For early adopters ranging from a major health system in Pennsylvania to a 25-bed critical-access hospital in New Hampshire, electronic health records are a driving force now. Sixteen years after implementing EHRs, Geisinger Health System in Pennsylvania relies on them for just about everything. "Our research and proven care model are powered by our EHR," says spokesperson Wendy Wilson. Citing Geisinger's genomic study of 100,000 people, she says the EHR "is behind all that."
Across the US, the landscape is changing quickly. In 2013, nearly six in 10 acute-care hospitals had adopted at least a basic EHR system, according to the latest available federal data. That was up 34% from 2012, and a fivefold increase since 2008.
"We find the majority of large hospitals are using health IT products [like EHRs] and just working to refine those...and the numbers continue to increase with small hospitals," says spokesperson Peter Ashkenaz of HHS's Office of the National Coordinator for Health Information Technology (ONC).
At Geisinger, a physician-run integrated health system serving central and northeastern Pennsylvania, its EHR database now holds information on three million-plus patients, with clinicians using records for inpatient and outpatient care. Its patient portal is used by 275,000-odd patients. Most recently, the system announced Nov. 4 the connection of a Geisinger-invented rheumatology app to its EHRs.
It wasn't always so, of course. Richard Martin, MD, a family physician in practice three decades, is among those at Geisinger who still clearly remember the early days of EHRs, then commonly known as electronic medical records (EMRs)—and even earlier, when paper records ruled.
Back in the days of paper records for patients, "the documentation from my perspective was easier but incomplete. We had forms with checklists," says Martin, department director in Geisinger's community-practice service line. EHRs have templates, too, he says, "but our documentation is much, much more accurate and complete."
"When we first implemented EHR in 1999, for the first several years we basically used it as a typewriter," typing in office notes, Martin says. "But then we learned how to extract clinical data we'd spent several years uploading into the EHR and use that data to change the way we practice" and improve quality of care. For example, he says, he now can monitor his 200 or so patients with diabetes at a glance, pulling up the screen and viewing graphs of their reports and test results over time.
Putting on his administrative hat, Martin notes that EHRs "continue to evolve to help us to be able to measure and manage higher quality care," promoting value-based purchasing and giving "feedback to our own hospitals, departments and physicians."
Geisinger also stresses the importance of keeping its EHRs available to patients. More than 100,000 patients are using its OpenNotes program, which allows patients to open and review physician notes, along with other information, in their EHRs. Geisinger spokesperson Wilson says, "It's not just that we have an electronic health record; it's very interactive with our patients...and we're finding those patients getting into their EHR are those patients getting more engaged in their own healthcare."
Martin says he has patients in their 70s and 80s who are adept at going online and using OpenNotes—and they typically arrive better prepared with questions for their subsequent visits.
Trying to connect inpatient, outpatient records
Valley Regional Medical Center, a 25-bed critical-access hospital located in economically depressed Sullivan County, NH, "was an early adopter of technology, so we are completely electronic—which is a good thing," says Peter Wright, Valley's president and CEO. However, he adds, "It's not the panacea everyone thinks it is."
An EHR system is "expensive to acquire, expensive to maintain," and "requires a small army to keep going," Wright says, noting that it takes up a big chunk of Valley's operating budget. That said, the administrator says he firmly believes in its benefits, including enhanced patient safety.
"Back in the old days, when it was a paper chart, it was [a matter of], 'Who has the chart?'" Wright recalls. Now, being able to share information across various clinicians makes life easier in the hospital, he says, "and I think EHRs make the outpatient world a lot easier, too."
However, he adds, Valley's EHR system has its drawbacks. "There's really no interconnectivity," he says. "We can transfer orders, demographic information, information from one [Valley] provider to the next," but not with outside providers since "everyone has their own proprietary system."
Nationwide, six in 10 hospitals electronically exchanged health information with outside providers in 2013, says ONC, which convened the first joint meeting of the HIT policy and standards committees in October in its effort to create a national "interoperability roadmap." In a separate federal effort to help small hospitals defray some costs, CMS said Nov. 4 the Medicare EHR Incentive Program paid a total of $32.7 million to CAHs in September 2014—and closer to $700 million to CAHs since the program began in 2011.
Aside from costs and connectivity, there is another issue that small hospitals must confront: "If you're a large organization like Dartmouth or Mayo, you probably have a[n EHR] system where inpatient and outpatient are in the same record," Wright says. "But if you're small like us, we have one product for outpatient and a completely different product for the hospital—and they're not connected."
"We work very hard to make sure our doctors in the emergency department and hospitalists get access to that information," he says. "But it's not as straightforward and fantastic as we'd originally hoped."