• Costs of EHRs need more attention

    EHR costs are changing, but a report in the Journal of the American Medical Informatics Association (JAMIA) says that Project planners tended to overlook certain costs. It emphasises that hospitals and governments need clarity on major costs and their cost drivers from the first decisions to proceed.

    The researchers evaluated three centrally procured systems in twelve different healthcare organizations as part of England’s £12.7 billion (USD $20 billion) National Programme for IT (NPfIT). As the NHS stopped NPfIT in September 2011, and it was the subject of a critical Parliamentary report in 2013, it is not surprising that the researchers found many problems. For the study, researchers completed 41 interviews with the people involved with NPfIT.

    The findings identified four main cost types: infrastructure, including hardware and software; personnel, such as training team; facilities, such as space; other, such as training materials.

    The European Commission (EC) study on interoperable EHRs study of nine successful EHRs and ePrescribing systems across Europe, found that the average organizational costs slightly exceed ICT costs, The cost of redeployed resources are almost as much as the cost of additional resources.

    Both studies are retrospective, so exclude a significant cost: risk. The tinTree eHealth Evaluation Database (TEED) has these exceeding 200% of some years. Other large-scale adjustments needed when using the research findings for prospective adjustments are optimism bias and sensitivity. The TEED also has additions to these eHealth costs for new priorities and challenges. These are the increased resources and functions for:

    • Effective cyber-security • New eHealth regulations • Appropriate ICT capacity to deal with increasing interoperability.

    The TEED includes socio-economic evaluations of failed eHealth initiatives. These reveal that limiting or failing to plan for the full cost of the resources needed is a major cause of failure. It is not the only one. Others include poor usability, weak or no risk management and feeble benefits realisation. Each of these has several sub-sets.

    Several new eHealth initiatives do not incorporate these lessons. It is vital that African countries, with their very tight budgets and resources do not overlook them.

  • Big data, EHRs and safer drugs

    The USA’s Food and Drug Agency (FDA) is keen to learn more about Adverse Drug Events (ADE). Its posting on the Federal Business Opportunities (FBO) website says it is looking for a partner to develop a database of de-identified EMR data. Regulatory Focus has a post on the initiative.

    The FDA sees access to longitudinal patient-level EMR data as helping to estimate the contribution of various risk factors to ADEs. Data includes demographics, health history, diagnoses, procedures, laboratory test orders and results, use of drugs and biologics, side effects, health encounters like hospitalizations or visits to a doctor, mother-baby linkages and national death index data.

    The big bit of the data is the aim to access data from over 10 million EMRs. Some of these will have three-year histories, enabling longitudinal tracking.

    African countries can:

    1 ensure that their new eHealth regulations fit these big data scenarios

    2 enhance drug regulation

    3 plan the big data models

    4 keep track of regulation issues through ehna.

  • EHRs are not enough

    Please, sir, I want some more” is probably the most well-known quote from Charles Dickens’ Olivier Twist. A report from IDC Health Insights says EHRs are not enough. They need more for healthcare to exploit their potential. For the USA, the main additional perspective is applications that support population health management by integrating claims and clinical data; data at the point of care that helps to improve decision-making, and workflow tools that help to create and manage care plans and communications channels for effective patient engagement. FierceHealthIT has a report on this too.

    Key applications for population management include:

    Analytics for performance measurement, patient identification and stratification

    Workflow applications that can create and manage care plans, track events and scheduling Patient engagement tools.

    In the future, these efforts likely will include more than a portal, including other channels such as texting to engage patients.

    But still this is not enough. Other applications might include:

    Computerized physician order entry Admission, discharge and transfer Billing Practice Management Enrolment Care management.

    And even more. EHRs need health information exchange (HIE) technology to integrate data from disparate systems such as EHRs, claims, imaging departments, laboratories and pharmacies. These need standard presentations.

    Three other proposals are:

    Organizations must understand their data before making changes based on performance measures They must begin with only a few quality metrics Change management is essential.

    Much of this is not new. It is a good reminder for African countries to check to see that their eHealth strategies and plans do not build information silos, and if they do, to change the strategy to comply. eHealth is like Oliver’s gruel. After one bowl full, it want’s more.

  • If you think EHR's are secure, read this

    Don Marquis was a USA humorist and journalist who said “Fishing is a delusion entirely surrounded by liars in old clothes.” A literature review by Ayanthi Saranga Jayawardena in the Sri Lanka Journal of Bio-Medical Informatics has found all EHRs have security, privacy and confidentiality weaknesses.

    The study found 25 published articles on PubMed to identify the major issues of security, privacy and confidentiality of eHealth, especially EHRs. It then describes the current methods for overcoming them. The main finding is that eHealth users need different approaches for social, cultural and governmental factors to improve security, privacy and confidentiality issues. The 25 PubMEd articles is about 11%of the total articles found.

    These findings are consistent with the ESA eHealth Regulation Study for Sub-Saharan Africa. It found that examples of good eHealth regulatory practice had about 60% of the regulation coverage needed.

    With cyber-security becoming a bigger challenge over recent months, and tales of security breaches emerging in a steady, often unspectacular flow, a belief in eHealth security seems like a fishing delusion. Constant vigilance and improvement are vital for all countries.

  • Are EHRs all they promise to be?

    Ambiguity can be a good prelude to amusement, like Groucho Marx’s character Captain Spalding in Animal Crackers who “One morning, I shot an elephant in my pajamas. How he got into my pajamas I’ll never know.” EHRs suffer from a similar, but more serious ambiguity in that there is no agreed, single definition. FierceHealthIT overcomes this in its recent EHR survey of USA doctors, where it is clear that EHRs have revolutionized health documentation and patient tracking, and offers potential for big data and its N=all and correlations. It puts these opportunities alongside a price indication of up to US$70,000 per provider.

    A previous FierceHealthIT editorial pointed out that there are several extra costs too, including training, loss of productivity during implementation and initial operation, ICT staff, maintenance and routine updates. eHNA adds to these the time needed to develop and change some clinical and working practices and the general demise driven by obsolescence.

    athenahealth’s annual survey for its 2013 Physician Sentiment Index reveals some continuing anxieties. Over half, about 51%, said the financial benefits of EHRs do not outweigh the cost. The opinion is an improvement compared to 2012. To eHNA, this net financial cost is not surprising. The tinTree eHealth Evaluation Database shows that successful EHRs rarely achieve a pure financial position, but despite this, the survey respondents still set a high store on net financial benefits. Most respondents like EHRs, with 38% reporting a somewhat favorable opinion, and 31% seeing EHRs as very favorable, nearly 70%. It is down from 71% in 2012.

    These attitudes show the need for complete clarity with physicians and other healthcare professionals on the interoperability, architecture, functionality, usability, costs and benefits of EHRs. The only way to achieve this is continuous, sustained engagement from the outset.

    Groucho would have understood the physicians emphasis on financial returns from EHRs. One version of his nickname is that during the Marx Brothers’ early days in vaudeville, he was the keeper of the act’s grouch bag, slang for a purse.

  • EHRs are not always time-savers

    Not all EHRs are the same. A new report published in Medscape Medical News and reported by FierceHealthIT found that the intention of EHRs to improve provider workflow, can require more time from doctors. This is the experience of two hospitals in California hospitals. The EHRs increased the average time of residents spent seeing patients and updating the EHRs from 21 to 37 minutes, up by 76%. The study also found that 70% of residents at one of the hospitals had less than five hours training, and 70% said that the training was not good enough.

    tinTree’s socio-economic evaluations of eHealth find that effective EHRs, and other types of eHealth, have direct benefits for the working days of healthcare professionals. The contrasting experience reported from California shows the critical requirement of engaging with healthcare professionals in all aspects of adopting EHRs. They are major stakeholders, and meeting their needs is vital.

    As African countries continue to step up their eHealth initiatives, the time spent by ICT teams and the healthcare professionals from the outset has the reward of helping to avoid wasted time after implementation, when it is usually too late to change.

  • EHRs are much more than just ICT

    CTs change the way we do things. That’s most people’s experience. Sometimes it needs many changes, sometimes just a few. In healthcare, EHRs bring big changes that need extra time to deal with, which then result in big benefits. Healthcare Informatics has a story of how Dr Peter Anderson, a physician in Virginia, USA, transformed his medical practices using an EHR.

    After a 35% cut in productivity over the first five years, he now relies on the EHR to deal successfully with patients with more comorbidities and prescribing needs. The EHR helps to keep the scale of data he needs“straight and organized.”

    His big change was that he had to teach his nurses and medical assistants to collect and document all the patients’ current and relevant medical data needed for a successful patient visit. Now, he sees more patients and provides better healthcare. Patient satisfaction was at its highest because he was able to see all of his patients when they needed him.

    The success of his new workflows enabled Dr Anderson to retire from practicing medicine. He has transformed his process into a new business, called the Family Team Care Model, in which Team Care Assistants work with the provider and do many of the functions that do not require a provider (gather data, scribe the visit in the EHR, patient education), which maximizes the provider’s efficiency in seeing patients. He could also deal efficiently with the 200 to 300 data points of many of his patients and use his team care model to develop patient-centered care.

    As Africans countries move forward with their EHR initiatives, it is important that they are realistic in the time and resources that doctors need to climb over the initial medium-term investment hump and use their new information to transform the healthcare they deliver in the way they need. This organic approach to change may seem that it takes too long, but as the Dr Anderson story shows, it brings sustainable benefits to doctors, other healthcare professionals, patients, carers and communities.

  • EHRs can help improve vaccination in Africa

    Despite advances in medicine and vaccinations, thousands die annually of preventable diseases. Many of these deaths are in Africa. eHealth initiatives such as electronic health records (EHRs) have the ability to address some of the challenges.

    Immunization forms a central part of healthcare and is used to prevent unnecessary deaths the world over. Using EHRs to share data between health providers and public health agencies enables healthcare providers to assist patients faster and more effectively.

    A study by researchers from Columbia University (CU) School of Nursing and partner institutions found that a robust records automation program increased knowledge about individuals and communities, allowing healthcare providers at all levels to make better decisions. They analyzed 1.7 million records submitted by 217 primary care practices to the New York Citywide Immunizations Registry between January 2007 and June 2011.

    “EHRs greatly enhance our ability to help at-risk populations for whom up-to-date immunizations are critical, such as children, immunosuppressed individuals, or the chronically ill” said lead researcher and CU Nursing professor Jacqueline Merrill, RN, MPH, DNSc.

    Automated EHR reports provide readily available immunization histories and can help officials and healthcare workers determine which patients are immunized and which ones need follow-up. Registries also track and provide the basis for decisions on vaccine formulations, vaccine supplies and delivery schedules. Findings from the study showed that technological transformation can help make healthcare more efficient for patients and providers and can help the overall system create better conditions for keeping people healthy.

    Although most African countries lag behind in terms of technological advances in healthcare, EHRs have the potential to transform the way we approach healthcare and help to alleviate some of the vaccine preventable diseases that plague the continent.  Countries should embrace these changes and include them in their health and eHealth strategies.

    For more of the EHR study findings click here.

  • Are all EHRs good EHRs?

    Not all doctors and other healthcare professionals see EHRs as beneficial. It seems that some don’t save time with their EHRs, they need extra time. A report of a survey in Health Affairs Blog says that policy makers and professional organizations are increasingly concerned about user satisfaction.

    A study of professional satisfaction in 30 USA practices found that EHRs offer:

    Perceived ability to deliver high-quality patient care Reasonable control over the work environment, pace, and content Sharing clinical values with organizational leadership Respectful professional relationships Incomes perceived as predictable and fair.

    Physicians also reported some negative effects of current EHRs on their professional lives and patient care:

    Poor EHR usability does not match clinical workflows Creates time-consuming data entry Interferes with face-to-face patient care Sends an overwhelming numbers of electronic messages and alerts Perform tasks that are more efficient by clerks and transcriptionists.

    The inability of EHRs to exchange health information electronically was deeply disappointing to physicians. Instead, some still fax medical documents from outside providers.  Physicians also expressed concerns about potential misuse of template-based notes with pre-formatted, computer-generated text. Using them can improve the efficiency for data entry when used appropriately, but there inappropriate use contain extraneous and inaccurate information about patients’ clinical histories, leading some physicians to question reliability of these types of medical records. On the money aspects, they see EHRs as significantly more expensive than planned, creating uncertainties about their sustainability.

    The American Medical Informatics Association (AMIA) is undertaking a multi-stakeholder effort to deal with the EHR issues. It includes:

    Organizing and leading work with EHR vendors and user communities to improve usability Helping physicians become better purchasers and EHR users to increase practice efficiency and augment direct physician-patient time Keep working with federal regulators, such as the Office of the National Coordinator for Health Information Technology (ONC) to address usability concerns and resolve problems with the details and pace of certifying EHR systems Working to reduce the number and pace of EHR requirements that vendors must satisfy for certification Working with policymakers and others concerned about institutional liability to liberalize the ability to use office support personnel to reduce physician clerical needed to use EHRs.

    Whilst EHRs can have considerable value and benefits, African countries need to establish physicians and other health professionals value their EHR solutions. The Health Affairs Blog highlights the essential role of continuous engagement with healthcare professionals from the first decisions to consider EHRs and beyond procurement and implementation and into benefits realisation. This is just as important as the ICT bits.

  • A survey finds the best ambulatory EHRs

    Before spending loads of cash on EHRs, it’s a good idea to find out how users rate them. A report on PR Web says that a survey by Black Book Rankings has identified the top USA EHRs and EMRs in ambulatory care. Free copies of two groups of EHRs are available after registration.

    They are:

    The 2014 Report Summary: Top Large Hospital/academic Medical Center Inpatient EHR Report The View 2014 Report Summary: Top Small, Rural & Critical Access Hospital Inpatient EHR Report

    The survey found that in the last six months, primary care user satisfaction increased in all practices using an EHR for more than two years. The source of satisfaction is the efforts of vendors to improve workflow issues, delivering on promises, meaningful use achievements and fortified client support.

    About 39% of family practice, general practice, paediatricians and geriatric specialists say that they returned to normal levels of productivity after rolling out their EHR systems. This is a bit disappointing if one of the benefits of EHRs is to improve productivity. However, last year, only 10% of practices reported productivity returns after two years.

    Since Black Book™ announced the “Year of the Great EHR Switch” in early 2013, the share of primary care doctors who said they would recommend their EHR vendor to a colleague increased from 13% to 52% over the past six months. This is a significant turnaround.

    Black Book Rankings is highly regarded internationally for its accurate and impartial customer satisfaction surveys in the services and software industries. Its results provide a valuable direction for African countries with EHR plans. There can be satisfied users, but the choice of EHR and matching them to their settings are important to success