Electronic Health Records - Market Landscape

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Electronic health record (EHR) is a computerized patient-centric history of an individual’s health …

Electronic health record (EHR) is a computerized patient-centric history of an individual’s health
care record that includes data from the multiple sources of care that the patient has used.

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  • 1. Electronic Health RecordsMarket Landscape Research Proposal DATE
  • 2. BACKGROUND A medical record is a confidential record that is kept for each patient by a healthcare professional or organization. It contains the patient’s personal details (such as name, address, date of birth), a summary of the patient’s medical history, and documentation of each event, including symptoms, diagnosis, treatment, and outcome. Relevant documents and correspondence are also included. Traditionally, each healthcare provider involved in a patient’s care has kept an independent record, usually paper-based. The main purpose of the medical record is to provide a summary of a person’s contact with a healthcare provider and the treatment provided in order to ensure appropriate healthcare. Information from medical records also provides the essential data for monitoring patient care, conducting clinical audits, and assessing patterns of care and service delivery. Integration of technology affords a great opportunity to leverage the value of medical records while incorporating the efficiency of newer electronic data management methodologies.1 The Value of Medical Records There is a longstanding research practice of combing medical records to glean information that could provide clues about the onset and progression of disease and to improve disease management and outcomes. In the past, paper medical records studies have been used to:  monitor the health of the population and detect emerging health problems;  identify populations at high risk for disease;  determine the effectiveness of treatment(s);  assess and quantify prognoses;  assess the usefulness of diagnostic tests and screening programs;  influence policy through cost-effectiveness analysis;  support administrative functions; and  monitor the adequacy of care. Electronic health record (EHR) is a computerized patient-centric history of an individual’s health care record that includes data from the multiple sources of care that the patient has used. Generally, EHR refers to the combination of the medical record created by the medical care system and personal health information. Because they are interoperable (can be accessed across networks by computers using a variety of operating systems and software), they can be accessed at any authorized point of care.2 The potential value of medical records data to clinical research could be magnified by the computing power associated with a system of digitized, or electronic, medical records. The application of information technology to patient records offers the promise of new knowledge that can be obtained only by integrating and analyzing data extracted from hundreds if not thousands of patient records, including medical history, physical examination, diagnoses, diagnostic tests, medical images, administrative data (claims, billing, outcomes), clinical information, environmental profiles, and genetic analyses, combined with new findings from molecular and genomics research. As institutions struggle with the adoption and implementation of EHR systems, it is crucial that they consider the needs of and seek the advice of the research community. Payers and consumers are increasingly including the results of patient surveys in performance measures used for payment, public reporting, and improvement. A fully functional electronic healthcare information system would enable physicians to contact patients directly, to solicit patient feedback related to specific conditions, and to compile actionable feedback to the practice.3 3
  • 3. Having electronic health information about the entire population of patients served by a givenpractice or provider enables queries about groups of patients who suffer from a specific condition,are eligible for specific preventive measures, or are currently taking specific medications. Amongother things, this population-based view enhances the ability of the practice to identify and workwith patients to manage specific risk factors or combinations of risk factors. It also can detectpatterns of potentially related adverse events and enable patients at risk to be quickly and correctlynotified. Outreach, patient education, and notification about particular risks are made possible bythis kind of system. For this to happen, we must be able to “disassemble” the information inelectronic health records and then “reassemble” it in various ways.4US Healthcare InitiativesThe potential of EHR to strengthen the health care system and improve quality of care has garnerednationwide attention. Now more than ever, physicians need information about implementing EHRsas the American Recovery and Reinvestment Act (ARRA) begins offering financial incentives forphysicians to implement EHR (Figure 1). Successfully implementing health information technologyinto an office practice can bring improvements in both quality of patient care and practiceprofitability. Using properly designed databases and powerful computers, informatics can provide aview of the relationships between health and illness and unwrap the mysteries of human variation.5Figure 1: The US Government Has Put Billions Behind Health Information Technology Source: Centers for Medicare & Medicaid Services, Office of Management and BudgetIn 2004, President George W. Bush launched an initiative to make electronic health recordsavailable to most Americans by 2014. This was followed by an August 2006 executive order callingfor federal programs to lead the way with HIT adoption, along with financial and qualitytransparency. Recent Federal legislation has charted a new path forward. The Health InformationTechnology for Economic and Clinical Health (HITECH) Act, a part of ARRA of 2009, authorizedexpenditures of at least $20 billion under the U.S. Health and Human Services Department (HHS) topromote the adoption and use of EHR technologies that would ideally be connected through anational health information network. Hospitals and physicians who make “meaningful use” ofinteroperable EHRs can qualify for extra payments through Medicare and Medicaid.6 4
  • 4. Responsibility for developing policies that implement the overall HITECH Act lies primarily withthe Office of the National Coordinator for Health Information Technology (ONC). In this role, ONCworks closely with the Center for Medicare and Medicaid Services (CMS), which is responsible forpromulgating policies that relate to Medicare and Medicaid payment for “meaningful use” of EHRsunder HITECH. Meaningful use specifically requires that organizations leverage EHRs to capturehealth information; use health information for continuous quality improvement; and use integrateddecision support functions to improve quality, safety and efficiency in real time. ONC and CMSrecently released final rules to implement the first phase of the HITECH Act, which begins in 2011.The 3 ONC rule specifies the standards, implementation specifications and other criteria for EHRsystems and technologies to be certified under HITECH and thus eligible for the Acts incentiveprograms while the CMS rule specifies how hospitals, physicians, and other eligible professionalsmust demonstrate their meaningful use of these technologies in order to receive Medicare andMedicaid payment incentives.5,6Depending on the amount of Medicare services provided, physicians who accept Medicare patientscould earn up to $44,000 in incentives over five years. The Medicaid incentive program will beadministered by the states, and has a more complex funding schedule based on EMR costs.Physicians can receive a one-time incentive payment for 85 percent of the allowable cost for thepurchase and implementation of a certified EHR in the first year. The legislation does not penalizeMedicaid physicians for failing to adopt a certified technology. Unlike Medicare penalties, noreductions in Medicaid payments are to be made if the physician does not adopt EHR technology.Both sets of rules strongly indicate that standards and criteria for achieving meaningful use of EHRswill grow more rigorous in subsequent phases (2013 and 2015) as the technology continues toevolve and providers gain experience and sophistication in its use. This funding enables the Centersfor Medicare and Medicaid Services and the Office for Civil Rights to carry out mandated audits andmake modifications in case and document management systems. The law also grants stateattorneys general authority to file suit on behalf of a state’s citizens and increases monetarypenalties for violations of certain provisions to a maximum of $1,500,000 per year for each identicalviolation.5,6In a report to the President on healthcare IT, the President’s Council of Advisors of Science andTechnology (PCAST) suggested that the Chief Technology Officer of the United States, incoordination with the Office of Management and Budget and HHS, develop within 12 months [ofDecember 2010] a set of metrics that measure progress toward an a operational, universal, nationalhealth IT infrastructure.5 They emphasized focusing these metrics on operational progress, asdistinct from research, prototype, and pilot efforts, to enable a more accurate continuingassessment of whether Federal efforts in health IT, including both executive initiatives andlegislative mandates, are in fact supportive of the President’s goal of increasing the quality, anddecreasing the cost, of healthcare (Figure 2). 5
  • 5. The Three Forces Shaping the Evolution of Healthcare Figure 2: The Three Forces Shaping the Value Demonstrating Evolution of Healthcare molecular access, medicine cost and and quality personalized of care medicine proficient use of information (e.health) Source: George Poste 41The Physicians’ PerspectiveIn cooperation with the Robert Wood Johnson Foundation, the New England Journal of Medicineconducted a study in 2008 to determine national electronic medical record (EMR) adoption rates,satisfaction with chosen systems, anticipated barriers to adoption, and perceived effect on qualityof care (Figure 3). The survey drew 2,758 responses. At the time of the survey, seventeen percent(17%) of the physicians surveyed used EMRs in their office practices, and twenty-six percent (26%)planned to acquire EMRs in the next two years. Those who had adopted EMRs had had successfulexperiences. The physicians overwhelmingly reported the following as the most important featuresof EMRs. Collectively, all of these improvements reflect positive changes in patient care and practiceoperations.7 Figure 3: Most Important EMR Features Source: Texas Medical AssociationOverall, the survey results describe a physician community that now favors the adoption of EMRs:  Physicians who are using EMRs in their offices can cite concrete benefits to their office operations and quality of patient care. Among the adopting physicians, 93 percent (93%) report that they are satisfied with a fully functional system that includes order entry capabilities and clinical decision support. Eighty-eight percent (88%) who utilize a more basic EMR system indicate that they are satisfied. 6
  • 6.  While physicians believe that EMRs are beneficial to their practice, a concern across the board is cost.  A large majority of respondents reported an overall positive effect on their practice with the use of their EMR system.More relevant to the individual physician, perhaps, is the need for change in the following fourareas, areas in which the application of HIT will be noticeably beneficial: patient safety, qualityimprovement, pay-for-performance reimbursement, and improved practice efficiency. As physicianincome continues to decline, controlling practice costs is becoming a critical issue for physicians inoffice practice. Medical practices that use HIT potentially can gain the same type of cost savings thatinformation technology has long been creating in other businesses through the substitution oftechnology for manual work. With EMRs, clinical staff no longer needs to pull charts for everypatient visit, every patient phone call, or every request for a prescription renewal, and no one has tosearch for lost charts. One study of a number of family practices that installed HIT systems foundthat the combination of more accurate coding and additional office visits (due to increasedefficiencies) generated an additional $23,000 per physician in annual revenue.The cost recovery and subsequent improvement in practice profitability result from a series ofprocess improvements that EMR capabilities facilitate.  A combination of template-based documentation and expert coding advice increases the use of higher-level codes because physicians and coders are more confident of their ability to demonstrate the appropriateness of their code selections. The elimination of paper records leads to numerous efficiencies that flow to a practice’s bottom line. The time spent pulling paper records for every patient visit, telephone call, or request for a prescription renewal is virtually eliminated. There are no more lost records. Medical record supply costs also are eliminated. The office space used to store medical records can be eliminated or put to profitable use.  The number of nonclinical employees can be reduced, or alternatively, each staff person’s responsibilities can be shifted to support a practice’s ability to handle an increased patient load.  The ability to run a profitable satellite office is greatly increased through the availability of EMRs over a practice’s network, which eliminates the need for faxing records back and forth.EHR ChallengesThe EHR is still in a developmental phase, and it will be several years before it will be possible todetermine the effect that the EHR will have on medical practices and patients. In the meantime,vendors and large consulting firms try to scale down their traditional big EHR methodologies forsmaller institutions, but all too often the packaging, pricing and resource requirements remainbeyond the reach of community hospitals. The traditional behemoth EHR implementation model isclearly out of step with the needs of today’s small-to mid-sized healthcare delivery systems.Solution platforms for EHRs should be highly customized for each hospital’s environment socaregivers can use all available, necessary data and functionality at the point of care. This ensureslarge health systems and community hospitals alike are well positioned for maximum clinical andfinancial benefit from their electronic records projects because they carry out every step of theirimplementations with clear, concise project plans.1,2 7
  • 7. EHR systems have the capability to serve as a broadly enabling research infrastructure thatfacilitates and promotes the sharing and reuse of data from the patient care process and thatchannels the results of clinical research back into the hands of patients and practitioners, where itcan create the greatest benefit. The greatest challenge to using the EHR for research is thereliability and validity of the data in the record. The bottom line is that data are as reliable as thepatient gives and the user enters. Although clinical data generally are valid, there may be mistakesor omissions.3In addition, although billing codes are considered part of the record, they are the least useful andreliable data elements for researchers and therefore almost meaningless for most clinical research.At some point soon, a critical mass may be reached in EHR adoption that will help acceleratesubstantially greater progress in standardization. This must occur in tandem with efforts tointegrate multiple databases for data mining. Standards for security and confidentiality also areneeded, as is the consistent use of messaging standards and a universal language for the exchangeof health data. An extensible markup language, where individual pieces of data can be tagged withcontext-setting metadata, is a straightforward solution and is superior to other proposedarchitectures.1,2In light of the much-needed overhaul of CMS’s antiquated IT infrastructure, it is important not toreplace one inflexible architecture with another. Fortunately, CMS now has new leadership, withthe appointment of an administrator. A solid technical plan, with the necessary resources, isrequired for success. A common infrastructure for locating and assembling individual elements of apatient’s records, via secure tagged “data element access services” (DEAS) allows for asophisticated, fine-grained model of implementing strong privacy controls (including honoringpatient-controlled privacy preferences where applicable) and strong security protection.Importantly, this approach does not require any national database of healthcare records; therecords themselves can remain in their original locations. Distinct DEAS could be operated by caredelivery networks, by states or voluntary grouping of states, with possibly a national DEAS for useby Medicare providers. DEAS should be interoperable and intercommunicating, so that a singleauthorized query can locate a patient’s records, across multiple DEAS.3,4E-Health InnovationsThe state of health IT today can be summarized as a mix of “the good, the bad, and the ugly.” Thisdiversity, and especially the fact that perhaps eighty percent (80%) of physicians still do not useelectronic records at all, except possibly for billing functions, creates a dilemma. Given the difficultyof bringing the healthcare system forward into the computer age, should we focus on smallincremental steps? Or, having seen the remarkable adoption rates and advances of Internet-basedtechnologies in other sectors, should we push for a more radical advance that risk leaving someproviders behind?Fortunately, there is a bridge between these two extremes. It is the fact that the Internet-basedtechnologies create a platform for “disruptive innovation,” meaning innovations that upset thestatus quo and can broadly expand markets. Cloud-based technologies and EHRs are potentialexamples of disruptive technologies in health IT. These types of technologies might allow the eightypercent (80%) of physicians who are non-digital to leapfrog some of the existing limitations of EHRsystems directly into more modern technologies. Indeed this is precisely what we want to happen,and it is a direction in which ONC and CMS could concentrate their efforts.7 8
  • 8. Some aspects of the new health IT infrastructure will enable new, competitive, entrepreneurialmarkets. Some other aspects are “public goods” and will require government leadership. Thebenefits of health IT affect, and are affected by, other aspects of healthcare reform, especiallypayment models. Other models, such as Geisinger Health System, are testing the power ofinformation technology to improve patient care through the use of online interactive self-assessment.3 It is conceivable that such an approach could be modified and easily adapted forresearch purposes.A further class of applications might help users compile and aggregate population-level data onhealth outcomes, physician performance, or population health. These applications could be gearedtoward provider organizations, insurance companies, public-health companies, and researchers,broadly defined. Likewise, the development of customized algorithms and pattern recognitionsystems will aid researchers while simultaneously providing physicians with smart clinicaldecision-support tools.4Other technology innovations include applications that provide physicians with mobile access toelectronic health records via iPhone™, iPad™, iPod® Touch, BlackBerry® or Android® smartphones.Physicians can also dictate clinical notes, document calls and send messages through theirsmartphone. This innovation encourages increased productivity, improved levels of care, andconnectivity to critical patient data whenever and wherever they need it.7Paper-to-Electronic Health Record TransitionThe successful transition from a paper- to electronic-based practice begins with developing anunderstanding of system functionality (what HIT actually does), analyzing a practice’s readiness tomanage a new operating system, and preparing staff for this major change. With hundreds of EHRproducts, the marketplace offers a robust choice, and selecting the right system depends heavily onassessing the practice’s needs. The efficiency benefits of an EHR derive from these changes thatoccur in practices as they move from paper to electronic:  The reduction in expenses associated with the management of paper records;  Significantly more efficient and accurate coding and billing of claims as a result of template- based documentation;  Redesign of workflow so that practice staff can become more productive users of the practice’s HIT system;  Real-time access to a patient records from multiple computers and locations, including remote access beyond the office, without physically retrieving a paper chart; and  Multiple people simultaneously accessing a single patient record from multiple locations, improving work flow in some situations.Current health care publications highlight an increased national interest in EHRs and personalhealth records. These forms of Health IT are ways to help resolve multiple issues within the healthcare system. With decreasing physician reimbursement, increasing overall costs of health care, andan increasingly uninsured and underinsured population, the dialogue is shifting from simplymanaging costs to include quality improvement. Improved health IT can directly affect, andimprove, clinical encounters between doctor and patient, healthcare organizations, clinicalresearch, and the monitoring of public health. The clinical research community sees enormouspotential in the ability of researchers to access and analyze the clinical information contained inmillions of medical and personal health records. With appropriate privacy and human subjectsprotection safeguards in place, this capability could speed the discovery of new therapies beyondanything imaginable today. 9
  • 9. To better understand the landscape of EHR system adoption and evaluate the challenges and opportunities involved in developing research uses of this vast resource, Harrison Hayes will conduct a broad overview and characterization of current efforts to promote EHRs and their potential research use, and to assess what is needed to optimize the creation and use of such databases for research purposes. This analysis rests on the premise that as the healthcare system addresses the challenges of widespread adoption of electronic patient record systems, research capacity should be a part of the architecture.REFERENCES 1. “Top Technology Innovations.” Health Data Management. July 2010. 2. “Think Research: Using Electronic Medical Records to Bridge Patient Care and Research.” FasterCures. 2005. 3. “How Electronic Records are Driving New Storage Challenges for Hospitals.” Forrester Research, Inc. January 2010. 4. “Transforming Health Innovation Area Projects.” MITRE. 2011. 5. “Report to the President Realizing Full Potential of Health Information Technology to Improve Healthcare for Americans: The Path Forward.” Executive Office of the President; President’s Council of Advisors of Science and Technology. December 2010. 6. Agrawal R, Johnson C. “Securing Electronic Health Records without Impeding the Flow of Information.” IBM Alamaden Research Center. 7. Marcus DD, Lubrano J, Murray J. “Electronic Medical Record: Impelementation Guide.” 2nd ed. Texas Medical Association. 2009. 10