Technology has been a boon to so many aspects of healthcare, and the industry has pushed forward several innovative frontiers in the process.
However, technology in certain aspects of the patient experience -- such as administration, payments, and health records -- remains well behind the curve.
The implementation of electronic health records (EHR) is one area which has been fraught with challenges. In this post, we examine the current state of health record digitization and the barriers that still remain.
Digitizing Paper Records in Healthcare: The Road So Far
During the throes of the Great Recession in 2009, the US government passed the Health Information Technology for Economic and Clinical Health (HITECH) Act as a catalyst to drive out costly healthcare inefficiencies and improve patient outcomes by transitioning from paper health records to electronic health records. HITECH was passed as part of the larger American Recovery and Reinvestment Act and represented the first time that the American government had committed federal resources to accelerate the pace of healthcare technology, using financial incentives to encourage EHR adoption.
To qualify for these financial incentives, healthcare organizations were required to demonstrate compliance with the the concept of "meaningful use" of EHRs, a program that was introduced by the Office of the National Coordinator for Health Information Technology (ONC) as part of the HITECH act.
"Meaningful use" is defined as using EHRs to:
- Improve quality, safety, efficiency, and reduce health disparities
- Engage patients and families
- Improve care coordination as well as population and public health
- Maintain privacy and security of patient health information
Brian Eastwood [registration required] at Tech Target compiled a list of requirements for healthcare professionals and hospitals to meet the criteria of "meaningful use" and qualify for federal incentives. Eligible healthcare professionals could receive up to $44,000 (through Medicare) or $63,750 (through Medicaid), while eligible hospitals could receive incentive payments totaling $2 million or more.
The introduction of HITECH has had a significant impact, especially among hospitals. Research published in Health Affairs in 2017 found that EHR adoption among hospitals in the years before the meaningful use program, 2008 to 2010, sat at 3.2 percent. However, in the half decade that followed, 2011 to 2015, hospital adoption of EHRs rose to 14.2 percent.
The Road Ahead: Making Electronic Health Records More Effective In Improving Healthcare Delivery
There are still numerous barriers to achieving 100 percent EHR use, as well as challenges in making EHRs more impactful in improving healthcare delivery and health outcomes.
Here are the three main challenges that lie ahead:
1. Lack of Interoperability
A more significant challenge to widespread use of EHRs lies at the systemic level: The lack of interoperability is limiting the positive impact of EHRs.
Statistics from the ONC show that there are 941 vendors providing more than 1,700 unique certified EHR products. The problem is a lack of data standardization and limitations in sharing data across different systems.
Research and studies on healthcare technology support this claim. A study by KLAS Research showed that "only 6% of healthcare providers report that information accessed from exchange partners on a different EMR is delivered in an effective way that facilitates improvement to patient care."
Physicians Kenneth D. Mandl and Isaac S. Kohane posit a similar argument in their research paper "Escaping the EHR Trap -- The Future of Health IT." In their view, there are two issues in the health IT marketplace:
- The lack of interoperability between different EHR systems has hindered doctors and patients in benefitting from digitized medical records.
- They also argue that "despite this sprawl, a few companies controlling much of the market remain entrenched in legacy approaches, threatening other vendors' viability."
Anna Maria Barry-Jester at FiveThirtyEight also agrees that interoperability poses a huge challenge to fully realizing the potential benefits of healthcare technology. She describes the ideal of an EHR as a record that "contain[s] all the things that are or were in a paper record -- medical history, diagnosis, lab tests and prescriptions -- as well as data collected from our many personal tracking devices and information that paper records never could, like reminders for best practices on treating certain diseases or warnings when there's a potential conflict between two medications. All of this in a secure location and readable format."
The current reality is much less rosy: Barry-Jester depicts it as "a bunch of records with bits of information that aren't linked together electronically."
Ross Koppel, a sociology professor at the University of Pennsylvania, has been a long-time critic of the lack of interoperability in healthcare IT systems. He argues that government incentives have mostly focused on selling software to healthcare providers without considering the usability of the EHR systems. Koppel characterizes current systems as "generally clunky, frustrating, user-unfriendly and inefficient."
"Had the IT systems first been made interoperable and easy to use, physicians would have flocked to them without incentives," he says.
It's clear that while the rapid adoption of EHR systems is heartening, the overall utility of such systems is still underdeveloped.
So, how can interoperability be achieved? Karen DeSalvo, the National Coordinator for Health Information Technology, outlined three key plans by the ONC:
- Standardize standards, including APIs and implementation standards.
- Clarify the shared expectations and actions around data security and privacy.
- "[I]ncentivize--in a durable and sustainable way -- interoperability and the appropriate uses of electronic health information."
Jared Jeffery at KLAS Research describes the current state of interoperability as a funnel. While the road of achieving interoperability is likely a long one, he believes that we will get there particularly if government legislation plays a part in encouraging its advancement.
2. High Costs for Healthcare Providers
The adoption of new technology often requires significant expenditures, and that's been the case with many EHR implementations. When the University of Vermont Health Network updated its old health recordkeeping systems with an EHR system from Epic Systems, it calculated the six-year total cost of ownership at $151 million.
On top of the upfront costs of implementation, Michael McBride at Medical Economics also points out other associated costs like IT support, additional hardware, and training add to the EHR total cost of ownership for healthcare providers.
Renee Cocchi, editor at Healthcare Business and Technology, agrees that there are unplanned costs when it comes to EHR installation. She cites the costs of security tools, other IT investments, and customization and future upgrades as costs that providers should consider when allocating their budget for going digital.
It's up to the individual providers to better prepare themselves for the financial and operational challenges that implementing an EHR system entails. McBride recommends developing a financial strategy that includes a buffer for 50 percent more capital than you expect to spend and training your staff before installing the EHR to ensure a smoother transition. When it comes to EHR implementation, it's crucial for healthcare providers to consider the long-term benefits over the short-term pain of installation.
3. Getting Patients On Board
One of the criteria for the meaningful use of EHRs is engaging and involving patients in the process. According to Traci Badalucco at U.S. News, this is becoming a hurdle for healthcare providers, as it is challenging to get patients to join the portal. Moreover, government quotas add pressure as providers may have their incentives docked if quotas are not met. Badalucco notes that many patient portals are not designed to be user-friendly, which hinders user adoption and data sharing.
John Squire at Physicians Practice shares four ways EHRs could improve patient engagement. He recommends making full use of your patient portal to communicate with patients, integrating other solutions with your EHR capabilities, sharing visual display data with patients, and using EHRs for shared decision making and education.
Even with these interoperability and adoption limitations, services like PokitDok's API platform are enabling developers to create applications and services that can exchange data across closed systems without the need to replace infrastructure or change workflows.
Tags: Dev, Enterprise, Health Innovation