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Electronic Medical Records at a Crossroads: Impetus for Change or Missed Opportunity?

Electronic Medical Records at a Crossroads: Impetus for Change or Missed Opportunity? The president's American Recovery and Reinvestment Act includes $19 billion in incentives for the adoption of electronic medical records (EMRs)1 and his health care reforms include an investment of $50 billion to promote health information technology. For physicians considering adoption of an EMR system, the legislation features both the carrot and the stick. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18 000, with reduced subsequent payment amounts in 2013 and 2014. Physicians can capitalize on similar incentives available through the Medicaid program (but not both). Those physicians who do not adopt EMRs by 2015 will face a reduction of 1% in their Medicare fee schedule, increasing to a 2% reduction in 2016 and a 3% reduction in 2017 and beyond. At the same time, leading US health care organizations, including the Department of Health and Human Services (HHS), its Centers for Medicare & Medicaid Services, and the Agency for Healthcare Research and Quality, are investing heavily in clinical data–dependent quality measurement and improvement initiatives such as Pay-for-Performance2 and Healthy People 2010.3 Few would disagree that upgrading the information infrastructure of US hospitals and clinics is essential for improving the quality of US health care. It is therefore understandable that so much attention has been given to the promise of widespread EMR adoption to enable US health care improvement. Lost in the conversation thus far is the fact that today's EMR systems are not designed to improve the quality of health care. Most EMR systems are designed to document individual patients' conditions, facilitate communication of patient conditions and treatments between clinicians, justify financial reimbursement, and serve as the legal records of events. In other words, they are designed to improve the efficiency of individual transactions. Widespread adoption of today's EMRs will introduce health care to the benefits of digitizing paper. However, for an investment equivalent to more than twice the annual research budget of the National Institutes of Health, more should be achieved than advancing health care to the state of information technology enjoyed by most other industries since the 1980s. Instead, leaders of health care must adopt a lesson long-since learned by manufacturers, insurers, and supermarkets: quality improvement requires access to measurable information captured from thousands of transactions. Current EMR systems' lack of consideration for learning from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in electronic records is formatted as unstructured free text—useful for the essential individual communication but unsuitable for detecting quantifiable trends. In addition, few data standards are widely implemented, limiting the ability to conduct analysis across institutions and even across departments. Hospital chief information officers and information technology departments responsible for supporting today's EMR systems may be understandably leery of permitting access to medical records for secondary purposes (such as quality improvement). In addition, the lack of emphasis on accessible data encourages EMR vendors to guard access to their systems' data models based on concerns for proprietary designs and system integrity. In light of the current state of the EMR, it is no surprise that quality initiatives such as Healthy People are forced to eliminate objectives, not because of their lack of importance, but for a lack of measurable data. As part of the American Recovery and Reinvestment Act's provision for health information technology, the HHS has until December 2009 to define the “meaningful use” of EMRs, upon which clinician reimbursement is contingent. Examples from the Veterans Health Administration and elsewhere have shown that it is the meaningful “reuse” of EMR data that leads to improved health care.4-6 If HHS capitalizes on this opportunity to mandate information systems that facilitate learning from existing data, US health care may finally begin to fulfill the decades-old promise of the EMR. Databases of vital signs, images, laboratory values, medications, diseases, interventions, and patient demographic information can be mined for new knowledge. Rather than base guidelines for care on roundtable discussions of few experts or a limited evidence base, practices that work best can be discovered based on analysis of entire populations. With just a few of these databases networked together, the power to improve health care increases exponentially. Regional networks of databases can be used to pinpoint outbreaks of infections or to highlight differences in care of patients from one hospital to the next. The eventual addition of genomic information, environmental factors, and family history to these databases will enable clinicians to begin to realize the potential of personalized medicine; the use of the most appropriate therapeutic intervention for each individual. If instead, the definition of “meaningful use” remains centered on supporting individual transactions, access to measurable information will remain secondary. Consequently, so too will health care quality measurement. No amount of digitizing inaccessible or immeasurable information will lead to significant improvements in patient health. Instead, the US health care system will continue the tradition of world-leading spending for less than optimal health returns.7 Fortunately, “meaningful use” that requires accessible and measurable information is, from a technical standpoint, rather straightforward to implement. First, the databases on which EMR systems are designed must support access and analysis. This requires that data elements are named intuitively and clearly documented. Whenever possible, standards should be used to define data elements to facilitate “apples-to-apples” comparisons. Interfaces and workflows in EMR systems must be flexible enough to capture new information at the point of care and put lessons learned into action. Most important, data governance policies must be implemented that recognize that protecting patient privacy and learning from aggregated data are not mutually exclusive activities. The time to make proper use of clinical data, medicine's most valuable untapped resource, is long overdue. The technologies required to reach these goals have matured in other industries during a period of years. The lack of investment traditionally blamed for health care's slow progress on this front may no longer be an issue. All that is missing is the collective realization that better health care requires access to better information—not automation of the status quo. Back to top Article Information Corresponding Author: Leonard W. D’Avolio, PhD, Veterans Affairs Boston Healthcare System, Massachusetts Veterans Epidemiology Research and Information Center (151MAV), 150 S Huntington Ave, Jamaica Plain, MA 02130 (leonard.davolio@va.gov). Financial Disclosures: None reported. Disclaimer: The views expressed herein are those of the author and not necessarily those of the Veterans Administration or the Veterans Affairs Boston Healthcare System. Additional Contributions: I thank Louis D. Fiore, MD, MPH (Massachusetts Veterans Epidemiology Research and Information Center [MAVERIC], Cooperative Studies Program Coordinating Center, Boston University Schools of Medicine and Public Health, Jamaica Plain, Massachusetts), for his reviews and insights, and Mary K. Goldstein, MD, MS (Geriatrics Research Education and Clinical Center, VA Palo Alto Health Care System and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Palo Alto, California), for provoking consideration of the topic. Neither received compensation for their contributions. References 1. H.R.1: Making supplemental appropriations for job preservation and creation, infrastructure investment, energy efficiency and science, assistance to the unemployed, and state and local fiscal stabilization, for fiscal year ending September 30, 2009, and for other purposes. Pub L No. 111-5, 111th Cong (January 26, 2009) 2. Centers for Medicare & Medicaid Services. Medicare “Pay for Performance (P4P)” Initiatives. Baltimore, MD: CMS Office of Public Affairs; 2005 3. US Department of Health and Human Services. About Healthy People. http://www.healthypeople.gov/About/. Accessed July 16, 2009 4. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141(12):938-94515611491PubMedGoogle ScholarCrossref 5. Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4):272-28115313743PubMedGoogle ScholarCrossref 6. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-222712773650PubMedGoogle ScholarCrossref 7. Starfield B. Is US health really the best in the world? JAMA. 2000;284(4):483-48510904513PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Electronic Medical Records at a Crossroads: Impetus for Change or Missed Opportunity?

JAMA , Volume 302 (10) – Sep 9, 2009

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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2009.1319
Publisher site
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Abstract

The president's American Recovery and Reinvestment Act includes $19 billion in incentives for the adoption of electronic medical records (EMRs)1 and his health care reforms include an investment of $50 billion to promote health information technology. For physicians considering adoption of an EMR system, the legislation features both the carrot and the stick. Medicare physicians adopting and making “meaningful use” of EMRs in 2011 and 2012 will be eligible for an initial payment of up to $18 000, with reduced subsequent payment amounts in 2013 and 2014. Physicians can capitalize on similar incentives available through the Medicaid program (but not both). Those physicians who do not adopt EMRs by 2015 will face a reduction of 1% in their Medicare fee schedule, increasing to a 2% reduction in 2016 and a 3% reduction in 2017 and beyond. At the same time, leading US health care organizations, including the Department of Health and Human Services (HHS), its Centers for Medicare & Medicaid Services, and the Agency for Healthcare Research and Quality, are investing heavily in clinical data–dependent quality measurement and improvement initiatives such as Pay-for-Performance2 and Healthy People 2010.3 Few would disagree that upgrading the information infrastructure of US hospitals and clinics is essential for improving the quality of US health care. It is therefore understandable that so much attention has been given to the promise of widespread EMR adoption to enable US health care improvement. Lost in the conversation thus far is the fact that today's EMR systems are not designed to improve the quality of health care. Most EMR systems are designed to document individual patients' conditions, facilitate communication of patient conditions and treatments between clinicians, justify financial reimbursement, and serve as the legal records of events. In other words, they are designed to improve the efficiency of individual transactions. Widespread adoption of today's EMRs will introduce health care to the benefits of digitizing paper. However, for an investment equivalent to more than twice the annual research budget of the National Institutes of Health, more should be achieved than advancing health care to the state of information technology enjoyed by most other industries since the 1980s. Instead, leaders of health care must adopt a lesson long-since learned by manufacturers, insurers, and supermarkets: quality improvement requires access to measurable information captured from thousands of transactions. Current EMR systems' lack of consideration for learning from aggregated health data has led to implementations and hospital information technology departments that can actually obstruct quality improvement. For example, much of the information contained in electronic records is formatted as unstructured free text—useful for the essential individual communication but unsuitable for detecting quantifiable trends. In addition, few data standards are widely implemented, limiting the ability to conduct analysis across institutions and even across departments. Hospital chief information officers and information technology departments responsible for supporting today's EMR systems may be understandably leery of permitting access to medical records for secondary purposes (such as quality improvement). In addition, the lack of emphasis on accessible data encourages EMR vendors to guard access to their systems' data models based on concerns for proprietary designs and system integrity. In light of the current state of the EMR, it is no surprise that quality initiatives such as Healthy People are forced to eliminate objectives, not because of their lack of importance, but for a lack of measurable data. As part of the American Recovery and Reinvestment Act's provision for health information technology, the HHS has until December 2009 to define the “meaningful use” of EMRs, upon which clinician reimbursement is contingent. Examples from the Veterans Health Administration and elsewhere have shown that it is the meaningful “reuse” of EMR data that leads to improved health care.4-6 If HHS capitalizes on this opportunity to mandate information systems that facilitate learning from existing data, US health care may finally begin to fulfill the decades-old promise of the EMR. Databases of vital signs, images, laboratory values, medications, diseases, interventions, and patient demographic information can be mined for new knowledge. Rather than base guidelines for care on roundtable discussions of few experts or a limited evidence base, practices that work best can be discovered based on analysis of entire populations. With just a few of these databases networked together, the power to improve health care increases exponentially. Regional networks of databases can be used to pinpoint outbreaks of infections or to highlight differences in care of patients from one hospital to the next. The eventual addition of genomic information, environmental factors, and family history to these databases will enable clinicians to begin to realize the potential of personalized medicine; the use of the most appropriate therapeutic intervention for each individual. If instead, the definition of “meaningful use” remains centered on supporting individual transactions, access to measurable information will remain secondary. Consequently, so too will health care quality measurement. No amount of digitizing inaccessible or immeasurable information will lead to significant improvements in patient health. Instead, the US health care system will continue the tradition of world-leading spending for less than optimal health returns.7 Fortunately, “meaningful use” that requires accessible and measurable information is, from a technical standpoint, rather straightforward to implement. First, the databases on which EMR systems are designed must support access and analysis. This requires that data elements are named intuitively and clearly documented. Whenever possible, standards should be used to define data elements to facilitate “apples-to-apples” comparisons. Interfaces and workflows in EMR systems must be flexible enough to capture new information at the point of care and put lessons learned into action. Most important, data governance policies must be implemented that recognize that protecting patient privacy and learning from aggregated data are not mutually exclusive activities. The time to make proper use of clinical data, medicine's most valuable untapped resource, is long overdue. The technologies required to reach these goals have matured in other industries during a period of years. The lack of investment traditionally blamed for health care's slow progress on this front may no longer be an issue. All that is missing is the collective realization that better health care requires access to better information—not automation of the status quo. Back to top Article Information Corresponding Author: Leonard W. D’Avolio, PhD, Veterans Affairs Boston Healthcare System, Massachusetts Veterans Epidemiology Research and Information Center (151MAV), 150 S Huntington Ave, Jamaica Plain, MA 02130 (leonard.davolio@va.gov). Financial Disclosures: None reported. Disclaimer: The views expressed herein are those of the author and not necessarily those of the Veterans Administration or the Veterans Affairs Boston Healthcare System. Additional Contributions: I thank Louis D. Fiore, MD, MPH (Massachusetts Veterans Epidemiology Research and Information Center [MAVERIC], Cooperative Studies Program Coordinating Center, Boston University Schools of Medicine and Public Health, Jamaica Plain, Massachusetts), for his reviews and insights, and Mary K. Goldstein, MD, MS (Geriatrics Research Education and Clinical Center, VA Palo Alto Health Care System and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Palo Alto, California), for provoking consideration of the topic. Neither received compensation for their contributions. References 1. H.R.1: Making supplemental appropriations for job preservation and creation, infrastructure investment, energy efficiency and science, assistance to the unemployed, and state and local fiscal stabilization, for fiscal year ending September 30, 2009, and for other purposes. Pub L No. 111-5, 111th Cong (January 26, 2009) 2. Centers for Medicare & Medicaid Services. Medicare “Pay for Performance (P4P)” Initiatives. Baltimore, MD: CMS Office of Public Affairs; 2005 3. US Department of Health and Human Services. About Healthy People. http://www.healthypeople.gov/About/. Accessed July 16, 2009 4. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141(12):938-94515611491PubMedGoogle ScholarCrossref 5. Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4):272-28115313743PubMedGoogle ScholarCrossref 6. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-222712773650PubMedGoogle ScholarCrossref 7. Starfield B. Is US health really the best in the world? JAMA. 2000;284(4):483-48510904513PubMedGoogle ScholarCrossref

Journal

JAMAAmerican Medical Association

Published: Sep 9, 2009

Keywords: electronic medical records

References