The Electronic Health Record System (EHRS)is a suite of software applications designed to improve quality of care and patient safety in NASA's Occupational Health Clinics. It provides a friendly graphical user interface (GUI) "front end" to a robust database, which permits improved access to important clinical information, direct entry of data by clinicians and other users, and clinical decision support tools at the point of care.

Technically, remote access to the Electronic Health Record (EHR) is certainly possible. All that is required is a broadband (high speed) Internet connection and Virtual Private Network (VPN) access to your facility's database. Whether or not this is permitted at a particular facility will be a decision made by NASA leadership. Because VPN gives users remote access, VPN accounts and access will be strictly controlled and closely monitored. A clear need for access in the interest of patient care must be demonstrated, and facilities will be responsible for appropriateness of use by their staff. As experience is gained and network capacity is increased, it is likely that remote access policies will be liberalized.

No. Certainly if some providers are using EHR and some are not, the latter may want to have electronically generated notes in the paper chart. However, this is time consuming, labor intensive, and unnecessary. Even those providers not using EHR to create notes can access the system to read them, and being encouraged to do this increases the provider's comfort and facility with the system. There is no legal reason to print electronic notes for the chart.

Yes, at least at first. The paper chart contains historical information of use to providers for some time. However, it is likely that after using the EHR for 1-2 years, providers will realize that they are not opening the paper record very often, and the facility will adopt a policy of pulling the record only upon request. In the short term, some paper will continue to be part of the patient chart in the form of discharge summaries, consult reports, ER visits, and other outside records, as well as internally generated paper such as EKG tracings. Ultimately, the EHR will include a document scanning and storage component that will provide electronic access to these records as well, leading to a truly paperless record.

One of the challenges currently is that many of the NASA Occupational Health (OH) clinics have different EHRs that are not being utilized to their full functionality. Other NASA OH clinics still rely mainly on paper for documentation. In addition, there are so many expectations of providers in terms of types of data to document, and many different forms on which to document them. The EHR does not necessarily reduce the data requirements, but provides a system in which required data elements are more obvious and easier to document and thus more standaradized across the Agency. Since providers will be directly responsible for most data entry, and will be able to immediately see and use the data they enter (such as problem lists), it is expected that the sense of ownership that this produces will lead to better and more complete data.

One of the main reasons that there is such a big national movement toward electronic medical records is the increasing evidence that they improve patient safety. The problem of medical errors has received much attention in recent years. It turns out that the majority of errors can be attributed to illegible or incorrectly interpreted handwritten orders, to inadequate or incomplete information about the patient, or to knowledge gaps about appropriate treatments or standards of care. The most important contribution that the EHR makes to patient safety is computerized provider order entry (CPOE). By entering orders, especially medication orders, directly into the system, errors caused by illegibility or incorrect copying can be virtually eliminated. The system allows automated checks for allergies and drug-drug interactions, and includes a comment field that providers can use to clarify new or changing medication orders. By making clinical decision support available at the point of care, the EHR can improve compliance with guidelines and standards of care. The EHR can provide patient- and disease-specific reminders, notifications about critical results, and access to Web-based resources such as the Centers for Disease Control

There is evidence that use of electronic medical records can reduce the costs associated with tort claims and malpractice judgments. It is intuitive that if the EHR improves patient safety through provider order entry and clinical decision support, fewer tort claims will result. Just as important is the fact that most malpractice claims, settlements, and judgments occur because the clinical documentation is inadequate to explain or justify the clinical decisions and care provided to the patient. Cases that go to trial tend to be those that are poorly documented. Private sector malpractice insurers often offer discounts to practices using electronic records because these practices have lower claim costs.

Many potential users of EHR, regardless of role or training level, are anxious about using the application if it requires them to type. This is particularly common among people in the second half of their careers, who may not have grown up using keyboards for education or recreation. This is a substantial barrier to EHR implementation, and it may be an invisible barrier; staff may not be willing to admit that they cannot type, and may resist EHR for other reasons. It may be necessary for facilities to explore the typing issue with EHR users and provide specific training. This can be done through group keyboarding instruction, but an economical, unobtrusive, and very effective alternative is simply to purchase a commercial CD-ROM based typing tutor and allow staff to practice and build their skills on their own time.

Small facilities may not have all the issues of complexity, multiple users, lost charts, and so forth that are common to large hospitals, but they still provide medical care services and collect the same kind of information. Moreover, small facilities may not have the same kind of inertia and systemic resistance to change, and implementation of a major innovation such as EHR may be easier.

For the most part, facilities should understand that the decision to implement the EHR is a collaborative one, as is the commitment of resources to accomplish it. This should be considered an investment, because the benefits of the EHR, including patient safety, risk reduction, and improved collections, accrue directly to the facility and its patients. Those facilities that start early on with the EHR will begin to reap its benefits. That said, the NASA deployment of the EHR is one of the highest priorities for OCHMO, and NASA leadership is determined to see it succeed.

NASA's EHR allows for entry of the full range of data to be done by clinical users. For example, vital signs, measurements, and immunizations are entered by nurses; purpose of visit, problem list, and CPT information by providers, patient education by a variety of users, and so forth. As a result, workloads for data entry personnel will decrease as more staff begin to use the EHR. The need will still exist for data entry backlog resolution, error report management, and data entry for non-electronic encounters, particularly those occurring during EHR system down time. In addition, it is expected that data entry personnel will be able to train into more demanding and higher-level positions, such as in medical records and business offices, as EHR use becomes more widespread.

Each has positive and negative aspects. Personal computers are clearly less expensive, both in terms of the necessary network cabling and the cost for the PC itself. However, PC's take up a lot of space in exam rooms, and since their location is fixed, more have to be purchased to equip every room. One advantage to the PC in the exam room is that both the nurse and the patient can use it for information entry while the provider is occupied elsewhere.

As wireless technology and security improve, more facilities are choosing this option. Wireless-enabled laptop or tablet computers have the same computing capacity as PC's, but are lightweight and portable. Providers can carry them from room to room (or move them on mobile carts), and can keep a patient encounter open when leaving the room, to finish it in the office or elsewhere. The cost for a wireless network exceeds that of a wired network, and tablets can cost 2-3 times as much as a PC. However, not as many wireless units are required in order for each provider to have access to one. Other limitations of tablets are battery life (which can be ameliorated with extra batteries or space-saving docking stations in exam rooms), damage from dropping, and loss or theft (which does not translate to a security breach because no patient data is stored on the tablet).

It would be nice if it were so easy. Implementation of the EHR is a complex process that affects every department and virtually every employee in an organization. Preparation has to be intentional and systematic, and must be driven by top administrative and clinical leadership, not by the IT department or a single enthusiastic clinician. Software installation and training are also complex, incremental, and require external support from multiple resources and the EHRS Project Team. Facilities interested in the EHR are encouraged to review the entire website and linked documents, and contact Program leadership for more information.

This is a policy issue that is presently in flux. Because current national policies on records retention and archiving were developed with only paper records in mind, these policies have questionable relevance to electronic records. Current interpretation of these policies suggests that for archiving purposes, electronic records would have to be printed out and stored in paper format. However it is recognized at a national level that such a requirement is not consistent with current national trends and governmental initiatives. NASA's NPD and NPR 1441 is being reviewed in regards to the storage and archival of electronic records.

Computer security is no less important in the EHR than it was before. Only authorized users will be given access to the EHR, and the level of their access will be consistent with their role. Strong policies for computer security, and enforcement of these policies, will be consistent with those outlined in the EHRS Information Technology Security Plan. With this in mind, however, it is important to consider EHR security in the context of the current situation, i.e. security of paper charts.

One thing that is certain about electronic systems is that there will be down time. Even if a system is available 99.9 percent of the time, this means that there will be 8.8 hours per year of unavailability. Certainly, every effort must be made to avoid these occurrences, but they will happen. Hardware crashes due to power outages and equipment failure are more common, and these risks are mitigated by the use of isolated power systems and redundant servers.

Having a plan in place to deal with these events will help to avoid chaos when they happen. The priority is continuing to provide quality patient care while the system is being fixed. Each facility will have its own approach, but typically this will involve deferring the care that can be deferred, utilizing those parts of the electronic system that still work, and resorting to paper-based documentation for the rest. Once the system is restored, the plan should include a means of repopulating the electronic system with information collected during the outage. Depending on policy, paper records generated during system outages might need to be retained as original documents, although scanned facsimiles may prove to be sufficient for this purpose. In either case, key information such as diagnoses and services should be abstracted for the EHR.

The basic consideration in answering the equipment question is that every staff member who needs to read or add to the medical record needs access to it. This means that they must have a Windows computer available wherever and whenever they need to see the record. For the most part this will mean computer access in every examination room, at every provider's desk, at all nursing work areas, and at all other points of patient care or consultation. This might be accomplished by fixed desktop computers or by mobile workstations.

The facility needs to have a reliable network connecting all of the above locations. This network should also have a high-speed Internet connection, to facilitate the clinical decision support functions of the EHR and handle the increased workload created by the EHR users.

Here are a few issues with paper records, and anyone who works with them could think of more:

• Only one person can have the chart at a time
• Keeping track of chart location is difficult
• Delays in retrieving charts are common and aggravating
• Handwriting is often illegible
• Charts may be disorganized, with information hard to find
• Some information doesn't get into the chart for many days
• There aren't enough tabs for all the different types of forms
• Many trees are sacrificed to print encounter forms and health summaries for each visit
• Charts get very fat
• Metal tabs break, and the charts fall apart
• New volumes don't contain important old information
• Back injuries from lifting charts have resulted in worker compensation claims
• Paper charts are insecure and can easily be browsed
• Charts may be stolen or tampered with
• Paper filing is time consuming and labor intensive
• Chart files take up a lot of valuable space
• Charts have to be retired just to save space

Providing a generic estimate of the cost for the hardware necessary to run the EHR is very difficult, because center clinic facilities vary so much in size and in the amount of equipment they already have in place. Everybody is starting from a different baseline. Sites are encouraged to keep in mind the multiple uses for this equipment (i.e. not just for EHR), and the potential return on investment that EHR brings.

It is expected that EHR implementation will result in changes in some duties within medical records departments, but changes in staffing levels, if any, will come relatively slowly. The immediate impact of electronic record implementation will be a reduction in the amount of paper filing, particularly laboratory results and encounter notes. However, considerable filing requirements will remain, chiefly consisting of paper from external institutions (discharge summaries, consults, etc.). Eventually these documents will be scanned into the system and viewed as images, but this process itself will be labor-intensive and require staff. Medical records staff in the EHR facilities will not need to pull (or search for) as many charts, as providers become comfortable addressing lab results, responding to telephone calls, and even seeing patients without the chart. Other more important medical records functions will not change, such as responding to release of information requests from outside or sending out locally generated ROI requests.

Yes, although it may take some time for this to become evident. Initially, the learning curve for using the EHR is expected to be fairly steep. When clinicians first begin using the EHR for order entry and note authoring, it will take them longer to see patients. The decrease may be as much as thirty percent at first, and facilities must be prepared for this. However, time saved by direct entry of orders and by not having to search for information will soon begin to reverse the productivity impact. Eventually, providers will be able to document both more thoroughly and more rapidly on digital document templates than previously possible by handwriting. Evidence from the private sector indicates that providers using electronic records can see as many patients or more, and bill at higher levels, than when they used paper.

This is a very important issue regarding a critical function. The EHRS Program Team feels very strongly about the need for users at any facility running EHR to have access to the skills of a Clinical Application Coordinator (CAC). The CAC is typically a health professional (nurse, Health informatics or RHIA credentialed specialist) who is comfortable with computers and has strong interpersonal skills. The CAC knows the EHR application better than anyone else in the facility, and provides real time support for clinical users, ensuring uninterrupted patient care.

The following is a sample listing of CAC duties:

• Primary training of users before initial EHR implementation
• Training for new users
• Training for updates and new EHR features
• Hand-holding for providers and other users during implementation
• Real-time support for providers and other staff during patient care
• Customization of templates
• Customization of CPT superbills
• Customization of ICD pick lists for purpose of visit
• Customization of provider order sets
• Customization of GUI screen views

There are several options for providing these CAC functions to a facility and its users. The most effective way, and the way recommended for large clinics and hospitals, is to hire a full time CAC. Larger hospitals may require more than one, as the EHR application penetrates to all clinics and wards. At smaller facilities, a part time CAC with other assigned duties may be adequate, as long as it is assured that providers can receive the troubleshooting help they need at all times of patient care. Very small facilities still need all the described CAC functions, but may not need a person on site at all times. Additional models for provision of CAC functions would be for an Area Office to have an applications coordinator who supports multiple facilities, for several small sites to partner on a single shared position, or for a larger facility to agree to provide regional CAC support for a defined group of smaller partners. If no CAC is available for real time service to providers, it is strongly recommended that a local "super user", typically a provider, be designated and given both training and time sufficient to provide troubleshooting assistance to his or her colleagues.

The only new position recommended by the EHR Program Team, is the Clinical Application Coordinator (CAC). The rationale for this position is described in another FAQ. It is possible, depending on the amount of new equipment purchased for the EHR, that a facility would need an additional person (or more) to maintain this equipment. The key point is that the EHR is a clinical system, meaning that it must be working during all hours of patient care. Somebody has to be available to perform CAC duties (clinical support) and IT duties (technical support) at all times that patients are being served.