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The Value of Speaking The Same Language
Health Data Management Magazine, February 1, 2008
This story is the first in an in-depth, three-part series Health Data Management will publish this year about EMRs, EHRs and PHRs. We’ll also be running three other series of feature-length articles on revenue cycle, point-of-care technologies and CIO Issues. These series represent our effort to provide insightful, concise and timely information to our readers on the technologies and business issues that shape their strategic initiatives. -Greg Gillespie, Publisher
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Two work groups funded by the Department of Health and Human Services are working to seek industry consensus on the definitions and use of these terms. The Networks Work Group is tackling RHIOs and HIEs, while the Records Work Group covers EMRs, EHRs and PHRs. The groups in January held a public forum to solicit industry input. A second forum is scheduled during the Healthcare Information and Management Systems Society Annual Conference & Exhibition in February.
Final reports, due in late March, can’t come too soon.
Just take a look at the Web site of dbMotion Inc., a vendor of data integration services and exchange platforms for health care organizations. In describing its services, the Pittsburgh-based company uses the term EMR. And EHR. And RHIO. And HIE. It also uses HIN for “health information network” and IDNs for “integrated delivery networks.” It even mentions “integrated healthcare delivery systems.”
“We ourselves are guilty of abusing the terms freely,” acknowledges Joel Diamond, M.D., chief medical officer and a practicing family physician. But from a corporate viewpoint, “we have to use everything because all these terms mean different things to different people,” he adds.
Indeed they do. Robert Kolodner, M.D., national coordinator for health information technology at HHS, wonders if progress in adopting electronic records and creating a national health information network is hampered by the lack of clarity in what the heck we’re talking about. “By being more consistent in the terminology, it will help us move forward more quickly,” he says.
Kolodner previously has tackled some of the terminology issues that face the HHS-authorized work groups (see sidebar, page 54).
But to link the misuse and possible misunderstanding of these and other terms to any slowness in I.T. adoption “is a stretch in my opinion,” contends Becky Quammen, CEO of The Quammen Group, a Winter Park, Fla.-based consulting firm. “Folks basically know what they are doing and why they are doing it.”
The question of what to call electronic records systems is not delaying physician purchasing decisions, contends Mark Renfro, executive director of North East Florida Regional Health Organization, an emerging HIE serving the greater Jacksonville area. “The fundamental problem is they do not want to pay for it themselves,” he adds. “Doctors say, ‘I can invest in technology and my take-home pay to my wife is less.’”
Some others, however, contend that inconsistent ways to describe information systems that physicians are being told they really need is contributing to delayed purchase decisions.
“Doctors are confused of the differences and wary of technological advances,” says Wendy Angst, general manager of the CapMed PHR software division of Bio-Imaging Technologies Inc., Newtown, Pa. “They don’t want to buy and find out in six months that they should have waited. So we need to better explain up front what these products do. People need to know what the thing is.”
Clarity in Law
What Kolodner knows for certain is that the lack of clear use and definitions for these terms isn’t helping politicians and government officials as they consider laws and regulations that affect health I.T. “We don’t have the clarity we need for them to help us move forward,” he says.
For instance, there’s no legal definition of any of these terms, but federal and state I.T. grant programs often use specific terms. So, if a grant program specifically targets RHIOs, can HIEs apply? If a grant program targets physician adoption of EHRs, can a physician adopting an EMR apply?
“These terms increasingly will be used in federal and state laws and regulations,” says Bill Bernstein, chair of the health care division in the New York law firm Manatt, Phelps & Phillips. He’s also co-chair of the Networks Work Group studying the terms RHIO and HIE.
Consistent terminology, he adds, will lead to less confusion in the marketplace. “If people can be clear on the definitions, it will help make sure when they are having conversations that they are having the same conversation.”
Confusion in rulemaking already has happened. When federal officials first proposed relaxing the Stark Act and anti-kickback laws to permit health I.T. donation or subsidy programs, initial regulations appeared to limit the relaxation to programs to encourage adoption of electronic prescribing. Language in the final regulations had to be changed to encompass other I.T. applications.
“What’s in a word can really determine from a policy standpoint what you’re going to give incentives for,” notes Michael Kappel, senior vice president for government and industry relations at the Provider Technologies division of McKesson Corp., San Francisco.
That’s why the current effort to define terms is necessary, Kappel believes. If mandates for use of electronic records are on the horizon, it will be “hugely important to be precise on what is required.”
In the Beginning
Before EMR, there was CPR—the computer-based patient record. Kolodner, the national I.T. coordinator, thinks he knows how CPR became EMR.
“Some saw CPR as an electronic substantiation of the paper record,” he says. “But others also saw CPR as an extension beyond the record with features such as reminders. Others said, ‘No, that’s an EMR. An EMR also would capture other information, such as vital signs from patient monitors in homes and pacemaker tracings.’”
There isn’t a clear answer to how EMR became EHR. The C-suite executives in many provider and payer organizations still prefer the term EMR, as do many I.T. departments as well as physicians, says Rush Rudish, vice chair of the health care provider practice at Deloitte & Touche LLP, a New York-based consulting firm.
And the majority of vendors use EMR in private conversations, although their marketing departments often use EHR because it “sounds broader,” he notes. “You want to have a broader view when you’re doing marketing.”
Westborough, Mass.-based eClinicalWorks LLC, a vendor of physician practice management and electronic records software, primarily uses the term EMR, but EHR does sneak in, acknowledges Girish Kumar Navani, president. “EMR still is more prevalent and growing in use,” he adds. “It’s the acronym doctors can most understand and it is going to stay.”
Navani believes consultants coined EHR and some vendors soon picked it up. Once federal officials adopted the term, its use rapidly spread.
President Bush used the term EMR in April 2004 when he announced the goal of most Americans having electronic records within 10 years. But an accompanying briefing paper included EHR. By July 2004 when then-HHS Secretary Tommy Thompson and David Brailer, M.D., the first national coordinator for health information technology, unveiled the strategy for a national health information network, federal officials were using EHR almost exclusively.
But it wasn’t Thompson or Brailer who coined EHR, says Kolodner, who previously served in the Department of Veterans Affairs. “We were using EHR in VA in 2001 or 2002,” he recalls. “VA used it because we knew the information a provider needed was more than a description of the medical encounter, but also the health of the patient outside the encounter.”
Just as EMR was seen as offering broader view of patient care than CPR, many observers believe EHR offers a broader view of care than EMR.
EMR is a provider-specific implementation, such as the use of electronic records in a physician practice, contends Kappel of McKesson.
The vendor prefers EHR because it tries to relate electronic records to Institute of Medicine reports in recent years that outline what electronic records ought to be, Kappel says.
“There’s some organizational boundary associated with an EMR. EHR is the composite record of data captured across settings and providers,” he adds.
“EHR is bandied around inappropriately because it’s one of those lofty goals,” Diamond says. He notes that most delivery systems’ various information systems — even from the same vendor — still can’t talk to each other, so the concept of an EHR being a record of the continuum of care, in large part, isn’t yet achievable.
Northwest Family Physicians, a three-site, 18-physician practice serving the Northwest Minneapolis suburbs, adopted electronic records three years ago.
At that time, most vendors were calling their products EMRs, and regardless of what vendors call them today, most doctors use the EMR term, says James Welters, M.D., chief medical officer.
Who Cares?
To Welters, an EHR implies expanded connectivity and an expansion of an EMR. But physicians don’t dwell on what to call the product for a simple reason: “Most doctors don’t care what it is called. Whether you call it an EMR or an EHR I don’t think makes any difference in my daily work, and I don’t think the patients care either.”
Welters believes that a true EHR that documents care across settings isn’t coming anytime soon. He notes that many hospitals in the Minneapolis region use clinical information systems from the same vendor, but the hospitals can’t yet exchange data. “If one company can’t make it work among multiple hospitals, how are multiple companies supposed to?”
At first glance, the North East Florida Regional Health Organization appears to be a RHIO. But the effort actually is an HIE for a number of reasons, says Renfro, the executive director.
One reason, he acknowledges, is that the term RHIO has become unattractive as most efforts have floundered. “RHIO has a little connotation attached to it,” he notes. With a recent report suggesting fewer that than 20 RHIOs are operational, there now is “an emotional detachment” to the term, he adds. HIE, on the other hand, is a more palatable term.
Some initiatives also hesitate to use the term RHIO because many of these pioneering organizations are creating large, centralized data repositories, which worries many physicians, Renfro notes.
Further, a RHIO implies that physicians have interoperable electronic records that exchange data with information systems at other provider organizations, he explains. But many physicians in the Jacksonville region don’t have electronic records and don’t think they need them.
At the same time, however, these physicians do want to access data from laboratories and hospitals. So, the model for Jacksonville is to extract patient data from hospital and lab systems and deliver the data to physicians via a hub. North East Florida will use enterprise master patient index and record locator software from Chicago-based Initiate Systems Inc., transmitted through the clearinghouse of Jacksonville-based Availity LLC, and organized using context management software from Carefx Corp., Scottsdale, Ariz.
On the other hand, the Ann Arbor Health Information Exchange in Michigan might someday become a RHIO. But participants, primarily 220 specialty and primary care physicians in five practices, struggle with the question of whether they even want to be a RHIO, says Carlotta Gabard, executive director and executive vice president.
She believes a RHIO’s definition assumes a broader base of stakeholders and functionality than the Ann Arbor HIE currently has or envisions. All the participating practices use electronic health records software from one vendor—NextGen Healthcare Information Systems, Horsham, Pa., although at some point practices using other software will come in. And only one area hospital—St. Joseph Mercy Hospital—uses the HIE’s Web site to provide physicians with access to laboratory, radiology and admissions/discharge/transfer reports, as well as discharge summaries. A lab interface with the University of Michigan Health System is expected to go live in early 2008.
A True Purpose
But the HIE also has a mission—to streamline the hand-off of care from hospitals to physicians or primary care physicians to specialists—that is narrower than many RHIOs. Nor is the HIE yet ready to accept broader participation from the community, including payers and employers, although someday it may. “We don’t see the need at this time or the value,” Gabard says.
But the hand-off of care is challenging for patients and providers alike, and, for now, the effort is solely focused on clinical information to ease that problem, Gabard adds. She notes a recent survey showed only 6% of responding specialists knew in detail before an appointment why a patient was coming.
There are other differences between RHIOs and HIEs, Gabard says. RHIOs, she believes, are more political. “My bias is it takes them a long time to get things done.”
Gabard’s bias against RHIOs is shared by some other data exchange efforts that remember the failed community health information networks of a decade ago and wonder what the difference is today, says Kappel of McKesson Provider Technologies.
“There’s some belief that RHIOs are CHINs and what you get is a different coat of paint,” he says.
Technology has changed quite a bit from the CHIN days, he adds, but business realities have not, and a new name for the networks won’t change that. “The fundamental problem with CHINs and with RHIOs, whether you call them HIEs or not, is economic sustainability.”
But others believe there are geographical differences between RHIOs and HIEs. A RHIO, says national I.T. coordinator Kolodner, is a more localized consortium. An HIE is a more geographically dispersed organization or a national one, such as a large delivery system or Kaiser Permanente’s combined provider/payer operation.
Physician software vendor eClinicalWorks has gone after the business of RHIOs and HIEs. But ask Navani, the president, what the difference is between the types of organizations and he replies: “I don’t even know. Everyone wants interoperability of records across a wide geographic region.”
As best as Navani can tell, HIE implies a supported technological solution, while RHIOs represent a business model. “But you cannot have interoperability without a business model.”
Consultant Rudish hears the term HIE a lot more often these days. “RHIO was the language a year or two ago.”
He believes HIE is a better term because it is broader and more accurate. But calling an information exchange initiative an HIE to mask over the problems of RHIOs isn’t solving anything, he adds. “You could call it ‘tomato;’ that’s not the fundamental problem.”
Consultant Quammen, however, believes there are differences between HIEs and RHIOs. “For me, HIE generally implies that it is more about the integration than about a regional program that requires extensive cooperation and collaboration.”
But at the same time, the term HIE may be a Band-Aid that organizations are using to fix the CHIN/RHIO perception problem, she acknowledges.
“It becomes an integration topic that seems to be psychologically easier to grasp than the other programs,” she notes. “I believe there is real action and real work being done, but that it might not net any greater benefit. As I move around in my client base, I just don’t see these projects on the same strategic level as other initiatives. They get a bit of attention for the periodic group meetings that occur, but quickly fade away between meetings in deference to the operational concerns, projects and activities of hospitals.”
Diamond of dbMotion believes RHIOs are putting the cart before the horse. The organizations have a goal, a structure and a governance model, but not the interoperability tools. They have committees and discussion, but no action. “How to interoperate and how to encourage I.T. adoption becomes an afterthought.”
The philosophy is different with HIEs, Diamond contends. “HIEs say, ‘We won’t get caught up in the b.s., we’re just going to build it.’ Most organizations that have the tools and really are going to build things have disassociated themselves from the RHIO name.”
While the rest of the industry may be trying to figure out what to call information exchange across enterprises, doctors don’t spend a lot of time thinking about it, says Welters of Northwest Family Physicians.
The terms RHIO and HIE are not widely known among practicing physicians, he contends. “Most would have no idea what you’re talking about.”
Consequently, physicians need a better sense of what the terms mean, he adds.
Mixed Feelings
So how meaningful is the debate over definitions? “Is there confusion? Absolutely,” says Kappel of McKesson. “It is long-lasting? No. Is it preventing people from making purchasing decisions? I don’t think so.”
Consultant Quammen doesn’t believe the debate is worth the effort, although she concedes 30 years in the industry has made her a bit jaded. “I believe there are so many other problems that need to be solved that this is more of an exercise than anything else, and the ultimate gain will not be that significant,” she contends.
Navani, president of eClinicalWorks, wants the market to decide on definitions. “Let the market dictate,” he asserts. “In other industries, terms have been decided by the market, not the government.”
Navani and others believe additional terms need to be added to this debate, and soon. For instance, there’s no clear definition of what “clinical decision support” is, he notes. “Does it mean materials a physician reads, or rules in software, or national standards for treatment?”
“Pay-for-performance” is another term that might need attention. Medicare is testing the concept in a high-profile pilot program, but calls the program PQRI for “physician quality reporting initiative.” That doesn’t bother consultant Russ Rudish of Deloitte & Touche, who suspects P4P programs will have a multitude of acronyms. “When the money shows up, those providing the money will be able to give the program whatever name they want and it will stick.”
Kolodner, the national I.T. coordinator, understands that other terms may need consensus definitions. “We started with the most central terms,” he says. “If others emerge, that’s okay. But if we can clarify what we started, that would be a tremendous step forward.”
Regardless of how the debate turns out, the primary goal should be to do no harm and not muddy the water further, Navani says.
The debate, he adds, comes at a time when physicians seem to finally understand the value of electronic records and interoperable systems. “I hope we don’t screw that up,” he pleads. “I hope we don’t come up with terms and terminologies that confuse the end user.”
Get On With It
Some observers fear that, as necessary as the debate may be, it is distracting from pressing issues. Far more important, contends Diamond of dbMotion, is getting hospitals to develop long-term views about information exchange and link with physician practices that have 80% of patient data.
“We’re not going to have RHIOs or HIEs unless we have real information exchange at a basic level,” he contends.
The bottom line, he and other observers say, is let’s quickly get these terms correct and then start tackling the real issues that imperil interoperable health I.T. For instance, getting the terminology right means nothing without developing financial incentives to get acute and ambulatory care facilities to adopt interoperable clinical systems, says Mark Renfro of the North East Florida Regional Health Organization. For Ann Arbor HIE executive Gabard, the biggest obstacle to interoperability is the lack of a national patient identifier. “Organizations like ours spend lots of time matching patient demographics,” she says. “So, I’d focus on that rather than definitions.”
Learn more online
* For information on the Department of Health and Human Services-authorized Networks Work Group and Records Work Group seeking consensus on the definitions and use of specific terms, visit www.definitions.nahit.org. * Additional information on government projects related to the national health information network is available at www.hhs.gov/healthit and under the Policies/Regulation portal at www.healthdatamanagement.com. (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com/
SIDEBAR
Paper Takes A Stab At Definitions
A paper published in the March/April 2005 issue of the Journal of the American Medical Informatics Association discussed pragmatic steps the federal government could take to facilitate interoperable health care information technology.
The paper, “Achievable Steps Toward Building a National Health Information Infrastructure in the United States,” was a primer to help informatics professionals explain to others the possible approaches to take in building a national infrastructure. It also included consensus definitions from the authors of “electronic medical record,” “electronic health record” and “personal health record.”
One of the authors was Robert Kolodner, M.D., then at the Department of Veteran Affairs. Now he’s the national coordinator for health information technology in the Department of Health and Human Services. He’s also paying for two HHS-authorized workgroups to seek consensus on the definition and use of these terms, plus “regional health information organization” and “health information exchange.”
Kolodner and co-authors William Stead, M.D., from Vanderbilt University and Brian Kelly, M.D., from the consulting firm Accenture, further defined the difference between an “electronic medical record” (EMR), and an electronic medical record system” (EMRS).
“An EMRS automates aspects of clinical practice, such as placing a care provider order, recording a clinical note, or capturing administrative functions such as scheduling and billing,” according to the paper. “A patient’s ‘electronic medical record’ (EMR) is generated as a by-product of these clinical and administrative functions. It often lives within the specific EMRS that created it and is unique to that system. In that case, the EMR’s meaning is clear only to that specific EMRS, since the record is constructed with terminology and data structures particular to that system.
“In contrast, we use the term ‘electronic health record’ (EHR) to refer to any information in electronic form about a person that is needed to manage and improve their health or the health of the population to which they are a part. An EHR is a superset of an EMR and totally includes it. To meet this vision, an EHR might collect information as appropriate from across the health care system (i.e., from several EMRSs) and a variety of personal information sources. The EHR exists outside of any particular EMRS and, therefore, has a consistent meaning.”
For the record, here is the authors’ PHR definition: “The term ‘personal health record’ (PHR) refers to a personal electronic collection of information. The PHR might include the patient’s own record of their progress and changes they made in therapy plus their electronic copies of information from their providers. They might also decide what parts to share with their providers or health care plan.”
Copies of the paper, “Achievable Steps Toward Building a National Health Information Infrastructure in the United States,” are available for $5.00 at www.jamia.org/cgi/reprint/12/2/113. (c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com/
SIDEBAR
Here Comes PHR
In addition to sorting out the terms EMR and EHR, the Records Work Group put together by the Department of Health and Human Services also is seeking consensus definitions for the meaning and use of “personal health records.”
These are medical histories that consumers can maintain on their personal computers or access via hosted, secure Web sites. Sometimes, an individual’s insurance company hosts PHRs and augments them with clinically pertinent claims data. Some physicians even give their patients select data from official electronic records to put in the PHR.
The issue here, observers say, isn’t that health professionals are confusing PHRs with EMRs or EHRs. But professionals and consumers alike are confused about what PHRs can do and how they should be used. Many consumers, for instance, don’t understand they have control over a PHR.
Other issues not yet resolved include how PHRs are funded, sponsored, owned and secured, and how information would flow between PHRs and official electronic medical records, says Michael Kappel, senior vice president for government and industry relations at the Provider Technologies division of McKesson Corp., San Francisco.
That confusion could heighten if health records banks—trusted third parties that compile an individual’s paper and electronic personal and official medical records into a hosted electronic file—become more common, he adds.
There’s also confusion about whether consumers can have access to their official medical records and put them in their PHRs, and how physicians should use PHR data.
“Doctors are concerned about having to accept PHR data and having to give access to the EMR,” says Mark Renfro, executive director of North East Florida Regional Health Organization, an emerging health information exchange in Jacksonville. “They’re very fearful of patients going in and changing the data. These are big fears.”
But while physicians don’t trust patient-entered data in a PHR, these same physicians give patients a clipboard to fill out forms asking for the same information, so they already rely on “inaccurate” data from patients, he adds.
Further, whether consumers will accept PHRs is far from certain. “We know the value of having a patient record and it being portable; we just haven’t seen a business case around that purpose,” says Girish Kumar Navini, president of physician software vendor eClinicalWorks LLC, Westborough, Mass.
Physician Concerns
A small but growing number of physicians are accepting the value of PHR data to augment their official patient records, says Wendy Angst, general manager at the CapMed PHR software division of Bio-Imaging Technologies Inc., Newtown, Pa.
In part, that’s because some physicians worry that they will be liable if they don’t look at all available data about a patient. But looking at patient-supplied data presents another dilemma, she adds. “Once they see the information, is it supposed to be weighed in the decisions they make?”
Until recently, physicians who wanted to see PHR data generally wanted it in a PDF report attached to the official medical record, Angst says. Now, a small but growing number of physicians are asking to enter discrete data from the PHR—sourced as being from the patient—into the official record, she notes.
This data, either self-reported by a patient or downloaded from in-home medical devices, includes values that can be tracked over time, such as weight, blood pressure, blood oxygen levels, and glucose levels. It also can include prescribed and over-the-counter medications, and a health history.
Consumers are learning more about PHRs, and CapMed is seeing an up tick in demand, Angst says. “We still get lots of questions about why they need PHRs because they think if their physician has an EMR that the physician has all the patient information regardless of where they were treated.”
At this stage, however, most consumers aren’t demanding their PHR data go in their offic ial electronic record, she adds. “But we see some of that among those in the I.T. industry.”
Even that’s not absolute, attests Becky Quammen, CEO at The Quammen Group, a Winter Park, Fla.-based consulting firm. “I’m in the business, have raised two children (one with significant medical history but not chronic disease) and I don’t feel that I am missing anything in my daily life by not having a PHR.”
If PHRs someday do become widely adopted, the industry will see the lines blurring between patient-controlled and official medical records, predicts Joel Diamond, M.D., a practicing physician and chief medical officer of dbMotion Inc., a Pittsburgh-based integration and data exchange platform vendor.
He believes the industry won’t be able to maintain two separate sets of records and still take care of patients. “Over time, patients will demand to see at least a subset of the EMR,” he says. “At that time, the lines will really blur at what is a PHR and an EMR.”
(c) 2008 Health Data Management and SourceMedia, Inc. All Rights Reserved. http://www.cardforum.com http://www.sourcemedia.com
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