Feb

7

Reality & Electronic Health Records

Well, I’m way overdue for another web blog installment. One of the big topics on the agenda for the federal government is the expanded use of electronic health records (EHR). In fact, US Department of Health & Human Services (HHS) Secretary Levitt indicated EHRs are one of the cornerstones in the effort to make Medicare and Medicaid more efficient. The idea, at least in the mind of Secretary Levitt, is expanded use of EHRs will lead to a significant increase in the electronic exchange of clinical data which will lower the cost of health care through efficiencies and increases in quality.

Unfortunately I beg to differ with Secretary Levitt. I do agree that the expanded use of EHRs has the potential of increasing efficiencies and quality but I don’t believe, at this point in time anyway, that it will increase the electronic exchange of clinical data. In talking to medical associations, a number of physicians are in the process of implementing EHRs but it generally takes a year or more to fully implement and integrate an EHR into a practice. During this time the focus is seeing a return on investment and not necessarily electronically exchanging data with other providers.

When talking to hospital associations, it appears hospitals are not opposed to electronic health information exchange (HIE) but hospitals and health care delivery systems are more concerned right now with just getting health care professionals (especially physicians) to use the EHR. If the EHR is not fully utilized by employed and affiliated health care professionals, the value of the data diminishes and is then also not available for exchange with other providers.

Another barrier is state and federal privacy laws. The combination of state laws providing special protections for certain types of patient health information and federal law specifically protecting alcohol and chemical dependency diagnosis and treatment means that to be effective in expanding HIE, the EHR needs the ability to segregate data and track patient authorizations. This includes the ability to electronically redact what is classified as specially protected health information that may be included in chart notes. As far as I know the issue with electronically redacting information from chart notes has yet to be addressed by any EHR vendor.

In a real life example, two large health care systems in the NW currently print out the medical record from the EHR and manually redact the specially protected health information. Then the record with the pertinent data redacted is faxed to the requesting provider. Not what I would call an improvement in efficiency…

Another issue with EHRs is interoperability. Even those EHRs that are advertised as interoperable, able to send and receive clinical data to other providers and other EHRs, really are not interoperable when it comes to actual EHR use. Providers tend to customize EHRs to fit their needs. This, more often than not, renders the EHR not interoperable with other EHRs, even those from the same vendor. As an example, Oregon Health & Sciences University (OHSU) and Kaiser both use the EHR Epic. Epic is a quality EHR but, as with most enterprise applications out there, is customized when installed. At this time Epic at OHSU and Epic at Kaiser can’t communicate.

One of the significant issues that needs to be addressed and is not the focus of great attention at this point is looking at interoperability from the provider and not the vendor level. Until installation standards are adopted that allow for interoperability between EHRs after they are installed, it will be a challenge to, at least in the near term, increase the exchange of clinical data between EHRs at different provider offices in an efficient and cost effective manner. EHRs need to be customizable but there also needs to exist the functionality and the standards related to EHR implementation to retain or build in the ability to use the EHR as a vehicle to expand HIE.

There are a number of other challenges that need to be addressed prior to realizing a broader rollout of HIE but just focusing on one area – the EHR – is important given this appears to be one of the touted cornerstones to improved efficiencies in Medicare and Medicaid. EHRs are part of the solution but, by themselves, are not the solution. I think it’s time for HHS and others to focus on what I would call “on the ground” use and application of technology rather than creating high level or even detailed standards that may or may not be in use right now, that may or may not address the immediate needs of the industry as we all hopefully march forward in an effort to increase electronic exchange of health information, increase efficiencies and improve quality.