By VINCE KURAITIS, EDWARD G. ANDERSON, and GEOFFREY PARKER
The COVID-19 pandemic has accelerated calls for the development of EHR 2.0 (electronic health record 2.0) – the next generation of EHRs with extended platform features and capabilities.
Who will answer this call? While existing EHR vendors have made modest efforts, the door is open for big tech companies and start-ups to develop functionality to envelop and disintermediate current EHRs. We highlight early efforts by Google Health Care Studio, an initiative that has been underway for several years but was only formally named in February 2021. We view Care Studio as having the potential to bring platform functionality to a sector of the healthcare industry known for resistance to change and innovation.
We coin a new term – “EHR Envelopment” to describe novel EHR platform capabilities under development by third parties. By “envelopment,” we mean the entry by one platform provider into another provider’s market by adding functionality and exploiting overlapping user bases. New EHR capabilities threaten to dislodge existing EHRs, e.g. through 1) new user interfaces (UIs) that sit above the current EHR, and/or 2) a focus on new value created by integrating, analyzing, and presenting disparate sources of data.
Through the lens of platform strategy, we focus on the impact that EHR Envelopment initiatives could have on the market for electronic health records for large integrated delivery systems. This market has been dominated by a few vendors for decades, but EHR Envelopment projects have the potential to disrupt EHR market dynamics.
The remaining sections of this essay will address:
The Current EHR Market for Health Systems: Ossified
Tuesday, in case you missed it, was the deadline for filing your 2020 federal taxes (it was postponed from its usual April 15 date due to “the unusual circumstances related to the pandemic”). Nothing, Benjamin Franklin famously said, is certain but death and taxes, but if you live in the United States, you might add the inevitability of paperwork involved with both (and with healthcare in general).
The question is, does it have to be as bad as it is?
A Washington Post op-ed by Helaine Olen argues that tax filing could, and should, be much simpler. A March article in The Conversation by Beverly Moran, a tax expert at Vanderbilt, agrees. Both make the point that, for most of us, the IRS could do the work for us.
Ms. Olen asserts:
The thing is, filing taxes just doesn’t have to be this hard. In 36 countries, the nation’s tax agency sends eligible residents a pre-filled return, and asks them to sign if they agree with the amount that’s indicated is owed or should be credited to them. Japan does this. So do Sweden, the Netherlands, Spain and others.
Professor Moran has slightly different numbers, but makes the same point. She adds that our tax system is 10 times more expensive than in other major economies. This should not be a surprise; collectively, we spend close to $200b annually on IRS paperwork, taking some 6 billion hours of our time along the way.
You’d think that all this time and money spent on tax filing would at least give us an efficient tax system, but the opposite is true. The last time the IRS took a look, for tax years 2011-2013, the “tax gap” – the estimate between taxes owed and taxes paid – was $441b annually, some 16% of tax liability. IRS Commissioner Charles Rettig told Congress last month that the number might actually be over $1 trillion annually now, due to new kinds of wealth creation and more sophisticated tax avoidance.
The timeline of a patient’s symptoms is often crucial in making a correct diagnosis. Similarly, the timeline of our own clinical decisions is necessary to document and review when following a patient through their treatment.
In the old paper charts, particularly when they were handwritten, office notes, phone calls, refills and many other things were displayed in the order they happened (usually reverse chronological order). This made following the treatment of a case effortless, for example:
3/1 OFFICE VISIT: ?UTI (where ciprofloxacin was prescribed and culture sent off)
3/3 Clinical note that the culture came back, bacteria resistant and treatment changed to sulfonamide.
3/5 Phone call: Patient developed a rash, quick handwritten addition on left side of chart folder, sulfa allergy. New prescription for nitrofurantoin.
3/8 Phone call: Now has yeast infection, prescribed fluconazole.
Each of these notes took virtually no time to create and you could see them all in one glance.
I recently asked my Primary Care Physician’s Medical Records Department for copies of my records covering the last eight months during which I had four office visits, five blood draws, and nine brief email exchanges. I should add that my PCP uses one of the two most popular EMR systems.
To my astonishment, I received 274 pages of digital records (PDFs). I’ve heard of “record bloat” but this was an explosion!
When I analyzed their contents, I found that 59 pages were legitimate documents containing “original” information and data. 22 Pages were Office Notes — or what are often called Progress Notes —applicable to my four visits; 14 were reports of my five blood draws; 23 included my nine email exchanges. In short, they were “normal” — what you’d expect from the number of contacts I had with my doctor and his lab.
But the remaining 212 pages shocked me. They were totally unexpected and, in my opinion, completely unnecessary! They were a slicing, dicing and recasting of the contents of the basic 59 pages! They included 82 pages of “Ambulatory Visit Instructions” (which I was never given), and 62 pages listing my immunizations, meds, problems, procedures, orders, and past medical, social and family histories — all of which are covered in my providers’ Office Notes!
With all due respect to the good intentions of Congress, HHS, CMS, ONC and their dedicated advisors, they are pursuing — and for years have pursued — the wrong approach to achieve medical record interoperability. Endless studies, reports and anecdotal evidence conclude that trying to standardize the way medical records are formatted and kept, and linking provider silos via health information exchanges, doesn’t work! It is far too rigid, complex and constraining, and far too costly. Most importantly, it doesn’t meet care providers’ needs for “total interoperability” — instant access at the point of care to a patient’s COMPLETE medical record from all his or her providers.
Despite having held endless hearings, listening sessions and receiving hundreds of responses to their draft proposals, they continue to ignore reality. Healthcare is dramatically different than banking and travel, the industries they frequently cite as role models. It is perhaps the most massive, complex, diverse and decentralized industry in the country, and requires a very different approach than used in simpler industries. Standardizing record content and formatting simply doesn’t work in healthcare.
Instead of trying to force care providers to accept their pre-conceived technology, they should adopt technology that meets the unique needs of providers. Simply put, they are trying to cut the man to fit the cloth rather than the cloth to fit the man!
Fortunately, there is a simple solution that accommodates the complexities of healthcare and meets the diverse needs of care providers. It focuses on how to MANAGE records rather than how to KEEP them. All we have to do is embrace it!
In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.
One thing that can make working with an EMR difficult is finding the chronologyin office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?) and outside reports (emergency room visit for anaphylactic reaction).
I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.
In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)
Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.
At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.
I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.
With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.
This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.
Healthcare providers are
moving forward with their digital initiatives, pursuing intranet development, implementing e-prescribing software, and deploying
EHR systems and patient portals to enhance patient care, maximize staff
efficiency, and improve the bottom line.
However, while medical professionals
are largely enthusiastic about digital healthcare solutions, the disparity
between the rate of clinical support and patient utilization of some of this
software, patient portals in particular, is enormous. Even though patient
self-service solutions have become ubiquitous in medical facilities nation-wide,
over 62% of US hospitals report that their patient portal systems are used by less than a quarter of all patients.
Patients still don’t see
enough value in patient portals, voicing concerns over the steep learning curve,
lack of training, anxiety regarding data security and confidentiality, and
other issues. Addressing these challenges is critical to encouraging patient
buy-in and getting more patients involved in their health.
Since most medical
facilities in the country already have patient portals in place, the next step
to overcome barriers to their adoption is to expand these systems to deliver
features that will get more patients involved.
Today on Health in 2 Point 00, Jess is in Italy…and has me up far too early in the morning for this episode. On Episode 79, Jess asks me for an update on uBiome after their raid by the FBI. We also talk about nutrition startup Noom’s $58 million raise and clinician house-call platform DispatchHealth’s $33 million raise. In other news, Kaiser Permanente is launching a network to integrate the social determinants of health with their EHR. –Matthew Holt
Back in the
‘stone ages’ when I (an MIT grad) was an intern, I was called at 4 AM to see
someone else’s gravely ill patient because her IV had infiltrated. I
started a new one and drew some blood work to check on her status. When
the results came back (on paper) I (manually) calculated her anion gap.
This is simple arithmetic but I had been up all night and didn’t do it right.
rounds the attending assured me that there was nothing I could have done anyway
but, of course, in other circumstances it could have made a difference and an
EHR could have easily done this calculation and brought the problematic result
to my attention. My passion for EHRs and FHIR apps to improve them really
traces back to this patient episode I will never forget.
My criticism of the recent Kaiser Health News and Fortune article Death by 1000 Clicks is generally not about what it says but what it doesn’t say and its tone.
The article emphasizes the undeniable fact that EHRs cause
new sources of medical error that can damage patients. It devotes a lot of ink
to documenting some of these in dramatic terms. Yes, with hundreds of vendors
out there, the quality of EHR software is highly variable. Among the major
weaknesses of some EHRs are awkward user interfaces that can lead to errors. In
fact, one of the highlights of my health informatics course is a demonstration
of this by a physician whose patient died at least in part as a result of a
poor EHR presentation of lab test results.
However, the article fails to pay equal attention to the
ways EHRs can, if properly used, help prevent errors. It briefly mentions that
around a 60% majority of physicians using EHRs feel that they improve quality. The
reasons quality is improved deserved more attention. The article also fails to
discuss some of the new, exciting technologies to improve EHR usability through
innovative third party apps and he real progress being made in data sharing
including patient access to their digital records.