In the 1990s, the Institute of Medicine’s Computer-based Patient Record (CPR) committee defined the CPR as an “electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids.” This committee and definition set into motion what we now know today as Electronic Medical Records (EMR).
An Electronic Health Record (EHR) is a logical extension of an EMR as the EHR goes beyond a single healthcare organization collecting and compiling patient data. The EHR operates in both the acute care and the ambulatory domain.
Early adopters in both domains saw EMRs as a way to solve business problems. However, the EMR or EHR struggled to gain traction because these operational initiatives lacked funding, resources and vendor support. Vendor product design was written by software programmers and the transformed workflow was dictated by the vendors. Clunky technology and the dichotomy between vendor design and the actual clinical workflow led to less than optimum adoption and great frustration.
However, all this changed when EHR systems were mandated during the Bill Clinton and George W. Bush administrations. The EMR/EHR gained velocity in meaningful deployment and adoption continues to grow as the federal deadline of 2015 nears. Financial incentives to the tune of $15 billion and enabling technologies for eVisits, medication adherence and clinical support gave the EMR initiative a much needed boost. Physician use of EMR/EHR systems increased from 18 percent in 2001 to 57 percent in 2011, with a reported 2 out of 3 patients willing to consider switching to a physician who offers access to medical records through a secure connection.
These glowing statistics do not call for cheering. Even though IT has enabled the changes, cost savings fall below expectations. EHR implementation is not a one-time event, but rather a series of change events that call for an implementation model of governance, workflow management, regulatory compliance and vendor optimization are key factors in changing end user behavior. The underlying stack is technology which supports clinical workflows, monitors patients remotely and engages them in their plans, and mobility for access. The goal should be to harness the power of technology to manage unstructured patient data and to improve clinical documentation.
Reliability of data must be assured without fear of lawsuits and make fraudulent billing difficult, if not impossible. These goals can be achieved by good documentation and good workflow. In fact, if properly designed and the “copy/ paste” function disallowed, an EMR/ EHR can improve the required, appropriate documentation for correct and accurate billing.
Vendors and implementers are equal partners. Good code and good design are equally important. Good testing is a product of the computing environment. Implementers are responsible for finding flaws and the vendor is responsible for fixing them.
In this ever-changing landscape, new challenges for EHR include new economic healthcare delivery models, such as Accountable Care Organizations, value based purchasing and pay for performance.
Ambulatory and acute care domains have not evolved in tandem for optimization of the EHR initiative. Typically, an IT organization is not involved in an ambulatory system implementation. The lack of IT expertise has created a vacuum. Meaningful use quality parameters measure performance in care delivery for ambulatory and acute care settings. Healthcare Effectiveness Data and Information Set, (HEDIS) measures performance on care delivery in the ambulatory settings. These quality metrics are inconsistent and not equivalent. Governing agencies must address this gap.
Unless the government steps in and forces the vendors to use standards, solutions that are platform agnostic and clinical software that can talk to each other, technology’s long term success in changing end user behavior will fall below expectations. Time is not on our side. EHR is more an ethical imperative and less a business imperative. Governing agencies must recognize this and help healthcare to align to this focus.