Building off a solid foundation

EMRs enter a new era, as hospitals invest in more advanced capabilities
By Mike Miliard
12:00 AM

The latest edition of HIMSS Analytics' "Essentials of the U.S. Hospital IT Market" has some interesting things to say about where the American healthcare system stands with regard its long and complicated relationship with technology.

Electronic medical records are by now well-ensconced at hospitals large and small. Now the focus is shifting to other IT capabilities that can augment mere note-keeping capabilities – enabling broader consumer engagement, leveraging data for more efficiencies and interfacing with diagnostic tools.

With EMR systems more or less in place, the growth areas nowadays have to do with outward-facing patient portals, data mining and radiology applications, the January 2014 report shows.

In examining the variety of IT applications that are and aren't installed  at the 5,437 hospitals tracked by HIMSS Analytics’ Electronic Medical Record Adoption Model, HIMSS found that first-time purchases of more advanced EMR apps like those, and others such as 3D imaging and clinical business intelligence, are on the rise.

More "foundational" technologies, meanwhile – lab information systems, pharmacy management, CPOE – have entered an era of saturation.
From Stage 2 meaningful use to payment reform and accountable care to an ongoing focus on patient safety, hospitals are moving beyond an era of EMRs as basic clinical tools, and looking toward a future where they're put to work transforming care.

"We are continuing to mature," says John Hoyt, executive vice president of HIMSS Analytics.

The long engagement

Especially notable is the coming-of-age of the patient portal. Its emergence as a priority for hospitals is driven by two factors, says Hoyt.

"One, it's the right thing to do," he says. "And we're getting to see some evidence that patient engagement is a major driver for chronic disease management improvement."

The other, not insignificantly, is that "meaningful use Stage 2 calls for this."

Patient portals are "not an expensive, complex thing," says Hoyt.

The challenge lies in the fact that complying with Stage 2 rules is, to a large extent, out of hospitals' hands. Not only do the regs require them to offer 50 percent of their patients access to their health record via a portal, but 5 percent of patients actually have to use it.

"It's a tough standard, 5 percent of patients," says Hoyt. "And that's not an average for your enterprise, it's on a per-practitioner basis. That's hard."

That's why it's incumbent on hospitals to make outreach, education and awareness – about the existence and value of the portals – a top priority.

On their HIMSS Analytics visits to verify Stage 7 EMRAM hospitals, they run-down a checklist to make sure hospitals are doing that, says Hoyt: "When you register a patient are you also registering them in the portal? Are you giving them a sign-on? How are you managing this?"

Hospitals are making use of different types of portals. Most use vendor developed products, such as Epic's MyChart. But "there's another that we see once in a while, and it's vendor neutral," says Hoyt.

He recalls an IT professional at one health system who told him, "'We want to be like the ATM machine: We'll take cards from any other bank. We're building a patient portal and we're going to reach out in our service area' – which was two states for them – 'and bring in the major providers and hook them into the patient portal.' That's pretty aggressive."

The benefits are clear: "A more comprehensive view. If you're a very sick patient going to multiple providers from maybe multiple health systems, you get one view this way."

In and out

Indeed, another sort of "comprehensive view" – between hospital and ambulatory EMRs – is one of the biggest priorities for hospitals nowadays: "the need for continuity of care electronically, making sure my outpatient and inpatient are as seamless as possible," says Hoyt.

There are two ways of doing this, of course. "Either I choose one vendor for both –Epic, Cerner and Meditech, or I do a lot of serious interfacing."
The latter choice is "becoming less prominent."

The drive toward accountable care has hastened the need for one record, ambulatory and inpatient together, that can therefore drive down cost through reductions of examinations and redundant testing, he says: "Medicare is tired of paying in silos. That's the move, we all know it. You'd better be able to do it. Or you're going to lose money."

Not long ago, in an interview with Healthcare IT News, Piper Jaffray analyst Sean Wieland dubbed Epic and Cerner "the Coke and Pepsi of this market."

There's no question that the past five years or so have seen each making huge strides among some big-name hospitals and health systems.

"I agree that it's become a two-horse race," says Hoyt.

Still, he said, "We have to keep in mind that Meditech, in terms of its footprint, is bigger than those two guys." Even though large-system EMRs are largely falling into one of two bins, its focus on smaller community hospitals mean "there are more hospitals running Meditech than Cerner or Epic."

At the same time, "that also tells us that Meditech is vulnerable, because small hospitals are getting bought," says Hoyt. "They're bought by someone running Cerner or Epic and they rip out Meditech."

For his part, Weiland said he liked the idea the hospital EMR market now belongs, more or less, to two major players.

Whereas before, when the market was more fragmented, Epic and Cerner had to spend lots of money fending off competitors, he explained. "Now what we have is a more concentrated marketshare, so these companies invest the appropriate amount of money in research and development to drive innovation," he says.
Hoyt isn't so sure he agrees. "I like competition and innovation," he said. "And I have heard some CIOs say we need more competition."

Could a third player enter the scene and compete on Epic and Cerner's turf? Probably not any time soon.

"I think it's not realistic in the U.S." he said. "Let's say a third vendor came in, maybe from Europe or Asia. Good luck. There's not that many big sales left."
Outside the U.S., that's where opportunity lies for EMR vendors looking to make big inroads among hospitals. Canada, for instance, is an opportunity: "They're not very far along in EMR adoption."

Asia, with all its economic growth, is also a hot market. "I think you will see a lot more vendors coming out of Asia," says Hoyt. He points out that Dubai Health Authority "just shocked a lot of folks and selected Samsung for their EMR. We scratched our heads: Really? Samsung? They're in this business?"

Here on the home front, the priorities for hospitals seem clear: keep abreast of the clinical realities within their walls and the new technologies they require; make outreach to patients a top goal; and continue the work toward a continuum of care, with one patient record for ambulatory and inpatient.

After all, it's essential, in this new era of accountability and shared risk, "that the hospital or the enterprise that signed up to become an ACO is in an economic position to understand all the care that's being consumed," says Hoyt. "That's the key thing."