[Med-privacy] a pro view of EMRs (EHRs)

[pmarshall]

*** The Electronic Health Record: Will It Become a Reality? ***

By Randa Upham, Principal, Phoenix Health Systems

The past few years have been busy ones for those involved with automation=
 of processes within the healthcare industry. IT professionals dedicated =
much of their time at the end of the last century addressing the Y2K cris=
is and then moved into the 21st century to take on the challenge of HIPAA=
=2E With the Y2K bug resolved and HIPAA becoming a way of life within the=
 industry, is it now possible to reinvest energies into improving one of =
healthcare's biggest challenges -- establishing an electronic healthcare =
record?

First, let's understand what we mean by "electronic healthcare record."

------------------------------
How Many Acronyms Does It Take to Make an Electronic Health Record?=20

The electronic health record (EHR) is an acronym used extensively in the =
healthcare industry, but often with ambiguous meanings. What exactly is a=
n EHR? To answer that question, let's first consider its evolution. The t=
erm EHR has been around for about three decades and yet is still being de=
fined. A brief summary of its history may help to clarify its meaning.

* Paper Medical Records
All current versions of the electronic records of the care provided to pa=
tients are based on the traditional medical record -- the paper version. =
The phrase "medical record" may be applied in differing ways based on the=
 actual healthcare practitioners providing the care, but most persons und=
erstand the medical record to be a history of the care they received from=
 various clinicians. An important characteristic to keep in mind is that =
EACH practitioner keeps its own medical record for each of its patients. =
There is no integration of the data from the various clinicians treating =
the patient. Therefore, as a patient, you most likely have many different=
 medical records.

* Computerization of Patient Records
The original objective for computerization of an individual's health reco=
rd can be found in the Computerized Patient Record (CPR), which was defin=
ed as a computer-based record that includes all clinical and administrati=
ve information about a patient's care throughout his or her lifetime. The=
 documentation of any practitioner ever involved in a person's healthcare=
 would be included in the CPR, extending from prenatal to postmortem info=
rmation. One of the expectations for the CPR included its role in decisio=
n support. Over a decade ago, the term CPR was used to distinguish the co=
ncept from the more traditional medical record to incorporate administrat=
ive and financial data often excluded from the patient medical record.

* Evolving Terminologies
Over the past few decades, similar acronyms have evolved representing cha=
nges in the industry perception of what should be the actual make-up of t=
he computerized "record" of the patient's healthcare experience. The indu=
stry has embraced models for the Computerized Medical Record (CMR), the E=
lectronic Patient Record (EPR), the Continuity of Care Record (CCR), the =
Digital Medical Record (DMR), and the Personal Health Record (PHR). Of pa=
rticular importance is Patient Medical Record Information (PMRI) in that =
the legislative act that made HIPAA a law (the Health Insurance Portabili=
ty and Accountability Act of 1996) charged the National Committee for Vit=
al and Health Statistics (NCVHS) to "study the issues related to the adop=
tion of uniform data standards for patient medical record information and=
 the electronic exchange of such information." To that end, NVCHS has bee=
n steadily working to establish PMRI standards for the information and te=
rminologies that would comprise a universal electronic patient health rec=
ord. Each of these concepts (and acronyms) exists as a building block in =
the current understanding of EHR. For an in-depth discussion of the evolu=
tion of industry terminology relating to what is now known as the EHR, se=
e: Waegermann, C. Peter, Status Report 2002: Electronic Health Records Wh=
y EHRs?

------------------------------
The EHR Today

Although no standardized acronym has been established by the industry or =
the government, EHR is often considered the term most reflective of the a=
ctual patient experience of receiving healthcare. The EHR incorporates al=
l provider records of encounters where the patient has received medical c=
are.

Documentation of many events occurs with the inpatient experience -- reco=
rding of encounters with clinicians, treatment received, test results, an=
d medications ordered. Following his or her discharge, the patient may ha=
ve office visits with practitioners and receive ongoing care ordered by t=
hese practitioners. The aggregate recording of these encounters and inter=
actions with the patient (across all involved healthcare enterprises) com=
prises the EHR.

In addition to serving as documentation of the clinical care provided to =
the patient, the EHR exists as a business record for all the providers wh=
o provide care to the patient. The provider uses the EHR to communicate w=
ith other practitioners about the delivery of care, as reference for the =
patient's history, to support its operations and billing, and for medical=
-legal purposes. It is the aggregate of the total experiences related to =
patient care that is currently understood to be the contemporary EHR.

Considering the decades of development that resulted in the current conce=
pt of EHR, it would be logical to assume that the industry has establishe=
d a sound foundation for universal implementation of an electronic health=
 record. Unfortunately, we know that the healthcare industry has yet to a=
ccomplish this objective. Yet there is general industry consensus that an=
 EHR is essential to the well-being of the healthcare environment. Why do=
es the vision of an industry=96wide HER seem so far from reality? What ar=
e the factors that have prevented universal adoption of EHR?

------------------------------
Understanding the Realities

Healthcare has lagged behind other industries in adopting Enterprise Reso=
urce Planning (ERP) as an essential business strategy. The many departmen=
ts within a hospital setting typically implement and use computerized sys=
tems according to their own established data conventions. Changing to sta=
ndardized protocols for charting patient care within an automated system =
requires an enormous and expensive effort. Some of the barriers that are =
typically noted include:

=2E lack of clinician acceptance
=2E concerns about inability to align workflow with a
  standardized EHR
=2E concerns that automation of clinical charting requires
  more time than paper charting
=2E lack of uniform standards for documentation of clinical
  services
=2E lack of standardized technical platforms to support EHR
=2E lack of support for startup expenses or reimbursement
  for implementation costs

Several observations can be made about these perceived issues. Studies ab=
ound concerning the resistance of physicians and other clinicians relativ=
e to their willingness to embrace the EHR. Although clinician acceptance =
is indeed an important factor in adoption of the EHR, the myth of univers=
al physician resistance should be debunked. There is much literature evid=
encing that physicians support EHR when the benefits of EHR can be demons=
trated to them. The industry's energies should be focused on establishing=
 the value of adopting EHR across all aspects of our delivery of healthca=
re -- not merely conducting studies measuring the time spent charting (pa=
per vs. electronic).

Many of the other identified hurdles involving lack of standardized termi=
nology, charting requirements and technical platforms are being increasin=
gly reduced as definite barriers. Across the nation, initiatives to addre=
ss lack of standardization issues are in process. A search on the Interne=
t on "electronic health record" (or any of its alternative monikers) yiel=
ds more than an abundance of active EHR and standardization initiatives. =
Of course, the industry closely watches the activities of NCVHS relative =
to standardization of the components and terminologies for an EHR.

The barrier to adoption of the EHR that is probably the most difficult to=
 overcome is the lack of easily apparent return on investment (ROI). Many=
 writers on the subject have noted that healthcare decision makers find i=
t difficult to readily demonstrate ROI or justify the expenditure of doll=
ars and time to undertake a comprehensive EHR within their organizations,=
 particularly while healthcare costs continue to spiral out of control. A=
 review of the literature yields an abundance of information from vendors=
 and healthcare professionals about how to measure the ROI for and implem=
entation of EHR. In fact, the NCVHS has suggested turning to the vendors =
to obtain experiential information on ROI. However, the literature has no=
t yet produced the universal guarantee for ROI that healthcare enterprise=
s would like to have when they are conducting strategic planning related =
to the huge initiative of establishing an EHR for their organizations. In=
 spite of this major hurdle, the national healthcare environment does not=
 appear ready to give up the vision of a universal EHR. Across the indust=
ry, initiatives in support of the adoption of an electronic health record=
 remain alive and well.

------------------------------
Arguing the Benefits of the EHR

Quite frankly, there is little argument over the other potential benefits=
 of EHR. Most healthcare professionals agree that if the industry could f=
inally implement a universal EHR, there would be considerable clinical an=
d administrative benefits to be recognized. Among them are:

=2E immediate and universal access to the patient record
=2E easier and quicker navigation through the patient record=20
=2E no lost charts
=2E standardization of care among providers within the
  organization
=2E clinical data that is formatted to be easy to read and
  analyze
=2E reduction of paperwork, documentation errors, filing
  activities
=2E coding efficiency and efficacy
=2E alerts for medication errors, drug interactions, patient
  allergies
=2E ability to electronically transmit information to other
  providers (assessments, history, treatments ordered,
  prescriptions, etc.)
=2E availability of clinical data for use in quality, risk,
  utilization, ROI analyses=20

For a discussion on how some physicians view the advantages of the EHR, s=
ee: David Smith, MD and Lucy Mancini Newell, MBA, A Physician's Perspecti=
ve: Deploying the EMR, Journal of Healthcare Information Management, Volu=
me 16, No. 2.

------------------------------
Getting on the EHR Bandwagon

Many respected national healthcare associations and advocacy groups have =
issued mission statements and established initiatives in support of the E=
HR. As healthcare professionals, we can make EHR a reality in this countr=
y through active involvement in a variety of initiatives to support the a=
doption of a universal (and comprehensive) electronic health record. Just=
 a few of them are noted below, as examples of the very solid commitment =
that our industry is making to achieve this milestone in healthcare infor=
mation:

* The Healthcare Information and Management Systems Society (HIMSS) has a=
nnounced its support of EHR in many ways. For example, it has proposed an=
 EHR Summit to convene the leading vendors, consultants, clinicians, HIT =
provider executives, payers, government agencies, pharmaceuticals, standa=
rds development organizations, associations, and others to develop a real=
istic action plan. The HIMSS Electronic Health Record Committee has been =
established to explore the definition and essential attributes for the EH=
R. HIMSS conferences have consistently offered an electronic medical reco=
rds track for presentations (http://www.himss.org).

* The American Health Information Management Association (AHIMA) believes=
 that "for the United States' healthcare industry to meet the current and=
 future needs of the nation, a properly funded and maintained national he=
althcare information infrastructure should be established" (http://www.AH=
IMA.org).

* The Medical Records Institute's (MRI) mission is "to promote and enhanc=
e the journey towards electronic health records, ehealth, & mobile health=
, and related applications of information technologies (IT)" (http://www.=
medrecinst.com).

* The Foundation for the Advancement of Electronic Health Records (FAEHR)=
 is a non-profit organization dedicated to addressing several of the most=
 urgent needs facing the healthcare delivery system today, including qual=
ity of care, reducing medication errors, and cost of healthcare reduction=
=2E

* NCVHS recommends that the federal government recognize a "core set" of =
PMRI terminologies as a national standard (http://www.ncvhs.dhhs.gov).

* The stated mission of the eHealth Initiative (eHI) and the Foundation f=
or eHealth Initiative is that "(c)onsumers, healthcare providers, and tho=
se responsible for population health will have ready access to timely, re=
levant, reliable, and secure information and services through an intercon=
nected, electronic health information infrastructure to support better he=
alth and healthcare" (http://www.ehealthinitiative.org).

* The EHR Collaborative is a group of organizations representing key stak=
eholders in healthcare which has established the following goal: "to faci=
litate rapid input from the healthcare community in this and other develo=
pment initiatives that advance the adoption of information standards for =
healthcare." This collaborative effort includes the following organizatio=
ns: AHIMA, eHI, HIMSS, American Medical Association (AMA), American Medic=
al Informatics Association (AMIA), College of Healthcare Information Mana=
gement Executives (CHIME), and National Alliance for Health Information T=
echnology (NAHIT) (http://www.ehrcollaborative.org).

It is important to note that support for the EHR comes from both the priv=
ate and public sector. Endorsement of and commitment to adoption of the E=
HR can be observed in numerous activities and initiatives within the fede=
ral government:

* The current administration's budget includes funding to the Agency for =
Healthcare Research and Quality (AHRQ) for IT Demonstration Projects. One=
 of the stated missions of the AHRQ is to advance the use of information =
technology for coordinating patient care and conducting quality and outco=
mes research.

* President Bush announced his support for interoperable electronic healt=
h records in his March 2003 address to the American Medical Association (=
AMA).

* The Centers for Medicare and Medicaid Services (CMS) has taken a leader=
ship position in improving the quality and efficiency of healthcare throu=
gh IT. For example, it has strongly supported the adoption of data standa=
rds within the federal government through the Consolidated Health Informa=
tics Initiative. The Medicare Prescription Drug, Improvement, and Moderni=
zation Act of 2003 recognizes the critical role that IT has in improving =
healthcare outcomes and reducing medical errors within the Medicare progr=
am. And, of course, CMS plays an active advisory and regulatory role in t=
he implementation of the HIPAA Transactions and Code Sets (TCS) standards=
=2E

* The HIPAA TCS standards must be recognized as a huge step in the evolut=
ion of the EHR. Once fully implemented, standardized transactions and cod=
e sets will serve as a major cornerstone of the EHR.

* Many of our country's legislators actively promote the EHR as evidenced=
 by some of the speeches at the 2004 HIMSS annual conference. Former Spea=
ker of the House, Newt Gingrich, in the keynote speech, talked about the =
need for changes in healthcare such as e-prescribing, electronic health r=
ecords, and an electronically-connected healthcare structure. Later in th=
e week, Patrick Kennedy, US Representative from RI, discussed his plan to=
 introduce new legislation, termed "QUEST" (Quality, Efficiency, Standard=
s and Technology) Act that uses technology to address many of healthcare'=
s woes. The act will call for a fully wireless, paperless EHR.

* The Department of Health and Humans Services (HHS) has commissioned the=
 Institute of Medicine (IOM) to design a standardized model of the EHR an=
d also asked the healthcare standards development organization, HL7, to e=
valuate the model. The proposed model is expected to be revealed in 2004.=


* In March 2003 HHS, and the Departments of Defense and Veterans Affairs =
announced the first set of uniform standards for the electronic exchange =
of clinical health information to be adopted for federal agencies.

* The Centers for Disease Control (CDC) created the Public Health Informa=
tion Network (PHIN), to support communications for public health labs, th=
e clinical community, and state and local health departments.

------------------------------
Commitment to Collaborate

These and other initiatives advocating and/or expanding on the concept of=
 the EHR indicate that the momentum towards an EHR is increasing in inten=
sity. In particular, the coordinated efforts of such affiliations as the =
EHR Collaborative offer a persuasive call to action to which healthcare p=
rovider organizations are increasingly paying attention. Is the industry,=
 in fact, moving closer towards the long-standing goal of a true, univers=
al EHR? We think it is. Watch HIPAAlert for further reports, as we contin=
ue to track future progress in the establishment of an industry electroni=
c healthcare record.

------------------------------
Randa Upham, M.A., Principal, is in charge of Program Development at Phoe=
nix Health Systems. Ms. Upham has 23 years' experience in the Healthcare =
and Information Services industries with an extensive background in produ=
ct development, clinical services, organizational management, software de=
sign, and educational planning.

[HIPAAlert]