Forecast 2010: Electronic Records

Jan. 9, 2010

An Aide for EMRs

By Farida Ali, CEO, Dynamic Computer

The industry is witnessing the beginning of a trend of including automatic identification and data capture (AIDC) with electronic medical-record (EMR) adoption. EMR adoption has lagged despite a strong push from both private and public entities. Simultaneously, there has been an increase in the adoption of real-time locating systems (RTLS) and other technologies in the healthcare market. The paired adoption of EMR and AIDC systems holds the highest potential for improving patient care, reducing costs and minimizing risks.

AIDC refers to methods that automatically identify objects and then capture data about them directly into computer systems. These include radio frequency identification (RFID) technologies, bar codes, biometrics, optical character recognition (OCR), voice recognition and other electronic means of automatically identifying people and tagged objects.

Frustration around the disruption in work flow is one of the main reasons (next to the cost of adoption) that EMRs are unpopular among doctors. This disruption in work flow not only affects staff morale, it affects the quality of care that patients receive.

Efficiency is gained with AIDC by capturing data automatically instead of manually. A change or pause in work flow is not required in order to enter and share patient information, nor will it add extra duties to staff and clinicians. Manual data entry is time consuming, expensive and prone to many of the same types of human error as paper records.

Accuracy is critical to EMR success. AIDC is accurate without requiring human intervention and seamlessly integrates with EMR systems. The best systems are up 100 percent of the time, with no missed events and no false positives, and they accept information in real time.

Most EMRs are accessible through Web browsers. Delivering information into the record immediately means that both individual patient and facility summary data are available both through EMR systems and through the AIDC system dashboards. These executive dashboards allow clinicians to make informed decisions based on the most-current patient and facility data.

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At the Crossroads

By Jay Deady, executive vice president of client solutions, Eclipsys

ARRA looks like it will accelerate the long-overdue adoption of electronic health records (EHRs). That slack will begin to pick up next year. Along with that EHR adoption, however, a ripple effect will occur. There will be greater demand for quality metrics and public reporting — that will be the real evolution, the big change.

As a whole, the healthcare industry does not currently communicate health information well, nor does it aggregate it well enough to see patterns and find trends. It will become increasingly obvious that health IT design needs to not only provide access to data, but also the seamless extraction of data for comparative and quality purposes. How this ultimately will play out is a progression from the basic need to automate transactions — which generates a plethora of data for retrospective analysis — to more focused, knowledge-based systems that can provide actionable data and analysis in near real time.

Quality reporting and accountability is a market reality for healthcare providers. Labor-intensive manual reporting is a huge cost for hospitals and it only offers views of past events. The rear-mirror view of quality compromises the hospital's ability to address issues in a timely manner. As a result, clinical-system design efforts will start to be geared toward quality-analysis functionality that is intertwined with the clinical work flow as the clinician takes care of that patient.

Furthermore, as quality indicators become more directly tied to reimbursement, or when the ARRA carrot becomes a stick, there will be a realization that siloed clinical and revenue-cycle systems will not deliver the level of quality information needed. The line between the use for clinical analytics, decision support and financial analytics will start to blur, both from a tracking and an alerting perspective.

The plans for standards of interoperability, privacy and security will be finalized next year. Free text and non-codified language will come under scrutiny as ARRA mandates exchange of “semantically interoperable” information among care providers, and between providers and patients. Organizations will begin to realize the data they have already captured may not be effectively shared or used for reporting and performance improvement efforts.

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Eclipsys solutions:

A Proactive Opportunity

By Brian Cleary, vice president of products and marketing, Aveksa

The Health Information Technology for Economic and Clinical Health Act (HITECH) puts significantly increased demands on healthcare organizations in the areas of HIPAA audit and notification. Organizations will also be impacted by new requirements for on-demand patient audit requests of who had access to health records, notification of potentially compromised patients and the provision of reports detailing the origin and nature of any given incident.

Compliance will be particularly difficult for organizations without strong access-governance processes and policies in place to provide a historical audit trail of who has access to, and who did access health records. For that reason, many organizations are already starting to rethink their processes.

Organizations should view the HITECH Act as an opportunity to implement an access-governance framework to improve and modernize how patient information is stored and accessed through electronic health records in 2010.

HITECH Act violations will take center stage this year. Fines can be substantial — up to $250,000 — and criminal penalties can also be imposed.

One area that will continue to lead to a significant number of audit findings for healthcare organizations is access-change management, and new stringent HITECH Act guidelines will make it even more challenging from a controls perspective. Organizations will need to shore up processes for governing requests for initial access and changes to existing access due to transfers and terminations.

Change will become so overwhelming for these organizations that processes for governing access will be unable to keep up with reality. Organizations typically do an adequate job controlling initial access requests, but when users transfer or terminate their relationship with the organization, it is more problematic, as most organizations lack a standardized process for dealing with access change.

To become HIPAA compliant and also ensure compliance with the new requirements brought on by the HITECH Act, organizations will need to replace many of these manual processes — an opportunity to proactively implement an access-governance framework that leverages the overlap with other regulatory obligations such as Sarbanes-Oxley.

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Aveksa solutions:

Leadership Is Important

By Glen Tullman, CEO, Allscripts

As a result of the American Recovery and Reinvestment Act (ARRA), the four conditions widely seen as necessary for rapid change are in place — vision, standards, incentives and a time frame to accelerate both the adoption and the meaningful use of electronic health records (EHR).

Technology alone, however, is not enough to bring lasting change to the U.S. healthcare system. That will require effective leadership from physicians and healthcare stakeholders across the nation in order to overcome the natural resistance to change and achieve the true goal: the free flow of, and real-time access to, critical healthcare information when and where it is needed.

While good policy can help, demonstrated leadership from physicians and healthcare systems will be needed. One recent example is a health system that has committed to provide its more than 7,000 affiliated physicians $40,000 of incentives on top of the ARRA incentives toward the implementation of a connected EHR. This network will share de-identified outcomes data and enable physicians to access and use real-time evidence-based standards to provide better care for patients.

Change is also coming from leading multispecialty practices. After aggressive deployment of an EHR, one New Jersey practice began using the EHR as a tool to improve the quality of care being delivered. The practice has already received more than $229,000 in Medicare incentives for meeting and exceeding standards and is poised to do the same for the 2009-2010 incentives.

Along with leadership comes collaboration. More organizations are cooperating in areas such as connectivity, even as they continue to compete for patients. One example of this is happening in Connecticut, where a number of organizations are building the infrastructure for connected systems via a statewide health information exchange.

As the industry prepares to demonstrate the meaningful use necessary to qualify for ARRA incentives, leadership will make the difference in 2010.

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Physicians Will Push EHRs

By Michael Nissenbaum, CEO, Aprima Medical Software

There will be two major trends in electronic health records (EHRs) in 2010. First, physicians everywhere, especially sole practitioners and those in small- and medium-sized group practices, will find they need EHRs and the advanced interoperable technology embedded in the more-advanced solutions to properly share information and collaborate with other clinicians and the hospitals in their area. Second, as physicians grow to rely on their EHRs, they will expect more from them, particularly in terms of clinical decision-support tools.

The Health Information Technology for Economic and Clinical Health Act encourages physicians to adopt EHR technology. As presented by the Office of the National Coordinator for Health Information Technology, which is in charge of the effort to encourage adoption and use of healthcare IT, healthcare transformation features a curve that moves from data capture and sharing in 2011, to advanced clinical process in 2013 and then to improved outcomes in 2015.

Providers claiming to have an EHR will be laid bare when the meaningful use litmus is in place. No longer will the simple digitization of patient charts pass for having an EHR. Physicians will have to make the commitment to get training for themselves and their co-workers on the requisite EHR features that will enable them to meet the meaningful-use criteria. Then, the physicians and healthcare facilities that have adopted EHRs will begin to demand more from the technology. Physicians will want interoperability between physician offices, labs, pharmacies, radiology centers and other organizations. In fact, the meaningful-use criteria demands that.

With interoperability in place, look for physicians to seek evidence-based clinical-information support that can assist them in diagnosing their patients. This is also known as clinical decision support (CDS). At its best, CDS offers timely, patient-specific information and knowledge that is structured and displayed to help physicians improve outcomes for their patients. CDS tools can range from summaries, alerts, reports and reminders to integrated diagnostic recommendations.

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A Key to Digitizing

By Ed Santangelo, senior vice president of healthcare, Iron Mountain

U.S. legislators appear determined to move forward with establishing a higher standard of care for all. One key to that ambition is the modernization of clinical-information systems and the digitization of patient records, an update many contend will result in fewer clinical errors and cheaper medical care.

Realizing these benefits of more-efficient systems, lower costs and better care requires hospitals and healthcare organizations to develop a plan for transitioning from paper records and medical films to an electronic health record (EHR). Amid all the rhetoric surrounding digitized records, however, and the money and technology required to do so, little to nothing has been said of the importance of a transition plan. A good transition plan allows hospitals to find money within their existing budget for digitizing patient records, simply by improving how they manage their paper ones.

U.S. hospitals annually spend billions of dollars to store and manage approximately 500 million patient records, along with the billions of financial, claims, business and film records associated with patient care. Much of the cost comes from rent and labor paid to maintain multiple file centers that in some cases stretch for acres. In addition, many healthcare organizations are paying to store records beyond their state-mandated retention laws — in other words, records they could destroy.

This “keep-everything” practice is due in part to hospitals complying with record-retention laws that vary widely by state. Healthcare organizations in Florida, for example, must keep records for seven years, while Massachusetts law mandates hospitals save patient records for 25 years.

The creation of a national, 10-year standard for retaining and then destroying older records would provide needed guidance to hospitals on what to keep, what to destroy and what to digitize, and, in the process, unlock cost savings that they could apply toward EHR. Short term, this national approach to record retention could cut the country's 500 million paper records by more than a third. In the long term, legislating this proposed national retention policy could reduce storage and transition costs up to $11 billion over a 10-year period.

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Meaningful Documentation

By Michael Finke, CEO, M*Modal

Make completing structured documentation faster and easier for physicians and they will more fully participate in electronic health records (EHR). Speed and simplicity are certainly factors to consider, but the real story on physician resistance is more likely based on their desire to preserve clinical effectiveness and quality of care than whether they prefer to type, click or talk.

Technology should adapt to how clinicians currently document in order to improve care. Emerging standards, along with ways to use those standards to build semantically interoperable data models, will prove that physicians were right to hold fast to comprehensive clinical narrative being part of the electronic patient record.

What healthcare needs is a way to collect and access structured data without reducing medicine to a multiple-choice exercise that compromises a provider's ability to express and share the patient's story.

In 2010, healthcare will make notable progress in closing the chasm between the physician's need to create and use the narrative and the enterprise need for structured and coded information capture. A key enabler to this is the Health Level Seven's (HL7) clinical data architecture (CDA), an open standard that specifies the structure and semantics of a clinical document for the purpose of exchange.

With HL7 CDA, the physician's written or spoken narrative can be the source for the majority of discrete and codified elements needed to populate EHR data fields: accessible and useful for research and data mining, to identify and assess treatments and protocols, and for evidence-based medicine.

Yet, the narrative remains whole and understandable for any care provider to read and use in the care process. It evolves the EHR from its data-centric roots to a more-inclusive, comprehensive and meaningful resource.

To get there, medical transcription companies should support creation and delivery of these standards-based documents, and EHR vendors' systems should have the ability to receive, display, transform and parse these documents.

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M*Modal solutions:

January 2010

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