This report originally appeared in the March 2009 issue of DOTmed Business News

It has taken a long time for health care providers to embrace Electronic Medical Records (EMRs) and Electronic Healthcare Records (EHRs) as a way of handling business. As it stands now, according to 2,000 doctors surveyed by NCHS (National Center for Health Statistics), only 4% said their EMR systems were totally functional. It looks like most of the physicians in the U.S. still rely on paper records.

However, with the financial incentive of the economic stimulus promise of $20 billion ($2 billion in grants and loans to install HIT (Health Information Technology) and $18 billion in payment incentives through Medicaid and Medicare, that could change. According to a Congressional Budget Office analysis, 90% of physicians and 70% of hospitals will be using electronic health records within a decade.




This, coupled with the 2005 findings by RAND Corporation, which state if EHRs are widely adopted the health care system could save more than $81 billion annually and improve the quality of care at the same time, makes the transition seem likely and well worth it.

Policy makers and health care workers are counting on the RAND study - barring some of the obstacles that seem to plague the HIT world.

When people hear the phrases electronic medical record as opposed to electronic health record they may think there is no difference. While EMR and EHR do share a goal of improving patient safety, quality and efficiency of patient care and reducing health care delivery costs, EMR and EHR are two separate tools that rely on each other to reach their full potential.

NAHIT (National Alliance for Health Information Technology (NAHIT) has established definitions for electronic medical records EMR and EHR.

EMR is the electronic, legal record of health-related information on an individual that is created, gathered, managed and consulted by licensed clinicians and staff from a single organization (hospital, clinic or other ambulatory environment) involved in the individual's health and care. It is composed of clinical data repository, clinical decision support, controlled medical vocabulary, order entry, computerized provider order entry, pharmacy and clinical documentation applications. It supports the patient's electronic medical record across inpatient and outpatient environments and is used by health care practitioners to document, monitor and manage health care delivery within a care delivery organization (CDO). EMR data is the legal record of what happened to a patient during a visit or stay at a CDO. It is owned by the CDO. EMRs are the data source for EHRs. Patients and consumers, health care providers, employers, payers/insurers and the government are what EMRs are composed of.

EHR is the summative electronic record of health-related information on an individual that is created and amassed cumulatively across more than one health care organization and is managed and consulted by licensed clinicians and staff involved in the individual's health and care. The EHR is owned by the patient and has patient input and access that spans periods of care across multiple CDOs within a community, region, state or entire country. EHRs are connected by the National Health Information Network (NHIN) and provide interactive patient access as well as the ability for the patient to append information.

In simple terms, EHR is similar to an EMR with interoperability because it can integrate other providers' systems to gain more information about a particular patient. Therefore, an EHR can provide a more in-depth view of a patient's health and history by pulling information from other systems, providing clinical decision support and alerting providers to health maintenance requirements.

Houston Neal of Software Advice said in terms of nomenclature, "electronic medical records" remains a more commonplace term relative to "electronic health records." He observed this in Google's search trend data. The average number of monthly searches for "electronic medical records" is 14,800, while "electronic health records" only gets 3,600. "One interesting geographical twist we discovered," says Neal, "search frequency in Washington, DC is about the same for both phrases. This probably reflects that many government organizations have adopted the EHR term well before the mainstream market." (Read more information and Software Advice for Electronic Medical Records.)

Mark Anderson, CEO and Healthcare IT Futurist of the AC Group, Inc. says it comes down to the words "medical" and health." An EHR will provide a more comprehensive view into a patient's health and history by pulling information from other systems and providing clinical decision support and alerting providers to health maintenance requirements. It helps providers report and measure quality indicators for pay-for-performance incentives. On the other hand, an EMR is a single diagnosis or treatment record, most likely used by a specialist. For example, an orthopedist setting a bone may need a stand-alone EMR because certain specialists may not need information about patient history as much as they need specialty-specific workflows and templates.

Whatever terminology is preferred, the key decision process for selecting an EMR/EHR is to figure out your organization's requirements and methodically assess systems against what you need. Anderson says that when choosing a system, "one should focus on the system itself, its features and feel, and perhaps most importantly, the track record of the software vendor." This task is one of the hardest for most physicians since there are almost 400 vendors stating that they sell the "best" product in the marketplace. Anderson says that there are a number of debates over the real cost with prices as low as $29.95 monthly for an integrated PMS (Practice Management System) and EHR to CCHIT certified products that cost $12,000 to $25,000, plus 18% maintenance costs per year. What's the right choice? "The answer can be found by determining what your needs are and matching your needs to the suite of vendors by category," says Anderson.

How far along is the health care community when it comes to EMH/EHR?

Outside of the Veterans Health Administration system, the vast majority of health care transactions in the United States still takes place on paper and has since the 1950s. The VA health system has over 155 hospitals and 800 clinics, and represents one of the largest integrated health care delivery systems in the world. It relies on a single EHR system called VISTA, which they have used for years.

Neal believes that there will be a major effort to fulfill President Obama's promise "to ensure that within five years, all of America's medical records are computerized." "No doubt, the current stimulus spending and focus on automating medical records will drive a major EMR adoption over the next five years," says Neal. Throwing money at the project does not guarantee success because change management and proper implementation processes will be critical. Another challenge will be getting small medical practices to make that investment and change their workflows. "In five years, we'll see a lot of progress however, I imagine it will take twice as long to execute on the vision that is being painted, perhaps longer," says Neal.

Other issues involved in the smooth transition from paper to computer are interoperability, standardization and connectivity of clinical information, training and technical support. Two other key elements in successful implementation of an electronic heath records system are financing and patient acceptance.

Eric Fishman, MD is President of EHRConsultant.com and EHR Scope, a compendium of information about physician system and speech recognition, which includes a free service to help physicians choose an EMR/EHR.

Fishman is aware of hundreds of different EMR company programs, has analyzed a significant percentage of them and reviewed the parameters of most. He believes since physicians are the ones paying for the service and third parties are the ones benefiting (like government and patients), the imbalance to physicians is disconcerting and can tend to hold back widespread adoption of electronic record keeping. Now that there is $20 billion in the recently passed economic stimulus program, this problem appears to have been fixed. And, he says, "Despite the significant amount of time and cost, essentially every physician who has been involved with a successful implementation says they would never go back to a paper office, and that includes me."

Fishman also believes that physician malpractice insurers commonly will offer discounts to offices that utilize EMRs. "Physicians who can provide greater quality of care will not only have greater gross revenue due to pay-for-performance, but will also be offered more meaningful malpractice insurance discounts," says Fishman. He emphasized, however, "One cannot implement a state-of-the-art, easily interconnected EHR for $5,000. What you can do is take the first step and automate your reports, but a number of those simpler systems are not CCHIT-certified.

CCHIT Certification

The Certification Commission for Healthcare Information Technology (CCHIT) has gained strength since its inception in 2004. It has a role in how EHR functionality is defined and promotes standards for EHR interoperability and security. It has also generated some controversy. Many EHR buyers use the certification titles as a way of helping to determine which products they should purchase. This often leaves non-certified vendors out of contention even if they may be as good - or better - than a certified competitor.

Because there are hundreds of EMR software products on the market, each with different functions, it can be easy to become confused by the choices. Since most physicians are not experts, it's hard for them to know which EMR system will best suit their needs. CCHIT, founded by HIMSS, AHIMA and NAHIT, is an independent non-profit, private sector initiative that certifies EMR/EHR software based on a specified set of parameters. Its mission is to accelerate the adoption of robust, interoperable health information technology by creating a credible and efficient product certification process (see http://cchit.org/files/CCHITPhysiciansGuide08.pdf for more information).

Since EMR/EHR is a long-term investment, choosing the right solution is imperative and certification can help with the evaluation and selection process by narrowing down the initial set of solutions. Some small vendors feel that a certification means certain death for their company because many cannot afford the $28,000 certification fee and many practices do not need the 300+ features mandated and evaluated by CCHIT for certification.

Reid Coleman, MD, FACP, medical director for LIFESPAN, a multi-hospital health care delivery system in RI, feels that the benefits of CCHIT far outweigh the price to acquire certification. "CCHIT certification is a great first step in guaranteeing HIT programs work together seamlessly enabling us to share critical clinical data between different products used in different facilities." When a certified product is selected, important guidelines for functionality, interoperability and security are met - vital in ensuring health care moves forward as an industry through the use of systems and technology.

"The CCHIT certification on a product is a help to purchasers of EMRs in at least three ways. First, there is predictability about the level of functionality and interoperability in the product. Second, it helps purchasers hold the vendors accountable for the quality of their software. If something in the system met the certification criteria, but is not working, the vendor has an incentive to get it fixed quickly. Third, it is helpful to know the certification requirements for future enhancements. When we know the timeframes for increased functionality that vendors must adhere to in order maintain certification, we can plan our implementations better," says Carol Cotter, senior vice president, chief information officer, LIFESPAN.

Not without controversy

Just as FDA certification of a medical device does not necessarily mean it can be used for all purposes, CCHIT certification does not guarantee a product is the right one for a practice or hospital-wide system (a certification process for hospital-based EMRs is in the works).

Questions have been raised in the medical community as to the validity of CCHIT certification. The key point of contention is the question as to its status as a legal entity. According to Sue Reber, Marketing Director, "CCHIT was founded originally as a LLC, but has subsequently transitioned to a private, nonprofit 501c 3 organization. CCHIT operates with a paid staff of about 20 personnel who support the work of the Commission and its 15 volunteer work groups, administer the certification inspections and provide outreach to its diverse stakeholders. CCHIT operates independently of HIMSS, AHIMA and NAHIT - its founding organizations and no money provided by ONC for development or by vendors for the conduction of inspections is returned to those organizations."

More legal challenges for universal EHR

The slow progress toward universal EHR implementation can also be partly blamed on legal challenges. Sharing electronic health records comes with legal barriers that specifically deal with things like:

· Paper-era state regulations that may not allow EHRs. (The precise relationship of the Act to paper era regulation of medical records is unresolved - authenticity issues).

· Anti-kickback Statute - The Medicare and Medicaid Patient Protection Act of 1987, as amended, 42 U.S.C. [SS]1320a-7b (the "Anti-kickback Statute"), provides for criminal penalties for certain acts impacting Medicare and state health care (e.g., Medicaid) reimbursable services. Enforcement actions have resulted in principals being liable for the acts of their agents. Of primary concern is the section of the statute, which prohibits the offer, or receipt of certain remuneration in return for referrals for, or recommending purchase of supplies and services reimbursable under government health care programs.

· Stark anti-referral rules (Limitation on certain physician referrals) - Many EHRs will facilitate referrals between hospitals and referring physicians and could implicate the Stark rules on compensation relationships. There are, however, two interesting exceptions: First, the most recent Stark rules state that wholly dedicated hardware is not remuneration. Thus, if a hospital provides medical staff hardware to support access to the hospital's EHR, and it was wholly dedicated to the use, there would not be an issue. There is also an exception for community wide health information systems - Stark protects "remuneration" in the form of hardware and software used in these information-sharing systems - with special qualifications. When provided, the party providing technology and support cannot take referrals into account in terms of who does and does not get support. The community wide system must be available to all providers who wish to participate.

· Concerns about malpractice (There are no cases that address liability when a physician uses or does not use an EHR system.

· HIPAA's privacy and security regulations (The clear bias of Privacy Rules favors disclosure and downstream use of medical information along familiar lines of medical practice and health care delivery). Sharing EHRs between a medical staff and a hospital is workable under the Privacy Rule, but nothing in the Privacy Rules anticipates the kind of wide open, unrestricted sharing of information among completely unrelated health care providers that the federal vision embraces. Add privacy to the challenges of appropriate security safeguards and there could be an argument that it could take years to make the federal vision workable.

New initiatives in the works

IBM has recently announced two groundbreaking initiatives to improve the capabilities and value of personal health records (PHR) and is tied to the Obama administrations' investment in health care IT to help improve patient care.

IBM and Google are improving the capabilities and value of personal health records - the core element of smarter health care delivery - starting with Google Health. The new advances - powered by IBM software - allow all kinds of personal medical devices used for patient monitoring, screening and routine evaluation to automatically stream their results into an individual's Google Health Account or other personal health record. From there, patients can direct how their "health diaries" will be shared with physicians, family and other members of the extended care network. It will mean that with the new technology, a busy mom can receive daily electronic updates on the health status of an aging parent who lives alone, is suffering from high blood pressure and is on multiple medications. Or, a traveling businesswoman who is diabetic and training for a marathon can have a real-time discussion about her blood sugar levels and heart rate with her coach hundreds of miles away.

Privacy concerns

Along with the potential benefits, there are privacy concerns associated with making patient records and device data more portable, experts warn. These concerns have come to be a major issue in lawmaker's debate over funds given to health IT in the economic stimulus package.

"People are worried about privacy, and rightfully so," says Dan Pelino, general manager of IBM's global healthcare and life sciences industry group. He believes that the best solution is the standard-based approach Google and IBM are taking which allows for more widely applicable security and frees technology vendors to focus on improving other features. Pelino noted that IBM has been inundated with phone calls from companies who are excited and ready to work with the new system.

No matter how many issues EMRs and EHRs face - no matter how much confusion or legal justifications - it is probably safe to say that EMRs and EHRs will soon affect our lives and the health care industry as a whole in a much larger sense than ever before - because they offer a vast improvement in our health care system over the old file cabinets and patient folder systems and because the government is pushing to make it happen.

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There are a number of acronyms concerning the health care
records industry. Some are confusing and some are redundant.
Some share subtle differences. The following terms
were provided by Dr. Eric Fishman. Dr. Fishman noted these
terms are most frequently utilized to describe the process
of documenting information concerning the medical care of
patients.

Automated Medical Record
Used only infrequently at present. It was an early stage of
'automating' the process of medical documentation.

EPR
Electronic Patient Record is similar to Computerized Patient
Record. It is an older term and is remaining popular largely
because of the Medical Records Institute, the entity which
runs the TEPR convention "Towards an Electronic Patient
Record' TEPR is now in its 21st year.

CPR
Computerize Patient Record - 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
health care would be included in the CPR, extending
from prenatal to postmortem information. This is one of the
original phrases for what was until recently called the EMR,
but is now generally referred to as the EHR.

CMR
Computerized Medical Record - This term is relatively infrequently
used in this century. However, in the 1990s it was
more common.

CCR
Continuity of Care Record - This is a standard of 'interoperability,'
which has recently become popularized. It is a 'snapshot'
of a patient's care which can frequently be downloaded into a
thumb drive or other very small portable memory storage device,
and brought by a patient to various health care facilities.

PHR
Personal Health Record - The emphasis in the PHR is on
the individual patient. With a PHR, patients can frequently
carry around a thumb drive or card holding digital data to
their various physicians, having each physician add to the
data.

EMR
Electronic Medical Record - This implies a level of sophistication
above a "Document Management' system. Not only
does an EMR allow you to create documents within your
office, it allows you to import information from a variety of
external sources.

EHR
Electronic Health Record - This implies a sophisticated level
of interoperability with the community. The implication of the
"health" as opposed to the "Medical" in EMR is that it is a
longitudinal record of an individual patient's health record.

This section was Provided by Eric Fishman, MD

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DOTmed Registered EMR/EHR Equipment Sales & Service Companies
Names in boldface are Premium Listings.

Domestic
Houston Neal, Medical Software Advice, Inc., CA
John Vossen, Automation Development Group, Inc., FL
Eric Fishman, EMRConsultant.com, FL
Ron Carson, Medical Voice Products, Inc., FL
Scott Anderson, Capital Healthcare Solutions, LLC, FL

International
Ahmet Guner, Ekolab Lab ve Bilgi SisTic Ltd, Turkey
Nikolai Gorlov, Computer Technologies in Medicine, Russia

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