Despite the myriad and often complex ways of attempting to achieve it, the goal of healthcare reform is to improve care while decreasing cost. Incentives put in place as part of the HITECH Act give reimbursements to physicians who convert from paper-based records to electronic medical records (EMRs) – although the ultimate cost savings of EMRs is still being disputed.
Especially for a small practice, the cost of purchasing and implementing an EMR system can be daunting. And although converting from paper-based records to electronic ones makes logistical sense, it is difficult to determine its overall impact on cost or return on investment, since it is not directly tied to revenue.
Although they’ve been around for about 30 years, usage of EMRs in the U.S. and Canada is up 50 percent since 2009, according to the Commonwealth Fund. But the rush to compliance often means attempting to make disparate systems work with each other. Combine this problem with antiquated core platforms, and the importance of interoperability and integration becomes clear.
Other issues include ease of use (a common complaint has been that EMRs reduce the face time doctors enjoy with patients); security (keeping records in the “secure” cloud is often touted as a possible solution); and patient engagement (buoyed by connecting the EMR to a personal health record).
For our first issue of 2013, Health Management Technology asked industry experts to weigh in with their perspectives on the near future of EMRs/EHRs (electronic health records):
Howard Zahalsky, M.D., U.S. medical director, Activ Doctors Online
The provider as PHR proponent
We in the medical community have been bantering back and forth about pros and cons of EMRs for years now. Some have long championed the transformation from paper to paperless and are thriving in the digital world. Others remain skeptical and frustrated, pointing to less-than-user-friendly technology. But until recently, personal health records (PHRs), the patient-centered companion to EMRs, have been at best a sideline conversation among most healthcare providers.
The limited focus on PHRs in the medical community is understandable, given that PHRs are “owned” by the patient, not the provider. But it’s a missed opportunity for providers to improve communications, increase patient engagement and compliance and boost patients’ “customer satisfaction” with their providers.
When quality PHR and EMR platforms are properly linked (interoperable) and supported by engaged patients and providers, outcomes can and do improve. For that reason alone, we need more providers to step up as PHR proponents in order to inspire more patients to get with the program. A study from the Markle Foundation highlights the value of PHRs to patients, and research findings presented in the fall 2012 issue of Perspectives in Health Information Management, titled “The Impact of Health Literacy on a Patient’s Decision to Adopt a Personal Health Record,” indicate that a broad spectrum of patients can use PHRs successfully.
And it’s not just the right thing to do for patients, it’s also a smart thing for providers to do to help achieve and exceed meaningful-use goals. Beyond that, the interoperable EMR/PHR platform also creates a solid foundation for exploring new practice innovations, such as e-consults and other telemedicine options, which will play an increasing role in helping more Americans access care as the final components of the Affordable Care Act are put in place.
Jay Deady, CEO, Awarepoint Corporation
Real-time locating systems (RTLS) will maximize EMR investments
There is no doubt that EMRs drive safer care, improve quality and patient safety, and reduce duplication, costs and variability; they provide the data needed to care for the individual patient and do no harm. However, because EMRs are neither resource nor context aware, they’re limited in their ability to orchestrate care. EMRs cannot track interactions between caregivers and patients, provide the location of equipment and other assets, or identify the cause of extended patient wait times and other delays.
By enabling the EMR with RTLS, automatically feeding location and time-stamp data without manual intervention, organizations can maximize their EMR investment. RTLS enables powerful clinical process analysis from an operational perspective, helping analyze care delivery steps at a finite level, identifying inefficiencies and risk, and targeting improvement efforts. By focusing on the orchestration of assets, patients and staff across the enterprise and especially in areas of high acuity such as the ED and OR, hospitals are able to improve capacity management, patient throughput, safety and quality of care, while enhancing the patient experience beyond the inherent capabilities of the EMR.
Tight integration between RTLS and EMR will be a necessity to deliver context and resource awareness. While the EMR delivers a patient-centric record, RTLS enablement provides an operational record that measures process effectiveness, efficiency, clinical workflow and resource management – all critical to survival in this new era of health reform.
Andrew Olowu, CTO, Axxess Technology Solutions
Home health agencies and hospitals should coordinate efforts
The CMS Readmission Reduction Program, an important part of the Affordable Care Act that went into effect on Oct. 1, 2012, will have a profound impact on how hospitals manage care transitions and work with community healthcare providers to prevent avoidable readmissions. With growing pressure to do more with less, hospitals cannot afford the 1-3 percent payment penalties or projections of total penalty over the next several years.
The latest study from the Alliance for Home Health Care Quality and Innovation showed that home healthcare is not only cost effective, but also helps prevent avoidable hospital readmissions. The data from the Alliance underscores the importance of strongly coordinated care efforts between hospitals and home healthcare providers. This has profound implications for overall healthcare expenditure and is great news for hospitals.
There will be an increase in hospitals partnering with home health agencies through health information exchanges (HIEs) as part of the shift for hospitals to become accountable care organizations (ACOs). The HL7 organization already provides standards for such an exchange and interoperability among healthcare providers that improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer. It is therefore imperative for hospitals to partner with home health agencies with the right technology platform and EMR – one that ensures compatibility of systems, continuity of patient care information, and the ability to collaborate to ultimately improve overall patient outcomes and prevent costly readmission penalties.
Hospitals should identify home health software vendors that are members of HL7 and have successfully demonstrated compatibility with hospital EMRs. Such software vendors are typically already working with leading and top-performing home health agencies based on quality outcomes, quality improvement and financial performance. These are the home health agencies that will be the strongest, most suitable partners.
Girish Kumar Navani, CEO and co-founder, eClinicalWorks
The evolving role of EHRs
This coming year will see significant advancements in EHRs and the role they play in healthcare. These systems will continue to expand to do more, especially around several key areas, including:
Cloud computing – Cloud technology has increased in popularity and aids in the increasing functionality of EHRs. Those companies that have invested in running an agile, cloud-based infrastructure will release some exciting new developments in 2013 that will aid in bridging the care continuum.
Analytics – The adoption of EHRs has made the industry data rich but insight poor. We need to take that data and create closed-loop analytics that can drive and change decision making. ACOs, along with similar care programs, are taking off with recent estimates reporting that as many as 31 million Americans now receive healthcare through this model. To be successful, this requires advanced coordination and analytics tightly integrated with the EMR.
Patient engagement – Getting patients more involved in their care is critical for a healthier population and the key to that involvement is better and faster access to their information. People, for the most part, want to be active in their care so long as they trust who is delivering the communication. This makes the healthcare provider a necessary piece to the engagement puzzle.
EHR enhancements – The industry will see touch screen, speech recognition and handwriting capabilities added to EHRs, making workflow simpler and more intuitive.
David A. Burton, M.D., chairman, Healthcare Quality Catalyst
Adaptive data warehouse, advanced analytics will maximize EHR value
In 2013, hospitals will cope with conflicting incentives during the transition from traditional fee-for-service reimbursement to value-based purchasing. EHRs provide only a starting point, not a solution to this schizophrenic dilemma.
Many hospitals will be disappointed that their EHR was not designed to generate the analytic information they need to improve care and reduce costs. Extracting the value from this massive influx of data requires a data warehouse that can: 1) extract, aggregate and integrate demographic, clinical, financial, administrative, patient experience and other relevant data; and 2) apply advanced analytics to, organize and measure clinical, patient safety, cost and patient satisfaction outcomes. Both Frost & Sullivan and KLAS forecast explosive growth in the implementation of analytics tools by healthcare organizations as they try to address this challenge.
This October the financial penalty clock began to tick for hospitals that cannot reduce preventable readmissions and achieve prescribed target clinical outcomes. That same clock has been ticking for four years on preventable complications. Add to that the specter of shared financial risk and a bleak picture emerges for unprepared healthcare systems. As the reality of these megatrends sets in, hospitals are earnestly seeking solutions that can generate useful results in a matter of a few months rather than the customary 18-month implementation wait. They also crave a solution to help them prioritize improvement initiatives, so they can focus on what matters most to their survival.
Hospitals are recognizing that their only sustainable course is to eliminate waste in three categories: 1) ordering care; 2) delivering the care that is ordered; and 3) reducing complications. Health systems that can demonstrate quantitatively that they provide high-quality, cost-effective and safe care have a competitive advantage in the emerging shared-risk payment environment.
Dan Riskin, M.D., CEO, Health Fidelity
Next-generation EMRs will provide a more meaningful user experience
Since before the QWERTY keyboard, capturing information has focused on increasingly intuitive data entry.
The first generation EMR, currently the predominant input system in healthcare, has been focused on capturing data and clinical workflow. Its drop-downs and text boxes help address key discrete data needs, though not in an elegant way. As the technology matures, next-generation EMRs will need to be more user friendly and provide a more meaningful user experience.
Accomplishing this requires an understanding of natural language, which will enable physicians to bypass the check boxes that they find so irritating. Natural language narrative notes have been used in healthcare for more than a century and represent the most robust source of clinical information. To date they have not been used for compliance and analytics, but that’s about to change.
As organizations strive to improve healthcare quality, they must be able to make sense of big data. However, this data poses a challenge because narratives are unstructured and not coded for downstream use. The EMR must be able to tap into this unstructured data and extract specific information critical to improving patient care.
As we look to the future, clinical natural-language-processing technology will enable the next-generation EMR to use the narrative content that already exists to make data entry more intuitive, information more accessible and patient care more robust.
Ray Desrochers, executive VP, HealthEdge
Payers are willing, but their technology is weak
The good news: Our recent “State of the Payer” survey confirmed payers’ interest in leveraging and supporting many next-generation healthcare business models; 68.8 percent plan to participate in ACOs, 65.6 percent in pay for performance (P4P) and 58.8 percent in value-based benefits (VBBs) over the next three years. The bad news: They don’t have the technology required. The same survey showed 41 percent don’t have the technology needed for ACOs, 34 percent for P4P, and 47 percent for VBBs.
Many payers are limited by antiquated core platforms, significant manual processing and large numbers of satellite systems that are hard to use and costly to maintain. As industry experts have predicted, continued reliance on these systems will prevent payers from taking advantage of new business models. It will also force them to continue incurring the massive administrative costs associated with manual processing of significant numbers of claims; prevent them from meeting new challenges, including interoperability, transparency and enhanced customer service; and hinder their ability to meet new regulatory challenges such as ICD-10 compliance.
With the future of health reform coming into focus, clarity in the direction of next-generation business models and renewed consumer involvement in their healthcare, 2013 will be the year that payers begin making the necessary changes to their infrastructure – jettisoning their outdated legacy systems and embracing modern technology platforms – enabling them to meet their 21st-century business goals. This year, we’ll continue to see the evolution of healthcare, with technology leading the way.
Eliot Muir, founder and CEO, iNTERFACEWARE
EMR success requires the right integration tools
In order to achieve meaningful use, more hospitals and healthcare organizations are implementing EMRs. According to a recent survey conducted by the Commonwealth Fund, usage of EMRs in the U.S. and Canada is up 50 percent since 2009. However, as organizations rush to comply with EMR certification, many are struggling to make disparate systems – often with varying and/or conflicting standards – work with each other.
One of the biggest questions remains, “We’ve adopted an EMR, now what?” Some of the major obstacles to integrating EMRs include vendor resistance to making services more interoperable; centralized decision making creating an environment unfavorable to technological innovation; and the prevalence of legacy integration engines unable to keep pace with today’s data demands.
Moving forward, there will be renewed interest among hospitals, medical systems and HIEs in robust healthcare integration engines capable of receiving and transmitting data from multiple entry points across health networks. Rather than spending several years “incentivizing” healthcare systems to change how they work, organizations will adopt systems enabling them to simplify integration, normalize data and store it in a centralized portal.
The adoption of an integration framework that can scale to meet the changing demands of the organization, industry and emerging technology is critical to long-term success. By critically evaluating their needs and accessing their technological resources, healthcare organizations can put themselves in a position to capitalize on recent and even future advancements in technology. They can also ensure that they are fully realizing their investment in EMRs.
Dave Dyell, founder and CEO, iSirona
Leveraging EMRs via integration and analytics
It seems that 2012 was the year in which the majority of the hospitals that took the incentivized leap and invested in EMRs collectively stopped and asked, “When are these things going to pay off?” My answer: When we start using them.
It’s my hope, and my prediction, that in 2013 we’ll see forward-thinking hospitals using their EMRs. That is to say, we’ll see them populating their records with accurate data and then analyzing that data to make care decisions.
Recent studies suggest that hospitals do in fact aim to use their EMRs. A 2012 CapSite study, for example, revealed that 54 percent of U.S. hospitals plan to invest in medical device integration, the syncing of device data and electronic records. This automation reduces the errors and time it takes to transcribe by hand. In short, hospitals looking to integrate devices want more robust, accurate records.
What will hospitals do with these perfectly populated records? Analyze them. A February 2012 report from consulting firm PricewaterhouseCoopers’ Health Research Institute found that roughly half of the country’s providers will add analysts in the next two years, and 35 percent will hire additional informaticists. Similarly, a 2012 report from Frost and Sullivan says hospitals will significantly increase their use of analytics in coming years.
Of course, there is a lot of collaborative ground to cover before data becomes truly actionable. Still, in 2013, it’s my belief that the most advanced hospitals will move closer to EMR payoffs via analytics – or data-driven care.
Anil Kottoor, president and CEO, MedHOK
Leveraging relationships enables EMR vendors to deliver critical tools
The EMR market in 2013 will be characterized by an acceleration of relationships with specialized health IT firms that will allow vendors to close two significant capabilities gaps: actionable data exchange and on-demand quality metrics.
ACOs and other patient-centered, integrated care-delivery models require a continuous flow of actionable information within and across participating organizations to achieve the desired end state: high-quality, affordable and compliant care that considers the patient’s complete history rather than a single encounter or setting. Because they are nearly ubiquitous across care settings, EMRs are uniquely positioned to serve as the conduit of this exchange. They contain the data necessary to properly manage chronic conditions, identify risk, trigger interventions and ensure appropriate utilization. What’s missing is the ability to make that data accessible across the care continuum and meaningful to the user. The right relationships will enable vendor-agnostic platforms to be layered on top of EMRs and leverage the affordability, convenience and security of cloud technology to pull pertinent data from previously siloed sources and deliver it where it is needed.
Strategic relationships will also enable EMR vendors to provide customers with access to real-time quality metrics that drive effective care management. Though most EMRs are capable of tracking basic metrics, providing on-demand access to more complex measures is not a current priority for multiple valid reasons. Leveraging relationships enables EMR vendors to quickly deliver these critical tools without diverting valuable resources away from core business needs.
Robert Connely, senior VP, Medicity
The convergence of EHRs and HIEs
Over the next five to 10 years, a new model – one that focuses on enabling collaboration – will emerge for EHR systems. And today’s EHRs must evolve quickly to embrace this trend.
While some EHR vendors offer guarantees that providers would meet meaningful use Stage 1, Stage 2 will determine what they are actually able to do to help physicians manage their patients’ care. Stage 2 requires, among other things, data exchange outside a provider’s four walls, as well as demonstrated efforts to engage patients in their care.
The healthcare industry is changing from a world of independent physicians and hospitals that collaborate in an ad hoc way, to managed networks of providers working together. The needs of these networks are different than what traditional EHR technologies have supported. A significant gap is in the technology to facilitate transitions in care and collaboration among providers and patients.
To enable the level of collaboration that will be needed, we are seeing a convergence of EHR and HIE technologies. Top EHR vendors are adapting by incorporating network exchange capabilities within their product sets. Similarly, top HIE vendors are evolving with clinical documentation capabilities and gaining more intelligence in their networks.
The data-centric EHR, which tracks what the physician does in a patient encounter, will give way to a dynamic, electronic collaboration system that focuses on enabling the care team to improve quality of care while lowering costs.
Janet Dillione, executive VP and GM, Healthcare Division, Nuance
EMRs to see advances in security, billing, voice recognition and data mining
With Health and Human Services listing health IT – specifically ensuring the “integrity and security of health information systems and data” – on their top-10 list of greatest challenges in 2012, we’ll undoubtedly see EMR vendors placing increased emphasis on maintaining the quality, privacy and security of patient information contained within these digital records. Building off of this, we also expect to see additional efforts being made by EMR vendors, potentially in the form of advanced clinical documentation tools and training for physicians, to help healthcare provider organizations ensure accurate billing that can stand up to CMS scrutiny.
From a mobile standpoint, we expect to see major advances in the latest EMR applications from vendors such as Cerner and Epic. A recent KLAS study, “Mobile Healthcare Applications: Can Enterprise Vendors Keep Up?” found that physicians are having difficulties with clinical documentation on mobile devices. In an effort to address this particular issue, both Cerner and Epic have voice-enabled their latest mobile applications. We also expect voice-enabled mobile EMR applications to quickly transition to intelligent applications that act as digital assistants to streamline workflow and support clinicians with tasks, such as scheduling appointments.
Lastly, we predict less focus will be placed on the EMR as a healthcare transaction and reporting system, and more so as an untapped source of information that can more directly impact the quality and efficiency of patient care. As we continue the move toward a pay-for-performance model from a pay-for reporting model, interest surrounding embedded data-mining capabilities within EMRs will continue to expand.
Scott Thie, director, healthcare, Panasonic
Combating growing EMR security risks
According to IDC Health Insights, EMR adoption is expected to hit 80 percent by 2016. Concurrently, the use of mobile devices to access digital records is also on the rise. While EMRs simply replace paper with a digital record, the advent of mobile technology puts digital information at greater risk for being stolen or lost. Lost records are resulting in increasingly large fines. Last year, U.S. Department of Health and Human Services fined Massachusetts General Hospital $1 million for losing the medical records of 192 patients. Besides fines, there are also public disclosure requirements, potential lawsuits and negative publicity that healthcare providers must consider. Because of these factors, healthcare institutions must ensure proper device security measures are in place to protect patient information.
In a perfect world, healthcare staff would all be using hospital-owned, professional-grade mobile devices. Unfortunately, there is a growing risk of consumer-grade devices being utilized that are not designed for enterprise use. If staff is using personal mobility devices to access confidential records, the healthcare IT team should consider storing the records in a cloud environment. This way, if the device is lost or stolen, data will not be at risk. Additionally, IT teams should consider partitioning a portion of these personal mobility devices so they can remotely manage data if a device goes missing.
For hospital-deployed hardware, it makes good business sense to ensure that all mobile devices are equipped with an array of security features, including hardware and software encryption; biometric security features such as fingerprint scanners, smartcard readers and device tracking options (i.e. RFID); and “kill switch” features to remotely disable the hard drive.
As the use of EMRs and mobile devices in healthcare continue to grow, security issues will only become more prevalent. The more secure your mobile devices are, the less your potential liability if (or when) a device is lost or stolen.
David Rhew, M.D., senior VP and CMO, Zynx Health
Clinical decision support critical to EMR success
As we enter 2013, new models of care delivery – such as ACOs and value-based purchasing (VBP) – are front and center. As a result, adoption of EMR systems has soared. Although EMRs are definitely a crucial part of the move toward improved care, many hospitals still need to infuse technology with clinical decision support (CDS) that will help them unleash the power of their EMRs and realize the full poten tial of their goals to improve care and reduce costs.
The value of leveraging CDS at the point of care is undeniable in driving cost and quality outcomes such as reduced mortality, readmissions, length of stay, hospital-acquired conditions and never events. Many healthcare organizations, however, do not yet have this type of CDS intelligence hard-wired into their EMRs. They may lack the resources needed to update and optimize their customized CDS throughout its lifecycle, a necessity as they seek to continuously improve key clinical processes and drive positive clinical and financial outcomes.
Within the next year, healthcare leaders must place an increased focus on optimized CDS as a critical financial and clinical strategy for hospital and health system sustainability. Doing so can help them comply with rapidly changing payment models that place a greater importance on value and less emphasis on volume. HMT