EHRs: back to the basic benefits; It's easy to lose sight of EHRs' basic advantages in today's national debate about electronic healthcare technology.

The popularity of electronic health records (EHRs) has reached a pinnacle. EHRs are now a topic of national debate, presidential candidates' platforms, and editorials in major newspapers. The move toward the National Health Information Network (NHIN) is recognized by and supported in many state and federal agencies. Trade show agendas, once dedicated solely to clinical, advocacy, and leadership topics, are seeking to educate behavioral health and addiction treatment providers on the need for, and challenges and benefits of, the EHR. Yet the topic of technology to many in the helping professions is daunting enough without the added complexity of many of the latest topics, such as regional health information organizations (RHIOs), interoperability, and national data standards. Many providers probably are seriously wondering what the simple rewards for this major capital purchase are.

The successful implementation of an EHR allows a provider to operate on a new plateau. New-found efficiency includes reduction of documentation time, immediate access to patient data, improved cash flow, streamlined clinical work flow, increased reimbursement, and detailed real-time aggregate reporting. Believe it or not, despite all the techno-garble, EHRs truly enhance the quality of care provided and ultimately reduce the cost of care delivery. Let's review some basic returns of a move from paper to electronic.

A Harvard Medical publication stated, "Such a structure [paper] is inherently costly to administer--the share of US expenditures devoted to administration is variously estimated at one-fourth to one-fifth of the health dollar." (1) Paper charts complicate data collection and require standard data to be collected at each point of the client's service. The preadmission and intake processes often have to be repeated, meaning clients are asked time-consuming questions again and again. Clients, often anxious and confused in this situation, are frustrated, and probably get the impression that the organization lacks proper internal communication.

Yet an EHR allows organizations to collect data only once. The impact of this on a once paper-based system is profound. A well-designed, EHR-based clinical work flow moves a patient through the preadmission, intake, treatment, and discharge processes without requiring data entry to be repeated. While we often are impressed by the glamour and glitz of an EHR's graphs and pictures, elimination of redundant data entry returns substantial time to a clinician's day (table).

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Not only do EHRs allow data to be collected only once, the data are available everywhere. With paper records, the client's ID and name have to be entered on each form, a tedious task eliminated by EHRs, which can place such information wherever and whenever desired.

Another basic benefit of EHRs is related to the storage and maintenance of charts. A client record is the only source of a patient's data an organization has to use as a tool in service delivery, yet in paper-based systems often the chart is not available when needed. In organizations with multiple sites, using paper-based charts as a real-time reference often is difficult or impossible. Staff members have to shuttle paper charts between buildings in an attempt to follow the point of service, but they often are far behind, meaning charts are not available to clinicians and doctors. Having only limited access to key data increases the risk of error as well as exposes organizations to potential privacy/security breaches. Tracking down charts becomes a part of day-to-day business and often is not recognized as a drain on productivity.

Maintaining paper-based records is a financial drain as well. Paper records are estimated to cost approximately $8.00 annually per record to maintain. Storage areas need to be maintained according to state, federal, and accreditation requirements. Storage policies typically require tracking, audit trails, and supervision, all of which are costly to organizations, add further human intervention, and increase expenditures in most instances. Many organizations have had to dedicate prime facility space to housing voluminous client records, in addition to incurring costly archival contracts with off-site storage facilities. In comparison, electronically storing data is extremely cheap and very compact. For example, a single computer CD can store in the region of 600 MB, equivalent to some 100,000 pages of text or about 200 large textbooks that would need more than 64 feet of shelf space.

HIPAA compliance requires organizations to adhere to not only technical security policies, but also administrative policies difficult to abide by with paper charts. An EHR is easily copied and stored off-site with minimal inconvenience to the organization; this allows for effective and sound disaster recovery policies mandated by HIPAA. No disaster recovery plan can retrieve destroyed paper records: The record itself likely is the only copy that exists, as duplication of paper records is extremely costly and counterproductive to a streamlined work flow (i.e., as streamlined as a paper-based system can be).

Aside from the revolutionary way EHRs can change administrative practices, an automated chart offers a better quality tool/medium for professional documentation. One clinician stated:

The [paper] record is an abomination.... More often than not the

chart is thick, tattered, disorganized and illegible; progress notes,

consultant's notes, reports and nurses notes are all co-mingled in

accession sequence. The charts confuse rather than enlighten; they

provide a forbidding challenge to anyone who tries to understand what

is happening to the patient. (2)

Yet once patient data are entered in an EHR, the documentation is available to all clinicians connected to the central database, while a paper chart is viewable by only one staff member at a time. An EHR eliminates the possibilities of losing the chart, missing data, and illegible entries. The data screens are structured templates that provide legible, easily attainable, and directed data.

EHRs also mitigate the risk of required or essential data being missing or buried within progress notes. EHRs require clinicians to collect important data elements prior to closing a document. This automated function allows for increased charting supervision without further human intervention, ensuring data will be complete and available when needed. The data can be used in standardized instruments to provide measurable outcomes, greatly improving service delivery and accreditation processes. Even if they have some initial grumbling, clinicians ultimately will view the EHR as a tool for their services, rather than as an obstacle.

Behavioral health and substance abuse organizations are well on their way to understanding the necessity of EHRs. However, necessity does not always bring adoption. It is in the realization that EHRs will offer a qualitative improvement to the delivery of care to patients that end-users will open themselves to change. Change related to cost and outside pressures is not new to our industries; therefore, we need to address this change from a quality improvement or performance improvement paradigm. While EHRs continue to be discussed and defined, remember their simple yet profound impact on patient care--after all, that is what they should be about.

William R. Connors, MSW, is President/CEO of Sequest Technologies, Inc. He has extensive experience in operations and clinical services, as well as informational technology experience in several industries, including behavioral health services. Connors is a board member for the Software and Technology Vendors' Association (SATVA) and has written numerous articles on the use of technology and implementation of software within a healthcare environment.

References

1. Cushman FR, Detmer DE. Information policy for the U.S. health sector: Engineering, political economy, and ethics. Report for the Milbank Memorial Fund. May 1997. www.med.harvard.edu/publications/Milbank/art/.

2. Bleich HL. Lawrence L. Weed and the problem-oriented medical record. MD Comput 1993;10(2):70-1.

BY WILLIAM R. CONNORS, MSW

IN THIS DEPARTMENT

members of the Software and Technology Vendors' Association (SATVA) examine information technology trends impacting the behavioral health field. The views offered here do not necessarily reflect the official views of SATVA and its members. For more information about SATVA, visit www.satva.org. Table. Paper records' staff productivity cost Consider if a clinician spends the following time per client per day on paper charts: Getting paper charts 2 minutes Entering redundant data 2 minutes Searching chart 1 minute Total 5 minutes If the clinician sees 6 patients a day, he is spending 30 minutes a day on paper charts. If a clinician works 260 days a year, this adds up to 7,800 minutes per year, or 130 hours per year spent on paper charts. If a clinician's billable hour of service is worth $40, the agency is losing $5,200 per year because of one clinician's time spent on paper charts. If the agency has 40 clinicians, it is losing $208,000 annually because of the clinicians' time spent on paper charts.