The use of electronic health records in Spanish hospitals

Research The use of electronic health records in Spanish hospitals Guillem Marca, Angel J. Pérez, Martín German Blanco-García, Elena Miravalles, Pere Soley and Berta Ortiga Abstract The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals and to identify potential barriers and facilitators to this process. We used an observational cross-sectional design. The survey was conducted between September and December 2011, using an electronic questionnaire distributed through email. We obtained a 30% response rate from the 214 hospitals contacted, all belonging to the Spanish National Health Service. The level of adoption of electronic health records in Spanish hospitals was found to be high: 39.1% of hospitals surveyed had a comprehensive EHR system while a basic system was functioning in 32.8% of the cases. However, in 2011 one third of the hospitals did not have a basic electronic health record system, although some have since implemented electronic functionalities, particularly those related to clinical documentation and patient administration. Respondents cited the acquisition and implementation costs as the main barriers to implementation. Facilitators for EHR implementation were: the possibility to hire technical support, both during and post implementation; security certification warranty; and objective third-party evaluations of EHR products. In conclusion, the number of hospitals that have electronic health records is in general high, being relatively higher in medium-sized hospitals. Keywords (MeSH): Hospitals; Health Information Management; Electronic Health Records; Informatics; Quality; Spain Introduction Electronic health records (EHRs) are being introduced variably in the different levels of the healthcare systems around the world (Institute of Medicine 2007). Investment in healthcare information technologies is a significant factor in the economy of many countries; for example in the United Kingdom and the United States such expenditure amounted to £12,800 million and $US38,000 million in 2009, respectively (Black et al. 2011). This investment is considered justified because it is expected that information technologies will help to achieve higher standards in terms of efficiency, quality and safety in healthcare, as well as a closer engagement of patients and their families, while maintaining adequate privacy and security (Kauschal, Shojania & Bates 2003; Pagliari, Detmer & Singleton 2007). While the association between resource investment and efficiency improvement has not yet been demonstrated with sufficient evidence (De Lone & McLean 1992; Smith 2004; Restuccia et al. 2012), there is a broad consensus on the potential benefits of health information sharing (Jha et al. 2009). The inclusion of key functions of electronic records, such as computerised requests and electronic referrals between different healthcare service providers and healthcare levels, enables a more efficient and safer management of resources. It also avoids duplication of patient records due to a lack of integration (Poissant et al. 2005). In this sense, there is a broad consensus about the potential benefits of the EHR and the incorporation of information coming from medical devices. Despite this, the health service providers are slow too adopt this technology (Jha et al. 2006). A recent study concluded that in the United States only 1.5% of hospitals had a comprehensive level of electronic medical records covering all clinical units, while a further 7.6% had a basic system present in at least one clinical unit. This percentage could rise to over 70% if we look at one of the key functions related to test and imaging results that should have the EHR (Jha et al. 2009). In 2009, the Spanish Ministry of Health stated that the healthcare ICT expenditure and investment in the National Health System accounted for 0.9% (¤544 million) of the Regional Health Services’ overall healthcare budget in 2009. It also stated that 97% of hospitals had information systems to manage admissions, beds, schedule and outpatient appointments, while 85% had radiology management, anatomic pathology and Unidose pharmacy systems. In addition, storage systems in digital imaging were available in more than 60% of Spanish hospitals and more than 90% had a Laboratory Information System. At the same time, the first pilot studies for a national EHR HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga 37 Research were initiated (Ministry of Health and Social Policy & Red.es 2010). Despite over 30% of Spanish healthcare professionals working with EHRs systems (de la Torre-Díez, González & López-Coronado 2013), the computerisation level of health records in hospitals is unknown. No national scientific study has investigated this issue in depth. The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals, as well as to identify potential barriers and facilitators for its implementation. Method Survey development For the elaboration of the questionnaire we reviewed and synthesised previous studies on the adoption of EHR systems or related functionalities (e.g. electronic order entry, laboratory and radiology results) in the previous four years (Jha et al. 2009; Robertson et al. 2010). More specifically, our questionnaire included most of the functionalities described in the computerised system sections of electronic clinical documentation, results viewing, computerised provider order entry and decision support of Jha et al.’s (2009) study. We also took into account its selected barriers to implementation as well as the possible policy solutions to overcome them. Our questionnaire was based upon that used by Robertson et al. in their evaluation of adoption of EHRs in English hospitals. Their study examined the previous training of hospital staff, their ongoing support during the change from paper files to an ERH and issues arising from the existence of previous information system software that was replaced by new Customer Relationship System software (Robertson et al. 2010). With this review we developed an initial draft of the questionnaire to be reviewed by a panel of professional experts in the electronic health record field. The professional experts were members of the Public Health School from the Region of Andalusia. In addition, a second group of hospital management experts were consulted. The hospital managers were all members of the Board of the Fundación Signo, which is a non-profit foundation whose goals are the promotion and financing of proposals based on management improvement and cost evaluations. In both cases, the survey was examined through a qualitative methodology. As a result of the input from these two professional groups, the questionnaire required some minor changes due to translation inadequacy, while major concerns focused mainly on the implementation process. Questions were added concerning the action plan for record digitisation, the involvement of 38 external support, the influence of the financial context, the steps following EHR introduction and its effects on record availability. Survey sample and questionnaire administration We collaborated with Fundación Signo in administering the questionnaire to all professionals associated with both public and private acute care hospitals. In the Fundación Signo members’ database, we specifically selected the chief executive officers, managing directors and their assistants, as well as the medical and nursing directors. Overall, managers and Centre directors transmitted the email and the request to respond to the questionnaire to the Chief Information System Officer. In case we received more than one possible response from one hospital, we first selected the most complete response and second, the response whose position was closer to the Chief Information System Officer. Reminder emails were sent up to three times if necessary, in order to increase the response rate. The survey was sent for the first time in September 2011 and the fieldwork was completed in November of the same year. Survey content The survey was carried out using a digital questionnaire available through a link, which was sent through a personalised email to the recipient. The respondents were asked about the presence or absence of 26 clinical features of an EHR system and the extent of its implementation, and whether in the future they had planned to implement any of them or not. The dimension of these features included clinical documentation, radiology and laboratory results, electronic requests and a support and alerts system. In addition we asked about the potential difficulties in EHR adoption (16 issues) and the solutions to overcome them.1 Given the potential heterogeneity in possible responses due to different combinations of features implemented, we chose two possible categories: basic EHR and exhaustive EHR (Table 1). To define these categories we considered the proposal made in a similar previous study by Jha et al. (2009), excluding the decision and alert system features due to a consensus with the hospital managers, whose results were analysed separately. In addition, we also considered that the functionalities selected for each of the categories shown in Table 1, which defined a basic or exhaustive electronic-records system in any hospital, which had to be fully implemented in all units, except for physicians’ notes and nurse assessments. For these 1 A copy of the questionnaire is available upon request to the authors HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga Research Table 1: Electronic requirements for classification of hospitals according to a basic or exhaustive electronic-records system EXHAUSTIVE EHR BASIC EHR Patient’s demographic characteristics x x Physicians’ notes x Nursing assessment x Discharge report x REQUIREMENTS NO EHR Clinical documentation x Results Radiology and laboratory results Laboratory results x x Radiology results x x Additional test results x Radiology images x Laboratory results report x There were a total of 64 responses from 214 hospitals contacted (30% response rate). 97% of the respondent hospitals were medium and large-sized hospitals that belong to the National Health Service (Table 2). The presence of certain electronic individual functionalities is considered to be necessary for defining basic or exhaustive levels of electronic-record systems (Table 1). We identified 25 hospitals (39.1%) with an exhaustive level, 23 (35.9%) with a basic level and 16 (25.0%) with no comprehensive electronic health record. Medium-sized (56%), urban (40%) and university (43%) are the types of hospitals that have the highest percentage of exhaustive electronic-record systems. Nevertheless, 32% of the larger, 27.6% of the university and 26% of the urban hospitals do not have electronic-record systems. Regarding adoption of different types of key EHR functionalities, we found that most clinical documentation functionalities are implemented in all units in over 40% of the hospitals, except for physicians’ notes, which are only electronic in all units in 34.3% of the cases (Table 3). It is also remarkable that the high percentage of affirmative responses related to the laboratory and radiology digital reports (84.3%). On the Computerized providerorder entry Laboratory x Radiology x x Medications x x Medical consultants x Medical orders x two functionalities, the panel of experts considered that they should be present in at least one clinical unit in order for the hospital to be classified as having an exhaustive electronic-records system. The reason for this is that the experts believed that investment in these functionalities was so high for the first unit that extending them to the rest of the clinical units within the hospital could be achieved with much less expenditure. Support and alerts system Clinical practice guidelines Clinical order reminders Drug alerts Results Number of hospitals 25 23 16 Adoption percentage 39.1 35.9 25.0 Table 2: Hospital characteristics and level of EHR adoption EXHAUSTIVE EHR All Signo hospitals (n=214) n (%) BASIC EHR NO EHR Hospital percentages (n=64) Size Small (0-99 beds) 60 (28%) Medium (100-399 beds) 98 (45.8%) 16 (25.0%) 2 ( 3.1%) 56.3 100 37.5 6.2 Large ( ≥400 beds) 56 (26.2%) 46 (71.9%) 34.8 32.6 32.6 Yes _ 35 (54.7%) 42.8 34.3 22.9 No _ 29 (45.3%) 34.5 37.9 27.6 University Location Rural _ 8 (12.5%) 37.5 50 12.5 Urban _ 25 (39.1%) 40 28 32 Urban - Regional capital _ 31 (48.4%) 38.7 38.7 22.6 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga 39 Research contrary, only 4.6% of the digital electrocardiograms are digitalised and only 25% of the hospitals have the option to incorporate external digitalised documents in the EHR. The computerised provider-order entry section is the least computerised, with percentages ranging from 37.5% to 50.1% in all its functionalities. It is precisely in these functionalities the respondents expected to initiate computerisation, similarly with incorporation of digital external information to the EHR (20.3%) and digital electrocardiograms (29.7%). Finally, the lowest computerisation level is found for decision support and alert functionalities. The drug alert functionality is the most highly implemented in this section, 23% of the hospitals having it fully implemented in all units. Whenever there were more resources available, more than 20% of respondents would decide to invest in this area. Regarding the opinion of the respondents about their main perceived barriers to adoption of the EHR (Table 4), the capital needed for investment and maintenance costs are the most cited barriers, both in hospitals with EHR (81.25% and 62.5%, respectively) and without them (62.5% and 56.3%, respectively). The third most cited barrier was physicians’ resistance, with 64.6% in EHR centres and 50% in centres without EHR. In fourth place, we found that 64.6% of the hospitals with EHR cited concern for the suppliers’ competencies. Hospitals without EHR cited the inability to hire external personnel to implement electronic records systems (50%). In this sense, hospitals with and without EHR identified technical support during implementation and maintenance, security certification warranty and objective third-party evaluations of EHR products as the most important Table 3: Selected electronic functionalities and its implementation level in Spanish hospitals REQUIREMENTS FULLY IMPLEMENTED IN ALL UNITS FULLY IMPLEMENTED IN AT LEAST ONE UNIT INITIATED AT LEAST IN ONE UNIT TO INITIATE SOON THERE ARE NO RESOURCES BUT THERE IS INTENTION NOT PLANNED NO RESPONSE Hospitals percentages (n=64) Clinical documentation Patient’s demographic characteristics 87.4 Physicians’ notes 34.3 25 9.4 Nursing assessment 43.6 14.1 Discharge report 75 9.4 Surgical report 46.8 12.5 Laboratory results 84.4 1.6 Radiology results 84.4 Additional tests results 42.2 Radiology images Laboratory results report 1.6 1.6 6.3 12.5 3.1 9.4 9.4 7.8 14.1 1.6 3.1 1.6 1.6 6.3 14.1 7.8 9.4 9.4 9.4 3.1 9.4 1.6 9.4 3.1 9.4 Radiology and laboratory results Electrocardiographic tracing Incorporation of external digital information 1.6 3.1 1.6 3.1 21.9 6.3 10.9 6.3 76.4 6.3 1.6 4.7 1.6 9.4 75 6.3 1.6 4.7 3.1 9.4 14.1 3.1 29.7 20.3 18.8 9.4 20.3 3.1 20.3 12.5 9.4 9.4 1.6 10.9 3.1 10.9 4.7 25 9.4 Computerised provider-order entry Laboratory 39.1 10.9 10.9 23.4 4.7 Radiology 40.6 12.5 4.7 20.3 9.4 10.9 Medications 50 20.3 3.1 10.9 4.7 Medical consultants 37.5 14.1 6.3 18.8 9.4 10.9 Medical orders 46.9 18.8 7.8 6.3 7.8 1.9 10.9 Supply chain 39.1 9.4 3.1 6.3 4.7 17.2 20.3 7.8 17.2 14.1 15.6 23.4 9.4 12.5 Clinical order reminders 12.5 6.3 6.3 17.2 23.4 15.6 18.8 Drug alerts 23.4 14.1 4.7 10.9 15.6 12.5 18.8 Support and alerts system Clinical practice guidelines 40 HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga Research Table 4: Perceived barriers to adopt electronic health records (EHRs) among hospitals with and without electronic-record systems HOSPITALS WITH EHR HOSPITALS WITHOUT EHR Technical support for the implementation and maintenance 87.5 62.5 facilitators for EHR adoption (Table 5). Incentives for implementation, or to exempt doctors from confidentiality responsibility, were less likely cited as facilitators. The improvements for the electronic record system (Table 6) for those hospitals with basic EHR are focused on adding new data sources (48%) and digitisation of paper files (30%). For hospitals with an exhaustive EHR, the steps are focused on adding new data sources (24%), digitisation of paper files (28%), incorporate data analysis and performance indicators (24%) and to reduce the paper files delivery (20%). In addition, we asked respondents their opinion on the impact of the current economic crisis on implementation of EHRs. The responses differed among hospitals with an exhaustive EHR and those with a basic EHR. In the former case, the economic crisis affected them less as most relevant decisions had been taken and most of the investment was already made before the onset of the crisis (44%). On the other hand, in the latter case, 56.5% of respondents mentioned that the economic crisis reduced investment in EHR projects drastically or they had even been paralysed. When we asked about the strategy concerning the digitisation of the paper files, hospitals with exhaustive and basic EHRs answered similarly, in that they would begin with the active files and reduce their delivery as soon as possible (18 hospitals, 37.5%) or to digitalise exclusively the files concerning scheduled or emergency admissions to the hospital for a certain period of time (22 hospitals, 45.8%). Security certification and warranty 81.3 62.5 Discussion Objective third-party evaluations of EHR products 77.1 56.3 Incentives for implementation 62.5 50 Exempt physicians from all responsibility in confidentiality 39.6 25 HOSPITALS WITH EHR Inadequate capital for investment HOSPITALS WITHOUT EHR 81.25 62.5 Maintenance cost 66.7 56.3 Physicians’ resistance 64.6 50 Concern for the supplier’s competencies 64.6 43.8 Lack of capability to hire and implement 60.4 50 Inadequate IT staff 58.3 43.8 Interrupts care while implementing 43.8 31.2 Lack of confidence in data protection 43.8 37.5 Uncertainty about effectiveness or efficiency 37.5 37.5 Concern for legality 31.3 25 Table 5: Perceived facilitators to adopt electronic health records (EHRs) among hospitals with and without electronic-record systems Table 6: Upcoming investments in improving electronic-record system BASIC EXHAUSTIVE n Adding new data sources n 11 48% 6 24% Digitisation 7 30% 7 28% Data analysis; performance indicators 4 17% 6 24% Outsource EHR custody 0 0% 1 4% Reduce paper files delivery 1 4% 5 20% According to our results, 39.1% of the surveyed hospitals had an exhaustive electronic-record system and in 32.8% of the cases it was basic. In addition, we found that 28.1% of the hospitals did not have an electronic record system according to our parameters, but almost all of these hospitals had some electronic functionalities, especially for clinical documents, including hospital discharge reports and electronic order entries. We found that the digitisation level of the hospitals was higher in medium-sized hospitals compared to the small-sized (<100 beds) and large (>400 beds). Managing change in hospitals sometimes requires disruptive strategies and its implementation can be more difficult in larger hospitals (Edmonson, Bohmer & Pisano 2001). If we analyse the prevalence of the different types of clinical documentation functionalities, it is significant that 34% of respondents have physicians’ notes in all the clinical units and 25% in at least one unit. In terms of nursing assessments, the total percentage is slightly higher (57.9%), and an additional 7.8% of the hospitals have the intention to initiate this func- HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga 41 Research tionality soon. Jha et al. (2009) stated that nursing assessments and physicians’ notes are the fundamental functionalities that determine an electronic record system. In 2009, these authors found that US hospitals had 27% of electronic physicians’ notes in at least one or all units and 57% had nursing assessments. Despite there being only three years’ difference between the two studies, the change in the implementation level for US hospitals could be significant, according to the amount of investment in this country. Conversely, given the low investment in information technologies by the Spanish Government (only 1% of the healthcare budget) (Ministry of Health and Social Policy & Red.es 2010), the numbers found in this study are surprisingly high. Other clinical documentation functionalities, usually easier to implement and previous to an EHR, such as electronic discharge reports and surgical reports are high, with rates of 84.4% and 59.4%, respectively. In the group of radiology and laboratory results, it is significant that most of these electronic functionalities are highly implemented in all clinical units of the hospitals, similar to what Jha et al. found in USA hospitals in 2008 (Jha et al. 2009). They also found that diagnostic test images such as electrocardiographic tracing had a low implementation. Similarly, only 4.7% of the Spanish centres confirmed the availability of this tool in all units and 14.1% in at least one clinical unit. The hospitals that reported having a digital radiology storage system had increased by 16% compared to the results published by the Spanish Ministry of Health in the year 2009 (La Moncloa 2009). The high level of implementation of clinical documentation and test and imaging results among Spanish hospitals is significant, as these are the key functionalities for future shared medical records throughout all the health services providers and regions from the National Health Service. In 2006, the Spanish Ministry of Health began the National Health System Electronic Health Records Project (HCDSNS) in order to provide a realistic cohesion instrument tackling information compatibility and health information exchange between the different stakeholders of the National Health System (Health Information Institute 2010). In the electronic order entry, functionalities such as medical orders and medications are the most prevalent, in 46.9% and 50% of cases respectively, in all units of hospitalisation. In contrast, there are few centres that have digitised the orders of the supply chain and few have the intention to invest in this functionality. It is a concern for some managers to be too focused on the health field, while neglecting optimisation opportunities from logistic processes and their 42 costs, supporting the health services. The improvement potential in the supply chain management can be an important point of cost savings without consequences in the health services field (McKone-Sweet, Hamilton & Willis 2005). This saving capability is hampered if the demand order entry is not computerised, because it makes planning more difficult, which is a basic step in the supply chain management. As Jha et al. (2009) found, decision support functionalities related to drug alerts are the most highly implemented functionalities in Spanish hospitals, 23.4% in all units and 14.1% in at least one inpatient unit. Similarly, clinical decision making related to the integration of clinical practice guidelines is underrepresented in both countries. In this sense, there is an opportunity to improve the quality and security of healthcare services (Shojania et al. 2010; Roshanov et al. 2011), raising the implementation of electronic decision support capabilities in the future. Respondents identified inadequate capital for investment and maintenance costs as the predominant barriers to adoption, dwarfing issues such as resistance on the part of physicians. That the costs due to information technology (IT) implementation and maintenance are an important barrier to an electronicrecord system adoption is well understood. This result is consistent with the primary barrier to EHR adoption found by a recent review analysing trends in health IT (Goldzweig et al. 2009). Other potential barriers to adoption are concern for the suppliers’ competencies and difficulties in hiring their services. These barriers could be overcome with the three most cited facilitators: the possibility of hiring technical support during the implementation and afterwards, security certification warranty and objective third-party evaluations of EHR products. In our opinion, the lack of confidence in external technical support is an important issue to take into account by companies who sell these products and services in Spain. Jha et al. (2009) also found that rewarding hospitals for using health information technology could play a central role in a comprehensive approach to stimulating the spread of hospital electronic-record systems. In our case, it was less important to reward hospitals for using health information technology, or maybe our results were a consequence for not using this facilitator by the healthcare authorities in the past which is consistent with the remarkable low budget invested in Healthcare ICT National Health System: ฀544 million in 2009 (Ministry of Health and Social Policy & Red.es 2010) compared to other countries, such as the UK, with a similar healthcare system. In addition, previous studies emphasised that the lack of exchange functionalities among the different health- HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga Research care levels and providers are critical for a becoming a more patient-centred healthcare (Darmon et al. 2014). In this sense, the development of a national strategy in the Spanish healthcare sector is needed and it is known that diffusion processes require good planning and are both time- and resource- consuming. Limitations of the study A major limitation of our study was the low response rate; the results are not therefore necessarily representative of all Spanish hospitals. It is possible that the results of our study overestimate the prevalence of EHR in hospitals because those which have implemented EHRs could be more motivated to respond to the questionnaire. For future investigations, in order to extend the scope of this study, we would like to take into account such aspects as the EHR usage level by the health professionals, the cost-effectiveness of the EHR compared to paper records and the satisfaction of EHR functionalities among professional users and managers. Conclusion In conclusion, this is the first scientific study undertaken in Spain that analyses the level of EHR digitisation in hospitals, and the main barriers and facilitators to its implementation. The number of hospitals that have EHRs is high, with the highest level of implementation in medium-sized hospitals. In contrast, a third of the hospitals surveyed still do not have EHRs in 2011, although they have launched some EHR functionalities, particularly those related to clinical documentation. The main barriers for EHR implementation are economical, both at the time of implementation and for continuing maintenance. The three most cited facilitators were the possibility to hire technical support during the implementation and afterwards, security certification warranty and objective third-party evaluations of EHR products. Support tools in clinical decision-making and alerts are less prevalent, with the related drug alerts being the most implemented. 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[email protected] Angel Pérez, MD Fundación Signo C/ Infanta Mercedes, 92, Bajo 28020 Madrid SPAIN email: [email protected] Martín German Blanco-García, MD Director General de Profesionales del Servicio Andaluz de Salud Servicio Andaluz de Salud Av. De la Constitución nº 18 41071 Sevilla SPAIN email: [email protected] Elena Miravalles, MD Fundación Signo C/ Infanta Mercedes, 92, Bajo 28020 Madrid SPAIN email: [email protected] Pere Soley, MD MBA Gerente Territorial Metropolitana Norte Institut Català de la Salut Carretera de Canyet s/n. 08916 Badalona, Barcelona SPAIN email: [email protected] *Corresponding author: Berta Ortiga, MD PhD MBA Subgerente Deputy Managing Director Hospital Universitari de Bellvitge C/ Feixa Llarga, sn 08907 L’Hospitalet de Llobregat Barcelona SPAIN Tel: +34 93 260 75 20 email: [email protected] HEALTH INFORMATION MANAGEMENT JOURNAL Vol 43 No 3 2014 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) http://dx.doi.org/10.12826/18333575.2014.0003.Ortiga