The Electronic Health Record: Will It Become a Reality?

By Randa Upham, Principal, Phoenix Health Systems
April 2004

The past few years have been busy ones for those involved with automation of processes within the healthcare industry. IT professionals dedicated much of their time at the end of the last century addressing the Y2K crisis and then moved into the 21st century to take on the challenge of HIPAA. With the Y2K bug resolved and HIPAA becoming a way of life within the industry, is it now possible to reinvest energies into improving one of healthcare's biggest challenges – establishing an electronic healthcare record?

First, let's understand what we mean by "electronic healthcare record."

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How Many Acronyms Does It Take to Make an Electronic Health Record?

The electronic health record (EHR) is an acronym used extensively in the healthcare industry, but often with ambiguous meanings. What exactly is an EHR? To answer that question, let's first consider its evolution. The term EHR has been around for about three decades and yet is still being defined. A brief summary of its history may help to clarify its meaning.

• Paper Medical Records
  All current versions of the electronic records of the care provided to patients are based on the traditional medical record – the paper version. The phrase "medical record" may be applied in differing ways based on the actual healthcare practitioners providing the care, but most persons understand the medical record to be a history of the care they received from various clinicians. An important characteristic to keep in mind is that EACH practitioner keeps its own medical record for each of its patients. There is no integration of the data from the various clinicians treating the patient. Therefore, as a patient, you most likely have many different medical records.
  
• Computerization of Patient Records
  The original objective for computerization of an individual's health record can be found in the Computerized Patient Record (CPR), which was defined as a computer-based record that includes all clinical and administrative information about a patient's care throughout his or her lifetime. The documentation of any practitioner ever involved in a person's healthcare would be included in the CPR, extending from prenatal to postmortem information. One of the expectations for the CPR included its role in decision support. Over a decade ago, the term CPR was used to distinguish the concept from the more traditional medical record to incorporate administrative and financial data often excluded from the patient medical record.
  
• Evolving Terminologies
  Over the past few decades, similar acronyms have evolved representing changes in the industry perception of what should be the actual make-up of the computerized "record" of the patient's healthcare experience. The industry has embraced models for the Computerized Medical Record (CMR), the Electronic Patient Record (EPR), the Continuity of Care Record (CCR), the Digital Medical Record (DMR), and the Personal Health Record (PHR). Of particular importance is Patient Medical Record Information (PMRI) in that the legislative act that made HIPAA a law (the Health Insurance Portability and Accountability Act of 1996) charged the National Committee for Vital and Health Statistics (NCVHS) to "study the issues related to the adoption of uniform data standards for patient medical record information and the electronic exchange of such information." To that end, NVCHS has been steadily working to establish PMRI standards for the information and terminologies that would comprise a universal electronic patient health record. Each of these concepts (and acronyms) exists as a building block in the current understanding of EHR. For an in-depth discussion of the evolution of industry terminology relating to what is now known as the EHR, see: Waegermann, C. Peter, Status Report 2002: Electronic Health Records Why EHRs?

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The EHR Today

Although no standardized acronym has been established by the industry or the government, EHR is often considered the term most reflective of the actual patient experience of receiving healthcare. The EHR incorporates all provider records of encounters where the patient has received medical care.

Documentation of many events occurs with the inpatient experience – recording of encounters with clinicians, treatment received, test results, and medications ordered. Following his or her discharge, the patient may have office visits with practitioners and receive ongoing care ordered by these practitioners. The aggregate recording of these encounters and interactions with the patient (across all involved healthcare enterprises) comprises the EHR.

In addition to serving as documentation of the clinical care provided to the patient, the EHR exists as a business record for all the providers who provide care to the patient. The provider uses the EHR to communicate with other practitioners about the delivery of care, as reference for the patient's history, to support its operations and billing, and for medical-legal purposes. It is the aggregate of the total experiences related to patient care that is currently understood to be the contemporary EHR.

Considering the decades of development that resulted in the current concept of EHR, it would be logical to assume that the industry has established a sound foundation for universal implementation of an electronic health record. Unfortunately, we know that the healthcare industry has yet to accomplish this objective. Yet there is general industry consensus that an EHR is essential to the well-being of the healthcare environment. Why does the vision of an industry–wide HER seem so far from reality? What are the factors that have prevented universal adoption of EHR?

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Understanding the Realities

Healthcare has lagged behind other industries in adopting Enterprise Resource Planning (ERP) as an essential business strategy. The many departments within a hospital setting typically implement and use computerized systems according to their own established data conventions. Changing to standardized protocols for charting patient care within an automated system requires an enormous and expensive effort. Some of the barriers that are typically noted include:

• lack of clinician acceptance
• concerns about inability to align workflow with a standardized EHR
• concerns that automation of clinical charting requires more time than paper charting
• lack of uniform standards for documentation of clinical services
• lack of standardized technical platforms to support EHR
• lack of support for startup expenses or reimbursement for implementation costs

Several observations can be made about these perceived issues. Studies abound concerning the resistance of physicians and other clinicians relative to their willingness to embrace the EHR. Although clinician acceptance is indeed an important factor in adoption of the EHR, the myth of universal physician resistance should be debunked. There is much literature evidencing that physicians support EHR when the benefits of EHR can be demonstrated to them. The industry's energies should be focused on establishing the value of adopting EHR across all aspects of our delivery of healthcare – not merely conducting studies measuring the time spent charting (paper vs. electronic).

Many of the other identified hurdles involving lack of standardized terminology, charting requirements and technical platforms are being increasingly reduced as definite barriers. Across the nation, initiatives to address lack of standardization issues are in process. A search on the Internet on "electronic health record" (or any of its alternative monikers) yields more than an abundance of active EHR and standardization initiatives. Of course, the industry closely watches the activities of NCVHS relative to standardization of the components and terminologies for an EHR.

The barrier to adoption of the EHR that is probably the most difficult to overcome is the lack of easily apparent return on investment (ROI). Many writers on the subject have noted that healthcare decision makers find it difficult to readily demonstrate ROI or justify the expenditure of dollars and time to undertake a comprehensive EHR within their organizations, particularly while healthcare costs continue to spiral out of control. A review of the literature yields an abundance of information from vendors and healthcare professionals about how to measure the ROI for and implementation of EHR. In fact, the NCVHS has suggested turning to the vendors to obtain experiential information on ROI. However, the literature has not yet produced the universal guarantee for ROI that healthcare enterprises would like to have when they are conducting strategic planning related to the huge initiative of establishing an EHR for their organizations. In spite of this major hurdle, the national healthcare environment does not appear ready to give up the vision of a universal EHR. Across the industry, initiatives in support of the adoption of an electronic health record remain alive and well.

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Arguing the Benefits of the EHR

Quite frankly, there is little argument over the other potential benefits of EHR. Most healthcare professionals agree that if the industry could finally implement a universal EHR, there would be considerable clinical and administrative benefits to be recognized. Among them are:

• immediate and universal access to the patient record
• easier and quicker navigation through the patient record
• no lost charts
• standardization of care among providers within the organization
• clinical data that is formatted to be easy to read and analyze
• reduction of paperwork, documentation errors, filing activities
• coding efficiency and efficacy
• alerts for medication errors, drug interactions, patient allergies
• ability to electronically transmit information to other providers (assessments, history, treatments ordered, prescriptions, etc.)
• availability of clinical data for use in quality, risk, utilization, ROI analyses

For a discussion on how some physicians view the advantages of the EHR, see: David Smith, MD and Lucy Mancini Newell, MBA, A Physician's Perspective: Deploying the EMR, Journal of Healthcare Information Management, Volume 16, No. 2.

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Getting on the EHR Bandwagon

Many respected national healthcare associations and advocacy groups have issued mission statements and established initiatives in support of the EHR. As healthcare professionals, we can make EHR a reality in this country through active involvement in a variety of initiatives to support the adoption of a universal (and comprehensive) electronic health record. Just a few of them are noted below, as examples of the very solid commitment that our industry is making to achieve this milestone in healthcare information:

• The Healthcare Information and Management Systems Society (HIMSS) has announced its support of EHR in many ways. For example, it has proposed an EHR Summit to convene the leading vendors, consultants, clinicians, HIT provider executives, payers, government agencies, pharmaceuticals, standards development organizations, associations, and others to develop a realistic action plan. The HIMSS Electronic Health Record Committee has been established to explore the definition and essential attributes for the EHR. HIMSS conferences have consistently offered an electronic medical records track for presentations (http://www.himss.org).
  
• The American Health Information Management Association (AHIMA) believes that "for the United States' healthcare industry to meet the current and future needs of the nation, a properly funded and maintained national healthcare information infrastructure should be established" (http://www.AHIMA.org).
  
• The Medical Records Institute's (MRI) mission is "to promote and enhance the journey towards electronic health records, ehealth, & mobile health, and related applications of information technologies (IT)" (http://www.medrecinst.com).
  
• The Foundation for the Advancement of Electronic Health Records (FAEHR) is a non-profit organization dedicated to addressing several of the most urgent needs facing the healthcare delivery system today, including quality of care, reducing medication errors, and cost of healthcare reduction.
  
• NCVHS recommends that the federal government recognize a "core set" of PMRI terminologies as a national standard (http://www.ncvhs.dhhs.gov).
  
• The stated mission of the eHealth Initiative (eHI) and the Foundation for eHealth Initiative is that "(c)onsumers, healthcare providers, and those responsible for population health will have ready access to timely, relevant, reliable, and secure information and services through an interconnected, electronic health information infrastructure to support better health and healthcare" (http://www.ehealthinitiative.org).
  
• The EHR Collaborative is a group of organizations representing key stakeholders in healthcare which has established the following goal: "to facilitate rapid input from the healthcare community in this and other development initiatives that advance the adoption of information standards for healthcare." This collaborative effort includes the following organizations: AHIMA, eHI, HIMSS, American Medical Association (AMA), American Medical Informatics Association (AMIA), College of Healthcare Information Management Executives (CHIME), and National Alliance for Health Information Technology (NAHIT) (http://www.ehrcollaborative.org).

It is important to note that support for the EHR comes from both the private and public sector. Endorsement of and commitment to adoption of the EHR can be observed in numerous activities and initiatives within the federal government:

• The current administration's budget includes funding to the Agency for Healthcare Research and Quality (AHRQ) for IT Demonstration Projects. One of the stated missions of the AHRQ is to advance the use of information technology for coordinating patient care and conducting quality and outcomes research.
  
• President Bush announced his support for interoperable electronic health records in his March 2003 address to the American Medical Association (AMA).
  
• The Centers for Medicare and Medicaid Services (CMS) has taken a leadership position in improving the quality and efficiency of healthcare through IT. For example, it has strongly supported the adoption of data standards within the federal government through the Consolidated Health Informatics Initiative. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 recognizes the critical role that IT has in improving healthcare outcomes and reducing medical errors within the Medicare program. And, of course, CMS plays an active advisory and regulatory role in the implementation of the HIPAA Transactions and Code Sets (TCS) standards.
  
• The HIPAA TCS standards must be recognized as a huge step in the evolution of the EHR. Once fully implemented, standardized transactions and code sets will serve as a major cornerstone of the EHR.
  
• Many of our country's legislators actively promote the EHR as evidenced by some of the speeches at the 2004 HIMSS annual conference. Former Speaker of the House, Newt Gingrich, in the keynote speech, talked about the need for changes in healthcare such as e-prescribing, electronic health records, and an electronically-connected healthcare structure. Later in the week, Patrick Kennedy, US Representative from RI, discussed his plan to introduce new legislation, termed "QUEST" (Quality, Efficiency, Standards and Technology) Act that uses technology to address many of healthcare's woes. The act will call for a fully wireless, paperless EHR.
  
• The Department of Health and Humans Services (HHS) has commissioned the Institute of Medicine (IOM) to design a standardized model of the EHR and also asked the healthcare standards development organization, HL7, to evaluate the model. The proposed model is expected to be revealed in 2004.
  
• In March 2003 HHS, and the Departments of Defense and Veterans Affairs announced the first set of uniform standards for the electronic exchange of clinical health information to be adopted for federal agencies.
  
• The Centers for Disease Control (CDC) created the Public Health Information Network (PHIN), to support communications for public health labs, the clinical community, and state and local health departments.

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Commitment to Collaborate

These and other initiatives advocating and/or expanding on the concept of the EHR indicate that the momentum towards an EHR is increasing in intensity. In particular, the coordinated efforts of such affiliations as the EHR Collaborative offer a persuasive call to action to which healthcare provider organizations are increasingly paying attention. Is the industry, in fact, moving closer towards the long-standing goal of a true, universal EHR? We think it is. Watch HIPAAlert for further reports, as we continue to track future progress in the establishment of an industry electronic healthcare record.

Randa Upham, M.A., Principal, is in charge of Program Development at Phoenix Health Systems. Ms. Upham has 23 years' experience in the Healthcare and Information Services industries with an extensive background in product development, clinical services, organizational management, software design, and educational planning.