According to HIMSS (2010), “The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting.” The record is kept in a digital format that can be shared across a variety of health care settings and may include data such as medical history, medications, allergies, immunizations, test results, billing information, radiology images, demographics, family history, etc… It is intended to be a complete record of patient encounters that streamlines patient care and improves quality management by preventing errors due to incomplete or inaccurate medical records.
Determining which electronic health record should be utilized by a facility warrants careful consideration. A basic SWOT analysis should be done before determining if any new software. (Shelly, Cashman, & Rosenblatt, 2003).
- Strengths: What are the company’s strengths and how can they be maximized?
- Weaknesses: What are the company’s weaknesses and how can they be overcome or minimized?
- Opportunities: What are the company’s major opportunities and how can the company take full advantage of them?
- Threats: What major threats does the company face, and what can be done about them?
If the SWOT analysis demonstrates there is potential for new software, it becomes important to determine just what software is needed. A needs assessment should be undertaken to gather information and define system requirements. These requirements should be prioritized based on input from the stakeholders. Once this is completed, you have a scope of work that can be used to create a prototype of new and proprietary software, or to generate and evaluate alternatives in existing software ‘out of the box’ options.
By prioritizing the scope of work, it becomes easier to make recommendations to the decision makers. The cost of the system can be more easily weighed against the advantages of the system.
It is important also to use the threat analysis to understand all regulations the software must meet in order to be used by the company. All potential barriers and obstacles must be analyzed to ensure the software can overcome or bypass them. The cost of the software is not limited to the actual purchase price; it also includes the costs associated with installing the software, such as downtime, employee man-hours, hiring consultants, providing training for users, and having technical support for the software. The software life cycle is an ongoing consideration, and the software will have to be updated and modified throughout its existence. The cost associated with updates and upgrades should also be taken into consideration when making a software decision. Some software vendors charge for providing technical support and training, which is another consideration when choosing the software. (Satzinger, Jackson, & Burd, 2004).
There are many barriers to adopting an electronic health record other than just the financial concerns. One important consideration is whether all the stakeholders will accept the software. A patient’s life may literally depend upon the security, completeness, and availability of the electronic health record. In addition to the software itself, what other methods should be implemented alongside the software to ensure the software is acceptable for use? The first major consideration should be the backup and restoration of the software and the data it contains. How will this be handled? Does the software backup all information automatically and immediately? Or does it require manual instructions to backup the system and only backup at particular intervals? Where will the backups be kept and how quickly, efficiently, and completely can a restoration be handled?
Security is another important consideration. Security and accessibility must always be balanced against each other. Both the existing data and the backup files must be kept secure from errors, bugs, and outright malice. How will the backups and existing data be kept secure from outside unauthorized influences? How will they be kept secure from inside unauthorized influences?
There are also technical considerations when implementing any new software. Will it be compatible with the other software used? Will it be compatible with the hardware used? What changes will need to be made to existing hardware and software in order to use the new system?
Making a change to an existing system must be meticulously planned in order to run smoothly. An electronic health record includes a vast amount of data, and a patient’s medical file must include information from before the EHR was implemented. An important consideration to take into account is how to transfer the existing information to the new system. Will it be necessary to hire additional staff for data entry, and if so, where will qualified and authorized staff members be found?
Another important consideration is what to do with the old files. Are they to be archived or destroyed? To prevent fraud or theft, the old files must remain secure or their destruction should be through and done in an authorized fashion. Simply carting the old files out and tossing them into the dumpster is an unacceptable solution, whether those files are on disk form or in paper form. Simply deleting data does not remove it from a hard drive, thus it may be necessary to arrange for the actual destruction of the old hard drives if they are not going to be reused.
Once the software is selected, it is time to consider how it should be implemented and supported. The documentation and training phases should actually begin prior to a company-wide installation. The installation must be tested and the data must be converted and added to the installation. Employees must be trained on how to use and maintain the system.
In most health-care settings, a parallel implementation is the best decision. In a parallel implementation, the old system and new system run simultaneously until the new system is ready to go on it’s own. This enables all kinks to be worked out with minimal disruption and data loss during the transition. The old system also acts as a backup system if something does go wrong with the new system, and allows for increased ease in data transfer. It also allows users to be properly trained and attain a degree of comfort and familiarity with the new software instead of just being thrown into the new system.
Based on the scope of work and size of the system, a timeline should be arranged with several milestones. The first milestone may be the final decision on which new software will be implemented, with the last milestone being a completed full transition to the new system. Milestones in between should highlight installation, data conversion, and training completion. How quickly a timeline can be completed depends entirely on the nature of the transition. Moving information from one EHR to another is an entirely different issue than moving from paper-based records to an EHR.
Quality assurance is an important consideration in determining if a new system is going smoothly, and the timeline assists with quality assurance. By having a clear timeline with designated milestones, it is possible to recognize and deal with a problem before it gets out of hand. If it is realized a project will fail to meet it’s first milestone in a timely fashion or worse, never meet it’s first milestone, changes can be made that can bring the project back to meet it’s goals. For this reason, it may be desirable to have a test group use the software before determining if it truly is the software desired for use company-wide. The test group can add sample patient records to the EHR from the existing system, make typical modifications to those records as they would in the course of their normal business, and evaluate the system based on their experiences. A cross-section of stakeholders should be used in this focus group and if possible, a trainer from the software vendor or other IT personnel should also be part of the focus group.
Choosing new software is rarely an easy decision, and when it is software as important as an EHR, the considerations may seem insurmountable. It is important to look at the project from all angles and viewpoints to ensure all bases are covered. When in doubt, plan for worst case scenarios rather than merely hoping everything will run smooth. To make the right decision, make sure the potential offered by the new EHR outweighs all costs and obstacles.
Zwillich (2008), “It cost us over $40,000 per doctor,” says Richard Baron, MD, who heads Greenhouse Internists, a five-doctor Philadelphia practice that installed a full electronic health records system in 2004. Baron says switching to the system caused an upheaval in his practice and even cost the office more than 2% of its revenue at first. But he also said the system offers a major advantage now that it’s up and running. Baron says test results are routinely delivered to patients via email within 24 hours and that computer tracking allows doctors, nurses, and aides to flag chronic disease patients who are overdue for appointments. “You no longer need to be a medical genius to access the information in the chart,” he says.”
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