According to the Center for Medicare and Medicaid Services, “An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person’s care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.”
The advantages of using EHR over paper/file based documents are multi-fold. Some of the significant benefits include:
- Improves patient care by limiting human and medical errors, because medical history, allergy, treatment and other information is available over time
- Reduces inefficiencies and improves accuracy and clarity of medical records
- Streamlines the clinician’s workflow and allows them to track patient health over time
- Automates information access and promotes the exchange of information among various entities in the healthcare environment
- Provides direct or indirect support for Clinical Decision Support (CDS), Quality Management and outcomes reporting/management
The US market for EHR systems has witnessed significant growth post the Health Information Technology for Economic and Clinical Health Act (HITECH Act, the Meaningful Use Incentive program, in particular) and is now the largest marketplace for EHRs globally. Under the HITECH Act, the United States Department of Health and Human Services has $25.9 billion to spend to promote and expand the adoption of health information technology. The EHR market is estimated to grow at a rapid pace and reach a staggering $9.3 billion by end of 2015.
Typically, each hospital or hospital chain does not have their own home-grown EHR system, though there are some that do. However, due to the impending penalties for not implementing EHR systems post introduction of the HITECH Act, most of these home-grown systems have been abandoned in favor of implementing one of the myriad EHR systems from an external vendor.
These are very interesting times for the EHR vendors. EHR systems have undergone a dramatic change over the last 10 years and the pace of change has actually accelerated over the last 5 years, especially in the backdrop of meaningful use deadlines.
Some of the major challenges (opportunities too!) which these EHR systems continue to face are:
- Although the year 2013 was dubbed as the “Year of the EHR replacement” by a Black Book survey, the trend is expected to continue well into this year. With this demand backdrop, it was difficult for many small to medium sized EHR vendors to keep up with the pace of change and several others saw this as an opportunity to gain market share. This industry continues to see high levels of consolidation activity in order to support these market dynamics. So much so, that one of the most important factors for EHR vendor selection is the long time viability of the EHR vendor.
- Eligible Professionals (EP) and hospitals must adopt certified EHR technology. Over a period of five years starting from 2011, the meaningful use criteria, measures and objectives are scheduled to evolve in three stages. Each EHR system needs to be certified for every stage.
- The validation of EHR compliance with Meaningful Use is done through certification by the Office of the National Coordinator for Health Information Technology (ONC) Certification Program, based on objectives and measures set by CMS.
- The number of EHR systems which are Stage 2 certified is far less than the number of EHR systems which were Stage 1 certified, indicating the difficulty that the EHR vendors are faced with when developing features to satisfy the Clinical Quality Measures (CQM). It can also point to the fact that significant effort is required to track and follow-up with certification requirements from an EHR vendor’s perspective.
Features to support Meaningful Use Stage 1, Stage 2 and Beyond:
- One of the overall objectives of Meaningful Use is to have common inter-operable data. Healthcare, by its very nature, relies on common terminology and standards (drug, disease, procedures and other concepts) like SNOMED, LOINC, RxNORM, NDC and others to achieve this. The vast array of standards to support the various stages of Meaningful Use Stage is mind-boggling. Starting with the implementation of HL7 v2, HL7 Clinical Document Architecture (CDA) and following coding standards like SNOMED-CT for findings and disease coding, LOINC for lab and ICD 9 CM for disease content has produced a sea change for the EHR systems from the days when they were just transcription systems.
- The features which require support from an EHR System to support Meaningful Use is quite extensive. Some of the challenging ones are: Computerized Physician Order Entry, e-Prescribing and integration to Formulary/Pharmacy systems, Order/Reminder Alerts, Audit Logs, Encryption for local storage, sessions, handling information for patients < 18 years of age, Secured Messaging, Patient Education, Medication reconciliation, Immunization Registries.
Compliance despite making information sharing easier:
- Health Insurance Portability and Accountability Act (HIPAA) sets clear guidelines on who can access medical records of a patient.
- The entire EHR has to be designed so that it does not violate the information sharing principles set by HIPAA, but on the other hand it also needs to make information sharing easier.
- For example, one of the core measures for MUF Stage 2 is “Provide patients the ability to view online, download and transmit their health information within four business days of the information being available to the Eligible Professional.” But this has to be implemented and designed to meet HIPAA guidelines. This means EHR systems having the ability to verify users of the EHR systems, using encryption/hashing algorithms and safe transmission / storage mechanisms which involve quite a bit of development overhead and may compromise ease of use.
Clinical Decision Support Implementation:
- One of the core rules, the CDS implementation can be particularly tricky. The CDS certification is predicated on the ability to support interventions for the following: Problem List, Medication List, Medication Allergy List, Demographics, Laboratory tests and values/results and Vital Signs.
- To implement the above along with the required drug-drug, drug-allergy contraindications frequently means development in conjunction with other Clinical evidence based content providers through HL7 Infobutton standard or other means. This can be a difficult process as this may require development and testing co-ordination.
Support for International Classification of Diseases revision 10 (ICD-10) :
- The U.S. Department of Health and Human Services (HHS) mandated the use of ICD-10 starting Oct 1. 2013. Although delayed for at least a year, the move to mandate support for ICD-10 codes means that the EHR systems would need to be ready for that. This is apart from the process and workflow redesign and training requirements. One particular feature that would also be dependent on content vendors is the HL7v3 Infobutton integration and support for ICD-10 based context rich information retrieval.
Customizing for specialties
- With the arrival of highly customized EHR systems that are targeted specifically for a practice, the generic EHR system vendors face the question of whether to cater to this market and if yes, how so (customized templates, versioning, add-on components are some methods used to customize).
Overall IT changes :
- The overall technology surrounding the healthcare in terms of hardware and software has undergone lots of changes over the last few years. With the change in the usage and acceptance levels of mobile devices/tablets in a hospital setting, conversion to 64 bit OS/hardware and the use of cloud technologies, there are several considerations for the EHR vendors to think about.
Despite these challenges, there also numerous opportunities for EHR system vendors who are able to adapt and adapt quickly.