During the past few months, I have visited several different academic medical institutions. Many of the hospitals had recently updated, or were planning to update, their electronic health record (EHR) system. While we know that EHRs will impact how we practice medicine, in my experience, it seems that much of the conversation has often glossed over some of the less obvious ways EHRs impact health.
Meaningful use requirements
To gain a better understanding of how EHRs could potentially impact health, it’s important to have a cursory understanding of the legislation surrounding EHRs, most notably the meaningful use (MU) requirements. As part of several pieces of legislation, health care providers are being provided monetary incentives to use EHRs. To receive these funds, the use of the adopted EHRs needs to fulfill so-called meaningful use (MU) requirements. These requirements are being implemented in three stages, and with each additional stage, providers are required to use the EHR in increasingly complex ways. Health care systems and providers that meet the requirement at each stage receive additional reimbursement for patients insured through the Centers for Medicare and Medicaid Services (CMS). Eventually, providers who do not use an EHR in a way that meets MU requirements will be penalized by CMS.
The MU requirements span a range of features including data collection (e.g., medication list, demographic characteristics, smoking status), data reporting (e.g., clinical quality measures), clinical decision support and patient communication (e.g., patient reminders for preventive care, clinical summaries for patient visits). While these features are designed to improve patient outcomes, during stage one of MU implementation, it has been clear that EHRs have not been the panacea that many anticipated. In fact, there have been many unintended negative consequences during the course of the paper-to-electronic conversion. As a result, many view EHRs with much disdain. Unfortunately, much of this early conversation has failed to discuss some of the potential long-term benefits of an EHR, benefits that extend beyond its purpose as a medical record.
Increasing ease of large-scale observational studies
A study conducted on the prevalence of acetaminophen supratherapeutic dosing in hospitals is a nice example of the many other benefits that come from EHRs.1 The first of these benefits is illustrated by the existence of this study. The authors of this study were able to use EHR data to identify how many patients during a three-month period in two academic centers received >4 grams/day (maximum recommended dose) of acetaminophen. These large-scale studies were impossible with a paper chart review. And as noted in a commentary in the American Journal of Epidemiology, the adoption of EHRs means that population-level studies like this can be done with increasing ease and lower costs than ever before.2
Decision support
An additional benefit of EHRs illustrated by this study is their ability to provide decision support for providers. The authors of recommend that an easy way to prevent administration of toxic doses of acetaminophen is to develop decision support tools into the EHR that notify providers when nearly four grams of acetaminophen have been provided to a patient. Many drug interaction and patient allergy warning messages are already built into EHRs, but additional decision support mechanisms may be useful (although it will be important not to overwhelm providers with too many messages).
Quicker drug safety reporting
Similarly, EHRs increase the ease of identifying adverse drug effects (ADE) that may not have been identified during Phase I-III clinical trials. The current post-marketing surveillance for ADE is highly dependent upon health care professionals reporting events from their patient experiences. Data present in EHRs will enable pattern recognition that will allow quicker identification of ADEs, creating, in effect, virtual Phase IV trials. The FDA has started utilizing some health information technology for this purpose via its Sentinel Initiative; including EHRs in these efforts will be the next step.
These are just a handful of ways in which EHRs can be used to improve health care and health. Others that have been mentioned include improved surveillance of public health issues3 as well as more dynamic and successful research and development for pharmaceutical companies.4 As EHR implementation becomes more widespread, we will continue to identify new ways that technology can improve health. We are the first generation to grow up with ubiquitous technology; we must also be the generation that creatively leverages health technology to improve health.
