Many people recognize how valuable it will be to connect electronic medical records (EHRs) and government health programs. There are examples where information (prevention schedules, assessments, etc.) can be delivered into EHRs and where information can flow in and out of EHRs (immunization histories, lifetime military records, etc.).
There are also cases – sometimes called “secondary uses of clinical data” – where information principally flows out of EHRs to programs at the local, state and federal levels, including for healthcare quality reporting, disease case reporting, post-market drug surveillance, disability eligibility determination, clinical research, and others.
Even from the standpoint of secondary uses alone, programs can benefit from increased speed, broader data and greater consistency over paper-based methods. For instance, clinicians can benefit from the automation of some of what they must now do manually and the support these programs can provide. The population can also benefit from more efficient processes and improved population health.
The value equation defined here, however, has traditionally been obstructed by a lack of alignment of incentives and poor coordination of the various programs. Consequently, providers are burdened by duplicative and uncoordinated reporting needs, EHR vendors say their customers do not demand these capabilities and the programs persist through suboptimal processes.
Unfortunately, the HITECH incentive funds and meaningful use program do not significantly rebalance this value equation even for the quality reporting that is so prominent right now.
For one thing, there is an assumption that all reported data must accrue as part of the immediate process of care and natively reside inside of an EHR per se. One study by Jane Metzger and others (“Hospital Quality Reporting: The Hidden Requirements in Meaningful Use”) showed that even for the initial meaningful use quality measures – picked in part because of the high likelihood their data would be available in EHRs – as little as one-third of those data actually exist in EHRs naturally.
Even if the rest of these data are available in electronic form in ancillary health systems, the expectation, moving forward, that every reporting need would require systems interface work to get all the data into EHRs is not supportable.
Even assuming that all these EHR interfaces would be developed, the duration of the HITECH incentive dollars at the pace currently contemplated does not come close to providing what is needed to incorporate the needs of these different programs. Finally, none of what is currently proposed allows for changing reporting needs such as in the case of rapidly occurring health events or even normal program learning and maturation.
The reality is that the hugely manual current reporting processes and many secondary uses will not suddenly be replaced by fully automated processes for many years – if ever. If we want to take advantage of population uses of EHRs we need to more fundamentally rebalance the value equation. There is a need for consistent and coordinated electronically supported entry of data in a way that is as minimally burdensome as possible on clinicians and their staffs. A well executed program for electronic forms (e-forms) can achieve these objectives.
First, the second stage of meaningful use should require a standard for e-forms. The World Wide Web Consortium’s “XForms” standard and Integrating the Healthcare Enterprise’s (IHE) transaction framework (including the “Retrieve Form for Data Capture”) have been successfully specified and tested by the Clinical Data Interchange Standards Consortium for post market drug surveillance and by the Centers for Disease Control and Prevention for public health case reporting and other things.
The way the standards work, the need for a form is initiated by data that exist in the EHR. The EHR auto-populates data for which standards exist and launches an e-form in a browser or renders it through its own software for additional necessary data. Forms can be queued for support staff completion to further reduce clinician burden. Data can be saved in the EHR or submitted it to a variety of endpoints. These processes have been prototyped and demonstrated by numerous vendors and programs in the HIMSS Interoperability Showcase.
Second, there needs to be a process for managing programs into a coordinated and minimized “ask.” This coordination is long overdue. It could reduce reporting demands on clinicians who readily attest to the overlapping and conflicting demands they now face. And it is the perfect time to initiate such a process because of the gates some programs face in having their needs met in moving from paper to electronic form.
At the same time, flexibility is needed for government programs to fund the common infrastructure that can make all this happen. Categorical funding lines have been accepted for too long as explanation of “stove pipe” program thinking and expenditures. Programs using a common infrastructure and making a common “ask” will also develop cost efficiencies that can be used to further support providers in fully participating.
There is an opportunity now to engineer standards and processes to rebalance the value equation for secondary uses of data and support clinicians. This engineering will require coordinated technical and policy steps soon.
--Dr. John W. Loonsk is chief medical officer for CGI Federal, Inc. From 2006-2009, he was director of interoperability and standards in the Office of the National Coordinator for Health IT.
