biggest savings would come through shorter hospital stays prompted by better-coordinated care; less nursing time spent on administrative tasks; better use of medications in hospitals; and better utilization of drugs, labs and radiology services in outpatient settings.3
I have 12 years of continuous experience at my current VA facility. I began with a paper chart, then participated in the Computerized Patient Record System introduction, and now see its benefits firsthand. Patient care remains my first priority; I have found that the EHR is an easy-to-use tool to document our high-quality care without our having to wonder whether the paper record would remain in the chart. Perioperative use of the EHR's snapshot of the patient's health picture, including risks, alerts, and history, helps me reduce errors. My fellow nurses and physicians are comfortable and confident in their use of the EHR. As an aside, it took more than 60 years to overcome legislative and industrial inertia for seatbelt use to be mandated by law and save lives.4 Initially, there were no empirical data. Today, empirical data prove seatbelt use does save lives. I believe that when fully implemented, a nationwide EHR system will help our profession provide better patient care with fewer errors, reducing overall human and liability costs. Response from Laurie Ann Saletnik and Margaret K. Niedlinger Asking questions such as whether an electronic medical record helps patients and/or reduces health care costs is important to understanding the value of such a significant expense. Although the benefits are not always immediately apparent, there are many ways in which the implementation of an electronic documentation system contributes to patient safety and improving patient care. Obtaining such benefits is often reliant on the construct and use of the system in individual institutions. Although research focused on validating this assumption is certainly indicated, several benefits are clear. Does it help patients? Though paper documentation has been reasonably effective for many years for communicating individual patient information to various health care providers, using this information to evaluate the effect of specific interventions on patient outcomes has been particularly challenging. Identifying trends that lead to improvements in the process of delivering care has been a labor intensive, manual effort that can no longer be supported in the current environment. Electronic documentation provides for the analysis of large volumes of data, facilitating evaluation of the effect of specific interventions on the outcome of care. One example of an intervention that has been analyzed at our facility is the use of specific prep solutions and their effects on surgical site infection. Analysis of data such as this is also used to monitor compliance with identified best practices and affords the opportunity to better educate clinicians on current recommended practices. It facilitates public reporting of compliance rates on measures such as the Surgical Care Improvement Project measures, as the public becomes more educated about health care and agencies limit the cost of care that will be reimbursed. Having access to electronic clinical documentation also facilitates the ability to ensure that it is accurate and complete in real time. There is the ability to designate specific data elements as required fields, forcing the clinician to provide information and not leave an element blank. Electronic documentation can also support the provision of links to other sites that might be beneficial to the care provider. An electronic policy and procedure manual or an electronic incident reporting site are examples of information that might be valuable to access in real time. In addition, electronic documentation can facilitate the display of important information to all care providers in the OR at the same time. With the use of large-screen monitors, data collected in disparate systems can be consolidated and displayed for the entire team, such as the planned procedure, site, side, patient allergies, patient age, and the timing of critical events such as cross clamp time and antibiotic administration. Does it reduce costs? The ability to analyze the effect of interventions on patient outcomes is likely to lead to focus on practices that improve outcomes versus those that do not contribute to a better patient outcome and should therefore be eliminated. Although assessment of interventions can more easily be conducted within a specific organization, there is also an ability to compare practice with other institutions. An electronic system is a helpful tool to better manage supply costs. There is potential for more accurate charge capture if systems are maintained with up-to-date information. It facilitates the evaluation of supply use over time, which can lead to improved stocking and minimization of redundant supplies, as well as elimination of items that are no longer used. It can serve as a mechanism for comparing practice related to supply use and facilitating a conversation regarding standardization. An electronic scheduling system is also valuable in that it standardizes language, thereby minimizing confusion and conflicts with equipment and/or supplies. This in turn should lead to minimizing case delays; reducing case cancellations; and ensuring that the necessary equipment, supplies, and instrumentation are available for surgical procedures. We agree that formal research is indicated to assess the benefits and disadvantages to electronic documentation in the OR; however, there are benefits to be realized even before such research is done. In addition, it is prudent to stay in close contact with your OR systems vendor as impediments to efficient documentation are realized. Most vendors appreciate the feedback and will work with their customers toward a better solution. Electronic documentation in the health care environment remains relatively new and, consequently, immature. Input from patient care providers in all environments is imperative to provide the most benefit to our patients, clinicians, and administrators. References a Broadlawns Medical Center, Des Moines, IA b AORN, Inc c Alaska VA Healthcare System and Regional Office, Anchorage d The Johns Hopkins Hospital, Baltimore, MD Editor's note: CNOR is a registered trademark of the Competency & Credentialing Institute, Denver, CO. Editor's note: Syntegrity is a trademark of AORN, Inc, Denver, CO. TheXS AORN Journal welcomes letters for its “Letters to the Editor” column. Letters must refer to Journal articles or columns published within the preceding six months. All letters are subject to editing for length and clarity before publication. Authors of articles or columns referenced in the letter to the editor may be given the opportunity to respond. Letters that are included in the “Letters to the Editor” column must contain the writer's name, credentials if applicable, position or title, employer, and employer's address. This information is intended for general use only. Please submit letters by e-mail to aornjournal@aorn.org and reference “Letter to the Editor” in the subject line, or submit letters by mail to AORN Journal, Letters to the Editor, 2170 S Parker Rd, Suite 400, Denver, CO 80231-5711. PII: S0001-2092(09)00622-X doi:10.1016/j.aorn.2009.09.004 © 2009 AORN, Inc. Published by Elsevier Inc All rights reserved. | |
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