Recently, through a class “The Internet and the Future of Patient Care” I am taking online at UC Davis on Informatics, I was introduced to the virtual reality site Second Life (http://www.SecondLife.com) The site was developed by a company called Linden Labs and has been up and running on the Internet since 2003. To interact on the site users must set up an account, which is free and become a “Resident.” Users must also download some client software necessary to interact inside the site, known as the “grid.” As part of the setup, users must chose an Avitar (an Avitar is computer image used to represent the user in the action on the screen) to represent themselves. Residents can explore, walk, run, fly, or transport themselves to the places in Second Life. Along the way Avitars meet other residents Avitars, socialize, and participate in activates as an individual and or also engage in group activities, and even buy, create and trade virtual property.
Part of the user interface includes menu and keystroke accessed software tools for building geometric objects that can be endowed with a myriad of attributes. There is also a scripting language that can be used to manipulate various aspects of the environment.
One of the most interesting aspects of this site is that it can be regarded, treated and used as a game for entertainment or simple amusement, but it can and is also being used as an amazing and powerful “tool” for accomplishing a wide array of real life tasks, with physical reality value.
The purpose of using the site for my UC Davis Informatics class is to demonstrate and teach about how the site is being used to provide diagnostic, treatment and informational services for people, in fact patients, needing various health care services in an alternative way. While a virtual reality experience cannot replace face to face clinical care for treating patients who require physical intervention to address their injury or disease, and obviously medication cannot be dispensed virtually, the virtual clinic or virtual health care provider can perform many valuable functions. Presently, Doctor, Physician’s Assistant, Nurse Practitioners, etc Avitars can interactively, in real time interact with patients. They can answer questions, provide detailed basic information and direct patients to information sites on the Internet - an amazing feature in Second Life is the ability for Avitars to interact real time with the real World Wide Web, through virtual browsers, in real time.
So, while this virtual clinical environment can be used to great advantage presently, in the near future through additional, yet to be developed interfaces, the capabilities of the virtual environments will be extended even further. Through real data interfaces to telemedical instruments Avitars will be able to take actual vital readings from a real patient being represented virtually in the online environment. This is another approach to telemedicine that will facilitate an added dimension of patient interaction and care delivery that has some advantages over the present conventional view of telemedicine. For instance, the patient may be more willing to disclose intimate information about a condition such as STD’s that the patient might be less inclined to disclose in a face to face encounter with a health care provider.
Further, implementation of future features for things like, medical training; mental health treatment, disease diagnosis, public health issue management and etc are as boundless as our imaginations. There is real value being derived already through these virtual worlds, but the possibilities for the future are truly exciting. If you haven’t experienced a virtual world before now, all I can say is you are missing out on an amazing experience.
Thursday, March 25, 2010
Monday, March 22, 2010
Understanding the Health Care Bill Overhaul
If enacted, the reconciliation bill combined with the Senate-passed bill would, from 2010-2019: -Spend $938 billion on expanding insurance coverage, including $464 billion in subsidies to help uninsured people buy coverage. -Expand Medicaid coverage to 16 million additional people. -Require many employers to offer coverage for their workers. -Collect $69 billion in penalties from uninsured individuals and employers for non-coverage. -Provide coverage through an insurance exchange to 24 million people. -Reduce the number of uninsured by 32 million people, but leave 23 million (including illegal immigrants) not covered. -Cut Medicare spending by $455 billion from currently-projected levels. -Not affect next month’s scheduled 21 percent cut in payment rates to doctors who treat Medicare patients. -Produce a net reduction in federal deficits of $143 billion.
Sunday, March 21, 2010
The Future of Health Care on the Internet and the Use of Personal Health Information Portals
Introduction
One of the most interesting and promising uses of the Internet in the health care arena is the prospect of broad adoption and use of one of the many available sources of applications/portals/websites for storing, managing, sharing and using personal health information, i.e. Personal Health Records or PHR. Internet juggernauts Google and Microsoft in addition to several others have launched feature rich Internet portals that allow individuals to collect manage and use their personal health information by and health care professionals. These sites go way beyond a static record file and are so much more than just repositories for historical medical data. The goal of these applications is to provide a comprehensive set of tools and features to improve users’ quality of life in addition keeping an information trail of medical history. And in the case of Microsoft and Google in particular, these sites, for now, are free or inexpensive to personal users.
Four Selected Providers
Microsoft’s Health Vault (free)
HealthVault is an Internet application website offered by Microsoft for storing and maintaining and sharing health and fitness information. The site was launched in October 2007 and is located on- line at http://www.healthvault.com. The site is intended to not only provide access and value to the individuals maintaining the records but also to health care service provider professionals at the information owners discretion and direction.
Google Health (free)
Google Health, http://health.google.com, provides an on-line web portal that allows one to organize in one place, all their health information. There are tools and features that assist in assembling medical records from doctors, hospital and pharmacies. Additionally there are tools to allow sharing of information with family members, physicians or other caregivers.
Dossia (Available to qualifying members only)
Dossia is a Web-based application for storing and managing personal health records (PHR). Unlike Google Health and Health Vault, Dossia, is not available to the public at large. Dossia is the product offering of an independent, non-profit organization known as the Dossia Founders Group.
Users have to be qualified. Presently, Dossia use is only offered only to employees, dependents and retirees of AT&T, Applied Materials, BP America, Inc., Intel Corporation, Pitney Bowes, Cardinal Health, Sanofi-Aventis and Wal-Mart, the Dossia group's founding companies.
Users have the ability to aggregate medical data, claims information from insurance companies and also pharmacy records. Dossia records are stored in a private, encrypted electronic health record hosted in a modified open-source database called “Indivo” that can be accessed over the Internet using a secure connection.
MyHealthArchive Ultimate (modest subscription fee)
MyHealthArchive is a subscription based web portal PHR application. For $9.98 per month, subscribers get access to what the developers call a “revolutionary tool which gives patients the power to collect their own health information and then access it using a secured website, anytime, anywhere in the world.” The application facilitates managing health and wellness for the customer.
Features
The applications currently available have an impressive array of features and benefits already and we can only expect that over time the applications will improve in terms of usability and functionality.In terms of current features below is a partial listing:
· Comprehensive medical record aggregation
· User configurable presentation of the user interface
· Secure access
· Control over with whom data will be shared
· Accessibility over the Internet
· Guided wizards and or comprehensive user help information
· Print, email or fax all or parts of records
· Tools to help plan visits to physicians or other care providers
· Wellness information, preventative advice and health information libraries
· Personal health goal planning, calendars and progress tracking
· Interfaces with biometric tools such as glucose testers, heart rate monitors and other fitness products
· Tools for managing medication regimens
Interoperability
One of the most poignant and problematic issues in health care today is the interoperability of the myriad of diverse systems in use by all of the stakeholders in the heath care arena that optimally will share data. Because there is and likely will continue to be a broad array of health care applications for managing health record information, the data formats, document taxonomies, networking protocols and data interchange formats will continue to be complex and significant issues. The notion of “one source of truth” for a patient’s medical information and history is likely a distant if ever achievable goal. Much data will be shared undoubtedly. The risk of problems as a result of data being passed from one system to another is significant and much effort will continue to be expended to insure the accuracy of the data will be required for the foreseeable future.
Societal Benefits
In addition to the significant, obvious and exciting benefits to be gleaned at a personal level from the broad adoption and deployment of Personal Health Information (PHI) systems, there are also potentially spectacular things that can also be accomplished in the area of public health management if scrubbed (meaning concealing or protecting the privacy rights and concerns of the individuals) PHI data can be aggregated for study, analysis, data mining and other use by public health management professionals and medical researchers. The potential benefits and advances that can be made as a result of this type of a data source being made available cannot be underestimated – it will be game changing in terms of the strides that can be made in managing health concerns at a societal level.
Barriers to Broad Adpotion
While the potential benefits to individuals and to society as a whole are legion, there remain many barriers and obstacles to achieving broad adoption of PHR/PHI systems. Some of those include:
· Lack of time
o Collecting and managing the amount of data that will constitute the complete comprehensive health record for an individual or a family will be a formidable task. Time is the enemy in modern life. The demands on our time are already limiting in terms of what we can accomplish in our lives – one more – enormous task will overwhelm most. Likely, the majority of people will attempt to collect and manage only the information that they deem most important for the present level of concern about health issues.
· Fear of security and privacy issues
o Many people, with good reason, will be suspicions of any on-line, public network, aggregation of PHI information especially when the service is provided at no direct charge to the individual. This will cause many to not participate voluntarily.
· Complexity
o This may be partially a generational issue. Many people will not find the on-line applications user friendly, intuitive or understandable.
· Data input errors
o Problems with data and or functionality with the system(s) may lead some users to not use or to stop using the systems. Especially in the case where a data or system error leads to a significant personal problem.
· Terminology
o Medical terminology and medical descriptions can be incomprehensible or too challenging for some people. A user friendly, “lingua franca” may not be achievable. If people don’t find the information ineligible or meaningful their rate of adoption and perception of value will be much lower.
Risks
In addition to the visceral apprehension expressed by some, there are real risks in putting sensitive personal information into a data repository that is accessible from the public network. While all of the providers are cognizant of the risks, have engineered to minimize them and purport to have them in hand and well managed[i], it is well known that risk of human or machine error and or accidental or intentional disclosure cannot be completely eliminated. While HIPPA and other compliance rules may not apply to all of the potential players in this space, there are those potential participants, i.e. health care service providers that have legitimate potential liabilities that have to be assumed, managed or still eliminated. Then there are all of the usual systemic risks that come as a result of using electronic data automation. Besides unauthorized access and inappropriate disclosure, loss of data by error, system failure or break down, corruption of data, and logic errors are all potential risks and problems that come with any electronic data strategy.
Future
The promise and potential value of personal health record systems is great. The real value and the tremendous benefits are yet to be realized and but the enormous potential of a feature rich database application with this level of detail is truly exciting. There is much work to be done as of yet and the real keys to achieving a tipping point in terms of ubiquitous use and adoption is yet to be fully understood and articulated. As is the case with clinical setting electronic record systems, part of the barrier is the labor and time required to create the records. Just as this aspect of EMR and EHR systems needs to be improved it is also true of PHR /PHI systems. Ease of access and data input methodologies are improving continuously and have been enhanced and improved recently by advances made in the mobile computing arena.
[i] Google’s claims “[Google]… stores your information securely and privately, but you always control how it's used. We will never sell your data. You are in control. You choose what you want to share and what you want to keep private. View our privacy policy to learn more.”
One of the most interesting and promising uses of the Internet in the health care arena is the prospect of broad adoption and use of one of the many available sources of applications/portals/websites for storing, managing, sharing and using personal health information, i.e. Personal Health Records or PHR. Internet juggernauts Google and Microsoft in addition to several others have launched feature rich Internet portals that allow individuals to collect manage and use their personal health information by and health care professionals. These sites go way beyond a static record file and are so much more than just repositories for historical medical data. The goal of these applications is to provide a comprehensive set of tools and features to improve users’ quality of life in addition keeping an information trail of medical history. And in the case of Microsoft and Google in particular, these sites, for now, are free or inexpensive to personal users.
Four Selected Providers
Microsoft’s Health Vault (free)
HealthVault is an Internet application website offered by Microsoft for storing and maintaining and sharing health and fitness information. The site was launched in October 2007 and is located on- line at http://www.healthvault.com. The site is intended to not only provide access and value to the individuals maintaining the records but also to health care service provider professionals at the information owners discretion and direction.
Google Health (free)
Google Health, http://health.google.com, provides an on-line web portal that allows one to organize in one place, all their health information. There are tools and features that assist in assembling medical records from doctors, hospital and pharmacies. Additionally there are tools to allow sharing of information with family members, physicians or other caregivers.
Dossia (Available to qualifying members only)
Dossia is a Web-based application for storing and managing personal health records (PHR). Unlike Google Health and Health Vault, Dossia, is not available to the public at large. Dossia is the product offering of an independent, non-profit organization known as the Dossia Founders Group.
Users have to be qualified. Presently, Dossia use is only offered only to employees, dependents and retirees of AT&T, Applied Materials, BP America, Inc., Intel Corporation, Pitney Bowes, Cardinal Health, Sanofi-Aventis and Wal-Mart, the Dossia group's founding companies.
Users have the ability to aggregate medical data, claims information from insurance companies and also pharmacy records. Dossia records are stored in a private, encrypted electronic health record hosted in a modified open-source database called “Indivo” that can be accessed over the Internet using a secure connection.
MyHealthArchive Ultimate (modest subscription fee)
MyHealthArchive is a subscription based web portal PHR application. For $9.98 per month, subscribers get access to what the developers call a “revolutionary tool which gives patients the power to collect their own health information and then access it using a secured website, anytime, anywhere in the world.” The application facilitates managing health and wellness for the customer.
Features
The applications currently available have an impressive array of features and benefits already and we can only expect that over time the applications will improve in terms of usability and functionality.In terms of current features below is a partial listing:
· Comprehensive medical record aggregation
· User configurable presentation of the user interface
· Secure access
· Control over with whom data will be shared
· Accessibility over the Internet
· Guided wizards and or comprehensive user help information
· Print, email or fax all or parts of records
· Tools to help plan visits to physicians or other care providers
· Wellness information, preventative advice and health information libraries
· Personal health goal planning, calendars and progress tracking
· Interfaces with biometric tools such as glucose testers, heart rate monitors and other fitness products
· Tools for managing medication regimens
Interoperability
One of the most poignant and problematic issues in health care today is the interoperability of the myriad of diverse systems in use by all of the stakeholders in the heath care arena that optimally will share data. Because there is and likely will continue to be a broad array of health care applications for managing health record information, the data formats, document taxonomies, networking protocols and data interchange formats will continue to be complex and significant issues. The notion of “one source of truth” for a patient’s medical information and history is likely a distant if ever achievable goal. Much data will be shared undoubtedly. The risk of problems as a result of data being passed from one system to another is significant and much effort will continue to be expended to insure the accuracy of the data will be required for the foreseeable future.
Societal Benefits
In addition to the significant, obvious and exciting benefits to be gleaned at a personal level from the broad adoption and deployment of Personal Health Information (PHI) systems, there are also potentially spectacular things that can also be accomplished in the area of public health management if scrubbed (meaning concealing or protecting the privacy rights and concerns of the individuals) PHI data can be aggregated for study, analysis, data mining and other use by public health management professionals and medical researchers. The potential benefits and advances that can be made as a result of this type of a data source being made available cannot be underestimated – it will be game changing in terms of the strides that can be made in managing health concerns at a societal level.
Barriers to Broad Adpotion
While the potential benefits to individuals and to society as a whole are legion, there remain many barriers and obstacles to achieving broad adoption of PHR/PHI systems. Some of those include:
· Lack of time
o Collecting and managing the amount of data that will constitute the complete comprehensive health record for an individual or a family will be a formidable task. Time is the enemy in modern life. The demands on our time are already limiting in terms of what we can accomplish in our lives – one more – enormous task will overwhelm most. Likely, the majority of people will attempt to collect and manage only the information that they deem most important for the present level of concern about health issues.
· Fear of security and privacy issues
o Many people, with good reason, will be suspicions of any on-line, public network, aggregation of PHI information especially when the service is provided at no direct charge to the individual. This will cause many to not participate voluntarily.
· Complexity
o This may be partially a generational issue. Many people will not find the on-line applications user friendly, intuitive or understandable.
· Data input errors
o Problems with data and or functionality with the system(s) may lead some users to not use or to stop using the systems. Especially in the case where a data or system error leads to a significant personal problem.
· Terminology
o Medical terminology and medical descriptions can be incomprehensible or too challenging for some people. A user friendly, “lingua franca” may not be achievable. If people don’t find the information ineligible or meaningful their rate of adoption and perception of value will be much lower.
Risks
In addition to the visceral apprehension expressed by some, there are real risks in putting sensitive personal information into a data repository that is accessible from the public network. While all of the providers are cognizant of the risks, have engineered to minimize them and purport to have them in hand and well managed[i], it is well known that risk of human or machine error and or accidental or intentional disclosure cannot be completely eliminated. While HIPPA and other compliance rules may not apply to all of the potential players in this space, there are those potential participants, i.e. health care service providers that have legitimate potential liabilities that have to be assumed, managed or still eliminated. Then there are all of the usual systemic risks that come as a result of using electronic data automation. Besides unauthorized access and inappropriate disclosure, loss of data by error, system failure or break down, corruption of data, and logic errors are all potential risks and problems that come with any electronic data strategy.
Future
The promise and potential value of personal health record systems is great. The real value and the tremendous benefits are yet to be realized and but the enormous potential of a feature rich database application with this level of detail is truly exciting. There is much work to be done as of yet and the real keys to achieving a tipping point in terms of ubiquitous use and adoption is yet to be fully understood and articulated. As is the case with clinical setting electronic record systems, part of the barrier is the labor and time required to create the records. Just as this aspect of EMR and EHR systems needs to be improved it is also true of PHR /PHI systems. Ease of access and data input methodologies are improving continuously and have been enhanced and improved recently by advances made in the mobile computing arena.
[i] Google’s claims “[Google]… stores your information securely and privately, but you always control how it's used. We will never sell your data. You are in control. You choose what you want to share and what you want to keep private. View our privacy policy to learn more.”
Saturday, March 20, 2010
Government Initiatives for Electronic Health and Medical Records Systems in the U.S., Issues and Barriers to a Rapid of Universal Deployment
Background
In 2004, President Bush issued Executive Order 13335 which called for substantial adoption of electronic health records (EHRs, or EMRs)[i] in private and public healthcare organizations within 10 years. “Additionally, the Medicare Modernization Act requires the establishment of a Commission on System Interoperability and the development of standards for electronic prescribing.”[1] These acts were intended to foster and promote the development and proliferation of national Electronic Medical and Health Records systems.
The following three paragraphs are taken from the 2007 report on “the major accomplishments” of the Health Information Technology Initiative by Health and Human Services Secretary Michael Leavitt since the Presidential directive was issued in 2004.
“Background: A Historical Perspective: Over the past 30 years, nearly every sector of the American economy has undertaken a sweeping transformation in the way information is collected, managed, and transmitted. The result has been consistently increased productivity and efficiency, and this shift has helped to secure America’s place at the top of the economic leader board.
Yet today, health care—one of the most significant sections of the American economy— has not made this transformation. However, this is beginning to change.
Today, evidence that use of secure, standards-based, electronic health records can improve patient care and increase administrative efficiency is overwhelming[2]. This use of interoperable health information technology (IT) will benefit individuals and the health-care system as a whole in profound ways.” [ii]
Specifically the 2007 report on “the major accomplishments” lists the following consumer and public health benefits:
Benefits to the health-care consumer:
· Higher quality care
· Reduction in medical errors
· Fewer duplicate treatments and tests
· Decrease in paperwork
· Lower health-care costs
· Constant access to health information
· Expansion of access to affordable care
Benefits to public health:
· Early detection of infectious disease outbreaks around the country
· Improved tracking of chronic disease management
· Ability to gather de-identified data for research purposes
· Evaluation of health care based on value, enabled by the collection of price and quality information that can be compared
These benefits, the report states, are the reasons behind the 2004 Presidential executive directive to establish an interoperable electronic health record system for most Americans, by 2014. (See the index for a more complete list of benefits [iii])
On April 27, 2004 the United States Department of Health and Human Services (HHS) was directed by President Bush in an executive order to create the new position of national health information technology coordinator. “The national coordinator is charged with providing "leadership for the development and nationwide implementation of an interoperable health information technology infrastructure," with the goal of establishing electronic health records for all Americans within 10 years.” [3] On May 6, 2004 HHS secretary, Tommy G. Thompson announced the appointment of the first person to be named to this position, Dr. David J. Brailer, MD, PhD.
Additionally, the national co-coordinator is “charged with improving healthcare quality, appropriateness, safety, efficiency, and coordination; improving market competition by improving the availability of information about costs, quality, and outcomes; and protecting patients' health information.”[4]
To fund the electronic initiatives the presidential budget for 2005 proposed $50 million in new state and local grants to support efforts for developing systems for health information interchange. Another $50 million was proposed for continuing research on how information technology could improve healthcare quality and safety. HHS was to report to the president on their recommendations for incentive options in their programs – that would encourage the adoption of health information technology and system interoperability capabilities.[5] [iv]
As early as June 17, 2004, Dr. Brailer, was already testifying before the House Subcommittee on Health, Ways and Means reported that HHS had already made the following significant progress.
· “SNOMED was licensed (Systematized Nomenclature of Medicine, a comprehensive set of clinical terminologies) to make it available without charge to everyone in the United States.”
· “As part of the Federal Health Architecture, clinical terminology standards were adopted across federal agencies through the Consolidated Health Informatics (CHI) initiative. The Department of Health and Human Services (HHS), Department of Defense (DoD), Department of Veterans Affairs (VA), and other Executive Branch agencies have endorsed 20 sets of standards, such as standards for medications, labs, and immunizations. These standards will make it easier for information to be shared across agencies and could serve as a model for the private sector.
· The Secretary created the Council on the Application of Health Information Technology (CAHIT), which has been the coordinating and internal advisory body for HHS. CAHIT has served as the primary forum for identifying and evaluating activities and investments that promote and/or complement evolving private sector initiatives and strategies.”[6]
In 2007, Michael O. Leavitt, Secretary of Health and Human Services department issued a report outlining the accomplishments of the first two years after President Bush’s executive order. (See link in the index for the report[v])
The report listed the following accomplishments:
Nine contracts were awarded for:
· Health Information Technology Standards Panel (HITSP) - To harmonize industry-wide health IT standards
· Certification Commission for Healthcare Information Technology (CCHIT) – To develop a certification process for health IT products
· Privacy and Security – To enhance safety of health information by addressing variations in policies and State laws affecting privacy and security practices
· Anti-Fraud for Electronic Health Records – To identify ways to enhance health-care anti-fraud activities with the use of health information technology
· Nationwide Health Information Network (NHIN) – To create prototype architectures for widespread health information exchange
· Adoption of Electronic Health Records – To develop a standardized way to measure adoption of electronic health records
· Clinical Decision Support – To form a group of qualified experts to advise federal activities concerning clinical decision support
· Health Information Exchange3 – To develop consensus for best- practice guidelines from existing, state-level efforts to exchange health information
· Hurricane Katrina Information Network and Digital Health Information Recovery Project – To foster widespread use of interoperable health IT in Gulf Coast regions affected by hurricanes in 2005
In May, 2006, the American Health Information Community (AHIC) delivered its first set of recommendations to the Secretary of HHS. The Secretary officially accepted these unanimous recommendations in four work group areas:
· Consumer Empowerment – To create a consumer-directed and secure electronic health-care registration information and medication history for patients
· Chronic Care – To use secure messaging, such as email, for communication between patients and their health-care providers
· Electronic Health Records – To create standardized, secure records of past and current laboratory test results that is accessible by health professionals
· Bio-surveillance –To enable the transfer of standardized and anonymized health data to authorized public health agencies within 24 hours
Additionally the report listed the following areas where specific objectives have been accomplished:
· Standards Harmonization – AHIC recommendations for “Interoperability Specifications” were approved.
· Executive Order on Value Driven Health Care - Executive Order issued requiring federal departments and agencies that purchase and deliver health care are required to use health IT interoperability standards.
· Product Certification – The Certification Commission for Healthcare Information Technology (CCHIT) certified the first 37 ambulatory—or clinician office-based—electronic health record products.
· Changes to Regulations - HHS issued new regulations to allow certain arrangements in which a hospital or other health-care entity donates health IT and training services to health-care providers.
· Health IT Adoption Measurement - a health IT adoption survey was conducted and established a current state base line of 10 per cent.
Despite President Bush’s initiatives, and the rapid progress of HHS in moving the objectives forward, the current administration has significantly altered the HER/EMR landscape. On February 17, 2009 President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act[vi], as part of the stimulus package (a.k.a. American Recovery and Reinvestment Act (ARRA)) which greatly expanded the scope and scale of the previous initiative to accelerate the development and deployment of EMR and EHR systems.
A main goal of the HITECH Act is to encourage the adoption of electronic health records (EHRs) through incentive payments to physicians. According to the Act, physicians are eligible to receive up to $44,000 in total incentives per physicians from Medicare for “meaningful use” of a certified Electronic Health Record (HER) starting in 2011. (Note: Physicians reimbursed by Medicaid can receive up to approximately $65,000 starting in 2011 based on state defined guidelines.) There are also disincentives and penalties for not participating. The HITECH Act has penalties and disincentives for practices that fail to implement an EHR system. If eligible professionals have not become "meaningful users" of certified EHRs by 2015, their Medicare payments will be reduced by the following schedule:
· 2015 Reduced by 1%
· 2016 Reduced by 2%
· 2017 Reduced by 3%
· All Subsequent Years: Reduced by 3%
It is also quite conceivable that these penalties and disincentives will become even more punitive as time goes on.
Barriers to Adoption
Some of the barriers are discussed in a paper by a group led by a UCSF researcher that appeared in the March-April 2009 issue of the journal "Health Affairs." Chief among these were cost, privacy concerns, design shortcomings and the difficulties encountered when sharing information across organizational boundaries. These issues along with some others to be discussed are critical barriers hindering broad implementation of electronic personal health records.
Cost
For physicians there are significant cost concerns. This is not only in capital expenditures, but also in practice disruption. An EHR system can cost as much as $200,000 or more initially. While there are some open source systems that can be obtained for as little as $20,000 but there is also the cost of ongoing maintenance, hardware, plus the costs of customizing the system.[7] The American Academy of Family Physicians has an online spreadsheet template available for help in estimating the acquisition and implementation cost of an EHR system. The bottom line, is an estimated 5-year total cost of ownership (TCO) for a small practice, of around $126,239 (2002 estimate) . [8]
More recent estimates are found in a “scholarly” study on EHR regulation by Case Western Reserve professors Sharona Hoffamn and Andy Pdgurski. Following is an excerpt from their article.[9]
“It is estimated that the cost of purchasing an EHR system is $33,000 for each physician, with an additional cost of $1,500 per doctor per month for maintenance. This expense has cost challenges for many providers, especially those in small practices.
A TCO projection would include all of the following:
initial hardware initial software
implementation, including system downtime
management
research of vendors & contracts
service
support & training
administration
upgrades & related re-training
capital purchases
direct and indirect labor
subscriptions
system integration
There is also a feeling by many that the “soft cost” savings would mainly benefit the public and private stakeholders. If these estimates area t all representative, clearly the HITECH reimbursement will not cover the investment required by the practice physicians and other healthcare organizations.
There also appears to be feeling among many that cost may not be the true underlying reason that physicians are slow to adopt EHR technology in their practices. Hoffman and Podurski observe that “some clinicians may resist computerization for more than just monetary reasons. There is concern that patients may suffer from less face to face time with their physicians if it becomes more time consuming for doctors to input information into a computer than it is to dictate notes. Others believe that EHR systems require time-consuming documentation of irrelevant facts, are difficult to navigate, and do not organize clinical information in a way that enhances the delivery of treatment.”
Privacy Concerns
Some consumer groups in particular are not happy with the Health IT Policy Committee’s recommendations released in July 2009 for EHR systems, which describe how doctors and hospitals may use electronic records and the due care required. A patient privacy coalition group, the Coalition for Patient Privacy says key privacy regulations need to be moved up from 2015, they are scheduled to be required, to 2011. They have expressed concerns about what it calls the policy committee's lack of attention to control over sensitive health information.[10]
Design Shortcomings
Below is a sample of design short comings being discussed on “Design of eHealth Records” discussion Posted by Dean Karavite on July 9, 2009 on the Design for Care,Design as a Critical Healthcare Profession. While not scholarly or journalistically rigorous, these practitioners certainly do represent many current concerns about EHR design. [11]
1. Design strategy of the contemporary EHR. Currently mimics paper processes. Decision support is rudimentary.2. IA/Usability of the contemporary EHR. Absolutely primitive. Vendors seem ignorant of all we have learned in other areas.3. Assessment of the current EHR. Jury is out on cost savings, productivity, improved outcomes and safety. What can we learn from how they fail?4. Implementing an EHR. A very $ and painful process. While we wait for the next EHR design, too many are already committed. Can we help design a better implementation process with the EHR's we have today? (my emphasis)5. Data and the EHR. Current design primarily focused on operational routines. Data access is difficult and complex. How can we make data access a higher level design requirement? Then, how we might go about designing to harness data in the aggregate, but also for the single patient at the bedside.6. Designing the EHR to promote clinician-patient interaction.The computer is taking over the exam room. How to design the focus back to interaction between the patient and the physician?
Interoperability Issues
Possibly the most challenging barrier to a broad and expedient deployment of EHR systems, is the issue of interoperability- a fundamental requirement of the HITECH Act. In the five years since President Bush issued Executive Order 13335 not nearly enough has been accomplished with respect to interoperability issues that hamper our national goal of portable and ubiquitous availability of patient health care data.
“In interviews conducted last summer with 22 health information technology experts from across the country, it was concluded by a January California HealthCare Foundation report based that, the nation's medical community is not substantially closer to an interconnected, interoperable EMR system now than it was in 2004.” [12]
There remain numerous issues including but not limited to technical, social, legal and policy-based issues. The number, proprietary nature, monetary and organizational investment and complexity of the legacy health care systems present a formidable barrier to data exchange and information portability. Even where viable technical solutions are at hand, the switching costs remain an enormous challenge. Even for small providers the monetary and organizational switching costs are a formidable problem.
“Interoperability is a fundamental requirement of ensuring that widespread electronic medical record (EMR) adoption gives us the social and economic benefits that we want.” Without it, EMR deployments will exacerbate the problem with information silos that exist today in paper-based medical records systems. This will result in even greater proprietary control of health information. Without interoperability, public support and funding would be questionable, since stand-alone EMRs might not increase the benefit to consumers, i.e. taxpayers. Interoperable information systems would increase consumers’ welfare through increased choice, portability, and control.”[13]
Conclusions
In July of 2007 a survey found that only 14% of physicians have minimally functional EMR systems. [14] The impediments to meeting the planned compliance milestones dates are significant and it seems highly unlikely that any can be met. The public funded monetary incentives appear to be inadequate to offset the projected capital and organizational costs of deployment. In this era of strained budgets and economic uncertainty, the propensity for capital risk taking especially in the microeconomic environment of the small practice is undoubtedly suppressed- especially given the widespread notions of questionable benefit. There is a cacophony of standards and technological approaches to vendor solutions. There is a steep learning curve that must be overcome for effective assimilation or the technical, institutional and organizational changes that would be necessary for a rapid successful deployment of ubiquitous EHR systems.
Following is a post on the EMR and HIPPA Open Forem for EMR, EHR, HIT and HIPPA related information by one Paul Roemer.
Regarding the HITECH objectives:
“I think the very question reinforces the magnitude of the issue. Providers have budgets for products whose cost they do not understand. They have implementation teams who have never implemented one. They are aiming at targets for certification and meaningful use, which from my perspective could just as well be written on an Etch-A-Sketch. Hundreds of committees work towards standards, a requirement forced upon them by hundreds of vendor applications and hundreds of Rhios.
The output of the recent HIT policy meeting shows just how befuddled the process is.
This is a mandated national roll out of EHR without half the required sources and almost none of the required leadership. Who is the decider?
The current failure rate for EHRs is understated due to the large number of small systems. The failure rate for those over $10 million will exceed the rate for large IT systems which is close to 80%.
A hospital CEO with who I met last month told me his peers are uniquely ill equipped to make these decisions. Decisions are based on what their friends did, what they read in a journal. They plan implementations based on meeting gossamer standards and tests. They do not base them on requirements.
Watch the dates move backwards. I think in 6-8 years the rolled out EHR will more closely resemble a single, national, browser-based open EHR.”
These seem to be credible observations. What then is to be done to improve the prospects for the most expedient deployment in order to to harvest the greatest potential value for stakeholders as soon as is possible? Probably nothing. The wheels of change are in motion and the entropy for forward movement- even if misguided, is probably too great to re-program. The substantial forces of the national healthcare infrastructure are at work for accomplishing this change and they will work themselves out over time (project performance will improve over time) – not the in the timeframes mandated by the HITECH Act, but in the timeframes necessitated by the realities of the technology, the scale and scope of the problems and the maximum ability of human beings and human enterprise to cope with change.
[1] Association of American Physicians and Surgeons, Inc, On-line Journal, Volume 60, No. 12 December 2004, http://www.aapsonline.org/newsletters/dec04.htm
[2] Walker, Pan, Johnston, Adler-Milstein, Bates, and Middleton: Health Affairs Online: January, 2005.
[3] Healthcare Financial Management Association, web page story, 2004, Copyright, 2004 the Gale Group
[4] Ibid.
[5] Ibid.
[6] Testimony: Statement by David J. Brailer, M.D., Ph.D., National Coordinator for Health Information Technology, Office of the Secretary, U.S. Department of Health and Human Services on Hearing: Health Information Technology before the Subcommittee on Health, Committee on Ways and Means, June 17, 2004. http://www.hhs.gov/asl/testify/t040617.html
[7] IM News, 8/15/04
[8] Jack Valancy. “How Much Will That EMR System Really Cost?” Family Practice Management. April 2002
[9] Sharona Hoffman, Andy Podurski. “Case Western Reserve University professors call for regulation of Electronic Health Records.” Case Western Reserve News Center, Online. October 30, 2008.
[10] Chris Silva. “EHR guidelines raise privacy concerns.” Amednews.com. Posted Aug. 20, 2009
[11] http://designforcare.ning.com/forum/topics/the-design-of-ehealth-records
[12] Dave Hansen. “EMR deadline does not compute: Falling short of 2014 goals.” amednews . May 19, 2008.
[13] David J. Brailer. “Interoperability: The Key To The Future Health Care System.” Health Affairs, The Policy Journal of the Health Sphere. Jan.19, 2005.
[14] Dave Hansen. “EMR deadline does not compute: Falling short of 2014 goals.” amednews . May 19, 2008.
[i] EHR vs EMR – What’s the Difference? By Houston Neal
I Posted on November 14, 2008 at 10:39 amhttp://www.softwareadvice.com/articles/medical/ehr-vs-emr-whats-the-difference/
EMR or an EHR? Do you know the difference? Is there a difference?
In theory, and by definition, there is a difference and it should play into any provider’s clinical software selection. At the same time, marketing messages and technical terminology have clouded provider’s understanding of the two software definitions.
Recently, National Alliance for Health Information Technology (NAHIT) established definitions for electronic medical records (EMR), electronic health records (EHR) and personal health records (PHR).
NAHIT Has Defined EMR and EHRThe NAHIT has produced the following definitions for EMR and EHR:
EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.
EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.
By these definitions, an EHR is an EMR with interoperability (i.e. integration to other providers’ systems). More on this later…
Who Needs Which?Marc Anderson, CEO of the AC Group, says it comes down to the words “medical” and “health.”
An EHR will provide a more comprehensive view into a patient’s health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives.
Meanwhile, an EMR is a more silo’d record of a single diagnosis or treatment, most likely used by a specialist. If your responsibility is taking care of one unique problem – perhaps an orthopedist setting a bone – then a stand-alone EMR may well be sufficient. Certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates.
The Market is Still Figuring it OutDespite the NAHIT definitions, we think the market is still figuring out which definitions to adopt. An analysis of Google Trends data shows that roughly four times more searches are performed for “electronic medical record” than for “electronic health record.” At the same time, “electronic health record” seems to be gaining in search frequency.
Google search frequency index by health care IT keyword phrase.
One interesting exception to the data: searches originating in Washington, DC are split evenly between “electronic medical record” and “electronic health record!”
Software Vendor Marketing Migrates SlowlyThe Google search trend data indicates an increased usage of EHR, but EMR remains more prevalent. The same is true when we look at the usage of terminology by software vendors.
In a review of 300 clinical records systems, 207 vendors market their software as an EMR, while 59 use the term EHR.
Why such limited adoption of EHR amongst vendors? First, it simply takes time and effort to change over marketing terms. Moreover, from a very practical standpoint, many vendors will want to continue to use the EMR label while it is the most commonly used – and “Googled” – term for clinical records systems.
Marketing Aside…Regardless of who’s using which terms, the key decision process for selecting an EMR/EHR is to map out your organization’s requirements and methodically assess systems against those criteria.
Justin Barnes, Chairman of the HIMSS Electronic Health Record Association (EHRVA) and VP of Marketing and Government Affairs at Greenway Medical Technologies, believes “the future of health care IT is interoperability.”
And while Barnes is an advocate of the EHR terminology, he distills the following three criteria for selecting a medical records system:
Current-year interoperability certification standards (CCHIT, HL7);
A unique workflow that matches your practice and specialty, and;
Excellent usability at the point of care.
If you purchase an EMR or EHR with these three requirements, you should receive a significant ROI on your investment, and position yourself to receive incentives from payers.
Well What’s a PHR?NAHIT has provided the following definition of a PHR:
ePHR: An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.
To be most effective, a PHR should include cumulative health information ranging from past and current illnesses, demographics, allergies, prescriptions and more. Given the nature of the PHR, it’s the individual’s responsibility to decide what information is stored, and who has access to it.
Microsoft’s HealthVault and Google Health are two prominent examples of PHRs. Whether these systems are widely adopted, and properly updated by patients, is yet to be seen.
So What Should I Implement?Even with complete definitions in place, it can be difficult to evaluate EMRs/EHRs and determine which system to buy.
At the same time, most providers will make their decisions based on their IT budget and their career stage. A young physician will almost certainly want to lay the IT foundation for participating in the future vision for healthcare interoperability. They will likely be supported in this effort by their health system.
Meanwhile, a more mature physician that wants to “go paperless,” but is not an aggressive adopter of IT, may well opt for a stand-alone EMR system and forgo the costs and challenges of integration.
In the end, these individual decisions underly what is a deliberate, but very slow, adoption of health care technologies.
[ii] http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848134_0_0_18/Accomplishments2006.pdf
[iii]
An Open Forum for EMR, EHR, HIT and HIPAA Related Information
http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/
Benefits of Using an EMR or EHR Over Paper Charts
Legibility of Notes – No more dealing with various handwriting styles since notes are typed.Accessibility of Charts – Indexed and easily searchable by multiple identifiers. No more searching the entire clinic for a lost paper chart.Transcription Costs Savings – Many users have been able to save on transcription costs by implementing an EMR.Space Savings – Many people are able to save space where they’d normally be storing shelves and shelves of paper charts.Eliminate Staff – This almost never happens immediately. Usually this happens through natural turnover of employees and usually occurs with your front desk or medical records staff.Eligibility for Pay-for-performance – It could take two years or more for you to implement an EHR and implement a meaningful quality improvement mechanism that would lead to your receiving payments from these programs.New Physician Recruitment – Many new physicians are looking for practices that use an EHR and will only work for an organization that uses an EHR.Multiple Users Use a Chart Simultaneously – Most EMR programs support multiple users accessing a chart at the same time. Many even allow multiple people to chart notes at the same time also.Lab Results Returned Automatically – This depends on a lab interface, but is more reliable and integrated with the care given.X-Ray Results Returned Automatically – This also depends on a X-ray interface, but has the same possible benefits of a lab interface.Save a Tree and the Environment – You won’t eliminate your use of paper, but you can significantly reduce the amount of paper/charts you use in your practice.Electronic Prescriptions – Scripts sent electronically or printed out avoid problems of legibility by the pharmacy receiving the script.Spell check – Many EMR software includes a spell check and often even include a medical dictionary.Disaster Recovery – Depending on your EMR backup schedule, you can store a copy of your data in multiple locations for better disaster recovery. Plus, in an emergency you could carry a backup of your data with you. Think about how you’d carry a room full of charts with you in an emergency.Drug to Drug Interaction Checking – Most EMR provide a database of Drug to Drug interactions when writing a prescription.Drug to Allergy Interaction Checking – Most EMR provide a database of Drug to Allergy Interaction checking when writing a prescription.Patient Safety? – Better information access, reduced gaps in communication between providers and reduction in duplicate testing.Quality of Care?Increased Efficiency?Better Patient Services?Improved Workflow?Improved Patient CommunicationsImproved Accuracy for Coding Evaluation and ManagementImproved Drug Refill CapabilitiesImproved Charge CaptureImproved Claim Submission ProcessReduced Medical Records Transportation Costs
[iv] April 27, 2004 Presidential executive order www.whitehouse.gov/news/releases/2004/04/20040427-4.html
U. S. Health and Human Service Department appointment of Dr. David J. Brailer, MD, PhD. As the first National Health Information Technology Coordinator www.hhs.gov/news/press/2004pres/20040506.html
[v] http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848134_0_0_18/Accomplishments2006.pdf
[vi] http://waysandmeans.house.gov/media/pdf/110/hit2.pdf
In 2004, President Bush issued Executive Order 13335 which called for substantial adoption of electronic health records (EHRs, or EMRs)[i] in private and public healthcare organizations within 10 years. “Additionally, the Medicare Modernization Act requires the establishment of a Commission on System Interoperability and the development of standards for electronic prescribing.”[1] These acts were intended to foster and promote the development and proliferation of national Electronic Medical and Health Records systems.
The following three paragraphs are taken from the 2007 report on “the major accomplishments” of the Health Information Technology Initiative by Health and Human Services Secretary Michael Leavitt since the Presidential directive was issued in 2004.
“Background: A Historical Perspective: Over the past 30 years, nearly every sector of the American economy has undertaken a sweeping transformation in the way information is collected, managed, and transmitted. The result has been consistently increased productivity and efficiency, and this shift has helped to secure America’s place at the top of the economic leader board.
Yet today, health care—one of the most significant sections of the American economy— has not made this transformation. However, this is beginning to change.
Today, evidence that use of secure, standards-based, electronic health records can improve patient care and increase administrative efficiency is overwhelming[2]. This use of interoperable health information technology (IT) will benefit individuals and the health-care system as a whole in profound ways.” [ii]
Specifically the 2007 report on “the major accomplishments” lists the following consumer and public health benefits:
Benefits to the health-care consumer:
· Higher quality care
· Reduction in medical errors
· Fewer duplicate treatments and tests
· Decrease in paperwork
· Lower health-care costs
· Constant access to health information
· Expansion of access to affordable care
Benefits to public health:
· Early detection of infectious disease outbreaks around the country
· Improved tracking of chronic disease management
· Ability to gather de-identified data for research purposes
· Evaluation of health care based on value, enabled by the collection of price and quality information that can be compared
These benefits, the report states, are the reasons behind the 2004 Presidential executive directive to establish an interoperable electronic health record system for most Americans, by 2014. (See the index for a more complete list of benefits [iii])
On April 27, 2004 the United States Department of Health and Human Services (HHS) was directed by President Bush in an executive order to create the new position of national health information technology coordinator. “The national coordinator is charged with providing "leadership for the development and nationwide implementation of an interoperable health information technology infrastructure," with the goal of establishing electronic health records for all Americans within 10 years.” [3] On May 6, 2004 HHS secretary, Tommy G. Thompson announced the appointment of the first person to be named to this position, Dr. David J. Brailer, MD, PhD.
Additionally, the national co-coordinator is “charged with improving healthcare quality, appropriateness, safety, efficiency, and coordination; improving market competition by improving the availability of information about costs, quality, and outcomes; and protecting patients' health information.”[4]
To fund the electronic initiatives the presidential budget for 2005 proposed $50 million in new state and local grants to support efforts for developing systems for health information interchange. Another $50 million was proposed for continuing research on how information technology could improve healthcare quality and safety. HHS was to report to the president on their recommendations for incentive options in their programs – that would encourage the adoption of health information technology and system interoperability capabilities.[5] [iv]
As early as June 17, 2004, Dr. Brailer, was already testifying before the House Subcommittee on Health, Ways and Means reported that HHS had already made the following significant progress.
· “SNOMED was licensed (Systematized Nomenclature of Medicine, a comprehensive set of clinical terminologies) to make it available without charge to everyone in the United States.”
· “As part of the Federal Health Architecture, clinical terminology standards were adopted across federal agencies through the Consolidated Health Informatics (CHI) initiative. The Department of Health and Human Services (HHS), Department of Defense (DoD), Department of Veterans Affairs (VA), and other Executive Branch agencies have endorsed 20 sets of standards, such as standards for medications, labs, and immunizations. These standards will make it easier for information to be shared across agencies and could serve as a model for the private sector.
· The Secretary created the Council on the Application of Health Information Technology (CAHIT), which has been the coordinating and internal advisory body for HHS. CAHIT has served as the primary forum for identifying and evaluating activities and investments that promote and/or complement evolving private sector initiatives and strategies.”[6]
In 2007, Michael O. Leavitt, Secretary of Health and Human Services department issued a report outlining the accomplishments of the first two years after President Bush’s executive order. (See link in the index for the report[v])
The report listed the following accomplishments:
Nine contracts were awarded for:
· Health Information Technology Standards Panel (HITSP) - To harmonize industry-wide health IT standards
· Certification Commission for Healthcare Information Technology (CCHIT) – To develop a certification process for health IT products
· Privacy and Security – To enhance safety of health information by addressing variations in policies and State laws affecting privacy and security practices
· Anti-Fraud for Electronic Health Records – To identify ways to enhance health-care anti-fraud activities with the use of health information technology
· Nationwide Health Information Network (NHIN) – To create prototype architectures for widespread health information exchange
· Adoption of Electronic Health Records – To develop a standardized way to measure adoption of electronic health records
· Clinical Decision Support – To form a group of qualified experts to advise federal activities concerning clinical decision support
· Health Information Exchange3 – To develop consensus for best- practice guidelines from existing, state-level efforts to exchange health information
· Hurricane Katrina Information Network and Digital Health Information Recovery Project – To foster widespread use of interoperable health IT in Gulf Coast regions affected by hurricanes in 2005
In May, 2006, the American Health Information Community (AHIC) delivered its first set of recommendations to the Secretary of HHS. The Secretary officially accepted these unanimous recommendations in four work group areas:
· Consumer Empowerment – To create a consumer-directed and secure electronic health-care registration information and medication history for patients
· Chronic Care – To use secure messaging, such as email, for communication between patients and their health-care providers
· Electronic Health Records – To create standardized, secure records of past and current laboratory test results that is accessible by health professionals
· Bio-surveillance –To enable the transfer of standardized and anonymized health data to authorized public health agencies within 24 hours
Additionally the report listed the following areas where specific objectives have been accomplished:
· Standards Harmonization – AHIC recommendations for “Interoperability Specifications” were approved.
· Executive Order on Value Driven Health Care - Executive Order issued requiring federal departments and agencies that purchase and deliver health care are required to use health IT interoperability standards.
· Product Certification – The Certification Commission for Healthcare Information Technology (CCHIT) certified the first 37 ambulatory—or clinician office-based—electronic health record products.
· Changes to Regulations - HHS issued new regulations to allow certain arrangements in which a hospital or other health-care entity donates health IT and training services to health-care providers.
· Health IT Adoption Measurement - a health IT adoption survey was conducted and established a current state base line of 10 per cent.
Despite President Bush’s initiatives, and the rapid progress of HHS in moving the objectives forward, the current administration has significantly altered the HER/EMR landscape. On February 17, 2009 President Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act[vi], as part of the stimulus package (a.k.a. American Recovery and Reinvestment Act (ARRA)) which greatly expanded the scope and scale of the previous initiative to accelerate the development and deployment of EMR and EHR systems.
A main goal of the HITECH Act is to encourage the adoption of electronic health records (EHRs) through incentive payments to physicians. According to the Act, physicians are eligible to receive up to $44,000 in total incentives per physicians from Medicare for “meaningful use” of a certified Electronic Health Record (HER) starting in 2011. (Note: Physicians reimbursed by Medicaid can receive up to approximately $65,000 starting in 2011 based on state defined guidelines.) There are also disincentives and penalties for not participating. The HITECH Act has penalties and disincentives for practices that fail to implement an EHR system. If eligible professionals have not become "meaningful users" of certified EHRs by 2015, their Medicare payments will be reduced by the following schedule:
· 2015 Reduced by 1%
· 2016 Reduced by 2%
· 2017 Reduced by 3%
· All Subsequent Years: Reduced by 3%
It is also quite conceivable that these penalties and disincentives will become even more punitive as time goes on.
Barriers to Adoption
Some of the barriers are discussed in a paper by a group led by a UCSF researcher that appeared in the March-April 2009 issue of the journal "Health Affairs." Chief among these were cost, privacy concerns, design shortcomings and the difficulties encountered when sharing information across organizational boundaries. These issues along with some others to be discussed are critical barriers hindering broad implementation of electronic personal health records.
Cost
For physicians there are significant cost concerns. This is not only in capital expenditures, but also in practice disruption. An EHR system can cost as much as $200,000 or more initially. While there are some open source systems that can be obtained for as little as $20,000 but there is also the cost of ongoing maintenance, hardware, plus the costs of customizing the system.[7] The American Academy of Family Physicians has an online spreadsheet template available for help in estimating the acquisition and implementation cost of an EHR system. The bottom line, is an estimated 5-year total cost of ownership (TCO) for a small practice, of around $126,239 (2002 estimate) . [8]
More recent estimates are found in a “scholarly” study on EHR regulation by Case Western Reserve professors Sharona Hoffamn and Andy Pdgurski. Following is an excerpt from their article.[9]
“It is estimated that the cost of purchasing an EHR system is $33,000 for each physician, with an additional cost of $1,500 per doctor per month for maintenance. This expense has cost challenges for many providers, especially those in small practices.
A TCO projection would include all of the following:
initial hardware initial software
implementation, including system downtime
management
research of vendors & contracts
service
support & training
administration
upgrades & related re-training
capital purchases
direct and indirect labor
subscriptions
system integration
There is also a feeling by many that the “soft cost” savings would mainly benefit the public and private stakeholders. If these estimates area t all representative, clearly the HITECH reimbursement will not cover the investment required by the practice physicians and other healthcare organizations.
There also appears to be feeling among many that cost may not be the true underlying reason that physicians are slow to adopt EHR technology in their practices. Hoffman and Podurski observe that “some clinicians may resist computerization for more than just monetary reasons. There is concern that patients may suffer from less face to face time with their physicians if it becomes more time consuming for doctors to input information into a computer than it is to dictate notes. Others believe that EHR systems require time-consuming documentation of irrelevant facts, are difficult to navigate, and do not organize clinical information in a way that enhances the delivery of treatment.”
Privacy Concerns
Some consumer groups in particular are not happy with the Health IT Policy Committee’s recommendations released in July 2009 for EHR systems, which describe how doctors and hospitals may use electronic records and the due care required. A patient privacy coalition group, the Coalition for Patient Privacy says key privacy regulations need to be moved up from 2015, they are scheduled to be required, to 2011. They have expressed concerns about what it calls the policy committee's lack of attention to control over sensitive health information.[10]
Design Shortcomings
Below is a sample of design short comings being discussed on “Design of eHealth Records” discussion Posted by Dean Karavite on July 9, 2009 on the Design for Care,Design as a Critical Healthcare Profession. While not scholarly or journalistically rigorous, these practitioners certainly do represent many current concerns about EHR design. [11]
1. Design strategy of the contemporary EHR. Currently mimics paper processes. Decision support is rudimentary.2. IA/Usability of the contemporary EHR. Absolutely primitive. Vendors seem ignorant of all we have learned in other areas.3. Assessment of the current EHR. Jury is out on cost savings, productivity, improved outcomes and safety. What can we learn from how they fail?4. Implementing an EHR. A very $ and painful process. While we wait for the next EHR design, too many are already committed. Can we help design a better implementation process with the EHR's we have today? (my emphasis)5. Data and the EHR. Current design primarily focused on operational routines. Data access is difficult and complex. How can we make data access a higher level design requirement? Then, how we might go about designing to harness data in the aggregate, but also for the single patient at the bedside.6. Designing the EHR to promote clinician-patient interaction.The computer is taking over the exam room. How to design the focus back to interaction between the patient and the physician?
Interoperability Issues
Possibly the most challenging barrier to a broad and expedient deployment of EHR systems, is the issue of interoperability- a fundamental requirement of the HITECH Act. In the five years since President Bush issued Executive Order 13335 not nearly enough has been accomplished with respect to interoperability issues that hamper our national goal of portable and ubiquitous availability of patient health care data.
“In interviews conducted last summer with 22 health information technology experts from across the country, it was concluded by a January California HealthCare Foundation report based that, the nation's medical community is not substantially closer to an interconnected, interoperable EMR system now than it was in 2004.” [12]
There remain numerous issues including but not limited to technical, social, legal and policy-based issues. The number, proprietary nature, monetary and organizational investment and complexity of the legacy health care systems present a formidable barrier to data exchange and information portability. Even where viable technical solutions are at hand, the switching costs remain an enormous challenge. Even for small providers the monetary and organizational switching costs are a formidable problem.
“Interoperability is a fundamental requirement of ensuring that widespread electronic medical record (EMR) adoption gives us the social and economic benefits that we want.” Without it, EMR deployments will exacerbate the problem with information silos that exist today in paper-based medical records systems. This will result in even greater proprietary control of health information. Without interoperability, public support and funding would be questionable, since stand-alone EMRs might not increase the benefit to consumers, i.e. taxpayers. Interoperable information systems would increase consumers’ welfare through increased choice, portability, and control.”[13]
Conclusions
In July of 2007 a survey found that only 14% of physicians have minimally functional EMR systems. [14] The impediments to meeting the planned compliance milestones dates are significant and it seems highly unlikely that any can be met. The public funded monetary incentives appear to be inadequate to offset the projected capital and organizational costs of deployment. In this era of strained budgets and economic uncertainty, the propensity for capital risk taking especially in the microeconomic environment of the small practice is undoubtedly suppressed- especially given the widespread notions of questionable benefit. There is a cacophony of standards and technological approaches to vendor solutions. There is a steep learning curve that must be overcome for effective assimilation or the technical, institutional and organizational changes that would be necessary for a rapid successful deployment of ubiquitous EHR systems.
Following is a post on the EMR and HIPPA Open Forem for EMR, EHR, HIT and HIPPA related information by one Paul Roemer.
Regarding the HITECH objectives:
“I think the very question reinforces the magnitude of the issue. Providers have budgets for products whose cost they do not understand. They have implementation teams who have never implemented one. They are aiming at targets for certification and meaningful use, which from my perspective could just as well be written on an Etch-A-Sketch. Hundreds of committees work towards standards, a requirement forced upon them by hundreds of vendor applications and hundreds of Rhios.
The output of the recent HIT policy meeting shows just how befuddled the process is.
This is a mandated national roll out of EHR without half the required sources and almost none of the required leadership. Who is the decider?
The current failure rate for EHRs is understated due to the large number of small systems. The failure rate for those over $10 million will exceed the rate for large IT systems which is close to 80%.
A hospital CEO with who I met last month told me his peers are uniquely ill equipped to make these decisions. Decisions are based on what their friends did, what they read in a journal. They plan implementations based on meeting gossamer standards and tests. They do not base them on requirements.
Watch the dates move backwards. I think in 6-8 years the rolled out EHR will more closely resemble a single, national, browser-based open EHR.”
These seem to be credible observations. What then is to be done to improve the prospects for the most expedient deployment in order to to harvest the greatest potential value for stakeholders as soon as is possible? Probably nothing. The wheels of change are in motion and the entropy for forward movement- even if misguided, is probably too great to re-program. The substantial forces of the national healthcare infrastructure are at work for accomplishing this change and they will work themselves out over time (project performance will improve over time) – not the in the timeframes mandated by the HITECH Act, but in the timeframes necessitated by the realities of the technology, the scale and scope of the problems and the maximum ability of human beings and human enterprise to cope with change.
[1] Association of American Physicians and Surgeons, Inc, On-line Journal, Volume 60, No. 12 December 2004, http://www.aapsonline.org/newsletters/dec04.htm
[2] Walker, Pan, Johnston, Adler-Milstein, Bates, and Middleton: Health Affairs Online: January, 2005.
[3] Healthcare Financial Management Association, web page story, 2004, Copyright, 2004 the Gale Group
[4] Ibid.
[5] Ibid.
[6] Testimony: Statement by David J. Brailer, M.D., Ph.D., National Coordinator for Health Information Technology, Office of the Secretary, U.S. Department of Health and Human Services on Hearing: Health Information Technology before the Subcommittee on Health, Committee on Ways and Means, June 17, 2004. http://www.hhs.gov/asl/testify/t040617.html
[7] IM News, 8/15/04
[8] Jack Valancy. “How Much Will That EMR System Really Cost?” Family Practice Management. April 2002
[9] Sharona Hoffman, Andy Podurski. “Case Western Reserve University professors call for regulation of Electronic Health Records.” Case Western Reserve News Center, Online. October 30, 2008.
[10] Chris Silva. “EHR guidelines raise privacy concerns.” Amednews.com. Posted Aug. 20, 2009
[11] http://designforcare.ning.com/forum/topics/the-design-of-ehealth-records
[12] Dave Hansen. “EMR deadline does not compute: Falling short of 2014 goals.” amednews . May 19, 2008.
[13] David J. Brailer. “Interoperability: The Key To The Future Health Care System.” Health Affairs, The Policy Journal of the Health Sphere. Jan.19, 2005.
[14] Dave Hansen. “EMR deadline does not compute: Falling short of 2014 goals.” amednews . May 19, 2008.
[i] EHR vs EMR – What’s the Difference? By Houston Neal
I Posted on November 14, 2008 at 10:39 amhttp://www.softwareadvice.com/articles/medical/ehr-vs-emr-whats-the-difference/
EMR or an EHR? Do you know the difference? Is there a difference?
In theory, and by definition, there is a difference and it should play into any provider’s clinical software selection. At the same time, marketing messages and technical terminology have clouded provider’s understanding of the two software definitions.
Recently, National Alliance for Health Information Technology (NAHIT) established definitions for electronic medical records (EMR), electronic health records (EHR) and personal health records (PHR).
NAHIT Has Defined EMR and EHRThe NAHIT has produced the following definitions for EMR and EHR:
EMR: The electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care.
EHR: The aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care.
By these definitions, an EHR is an EMR with interoperability (i.e. integration to other providers’ systems). More on this later…
Who Needs Which?Marc Anderson, CEO of the AC Group, says it comes down to the words “medical” and “health.”
An EHR will provide a more comprehensive view into a patient’s health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements. It will help providers report and measure quality indicators for pay-for-performance incentives.
Meanwhile, an EMR is a more silo’d record of a single diagnosis or treatment, most likely used by a specialist. If your responsibility is taking care of one unique problem – perhaps an orthopedist setting a bone – then a stand-alone EMR may well be sufficient. Certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates.
The Market is Still Figuring it OutDespite the NAHIT definitions, we think the market is still figuring out which definitions to adopt. An analysis of Google Trends data shows that roughly four times more searches are performed for “electronic medical record” than for “electronic health record.” At the same time, “electronic health record” seems to be gaining in search frequency.
Google search frequency index by health care IT keyword phrase.
One interesting exception to the data: searches originating in Washington, DC are split evenly between “electronic medical record” and “electronic health record!”
Software Vendor Marketing Migrates SlowlyThe Google search trend data indicates an increased usage of EHR, but EMR remains more prevalent. The same is true when we look at the usage of terminology by software vendors.
In a review of 300 clinical records systems, 207 vendors market their software as an EMR, while 59 use the term EHR.
Why such limited adoption of EHR amongst vendors? First, it simply takes time and effort to change over marketing terms. Moreover, from a very practical standpoint, many vendors will want to continue to use the EMR label while it is the most commonly used – and “Googled” – term for clinical records systems.
Marketing Aside…Regardless of who’s using which terms, the key decision process for selecting an EMR/EHR is to map out your organization’s requirements and methodically assess systems against those criteria.
Justin Barnes, Chairman of the HIMSS Electronic Health Record Association (EHRVA) and VP of Marketing and Government Affairs at Greenway Medical Technologies, believes “the future of health care IT is interoperability.”
And while Barnes is an advocate of the EHR terminology, he distills the following three criteria for selecting a medical records system:
Current-year interoperability certification standards (CCHIT, HL7);
A unique workflow that matches your practice and specialty, and;
Excellent usability at the point of care.
If you purchase an EMR or EHR with these three requirements, you should receive a significant ROI on your investment, and position yourself to receive incentives from payers.
Well What’s a PHR?NAHIT has provided the following definition of a PHR:
ePHR: An electronic, cumulative record of health-related information on an individual, drawn from multiple sources, that is created, gathered, and managed by the individual. The integrity of the data in the ePHR and control of access to that data is the responsibility of the individual.
To be most effective, a PHR should include cumulative health information ranging from past and current illnesses, demographics, allergies, prescriptions and more. Given the nature of the PHR, it’s the individual’s responsibility to decide what information is stored, and who has access to it.
Microsoft’s HealthVault and Google Health are two prominent examples of PHRs. Whether these systems are widely adopted, and properly updated by patients, is yet to be seen.
So What Should I Implement?Even with complete definitions in place, it can be difficult to evaluate EMRs/EHRs and determine which system to buy.
At the same time, most providers will make their decisions based on their IT budget and their career stage. A young physician will almost certainly want to lay the IT foundation for participating in the future vision for healthcare interoperability. They will likely be supported in this effort by their health system.
Meanwhile, a more mature physician that wants to “go paperless,” but is not an aggressive adopter of IT, may well opt for a stand-alone EMR system and forgo the costs and challenges of integration.
In the end, these individual decisions underly what is a deliberate, but very slow, adoption of health care technologies.
[ii] http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848134_0_0_18/Accomplishments2006.pdf
[iii]
An Open Forum for EMR, EHR, HIT and HIPAA Related Information
http://www.emrandhipaa.com/benefits-of-emr-or-ehr-over-paper-charts/
Benefits of Using an EMR or EHR Over Paper Charts
Legibility of Notes – No more dealing with various handwriting styles since notes are typed.Accessibility of Charts – Indexed and easily searchable by multiple identifiers. No more searching the entire clinic for a lost paper chart.Transcription Costs Savings – Many users have been able to save on transcription costs by implementing an EMR.Space Savings – Many people are able to save space where they’d normally be storing shelves and shelves of paper charts.Eliminate Staff – This almost never happens immediately. Usually this happens through natural turnover of employees and usually occurs with your front desk or medical records staff.Eligibility for Pay-for-performance – It could take two years or more for you to implement an EHR and implement a meaningful quality improvement mechanism that would lead to your receiving payments from these programs.New Physician Recruitment – Many new physicians are looking for practices that use an EHR and will only work for an organization that uses an EHR.Multiple Users Use a Chart Simultaneously – Most EMR programs support multiple users accessing a chart at the same time. Many even allow multiple people to chart notes at the same time also.Lab Results Returned Automatically – This depends on a lab interface, but is more reliable and integrated with the care given.X-Ray Results Returned Automatically – This also depends on a X-ray interface, but has the same possible benefits of a lab interface.Save a Tree and the Environment – You won’t eliminate your use of paper, but you can significantly reduce the amount of paper/charts you use in your practice.Electronic Prescriptions – Scripts sent electronically or printed out avoid problems of legibility by the pharmacy receiving the script.Spell check – Many EMR software includes a spell check and often even include a medical dictionary.Disaster Recovery – Depending on your EMR backup schedule, you can store a copy of your data in multiple locations for better disaster recovery. Plus, in an emergency you could carry a backup of your data with you. Think about how you’d carry a room full of charts with you in an emergency.Drug to Drug Interaction Checking – Most EMR provide a database of Drug to Drug interactions when writing a prescription.Drug to Allergy Interaction Checking – Most EMR provide a database of Drug to Allergy Interaction checking when writing a prescription.Patient Safety? – Better information access, reduced gaps in communication between providers and reduction in duplicate testing.Quality of Care?Increased Efficiency?Better Patient Services?Improved Workflow?Improved Patient CommunicationsImproved Accuracy for Coding Evaluation and ManagementImproved Drug Refill CapabilitiesImproved Charge CaptureImproved Claim Submission ProcessReduced Medical Records Transportation Costs
[iv] April 27, 2004 Presidential executive order www.whitehouse.gov/news/releases/2004/04/20040427-4.html
U. S. Health and Human Service Department appointment of Dr. David J. Brailer, MD, PhD. As the first National Health Information Technology Coordinator www.hhs.gov/news/press/2004pres/20040506.html
[v] http://healthit.hhs.gov/portal/server.pt/gateway/PTARGS_0_10731_848134_0_0_18/Accomplishments2006.pdf
[vi] http://waysandmeans.house.gov/media/pdf/110/hit2.pdf
Tuesday, March 16, 2010
Some Thoughts on the Health Care Reform Bills
One of the primary objectives of the health care bill is health care cost control. One estimate of the cost of the measures in the bill by the CBO was around $1 trillion. This looks like cost increase and not cost control or at least not cost reduction. All of the statistics indicate that the percentage of GDP represented by health care costs is increasing precipitously. Another less talked about objective is to make the taxation for delivery of health care in the U.S. fairer. Control costs and spread the burden more fairly then are two objectives of the bill. Statistics show that the tax burden for middle income wage earners overall has gone up over the past decade and especially as a result of regressive taxes on everything from sales taxes to motor vehicle fees, while the percentage tax burden on big business has been reduced. While it may be argued that the “people” are the beneficiaries of personal health care and the burden for the cost of providing that care “should” be their responsibility, given the way our laws for business are structured and their place in society is engineered i.e. corporation law, if the cost of this bill is to be around $1 trillion and the taxation burden trend has been to increase the amount paid by middle income wage earners and lower the share of burden for corporations, and I expect this trend to continue or endure, I deem this not to be a more fair distribution of the burden of the cost. Nor does it appear to control costs unless one is willing to assume that if nothing is done the increase cost to the federal government for health care over the same period would exceed $1 trillion – (this is not a given) . Given that the bill is clearly an expansion of entitlements and additional people are going to be franchised into the health care system in a new way, it seems likely that costs will in fact rise as predicted by the CBO and if the trend with taxation continues, middle class taxpayers will shoulder an increased burden. What I would change in the bill, to properly address the goals of cost control and fair distribution of the burden, that would be an improvement, would be to include more and more serious investment (meaning on a scale commensurate with the size of the problem) to reduce the COST of healthcare. This means direct investments (tax incentives, subsidies, grants and scholarships) that yield efficiencies and lower costs through lower prices, i.e. availability, accessibility and increased competition for goods and services e.g. more doctors, nurses, medical schools and lower drug costs accomplished by increased direct government subsidy of biomedical and pharma research and development. These things would address the supply side. To affect cost from a demand side, the bill should have more targeted incentives and disincentives for behavior that improves public health morbidity rates and reduces societal healthcare costs. This would come in the form of subsidies and tax incentives for promoting physical fitness, healthy eating and education mandates for teaching “health” in public schools starting at K and continuing through high school. There also must be incentives for promoting healthy lifestyle in the workplace and disincentives for companies that ignore employee health concerns. To make the tax burden more fairly distributed, I would extend the mandate to provide coverage to all businesses that employ more than 5 people le regardless of size, but scale the contribution to account for small businesses more limited economic means.
Monday, March 15, 2010
Five features missing from most EHRs
The following article appeared recently on the on the Healthcare IT News mobile section of the HIMSS website.
“Five features missing from most EHRs"
While EHRs are increasingly essential for healthcare providers, their efficacy can be constricted by the nature of their design, their use and the interpretation of data.
Jerry Buchanan, Program Manager and Scrum Master at eMids Technologies, Inc., an IT and BPO consulting company, weighs in on some features that are missing from EHRs:”
1. Information, not dataWhile EHRs hold data, that's not the same as holding information, Buchanan notes. Data needs to be converted into relevant information to be of practical use. However, there's also the possibility that EHRs can get overloaded with information. The goal, Buchanan says, is technology that organizes data in a way that assists healthcare providers most efficiently and effectively in making clinical decisions. This includes EHRs capable of providing alerts and alarms about patient conditions, given to caregivers in real time.
2. Comprehensive health history
Buchanan says that clinical data is usually entered into an EHR after a health episode. He notes that a history of recorded episodes is not the same as an overview of someone's health history. Some health systems are beginning to change this feature, propelled by the needs of chronic disease management, Buchanan says. Ultimately, it may be the standard for all patients.
3. Information tailored for various users
Who is the audience for the EHR's information? Buchanan says information is most useful when it matches the needs of various recipients. For example, a cardiologist, a primary care physician and a nurse might have different needs when it comes to the type of information and the level of detail they seek about a patient. Ideally, an EHR would be configured to the needs of the individual end-user.
4. Tracking the transition of care
Appropriate patient care is not static -- it must flow from one caregiver to another, from one facility to another. An EHR works better for a patient if it includes features that track tasks -- such as giving medications, monitoring conditions and administering medical tests -- to completion, and then reassigns them, if necessary.
5. Patient-side management of information
Buchanan says the ultimate EHR would give the patient -- the consumer -- the ability to manage just what health-related information (HRI) is available to which practitioners.
Referencing each of the topics listed by Jerry Buchanan I have listed my thoughts regarding each item.
1. Information, not data - This is of course the age old pursuit – but is acute and especially poignant in healthcare - to create or harvest knowledge and actionable information from data often urgently – and in real-time. This issue is then of course of particular concern to healthcare professionals. The body of data and information relevant to the care and treatment of a given patient can be immense and even overwhelming and as stated, at times urgent. The patient’s life may hang in the balance as data is converted to something useful for creating and managing a potentially lifesaving intervention or care strategy.
2. Comprehensive health history - The bringing together of all of the information that comprises a person’s complete medical history, today is almost too futurist a concept to be contemplated – but not quite, as we have this goal in our sight. We are laying the groundwork for a future state where such a concept will become relatively commonplace. And there will be a quantum leap in the history of mankind with respect to personal and public healthcare wherein information about a person’s physiological and health evolution will available for rapid retrieval, review, analysis and will be part of vast body of public information where new perspectives and unprecedented understanding about human physiology and evolution will emerge.
3. Information tailored for various users - Truly one of the most wonderful things about software is it adaptability, configurability and malleability for displaying context sensitive information. It can be rendered according to platform, (browser or operating system or device e.g. mobile computing device. etc.) user or any number of modifying variables. In effect giving us the beauty and elegance of mass produced data (available in 1 to N venues simultaneously) customization according to our need, desire or preference. So, the, or a, record can be opened to a view that renders the most value and efficiency as desired or required by the user.
4. Tracking the transition of care – Surely the significant magic of the electronic health record has its roots in its potential for being universally available, made possible by the immense utility of packet switching protocols, LANs, MANs and the Public Network architecture. Additionally, the chain of care, the history of ailment, morbidity, treatment and response, in an integrated format will make health care more comprehensive, efficient and effective in terms of cost and will ultimately contribute significantly to a better quality of life for the beneficiaries of these systems.
5. Patient-side management of information – This aspect is little talked about thus far, but giving patients the ability to add to and in some respects and in some areas of the record, the ability to redact and add to narrative information within their own record and health history will prove, I think, to be a significant improvement to the current health record data collection concept. Theoretically, no one has a greater interest in making the information correct, comprehensive and articulate than the individual patient or family member. This is not a given and or an absolute concept to be sure, but there is great potential for better records and significantly richer information when the patient is allowed and in fact encouraged to participate in the data collection and information management process.
“Five features missing from most EHRs"
While EHRs are increasingly essential for healthcare providers, their efficacy can be constricted by the nature of their design, their use and the interpretation of data.
Jerry Buchanan, Program Manager and Scrum Master at eMids Technologies, Inc., an IT and BPO consulting company, weighs in on some features that are missing from EHRs:”
1. Information, not dataWhile EHRs hold data, that's not the same as holding information, Buchanan notes. Data needs to be converted into relevant information to be of practical use. However, there's also the possibility that EHRs can get overloaded with information. The goal, Buchanan says, is technology that organizes data in a way that assists healthcare providers most efficiently and effectively in making clinical decisions. This includes EHRs capable of providing alerts and alarms about patient conditions, given to caregivers in real time.
2. Comprehensive health history
Buchanan says that clinical data is usually entered into an EHR after a health episode. He notes that a history of recorded episodes is not the same as an overview of someone's health history. Some health systems are beginning to change this feature, propelled by the needs of chronic disease management, Buchanan says. Ultimately, it may be the standard for all patients.
3. Information tailored for various users
Who is the audience for the EHR's information? Buchanan says information is most useful when it matches the needs of various recipients. For example, a cardiologist, a primary care physician and a nurse might have different needs when it comes to the type of information and the level of detail they seek about a patient. Ideally, an EHR would be configured to the needs of the individual end-user.
4. Tracking the transition of care
Appropriate patient care is not static -- it must flow from one caregiver to another, from one facility to another. An EHR works better for a patient if it includes features that track tasks -- such as giving medications, monitoring conditions and administering medical tests -- to completion, and then reassigns them, if necessary.
5. Patient-side management of information
Buchanan says the ultimate EHR would give the patient -- the consumer -- the ability to manage just what health-related information (HRI) is available to which practitioners.
Referencing each of the topics listed by Jerry Buchanan I have listed my thoughts regarding each item.
1. Information, not data - This is of course the age old pursuit – but is acute and especially poignant in healthcare - to create or harvest knowledge and actionable information from data often urgently – and in real-time. This issue is then of course of particular concern to healthcare professionals. The body of data and information relevant to the care and treatment of a given patient can be immense and even overwhelming and as stated, at times urgent. The patient’s life may hang in the balance as data is converted to something useful for creating and managing a potentially lifesaving intervention or care strategy.
2. Comprehensive health history - The bringing together of all of the information that comprises a person’s complete medical history, today is almost too futurist a concept to be contemplated – but not quite, as we have this goal in our sight. We are laying the groundwork for a future state where such a concept will become relatively commonplace. And there will be a quantum leap in the history of mankind with respect to personal and public healthcare wherein information about a person’s physiological and health evolution will available for rapid retrieval, review, analysis and will be part of vast body of public information where new perspectives and unprecedented understanding about human physiology and evolution will emerge.
3. Information tailored for various users - Truly one of the most wonderful things about software is it adaptability, configurability and malleability for displaying context sensitive information. It can be rendered according to platform, (browser or operating system or device e.g. mobile computing device. etc.) user or any number of modifying variables. In effect giving us the beauty and elegance of mass produced data (available in 1 to N venues simultaneously) customization according to our need, desire or preference. So, the, or a, record can be opened to a view that renders the most value and efficiency as desired or required by the user.
4. Tracking the transition of care – Surely the significant magic of the electronic health record has its roots in its potential for being universally available, made possible by the immense utility of packet switching protocols, LANs, MANs and the Public Network architecture. Additionally, the chain of care, the history of ailment, morbidity, treatment and response, in an integrated format will make health care more comprehensive, efficient and effective in terms of cost and will ultimately contribute significantly to a better quality of life for the beneficiaries of these systems.
5. Patient-side management of information – This aspect is little talked about thus far, but giving patients the ability to add to and in some respects and in some areas of the record, the ability to redact and add to narrative information within their own record and health history will prove, I think, to be a significant improvement to the current health record data collection concept. Theoretically, no one has a greater interest in making the information correct, comprehensive and articulate than the individual patient or family member. This is not a given and or an absolute concept to be sure, but there is great potential for better records and significantly richer information when the patient is allowed and in fact encouraged to participate in the data collection and information management process.
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