An EHR primer


An EHR should streamline the workflow of all who interact with it. The difficulties surrounding interoperability are the most significant obstacles to achieving a streamlined workflow.


Electronic health records (EHRs) or electronic medical records (EMRs) have become not only commonplace, but a virtual federal mandate. Doctors no longer write, but instead must point, click, and type, and do it quickly. In this 2-part series we will introduce you to current regulations and federal subsidies, discuss software solutions to help improve your daily workflow, review the current technology, and educate you about the jargon-filled mail/email that you receive daily.

For simplicity, we will use the acronym EHR to broadly discuss electronic health records. How to distinguish between an EHR and an EMR? In the purest sense, an EMR contains only the information that your patient generates in your practice, and an EHR is the patient’s complete health records from all providers who have communicated with your health record system.

The promise of the EHR

In an ideal world, the EHR provides a longitudinal electronic record of a patient’s complete medical history. It is populated with the patient’s demographics and a complete and detailed outline of the patient’s medical history, surgical history, previously taken medications, current medications, allergies, and active medical problems. It includes a comprehensive record of all patient encounters and efficiently links all associated laboratory tests/results, procedures, and interventions. Ultimately, the EHR is designed to streamline the workflow of all who interact with it (eg, physicians, physician assistants, nurses, technicians).

It is important to recognize that first-tier improvements in healthcare outcomes can be achieved by reducing medical errors. Notes can be streamlined for easy understanding. Specific data fields can be linked to laboratory testing and medical orders to help facilitate care. Automated alerts for abnormal laboratory testing and drug interactions can help decrease the risk of complications.

Globally, a properly implemented EHR can track the individual healthcare outcomes of specific patients, groups of patients, or even whole populations. These data can give local health, state, and national agencies the information to make evidence-based healthcare policy decisions. Office practices can become more efficient using an EHR to manage both the patient encounter and ancillary office processes. Chart rooms are downsizing, along with the associated staff needed to process charts and copy records.1 E-prescribing allows for prescriptions to be directly transmitted to the pharmacy, reducing the potential for error as medication orders move from physicians to nurses to pharmacy assistants and, finally, to pharmacists. Additionally, e-prescribing allows for automated drug interactions and formulary checking, further increasing efficiency. Similarly, ordering laboratory and diagnostic testing electronically reduces another paper-driven and labor-intensive task. Using secure electronic communication further streamlines office practices.

The reality of the EHR

Unfortunately, there is no single manufacturer that has the “ideal” EHR because, quite simply, we do not have a unified healthcare system. Instead, those physicians who are in private practice have the freedom to choose their own EHRs, those associated with hospital-based practices typically have to use a system that communicates with the hospital’s system, and those who practice in government-based systems (ie, the Veterans Health Administration) must use the government-issued EHR. While it can be profitable to be an EHR manufacturer, it can be a bit overwhelming to be an EHR consumer, due to the sheer breadth and depth of the available electronic health solutions.

In an attempt to level the playing field by defraying the mind-boggling costs of implementing an EHR and help bring all providers from paper to computers, President Obama signed the American Recovery and Reinvestment Act (ARRA) in 2009. Within this bill was a section called the Health Information Technology for Economic and Clinical Health Act (also known as the HITECH Act). Under this stimulus package, the federal government laid out a plan to incentivize EHR adoption for Medicare and Medicaid providers. In essence, the government offered subsidies for those Medicaid/Medicare providers who adopted EHRs, but the providers had to demonstrate that the EHR was going to be used in a meaningful way. Providers who were not hospital-based and who participated in Medicare or derived 30% or more of their revenue from Medicaid were eligible to receive subsidies. Although providers could apply for either of these programs, they could not receive subsidies from both.2,3

According to the Centers for Medicare & Medicaid Services (CMS), “The Medicare and Medicaid EHR Incentive Programs are staged in 3 steps with increasing requirements for participation. All providers begin participating by meeting the Stage 1 requirements for a 90-day period in their first year of meaningful use and a full year in their second year of meaningful use. After meeting the Stage 1 requirements, providers will then have to meet Stage 2 requirements for 2 full years. Eligible professionals participate in the program on the calendar years, while eligible hospitals participate according to the federal fiscal year.” For individual practitioners, CMS outlines a total of 24 “meaningful use objectives;” a provider can apply for a subsidy only after 19 of the 24 objectives are met.4

Those Medicare providers who applied in 2011 or 2012 were eligible to receive $18,000 in reimbursements that year, followed by annual payments of $12,000, $8,000, $4,000, and $2,000. Those who apply in 2013 can receive $15,000 in the initial year, followed by 3 years of diminishing payments. Providers who apply in 2014 will receive a first-year subsidy of $12,000 with lower incentives the following 2 years; those who apply after 2014 will receive no subsidies. There are also no payments after 2016. Thus, a Medicare-eligible professional qualified in 2011 or 2012 would receive a total payment of $44,000. For those qualified in 2013 the total payment would be $39,000, and those who qualified in 2014 would receive a total payment of $24,000. Medicare-eligible professionals who predominantly deliver services in areas designated as Health Professional Shortage Areas (HPSAs) can receive a 10% increase in their annual EHR incentive payments.5

The Medicaid system also has a yearly subsidy but the total payment is the same regardless of the year of enrollment (as of June 2013); it is $63,750 over 6 years. The additional 10% HPSA incentive is not available for eligible professionals who participate in the Medicaid EHR Incentive Program. (Table)

There are also penalties for not playing well in the proverbial sandbox. Medicare providers who do not adopt EHRs by 2015 will receive diminishing Medicare reimbursements: by 1% in 2015, by 2% in 2016, and by 3% in 2017. Cuts may continue to 5% by 2019. Penalties can also be applied if 75% of office-based physicians in a practice have not achieved meaningful use. As of June 2013, there are no scheduled Medicaid penalties. It is possible to switch between Medicare and Medicaid incentive programs one time but the last payment year during which a switch can occur is 2014.6

Even if you are not a Medicare/Medicaid provider, be aware that health insurance companies typically take their cost-saving cues from the federal government. The only twist is that a health insurance company will likely not incentivize the adoption of an EHR.

Making the transition

Obviously, transitioning to an EHR is costly. In fact, when evaluating EHR adoption, it is important to factor in 3 specific costs: 1) The cost of purchasing the EHR and the requisite computers/hardware, 2) The time spent in not only learning how to use the EHR, but also uploading patients’ charts and altering workflow efficiency, and 3) The cost of continued maintenance, upgrades, and backups. In short, it is hard to make money without spending money.

But EHR transitions are not always negative experiences. In fact, in a recent CDC publication, it was reported that the majority of physicians who adopted an EHR system (85%) were either very satisfied (38%) or somewhat satisfied (47%) with their system (Figure). Only about 15% of providers were either very dissatisfied (5%) or somewhat dissatisfied (10%) with their EHR system. In fact, more than two-thirds of adopters (71%) would purchase their EHR system again. The report goes on to state that the high degree of physician satisfaction was rooted in the ability to access a patient’s chart remotely (74%) and to be alerted to critical lab values (52%). A majority of physicians (74%) reported that they felt that their EHR had resulted in better patient care.7

And in case you were wondering how many folks have really made the transition, in the same CDC report, it states that as of 2011, 54% of physicians had adopted an EHR, with nearly three-quarters of physicians reporting that their system met federal “meaningful use” criteria. This means that not only are physicians adopting the technology, but also that they are using it and being reimbursed for their actions.8

Though an EHR’s potential is limited only by the creativity of those who design it, it is not a magic remedy for all that ails the healthcare system. Interoperability-the ability to communicate both within a single healthcare system and among different healthcare systems-remains the most significant obstacle to the transition to effective and efficient care.9 Without seamless communication among the various EMR/EHR products, the goals of improving quality of care, tracking healthcare outcomes, and reducing healthcare costs will remain far short of expectations.

You now have a sense of where EHR technology originated and where it needs to go. In our next installment we will dive into the technical aspects of the “hows,” “whats,” and “whys” of EHR adoption and implementation.



1. Case study: Managing paper records in preparation for an EHR. Published March 30, 2012. Accessed June 16, 2013.

2. Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382-385.

3. Steinbrook R. Health care and the American Recovery and Reinvestment Act. N Engl J Med. 2009;360(11):1057-1060.

4. Meaningful Use. Accessed June 4, 2013.

5. Medicare and Medicaid EHR Incentive Program Basics. Accessed June 4, 2013.

6. Texas Medical Association. Medicare and Medicaid EMR Incentive Comparison. Accessed June 4, 2013.

7. Jamoom E, Beatty P, Bercovitz A, et al. (2012) Physician adoption of electronic health record systems: United States, 2011. NCHS data brief, no 98. Hyattsville, MD: National Center for Health Statistics.

8. Kellermann AL, Jones SS. What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health Aff (Millwood). 2013;32(1):63-68.

9. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363(6):501–504.

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