Building an EHR: Goals, Challenges and Tactics
Technology in healthcare has made great progress in diagnostic and therapeutic applications. Using computers to assist in imaging, surgery and critical life support has meant lives are being saved that as recently as five years ago were being lost.
However, the application of health information technology (HIT) to clinical records has been dreadfully slow. The ability for different providers and organizations to electronically store and then exchange health-related information anywhere that a patient needs care does not exist, and looks likely not to exist, unless significant coordinated efforts are undertaken by all parties in the health industry.
Rewards for implementing electronic health records (EHRs) have proven elusive, and the expense is considerable. Confounding the progress of even this small amount of EHR implementation is the distressing fact that none of the disparate EHR systems currently in the market are capable of communicating with each other (or in most cases even themselves) in any but the most rudimentary ways, if at all.
A Universal Issue
Although the U.S. lags behind many other countries in significantly expanding the use of HIT, it is not alone in its lack of progress with EHRs. The need to enhance the quality of patient care through electronically portable clinical information is truly an international one. Healthcare leaders from across the world consider EHRs to be among the most important applications their organizations will need to invest in over the next two years. Countries that are beginning to address widespread adoption of EHRs include Australia, Canada, Finland, France, Germany, New Zealand, the Netherlands and the U.K.
In the U.S., President George W. Bush established a vision of interoperable EHRs and appointed David Brailer,M.D., Ph.D., to serve as the national coordinator for HIT. This created a focal point for action and captured the attention of both the healthcare industry and the nation. In a publication by Health and Human Services former Secretary Tommy Thompson and Dr. Brailer, four overarching goals were established. Paraphrased, these goals are: informing clinical practice; interconnecting clinicians; personalizing patient care; and improving population health, including access to care for underserved Americans.
The federal governments in the U.S. and many other countries have issued their calls for action, but many unanswered questions remain. How will HIT and EHRs be developed and by whom? Where will the money required for development and implementation come from? What are the implications for clinicians, hospitals, payers and employers?
Overcoming the Barriers
There are significant challenges facing HIT and EHRs, encompassing structural, technical, financial and social/cultural issues. Although the organizational and financial environment in the U.S. is markedly different from what is found in the other countries, many of the issues that need to be addressed are universal, and numerous lessons can be learned from the experiences abroad.
None of the challenges represent insurmountable barriers to successful national adoption, but they will need to be addressed nevertheless. First and foremost the process will need to address funding for capital outlays and financial incentives to encourage provider adoption. In the U.S., funding will need to come from private- public partnerships and include a combination of grants, loans, reimbursements, and tax and other policy incentives. And even in other countries, healthcare organizations will need to self-fund at least a portion of EHR acquisition and local infrastructure development through business process changes that yield administrative efficiencies and cost savings.
Additionally EHR adoption will require standards to facilitate accurate and easy exchange of data from one computer system to another, or interoperability. Regardless of whether the approach taken is centralized or decentralized, a national health information infrastructure of standards and privacy safeguards that restricts access only to caregivers authorized by the patients themselves will be required at some level. And the issue of patient and provider identifiers will need to be resolved so that clinical information can be connected at the patient level while ensuring individuals privacy.
Broad HIT adoption most certainly will require major changes in the relationships between clinicians, hospitals, payers, employers, technology vendors and patients. All will need to participate and be invested in technology development, implementation and success. A high degree of collaboration at a local level will be necessary, and constituents will need to overcome historical animosities.
The Vision
Achievement of a national health information infrastructure is surely a long-term vision. Progress will occur over the next seven to 10 years and will continue to evolve even after that. At this early stage in the strategic formulation of a national HIT agenda, it is difficult to predict what the specific results will look like. Given the from the ground up approach that is being adopted, the models will certainly vary between nations; even within one country, the details are likely to vary from region to region, at least in the near term.
What is clearer is what the process will look like and what issues will need to be addressed. To accomplish the strategic goals that have been established, the process will need to address existing barriers such as funding for capital outlays, incentives to encourage clinician adoption and standards to facilitate interoperability. In the end, structural and technical challenges will need standardized solutions, while approaches to the financial and social/cultural challenges will be more variable. In truth, such variability represents an excellent opportunity for imaginative solutions.
Ultimately the widespread adoption of EHR will completely revolutionize how we measure success in healthcare. It will provide an opportunity to redefine measures of quality and outcomes, and as a nation we will be able to gauge levels and improvements in patient safety like never before. There is no doubt that the EHR will come to occupy a central place in our healthcare system.What comes in the next 10 years will be the reality of how that occurs.
Taking Action
While it is early on a national level in most countries, it is not too early for organizations to take action in HIT, and ultimately take action toward implementation of the EHR. Certain actions can be undertaken now or in the near term in order to build the necessary base of support and infrastructure. Examples of such actions are as follows.
Engage the Community. No organization can be successful with HIT and EHRs by itself. Open and cooperative discussion and action must occur between hospitals, professional healthcare providers, payer or insurance executives, business leaders and consumers. In the U.S., this is frequently taking place under the auspices of a regional health information organization, many of which have been started with seed money either from the federal government or from local initiatives by payers and provider systems. The needs of all parties, the proposed benefits to all parties and the reality of the environment must all be addressed. In this way, local or regional approaches can be taken, upon which broader achievements can be built.
Redesign Processes and Workflows. No software solves problems by itself. As HIT and EHRs are implemented, organizations must redesign their processes and workflows to take advantage of efficiencies created by new technology. Failure to do so will most likely result in disgruntled clinicians and grossly suboptimal outcomes, to say nothing of a significant investment wasted. In addition, service levels must be defined and measured to ensure that improvement goals are being met.
Create a Business Case for HIT and EHR Implementation. To enter into HIT and EHRs without a well-defined business case is to risk a poorly executed and overly expensive undertaking. Organizations must define goals and investment returns associated with new technologies. Investment returns need not be strictly financial; they can be clinical (e.g., measurable improvements in patient safety) or service-oriented (e.g., measurable improvements in patient satisfaction). The first step in its creation is the creation of measures that will inform the business case; examples might include patient safety (e.g., medication errors), clinical support costs (e.g., costs of medical records), and financial improvement (e.g., improved coding and billing). The discipline of a business case provides guidance for success and cannot be bypassed
Work with Clinicians. All clinicians, but most especially physicians, must be an integral part of the process. If physicians cannot see how HIT and the EHR will improve their working lives, they will resist it. It is not sufficient to simply install new systems and expect clinicians to fully embrace it, nor will new systems necessarily achieve improved outcomes if physicians are not taking complete advantage of available capabilities. Clinical leaders must not only be deeply involved in all appropriate aspects of HIT and EHRs, they must serve to translate the organizations goals and objectives into terms meaningful to other clinicians.
Work Closely with IT Vendors. Any organizations IT vendors must be engaged, whether its clinical support systems for hospitals, practice management systems for physician practices or e-prescribing vendors working with physicians and payers. How is the vendor looking to the future in terms of compliance with national initiatives, voluntary standards, connectivity and electronic communications, clinical support, messaging infrastructure and data analysis? It is important for the organization to make it clear what its expectations are, and for the IT vendors to make it clear what their path to the future is.
Work with Patients and Consumers. Find out what is important to patients and consumers that might be part of the HIT and EHR strategy. Examples might include Web portals with health information, including access to their own health records (including test results), the ability to communicate with clinicians or the hospital, the ability to schedule visits or procedures and so forth.
Conclusion
After years of mostly ineffective talk, the forces are now aligned for the successful implementation of HIT and EHRs in countries across the world. Governmental and health industry leaders agree on the need, and if there are differences of opinion as to the degree of value, there is no disagreement that the value is positive. Given the massive size of the healthcare sector in the economy as well as the complexity of the task, there is no shortcut; success is likely to take at least seven to 10 years, or even longer depending on the country and the level of support provided. But what have served in the past as insurmountable barriers to success are now seen as challenges that can be successfully addressed by all of the individuals and organizations affected. When people of good will, supported by visionary public policy and resources, put in the effort, success will follow.
