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The Future of EHRs - Trends Driving EHR Adoption

Dr. Robert Hoyt, health informatics expert, explains the need for electronic medical records for practices and healthcare alike.

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Practice Fusion - Benefit of switching to an EHR » Health Informatics: A Practical Guide – Page 8

Recommended Reading

The following are several articles readers might consider to augment their understanding on the potential impact of EHRs.

  • Do Electronic Health Records Improve Processes Of Care And Outcomes Of Preventive Care? In an editorial Lin discusses the controversy surrounding the potential impact of EHRs on preventive care. The results are mixed and comparing the success by one organization with an entirely different organization’s failure is difficult. 221
  • Implementation Of An Outpatient Electronic Health Record And Emergency Department Visits, Hospitalizations And Office Visits With Diabetes. Authors from Kaiser Permanente studied the impact of implementing a system wide EHR into their integrated delivery network. They reported a modest reduction in ED visits, hospitalizations but no change in office visits. This was a before and after study so cause and effect are difficult to prove. 222
  • Electronic Health Records And Quality Of Diabetes Care. Authors compared diabetes care in greater Cleveland that included 38% safety net clinics. They reported composite standards for diabetes and improvements were greater for clinics with EHRs, compared to paper based clinics, regardless of insurance status. This study was not randomized and while controlling for co-variants it is probably still difficult to prove cause and effect. 223
  • E-Measures: Insight Into The Challenges And Opportunities Of Automating Publicly Reported Quality Measures. This early 2014 study by Kaiser Permanente scientists explains how they automated their quality measures generated by their enterprise EHR. The note that this is a very expensive process with ROI occurring in four years. Currently, automated quality measures save 5-14 minutes per measure compared to standard manual extraction. 224
  • Mining Electronic Health Records in the Genomic Era. Excellent summary of the potential of the electronic health record to store phenotypic information that can be used to compare with genomic information. Author discusses the types of data within the EHR, as well as the technological challenges to making the EHR a robust research tool. 225

Future trends

One doesn’t need a crystal ball to determine the direction that EHRs in the US will take over the next several years. The potent force shaping that direction will be the Meaningful Use (MU) criteria of the EHR Incentive Programs. The developer of these criteria is the Health Information Technology Policy Committee (HITPC), a Federal Advisory Committee that advises the Office of the National Coordinator (ONC) and the Department of Health and Human Services (HHS). So far those agencies have closely followed HITPC’s recommendations, and it is likely that they will continue to do so in the future. ONC in turn is responsible for creating the EHR certification criteria that ensure that EHRs can perform to specifications that allow for Meaningful Use.

The Meaningful Use program is currently in its first stage (2011-2013), will start its second stage in 2014, and then move to its third stage in 2017 (proposed).

So what direction is HITPC headed? HITPC has designed the MU criteria around five policy areas:

  • Improving quality, safety, efficiency and reducing health disparities – goals set out by the Institute of Medicine (IOM)
  • Engaging patients and families in their care – another IOM goal
  • Improving care coordination
  • Improving population and public health
  • Ensuring adequate privacy and security protections for personal health information

The Stage 2 criteria, and early suggestions about Stage 3 from HITPC, point to increased care coordination, increased reliance on electronic ordering, more patient portal use, and a greater focus on clinical measurements and quality reporting. Thus clinicians can expect to see EHRs that have more sophisticated analytics, increased standardization, enhanced interoperability, and tight linkages with more sophisticated patient portals than now exist. A desired outcome is that data and information will no longer remain locked in the plethora of EHR silos built by physicians and hospitals, but will electronically flow from one to the other.226 It can also be expected there will be more integration between hospital EHRs and the myriad of pumps, medical devices, monitors, etc.

Beyond 2016, when the CMS EHR Incentives for the Medicare program end, the direction that EHRs will take is less clear. Will some groups revert to paper and new medical groups decline EHR adoption? Without robust funding will ONC and CMS be able to continue monitoring meaningful progress? What will be the impact of fines on physicians who failed to meet meaningful use?

ONC and CMS will continue to monitor adoption, meaningful use progress, certification and EHR use and misuse. It is estimated that 5% of attesters for meaningful use will be audited in 2013 for compliance.227 The federal government will also looking for evidence of over-coding and other potential abuses.228 It is likely there will be new coding guidelines in the near future as a result of multiple questions about legitimate EHR billing practices. IT vendors are also being scrutinized, evidenced by the revocation of two EHR certifications in 2013.229

Experts suggest a number of trends, including an increased reliance on cloud computing,230 large shared databases used for comparative effectiveness research231-232 increasing use of natural language processing233 more pervasive use of telehealth (virtual visits and consultations),234 improved clinical decision support, more use of patient registries built into EHR workflow,235 and greater use and integration of wireless remote outpatient monitoring of patients.236-237

Of course, down the road, one or more unforeseen health IT technologies breakthroughs could alter EHRs in ways that one can currently only barely imagine.

Key Points
  • Electronic health records are central to creating health information organizations and a nationwide health information network
  • The current paper-based system is fraught with multiple shortcomings
  • Reimbursement by the federal government for electronic health records use has greatly increased adoption
  • In spite of the potential benefits of electronic health records, obstacles and controversies persist
  • Clinical decision support is still in its infancy and will likely improve in the future with artificial intelligence
  • Advance planning and training is mandatory for successful implementation of EHRs

Conclusion

In spite of the initial slow acceptance of EHRs by clinicians and healthcare organizations, they continue to proliferate and improve over time. Electronic health records have been transformational for large organizations like the VA, Kaiser-Permanente and the Cleveland Clinic, but the reality is that medicine in this country is mostly practiced by small medical groups, with limited finances and IT support. As a new trend, some outpatient clinicians opt to re-engineer their business model based on an EHR. Their goal is to reduce overhead by having fewer support staff and to concentrate on seeing fewer patients per day but with more time spent per patient. When this is combined with secure messaging, e-visits and e-prescribing the goal of the e-office is achievable.238

Buyers have a wide choice of features and cost to choose from. At this time cost is a major obstacle as well as the lack of high quality economic studies demonstrating reasonable return on investment. As more studies show cost savings, medical groups that have been sitting on the fence will make the financial commitment.

Without doubt, Medicare and Medicaid reimbursement for EHRs and e-prescribing is the most significant impetus to jump start EHR adoption. Preliminary studies have shown a significant increase in EHR adoption as a result of reimbursement programs. It is too early to know how well received Stage 1 Meaningful Use objectives and measures will be received, implemented and reported. Detailed data regarding EHR failure rates are lacking as well as lessons learned from stage 1 and yet, stage 2 Meaningful Use is planned for 2014. For those practices that can afford and need complexity, multiple high-end vendors exist. For smaller, rural, primary care practices, simpler alternatives exist.

Potential obstacles to achieving stage 2 early on might include: vendor not achieving 2014 certification; not enough patients using the portal, inability or failure to do electronic referrals, failure to achieve adequate CPOE and ability to see images within the EHR. Therefore, multiple challenges loom. It is also worth noting that purchasing EHRs is only one of multiple difficult challenges facing clinicians and their staff. According to a mid-2009 Medical Group Management Association (MGMA) survey implementing an EHR was ranked third in difficulty preceded by rising operating costs and maintaining clinician salaries in the face of decreasing reimbursement.239

Acknowledgement:

We would like to thank Brandy Ziesemer for creating the section on practice management systems.

Appendix 4.1

Stage 1 and 2 Meaningful Use core objectives and measures

Stage 1 Meaningful Use Stage 2 Meaningful Use
Description Goal/Type Description Goal/Type
CPOE: Use Computerized Physician Order Entry (CPOE) for unique patients with at least one medication on their medication list. > 30% of
ordersCore		 Use Computerized Physician Order Entry (CPOE) for medication, laboratory and radiology orders. > 60% of medication
> 30% of Laboratory
> 30% of Radiology/imagingCore

Demographics: Record the following demographics as structured data:

  • Preferred language
  • Gender
  • Race
  • Ethnicity
  • Date of birth
 > 50% of
patientsCore

Record the following demographics as structured data:

  • Preferred language
  • Gender
  • Race
  • Ethnicity
  • Date of birth
 > 80% of
patientsCore

Vital signs: Record and chart changes in vital signs as structured data:

  • Height/length
  • Weight
  • Blood pressure (BP) (age 3+)
  • Calculate and display BMI
  • Plot and display growth charts for children 0–20 years, including BMI
 > 50% of
patientsCore

Record and chart changes in vital signs as structured data:

  • Height/length
  • Weight
  • Blood pressure (BP) (age 3+)
  • Calculate and display BMI
  • Plot and display growth charts for children 0–20 years, including BMI
 > 80% of
patientsCore
Clinical Decision Support: Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule. 1 ruleCore Implement 5 clinical decision support rules relevant to specialty or high clinical priority along with the ability to track compliance with that rule. 5 rules plus
drug-drug interaction
drug allergy interactionCore
Smoking: Record smoking status as structured data for patients 13 years old or older. > 50% of
patientsCore		 Record smoking status as structured data for patients 13 years old or older. > 80% of
patientsCore
Patients by Condition: Generate a list of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. > 1 reportMenu Generate a list of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach. > 1 report*Now a Core Measure
Patient Reminders: Unique patients 65 years and older or 5 years or younger seen with the EHR are sent an appropriate reminder per patient preference for pre-ventative/follow up care. > 20% of
patients
65+ or 5-Menu		 More than 10% of all unique patients who have had two or more office visits with the EP within the previous 24 months are sent a reminder per patient preference, if available. > 10% of
patients*Now a Core Measure
Patient Education: Use CEHRT to identify patient-specific education resources and provide those resources to the patient. > 10% of
patientsMenu		 Use CEHRT to identify patient-specific education resources and provide those resources to the patient. > 10% of
patients*Now a Core Measure
Transitions of Care: Provide a summary record of care for each patient in transition of care or referral. > 50% of
patientsMenu		 Provide a summary record of care for each patient in transition of care or referral. > 50% of
patients
>10% electronically*Now a Core Measure
eRx: Generate and transmit permissible prescriptions electronically for patients whom the EHR was used. > 40% of
prescriptionCore		 Generate and transmit permissible prescriptions electronically for patients whom the EHR was used. > 50% of
prescriptionCore
Medication Reconciliation: Performs medication reconciliation for instances of new patients in care transition or referral. > 50% of
patientsMenu		 Performs medication reconciliation for instances of new patients in care transition or referral. > 50% of
patients*Now a Core Measure
Lab Results: Incorporate clinical lab results into CEHRT as structured data. > 40% of
resultsMenu		 Incorporate clinical lab results into CEHRT as structured data. YesCore
Health Information Protection: Protect privacy and security of electronic health information through appropriate technical capabilities. YesCore Conduct or review security analysis of electronic health information and incorporate a risk management process. YesCore
Patient Portal: Provide patients with the ability to access online, download, and transmit their health information within 4 business days of availability. > 10% of
patients
witin 4 daysMenu		 Provide patients with the ability to access online, download, and transmit their health information within 4 business days of availability. > 50% of
patients
> 5% actually accessing
witin 4 days*Now a Core Measure
Clinical Summaries: Provide patients with a clinical summary within 3 business days. > 50% of
patients
witin 3 daysCore		 Provide patients with a clinical summary within 1 business day. > 50% of
office bisits
witin 1 dayCore
Immunization Registries: Capability to submit electronic data to immunization information systems. YesMenu Capability to successfully submit electronic data to immunization information systems. Yes*Now a Core Measure
Provide patients with secure electronic messaging about relevant health information. > 5% of
patientsCore
Syndromic Surveillance: Capability to submit electronic syndromic surveillance data to public health agencies. > 1 testMenu Successful ongoing submission of elec-tronic syndromic surveillance data from CEHRT to a public health agency. > 1 testMenu
Record electronic notes in patient records. They must be searchable and may contain drawings and other content. > 30% of
patientsMenu
Imaging results, explanations, or any other accompanying information are accessible though CEHRT. > 10% of all
images/resultsMenu
Record patient family health history as structured data. > 20% of
patientsMenu
Successful ongoing submission of cancer cases to a public health central cancer registry from CEHRT to a public health agency. YesMenu
Successful ongoing submission of specific cases (other than cancer) to a public health central cancer registry from CEHRT to a public health agency. YesMenu
Drug Formulary Checks: Implement drug formulary check with access to at least one internal or external drug formulary. YesMenu
Medication Allergy List: Patients have at least one entry or an indication that patient has no known allergies. > 80% of
patientsCore
Medication List: Patients have at least one entry or an indication that patient is not currently prescribed any medications. > 80% of
patientsCore
Problem List: Establish and maintain an up to date problem list of current and active diagnosis recorded as structured data. > 80% of
patientsCore

Appendix 4.2

Proposed Stage 3 Meaningful Use goals (Courtesy Government Health IT)

Functional Goals MU Outcome Goals
All relevant data accessible through EHR.
CDS supports timely, effective, safe, efficient care and prevention.
CDS helps avoid inappropriate care. access to health information.		 Patients receive evidence based care.
Patients are not harmed by their care.
Patients do not receive inappropriate care.
Provide patient and caregivers online access to health information.
Provide ability to contribute information in the record.
Patient preferences recorded and used.		 Patients understand their disease and treatments.
Patients participate in shared decision making.
Patient preferences honored across care teams.
Relevant patient information is shared among healthcare team and patient, especially during transitions.
Goals, care plans, and interventions are shared and tracked.		 All members of a patients care team participate in implementing a coordinated care plan.
Efficient and timely means of defining and reporting on patient populations to identify areas for improvement.
Shared information with public health agencies.		 Providers know the status of their patient’s health.
Bidirectional public health data exchange.
CDS support to avoid duplicative care.
CDS support to avoid unnecessary or inappropriate care.		 Eliminate duplicative testing.
Use cost-effective diagnostic testing and treatment.
Minimize inappropriate care (overuse, underuse, and misuse).
Patient conditions are treated appropriately (e.g age, race, socio-economic status, education, sexual orientation).		 Eliminate gaps in quality of health and healthcare across racial, ethnic, sexual orientation and socioeconomic group.

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