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EHR Innovation Gap Threatens Healthcare Progress

EHRs remain stuck in the pre-Internet age and dominated by entrenched vendors, according to recent New England Journal of Medicine commentary.

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8 Health Information Exchanges Lead The Way
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Electronic health records suffer from a lack of innovation that thwarts physicians' attempts to advance healthcare processes and workflow. Unlike word-processing programs, search engines, social networks, and mobile phones and apps, EHRs are stuck in the pre-Internet world where EHR vendors not only control the data, but also resist improvements to functionality while reaping huge financial rewards, concludes a commentary that appears in the June 14 issue of the New England Journal of Medicine.

Penned by Kenneth Mandl and Isaac Kohane, both professors at Harvard Medical School, "Escaping the EHR Trap – The Future of Health IT", says EHR vendors insist that the healthcare industry is so unique that data collection, the sharing of health information, and many other tasks associated with healthcare workflow require a highly specialized set of tools. This myth, the authors say, has led to EHR vendors declaring that only they can develop health IT to meet the current demands of the healthcare system--a notion with which the authors sharply disagree.

"We believe that EHR vendors propagate the myth that health IT is qualitatively different from industrial and consumer products in order to protect their prices and market share and block new entrants," the article states.

In a joint interview with both authors, Kohane further explained that: "Leading companies like EPIC will claim that it's unsafe for health IT to be done outside their monolithic system and that their monolithic system is actually enabling patient safety and the correct conduct of healthcare process."

Kohane, who is also the director of the Children's Hospital Informatics Program, Boston, Mass., told InformationWeek Healthcare that we need EHRs because they provide core features that are unique to medicine, including particular medical workflows, specific medical decision support functionality, and distinct medical vocabularies. But Kohane wants the technology to be much more generic than specialized.

[Is it time to re-engineer your Clinical Decision Support system? See 10 Innovative Clinical Decision Support Programs.]

The authors lament that with more than 700 vendors and about 1,750 distinct certified EHR products, their lack of interoperability hasn't helped doctors or patients.

"Commercial EHRs evolved from practice-management (i.e., billing) systems, and in response to the patient safety movement, vendors tacked on documentation modules and order entry for physicians. Since each EHR product has been built as an isolated silo, the market for any good innovation is fragmented," the article said.

As the healthcare system sets up accountable care organizations (ACOs) that tie reimbursements to performance metrics and health information exchanges that require greater interoperability between organizations and their various EHR systems, the need for innovation becomes critical.

With this in mind, Mandl emphasized the need for communication and coordination across healthcare providers; but EHRs only provide a document repository that doesn't really serve that purpose.

"EHRs are used for communication; people can perhaps go in and read the same documents that their colleagues have written, but it's not designed to provide that kind of collaborative tool set. EHRs weren't really designed to create a rich data repository to support what the Institute of Medicine calls a learning health system," Mandl observed.

According to Mandl, who is also director of the Intelligent Health Laboratory at the Children's Hospital Informatics Program in Boston Mass., EHRs don't generally export their data in a usable fashion and don't possess search capabilities that allow doctors, for example, to enter a keyword to pull up a group of patients who are all on a particular medication.

During the interview, both Kohane and Mandl agreed that EHRs would benefit immediately by creating open APIs--both APIs to export the data and APIs to run applications that allow external product integration with the EHR.

To give current EHRs added functionality, the article identifies many current technologies that EHRs can benefit from, and states that: "Only a small subset of loosely coupled information technologies need to be highly specific to health care. Many components can be generic."

These generic components include:

-- Local or cloud-based storage similar to that provided by EMC and Amazon. Healthcare providers can adapt such storage if it's accompanied by strong, compliant privacy policies.

-- Communications tools such as the Direct Project, which promotes a secure communications system for healthcare based on SMTP (Simple Mail Transfer Protocol), the decades-old store-and-forward e-mail standard. The Direct Project illustrates how highly effective general technologies can be adapted to healthcare in an open, standard way that also provides integration between systems.

-- Documentation tools such as text-processing and other software that support task-oriented group processes in multiple industries. These tools easily outperform EHR systems. Many EHR text processors don't even offer spell checking. Similarly other industries use highly adapted project-management software to manage complex processes, as well as advanced tools such as Teambox, Basecamp, and Huddle to record extended interactions.

EHRs could also benefit from tools that provide loading, graphing, mapping, and analyzing data. There are free and open source tools like Google Maps and the R statistical package as well as ArcGIS and SAS, which are proprietary but have public programming interfaces for integration into the workflow of various users across disciplines.

The commentary concludes by asserting that: "Health IT vendors should adapt modern technologies wherever possible. Clinicians choosing products in order to participate in the Medicare and Medicaid EHR Incentive Programs should not be held hostage to EHRs that reduce their efficiency and strangle innovation."

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User Rank: Apprentice
6/19/2012 | 2:32:14 PM
re: EHR Innovation Gap Threatens Healthcare Progress
EHR companies were innovating until Meaningful Use consumed all development resources and dominated product roadmaps. Just keeping up with government regulations is strangling innovation. While there is no disputing that EMR isnG«÷t as evolved as it needs to be, putting the lack of innovation on the EMR companies shows a clear lack of understanding of what really goes on in EMR. And, by the way, of the 462 certified EMR vendors, most are struggling and will not make past Stage 2. And the big companies aren't "reaping huge financial gains." Allscripts, McKesson, GE to name a few, have been issuing disappointment guidance to their investors. Kenneth Mandl and Isaac Kohane clearly live in academia, not the real world.
User Rank: Apprentice
6/19/2012 | 6:54:46 PM
re: EHR Innovation Gap Threatens Healthcare Progress
Go Printgeek! That was exactly what I was thinking.
Real world is that everyone is chasing the government standards right now and there's very little room or time for innovation. I'm all for open APIs though, I agree that would be a good start.

InformationWeek Contributor
User Rank: Apprentice
6/21/2012 | 5:29:05 PM
re: EHR Innovation Gap Threatens Healthcare Progress
IG«÷m a healthcare clinician, software inventor and entrepreneur who has been involved with health IT for over 30 years; I commend Drs. Mandi and Kohane for their on-target insights!

My personal experience--as the president/CEO of a small, nimble health IT company offering novel, secure, inexpensive disruptive innovation--coincides with much of what the authors are saying. IG«÷ve seen numerous examples of both public and private efforts to stifle, or at least fail to support, true innovation in favor of maintaining the power and control wielded by large corporations fueled by the faulty belief that G«£bigger is always betterG«•). IG«÷ve seen firsthand how mandated regulations add tremendous unnecessary cost and complexity by establishing technical standards that ignore simple, low-cost, creative alternatives. It is very frustrating especially with our countryG«÷s economic woes.

I agree with the authors that todayG«÷s EHRs, while being an essential component of a complete health IT system, simple lack critical capabilities required for improving patient care. Filling this EHR capabilities gap requires innovative G«£bolt-onG«• tools that provide cost-effective ways to help improve clinical outcomes and control costs by (a) coordinating care across specialties, settings and organizational boundaries; (b) presenting a G«£whole-personG«• (biopsychosocial) lifetime health records containing rules that support clinical decisions (for prevention, diagnosis and treatment), as well as continuous quality improvement; (c) providing health data to researchers enabling ever-evolving evidence-based guidelines and public health surveillance; and (d) measuring and incentivizing high-value care.
User Rank: Apprentice
6/21/2012 | 7:20:11 PM
re: EHR Innovation Gap Threatens Healthcare Progress
The History of the Healthcare HIT vendors has been the Development of Proprietary Systems, non Standardized Systems. I saw this in 1998, at the NYC HHC $500 million Competitive Procurement Pilot Project, very clearly.

Gadema Quouoi
User Rank: Apprentice
9/15/2012 | 11:18:42 PM
re: EHR Innovation Gap Threatens Healthcare Progress
If EHR companies are disrupting innovation so much, why doesn't someone new and innovate enter the market? My feeling is that if it were so easy there would be a few dominate systems and not 10-20. Look at Microsoft Office, Apple, Google, Facebook, etc. They all showed they could innovate better and therefore dominate their various markets. While I agree that EHR companies could be innovative, they're often stifled by all of the new regulations that come out every year they mst deal with. ICD10, Meaningful Use, etc. and it's been very clear through this Meaningful Use process that the government just doesn't understand how a normal SDLC process works.
Jay Simmons
Information Week Contributor
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