University of Texas at Tyler University of Texas at Tyler
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MSN Capstone Projects Nursing
Spring 4-16-2023
Benchmark Study: Impact of Electronic Health Records vs. Paper-Benchmark Study: Impact of Electronic Health Records vs. Paper-
based Records based Records
Erin Emmerich
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Recommended Citation Recommended Citation
Emmerich, Erin, "Benchmark Study: Impact of Electronic Health Records vs. Paper-based Records" (2023).
MSN Capstone Projects.
Paper 246.
http://hdl.handle.net/10950/4210
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IMPACT OF ELECTRONIC HEALTH RECORDS 1
Benchmark Study: Impact of Electronic Health Records vs. Paper-based Records
A Paper Submitted in Partial Fulfillment of the Requirements
For NURS 5382: Capstone
In the School of Nursing
The University of Texas at Tyler
by
Erin-Michael Emmerich BSN, RN
April 15, 2023
IMPACT OF ELECTRONIC HEALTH RECORDS 2
Acknowledgments
I would like to express my sincere gratitude to my family for their continuous support
and encouragement throughout my education. Their love and patience have given me the
strength to pursue my academic and career goals. Without them I would not be where I am
today. I would also like to thank my amazing preceptors whose mentorships provided me with
valuable knowledge and skills to prepare me in my future endeavors. Finally, I would like to
acknowledge the dedication of my professors, whose teachings challenged me to think critically,
analyze issues and develop effective solutions. Their continuous guidance and motivation have
pushed me not only to excel academically but has been instrumental in tailoring me to become a
better leader and wanting to make a positive impact in my profession.
IMPACT OF ELECTRONIC HEALTH RECORDS 3
Executive Summary
Patient information is a valuable asset in healthcare, and proper documentation of this
information is critical to delivering high quality care. Without a proper documentation system in
place, patients are at risk and the safety and effectiveness of their treatment may be jeopardized.
The inadequacies of Texas Orthopedics Surgery Center’s paper-based system have led to an
increase in patient complaints involving the exchange of their information, safety concerns and
increased costs associated with paper charts. With the increase in aging population and the high
demand on outpatient facilities, managing patient information while ensuring the continuity of
effective care and improved outcomes is becoming very challenging. Utilizing an electronic
health record (EHR) can enhance patient care by providing a more efficient way of managing
and sharing patient information. EHRs can also reduce medical errors by improving the accuracy
of records, make health information more readily available, and keep patients well informed
(Centers for Medicare and Medicaid Services, 2023).
Texas Orthopedics Surgery Center’s paper-based documentation system is not a
sustainable method, nor is it best practice. By familiarizing themselves with the benefits of
information technologies through training and development workshops, the facility can provide
high-quality care, reduce healthcare costs, and position themselves for long-term success in an
increasingly digital healthcare environment. Therefore, it is recommended that Texas
Orthopedics Surgery Center adopt an EHR to replace the current paper-based record system.
IMPACT OF ELECTRONIC HEALTH RECORDS 4
Rationale for the Project
Medical documentation is an essential component in any healthcare setting. Conducted at
the highest standard, documentation ensures the delivery of safe and high-quality healthcare
services (Noureldin et al., 2014). In the early 1990s, a shift from paper-based health records to
electronic records began as a result of the inadequacies of paper-based health records (Tsai et al.,
2020). Paper records lag in modern day healthcare due to the inefficiency of accessing, entering,
and retrieving medical data (Yu et al., 2013). Yu et al. (2013) also states paper charting can be
inaccurate, illegible, incomplete, or repetitive. EHRs, however, have shown to be more beneficial
and a better choice for medical documentation. EHRs reduce medical errors, report patient data
more effectively, and reduce costs associated with paper records (Geier & Smith, 2019).
Texas Orthopedics Surgery Center, unfortunately, has seen the consequences of being a
paper-based facility. The results of their Press Ganey Patient Experience Survey showed a
decrease in patient satisfaction in both quarter one and two of 2022. The survey indicated areas
of concern are patients having difficulty understanding their procedure information (Score 15th
percentile) and trouble accessing their health information (Score 17th percentile). Patients have
stated their chart information is illegible, and that it takes significant time to make their chart
information accessible in their electronic medical passport. This adds to the concern of time and
cost consumption of auditing and storage of paper charts. Texas Orthopedics Surgery Center
estimates it costs around $40,000 (not including overtime) a year to have one chart management
personnel to audit charts and upload them into patients’ medical passports. This facility employs
four chart management personnel and with the implementation of an EHR, cost savings could be
around $120,000. Another concerning issue with being paper-based is the inconsistent
documentation of patient allergies and their related reactions. Without the standardization of an
IMPACT OF ELECTRONIC HEALTH RECORDS 5
EHR, it has been difficult to locate the patient’s allergies and the associated type of reactions in
the paper chart. Centers for Medicare and Medicaid Services (CMS) and Accreditation
Association for Ambulatory Health Care (AAAHC), both require any allergies and the type of
allergic reactions to be located in a consistent area of the chart (Centers for Medicare and
Medicaid Services, 2020; Accreditation Association of Ambulatory Health Care, 2020). The
result of this patient safety issue has led to two allergic reactions in this year’s second quarter.
With the advantages of supporting interfaces and the ability to access real-time data,
EHRs are superior to paper-based records. In need of evidence-based change, the Quality
Assurance and Performance Improvement (QAPI) Committee posed the following question: In
ambulatory surgery centers (P), how does using Electronic Health Records (I) compared to
paper-based records (C) affect quality of care and costs (O) during one quarter (T)?
Literature Synthesis
During the review of literature, several studies with strong levels of evidence (see
appendix A) supported the adoption of an EHR and discussed the benefits of utilizing the system.
Adoption of an EHR has many contributing factors that have a lasting influence on the
performance of an organization. The common areas impacted by an EHR found in several
studies are clinical, operational and financial.
Clinically, an EHR has the capability of positively impacting many aspects of quality of
care. Nguygen et al. (2014) and Campanella et al. (2016) both conducted systematic reviews of
literature on the impacts of EHRs on quality of care. The studies found a reduction in medication
errors, decreased adverse drug effects, and a better adherence to professional practice guidelines.
Holderried et al. (2020) investigated the effects of electronic records on the ability of medical
professionals to identify patient hazards compared to paper charts. The study found no indication
IMPACT OF ELECTRONIC HEALTH RECORDS 6
that electronic records had a negative effect on detecting patient hazards. The advancement of
data exchange in EHRs, has increased communication due to the timely and improved access to
patient information resulting in increased quality of care (Nguyen et al., 2014; Seyyedi et al.,
2020). Tsai et al. (2020) noted accessibility of information has led to more collaboration between
patients and physicians following EHR implementation. In a qualitative study by Monturo et al.
(2021), transitioning to an EHR did not have an overall effect on patient experience.
According to Tsai et al. (2020), improved efficiency and documentation time by using
EHR templates led to an increase in productivity. The study also suggests documentation in
EHRs are better than paper-based records due to improved documentation and data accuracy.
McCarthy et al. (2018) state evidence of electronic records points to improved time spent
documenting, documentation compliance and a reduction in documentation errors.
A decrease in medication errors and adverse events not only improves quality of care and
patient safety, but it is also associated with decreased costs (Campanella et al., 2016). Increase in
turnover time is a huge tribulation in a surgical setting. The literature revealed decrease in turn
over time due to the use of an EHR which also increased cost savings and patient satisfaction
(McDowell et al., 2017).
Project Stakeholders
With the magnitude of this benchmark study, it is important to involve all stakeholders in
the implementation process to ensure the EHR is effective, efficient, and meets the needs of
everyone involved. Stakeholders affected by this change will include the administrative team,
non-clinical staff, clinical staff, licensed independent providers (LIPs), payors, information
technology (IT) individuals and patients.
IMPACT OF ELECTRONIC HEALTH RECORDS 7
The administrative team will oversee the project by planning the implementation of the
EHR. Non-clinical and clinical staff are important stakeholders in this project. According to
Rodgers et al. (2019), staff have the best position to identify ineffective processes, and their
engagement is a priority for change to be successful. LIPs have a stake in the project as they will
be using the EHR to document patient care, access information, and collaborate with other
healthcare members. Payors will require data from the EHR to process claims and provide
reimbursement. IT individuals provide the EHR software while being responsible for
maintaining security and privacy protection. Lastly, patients are a key stakeholder as they will
rely on the EHR to access their information and communicate with their healthcare team.
Implementation Plan
Prior to implementing an EHR, it is imperative to establish an EHR team or “change
team.” The purpose of a “change team” is to guide the implementation process by following
steps, evaluating each phase, educating stakeholders and providing feedback. The team leaders
will consist of the administrative director and clinical director. “Change champions” will also be
selected as these members are crucial for establishing an effective team. Cullen et al. (2020)
describes a change champion as a “charismatic individual who throws his or her weight behind
an innovation, thus overcoming indifference or resistance that the new idea may provoke...[and]
can play an important role in boosting an idea” (p. 128). Change champions assisting in the
implementation of the EHR include the Medical Executive Committee (one physician, one
anesthesia), each department lead (e.g. Pre-op, O.R., PACU), the business manager, the quality
coordinator, the infection control nurse, the Governing Board, and the QAPI committee. Once a
team has been established, the selection process for an EHR system may begin. Selection of an
EHR should be based on usability and interoperability of the system (Ratwani et al., 2016).
IMPACT OF ELECTRONIC HEALTH RECORDS 8
Flexibility or the ability to configure the system to meet the needs of each department should
also be considered when selecting an EHR. Ultimately, the selection process must be mindful of
the patient experience and patient safety. Another critical point to consider in the selection
process is the importance of a thorough plan on how to disseminate and educate information on
the use of an EHR. Without proper training for key stakeholders, optimal outcomes such as
decrease in cost, increase in patient satisfaction, and increase in safety, may be difficult to
achieve. Selecting an EHR system that provides on-site training (e.g. system IT developers)
during each phase of implementation, will give the adequate training needed to enhance the
usefulness and optimize the full benefits and attributes of a successful EHR.
Once an EHR system is selected, the team will work in conjunction with the system
developers to determine the hardware needed to run the EHR. Hardware may include computers,
laptops, tablets or routers. When the proper hardware is available, then the EHR system will be
installed.
After installation, the development or customization of the EHR will begin. Workflows
will be created to outline the system process a user will follow for a specific situation. The
processes include but are not limited to, patient admission, insurance verification, patient transfer
from pre-op to the operating room, or patient discharge. Due to the barriers associated with
workflow and design, each department lead will be involved in the development of the EHR
along with the help of the system IT developers. This will ensure all critical aspects of each
department are included in the EHR to ease workflow and usability. Those involved in the
development of workflows will have access to a Microsoft teams communication board. The
board is an important opportunity to submit concerns, comments, or ideas pertaining to the
workflow and usability of the EHR system. Each month the “change team” will examine the
IMPACT OF ELECTRONIC HEALTH RECORDS 9
communication board to discuss areas of concern and identify risks to quality, safety, or
compliance. Workflow processes can be complex and institutions using a new EHR can lack
workflow knowledge (Ratwani et al., 2016). It is imperative that the “change team” evaluate the
discussion board with EHR developers who have a better understanding of workflow needs and
can implement products to meet these needs.
Different levels of computer literacy and comfort pose another barrier to foresee. On-site
training will be the next step and be conducted by the EHR IT developers for all stakeholders to
increase comfort and computer literacy. On-site training will include one-on-one training with
each member of a department. Scenarios or simulations will also be used as educational material.
Employees chosen as “super-users” will be established at this time. “Super-users” are those that
have proper computer skills and an understanding on how to use the EHR. Each department will
have a “super-user” to supplement IT support.
After training has concluded, the EHR will be put in a “Go-Live” mode, where users will
use the system in real time. The “change team” and the system IT developers will all be present
to assist users if needed. Feedback will be collected at this time to help fix any issues or further
customize the system.
Each month an evaluation of EHR use will be conducted. This is a way for each
department to communicate workflow and usability issues of the EHR to the “change team.” In
addition, the QAPI committee will meet each quarter to evaluate risk data associated with the
EHR. Risk data will include but not be limited to medication errors, chart completions,
discrepancies, and adverse events. The feedback will be used to make changes to reduce risk,
increase usability and workflow. Cost evaluation will also be performed using a budget to
examine if there has been a Return On Investment (ROI) post implementation. A pre and post
IMPACT OF ELECTRONIC HEALTH RECORDS 10
budget will be compared and evaluated. ROI should be evaluated every quarter to see if there is a
positive trend. If there is a negative trend, then the “change team” will evaluate where costs can
be saved.
Timetable/Flowchart
In March 2022, evidence was presented to the leadership team and the QAPI committee
suggesting the adoption of an electronic record system. After deliberation, the leadership team
decided to move forward and developed a “change team” made up of department leads and the
administration team. Over the course of a month, the “change team” consulted with different
EHR programs to determine the best fit for the organization. On May 5, 2022, the “change team”
developed a flowchart to illustrate the implementation plan (see appendix B). Due to unforeseen
events, the “change team” could not implement the EHR. The following is an estimated timeline
that describes the events for each implementation phase:
• Phase One: Resources (four weeks)
• Hardware installation (Computers/laptops)- 3 weeks
• EHR software installation- 1 week
• Phase Two: Training (1.5 months)
• On-site training for all staff
• “Super-users” established
• Phase Three: “Go-Live”
• EHR use in real time by all personnel
• Phase Four: Evaluation period (Begins when “Go-live starts)
• Corrections are made to enhance usability
• Software issue updates
IMPACT OF ELECTRONIC HEALTH RECORDS 11
Data Collection Methods
The QAPI committee will pull data generated by incident reports. The data will
specifically be related to patient safety and quality incidents. To evaluate the data, patient safety
incidents such as falls or adverse reactions will be calculated as a rate. The rate will be based on
per one thousand cases. Each quarter the information collected will be presented to the “change
team.” The “change team” will compare each quarter data to analyze trends and determine if
there needs to be a change in the EHR system. To evaluate costs, the Medical Executive
committee will meet each quarter to analyze costs. The committee will evaluate overall
investment of the project by utilizing a monthly budget that incorporates the fixed and variable
costs associated with EHR use.
Cost/Benefit Discussion
Implementation costs associated with this project are broken down into two categories:
software and hardware. The initial cost to install the software for the EHR was quoted at
$37,000. The software also requires a yearly cost which was quoted $8,000. Additional hardware
needed to be purchased totaling $10,540. The network infrastructure was adequate to support the
EHR and did not require any additional costs. To effectively train the healthcare providers and
staff required the EHR software company to be onsite for training sessions. The total training
costs were $4,000. The total costs for the initial set up of an EHR is over $59,000. The price does
not include any additional fees associated with upgrades or maintenance.
The benefits of an EHR have an indirect and direct effect on costs. EHRs decrease costs
by minimizing the need for paper supplies and the costs associated with storing paper charts
(Geier & Smith, 2019). The data accuracy of an EHR can eliminate salary costs of chart auditors
or transcription costs supporting a return on investment. Indirectly, EHRs ability to improve
IMPACT OF ELECTRONIC HEALTH RECORDS 12
quality of care by reducing medical errors or adverse events reduces organizational costs
associated with these events.
Discussion of Results
The project was not successful because of the inability to implement an EHR. To
successfully implement an EHR, all key stakeholders need to have full engagement with the
project. Due to an unexpected death of the business office manager, the project had to be
postponed. However, with a new business office manager and the support from all stakeholders,
the project is expected to continue its implementation efforts.
Conclusions/Recommendations
Across the literature, the body of evidence has pointed out the importance of a thorough
plan on how to disseminate and educate information on the use of an EHR. Without proper
training for key stakeholders, optimal outcomes may be difficult to achieve. Therefore, it is
recommended to provide adequate training and education. Proper training enhances the
usefulness of an EHR and enables the full benefits and attributes of an EHR (Ratwani et al.,
2016). Another important factor to consider is the usability of the EHR. One of the main gaps or
barriers to the success of implementing an EHR is usability. Usability is not always initially seen
as an issue and may be more apparent at different phases of implementation. A recommended
strategy that would help manage the change process is using the Iowa Model (see Appendix C).
The Iowa Model outlines a pragmatic multiphase change process with feedback loops and would
be the optimal choice for a strategic guidance on implementing an EHR (Dang et al., 2019).
Following a basic problem-solving approach, the interprofessional team will be able to utilize
multiple feedback loops that assess, analyze, and evaluate data throughout the change process
(Dang et al., 2019). The benefits of feedback loops are to gather information to help support the
IMPACT OF ELECTRONIC HEALTH RECORDS 13
team when it comes to identifying usability issues and ultimately promote sustainability of such
evidence-based change.
Compared to paper-based record systems, EHRs provide a state-of-the-art system that
improves quality of care and reduces costs. EHRs can drive performance in areas such as
clinical, operational and financial. The current paper-based documentation system is not a
sustainable method, nor is it best practice. In order to provide high-quality care, reduce
healthcare costs, and have a position for long-term success in an increasingly digital healthcare
environment, an EHR must be utilized. Therefore, it is recommended that Texas Orthopedics
Surgery Center adopt an EHR to replace the current paper-based record system.
IMPACT OF ELECTRONIC HEALTH RECORDS 14
References
Accreditation Association of Ambulatory Health Care. (2020, November 19). AAAHC publishes
allergy documentation benchmarking study. https://www.aaahc.org/news/aaahc-
publishes-allergy-documentation-benchmarking-study/
Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia,
M. L. (2016). The impact of electronic health records on healthcare quality: a systematic
review and meta-analysis. The European Journal of Public Health, 26(1), 60-64.
Centers for Medicare and Medicaid Services. (2023, February 2023). Electronic health records.
Retrieved April 15, 2023, from https://www.cms.gov/medicare/e-
health/ehealthrecords#:~:text=Making%20the%20health%20information%20available,in
formed%20to%20take%20better%20decisions.
Centers for Medicare and Medicaid Services. (2020, February 21). State operations manual
appendix l - guidance for surveyors: ambulatory surgical centers.
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf
Cullen, L., Hanrahan, K., Farrington, M., Anderson, R., Dimmer, E., Miner, R., Suchan, T. &
Rod, E. (2020). Evidence-based practice change champion program improves quality
care. JONA: The Journal of Nursing Administration, 50(3), 128-134.
Dang, D., Melnyk, B. M., Fineout-Overholt, E., Yost, J., Cullen, L., Cvach, M., Larabee, J. H.,
Rycroft-Malone, J., Schultz, A. A., Stetler, C. B., & Stevens, K. R. (2019). Models to guide
implementation and sustainability of evidence-based practice. In B. M. & E. Fineout-
Overholt (Eds.), Evidence-based practice in nursing & healthcare: A guide to best practice
(4th ed., pp. 378-427). Wolters Kluwer.
IMPACT OF ELECTRONIC HEALTH RECORDS 15
Geier, A., & Smith, D. (2019). The role of electronic documentation in ambulatory surgery
centers. AORN journal, 109(4), 444-450.
Holderried, F., Herrmann-Werner, A., Mahling, M., Holderried, M., Riessen, R., Zipfel, S., &
Celebi, N. (2020). Electronic charts do not facilitate the recognition of patient hazards by
advanced medical students: A randomized controlled study. PloS One, 15(3), 1.
doi:http://dx.doi.org/10.1371/journal.pone.0230522
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett‐Collins, G., Clancy, M., Sheehy,
A., Denieffe, S., Bergin, M. & Savage, E. (2019). Electronic nursing documentation
interventions to promote or improve patient safety and quality care: A systematic
review. Journal of nursing management, 27(3), 491-501.
McDowell, J., Wu, A., Ehrenfeld, J. M., & Urman, R. D. (2017). Effect of the implementation of
a new electronic health record system on surgical case turnover time. Journal of Medical
Systems, 41(3), 1-6. doi:http://dx.doi.org/10.1007/s10916-017-0690-y
Monturo, C., Brockway, C., & Ginev, A. (2021). Electronic Health Record Transition: The
Patient Experience. CIN: Computers, Informatics, Nursing, Advance on-line publication.
Retrieved from
http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftw&NEWS=N&A
N=00024665-900000000-99236. https://doi.org/10.1097/CIN.0000000000000805
Nguyen, L., Bellucci, E., & Nguyen, L. T. (2014). Electronic health records implementation: an
evaluation of information system impact and contingency factors. International journal
IMPACT OF ELECTRONIC HEALTH RECORDS 16
of medical informatics, 83(11), 779–796. https://doi-
org.ezproxy.uttyler.edu/10.1016/j.ijmedinf.2014.06.011
Noureldin, M., Mosallam, R., & Hassan, S. (2014). Quality of documentation of electronic
medical information systems at primary health care units in Alexandria, Egypt. Eastern
Mediterranean Health Journal, 20(2), 105.
https://ezproxy.uttyler.edu/login?url=https://www.proquest.com/scholarly-
journals/quality-documentation-electronic-medical/docview/1518627885/se-
2?accountid=7123
Ratwani, R., Fairbanks, T., Savage, E., Adams, K., Wittie, M., Boone, E., Hayden, A., Barnes, J.,
Hettinger, Z. & Gettinger, A. (2016). Mind the Gap. A systematic review to identify
usability and safety challenges and practices during electronic health record
implementation. Applied Clinical Informatics, 7(4), 1069-1087.
Rodgers, C. C., Brown, T. L., & Hockenberry, M. J. (2019). Implementing evidence in clinical
settings. In B. M. & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing &
healthcare: A guide to best practice (4th ed., pp. 269-292). Wolters Kluwer.
Seyyedi, N., Moghaddasi, H., Asadi, F., Hamidpour, M., & Shoaie, K. (2020). The Effect of
Information Technology on the Information Exchange between Laboratories and
Ambulatory Care Centers: A Systematic Review. Laboratory Medicine, 51(4), 430-440.
Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of
electronic health record implementation and barriers to adoption and use: A scoping
review and qualitative analysis of the content. Life (Basel, Switzerland), 10(12)
http://dx.doi.org/10.3390/life10120327
IMPACT OF ELECTRONIC HEALTH RECORDS 17
Yu, P., Zhang, Y., Gong, Y., & Zhang, J. (2013). Unintended adverse consequences of
introducing electronic health records in residential aged care homes. International
Journal of Medical Informatics (Shannon, Ireland), 82(9), 772-788.
https://doi.org/10.1016/j.ijmedinf.2013.05.008
IMPACT OF ELECTRONIC HEALTH RECORDS 18
Appendix A
Synthesis Table
Level of Evidence
1
2
3
4
5
6
7
8
9
10
11
12
I: Systematic
review/meta-analysis
of RCTs
X
X
X
X
X
X
X
X
II: Single RCT
X
X
III:
QE/Nonrandomized
controlled trial
X
X
IV: Cohort or case-
control studies
V: Systematic
review/meta-synthesis
of qualitative studies
VI: Single qualitative
or descriptive
studies/evidence
implementation and
QI projects
VII: Expert opinion
IMPACT OF ELECTRONIC HEALTH RECORDS 19
Appendix B
Flowchart
Establish
Change Team
(1 week)
Selection of
an EHR system
(about 1
month)
Hardware
selection (3
weeks)
System
Installation (1
week)
Development /
customization/workflows
created (1 month)
Users training (1.5 months)
"Go-Live" (1 month)
Evaluation period (1 month)
IMPACT OF ELECTRONIC HEALTH RECORDS 20
Appendix C
Iowa Model
