Monday, March 23, 2009

A Healthcare IT Primer

Now that Healthcare IT is part of the stimulus and newsworthy, I receive many questions from reporters about the fundamentals of healthcare IT. Here's a primer with the Top 10 questions and answers:

1. Can you define EHR, EMR, PHR and PM in simple terms?

Electronic Medical Record - An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

Electronic Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff, across more than one health care organization.

Personal Health Record - An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.

Practice Management - An application used to manage the physician business operations including scheduling, registration, and billing

2. How large is the unserved market for HIT?

There are 800,000 clinicians in the US. 17% have EHRs today. This leaves 664,000 who need EHRs. Over the next 5 years the early to mid-adopters will work hard to gain the full stimulus incentive amounts available in 2011-2012. Late adopters will gain the reduced stimulus available in 2013-2014. Resistors will begin receiving penalties in 2015.

3. How many companies are currently competing in the small practice/ ambulatory EHR market? Are there any clear leaders in terms of client base or innovation?

There are over 100 companies providing EHRs for small practices. In my experience the ambulatory market leaders are eClinicalWorks, Allscripts, NextGen, GE Centricity, and Meditech/LSS (for small practices tightly affiliated to a hospital using Meditech). Epic is a market leader but not for small practices.

4. What does “meaningful use” really mean? Do you think physicians currently feel compelled to wait for clearer language from the government on the interoperability standards before investing?

"Meaningful use" is demonstrating to the satisfaction of the Secretary that the professional is using a certified EHR in a meaningful manner, which includes the use of e-prescribing, electronic HIE, and submission of information on clinical quality measures. Additional clarity on interoperability will be complete by the end of 2009. I do not believe clinicians should wait for all the details before investing. They should begin EHR implementation now.

5. What other details about meaningful use are listed in the bill?

-The Secretary may develop more stringent measures of meaningful use over time.
-For eligible professionals that are not meaningful users of EHRs, Medicare reimbursements will be cut 1% in 2015, 2% in 2016, and 3% in 2017.
-If less than 75% of professionals are meaningful users in 2018, Secretary can cut reimbursements another 1 percentage point, to maximum of 5%.
-Exceptions to the reimbursement reductions may be made on a case-by-case basis for hardships.
-The CMS Website will list eligible professionals who are meaningful EHR users.

6. Will Healthcare Smart Cards replace PHRs?

Smart cards have not received wide acceptance in any US industry, although they are very popular in other parts of the world. Reading and writing to smart cards would require a substantial investment in hardware throughout the healthcare industry. There are likely to be privacy concerns associated with lost or stolen smart cards. For all these reasons, I believe it is much more likely that web-based Personal Health Records, such as those provided by Google, Microsoft, and Dossia, will be more popular than smart cards. These PHRs are secure, protect confidentiality, and are automatically updated by labs, pharmacies, hospitals, and clinician offices.

7. Will clinicians be able to migrate easily from one EHR to another?

Interoperability in 2009 includes e-Prescribing, laboratories and clinical summaries needed for continuity of care. It does not include every field in the EHR. Conversion for one to EHR to another requires a combination of automated and manual data transfer. For the next few years, replacing one EHR product with another will still be a data conversion challenge.

8. What is the roadmap for interoperability?

See my blog on this topic. Over the past 3 years, HITSP has focused on Labs, Medications, Clinical Summaries, Public/Population Health, and Devices. In 2009 and beyond we'll add clinical research, newborn screening and close numerous gaps. In general, I believe meaningful use will include exchange of

Problems lists/Diagnoses
Medications including e-prescribing
Text-based summaries
Quality data sets
Population health data sets submitted to CDC, public health departments, and other government agencies.

9. "After standards are adopted in 2009, the National Coordinator shall make available at a nominal fee an electronic health record, unless the Secretary determines that the needs and demands of providers are being substantially and adequately met by the marketplace. Nothing in the legislation requires that entities adopt or use the technology made available through this provision.” -from HITECH Act. Do you see this as a viable solution for small practices who want to wait it out and go with a cheaper software product?

See my blog on this topic. Open Source may provide reduced licensing cost, but other costs beyond license fees are the majority of implementation expenditures including practice workflow redesign, interfaces, and training. Open Source is an important part of the nationwide acceleration of EHR implementation, but it is not a panacea.

10. Do you see PHR’s and EHR’s as separate markets currently and what about in the future?

PHRs and EHRs are different products and I do not believe that PHRs will replace EHRs. EHRs are workflow tools for clinicians. PHRs are lifetime clinical summary and workflow tools for the consumer. They are complementary not competitive technologies.


Char said...

Your definitions, which are consistent with those published by NAHIT, are clear and concise, indicating that an organization/physician practice uses an EMR--a single product/system or network of systems within the organization.

So how has EHR become the favored name--by the government (government documents and regulations, including ARRA and the HITECH Act, identify systems used by physicians as "EHRs"); by most news media (WSJ yesterday); even this blog (PHRs and EHRs are different products...EHRs are workflow tools for clinicians.)?

Deborah said...

Excellent comments and a clear way to provide definitions that understandable by everyone. I often get asked these same questions, and I provide similar answers, but since you have stated them so eloquently, I can now I can point them here. Thanks John for sharing.

Chasing Paper said...

Again, thanks for the lucid descriptions.Excellent summary of terms.
A huge opportunity that always seems to be under the covers is the enormous amount of information that currently resides in paper charts - and could be a valuable resource if mined correctly. In addition, at least in some cases, the legacy information held in those charts might have important patient safety consequences if not gathered and integrated during the adoption of an EMR. (Flomax ->Cataract surgery, allergic reactions in the past, etc.)Many of the elderly patients have difficulty remembering current meds, much less drugs they have been on in the past. Can you elaborate on your experiences moving from the paper to digital (specifically how you folks handled moving paper chart data into the electronic systems)? Was it scanned in as PDF documents, or was a more concerted effort made to pull the data into the EMR?

Jim Harter said...

Jim said...
A number of times you have mentioned data element dictionaries. I'm a developer of a new database dictation platform and certainly could use such a dictionary. Our technology produces documents and discrete data from each dictation session and we would like to use any new standards for data elements.