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Going Live With Electronic Health Records: A Guide For Private Physicians

David R. Donnersberger Jr. MD, for HealthLeaders News, February 12, 2008

The vast majority of healthcare transactions still take place on paper, a system that has remained unchanged since the 1950s. The interoperability of EHRs can mean a patient's entire medical history is available--for editing, eyeballing or lawsuit-mongering-- system-wide. In a large hospital, roughly 150 people, from doctors and nurses to technicians and billing clerks, have access to at least part of a patient's records during a hospitalization.

Hospitals and health systems have an ethical, and likely soon-to-be-legal, obligation to investigate the potential breach of confidentiality. However, without interoperable EHRs, practicing physicians, pharmacies and hospitals cannot readily share patient information.

In the United States, standards for electronic health records are at the fore of the national medical agenda. But implemetation remains a legal gray area. Currently, no law obliges physicians or hospitals to inform their patients of the switch to electronic recordkeeping. That landscape may soon change.

In 2005, our private practice was issued a tax-free grants from Evanston Northwestern Healthcare to non-employee physician offices. The grants were intended to defray the cost of implementing an electronic system in our office, including hardware, software, staffing, training, and lost hours of patient care.

As a concierge practice for 30 years, we looked at EHRs as a way to stay on the cutting edge and improve service for our patients. With the help of these funds, our private practice of four full-time physicians and two nurses in Winnetka, IL made the full switch to electronic recordkeeping.

Implementation was by no means easy. My advice to those interested in establishing themselves electronically is to budget time and financial resources for over a year, as well as to inform your patients. A schedule of dry runs and staggered implementation were key for our office. First, billing was instituted through the electronic system, followed by scheduling, office visits and note-writing. We raised our rates slightly and found revenue in new places like an in-house lab.

We began informing patients with each visit that in mid-2007, we would be changing to a new electronic charting system and that there would be periods of disruption. All staff members were required to take detailed classes necessary to work the EHR system.

Implementation also meant budgeting more time to type in data. Annual visits were given a breadth of 80 minutes; general office visits were to last 20-40 minutes. We also built in time for us to type information into the new system. We were prepared financially to weather a significant decrease in revenue because we would be seeing fewer patients.

We scheduled our go-live date to begin directly after our quarterly taxes and malpractice insurance were due. Four weeks prior , we mailed every patient in our system a letter explaining that their charts were being converted to EHRs and what that meant to them: potential access of personal health information to many more healthcare providers, for example. We promised better billing and scheduling in the future. As a practicing attorney with a specialty in medical ethics, this step is essential to covering your legal bases.

Prepare for a range of patient reactions. Most were pleased by the billing efficiency. Others left the practice entirely, claiming our affiliation with Evanston Northwestern Healthcare made their information vulnerable to too many parties. Staffing was also interesting. Before the implementation there were three employees out of 16 who we felt should retire or leave for reasons not involved with the EHR. As we began to plan for implementation and as all the employees began to take the detailed classes necessary to work in the EHR system, it became apparent that those same three employees were having trouble with the change. Without prompting, they all left before or very soon into the new system. The change in office culture and alteration in traditional work flow can be difficult for some employees.

On a larger scale, I was the senior resident in the Glenbrook Hospital ICU when Evanston Northwestern Healthcare went live with electronic records, a trying but successful night. ENH then continued to expand its inpatient adoption of the system to the ER and the floors. Finally, outpatient clinics of the employee-physicians went live.

ENH is one of the few hospital systems in the country to have fully implemented an electronic medical records system with computerized physician order entry capabilities across 100 percent of its operations. The improvement in billing and scheduling, the accessibility of patient medical information from all three hospitals and other doctors offices, as well as the security of getting rid of paper charts, convinced both ENH and our small private clinic that electronic records were the best option for timely, patient-centered, portable care.

But what of the legal ramifications? According to a study recently released by the eHealth Vulnerability Reporting program, EHRs can be accessed and personal information gained through "standard tools and techniques," making EHRs, well, no less vulnerable than any other traditional data system. The study also revealed that some health systems may be as ignorant of the threat to privacy as their patients because vendors were inadequately disclosing system vulnerabilities to their customers. The exploitation risk can be "dramatically reduced when vulnerabilities are known and appropriate security controls are in place," the report states.

eHealth recommended that EHR software vendors implement better testing of their systems' security and disclose to customers any vulnerabilities they find. Vendors' remediation of vulnerabilities often takes too long, the report added. One of the systems tested was the system used by HealthCare Partners Medical Group in Southern California. Physicians and hospitals should not only insist full disclosure on the part of their vendors, they may reference HL7, the organization currently setting the standard for flexible guidelines and methodologies enabling the exchange and interoperability of electronic health records.

HL7 has allowed for the interoperability between electronic Patient Administration Systems, Electronic Practice Management systems, Laboratory Information Systems, Dietary, Pharmacy and Billing systems as well as EHRs. These data standards are meant to allow healthcare organizations to easily share clinical information.

Ultimately, the implementation of EHRs will be necessary to ensure patient records geographically accessible and consistent. The successful information achieved by electronic health records keeps hospitals and health systems on the cutting edge, and will soon be the gold standard in care.


David R. Donnersberger Jr. MD, JD, FCLM is the site director for the Internal Medicine Clerkship for Northwestern University Feinberg School of Medicine/ Evanston Northwestern Healthcare in Evanston, IL. He can be reached at drdonnnersberger@yahoo.com.
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