The changing face of EHRs

As we approach the 1-year anniversary of the American Recovery and Reinvestment Act of 2009 (ARRA), its impact on health care delivery-system reform deserves review. Contained within ARRA is a section (HITECH) that earmarks considerable money intended to improve the electronic infrastructure for health care delivery.

The premise is that the health care ecosystem is fragmented, arcane, and largely opaque, with much health data residing in paper documentation – the result has been cost escalation in excess of GDP growth, highly variable utilization of resources in a seemingly-random distribution, and health outcomes that are not in the top quartile for developed nations. Though not a solution in itself, a necessary foundation for moving forward out of this mess is the migration of health data from paper to an electronic platform.

Historically, some health data has been electronic – mainly residing with insurance companies (including the Centers for Medicare and Medicaid Services – CMS), and based on claims for payment of fee-for-service activity. Hospitals and laboratories have also kept much of their data in electronic form, though those data stores have largely been proprietary silos, and data sharing has been problematic – hindered by lack of standards, difficulties in ensuring privacy and security, and reluctance to share proprietary data. Clinical data – the front-lines documentation done by physicians taking direct care of patients – has been largely collected on paper. This is especially true in the smaller ambulatory practices, though some large institutions have implemented Electronic Health Records (EHRs)

The EHRs that have dominated the landscape up until now have been built with large institutions in mind – they have been built as self-contained, proprietary, all-in-one clinical/financial packages, which are very expensive and are locally installed into a closed client/server network. They have been built on technology from the 1990s and have centered around creation of billing events, helping clinicians justify the evaluation and management steps taken in order to capture all the justifiable charges for the visit or hospital stay – see David Kibbe’s excellent review of this here.

The HITECH incentives have attempted to change this landscape profoundly. There are two closely-interrelated arms: (1) Meaningful Use, which represent activities an individual physician must demonstrate in order to access incentive payments for “meaningful use of a certified EHR” beginning in 2011; and (2) Certification of EHRs.

Meaningful Use incentives, currently referred to as the Notice of Proposed Rule Making (NPRM), is deployed through CMS, and therefore offers incentive payments through Medicare or Medicaid. As we commented previously, this leaves certain practitioners “out of the loop” – physicians who do not take Medicare, and most pediatricians (who do not concentrate Medicaid patients into their practices).

Perhaps even more importantly than the Meaningful Use incentives aimed at physician behavior, the Certification proposals (referred to currently as the Interim Final Rule, or IFR) impacts how the EHR-vendor community develops the electronic platform that all this health care reform activity sits upon. It changes the entire EHR landscape, beyond those impacted by CMS incentive moneys.

Philosophically, the new rules change the basic core of “why” EHRs are built – from payment-capturing, fee-maximization tools to ones aligned more with the tradition of quality improvement and safety enhancement: electronic prescribing and order entry, clinical decision support, data gathering for individuals and populations, and data sharing between all participants so that the system becomes more transparent.

The “new blueprint” for EHR technology can be thought of as having three parts:

(1) Certification will be an HHS-controlled process, not an industry-led process as had been the case with the legacy certification body (CCHIT). The method for carrying out this new approach to EHR certification is still in-process, and multiple bodies (which may include CCHIT) are expected to carry out such certification. This has been an important signal to the industry.

(2) EHR products should be modular and interoperable. There are about 25 “modules” needed to have full “EHR Technology,” and this can be done either through a single product, or by assembling multiple products together to achieve the functional result. No longer will a proprietary “all encompassing” self-contained EHR product be the “desired product.” Plug-and-play modules, such as is typical in Health 2.0 products, is the technology to-be-encouraged – similar to what is seen in many other industries.

(3) Separation of content from transport standards. Data is meant to be interoperable between different systems, and standardized ways of exchanging data (e.g. through Continuity of Care Records, or CCRs) are expected of everyone. Standardized “vocabularies” for tagging data are defined. Much of health care still lacks this level of standardization – from regional Immunization Registries, to Laboratories (surprisingly) – and the “new blueprint” is a call for everyone to converge onto a common set of transport standards. This will enable and encourage “plug and play” as the core of health IT.

For these reasons, ARRA/HITECH has been referred to as “the other health care reform.” It is quiet, and somewhat “inside baseball,” and receives less media attention than the debate on health insurance reform. But it may well have a more profound and long-lasting impact on health care delivery than anything else that has come along to date.


Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc.