You love it, you hate it, and you can’t live without it!
Electronic Health Records. They are of course, a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users. That is, until you want to share that information outside your network.
The ability (or inability!) to cleanly share information between EHR systems took center stage at HiMSS last week. New interoperability initiatives championed by Medicare and Medicaid Services Administrator Seema Verma drew enthusiastic applause from a packed house of clearly frustrated healthcare leaders, IT professionals, and clinicians who have struggled with the seemingly endless compatibility issues inherent in differing data systems.
Whether the White House will be successful in its new efforts is debatable but the initiative got us to thinking about how we got to where we are in the information sharing process and how healthcare technology and electronic health records have evolved over the last century.
First Medical Records Emerge in the 1920s
The roots of the health information management (HIM) industry can be traced back to the 1920s when healthcare professionals started using medical records to document details, complications, and outcomes of patient care.
In 1928, the American College of Surgeons (ACOS) established the Association of Record Librarians of North America (ARLNA) – now known as the American Health Information Management Association (AHIMA) – to standardize medical records.
The ARLNA sought to standardize how medical records were used and how information was documented.
40 Years Later: New Approaches to HIM
Paper records were utilized until the 1960s/1970s, when technological innovations such as the use of computers led to the beginning of new approaches to HIM — the standardization and sharing of medical records.
That standardization wouldn’t have been possible without the efforts of Dr. Lawrence Weed, a professor of medicine and pharmacology at Yale University. Weed created the first problem-oriented medical record (POMR) to organize the information used in medical records. Clinicians now had access to a patient’s entire medical history and the system allowed third-party facilities to verify diagnoses.
Medicare and Medicaid were introduced in 1965 and drove the development of healthcare information systems since reimbursement made accurate record keeping a priority. Using computers to collect and manage medical records was uncommon but growing. By 1965, electronic medical records were being used in about 73 hospitals. Healthcare information technology was expensive. Computers meant big mainframes and only the largest providers could dedicate the resources to leverage technology for medical recordkeeping. The Mayo Clinic in Rochester, Minnesota, was one of the early adopters.
Pioneers in HIM Emerge in the 1970s
The late 1960s and early 1970s saw technological advances in computers that inspired the development of many healthcare information management systems:
- Lockheed Corporation created Eclipsys in 1971, a computerized physician ordering system for El Camino Hospital in California.
- The University of Utah, 3M and Latter Day Saints Hospital collaborated on a clinical decision support system called Health Evaluation through Logical Processing (HELP).
- Massachusetts General Hospital and Harvard University collaborated on the Computer Stored Ambulatory Record (COSTAR).
- The Regenstrief Institute in Indianapolis created the Regenstrief Medical Record System in 1972.
These early systems were pioneers in healthcare information technology but widespread acceptance was still years in the future. Although the federal government started to invest in HIT with the Veterans Health Information System and Technology Architecture (VisTA), it wasn’t ready for public use until the next decade.
Computers Become Prominent in the 1980s
The introduction of the desktop personal computer really ushered in the modern age of healthcare information technology in the 1980s. Finally, hospitals were able to invest in systems that touched the patient floor. Doctors in small practices were able to afford the machines that would revolutionize the industry (for better or worse!).
In 1982, Dragon Systems developed a voice recognition prototype to the cheers of medical assistants everywhere!
By the late 1980s, personal computers and Windows-based software became prevalent in physician offices although they were used more for billing and scheduling rather than electronic medical records. At the hospital level, computerized registration made check-in processes more efficient but hospital computer systems were still segmented by department with no ability to communicate.
The 1980s – 1990s Bring Increased Awareness of the Benefits of EHR
By the mid-1980s, the Institute of Medicine (IOM) started studying health records and the benefits of electronic medical records. The study wouldn’t be published until 1991, but it found security issues, lack of standards and cost were the primary barriers to adopting electronic health records at the time. The IOM report set the standard for what we now expect from HER systems.
The Master Patient Index (MPI) was introduced in the 1980s to keep track of patients and their medical data. This paved the way for the Indiana Network for Patient Care (INPC), the healthcare information exchange (HIE) operated by Indiana Health Information Exchange. It leveraged an internally developed MPI which today includes 100 hospitals, representing 38 health systems; 12,000 practices with over 20,000 providers; 1,100 Veterans Administration sites and 12 million patients.
In 1990, Tim Berners-Lee established the World Wide Web and while healthcare wasn’t immediately affected, the web and browser technology established an expectation of how to access, share and navigate information.
In 1994, the World Health Organization adopted the ICD-10 coding standard. The new standard for diagnosis codes expanded the number of codes that can be used in medical records.
HITECH, Meaningful Use Arise in the 2000s
At the turn of the century, the Institute of Medicine (IOM) estimated that “between 44,000 and 98,000 hospitalized Americans die each year as a result of preventable medical errors.” Government sources could not substantiate the statistic but President George W. Bush called for computerized health records in his 2004 State of the Union address. The White House cited the IOM statistic to support the need for a plan to give most Americans access to electronic health records within 10 years.
In 2009, President Barack Obama signed the Health Information Technology for Economic and Clinical Health (HITECH) Act as part of the American Recovery and Reinvestment Act (ARRA). to adopt electronic health records by 2014 and set several stages of electronic health record adoption — referred to as “meaningful use.”
EHRs Become Commonplace by 2010
In 2011, the Office of the National Coordinator for Health Information Technology started working with the 62 Regional Extension Centers (RECs) across the nation to help healthcare providers migrate to electronic healthcare record systems. The RECs catalogued challenges that healthcare providers experienced while trying to achieve meaningful use.
Which brings us to today and the subject of interoperability — sharing information seamlessly among healthcare products and systems.
- How applications interact with users
- How systems communicate with each other
- How information is processed and managed
- How consumer devices integrate
Healthcare providers turned to integrated electronic health record systems because of the federal mandate and the incentive reimbursement. The impetus behind the federal programs includes the need to create access to integrated systems that would then promote better decisions, a reduction in medical errors, as well as decreasing duplication of costly services.
Despite widespread adoption of EHR systems since the passage of the HITECH act, by 2014 healthcare systems were not widely sharing healthcare data outside their organization. There was little financial incentive to sharing and using data to reduce costs or improve quality of care. The barriers to aggregating and harmonizing information among healthcare systems included:
- The cost of creating infrastructures to exchange healthcare data
- A lack of standards for interoperability
- Concerns about patient privacy and data security
Healthcare Information Technology Today
For better or worse, this is HIT today.
- EHRs still need work — The primary complaint by physicians is that poorly designed EHR interfaces are confusing and more time consuming than paper.
- Actionable insights from data — Healthcare organizations are investing in data tools to lower costs, improve care outcomes and comply with value-based mandates.
- Cloud adoption — Healthcare organizations are shifting from data centers to cloud based computing. The goal is to lower the cost of data storage and enhance the ability to share healthcare data within departments and among other entities.
- Internet of Things (IoT) healthcare devices — Connected devices are improving real-time data availability and information sharing. But IoT devices are targeted by hackers and the technology still has some maturing to do.
- Accessing unstructured data — EHRs have been structuring data but healthcare organizations have been turning to platforms that support and enable access to unstructured data too.
- Automating healthcare administration — While much of the focus has been on technology use by the clinical side of healthcare, major administrative functions of healthcare — such as hospital billing, financial applications and physician billing — have been automated.
- Technology driven innovation — Emerging opportunities in healthcare innovation mostly have driven by “the availability of large-scale databases; the development of true relational database software; and the emergence of the Internet into the commercial marketplace.” These technological advancements are expected to drive innovation in reducing medical errors, computerized physician data entry (CPDE) and disease management.
- Pace of IT — Market conditions and technology change much more quickly. Long-term plans quickly become outdated.
- Application programing interfaces (APIs) — Healthcare organizations cautiously approach migration to cloud services. Once they do adopt cloud services, HIT departments continuously need to assess how much they’re using and how much it costs.
- Flexible infrastructures — Historically, networks have been too complex to adapt quickly to new device connections and increases in workload. Networks are needed that adapt to business needs.
- Application programing interfaces (APIs) — HIT departments are working with APIs to ensure systems can share data and work.
- Customer satisfaction — While HIT departments see themselves as responsible for serving internal staff members, they are realizing how their work influences the customer experience and satisfaction with the healthcare organization.
Looking to the Future
It took us a century to go from scribbled notes to the ability to access medical information on hand-held devices and cell phones. But consider that almost 75 percent of all communication among healthcare organizations happens via fax machines. Unbelievable.
The future, like the past, will be driven by everyone with a stake in today’s healthcare industry.
- Payers and government regulators want total portability of health data among patients, physicians, hospital systems and healthcare payers.
- Clinicians want more intuitive EHR interfaces that take less time to enter patient data.
- Patients are using consumer medical devices that collects health data.
- Clinicians want access on any device, anywhere, and at any time.
A look back at the last 100 years suggests we should be up to the challenge.