Background Brief
Background
Personal Health Records
Electronic Medical & Health Records
E-Prescribing
Privacy Issues
Implementation and Costs
Impact on Health System Costs
Discussion Questions
With health care costs and quality assurance taking central roles in the health care arena, increasing attention is being directed towards the potential of health information technology (IT) to lower health care spending and to improve efficiency, quality and safety of medical care delivery. A growing body of research has explored the potential of health IT systems to increase adherence to clinical guidelines, enhance disease surveillance, and decrease medication errors. A host of private and public organizations are focused on finding effective uses for IT in the health care sector. This issue module focuses on some of the major advances in health IT, namely personal health records (PHRs) and electronic medical records (EMRs), and some of the major policy and delivery system issues that have arisen as a result.
There is growing emphasis on having individuals take a more active role in managing and coordinating their own health care, using tools such as personal health records (PHRs), which allow individuals to collect, view, manage, or share their health information electronically. The overarching purpose of a PHR is to facilitate an individual’s access to and creation of personal health information in a usable and portable computer application that the individual owns and controls. Currently, there are two dominant PHR models: the standalone PHRs that are updated by the patient; and the integrated or networked PHRs that can be populated with patient information from a variety of sources including EHRs, insurance claims, pharmacy data and home diagnostics. Over 200 PHR products are available varying in regards to format, features, functionality and degree of integration with other health information systems.
In contrast to personal health records which are owned and primarily used by the patient, electronic medical records (EMRs) are primarily intended for health care providers and are stored within a given institution or organization such as hospital or health delivery system. Generally, EMRs refer to a set of databases that store the health information of patients (drug allergies, diagnoses, treatments, lab results and medical history), which are adapted to fit an organization’s standards and clinical delivery processes, such as pharmacy data and preventive care delivery. Streamlining existing paper medical records, EMR systems can enhance communication, coordination, measurement, and decision support in health care settings, especially when utilized in disease prevention and chronic disease management. They allow health care providers to identify and recommend patient-specific services, generate reminders to increase patient compliance with physician recommendations, and communicate and coordinate with other specialists treating the same patient.
Electronic health records (EHRs) have a similar structure to EMRs, but can be shared cross-institutionally to link data from various providers to give a more comprehensive view of any single patient’s health record and to facilitate interactions with the entire health system. EHRs are generally more patient-focused in that they allow interactive patient access, particularly when a PHR is “tethered” to the EHR. Development of a standardized system for EHRs could assist in quality control reporting to the Centers for Disease Control and Prevention and the Food and Drug Administration that monitor hospital-acquired infections, as well as adverse events associated with drug use and medical devices.
EMRs and EHRs are said to be “interoperable” if they can exchange and receive data, and if the coding of the health records is in a standard format that is recognizable across systems. However, since there is no single standard EMR or EHR program on the market, interoperability presents a sizable challenge as providers and even larger health care organizations are faced with the task of determining which product to purchase or develop. Consequently, uniformity of EMR/EHR systems across hospitals, physicians, emergency rooms, and other health centers and health care organizations is a major issue in the advancement of these systems.
As one application of EMRs, computerized physician order entry (CPOE) technology has been designed to increase efficiency by allowing clinicians to electronically order tests, medications, services and referrals for patients. Furthermore, it may improve patient safety and health outcomes by presenting relevant information such as patient data, educational materials, and evidence-based decision support to clinicians upon entering a medical order. Alerts, reminders and other features can also warn physicians of patient conditions or potential adverse drug events and prevent medication errors.
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E-prescribing systems are a component of CPOE systems that allow physicians to enter prescription data for patients into an electronic system, which can help them prevent prescribing errors, adhere to treatment guidelines, and monitor patients’ responses to treatment. Some e-prescribing systems also have the ability to cross-check with other medications that a patient is receiving to prevent adverse reactions from combining certain drugs. Studies have found that e-prescribing systems can decrease serious medication errors and increase adherence to formulary medication. [1]
Despite the potential benefits of e-prescribing, there is still much work to be done before it becomes fully integrated into medical care. Currently, commercially available e-prescribing systems vary in their implementation of features such as reminders for medication and safety alerts. Thus, uniform standards for baseline data need to be established in order to allow information exchange among systems. [2]
Privacy has emerged as a top concern regarding the broad adoption of health IT among the public. Many are worried about insufficient data security and the possibility of inappropriate access to medical records. [3] The Health Insurance Portability and Accountability Act (HIPAA) of 1996 established regulations for the use and disclosure of information about health status, provision of health care, and payment for health care that can be linked to an individual. HIPAA also requires that electronic health transactions—claims, enrollment, eligibility, payment, and coordination of benefits—be standardized in order to improve efficiency and effectiveness in the nation’s health care system by encouraging use of electronic data. [4]
While health IT use has certainly increased over the past few years, hospitals are still far from universal adoption. In a 2006 survey conducted by the American Hospital Association, only 11% of hospitals reported having fully implemented electronic medical records, while 57% “partially” implemented systems and 32% had not yet started. Moreover, physicians in only 10% of hospitals routinely ordered medications electronically at least half of the time. [5]
Many barriers stand in the way of universal adoption, particularly the costs associated with initial implementation of electronic health systems. In addition to the costs of purchasing a system, there are costs associated with training personnel to navigate the new programs, maintenance, and upgrades. Adopting these new technologies also presents challenges related to technical barriers, adherence to privacy laws, and the establishment of a new set of industry standards. Furthermore, some observers claim that health care providers and health systems do not have enough incentive to adopt health IT systems because providers could end up absorbing the costs, while the benefits and cost savings are reaped by consumers and payers. [6] Not surprisingly, certain kinds of hospitals, such as those in urban areas, teaching hospitals, and hospitals with positive margins, use more health IT than smaller, less financially stable hospitals. [5]
Although many barriers exist, two of the nation’s largest health care systems have already fully implemented EMRs. Both the federal Veteran’s Administration and the private Kaiser Permanente systems have implemented electronic medical record systems. Undoubtedly, other hospitals looking to further integrate health IT can draw important lessons from their experiences.
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Some proponents of expanding health information technology cite the potential of IT in drawing significant cost savings to the health care system. One estimate projects that widespread adoption of health IT can lead to a potential efficiency savings for both inpatient and outpatient care that averages more than $77 billion per year. [3] These cost savings assume a reduction of costs associated with medication errors, communication and documentation of clinical care and test results, staffing and paper storage, and processing information. In April 2004, President Bush set a goal of implementing healthcare IT initiatives designed to achieve these efficiency savings within ten years. He also established a new administrative unit, the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services, to lead federal efforts in developing and implementing the nationwide infrastructure for health IT. With the upcoming 2008 election, several of the presidential candidates have emphasized a nationwide health IT system as one of the promising strategies they will support to significantly reduce health care expenditures. However, many analysts point to the challenges in broad use of health IT to achieve cost savings that are presented by the U.S. health care system—with multiple providers delivering care for patients, compatibility and interoperability issues arise in setting standards for using health IT.
- What are some of the major milestones in the development and advancement of Health IT?
- Are EMRs and EHRs developed enough to be successfully implemented in the U.S. health care system?
- Who should be responsible for funding the implementation of EMRs and/or EHRs? What types of incentives could policymakers use to influence providers’ or payers’ decisions to adopt use of such systems?
- Who will monitor quality of care and develop standards for computerized systems? What is the role of the federal and state governments? Private organizations or professional societies?
- How should compliance with standards be evaluated?
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[1] Bell, D.S. and M.A. Friedman. September/October 2005. E-Prescribing and the Medicare Modernization Act of 2003. Health Affairs 24(5):1159–1169.
[2] Fonkych, K. and R. Taylor. 2005. The State and Pattern of Health Information Technology Adoption. RAND Corporation.
[3] Hillestad, R., J. Bigelow, A. Bower, et al. September/October 2005. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs 24(5):1103–1117.
[4] Centers for Medicare & Medicaid, HIPAA Overview, December 14, 2005.
[5] American Hospital Association. 2007. Continued Progress: Hospital Use of Information Technology.
[6] Hackbarth, G., Milgate, K. 2005. Using Quality Incentives to Drive Physician Adoption of Health Information Technology. Health Affairs 24(5): 1147-9.
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