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NINE TECH TRENDS
Healthcare IT advances are pulling together to manage an expanding universe.
ELETRONIC HEALTH RECORD - by Kevin Featherly


The electronic health record (EHR) is heading forward and progress toward its adoption will continue, agree experts interviewed for this story. But accompanying the advancement is continuing confusion about exactly what the term means. For the past year, particularly since it was broached in the presidential State of the Union address in January 2004, the EHR (or the electronic medical record [EMR], a term interchangeably applied by some, much to the chagrin of others) has been the talk of the industry. It dominated conversation at the February 2004 Healthcare Information and Management Systems Society (HIMSS) conference in Orlando, Fla. And a great deal of public activity in 2004 validated the discussions.

Former Health and Human Services (HHS) Secretary Tommy Thompson made several bold moves, perhaps the most notable being appointment of the first National Health Information Technology Coordinator, David Brailer, M.D., Ph.D. Last summer, Brailer presented a framework for creating an interoperable EHR-based national health infrastructure within 10 years. Around the same time, Health Level Seven (HL7), Chicago, put forth a draft standards document listing what its members deem the essential features and functions of the base-level EHR.

Later, partly at Brailer's instigation, an industry consortium was formed to develop HER certification standards for providers unsure whether they're buying a genuine EHR or electronic snake oil. Payers, largely for that reason, have been slow to reimburse caregivers for adopting the technology.

So that's where things stand on the EHR front. But where are they going?

Before that question can be answered, says Dave Garets, president and CEO at HIMSS Analytics, Blaine, Wash., an even more fundamental question remains: What is an EHR? Despite the best efforts of HL7, Brailer and others, Garets indicates, the question is still wide open. "And that's a problem," he says, "because I think it's just hype city."

Wes Rishel, an analyst at Gartner, Stamford, Conn., and a member of the HL7 group that formulated the draft standards, says the EHR is, like most new technologies, falling prey to what Gartner famously calls "the hype cycle."

New technologies, Gartner says, start out with a lot of excited attention, rise to the peak of hype and then--as their shortcomings come into clearer view--fall into a "trough of disillusionment." After that, reality sets in, and either the new technology falls off the charts or adoption proceeds based on more realistic expectations. The process can take years.

At the moment, says Rishel, "it's not even clear where the peak of hype is" with the EHR. Garets, Rishel's former Gartner colleague, agrees. "EHRs are still climbing the hype cycle; they're not even at the top, in my opinion," Garets says. "They're going to go screaming down the other side and land."

Trend without a name
One problem with attaining a clear definition of the EHR stems from the fact that people aren't even sure what to call it. Although some disagree, Garets regards the EHR as the ultimate realization of the concept that has passed through various names, from computerized patient records to EMRs. In Garets' view, the EMR is the province of providers--the deep, digitized, contextual and lifelong patient record that clinicians can access in-house to facilitate better care. The EHR is much the same idea, according to Garets, but bigger. The EHR is an EMR that patients can access and add to--without being able to edit physician- or machinegenerated data. It is the record that patients own.

The reality, according to Garets, is that not one EHR has been successfully implemented. A successful system, he insists, has to include controlled medical vocabulary, real clinical decision support, workflow enhancement, electronic medication administration, and integration of nursing documentation, the pharmacy and the supply chain. "There are a lot of people that are making a lot of progress," he says, "but nobody has all that stuff, plus patient access and input."

But none of that prohibits making an educated guess about where ultimately successful iterations of the EHR might originate, says Scott Tiazkun, program manager for healthcare IT at market research firm IDC, Framingham, Mass. Many companies are involved in developing EHR-related products and technologies, but Tiazkun thinks the database firms may be in the best position to see the technology through--companies like IBM, Armonk, N.Y.; Oracle Corp., Redwood Shores, Calif.; and SAP, Newtown Square, Pa. "IBM is doing this," he says. "Oracle should be able to do this, too. They have the database but also the applications that sit on top. They have the technology stack. ...

Maybe even SAP, if they jump in this like they promised to do. The database vendors initially will be at the heart of this because they will have the data story. You have to be able to tie all of this together in order to produce the electronic patient record." There may be an even simpler answer to spurring adoption. Tiazkun points to portable health records from companies like CapMed, Newtown, Pa., and Med-InfoChip L.L.C., Boynton Beach, Fla., which provide portable key chain dongles that slide into USB ports and can be uploaded with health data from a PC. CapMed's Personal HealthKey was featured at last year's TEPR conference in Fort Lauderdale, Fla., in a demonstration involving new continuity of care record standards. "I think those kinds of initiatives from these small companies are just as important as these huge multi-million- or billion-dollar efforts from these service vendors," Tiazkun says. "It's just as important because it's going to have a psychological component."

With a palpable device they can easily use, he says, people will begin to understand the EHR. Then it will begin to take off. Rishel warns that such efforts should not be viewed as a substitute for building the national architecture that is needed for digital records to travel with a highly mobile U.S. citizenry. Tiazkun agrees: "You would still do that. But this drives the point home, how important this could be."

Public money?
Brailer has argued in favor of public funding of a national health infrastructure to interconnect EHR systems, which in any many cases lack the standardization needed to make various vendors' software interoperable. But he also has stated that, even with public funding, the government is not going to build the network the way it built the interstate highway system or the Internet itself. Private money is also essential, Brailer says.

That point hit home hard in late November, when Congress declined to allocate a modest $50 million to fund Brailer's office and several pilot projects for 2005. The New York Times reported that Brailer won't lose his job, because HHS will likely dip into discretionary funds to pay his way. But the snub sent a signal some interpreted to mean politicians aren't prepared to back President Bush's goal.

Garets doesn't think the political machinations will seriously alter the EHR's fate. "Congress is distracted in a big way," he says. "It's got all kinds of political games that are being played. I don't think this is any indication at all that they don't care."

Peter Basch, medical director for e-health initiatives at MedStar Health, Washington, D.C., and co-chair of the newly formed Physicians EHR Coalition, is optimistic about the EHR's future, mainly because for the first time in the 25 years he has pushed it, the technology has the ears of both the public and policy leaders. Meanwhile, vendors are beginning to produce quality EHR products. "We have achieved an alignment of the stars," Basch says. He predicts that within three to four years, close to half of practicing clinicians will "be at some stage of adoption."

Bill Bria, medical director for clinical information systems at the University of Michigan, Ann Arbor, also sees things pointed in the right direction for the EHR. "The most hopeful thing I've seen is, Health and Human Services is taking charge here, because we've been bellyaching for a long time about nothing being standardized and who's going to make them standardized and the FDA is going to get involved and it's going to hell," he says.

But before real progress is made, key issues must be resolved, in Bria's view: "First of all, we need basic systems that aren't as mysterious. Second, it needs to be possible for large and small health systems to be able to afford these things." And the debate on inpatient versus outpatient care as the focus for EHR development must come to a close. "That's over," Bria says. "It's the continuum, stupid."

Rishel, too, is guardedly optimistic. "The important thing to remember about the hype cycle is that during that period where disillusionment is growing--so attention is crashing--there are individual success stories going on in the midst of other lack of successes," he says. "It only takes a few successes ... to say that we're beginning to see the process of turning it around."

Many in the industry are seeing that turnaround already as they anticipate the future.

 
(extraído da publicação Healthcare Informatics, focada no estudo de TICs para Healthcare) Fevereiro 2005


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