Editorial: How Current EHR Initiatives Can Help Shape Buying Decisions

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.

The need to improve the quality of care while lowering its cost is at the root of every major initiative in health care today. While new models of care are evolving to meet this need, new technology applications are being developed simultaneously to make these models viable. The electronic health record is both the means and the end of these revolutionary processes.

An EHR’s raison d’être is to collect and share data important for the treatment of patients. This seemingly simple function, however, rests on complex, multifaceted relationships that seek to balance caregivers’ needs against information systems’ capabilities. Driven forward by federal government mandates, the next several years promise to bring issues of EHR standardization, usability, and interoperability to the forefront of practicing physicians’ collective awareness.

EHR Development: Where Is It Going, and Why

While change is constant in health care – and exponential in technology – three EHR developmental imperatives are emerging in response to industry trends, as well as existing and imminent federal requirements:

• Interoperability. Standardization – the prerequisite for sharing records between and among IT systems – has been an important, though hard-to-achieve, goal of EHR development since 1991, when the Institute of Medicine’s report, "The Computer-Based Patient Record: An Essential Technology for Health Care," introduced the idea of "an electronic patient record ... specifically designed to support users through availability of complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge and other aids."

Since that time, several organizations have worked to further the development of standards, with some success as evidenced by standardization of lab results, medication names, allergies, and demographic data. Other data elements, such as physician progress notes that require multiple concepts to express, are proving more problematic. The challenge: ensuring interoperability for public health reporting and research without hindering or further complicating the physician "conversation." Meeting this challenge demands ongoing, industry-level standards development.

• Usability. As federal mandates increase quality and reporting requirements, EHR solutions must evolve to help rather than hinder physicians’ efforts to meet them. For example, an EHR that requires numerous "clicks" to order a single medication is not going to streamline a physician’s workflow. The problem is finding ways to objectively measure something as seemingly subjective as usability.

However, the issue is now on the federal radar and fast becoming a must-have for EHR products. Certification organizations increasingly are looking for ways to measure and mandate usability of EHR products, from the National Institute of Standards and Technology’s (NIST) search for sources "to fully develop and execute a project to create a usability framework for health information technology (HIT) systems" to the Certification Commission for Healthcare Information Systems’ (CCHIT) 2011 Usability Testing Guide for Comprehensive Ambulatory EHRs.

• Care coordination. Despite spending one-sixth of our entire gross domestic product on health care, the United States falls far short of being the healthiest society in the world. One reason: We spend the vast majority of our resources treating the symptoms rather than the causes of disease. Care coordination across all elements of the complex health care system (for example, subspecialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community is essential to creating a shift from treatment to prevention – and EHRs are essential to care coordination.

In addition, care coordination is a key characteristic of the patient-centered medical home, an emerging care concept based on evidence, driven by data, focused on health and wellness, and centered on the needs of the patient.

These three imperatives – interoperability, usability, and care coordination – are driving EHR development. As such, they also are key considerations in the selection of an EHR solution.

Functional Matters: Choosing an EHR Solution

The 2009 American Recovery and Reinvestment Act’s (ARRA) HITECH Act may have brought EHRs to the forefront of health care discussion, but it did not alter their primary function – improving the quality of care. To ensure this result, physicians should look for the following in an EHR product:

• Certification: Certification assures a product has met core criteria considered essential by a broad range of stakeholders, which is key to maximizing the system’s value. One-time certification is not enough; annual certification evidences the continual development necessary for the product’s ongoing viability.

The sole organization designated by the Department of Health and Human Services (HHS) since 2006, CCHIT is the industry’s leading EHR certification body and the de facto standard for usability and other criteria. However, with the advent of ARRA and the resulting need to preclude any conflict of interest, HHS now will oversee multiple certification organizations. The Office of the National Coordinator (ONC) for Health Information Technology is developing its own certification criteria with NIST, which will assess conformity and accredit certification bodies.

Still, those that now possess CCHIT usability ratings and certification have positioned themselves in the forefront of the certification process.

• Structured data: Structured data reside in fixed fields within a record or file. These discrete data fields (for example, blood pressure, body mass index, and height/weight) establish the predetermined data types and understood relationships necessary for efficient quality reporting. Since 2008, the Centers for Medicare and Medicaid Services has allowed reporting of quality measures data to a qualified registry. As early as this year, CMS could begin accepting direct EHR-based quality reporting. As early as 2012, CMS could mandate it. EHRs built on unstructured data (as is found in many transcription/dictation systems) will not support compliance.

• Meaningful use guarantees: Incentives should not be the sole reason why physicians deploy EHRs, but the ability to secure incentives must not be overlooked. EHR vendors with a commitment to – and a plan for – meeting meaningful use criteria as they are established will offer guarantees to that effect.

• Clinical decision support: Evidence-based practice is the inevitable future of health care. EHRs with clinical prompts and reminders support best practice and systemize the use of evidence at the point of care.

• Support for coordinated care: Increasingly, EHRs will serve as the foundation for data registries, health information exchange, and other means to assure patients get the indicated care when and where they need and want it, and in a culturally and linguistically appropriate manner. Expanded patient data access – via secure communication portals, for instance – also will require more robust data controls to ensure secure data exchange. However, it will enable patient-centric care through greater patient involvement.

Health care is a dynamic industry, driven by the needs – changing and continuous – of its stakeholders. Developing, choosing, and deploying EHRs will continue to challenge. Keeping standardization, usability, and interoperability as the prime focus of all development and purchase decisions ultimately will smooth the path for everyone.

Dr. Corley is the chief medical officer for NextGen Healthcare Information Systems, an electronic health record vendor. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates medical handheld references.

References

1. The Computer-Based Patient Record: An Essential Technology for Health Care Committee on Improving the Patient Record, Division of Health Care Services, Institute of Medicine Richard S. Dick, Elaine B. Steen; eds. 190 pages. Washington, D.C.: National Academy Press; 1991.

2. National Institute of Standards and Technology. Health Information Technology Usability Framework. Federal Business Opportunity. Solicitation Number: AMD-10-SS39 Web.