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The Impact of the Electronic Health Record on an Academic Pediatric Primary Care Center

Samaan, Zeina M. MD; Klein, Melissa D. MD; Mansour, Mona E. MD, MS; DeWitt, Thomas G. MD

Journal of Ambulatory Care Management: July/September 2009 - Volume 32 - Issue 3 - p 180–187
doi: 10.1097/JAC.0b013e3181ac9667

Many hospitals and practices are transitioning to electronic health records (EHR), but there is little information on the impact on patient care in a busy pediatric academic setting. The objective of this study was to determine the impacts of EHR on documentation, clinical processes, billing, ancillary staff responsibilities, scheduling, and cycle time. A descriptive study to assess the impact of EHR implementation and subsequent use on documentation, clinical processes, and patient access and flow was performed in a large urban academic pediatric primary care health center. Six months and 2 years after implementation, EHR impact on documentation was collected and compared with baseline value by measuring the percentage of charts with problem lists present. Several clinical improvement processes were collected at baseline and 6 months later including medication refill turnaround time, percentage of charts without attending signature at 3 days, and type of appointment billed on ill visits. The volume of appointments and cycle time were measured at regular intervals from baseline to 2 years after implementation. The percentage of paper charts attempted to be pulled for patient visits was obtained at baseline and 1 year later. Of the 500 charts audited before implementation, and 25 charts audited 6 months and 2 years after the implementation, the percentage of the presence of problem lists improved from 29% to 84%. Medication refill turnaround time improved from an average of 48 hours to 12 hours. Charts with incomplete documentation at 3 days postvisit decreased from 3% to 1.6%. Visit coding for detailed level visits (99214) increased by 13% and for problem-focused visits (99212) decreased by 7%, resulting in increased revenue collected. Medical records support staff needs decreased from 1 full-time equivalent to 0.5 full-time equivalent. One year after the EHR implementation, the medical records staff pulled and refiled 5.2% of paper charts compared with 100% at baseline. Despite plans to return to full volume of scheduling patients by 4 weeks postimplementation, volume continued to be reduced by 10% for 3 additional months because of user inefficiency and high number of new learners/users. Patient cycle time was increased from 76 minutes preimplementation to 119 minutes immediately postimplementation and decreased to 85 to 90 minutes 2 years later. EHR can be successfully implemented in a large urban academic pediatric healthcare center. EHR implementation improved documentation of patient care, improved clinical processes, and resulted in increased revenue. However, the implementation of the EHR also led to short-term decreased appointment availability and a persistent longer cycle time. Ongoing information system training support is a key for maintaining efficiency due to the large number of new learners.

Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Ohio.

Corresponding Author: Zeina M. Samaan, MD, Division of General and Community Pediatrics, ML 2011, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Ave, Cincinnati, OH 45229 (

Disclaimer: Each author (Samaan, Klein, Mansour, and DeWitt) declares no conflict of interest and discloses no affiliation, financial agreement, or other involvement with any company whose product figures prominently in this article. None of the authors have financial agreements or affiliations with organizations that would affect the publication of this article.

The authors thank Pediatric Primary Care Center support staff and physicians, and Information System staff at Cincinnati Children's Hospital Medical Center for their support.

© 2009 Lippincott Williams & Wilkins, Inc.