EMR / EHR
Whither Healthcare IT
From the impact of HITECH to the industry's perception of healthcare IT, our panel of experts weighs in on some heavy issues:
The federal government's role in healthcare IT continues to evolve; where do you see it heading after a couple years of HITECH implementations? Will a single, lead certification and standards entity emerge after the HITECH dust settles?
There is some chance that the rapid influx of federal incentive money for HIT adoption, with short deadlines and unsettled changes in certification processes, will temporarily add to the confusion and anxiety experienced by prospective adopters. These are very complex and expensive decisions that require skill sets that are not ordinarily part of the mix. It is telling that a concurrent federal initiative is designed to create training and advisory services, acknowledging that there are not enough skilled healthcare informaticists and technology specialists out there to make efficient use of important financial incentives.
As with any large-scale initiative, there will be both anticipated and unanticipated consequences. An anticipated consequence will be that these initial efforts will not be adequate for widespread adoption and effective use to truly coordinate the care of the majority of complex patients. I suspect that an unanticipated consequence will be the need for significant payment-system and medical-cultural changes. Technology currently available, but not yet widely used, is capable of enabling truly coordinated care. But time required for real coordination is not compensated, and medicine is not yet a team sport.
I certainly see the roles of CMS and ONC as ongoing enterprises, as the administration of meaningful use continues through Stage 2 and Stage 3 criteria. Like the current Stage 1 requirements, further stages will need coordinated rulemaking and stimulus payouts.
I suspect that the HHS role will become more of a stewardship as CMS and ONC oversee these stages of updates and maintenance which are already planned through the next decade. Throughout this process, it will remain important for private sector collaboration to remain intricate for the success of any of these programs, processes and policies.
I agree with ONC's vision that the private sector administers certification when the permanent certification process rolls out in the near future, although ONC will still have a hand in oversight and must provide necessary transparency to the transition and process. Ultimately, we'll have to see what market forces prevail. I think I can safely predict that CCHIT will emerge as one of the first, if not the first, ONC-ATCB, which will bring some short- and long-term stabilization to the process.
As the final rule for meaningful use shows, the government is placing great emphasis on adoption of EHRs and on implementing basic capabilities that can expand in the future. The focus will move toward making use of EHRs for improved performance and outcomes, clinical decision support to improve quality and safety, and analytics and reporting to measure it.
Although the final ruling on meaningful use provides a clear HIT path to follow, it seems the [journey] is bound to be a slow one. And it may not be a path that leads to ultimate HIT nirvana.
Plenty of opportunities remain to optimize work flow and standardize processes that will improve, in a very real and measurable way, patient safety beyond the established meaningful-use criteria. Even in healthcare facilities with EMR/EHR systems deployed, a significant percentage of patient charts may still exist on paper or as unstructured data. Forms, legacy patient documents, physicians' orders and insurance cards support the patient's medical record. For that patient record to be truly meaningful, it must be comprehensive. It must include all patient data that lives both in and outside of the EMR. This is enterprise content management's (ECM's) role in healthcare, and more healthcare providers are realizing ECM's place as a strategic asset in their meaningful-use strategies.
Whether one or many bodies of certification and standards emerge, the bigger challenge is that a certified EMR does not guarantee meaningful use.
Since the inception of healthcare IT, standards have been a necessity within in the industry; in order for systems to talk to one another, they need to speak the same language. Government-initiated standards, such as the CCR and CCD, were created to stimulate demand for electronic exchange of clinical data — not because there was particular demand in the market, but because the ability to exchange clinical data is the ultimate goal of the EHR. When the HITECH dust settles, the need for government-initiated or government-led standards should decrease and market-driven standards should return.
As a result of HITECH, all EHRs are required to be functionally equivalent to be certified. Past the initial certification for baseline functionality, the need for further certification will decrease as the focus turns in Stages 2 and 3 from fostering adoption to fostering interoperability and eventually analyzing and improving outcomes.
The government's role will continue to increase. As government pushes for more accountability regarding quality and outcomes, that activity will be predicated on hospitals having the information systems and the reporting. There is also interest being shown by Congress in making sure that clinical systems function properly and are current with evidence-based medicine. The government has told us that there will be multiple certifying bodies, perhaps for competitive reasons or to handle the volume of certifications or convenience. Regardless, we believe there will be several [bodies]; only time will tell if one emerges as the lead certifier.
The HITECH Act, as it is written, is intended to drive the increased adoption and utilization of healthcare information technology. The expectation is that this increased adoption will have the subsequent impact of improving the quality and decreasing the cost of care delivery.
Appropriate utilization of healthcare resources, including diagnostic testing, is a significant lever in decreasing the cost of care delivered.
As the single largest payer for healthcare services in the country, the federal government stands to gain significant benefits if the clinical and economic expectations of meaningful use are realized.
The HITECH initiative holds great promise if implemented as contemplated by the legislation, specifically in the areas of improved efficiency, delivery of healthcare and cost. Improving access to test results could eliminate unnecessary tests. After a couple of years, organizations will be held accountable. As the consumers of healthcare become more knowledgeable, provider organizations will be evaluated on the quality and cost [of their systems]. Organizations that work well as an integrated delivery system will be more successful than those that don't.
Information technology has often been viewed as a cost center, a necessary negative and, in some rare cases, evolved to acceptance as core to healthcare's future. What have you seen in the evolution of IT as it is perceived and embraced by healthcare provider organizations?
HITECH has put IT on every organization's agenda. It is now seen as a regular strategic tool, something that CMOs and chief quality officers think of early in the discussion of how to address major issues and goals. There is broad realization that, properly implemented, [IT] is something that has made a substantial difference in quality, safety and cost of care.
Aggregation and sharing of internal data, including the ability to make sense of it in a way that improves efficiency and quality, is becoming a focus of provider systems [with] extensive but non-interoperable HIT systems. This involves recognition that the data in both healthcare business and clinical systems should be integrated. This is a more basic need in HIT-sophisticated organizations than achieving "meaningful use" and will be an underlying core business need, regardless of how the federal initiatives evolve.
We do a lot of business around the world directly with provider organizations, including government-managed delivery systems, in more than 20 countries and in many languages. Our customers in other countries are not affected by the ARRA HITECH incentives, but they are strongly affected by the same core business needs: greater efficiency and improved clinical outcomes. This is true internationally regardless of the nature of local payment systems. In many ways other countries — for example, Scotland, Chile, Brazil and Thailand — are showing how very large-scale, patient-centric HIT systems can enable care coordination, clinical outcome improvements and cost efficiencies.
Speaking as a clinician that practiced nursing almost 20 years ago, I am constantly reminded of how inefficient and error enabling the world of healthcare was before the arrival of clinical systems and applications. BCMA (barcode medication administration), CPOE, EMRs and clinical decision support are among some of my favorite advances in healthcare IT. If I were to return to nursing today, I would want to work at a place that has deployed this type of technology! Now that healthcare IT has grown from "necessary evil" to "core," increases in safety, efficiency and productivity have been realized. This, in turn, inspires improved patient care and gives back time for clinicians to do what they do best — care for patients.
As systems improve and clinicians have the data they need when and where they need it, continuity of care across providers evolves. We can finally realize improvement in quality of care and access, increased patient safety, enhanced patient-focused records and increased safety and efficiency for healthcare providers — and all at a time when more patients are being added to the system through healthcare reform.
Organizations will embrace a technology that fits their needs and offers usability that matches work flows. If those standards are established up front, practices and hospitals have been shown to experience robust ROI, and healthcare information technology becomes an enabler of profitability rather than a cost center. We've seen declining practices revitalized by the right analysis and implementation.
I think the industry expects more acceptance as the provisions of ARRA and the HITECH Act take hold. I think we've all seen encouragement by the early adoption and movement being seen by the regional extension center (REC) programs, for example. And finally, I think that these acts are furthering the understanding that standards-based interoperability can also be a driver of acceptance as practices realize they can exchange data internally and externally to satisfy stimulus programs, pay for performance measures and advance interaction with patients.
Clinicians are reimbursed on quantity, not on quality, so physicians in particular have been hesitant to accept that IT leads to greater efficiency, as has been the case in nearly every commercial endeavor.
Health reform is driving reimbursement to a quality-based model and driving clinical HIT as a mechanism to manage reimbursement. In the case of financial practice management, HIT has been overwhelmingly adopted because a clear ROI can be demonstrated — provider organizations can essentially not survive without it. When the same can be said for clinical IT, it will gain the same level of acceptance.
Our customer base is community hospitals and they still view IT as a necessary negative because of the capital cost and the challenges with changing work habits among staff and physicians. For those hospitals that take the initiative, the outcome is generally good; staff and physicians don't want to go back to paper. Physicians and hospitals begin to understand the negotiating power derived from the clinical quality and cost data that comes from a fully integrated HIT system. The challenge is getting providers to that point.
In addition to the leadership in adoption of information technology, the lab has taken the initiative to couple the technology with Six Sigma processes to drive further efficiencies and reduce variation in their processes. This combined effort is key to decreasing the potential for errors in the testing and resulting processes, upon which approximately 70 percent of patient care decisions are based.
Laboratory test results are among the most requested pieces of information by all constituents within the healthcare value chain.
The emergence of the personal computer and the transition from the mainframe computer system to server-based applications brought an entire new suite of applications to healthcare providers that penetrated all facets of the delivery and administrative areas of healthcare IT. This has profoundly affected the embracement of technology by all users in provider organizations.
You can see this when you visit any hospital emergency room. Registrations are done via computer; benefits are verified real time; co-pays and/or deductibles are paid; diagnostic procedures are conducted; and results are available in minutes [instead of] hours. From there, nurses are able to chart what was done for the patient, and the coding and billing processes are completed typically in a day or two (at the most), with a claim being sent to the payer immediately thereafter with an electronic remittance likely received in less than 10 days. Most of this can be done with minimal administrative overhead, paperwork or data entry. Permanent records can be maintained, thereby reducing storage costs and ensuring access more readily to the provider organization.
IT is now one of the most important departments in the healthcare enterprise, and I cannot imagine any provider not appreciating the impact IT has had on the improvements described herein.
M.D., senior advisor, medical informatics, InterSystems
vice president, healthcare solutions and strategy,
vice president, marketing, Sunquest Information Systems
vice president, marketing, corporate development and government affairs, Greenway Medical Technologies; chairman emeritus, Electronic Health Record Association
president, Sage Healthcare Division
M.D., Ph.D., chief medical informatics officer,
CEO, Healthcare Management Systems
director of product management, HealthPort
executive vice president, sales and marketing,
The SSI Group
Tags: EMR / EHR