The health information technology (Hoyt et al., 2012). Implementation

The American Recovery and Reinvestment
Act (ARRA) drastically impacted the field of Informatics. In particular, this
government initiative affected the adoption of electronic health records
(EHRs). The implementation of the EHR, especially linked to a patient portal,
is successful in meeting most, if not all, of the goals of the ARRA. Furthermore,
two major parts of the ARRA, Title VI and Title XIII, also known as the Health
Information Technology for Economics and Clinical Health (HITECH) Act were
detrimental in the EHR initiative. The HITECH Act was signed by President Obama
in 2009 to support the changes in health informatics. It was devoted to funding
of health information technology (HIT). “Approximately $20-30 billion was
dedicated for Medicare and Medicaid reimbursement for EHRs to clinicians and
hospitals” (Hoyt et al., 2012, p. 78).  These financial incentives aided in the
improvement of the healthcare
system through the use of EHRs (Thurston, 2014). The Office of the National
Coordinator for Health Information Technology (ONC) was one of the programs
included in the ARRA of 2009 that impacted information sciences. The most
significant goal, of the ONC, was to create a universal interoperable
electronic health record by the year 2014 (Hoyt
et al., 2012). The ONC proposed
Goals of the Federal Health IT Strategic Plan. These
goals are far surpassed by improving care, reducing costs, and engaging
individuals with health information technology (Hoyt et al., 2012).  Implementation of the EHR, linked to a
web-based patient portal, aids in reaching many of the goals of the ARRA and
the HITECH Act, as well as the goals of the Federal Health IT Strategic Plan.
The benefits of the EHR are to succor in improving patient safety and patient
satisfaction, while concurrently reducing facility costs.

“In 1991, the Institute of Medicine (IOM) recommended electronic
health records as a solution for many of the problems facing modern medicine” (Hoyt
et al., 2012, p. 59).  The EHR does not have one true
definition. However, it was defined by the National Alliance for Health
Information Technology as, “An electronic record of health-related information
on an individual that conforms to nationally recognized interoperability
standards and that can be created, managed and consumed by authorized
clinicians and staff across more than one healthcare organization” (Hoyt
et al., 2012, p. 60). The EHR allows for
easy navigation through a patients’ entire medical history. Not only is
navigation simple, accessibility is at an all-time high; charts can be accessed
by multiple different providers on any given day, twenty-four hours a day and
seven days a week. Charts may also be accessed simultaneously and/or from
different locations. There are many components that make up the electronic
health record, including computerized physician order entry (CPOE), clinical
decision support systems (CDSS) and electronic prescribing (e-prescribing).
CPOE processes orders for medications, lab tests, radiology tests, consults
and other diagnostic tests. CDSS takes into
consideration patient specific characteristics and determines assessments or
recommendations which are presented to the provider for review. CDSS provides alerts and reminders to perform
preventative tests as part of CPOE (Hoyt
et al., 2012, p. 69). E-prescribing allows
physicians and other providers to electronically send prescriptions to a
designated pharmacy of the patients’ choice.

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The EHR has many advantages, the utmost of which is the ability to
reduce medication errors and preventable adverse drug reactions, in turn,
improving patient safety. Medication errors are defined by Nuckols et al.
(2014) as “…errors in the process of prescribing, transcribing, dispensing, or
administration of a medication, which had the potential to or actually did
cause harm.” The previously addressed components of the EHR: CDSS, CPOE and
e-prescribing, all play a colossal part in reducing medication errors, largely
related to prescribing and transcribing. Medication management through the EHR
improves patient outcomes with time. Per the Center for the Advancement of
Health, “Each year, more than one-half million patients sustain injuries or die
in hospitals from adverse events…”
(2007, para. 9).

CPOE,
embedded within the EHR, plays a drastic role in reducing medication errors.
For example, many medications have similar names. One of the Institute of Safe
Medicine Practice’s (ISMP, 2015) “Confused Drug Names” examples is Amlodipine
and Amloride. Amlodipine is a calcium channel blocker used to treat high blood
pressure and chest pain. Amloride is a diuretic used to treat congestive heart
failure, high blood pressure and low potassium levels in the blood. If a
physicians’ handwriting were scribbled, these two medications may inadvertently
be confused leading to life threatening reactions. “Illegible handwriting and
transcription errors are responsible for as much as 61 percent of medication
errors in hospitals” (Center for the Advancement of Health, 2007, para. 2). CPOE
also solves the simple issue of putting a decimal point in the wrong place, precluding
patients from receiving doses much higher or lower than they should truly be
ordered (Center for the Advancement of Health, 2007, para. 2). The statistics alone, a 66% drop in prescription
errors due to switching to CPOE, prove that the EHR, with all of its
components, can be a game changer in preventing medication errors (Center for the Advancement of
Health, 2007).

The EHR with CDSS also supports the reduction of medication
errors. The CDSS component of the EHR prompts the provider of patients’
allergies, potential medication interactions, incorrect dosages and issues
related to patient conditions, for example lower doses of certain medications
in patients with renal impairment. A study completed by Abramson et al. (2013)
found a noteworthy decline in prescribing errors two years after the
implementation of a strong CDSS within the EHR. One drawback of CDSS is alert
fatigue. Due to the cumbersome number of alerts and reminders received by the
healthcare providers, from the CDSS, it has been found that some providers may
begin to ignore and/or disregard these alerts. In order to properly maximize
safety benefits of CDSS, limiting alert firing may be something to consider (Abramson et al., 2013).

E-prescribing has many of the same benefits as CPOE. Similar to
paper charts, “paper prescriptions can get lost or misread” (HealthIT.gov,
n.d., p. 2). By having the
ability to electronically enter, sign and send prescriptions to pharmacies,
physicians are able to remove the issues of illegibility and incorrect dosages
from the table. Furthermore, it has been found that, with e-prescribing, the
use of inappropriate abbreviations is reduced, thus averting inappropriate
medications, dosages, routes, frequencies, etc. (Abramson
et al., 2013, p. e52). “An e-prescribing
system can save lives (by reducing medication errors and checking for drug
interactions), lower costs, and improve care” (HealthIT.gov, n.d., p. 2). Overall, many studies have been extremely indicative of a
link between the EHR and a decrease in medication errors. By reducing
medication errors, patient safety is improved. Whether the errors that are
avoided are associated with prescribing, transcribing, etc.; adverse drug
reactions, possibly even life-threatening injuries and/or death can be avoided.

Another way the EHR convalesces patient safety is by decreasing
the ordering of duplicate tests. Per Hoyt et al., “In order to make evidence
based decisions, we need high quality data that should derive from multiple
sources: inpatient and outpatient care, acute and chronic settings, urban and
rural care, and populations at risk” (Hoyt
et al., 2012, p. 64). Health information
exchange (HIE) makes this need a reality. “HIE most commonly involves the
exchange of clinical results, images and documents” (Hoyt et al., 2012, p. 115). HIE
makes it possible to share information within one organization, and more
importantly, amongst different organizations. Prior to the EHR, testing,
including imaging and laboratory testing, were frequently being ordered, on one
patient, by multiple different providers. Paper charts are typically bulky and
inconvenient to search through for specific information. Some reasons behind
duplicate tests include lost and/or missing information from a paper chart or
patients being transferred between units and/or facilities. Likewise, when
patients have tests performed at one facility but seek treatment for those test
results at another facility, the results may not only be difficult to obtain,
but difficult to obtain in a timely manner, resulting in a delay of care. According
to a study in the Journal of the American Medical Informatics Association, patients’
entire charts are missing about 25% of the time (Tang, LaRosa, Newcomb, &
Gorden, 1999). Another study by Smith, et al. conveyed, “Clinicians
reported missing clinical information in 13.6% of visits” (2005, para. 5). Of the
missing information, two of the most common were laboratory and radiology
results (Smith et al., 2005).
Providers have a difficult time making informed decisions without all of the
data necessary to do so. Therefore, if important test results are missing,
these tests may end up reordered. It becomes unsafe for patients when their
healthcare information is missing. Moreover, it jeopardizes the patients’
health and safety to have repeated radiology tests, such as computerized
tomography (CT) scans and x-rays, putting their bodies under high levels of
radiation unnecessarily or to have to have blood drawn multiple times when the
patient may already be anemic, with low blood counts as it is, for example. The
EHR, in conjunction with HIE, makes it physically impossible for charts to be
lost and nearly impossible for results to go missing. In a survey from the Healthcare
Information and Management Systems Society (HIMSS), it was found that “…the EHR
reduced the amount of duplicative testing and allowed clinicians to share
information with one another,” resulting in more efficient care and better
clinical outcomes (Heath,
2016, para. 3). In a study that evaluated the nurses’ views of the EHR, the
results revealed that nurses, who worked at a facility with an EHR, were less
likely to report that information went missing or tests were incomplete due to
the transferring of a patient from one unit to another (Kutney-Lee & Kelly, 2011).

Besides its’ countless patient safety benefits, the EHR has also
been confirmed to increase patient satisfaction. The Agency for Healthcare
Research Quality (AHRQ, 2016, para. 4) states that patient satisfaction is,
“…about whether a patient’s expectations about a health encounter were met.” “The
Center for Health Information Technology would argue that EHR adoption results
in better customer satisfaction through fewer lost charts, faster refills ad
improved delivery of patient educational materials” (Hoyt et al., p. 63). The EHR
can allow practitioners to provide better medical care, which in turn improves
patient outcomes, the end result being more satisfied patients (HealthIT.gov,
n.d.). With EHR use, patients are more
specifically satisfied with e-prescribing. A study on patient satisfaction with
electronic prescribing unveiled that 91% of patients were happy, overall, with
the fact that their doctors used e-prescribing (Duffy, Yiu, Molokhia, Walker,
& Perkins, 2010, table 3). The EHR delivers convenience to providers
through, “Enhanced decision support, clinical alerts, reminders, and medical
information; legible, complete documentation that facilitates accurate coding
and billing; and safer, more reliable prescribing” (HealthIT.gov, n.d., p. 1). It
also delivers convenience to patients through reduction in redundant forms,
reliable information in real time, e-prescriptions sent directly to the
pharmacy and, most importantly, through patient portals (HealthIT.gov,
n.d., p. 1). The web-based patient portal, linked to the EHR, plays an
integral part in patient satisfaction. Web-based portals are described by Hoyt
et al. as, “…web-based programs patients can access for health related
services” (2012, p. 224). Web-based portals essentially allow patients to
access their EHRs. They can then “…read, print, and send their health
information to providers” (Hoover, 2016, p. 21).
Web-based patient portals provide patients with their health information at
their fingertips. Features of the web-based patient portal are
plentisome. Some examples are the ability for patients to view medication
lists, laboratory, and radiography results and secure messaging (Hoyt et al.,
p. 225). A study conducted by de Lusignan et al. (2014) disclosed that patients
access to their electronic health records and linked online services led to
improved patient experience and satisfaction by better supporting self-care and patient provider communication. Undoubtedly,
the primary benefit of the patient portal is improved patient provider
communication via secure messaging. Secure messaging enables patients to
message their providers regarding any aspect of their care. The easy access to
communication with their providers, in addition to a timely response from those
providers, makes patients feel more empowered and involved in their healthcare.
Patient satisfaction improved in relation to timely responses from providers
via secure messaging through the patient portal, in one study (Lusignan et al.,
2014).

As previously discussed, the adoption of the EHR, linked to the
patient portal, both improve patient safety and satisfaction. Simultaneously,
both contribute to reducing facility costs. Although it may be argued that the
implementation phase of the EHR is costly, amongst a few other drawbacks, the
benefits are more superfluous than the disadvantages. In the long run, cost
reduction after EHR implementation will compensate for the costs of the EHR
initiation process. The HITECH Act was a crucial influence on EHR advocacy. “EHR
reimbursement is a major focal point of the HITECH Act” (Hoyt
et al., 2012, p. 63). In addition to the federal government support
through the HITECH Act, there is also state payer support to urge EHR
implementation. The Centers for Medicare and Medicaid Services (CMS) requires
physicians to follow Meaningful Use criteria. “Medicare physicians who do not
use a certified EHR nor demonstrate Meaningful Use will receive penalties…” and, additionally, as the years go by the percentage
increase in the penalties will rise, potentially to 5% by 2018 if less than 75%
of physicians are using EHRs (Hoyt
et al., 2012, p. 79). By
adapting to the changes of the EHR initiation, hospitals and eligible providers
are able to avoid these penalties. Per CMS guidelines, “Organizations that
accept Medicare and Medicaid dollars are eligible to participate in the
Electronic Health Record (EHR) incentive programs and receive EHR incentive
payments beginning with $2 million base payment, with over $5 billion paid to
date” (Hessels, Flynn, Cimiotti, & Bakken, 2015, p. 2). On top of avoiding penalties, facilities have the ability
to be reimbursed for their use of the EHR. “The Center for
Information Technology Leadership (CITL) has suggested that ambulatory EHRs
would save $44 billion yearly and eliminate more than $10 in rejected claims
per patient per outpatient visit” (Hoyt
et al., 2012, p. 63). The EHR also assists
with improved coding. With the transfer to electronic documentation, voice
recognition and templates allow the providers’ notes to be more structured
(Hoyt et al., 2012). This will assist in proper billing and coding. If coding
is inefficient, and a lower level of coding is submitted, the patient
will be billed less than they should have for the services received.
Documentation templates help physicians to make sure they are specific enough
to justify a higher level of coding. The ability to interface the EHR with a
billing program that submits claims electronically will drastically change the
way coding and billing is performed and result in more realistic results (Hoyt
et al., 2012). Another way the EHR can aid in cost reduction over time is by
decreasing patients’ lengths of stay, as well as seven-day readmissions. One
study ascertained higher levels of EHR adoption resulted in significantly fewer
incidences of prolonged length of stay and lower rates of seven-day
readmissions (Hessels et al., 2015). There is a plethora of other ways that
costs may be reduced via the EHR such as, by reducing medication errors, by
reducing redundant tests, and by doing away with paper charts and non-essential
labor costs. The US Department of Veterans Affairs accumulated a total savings
of $4.64 billion alone from preventing adverse drug events (HealthIT.gov,
n.d.). When laboratory or diagnostic
testing needs to be repeated because it is missing, these costs add on to the
country’s healthcare bill, $2.3 trillion dollars of which is for administration
(Hoyt et al., 2012). The
EHR has even saved money by “…decreasing full time equivalents (FTEs) and
converting record rooms into more productive space, such as exam rooms” (Hoyt et al., 2012, p. 62). As
evidenced by these many examples, the adoption of the EHR will considerably
reduce costs in healthcare.

As usual, the advantages do not come without limitations. The
limitation with the most impact is definitely provider resistance to the EHR,
as well as the patient portal. Change is disliked by many; however, it is an
inevitable part of life. Many physicians and nurses are resistant to HIT
adoption, in general. Some common themes for resistance include inadequate
time, inadequate expertise and workforce and change in workflow (Hoyt
et al., 2012). At
one facility, the nurses worried that the portal would cause an influx of phone
calls or messages due to the patients’ ability to see laboratory results. The
nurses believed the patients might misinterpret the information provided to
them (National Health Board, Ministry of Health, 2015). After implementation, the nurses learned that the portal
caused a significant increase in time savings due to posting test results on
the portal (National Health
Board, Ministry of Health, 2015). Another major cause of resistance is
the cost of implementation. Nonetheless, as cited beforehand, cost reduction is
at an all-time high once the EHR is implemented and cost savings are
insurmountably greater than the expenses. There should be designated “super
users” of the newly adopted EHRs; those staff whom are trained as experts in
the software and whom everyone can turn to for assistance, during initial
training, if needed. Some other interesting limitations noted were that patient
portal use is more popular in women than it is in men, and in the younger
versus the older population. “Cathcart has found the portal to be particularly
popular with younger people, who tended to be more IT-savvy” (National
Health Board, Ministry of Health, 2015, p. 31).

These limitations lead this author to a discussion of how to
accommodate populations with specific needs. After thorough research of the
topic, this author has concluded that the patient population most commonly
affected is those with limited literacy. It is necessary to try a little bit
harder to accommodate this patient population. Especially because, more times
than none, patients with specific needs are the ones that will really benefit
from the patient portal. Although these populations may have less interest in
the portal or have a more difficult time in utilizing it, there are many ways
to accommodate these patients. Presently, many tools exist to examine that
content of these types of websites is clearly communicated to patients. “The
Patient Protection and Affordable Care Act of 2010, Title V, defines health
literacy as the degree to which an individual has the capacity to obtain, communicate,
process, and understand basic health information and services to make
appropriate health decisions” (Center for Disease Control and Prevention CDC,
n.d., para. 1). eHealth, such as web-based patient portals, may be used to
improve health literacy. However, portals also require patients to comprehend
complicated information, have access to computers or other electronic devices
and can perform the necessary functionalities to acquire and manipulate data
(Sharit et al., 2014). Low health literacy is linked to less use of the
web-based patient portals, including viewing laboratory results, scheduling
appointments, and messaging providers (Alpert, Desens, Krist, Aycock, &
Kreps, 2017, p. 141). One way to improve health literacy is through the use of
plain language. Per the CDC, plain language allows for health information to be
easier understood by placing it at a much lower literacy level (Centers for
Disease Control and Prevention CDC, n.d.). Another way to improve health
literacy is by employing the CDC’s Clear Communication Index. This tool
assesses that the communication is clear to the public through the use of plain language (Alpert, Desens, Krist, Aycock, & Kreps, 2017). According to the study completed by Alpert et al. (2017,
p. 147), “…the CDC’s Clear Communication Index may be a useful tool in identifying
areas of unclear communication in a patient portal and referenced health
websites.” To accommodate patients not having access to electronic devices,
such as computers or tablets, the healthcare facilities could try to team up
with community libraries and promote access of those computers for these
functions. The facilities could also provide access to computers within their
campuses for patient use to access the patient portals.

            In summary, the EHR, linked
to a web-based patient portal, has a major impact on patient safety and patient
satisfaction. The EHR, composed of CPOE, CDSS and e-prescribing, largely
decreases medication errors and duplicate testing. In addition, the patient
portal aspect drastically improves patient satisfaction by empowering patients
to be more involved in their healthcare. Furthermore, it has been recognized
that instituting these systems within a healthcare facility has an enormous
effect on cost reduction. As with all HIT, there are disadvantages that coincide
with the advantages. However, research corroborates that, in the case of the
EHR and web-based patient portal, the advantages far surpass the disadvantages.