Chapter 3
Challenges of EHR Adoption
1
© 2007
Nature of Challenge
• Perception
– EHRs have design
limitations
– Data entry takes longer
in EHR than paper
– Cost is prohibitive
– There are legal issues
with EHRs
• Reality
– Early designs were limited but
efforts have overcome their
limitations
– Data entry may really take
longer, but there are real
downstream time savings
– Establish expectations and
metrics and measure benefits
– Most legal issues are waning
© 2007
Legal Issues
• Even as legal concerns are being addressed to
improve the flow of information while still
providing for confidentiality and privacy, we
must be aware of concerns of both providers and
patients
© 2007
Legal Issues: Sources of Law
• Primary source: State law
– with federal input becoming more common
• Secondary source: Case law
– Legal precedent is created by judges rather than
legislatures.
– In case law, judges can either interpret statutory law
or common law.
© 2007
Legal Issues: Authentication
• Electronic signatures as a legal form
– Most states have applied existing business rules, while some states have
enacted new laws.
– Federal law (HIPAA - 1996): addresses PHI in an electronic environment,
including access controls and authentication
– Federal law (MMA - 2003): e-prescribing (although DEA must still weigh
in on controlled substances)
– Federal law (E-SIGN): The Federal Electronic Signatures in Global and
National Commerce Act of 2000
– Uniform Electronic Transactions Act, approved in July 1999
– FDA Regulations, 21 CFR Part 11 (1997)provides criteria for acceptance
of electronic records and signatures
– The Joint Commission: Standards safeguarding records and information
– CMS: Medicare Conditions of Participation address maintenance of the
health record
© 2007
Forms of Signature in EHR
• Intent is to replicate the strength of a “wet signature”
(pen on paper)
– Digitized signature:
– Electronic signature:
– Digital signature: Cryptographic signature that positively
authenticates the user, and can provide nonrepudiation and
message integrity
© 2007
Legality of Records Issues
1. Retention and
durability
2. Storage
3. Signature
4. Accuracy of entries
5. Transmission integrity
6. Admissibility
7. Evidence
8. Discoverability
• Common thread:
– Records are retained as
they were created and are
not altered
• Custodian of records
must be able to testify
that the record was
compiled in the normal
course of business
© 2007
E-Discovery
• Amendments to Federal Rules of Civil Procedure
and Uniform Rules Relating to Discovery of
Electronically Stored Information
• Enable motion for court to order EHR’s metadata
(data about data), such as:
–
–
–
–
Audit trail information
Decision support rules
Clinical practice guidelines
Other information not typically defined as the “legal
health record”
© 2007
Overcoming Clinician Resistance
• In hospital:
– Physicians often have less
“say”
– Some physicians may be
less frequent users
– Process improvements and
workflow changes need to
address physician
concerns, not just hospital
worker issues
• In office:
– Physicians are primary
decision maker, except
potentially in a large
practice
– Other clinicians will also
use EHR and often are not
included in decision
making
– Administrative processes
cannot be negatively
impacted
© 2007
Clinician Involvement
• Seek active involvement of all types of clinicians and
create teams that are both focused and cross-cutting
• Recognize that time is perhaps the most precious
commodity any clinician owns. Use it wisely and plan
for an EHR that saves time
– Emphasize downstream time savings where data entry may
take longer
• Engage sufficient numbers of clinicians so that all points
of view are represented (the inherent educational
process is also spread to all)
• (Cautiously) compensate clinicians for their
participation, but not for use
© 2007
Gaining Acceptance of Change
• Effective management of change requires some hard
questions to be asked and answered:
– Is there an environment of readiness for change?
• Education and set realistic expectations
– Is there a clear vision and migration path established?
• Is the vision limited to just a few “pain points” or to the full scope of
what is feasible
– Have realistic expectations been established?
• Benefits must be measurable
– Have sufficient funds been committed?
• Access to workstations must be ubiquitous
• Systems that go down frequently are unacceptable
© 2007
Patient/Consumer Issues
• Many patients understand and desire the
efficiencies associated with the adoption of an
EHR, but have issues with some aspects of
automation of their information:
– Privacy
• Confidentiality
• Consent management
– Security
• Identity theft
– Quality of information
© 2007
% Very or
Somewhat
Concerned
% Not Very
Concerned
Sensitive personal medical-record information might
be leaked because of weak data security.
70
38
There could be more sharing of your medical
information without your knowledge.
69
42
Strong enough data security will not be installed in
the new computer system.
69
34
Computerization could increase rather than decrease
medical errors.
65
29
Some people will not disclose sensitive but necessary
information to doctors and other healthcare providers,
because of worries that it will go into computerized
records.
65
29
The existing federal health privacy rules protecting
patient information will be reduced in the name of
efficiency.
62
28
Patient Concerns
Source: America’s Health Insurance Plans, July/August 2005.
© 2007
Business Challenges
• Healthcare is a business and faces many
business-related challenges for EHR
implementation.
–
–
–
–
–
Economic issues
Reduced reimbursement
Staffing shortages
Escalating costs for all aspects of operations
Limited access to capital
© 2007
Addressing Business Challenges
• Technological advances are making EHR systems more
cost-effective
– Although lower cost of technology is often offset by
greater complexity of systems
• Vendors realize they must meet time and budget
commitments
– CCHIT certification has helped
• Providers are finding innovative ways to fund EHR
systems, including outsourcing, grants, HIE
participation, and incentives
© 2007
Leadership and Change
• Exemplary EHR implementations display the
following characteristics of their executive
leadership:
– Significant involvement
– Strategic imperative
• Not just financial return on investment
• Value proposition is important
– Continuity of leadership
– Commitment not to automate what is not working in
manual environment
– Customer service and end-user orientation
© 2007
Nationwide Health Information Network
• Individual provider leadership is essential for
successful EHR implementation within an
organization
• Federal leadership has been provided to address
overall health of nation:
– Growing federal initiatives and support
– Private sector initiatives for standards setting
– State-led initiatives
• NHIN is a concept. Will it meet the challenge?
© 2007
Conclusion
• Adoption (not just implementation) of EHR faces
many challenges
– Some are real and some are perceived (often
lingering from a time when certain issues were more
real)
– New issues may be arising, especially in the area of
privacy and security; and as more consumers become
engaged
• Many challenges are being overcome by
clinician and patient engagement
© 2007