As a practicing internist at a county hospital, Charles Kennedy was troubled to find that even though he had a very good idea of what he was doing for his patients, he knew little about what all the other caregivers were doing for his patients. He and the other parties involved did not have the comprehensive, structured data they needed to achieve optimal results for the patient.
Despite vigorous attempts by vendors to peddle digital health care technology for records storage, the systems simply weren't catching on.
"The reason most physicians have not embraced electronic medical records (EMR) in the past is that they haven't found them that useful," says Kennedy, now VP of health IT at WellPoint Inc., an Indianapolis, Ind.-based independent licensee of the Blue Cross and Blue Shield Association.
However, this seems to be changing. The American Recovery and Reinvestment Act of 2009 (ARRA) lifted the prospects of electronic health records (EHRs)-or EMRs (as they are often interchangeably called)-and personal health records (PHRs), which have experienced sluggish growth for years. The stimulus's Health Information Technology for Economic and Clinical Health Act, or HITECH Act, offers $18 billion in incentive payments through Medicare and Medicaid reimbursement systems to prod hospitals and physicians to implement digital health record systems.
The ARRA legislation says providers will be reimbursed for the "meaningful use" of certified EHRs. Though still being fleshed out, such "meaningful use" includes not only ensuring that the EHR system records medical information, but also that it is able to share such data with other systems. Payer-based PHRs also can qualify for some of these funds to the extent that they satisfy the meaningful use criteria. To help build industrywide consensus and standards, the ARRA created the Health Information Technology Policy Committee, an advisory body that provides recommendations on issues such as how to use technology to create a single understanding of the patient shared across all providers.
GROWTH AND THE ARRA
Typically, an EMR is clinician-focused, offering a single place where all medical information related to a patient resides. This can include patient readings, lab results, EKGs and X-rays. In contrast, a PHR generally is sponsored by a carrier health plan, and it gives patients an Internet-based repository for their personal health information so they can keep track of allergies and medications in a fashion they can understand it.
The HITECH Act boosted recognition that patients' information needs to be electronically archived. Still more vital, it underscored the need for health IT vendors to build "shared clinical intelligence" on top of the raw data. To get value from an electronic health solution, behavior needs to be altered; simply providing reams of data to physicians and patients is not helpful. "You have to analyze the data so that it is personal," says Kennedy, who is a member of the Health Information Technology Policy Committee. "You have to get to personal, timely, specific and, most importantly, actionable information in order to get the value from the solutions. And you see the foundation for that kind of thinking reflected in the HITECH Act."
Recent trends for EMR and PHR growth are encouraging, according to some observers. "We are just seeing a dramatic uptake in both PHRs and EMRs," says Larry Leisure, a managing director in the payer and employers markets practice of Ingenix Consulting, an Eden Prairie, Minn.-based health IT subsidiary of UnitedHealth Group. "Health plans left and right are in the process of not just rolling out PHR capabilities, but enhancing the capabilities of those PHRs."
Sophisticated EMRs and PHRs now provide for rich and convenient conversations between physicians and patients. For instance, surging in popularity are e-visits, in which a patient and physician exchange e-mails around a specific set of data, says Leisure. He expects such visits to continue since the patient need not get in his car and the doctor can schedule more efficiently.
With 34 million members, WellPoint implemented digital health record initiatives that use claim data and apply algorithms to identify cost-reduction opportunities, while sending both paper and electronic messages to patients and physicians to increase the quality of care. It also launched EHR pilots that it developed with the Kettering Health Network.
During a one-year period for a WellPoint pilot in Ohio called the DaytonHealthKonnect Individual Health Record, members using the system lowered overall health care trend costs for medical benefits by 7.4% more than non-users, while they also had up to a 40% greater likelihood of receiving key disease screening tests than non-users. The pilot also yielded cost reductions, including a 10.3% decline in cost per employee for inpatient services year to year.
More so than EMRs, PHRs have struggled to find a foothold. According to a study on PHRs late last year by Forrester Research, two-thirds of consumers do not have a PHR, nor do really know what one is. Nonetheless, carriers such as Hartford, Conn.-based Aetna are leading the way in revolutionizing the use of PHRs. In order to interface with its rules-based technology, called Care Engine, Aetna developed PHR technology that went into full production in January 2008. Its tools scan patients' records and identify gaps in care as well as opportunities to improve care. They also shoot out targeted, personalized alerts to people based on their condition. For instance, if an Aetna member has diabetes and has not had a hemoglobin A1c test in six months (which the rules engine recognizes as being too long), he will get an automated alert recommending that he get such a test. His physician also will receive such an alert.
At Aetna, the PHRs have seen steady adoption, and greater use has meant better health for members, says Dan Greden, head of E-health product management for the company. Across Aetna's entire book of business, more than 9 million enrolled members have a PHR, and approximately 15% have used their PHR at least once. Aetna's PHR has seen much higher adoption rates among people spending heavily on health care-those with medical conditions are twice as likely to use Aetna's PHR. Further, those members it calls "heavy users"-or those who have viewed their PHR more than four times-are receiving more alerts than non-users. And heavy users have a 56% higher rate of having their alerts (i.e., their health concerns) resolved.
"Getting our members to interact with tools like this adds value to improving their health, and the economics of a healthier population are pretty clear," explains Greden. "Health care is expensive; the healthier our populations are, the less money we will spend on health care. And more importantly, the spend will be of a higher quality. It will help improve people's productivity and people's longevity, as opposed to taking a more reactive type of care investment."
Aetna's future aims include increasing adoption of its mobile PHR, which it launched earlier this year, and of looking more at EMRs. "When we started our PHR, from the very beginning we conceived it as a transition state to the EMR-enabled world," says Greden. "For a lot of reasons we saw the optimal future as being one where we have a highly integrated system that shares data among the whole health care infrastructure."
Health providers may also be drawn to digital records by their ability to help them with compliance or to reduce malpractice insurance. "A number of our providers have seen a reduction in their malpractice insurance [upon] the adoption of EHRs because it is focused, streamlined and there can't be any questions," says Michael Nissenbaum, CEO and president of Aprima Medical Software Inc., an EHR system provider based in Carrollton, Tex.
COST CONCERNS
Still, major cost concerns are inhibiting adoption of EMRs and PHRs. The cost of EHRs, in particular, can be exorbitant. "When you look at Kaiser Permanente's implementation of their new EHR system, they spent billions of dollars implementing that over their entire company, and they are not done yet," says Dave Pinkert, SVP of network management and consistent Web solutions for the Trizetto Group Inc., a Newport Beach, Calif.-based provider of PHR technology. To reduce the pain for those hoping to adopt the less expensive PHRs, Trizetto offers its PHRs free to clients using the company's claim system.
Related to cost concerns is the prickly problem of integrating data across multiple providers into a single record. It isn't until all the data about a patient is in one place that one gets true value from the records. If the data "gets wrapped up in a Tower of Babel, where the systems can't speak with each other," problems arise, says Nissenbaum.
And yet very few vendors have an EMR system that meets the criteria of meaningful use objectives, says Jeffrey White, a consultant for Health Strategy Associates, a Madison, Conn.-based consulting firm that specializes in managed care. "The ARRA of 2009 put very strict and stringent requirements with regard to 'meaningful use' and the certification of EHR technology, requiring many vendors to go through processes that are very expensive, like certifying with the Certification Commission for Healthcare Information Technology (CCHIT)," says White, who left an EMR company that he started in 2001. "That basically meant that only the big boys would be able to play in the certification process and actually achieve some type of meaningful use objective for physicians to be able to get reimbursed, or be heavily subsidized."
Apart from the issue of cost, the cultural shift required for patient and physician alike in adopting digital records may be too large for some. Many physicians do not take to change easily. "There will be some significant struggles along the way," says John Moore, managing partner for the Cambridge, Mass.-based analyst firm Chilmark Research."It is not so much the technology, but it is remapping the workflow to effectively adopt and use the technology, and getting the actual people that are going to be using these systems-nurses and physicians-on board to use them appropriately." Concerning solo and small group practices, the value of EHRs over paper has not been great because small practices can keep track of what they need to know about the patient fairly well, notes Wellpoint's Kennedy.
Though digital health records can be a great boon for consumers, apart from technophiles and the highly pro-active, most are not yet clamoring for them. A recurring concern for patients has been whether their records will remain secure and private, notes Aetna's Greden. Consequently, as patients log on to their PHR, Aetna prominently explains that it is a HIPAA-covered entity and indicates all that it is doing from a technological and an operational standpoint to protect their information.
As they grow in popularity, EMRs may give rise to alternative models and technologies for providing care to patients. This would bode well for Minute Clinics (such as CVS Pharmacy) and American Well, a videoconferencing company through which patients can find primary care physicians and specialists, says Leisure. Or it could lead to a growth in "Teledoc" services, which enable patients to discuss medical issues over the phone. Meanwhile, PHRs are becoming more sophisticated, enabling patients to refill prescriptions, check lab tests and schedule appointments.
Indeed, despite the obstacles, there is much hope for the success of EHRs and other digital records. "The magic of electronic health records is not helping physicians understand what their care actions are, but rather building a comprehensive understanding of what the entire care team is doing for the patient so that all can act as one," says Kennedy. "And most current EMRs don't do that; especially in small practice settings-in part because of the connectivity, the data standards, and the infrastructure for them to share information has not been there. Physicians in general are motivated to provide the highest quality care that they can for their members. And when they find something that helps them improve the quality of care most physicians will use it."
Daniel Joelson is a business writer based in Arlington, Va.
