Is the post-EHR era upon us?
When announcing his company's seismic $1.3 billion acquisition of Siemens Health Services this past summer, Cerner CEO Neal Patterson noted the deal was meant, in part, to help the electronic health record giant chart a course for the "post-meaningful use" era.
Buddying up with a company as broadly skilled as Siemens was meant to be a strategic pivot toward "the next decade," said Patterson. "The alliance we're creating will drive the next generation of innovations that embed information from the EMR inside advanced diagnostic and therapeutic technologies."
Well, perhaps "post-meaningful use" isn't quite the mot juste.
As Mark Segal, chair of the HIMSS Electronic Health Record Association, reminds us: "Meaningful use is forever."
Sure, it eventually switches from incentives to penalties. But unless and until the law is changed, "it doesn't sunset. That doesn't mean it can't, but it's not written to," says Segal.
Or then again: Perhaps it may be over sooner than anyone thought?
Upon hearing of the Centers for Medicare & Medicaid Services' August Stage 2 rule change – ostensibly meant to offer more flexibility, but also requiring 365 days of EHR reporting in 2015 – CHIME CEO Russell Branzell struck an apocalyptic tone.
Upon learning of the rules newly-onerous requirement, one commenter on HealthcareITNews.com was more willing to put it definitively: "Lets all take a deep breath, and say it: Meaningful use is dead. Now is the time to figure out what to do next."
Whether or not there's any such thing as a "post-meaningful use" era, there's been plenty of discussion recently of a "post-EHR era" – one in which, with the basic commodity of electronic health records now in place and in use, the technology can evolve and improve: better usability and design, mobile device interfaces, more seamless interoperability.
The EHRs of the future will be more intuitively designed to support new models of care delivery and payment, observers say. They'll be souped up with analytics capabilities, able to digest consumer-generated data from Fitbits and Jawbones, robust enough to handle a flood of genomics data and translate that into finely personalized clinical decision support.
One day – sooner, or later – the attestation deadlines for meaningful use will be but a memory. But EHRs will still be in place, and, hopefully, much-evolved from their current form, helping deliver care in new, innovative and more effective ways.
This summer, the U.S. Department of Health and Human Services touted new data from the Office of the National Coordinator for Health IT that found "significant increases in the use of electronic health records."
A pair of studies, published in Health Affairs, showed how, by 2013, some 78 percent of office-based physicians had adopted some type of EHR system – and about 48 percent were using EHRs with advanced functionalities. Meanwhile, 59 percent of hospitals had "adopted an EHR system with certain advanced functionalities in 2013, quadruple the percentage for 2010."
So there you have it: By those metrics, Stage 1 meaningful use has been a smashing success. EHRs have been adopted, implemented and are now widely in use, all in just the past five years. Moreover, more and more providers are using systems designed for more than just basic record keeping.
"Patients are seeing the benefits of health IT as a result of the significant strides that have been made in the adoption and meaningful use of electronic health records," said National Coordinator Karen DeSalvo, MD, in a press statement celebrating the results.
Still, she acknowledged, there was plenty of work yet to be done, most notably on interoperability. Stage 1 may have been a relative cakewalk, but Stage 2, as we've seen, has so far been anything but.
"We look forward to working with our partners to ensure that people's digital health information follows them across the care continuum so it will be there when it matters most," said DeSalvo.
As John Halamka, MD, chief information officer of Boston's Beth Israel Deaconess Medical Center was quoted across the Twittersphere after a briefing on those adoption numbers: "EHRs are bi-planes, not yet jet aircraft."
Indeed, John Glaser, CEO of Siemens Health Services – and, back when he was CIO of Partners HealthCare, Halamka's cross-town counterpart – echoed those sentiments in an August interview with Healthcare IT News.
Asked for his thoughts on the "post-EHR era," Glaser said, "I'd be a little careful with the 'post' word. Because there are a lot of EHRs in place that are not used as well as they should be. The technology has been installed, but the organization hasn't leveraged it as well as they should to reengineer their processes and improve care."
While there's a point "at which you shift from installing the technology to really making it work, and work well," he said, too many providers are still not there yet. "So, better to say 'post-installation,' for lack of a better word."
Despite the encouraging uptake numbers, DeSalvo too seems to recognize that most back-patting should be delayed until EHRs are a universal currency. "The policy goal is for everybody to come along and for us to not leave anybody behind, and that includes those served by rural and critical access hospitals," she told Politico.
Nonetheless, it's hard to argue that for the majority of providers, inpatient and outpatient, EHRs are here to stay: widely-used, and almost taken for granted.
A tossed-off turn of phrase in the recent HIMSS Analytics Ambulatory Practice Management and Electronic Health Record study seems to bring that point home: Once so exotic, perhaps even frightening, to physicians, EHRs are now seen as "standard business tools," according to the report.
So now what?
If Mark Segal disagrees with the notion of post-MU, he does think the landscape is shifting – and could, a few years down the road, start to get truly exciting.
"I think what we're looking at right now is not so much a post-meaningful use, but an evolved meaningful use," says Segal, who, in addition to chairing the EHR Association, is vice president of government and industry affairs at GE Healthcare IT.
"Our customers are facing so many new initiatives, in the public and private sector, other than meaningful use," he explains. "You've got the Comprehensive Primary Care Initiative. You've got Shared Savings ACOs. You've got bundled payments. So if you think about the environment that our customers have to operate in, and where they need healthcare IT to help them, it's beyond meaningful use."
That's necessarily going to require some EHR horsepower beyond what most systems are currently able to provide.
"I don't have a crystal ball, but I don't see us being in a post-EHR world as much as an evolved EHR world," says Segal. "If you look at some of the definitions of EHRs, some of the distinctions are (akin to) 'how many angels can dance on the head of a pin' – what's an EHR, what's an EMR, etc."
Increasingly, he says, "I think we'll be looking at a world where the EHR, from the standpoint of the clinician and the patient, actually lives in multiple solutions. In other words, some of the information that's relevant to a patient will be in a solution that's marketed as a certified EHR. Or it will reside in multiple EHR products, across different physician, hospital and post-acute settings. Or in a patient portal, or in an imaging information system. Increasingly, those will be interoperable."
From the patient's point of view, this seamlessly-linked aggregation of data would essentially "become their EHR – their longitudinal electronic health record," says Segal.
That idea was echoed early this year in an IDC report titled "IT Priorities for the Post-EHR Era." It won't be long, IDC Research Director Judy Hanover told Healthcare IT News, before the EHR is "just another" app in a larger technology space.
As "larger organizations that have been successful with EHRs" start "maturing and moving on to the next step," said Hanover, they're casting a broader view of what clinical IT can accomplish.
They're looking for "infrastructure and platform options that will help augment functionality, perhaps to go beyond what's available from the basic EHR in order to meet the needs of their workflow and how that's changed with accountable care," she said. "They're looking at storage environments that start to centralize and organize clinical and imaging data. They're pulling away from an EHR application-centered focus and looking at the broader IT ecosystem."
Still, there's a long way to go before that approach takes hold industry-wide – at least as long as providers are trying, by hook or by crook, to meet the many mandates of meaningful use.
"For the foreseeable future we will continue to see products that are developed, marketed and labeled as electronic health records," says Segal. "In part because of meaningful use certification, and in part because, for now, that's something the market looks for."
Soon, though, he says those market demands will mature. "Functionality and data will be added to products that we think of, are developed and marketed as, EHRs: analytics, population health management, some aspects of genomics."
Similarly, "I think we're looking at a world where there will be more collection of data from various kinds of traditional devices, through standards-based interfaces and through various types of patient and consumer devices like Fitbits – and things we can't even imagine," he says.
Will vendors have much more latitude to innovate – perhaps even to offer providers capabilities they weren't even aware they wanted – once they're able to stop spending all their time and resources trying to meet meaningful use certification criteria?
"I think absolutely yes," says Segal. "CMS has stated that Stage 3 will be the last stage. And we're also hoping that ONC will not continue adding certification requirements. But I think basically we anticipate that developers will have more resources and more space to focus on market-driven product enhancements."
EHRA's vendor members "all serve different customer segments, by size, by geography, by specialty," he says. "We'll have more resources to do what our customers are asking us for. To put more resources into things like usability. And, ultimately, what we all really want to do, which is to delight our customers."
Post-meaningful use – or at least post-Stage 3 – "we absolutely think there will me more space to do that: To innovate, to take advantage of evolving technologies like cloud and mobile platforms, in new and emerging usability tools and frameworks," says Segal. "And then to compete against each other, using that competition to discover the best ways to do things."
Another boon for EHR creativity in the coming years is that the customer – the end-user, the physician, nurse or clinician – is now so much more sophisticated and familiarized with these tools than before meaningful use began.
"We are looking right now at a much more digital environment than we were five years ago," he says. "If you look at the adoption numbers for physician and hospital EHRs, the number of folks who are using these systems, the amount of data that's digitized, the networks that are available for exchange, it's just much bigger than it was three to five years ago, and that will be what our customers are looking for.
"I think our customers are really going to be expecting us to be even more responsive to their requests, particularly as more resources become available as meaningful use demands reduce, he says.
Among the areas he sees a pent-up demand: usability, more seamless interoperability, and a new "a emphasis on mobile connections to various devices and their core systems," says Segal. "Something that often doesn't get talked about very much is support for new payment and delivery models, whether it's value-based payment or ACOs or patient-centered medical home. And I guess finally – and this is critical table-stakes – is doing all this with very strong, incredible security and privacy."
The coming data deluge
Beyond rigorous data protection and intuitive usability, this generation of clinicians, having grown so used to their smartphones, lightning-fast laptops and social media apps, "want their IT experience to resemble their IT experience in their personal life," says Segal.
Increasingly, their IT experience may soon be much more reflective of the personal IT experience of their patients. With technology evolving at an incredible pace – gadgets, sensors, the Internet of Things, the Quantified Self – most EHRs are still relatively simplistic record-keeping tools.
As David Lee Scher, MD, an electrophysiologist and medical technology blogger wrote recently, "The EHR does not represent the face of digital technology in healthcare. Mobile health technologies, wearable sensor technologies, aging at home technologies, and ingestible medication sensor technology populate today's digital health landscape."
Increasingly, those technologies are going to be brought to bear on care delivery, and the EHR is going to have to reckon with many of them.
"We are at the dawn of a health data revolution," writes Drew A. Harris, director of the health policy program at Jefferson School of Population Health. Thanks to a galaxy of gadgets, apps and wearable technology, "our vital functions are fully tracked and reported, each of us will generate more data in a few minutes than our great-grandparents did in a lifetime."
"Emerging technologies such as genomics (your genes), proteomics (the proteins genes make), microbiomics (the colonies of bacteria essential to bodily functions), transcriptomics (RNA) and connectomics (neural connections) will generate terabytes of clinically significant data," wrote Harris.
Together with the plethora of constantly updated digits that comprise the quantified self, it all adds up to "an analytic nightmare," Harris writes. "Facebook, Google and Amazon can do more with your posts, searches and purchases to predict your future actions than the typical EHR can do to predict what diseases you will get."
Nonetheless, EHRs and other clinical systems are finally starting to catch up. And more data feeds into them, and as analytics get smarter with the help of technologies like IBM's Watson, he predicts the emergence of a new species of health data analyst: "These experts will work directly with the care team to analyze trends, merge disparate datasets, and develop better clinical interfaces to ensure health-related data points are turned into information and action."
There's been a lot of excited discussion lately about Apple's forthcoming, heavily-rumored HealthKit technology, for which the company has been working alongside EHR vendors Epic and Allscripts – and blue-chip provider organizations Cleveland Clinic and Johns Hopkins.
As of this writing, the app itself has not been officially unveiled, but early scuttlebutt suggested that at least one of the features would enable Epic customers to flow wellness data from HealthKit directly into Epic's MyChart, personal health record.
"Apple is going into this space with a data play," Forrester Research analyst Skip Snow told Reuters. "They want to be a hub of health data."
MyChart is a consumer-facing record, though. How far off are we from seeing data about our daily jogs and sleep patterns fed directly into the clinician facing EHR? Not so fast, says Mark Sullivan, writing – in an article titled, "Guess what? Doctors don't care about your Fitbit data" – on VentureBeat.
Never mind the fact that few clinicians have the time or resources to manage another constant stream of biometrics – let alone keep it all safe and secure – there's the bigger issue of the "quality of the data coming from consumer wearables."
"In order for the data from your Fuelband to matter clinically, it would have to flow securely into the electronic health record used (by) the clinic and/or hospital," he writes. "And in the cases of Apple's and Samsung's platforms that means the Epic electronic health record.
"Epic has proven to be very pragmatic and non-progressive when it comes to data sharing. So is Epic really a company that's likely to work hard to collect consumer biometrics data, crunch it, and display it in the EHR in a way that doctors can easily understand and use? It's easy to find people in the industry who have serious doubts."
Time will tell what the real impact of the consumer data revolution will be on EHRs. In the meantime, the systems are starting to evolve in more practical ways to meet the needs of their clients.
In August, for instance, Greenway announced that it had received a new patent for "clinically driven revenue cycle management" – a function in PrimeSUITE, its practice management and EHR, that automatically aligns billing codes with payer- and location-specific fee schedules.
With this "location-driven bill coding," PrimeSUITE populates the EHR with the patient's payment method and the provider's geographic location. When certain data is plugged into the EHR, PrimeSUITE assigns an allowed service cost consistent with the payer fee schedule for that provider's location.
The functionality is meant to help providers navigate "the growing complexity of payer models, including variations among payers and U.S. regions," said Greenway CEO Tee Green, in a press statement. Greenway officials note that the innovation points to "yet another way in which the data collected in EHRs can deliver tremendous value."
Another evolution is happening with data exchanges – with more and more EHR developers deciding to embed HIE tools directly into their software workflows.
"Increasingly, vendors are fueling the demand from providers to come up with health information exchange solutions," Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, told Healthcare IT News in September.
"They're saying, 'If my providers are demanding health information exchange, I'm going to come up with health information exchange solutions,'" he added. "But I'm not going to assume there's going to be a nationwide network of health information exchange organizations that I'm going to have to rely on in order to interoperate with other providers or vendor systems in this community.'"
The next couple years will be interesting to watch as the demands of the healthcare marketplace evolve – perhaps differently in some regions, compared to others – and the technology does too.
"I think we're looking at a world where the health IT will be a lot more modular," says Mark Segal. "It will be more and more resembling what we see with apps. And I think we'll also be increasingly looking at a world where we'll have specialized health IT – a population health management application, an analytics package – that will integrate either tightly or loosely with sort of a core EHR."
It's happening already, of course. In August, our sister publication, Medical Practice Insider, spotlighted seven add-ons that can be integrated with an existing ambulatory EHR system to enhance its performance in specific areas. These include apps that offer speech recognition capabilities, the ability to access cross-speciality images and even help with transferring clinical data for patient referrals.
Give the providers what they want
When we spoke with Maria Ryan, RN, CEO of Cottage Hospital, a 25-bed critical access facility based in rural New Hampshire, about how her hospital was able to successfully attest to Stage 2, we asked her to weigh in with a wish list for what EHRs might feature as they evolve over the next few years.
"You can't see me," she said over the phone, "but I have the biggest smile on my face. I've always known what I've wanted."
Having been in the business a long time, "I've seen how clinical people struggle," Ryan said. "Nurses, doctors, everybody. All of them talk about time away from the patient, how much more time it takes to be on the computer.
"I've always envisioned, sort of like Star Trek, this thing on a lapel," she said. "When you go into a patient – 'Hi Mrs. Smith, yes you were admitted yesterday with pneumonia, this is the antibiotic you received, let me listen to your lungs ... they're clear' – that would automatically go into the note."
"Of course you'd have to proof it and sign off on it," said Ryan. "But any clinician – doctor, nurse, respiratory therapist, anyone – can see a clinical picture of the patient, quickly and integrated: I can see that the nurse did her or his assessment in the past 24 hours, or how far the patient walked that day. Everything is quick and integrated. Ease of use, and much more voice recognition – I think that's the wave of the future.
For her part, Rebecca Weber, CIO of Neptune, N.J.-based Meridian Health, wants to see better biomedical integration with EHRs.
"It's happening, but not significantly," she says. "As we move forward with technology and genomics, the efficacy of certain drugs on an individual – those are going to be the types of things we're going to be looking at."
As Weber sees it, "the EMR is going to be more of a feeder system, into research and proper treatment of the patient, which is done at a higher level. To say that, if you have a patient and their XYZ levels are in this criteria and their pathology is this, then this medication is better if their genetics are within here.
"We're going to learn so much from this data," she adds. "I really see the future of EHRs being the foundation for us to learn more about the human body, and the ways we can treat the patients. I believe in the future a lot of this is going to relate to advancements in medicine and how you treat a patient with these genetics, this age, this type of pathology.
"That's where I see EHRs going," says Weber. "Not just to collect this, that or the other but to collect all the details and bring them up so we can understand why this CHF patient is different from this one, and how they can be treated, maybe differently, based on particular biomarkers they may have. EHRs will be feeder systems to our our growing knowledge."
When Healthcare IT News interviewed Siemens' John Glaser in the days after his company merged with Cerner, he was excited about the future. Already, he was looking to a not-too-distant point on the horizon where EHRs as we know them now are just a memory, not unlike the floppy disk or the dial up modem.
"We see this across industries and across time – that the technologies you put in place today, over the course of 10 years, become obsolete, or are certainly overtaken by new, cool, much more potent stuff," said Glaser.
Looking ahead, he sees "waves of replacements, because the technologies will just offer more opportunities," in areas such as population health and care coordination.
"So there's a series of waves coming: a revenue cycle wave, a population health management wave," he says. "But also next-generation of EHR wave that is probably a couple years out but coming nonetheless."
What will that look like? "You might have an EHR installed, but the underpinnings, and the way it's put together, are really different," Glaser posits. "In a lot of ways it will look the same: I can still write a prescription, look up results – those are core, atomic capabilities that will still be there."
But beyond that, he foresees some fundamental changes coming down the pike.
EHRs "will be much more intelligent," says Glaser. "I was a CIO for a bazillion years and have put in a lot of EHRs, and fundamentally it's a form of transaction: write a prescription, retrieve the results, document care."
But increasingly, "we're going to surround that transaction and that data with intelligence," he says.
"We'll see a range of these things: decision support; workflow engines, predictive algorithms; logic that looks at EHR data and cleans it up so it stays consistent; advanced diagnostic technology which takes in image, molecular medicine data and EHR data; intelligence that brings in stuff from your device to my device. At the service level it will be very similar to now, but deep in the interface it will be quite different."