Discuss how emerging technology is evaluated in the reimbursement process.? An EHR is a concept that has been around since the late 1960s and that consists of a host of integrated component ISs and technologies. The intent of EHR technology is to capture clinical data from multiple sources for use at the point of care in clinical decision-making and to exchange such data across the continuum of care for care coordination.

As originally described in its landmark work on patient records, the IOM defined what is today referred to as the EHR as a record

that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids. This definition encompasses a broader view of the patient record than is current today, moving from the notion of a location or device for keeping track of patient care events to a resource with much enhanced utility in patient care (including the ability to provide an accurate, longitudinal account of care—meaning that information is available about all of the patient’s health conditions over a lifetime), in management of the healthcare system, and in extension of knowledge. (IOM 1991)

In addition, the IOM provided the caveat that “merely automating the form, content, and procedures of current patient records will perpetuate their deficiencies and will be insufficient to meet emerging user needs” (IOM 1991; reaffirmed by the IOM in a 1997 update to its original patient record study). EHR implementation, use, and optimization of workflow provides an opportunity for greatly improved patient care; not just automation of existing paper records and documentation.

As with any revolutionary system, the EHR has suffered somewhat from multiple different interpretations and rapid development of products that may not have fully met the vision. Optimization of EHR functionality continues today to provide efficient and effective patient care.

Ultimately, the EHR should be able to do the following:

• Improve the quality of healthcare through data availability and links to knowledge sources

• Enhance patient safety with context-sensitive reminders and alerts, clinical decision support (CDS), automated surveillance, chronic disease management, and drug and device recall capability

• Support health maintenance, preventive care, and wellness through patient reminders, health summaries, tailored instructions, educational materials, and home monitoring and tracking capability

• Increase productivity through data capture and reporting formats tailored to the user; streamlined workflow support; and patient-specific care plans, guidelines, and protocols

• Reduce hassle factors and improve satisfaction for clinicians, consumers, and caregivers by managing scheduling, registration, referrals, medication refills, and work queues and by automatically generating administrative data

• Support revenue enhancement through accurate and timely eligibility and benefit information, timely claims adjudication, cost-efficacy analysis, clinical trials recruitment, rules-driven coding assistance, external accountability reporting and outcomes measures, and contract management

• Support predictive modeling and contribute to development of evidence-based healthcare guidance

• Maintain patient confidentiality and exchange data securely among all stakeholders (IOM 1991)

Overall, the EHR should help clinicians and other healthcare professionals provide safer, more efficient, and more cost-effective care by providing information and decision support to end users.

EHR Terms

As the EHR has evolved, a variety of terms have been used to describe what today the federal government is calling the EHR. In fact, there has been considerable confusion between electronic health record and electronic medical record (EMR). Hospitals sometimes describe that they have both an EMR, which is an EDM system, and an EHR, which is composed of applications used by clinicians at the point of care.

In 2008, the federal government asked the National Alliance for Health Information Technology (NAHIT) to develop a set of terms and definitions to help the industry avoid confusion and achieve consensus on terminology. While NAHIT no longer exists, the definitions it published serve as the foundation for the government’s adoption of the term EHR and are distinguished as follows:

• Electronic health record (EHR) is defined as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization” (NAHIT 2008).

• Electronic medical record (EMR) is defined as “an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization” (NAHIT 2008).

The key difference between the terms EHR and EMR as suggested by NAHIT is in EHR being interoperable and EMR not. Interoperability refers to the ability of two different systems to communicate and exchange data with each other. Unfortunately, many healthcare organizations are challenged with systems not being as interoperable as desired within their own organization, let alone with other organizations.

Neither of NAHIT’s definitions of EHR or EMR addresses the functionality that contributes to enhanced utility beyond that of paper-based records that the IOM originally envisioned in 1991 or which it supplied in its 2003 letter report to the secretary of Health and Human Services (HHS) (IOM 2003). In 2004, the standards development organization Health Level Seven (HL7) also helped overcome the lack of a comprehensive description of the EHR in its EHR-System Functional Model, which described a highly functional and interoperable system. However, the Health Information Management and Systems Society (HIMSS) continues to use the term EMR in its HIMSS Analytics EMR Adoption Model (HIMSS Analytics 2010). This model is widely referenced as it provides a quarterly survey report on the cumulative capabilities of EHRs in hospitals.

EHR Complexity

The EHR remains a complex system to implement. Its many elements must work together to achieve specific goals. For an EHR, these system elements must include not only hardware and software but also attention to people, policy, and process.

Even for clinicians who use computers frequently, the EHR represents a significantly different way of practicing their professional skills. For instance, most clinicians are taught to quickly assess a patient, take immediate action to stabilize a patient in an emergency, and then gather further information about the patient through referencing previous records of care, interviewing the patient, and obtaining data diagnostic studies. Only after much of the fact finding is completed is information documented in narrative. As a result, the documentation is largely a summary of findings. Furthermore, where clinicians are generally expected to document an assessment and plan of care, and ideally should engage the patient in making clinical decisions about his or her ongoing care, the result often is simply the recording of a differential or final diagnosis and orders for any additional studies and treatments.

When the EHR is introduced, the clinician is expected to document and even practice in very different ways. Data are to be entered as captured at the point of care, and in standardized and structured form rather than unstructured data or narrative form, often taking longer to enter than the typical dictation of a report and without the ability to express nuances important to clinicians (Ford et al. 2016). The result of this structured data (data that can be captured in a fixed field) often is a bulleted list of findings that clinicians do not find very user-friendly. The clinician is expected to receive and be guided by CDS systems that process the structured data against a drug knowledge database (DKB) and other EBM into alerts, reminders, and context-sensitive templates for data capture, although the volume of these alerts are frequently ignored (Ford et al. 2016). Additionally, giving the patient a health summary, supporting a patient in compiling a personal health record (PHR), or accepting information from a PHR are also new concepts for many physicians, who in the past shied away from providing patients with access to their health information (Witry et al. 2010). Refer to chapter 14 for more discussion on PHRs.