EHRs/EMRs Show Big Promise, But U.S. Progress is Slow

Electronic medical records (EMRs) and electronic health records (EHRs): just about everyone who has a say in the matter wants them to be systemized, accessible and widespread, and yet this seemingly simple plight is more complex than solving a Rubik’s Cube in a vat of chocolate pudding. Blindfolded. Without hands.

The use of electronic records in healthcare lags behind the adoption of information technology (IT) in other sectors of the economy, claim researchers from the Centers for Disease Control and Prevention (CDC). Electronic billing is widely used, but the computerization of clinical records has been much slower. President Bush in 2004 called for a majority of health records to be electronic within 10 years,¹ but so far that goal is far from met.

Some say that transferring patient information across healthcare networks isn’t possible without a national, systemized approach. Either way, healthcare IT is important to patient safety, says Tom Hui, CEO of Healthcare Systems and Technologies (HST). Hui specializes in software for surgery centers and has worked in the industry for 23 years.

Proper IT integration requires complete support and understanding by physicians, nurses, and administrative staff, Hui says.

“The first step is to identify where most of the medical errors are made,” he adds. “Only then can we design sensible and practical solutions — which can include information technology — to reduce or eliminate such errors.”

Defining Healthcare IT

Many in the industry believe that a specific discussion of healthcare IT is challenging due to the rapid change of technology, the volume of applications and a lack of precise definitions. In general, IT allows medical practitioners to collect, store, retrieve, and transfer information electronically. Similar terms can be used to define sundry products, and the exact functions of a system often depend on how it is implemented.² 

In short, it’s convoluted.

The term EHR, for example: EHRs are also known as electronic medical records, automated medical records, and computer-based patient records, among other names.³ This technology can be used simply to store patient information, or for a wide range of motions from patient reminders to lab work results. Some use the terms interchangeably, while others see EMRs as a subset of EHRs. For the purposes of this article, the terms will be treated as synonymous.

The variation of definitions confuses purchasers, says Linda Peitzman, MD, chief medical officer of Wolters Kluwer Health, a global information services company that includes brands like ProVation Medical, an electronic documentation system that replaces dictation and transcription. A lack of integration and standards of communication makes interoperability difficult. Peitzman says that companies are trying to solve these challenges, but that it’s a tough road. The complexity is even greater in the ambulatory surgery center (ASC) field than in other areas, she says.

“At a high level, an ASC EHR needs to provide functionality to address documentation (images and text) for the physicians and nurses, in addition to producing ancillary information like billing codes, post-op orders and patient instructions,” she says. “Additionally, the EHR should be able to receive other types of documents via scanning (a driver’s license, for example). All of this information needs to be available online in a standard chart view.”

The Grand Potential

There is no question that EHRs have the potential to transform parts of healthcare, says Don E. Detmer, MD, MA, president and chief executive officer of American Medical Informatics Association (AMIA). The potential, however, will not necessarily come to fruition.

“If you spend only enough money on an electronic record (with which) you essentially just do the data reporting function but not decision support, you will get some benefit but you won’t get that much,” Detmer says. “It’s really when you put in decision support that you get the true major benefits. The point is whether we do it or whether we do it right. It’s an open question right now. At least we are finally seeing CMS (Centers for Medicare & Medicaid Services) … talking about helping the doctors put this into their practices.”

Most importantly, adequate healthcare IT can improve patient safety, Peitzman adds.

“The more manual the process is, the more likely it is that medical mistakes will be made, which certainly impacts patient safety,” she says. The solution, she professes, is fast access to medical data at the point of care, accurate multimedia documentation, compliant coding, and information that is entered once but used many times.

EHR’s will transform healthcare to an even greater extent than most believe, says Donald Fallati, senior vice president of marketing for Amkai, a company that delivers integrated administrative and clinical software to ASCs, surgical hospitals and affiliated physician practices. Amkai’s software suite allows these entities to share data and become paperless. Industries such as banking and insurance have undergone effective IT evolution and the benefits in healthcare are much more vast, Fallati says.

“What often falls short is the particular solution — not the concept,” he says. “Healthcare IT is critical to patient safety. From discovering potentially fatal drug-to-drug interactions, to enforcing the time out in surgery, to ensuring correct site surgery, there are just too many areas to mention.”

Worth the Investment?

Not every surgery center has the same needs. Therefore, the leaders of a typical center should ask themselves what benefits they hope to receive from using EMRs, Hui says. Do they really want to process medical information as data or do they simply want to go paperless?

“There are less expensive and less disruptive alternative technologies to deliver paperless environments without the financial risks and difficult cultural changes associated with EMR or EHR implementations,” Hui says. “An ailing center should focus its best resources and attention to improving fundamental and structural problems like case volume, case mix, payer contracts, competitive analysis and aligning its operating costs with revenue models.”

An investment in healthcare IT, such as EHRs, is absolutely worth it for most centers, but only if the center properly adapts, Peitzman says.

“Simply automating an existing process is not enough; the center must closely examine their processes to help maximize the benefits of the system,” Peitzman says. “Changing management skills and creativity are also critical to realizing value from any system. It is even more critical for an ailing center to leverage the advantages an EHR (system) can bring them, including lowered costs and increased revenues.”

While IT does require some investment, the better documentation and coding it brings can be critical for long-term survival. It can even lift a center’s bottom line from the negative into the positive in a short amount of time, Peitzman says.

The EHR is a natural evolution of the use of technology in healthcare, Fallati believes. “Any doubt about the value of the EHR is the direct result of horror stories of implementations gone badly,” he says. “There are many mediocre to outright bad EHRs on the market.”

Slow to Adapt

True, EMRs have tremendous potential, but they are falling short of it, Hui says. He blames the following:

• The industry has not addressed who owns patient medical information 
• Privacy and security issues have not been satisfactorily defined 
• The lack of data standards is impeding the collection and integration of medical records into a central (physical or virtual) data repository 

Hui believes that effective transformation would provide better medical outcomes to more people at a lower cost-per-unit of medical service. The path is complex, however.

Peitzman agrees that the situation is challenging.

She says that a main reason why acceptance of EMRs has been difficult is because many systems do not provide enough value for physicians.

“A ‘shell’ system is good for moving a lot of information around to a lot of people, and for administrative functions,” she says. “However, when it comes to the delivery and documentation of care, physicians need a system that is fast and easy to use, but also provides deep medical content. Without core medical content, physician adoption suffers.”

The medical industry has definitely adapted to IT more slowly than many other industries, Detmer says. That’s because healthcare is so complex, regulated and uses such a curious payment structure.

“If I fly on an airplane, I get the ticket and I pay for it, whereas in healthcare, I may pay some of it, (and other groups) may pay some of it. It’s very complicated,” he says. However, Detmer knows that the “it’s complicated”

excuse doesn’t hold much water. “It’s not like other nations aren’t (adopting healthcare IT) and moving along,” he says. “Some of it is that no one is in charge of our healthcare system and typically it takes leadership to get this done.”

In many areas of healthcare, automation and IT is widespread, Hui says. He agrees, though, that it has a long way to go. One reason it’s not moving swiftly is because the return on investment (ROI) is difficult to calculate, he says. Also, there is a lack of industry-wide standards, and healthcare executives in general have not prioritized IT as a strategic tool beyond operational and financial systems.

“Healthcare information technology is traditionally treated as a ‘cost center’ and a necessary evil,” Hui says.

Generally, pharmacies seem to be the most advanced users of healthcare IT while physician offices and nursing homes are further behind, some believe. Peitzman subscribes to this theory. “Pharmacists have embraced technology and the systems have developed over many years to meet their needs,” Peitzman says. “EHRs have a much more recent history, and have traditionally lacked much of the functionality and medical content needed to make the physician productive.”

Physicians are often portrayed as being averse to technology, but this depiction isn’t fair, Peitzman says.

“The fundamental problem is that, in general, they have not been given great systems that provide personal benefit,” she says. “Once that occurs, they are as a whole more than willing to embrace technology, as they have done with the delivery of healthcare for many years. Remember, these are the same people who are doing highly skilled procedures using very sophisticated technology most of us don’t even understand.”

The Push by Bush

When President Bush in 2004 touted the potential of EMRs and suggested the majority of Americans should have EMRs within the next 10 years, it generally aided the healthcare IT movement, Detmer says.

“Just to say that this is something that the country ought to do was a good thing and it has helped move things along,” he says. “On the other hand, the amount of money that we’re putting in from the government’s side has been very small compared to what England or Canada or Australia has done.”

President Bush was reacting to the general consensus within the United States that the healthcare system could operate better. Some feel much more extreme, Hui says, and call our system flat-out broken. There is no reason the system can’t be improved, Hui says.

“In the 1960s President John F. Kennedy set a goal for the nation to reach the moon by the end of the decade. That goal was reached,” Hui says. “The material realities of President Bush’s statements have prompted much attention and investment dollars by both private industry and state governments into the development of electronic medical record products and services.

Whether we achieve this goal, and to what extent, will be determined by economic factors and political influences over the next 10 years.”

Uncle Sam’s Role

The debate of how much our government should control or finance is a core part of the political division in the United States and plays a role in healthcare too. Detmer, for one, thinks Uncle Sam needs to pony up more funding. This could lead to standards that improve connectivity and interoperability.

“(That way) communications can actually move from one place to another and connect,” Detmer says. “That’s a big challenge. Another way government can help — but they aren’t doing this today much — is to help build the infrastructure that you need to move the data securely from one part of the system to another. They have these regional health information organizations, but exactly how to make those cost effective is still really a challenge. Today at least, the government doesn’t see this as a government function and yet if you look at (Hurricane) Katrina, for example, we know (accessible medical records) are important for national catastrophes and for bio-surveillance and bioterrorism and disease transmission (research).”

In short, adequate healthcare IT is about public health, not just the individual. Government help can be a blessing or a curse. One way that federal tinkering could make IT worse, Detmer says, is if it went overboard in the effort to protect privacy and didn’t allow the data to be used for responsible healthcare research. “There are bills being considered today that I think would make it almost impossible to give high quality care,” he says. “If things like that will pass it could be a problem.”

Government can assist by setting quality indicator standards and definitions for interoperability, Peitzman says. One problem is that the government has not provided an adequate definition of ASC EHRs, she adds.

“They are also the nation’s biggest payer, through CMS. They can use that leverage to provide incentives for centers to acquire EHRs,” she says. “They should be careful, though, that the incentives they provide are not overly punitive.

This would be an opportunity to frame the move to EHRs as something positive and they shouldn’t squander that.”

The government should require quality indictor tracking, she adds.

“Without appropriate systems, it is nearly impossible to effectively measure quality in the delivery of care,” she says. “If physicians and institutions realize higher reimbursement for tracking quality indicators, they will move faster to adopt the necessary infrastructure.”

Hui agrees that defining and forcing of healthcare data standards is best left to the government. He recognizes that a few organizations have worked to meet these goals, but that special interests on some committees convoluted the mission.

While politicians talk and special interests pollute the process, the outcome, according to Hui, is an uncertainty in product design by software vendors and impediments to the exchange of medical information. All of this adds to the ultimate cost of acquiring and maintaining healthcare IT.

Examples from Abroad

No one can say that the widespread adoption of functional healthcare IT and EMRs is impossible. Well, they could say it, but they’d be wrong. Examples of good systems abound.

“It looks like there’s some prospects but America basically is falling behind an awful lot of the developed economies, (because) we’re not looking at it as a national priority,” Detmer says. “We’re looking at it as something doctors ought to do themselves and it costs enough money, particularly in the small practice environments even though they’re not the ones who mostly benefit. The patients benefit and the insurers benefit, but (the physicians) are being asked to pay for it.

“If we expect to see it done, we’re going to have to do something for the small practices,” he says. “I’m cautiously optimistic that we’ll figure it out, but how soon we will is anybody’s guess at the moment. If you look at what’s happening in other countries, in Denmark for example, boy, they’ve got a fabulous system. You’re starting to see (similar results) in England, Scandinavia, France, Germany — the importance and value of this is becoming more obvious.”

The United States does not have a good healthcare system, Detmer says. He calls it costly, dangerous, and in need of reform.

“An information technology infrastructure needs to be part of that reform, but I don’t think we are hearing from either party about the kind of reform that I think is really going to be needed,” he says. “If you ask them, they say it’s a good thing (but they don’t want to invest heavily in it). In the meanwhile we waste a lot of money and our citizens don’t get as good of care as a result. The incentives are just not right for the system to evolve in this country. If the government isn’t going to do it, I don’t know for certain if we’ll see it done.”

Detmer has heard that fewer than 20 percent of American general practitioners use EMRs, whereas he has heard that in England, all but a handful of general practitioners use EMRs.

“That’s why I say that we’re really getting lapped by these other countries and their systems,” he says. “I’m optimistic in one sense. If at some point the government paid over half the bills it seems to me that they would have a stake in helping us get this done, because honestly it saves money as well as saving lives.”

Other countries don’t necessarily have it right, some believe.

“To the best of my understanding the British experiment has not yet been proven successful,” Fallati says. “It is difficult to believe that the one-size-fits-all approach could ever be successful or great in an area as diverse as the EHR in healthcare. Each specialty and type of healthcare facility has special, distinct needs.” Fallati is wary of government micromanagement but still believes Uncle Sam should get involved with healthcare IT. “The U.S. government should mandate the EHR and provide financial incentives for its timely implementation,” he says.

Trends

Hui predicts that within the next year various healthcare IT vendors will upgrade tools to keep up with computer technologies.

“For the long term, we will see healthcare information technology reacting rather than leading advances in automated clinical information systems of which EHRs is only one component,” Hui says. The good news, he adds, is that within the next few years, we will probably see some efforts to align patient safety and better medical outcomes, financial incentives for medical service providers, and financial incentives for third party payers via healthcare IT.

So far, healthcare IT has been a fairly bipartisan topic, Detmer says.

“Today that’s really saying something,” he jokes, partly. “At least in terms of rhetoric, both parties talk about (IT) being important. I can’t see one party being more supportive than the other. I do think there’s some chance that we’ll see some IT legislation this year.”

Detmer also notes that Google and Microsoft representatives have talked about creating personal record vaults.

“That could be a good thing,” he says. “On the other hand, those are both private companies. If you had a public opened-architecture that was supporting it, you might ultimately have a better sharing opportunity to move things around since it wouldn’t be in one company’s system.” It’s a series of tradeoffs, he says, which means there is no panacea.

“I don’t think an IT system right now will make our system all wonderful, and that’s because we have too many dimensions of disorganization and IT isn’t a magic bullet,” he says. “If other things are done right, it can make a big difference. That’s just one of the things that need to come together for our system to be a lot better.” 

References 

1. Burt CW, Hing E. Use of computerized clinical support systems in medical settings: United States, 2001-03 Advance data from vital and health statistics. National Center for Health Statistics. 2005.

2. MedPAC. Report to the Congress: New Approaches in Medicare, information technology in healthcare. June 2004.

3. Brailer, DJ, Terasawa EL. Use and adoption of computer-based patient records in the United States: A review and update. Manuscript. California Healthcare Foundation. March 2003.