A Road Map for the Allergist / Immunologist
Electronic Health Records Overview: A Road Map for the Allergist / Immunologist
Russell B. Leftwich, MD, FAAAAI
It is generally understood that disseminated, frequently illegible patient records held separately in different medical provider offices has led to inefficient patient care. Furthermore, the goals of assuring the quality of healthcare provided in the United States and demonstrating optimum outcomes require the ability to analyze the data of individual practices. These are the primary reasons for the increased efforts to computerize and automate medical records. In theory, using currently available technology to help in the analysis and the instantaneous transfer of this information should be effective. However, the stress caused by changing how established physicians go about documenting their patient interactions has caused anxiety in the provider community. Also, the ability to guarantee privacy with this evolving technology is an enormous challenge. That challenge, as well as the expense of obtaining and maintaining electronic health records, falls largely on the physicians and hospitals that use them.
It seems clear that the need to facilitate this change is inevitable, and all physicians must address this issue when evaluating practice opportunities and the future of their practices. In 2008, only a few percent of existing allergy practices operate with a fully functioning EHR that has the capability to fulfill the functions noted above.
Initially this change will represent a real financial burden. Apart from acquisition of an office space, purchase of an electronic health record system almost certainly represents the largest capital investment that an allergy practice will make. Unfortunately, this financial burden might be compounded because several recent studies have shown that about 50 percent of EHR implementations fail. Reasons for these failures include:
- Poor preparation in planning and organization of the conversion from paper records to electronic records
- Lack of commitment on the part of principals involved to change the system used
- The actual disappearance of a large number of EHR systems because of the business failure of EHR vendors, both large and small, or their inability to upgrade technology
In early 2009, legislators passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009 (ARRA). The intent of the act is to encourage widespread adoption of health information technology that will allow sharing of clinical data, computerized ordering and prescription writing, support for clinical decision making, and analysis of clinical data to support quality assurance efforts and analysis of population health.
The HITECH Act addresses the financial burden on physician practices adopting an EHR by providing an incentive program that will provide cash incentives to practices who demonstrate "meaningful use" of an EHR. Incentives will begin in 2011 and will diminish over the subsequent 4 years, to be replaced in 2015 by monetary penalties in the form of decreased payments from government payor programs. These incentives do not however address the initial capital outlay in purchasing an EHR nor the ongoing maintenance costs, typically estimated at 20-25% of the initial cost.
Electronic Health Records vs. Paper Records
A 2006 survey by the CDC of EHR use in the United States showed that somewhat less than 10 percent of physicians had implemented an EHR that met a minimal list of criteria. An update of these statistics in 2007 suggested that these numbers had no more than doubled. It is likely that EHR use by allergists is in a similar range.
Information from politicians, policymakers, and EHR vendors would suggest that the decision to convert to an EHR is a slam-dunk— simple step on the road to medical documentation nirvana. But in reality there is no clear or simple answer to the question of when adoption of an EHR is appropriate or when the return on investment will be a positive number. The answer to this question depends in large part on the specifics of each individual office practice. It does seem reasonable to assert that the time is here for virtually every practice to begin an analysis of the appropriateness of an EHR.
Converting to EHR
Moving from a paper-based system, even with a computerized practice management system, to a fully implemented EHR requires a reengineering of practice workflow and procedures. This must begin with an analysis of current practice workflow, responsibilities of different staff members, patient flow through areas of the office, and identification of bottlenecks and inefficiencies.
One of the key elements in successful EHR implementation is the identification of a physician champion: a physician who will take the lead in adopting and promoting the EHR in the practice. There would logically be several reasons why a physician new to the practice might be in the best position to undertake this role, although uninitiated status at the same time poses a challenge. Recently trained physicians are likely to have exposure to EHR systems in training since academic medical centers tend to have a higher penetration of EHR systems. Surveys have shown computer literacy to be higher among younger physicians. Additionally, new practitioners are likely to have more time available in their schedules due to a lower burden of existing patients and administrative tasks. Competencies in the area of medical informatics, which are becoming a part of basic medical education, may be one of the greatest values that new physicians bring to a practice.
A second key element is the involvement of all elements of the practice very early in the process. Everyone from the front office to the back office should be given a stake in the process from early on. This means involvement in the initial stages of reviewing practice workflows and anticipation of changes that will be brought about by the EHR, not just involvement at the implementation stage.
The most careful organization and planning is required to avoid being in the 50 percent of EHR implementations that ultimately fail. Realistic timelines need to be set; many failures result from trying to complete this complex task in a matter of weeks when the process should extend over a year or more. The beginning of this process is a time when money may be well spent on a consultant whose expertise is in the area of medical informatics and is not associated with any particular EHR vendor. At the very least, one of several books on the topic should be adopted as a guide.
Choosing an EHR System
It is tempting to ask the question, "What is the best EHR system for an allergy practice?" But there is not a single answer to this question. The answer differs among practices and perhaps even among regions of the United States. One of the most common errors, many consultants say the single biggest error, is to look at EHR systems before analyzing the practice itself and its needs. The features of an EHR system displayed and promoted in vendor exhibits and promotional materials are typically and understandably the attention-getting bells and whistles of a system. However, these features may not be truly relevant to the needs of the practice and may not be cost effective in their eventual implementation.
One decision to be made early in the process is whether to hire a consultant to assist in the selection of an EHR system. Several factors should influence this decision. One important factor is the availability of an experienced consultant who has no affiliation with any EHR vendor. Individuals with experience and training in medical information technology are very scarce because there is an extraordinary demand for such skills. The ongoing evolution of the ambulatory EHR field makes practice management consultants who have significant relevant experience scarce as well. Nevertheless, some practices may wish to assign the task of selection and implementation to someone outside their practice, keeping in mind it is extremely unlikely any such consultant will have knowledge of the unique needs of an allergy practice. When selecting a consultant, it would be prudent to ask for details of past experience, including a list of clients (at least by practice type and size) and the vendors considered and chosen. Prices range from a fixed consulting fee, likely to be several thousanto exist. Read the fine print before you sign the contract!
Types of EHRs
There are three methods by which you might possess an EHR. The first, very simply, would be if you owned the software and the hardware on which it runs, including the server (in layman's terms, the "main computer"), the terminals or workstations used to access the server, printers, scanners, and other computer hardware. Everything would likely be located in your office or one of your offices. This is usually referred to as the "server model."
A second and increasingly common scenario is the Application Service Provider (ASP) model. The software in this case is on a server— larger, more powerful computer than a typical PC – that is located far from your office. PCs (workstations) in your office with printers and scanners are connected to the faraway server by the Internet. The advantages of the ASP model are that software updates do not have to be installed in your own office, backups of your data can be handled elsewhere, and you require less computer expertise in your own practice. The principal disadvantage is that you are dependent on a reliable, high-speed Internet connection.
The third situation, which some experts believe will become more common, is to be a user of an EHR that belongs to a hospital or healthcare system, with the software usually located on a server in their facility. The advantages are similar to the ASP model. The disadvantages are similar as well, with the additional concerns that you are tied to that one entity, you may have little to say in their selection of a particular EHR, the EHR may not have important features that you desire, and that other entity may decided some point in the future that the arrangement is no longer to their advantage. A cautionary note here is that although allergists are usually treated politely by hospitals and integrated healthcare systems, strong relationships with allergy practices are not coveted by them in the way that those with providers who admit many more patients or perform procedures in their hospitals are.
As you may know, the Centers for Medicare & Medicaid Services (CMS) has created an exception tt is a unique number that needs to be calculated for each individual practice situation. The reality is that it may be a negative number, although there will not even be a hint of this possibility in the sales presentation of an EHR vendor.
Economies such as the reduction of employees or storage space may not apply in smaller practices. Even in larger practices they may take years to realize. You cannot really shrink office space that already exists, and no EHR system can answer the phone or replace the human interaction with patients that is essential to our practices. As a result, the proportional savings are likely to be less for smaller practices and may disappear altogether.
It has long been acknowledged in the field of medical informatics and by policymakers in health care that one of the obstacles to adopting electronic medical records is that the greater financial benefits tend to accrue to stakeholders other than those who must make the investment in software and hardware. The benefits to insurance carriers, government payors, pharmaceutical companies, and patient safety advocates are often greater than the benefit to providers themselves. There are efforts to address this, but it remains part of the return on investment equation.
Contracting and Purchase
Like any large purchase and EHR system involves a complex purchase contract. This aspect, perhaps more than any other, should be an area to consider legal advice or that of an independent EHR consultant.
Standard purchase contracts often include several provisions that are to the disadvantage of the purchaser and seeking to revise these provisions would seem prudent. Among these are:
- Restriction of assignment. You sell your practice, but the EHR cannot be sold with it.
- Ownership of data. The vendor, not the practice may own the data.
- Access to data. The vendor may have a right to mine data without your permission.
- Loss of computer code if the vendor fails. Computer code should be escrowed in case the vendor does fail, so that all is not lost to the practice.
- An acceptance period. A money back guarantee period after implementation.
- Confidentiality. Contract provisurself early on, before planning it has part of your medical record system. Additionally, consider the impracticality of dictating and proofreading in a busy office hallway, let alone in the exam room in front of the patient. If you possess or are willing to develop the necessary keyboarding skills, however, you can touch type on a laptop computer while maintaining eye contact with the patient.
A common reason for failed EHR implementations is not allowing enough time for planning, selection, training, and implementation. For example, one EHR consultant will not accept a contract with any practice that insists on a timetable of less than six months to begin implementing a system. References listed at the end of this chapter include timetables for planning and implementation.
Privacy and Security
The Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) addressed the security and privacy of healthcare data. The deadline for compliance with privacy provisions was April 14, 2003, and the deadline for compliance with security provisions was April 20, 2005. Details of the provisions under HIPAA are included at the CMS website listed at the end of the chapter. Anticipation of the emergence of the electronic health record led to the creation and passage of this legislation. The administrative burden of compliance, whether practicing with an electronic health record or a paper chart, cannot be understated.
HIPAA Privacy Standards
Privacy involves the restriction of release of protected health information – information that is individually identifiable. Any release must be authorized by the patient or fall under categories of permitted release, including release to insurance carriers, pharmacy providers, and government entities under certain circumstances.
There has been considerable angst among medical providers about compliance with these standards. Much of that angst that existed before implementation deadlines has proven to be unjustified. Nevertheless, it is prudent to be attentive to the essential elements of having a carefully written Privacy Practices essential part of the maturation of electronic medical records and the continued development of widely accepted and robust standards is essential to recognizing the promise of the electronic record.
We are all familiar with the Current Procedural Terminology (CPT) codes for medical procedures published by the American Medical Association and the ICD-9-CM diagnosis codes, a subset of the International Classification of Diseases (ICD) codes published by the World Health Organization. These have been essential to the system of third-party payors in the US. The ICD codes – first published in 1893, long before the World Health Organization and before electronic records were even a twinkle in anyone's eye – have been essential to development of medical statistics as well as public health organizations.
Interoperability, or the ability of different electronic health record systems to communicate with one another, demands the development of even more robust and widely accepted standards. Achieving the promise of improved quality of care, improved patient safety, reduced healthcare cost, and portability of medical records requires interoperability that does not exist today. Interoperability has not been one of the criteria for CCHIT certification because it does not exist.
Instead of a graduate-level lecture in medical informatics, here is a single paragraph to provide some insight on interoperability. A typical hospital in the US possesses about a dozen computer systems that support different departments. To create a link between any two of these computer systems requires creation of special software at a cost of about $75,000. This is because no standard for communication between systems existed when most of those computer systems were created. Therefore, in a typical hospital, the cost would be 12 times 12 times $75,000 — a very large number! Starting from scratch with 12 new systems that could communicate with one another, or a single system that replaces all 12 systems, would also be prohibitively expensive.
Health Level Seven (HL7) is a not-for-profit volunteer standards development organization certified by the American National Standards Institute (ANSI) working toward the development of standards, often also referred to as HL7, that will allow the exchange of structured, encoded information between different electronic systems (not just computer systems, but devices such as IV pumps, glucose meters, and computer systems). HL7 is not the only organization attempting to develop such standards, but at this point it appears to have gained the widest acceptance and is in use in many software systems and medical devices. Still, it is far from universal. More information is available at their website: http://www.hl7.org.
Another organization involved in the development of standards is the Healthcare Information Standards Panel (HITSP – www.hitsp.org). This is a voluntary cooperative effort between public and private stakeholders in HIT area formed in 2005 to coordinate the development of standards that will make interoperability and the exchange of information between systems and healthcare institutions and providers possible. As of 2009 interoperability and information exchange are goals, not reality.
We practice today at the beginning of the electronic record era. Only about 20 percent of allergy practices have implemented an ambulatory EHR in any form. The timing of when to adopt an EHR is not the same for every practice, and the choice of which EHR likewise is not universal. Successful implementation requires months of careful planning and analysis of the practice. It is likely to require several more months to reach an efficient level of usage of the EHR. The process of adoption should be an evolution, not a revolution.
Whether the HITECH Act will accomplish all of its goals is uncertain. But it will profoundly affect the evolution of the EHR and the land
The EHR itself continues to evolve, and much of its potential has yet to be recognized in any existing EHR. Few existing EHRs offer features specifically for the allergist. Development and universal adaptation of standards is necessary for the promise of interoperability to be achieved. The recently started process of certification for the EHR will help to provide assurance of the function and survival of individual EHR systems and will help to define the standards that are necessary for interoperability.
American Academy of Allergy, Asthma, and Immunology. Joint EMR Task Force: Final Report. Accessed June 20, 2009.
Centers for Medicare and Medicaid Services website. HIPAA – General Information page. Accessed December 15, 2007.
NTM Informatics. Electronic Health Records. Accessed June 16, 2009.
Hartley CP, Jones ED. EHR Implementation: A Step-by-Step Guide for the Medical Practice. Chicago, IL: American Medical Association; 2005.
The Health Information Technology for Economic and Clinical Health (HITECH) Act Summary. Accessed June 15, 2009.
Medicare Quality Improvement Community. EHR Roadmap. Accessed December 15, 2007.
Ohio State Medical Association EHR Standards of Excellence Program. Accessed June 20, 2009.
Pennell U, Fishman E. EMRConsultant.com. Known Pitfalls and Proven Methods for a Successful EMR Implementation. Accessed June 15, 2009.