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36
THE CURRENT STATE OF ELECTRONIC MEDICAL RECORDING
IN THE USA
DOI 10.24411/2072-8735-2018-10181
Elena G. Kukharenko,
Moscow Technical University of Communications and Informatics, Russia, Moscow, elena.kukharenko@mail.ru
Alexey V. Yankevskiy,
Peoples' Friendship University of Russia, Russia, Moscow, yankevsky@gmail.com
Olga Aminev,
Moscow Technical University of Communications and Keywords: health, information, technology,
Informatics, Russia, Moscow, oaminev@yahoo.com electronic, medical, record, system.
The article deals with the dynamics of the issue on the organization of electronic document management in medical institutions in the United States. The road map for the development of this class of systems at the national level for the period from 2004 to 2015 is presented. The stages of further development of electronic medical document systems turnover in the long term from 2015 to 2024. The review of the main provisions on the standardization of this class of medical information systems is given. Requirements for the provision of information and transmitted content, information security and information protection. The results of analytical studies for the period from 2013 to 2015 on the use of these systems in public and private medical institutions for each state individually and in the country as a whole. The examples of practical application of medical electronic document management and information exchange systems with the presentation of interfaces for the patient (schedule of appointments with the doctor, prescribed drugs and and the scheme of admission, other necessary information), and for medical personnel (contact information, which staff is involved in the treatment process, the results of examinations and prescribed procedures and drugs, the schedule of outpatient and non-outpatient treatment).
Information about authors:
Elena G. Kukharenko, Moscow Technical University of Communications and Informatics, PhD, Associate Professor, Moscow, Russia Alexey V. Yankevskiy, Peoples' Friendship University of Russia, PhD, Associate Professor, Moscow, Russia Olga Aminev, Moscow Technical University of Communications and Informatics, Moscow, Russia
Для цитирования:
Кухаренко Е.Г., Янкевский А.В., Аминев О. Современное состояние электронного медицинского документооборота в США // T-Comm: Телекоммуникации и транспорт. 2018. Том 12. №11. С. 84-96.
For citation:
Kukharenko E.G., Yankevskiy A.V., Aminev O. (2018). The current state of electronic medical recording in the USA. T-Comm, vol. 12, no.11, pр. 84-96.
The focus should be on collective efforts to ensure reliable access to standardized electronic medical information for those who need ¡1, and in a way that is as convenient and useful as possible.
It is important to emphasize that current efforts should use and rely on technologies and investments made to date, continuing to explore ways of supporting "innovation" and moving beyond 11 As as the only source of data for electronic medical information for a wide range of medical information technologies used individuals, suppliers and researchers. The road map (shown below), three high-level goals for the interoperability of IT health systems reflect the progress that needs to be made to achieve the health education system by 2024. This leads to a short-term goal that aims to send, receive, search and use priority data areas in order to have a direct impact on the care and health of people.
The three high level goals arc expected to be met in the following durations:
• 2015-2017: Send, receive, find and use priority data domains to improve health care quality and outcomes.
• 2018-2020: Expand data sources and users in the interoperable health IT ecosystem to improve health and lower costs.
• 2021-2024: Achieve nationwide interoperability to enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.
The road map is deeply focused on the first priority goal and its accompanying milestones, the most important points of action and commitments. To address the current challenges, the road map identifies four key areas that should be focused at present to create the basis lor long-term success:
• Improvement of technical standards and guidelines for the implementation of priority data domains and related elements. In the short term, the Road map focuses on the use of generally accepted standards and the desire for their wider implementation systematic and innovation related to new standards and technologies approaches, such as using the API.
• Rapid bias and alignment of federal, state and commercial Cost-based models to stimulate demand for services compatibility.
• Clarify and harmonize federal and state requirements for confidentiality and security, enable interaction.
• Coordination among stakeholders to promote and harmonize coherent policies and business practices that support interoperability and remove barriers compatibility.
The road map consists of three sections, beginning with "drivers", which are mechanisms that can stimulate the development of a favorable payment and regulatory environment that relies on and deepens compatibility. The next section discusses "policies and technical components" that stakeholders need to implement in a similar or compatible way to ensure compatibility, for example, common standards and expectations for confidentiality and security. The last section discusses "results" that serve as indicators by which stakeholders will measure our collective progress in the implementation of the Roadmap. Each section includes specific milestones, calls for action and commitments that will contribute to the development of a nation-wide, interoperable health IT infrastructure.
So, what do we know about the dynamics of certified electronic health systems record and electronic information
exchange? According to the National Survey of Electronic Medical Cards of 2014:
• In 2014, 74,1% of office doctors had a certified electronic medical card (EHR) system, compared with 67.5% in 2013,
• The percentage of doctors with a certified EMC system ranged from 58.8% in Alaska to 88.6% in Minnesota.
• In 2014, 32.5% of otfice doctors with a certified EMC system exchanged information about the health of patients with external suppliers in electronic form.
• The proportion of physicians with a certified EMC system sharing health information by electronic means with external suppliers ranged from 17.7% in New Jersey to 58.8% in North Dakota,
This report uses the National Electronic Medical Record Survey (NEHRS) to describe the introduction by physicians of EUR certified systems from 2013 to 2014 in the United States and the extent to which doctors with certified EHR systems share patient health information. This of course, after medical information technology for the economic and clinical health law (high-tech) in 2009, provides incentive payments that are eligible for hospitals and providers that have demonstrated the meaningful use of certified electronic medical records (EHR) and after the Office of the National Coordinator for Medical IT started to certify EMC-systems in 2010, having the opportunities that would allow meeting important criteria.
In addition, from 2013 to 2014, the number of certified electronic medical records systems in doctors' offices increased. In 2014, 74.1% of office doctors reported having a certified EMC system compared to 67.5% in 2013. The percentage of primary care physicians with certified EMC systems in 2013 (72.1%) and 2014 (78, 6%) exceeded the same indicator for non-primary health care specialists for both years (63.1% and 70.3%, espectively).
AH ifiMiaities
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Figure 3. Office-based physicians with a certified electronic health record system, by physician specialty: United States, 2013-2014
Nevertheless, the introduction of certified electronic medical record systems into office practice varies from country to country. In 2014, the proportion of doctors certified by the EIIR system ranges from 58.8% in Alaska to 88.6% in Minnesota and the percentage of doctors who certified the EHR system was less than the national percentage (74,1%), Alaska (58.8%) and more than in the whole country in six states: Iowa (83,4%), North Carolina (84.8%), Oregon (85.0%), Vermont (85.0%), South Dakota (86.1%) and Minnesota (88.6%).
physicians "" your current system meets the meaningful use criteria as determined by the Department of Health and Social Services? "Physicians who answered" yes "were deemed EHR certified.
Exchange patient health information: doctors who exchange patient medical information with other providers were identified by answering "Yes" to "You share any patient medical information (for example, laboratory test results, visualization reports, problem lists of medications are listed) electronically (not by fax) with any other providers, including hospitals, outpatient clinics, or tests? "Office doctors reporting that they shared information about patients with" external supplies " they shared information about patients' health electronically either with outpatient care providers outside their own group or with hospitals with which their practice is not connected,The exchange of information with external providers does not include health, mental health, or long-term care, -based physicians who reported that they shared the patient's medical information with "internal providers" of the patient's general medical information electronically with suppliers in their group or hospitals, but not from an outpatient power beyond their own group or hospitals with which their practices are not affiliated.
Exchange of patient health information on four aspects of interoperability: The National Electronic Medical Record Survey (NEHRS) of 2015 asked doctors a few questions about sending, receiving, integrating and retrieving patient health information electronically:
• Sending patient health information electronically: NMSAs ask physicians: "Do you send health information to other providers and public health institutions outside your medical organization using the following data transfer methods?" Doctors who answered "yes" to The methods "EHR (not eFax)" or "Web Portal (separate from EHR)" were defined as having electronic sending of patient health information.
• Obtaining information about patients' health in electronic form: the NMSA asked the doctors"" do you receive information about the health status of patients from other providers and public health institutions outside your medical organization using the following methods of data transfer? "Physicians who answered "yes" to the methods "EHR (not eFax)" or "Web Portal (separate from EHR)" were defined as having electronic information about the health of the patient.
• integration of patient health information electronically: CNPV asked physicists: "when you receive information electronically from other providers, can you integrate the following types of patient health information into your EMF without much effort, such as manual input or scanning?" 10 various types of patient health information are included: drug lists, patient problem lists, medication and allergy lists, imaging reports, laboratory test results, registty data, directions, hospital discharge notification from the emergency room, and summary medical records for the transfer of care or referrals. Doctors who answered "yes" to at least one of 10 different types of medical information about patients were identified as having electronic integrated medical information about patients.
• Searching for information about patient health in electronic form: the NMSA asked the doctors "how often do you electronically seek health information from sources outside your medical organization when visiting a new patient or an existing patient who has received services from other providers?"
Doctors, who answered "always", "often" or "sometimes", were defined as having an electronic search for information about the health of the patient.
How it the Electronic He:ilth Records System Actually Applies:
In the age of increasing use of technology, the medical system of the United States has made the commitment to move on from paper interactions to ones that involve screens. Patients in 2018 can now make appointments, converse with doctors, and obtain medical information without even lifting a pen or even leaving their homes. With apps and software like EpicCare, hospitals are able to stay up to date with government regulations, make it easier for patients to be informed, and allow doctors, hospitals and patients to have clearer financial discussions.
When a patient first enters a modern hospital with an updated electronic health record system, they can submit their health and personal information either through an app or on the hospitals iPad. This allows the hospital to immediately establish a file on the patient. In many cases, when the patient returns - (hey can simply inform that they have showed up to their appointment through the app. In cases where the patient has created an appointment online, the patient can usually submit personal information and health history ahead of time so it is not necessary for them to arrive earlier to fill out paperwork.
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Figure 13, An example of how a patient's file would show up on an
Electronic Medical Record App: Includes Name, Address, Phone Number, Current Medical Issues and Medications Prescribed
With online health records and an online approach, doctors can easily see a patient's available medical history, their current schedule with patients (an online approach also prevents situations with double-booking), reason for patient's visit, current prescriptions and past diagnoses. If the doctor is working in a setting that Lises cloud-based electronic medical records, he/she has greater accessibility to vital information at any time, in any setting. Furthermore, medical information can be backed up in case of disaster.
And yet the current question asks: is the current electronic medical record system worth it? Though many believe that the current state has the potential to bring in trillions of dollars of year - many seem to forget the initial investment in implementing and utilizing the record systems in the first place. Though we have touched on the challenges of electronic recording earlier -what was mentioned earlier was only the tip of the iceberg.
To simply put in a working electronic medical recording system would cost a solo practitioner over $150,000 — and that is not just because of the cost of the program.
The major reason is security. Most Americans have at least one electronic record - created when they enter a medical setting, This may not seem like much except when a data breach occurs. All of a sudden, all that personal and sensitive information becomes easily available to those who intend on profiting from the patient's misfortune. Data breaches and security threats are becoming so problematic that the American Action Forum believes such issues have caused the health care industry about $50 billion since 2009.
Besides implementing the program, the clinic or physician has to receive training on how the program works. The program has to be continually updated and maintained. And all of this is under the assumption that the computers and hardware are up to par for the implementation of the program - if not, that is an additional cost. In certain situations, clinics may even choose to hire an employee whose sole job is to keep all practitioners up to date on the program and to keep up to speed with ongoing updates and changes.
The average cost for a physician practice to transition to electronic medical records as a solo practitioner is about S165,000 and for a practice with five physicians is about $240,000. Because many of the costs are fixed, such as the software and much of the hardware, it is much cheaper to share the costs amongst multiple providers in a single practice.
As of mid-2015, the Centers for Medicare and Medicaid Services have spent more than S30 billion in financial incentives to half a million Medicare and Medicaid providers in an effort to implement electronic medical recording. And with such incentives comes the question as to why a physician might potentially not want to invest an electronic medical record program if it could potentially be a fruitful investment in not just profit but in saving lives?
Average Cost of Data Breach Per Record
2008 1009 2010 2011 2012 2013 2014 -AIL 1 rdustries -Health Care
Figure 23. Average cost ofdata breach per record compromised
In 2013, 90 percent of hospitals claimed to have a computerized system capable of conducting or reviewing a security risk analysis. Despite this, the number ofdata breaches, and the number of records compromised, continues to climb. This is costing the industry more and more money and costing patients and physicians their peace of mind.
Total Number of Records Breached Per Year
94.010.272
13.125.i72
12.503,190
134.773
5,524,176
2.75C.360
2C09 2010 2011 2012 2013 2014 2015"
Figure 24. Total number of records breached per year
With 135 million health care records having been compromised in more than 1,200 separate data breaches since October 2009, American Action Forum estimates the total cost of these breaches to be S50.6 billion in less than 6 years. As the years continue, the number of records compromised and the resulting cost will increase even further.
The dramatic increase in the average number of records compromised in a single breach is alarming and may be a con sequence of the more connected health care system for which we are striving. With the growing number of electronic records and increased sharing among providers, the number of records potentially accessed in a single incident is growing exponentially.
And this leads to another issue - "data blocking". Despite the myriad benefits which could accrue to the health care system as a whole through access to the trove of information being collected, the conflicting interests of the various stakeholders means that it is not in stakeholders' self-interest to share their information. If a patient's privacy or a doctor's reputation is at risk with every click of a button, what's the point of even posting anything online in the first place?
A study by the Agency for Healthcare Research and Quality found that only 14 percent of providers in 2013 were sharing data with health care providers outside their organization, hindering the ability to improve patiem care coordination as desired. For now, electronic medical records are still primarily viewed as an administrative tool. A survey analysis from Software Advice finds that the most commonly requested functionality tor an electronic medical record system continues to be billing (45 percent) followed by claim support (27 percent) and patient scheduling (23 percent).
So do American doctors believe that the transition to the electronic medical system is worth it? Well, while the costs for many providers transitioning to an electronic medical system have been largely offset by the federal incentive payments, the evidence thus far seems to suggest that most providers are not yet seeing the pay oil".
Research derived from analyzing hospitals using electronic medical systems from 1996-2009, found that these early adopters, on average, had increased costs, at least for the first three years after adoption. There w:ere differences, though, based on the strength of the local Information Technology labor supply. In areas without a strong IT workforce, costs increased 4 percent,
but in IT-intensive areas, hospitals with basic electronic medical system saw cost decreases of 3.4 percent three years after adoption. As the number of workers in IT-related jobs continues to increase and EMR technology is adapted and improved, all areas may begin to sec cost decreases.
Other research examining thirty ambulatoiy practices for two years after electronic medical record implementation found that, on average, productivity declined by an average of 15 patients per physician per quarter following implementation of an electronic medical record system. This is most likely due to physicians being required to have a set time to view patients (i.e. minimum of 15 minutes) as the duration of the patient visit is recorded in the record. At the same time, reimbursements to the practices actually increased. The researchers found that this was not a result of upcoding (when a doctor puts a code that suggests a higher ievel of care than was actually received by the patient) or more generous reimbursements per charge, but rather a significant increase in the number of necessary procedures billed following electronic medical record implementation. While we look to increase access to care and simultaneously decrease costs, this study finds that physicians are instead receiving more money for treating fewer patients - which runs counter to the intended result.
Additionally, 60 percent of electronic medical record purchasers in 2015 are replacing current electronic medical record systems, which may delay full interoperability and the use of the more advanced functions as providers continue to spend lime learning new systems. As more providers progress through the various stages, each requiring more advanced functionality and use among a greater percentage of patients, the systems should begin lo provide more comprehensive benefits. Researchers have found significant reductions in medication errors and, consequently, reductions in mortality rates for hospitalized patients, with use of computerized provider order entry.
Widespread use of electronic medical records could bring beneficial change lo the health care system in a variety of ways, largely because they are the foundational piece to many technologies and analyses that could change health care delivery. Having every patient's data stored electronically, in a standardized form creating an easy transfer and comparison of data among providers, insurers, and researchers will allow the recognition of patterns that could provide smarter, more targeted personal, population, and public health measures. For example, the development of not just personalized medicine, but predictive medicine; reductions in medical errors; better disease management and treatment adherence; predicting and potentially preventing disease outbreaks; elimination of insurance fraud; identification of the most effective treatments for the fewest dollars; and identification of the best treatments that are worth the extra money.
All of these potential advances could greatly improve health outcomes and help bend the health care cost curve. Unfortunately, these advances come with significant costs, both financially and in terms of personal privacy. Going forward, policymakers should work lo ensure limited resources arc used in a more cost-effective manner. As electronic medical record adoption continues to increase along with the type of information gathered, policymakers should work with experts and the public to ensure that the appropriate balance is struck between sharing information to allow advancements and providing necessary privacy protections - even on a global scale.
References
1. The Office of the National Coordinator for Health Information Technology. Federal health IT strategic plan: 2015-2020. 2015.
2. The Office of the National Coordinator for Health Information Technology. Connecting health and care for the nation: A shared nationwide interoperability roadmap Version 1.0. 2015.
3. CDC/NCHS, National Electronic Health Records Survey 2013-2014.
4. CDC/NCHS, National Electronic Health Records Survey, 2014.
5. Jam Centers for Medicare & Medicaid Services. Electronic Health Records (EHR) Incentive Programs. Baltimore, MD.
6. Williams C, Mostashari F, Mentz K, Hogin E, Atwal P. From the Office of the National Coordinator: The strategy for advancing the exchange of health information. Health Aff (Millwood) 31(3):527-36. 2012.
7. Blumenthal D, Tavenner M, The "meaningful use" regulation for electronic health records. N Engl J Med 363(6):501-4. 2010.
8. Centers for Medicare & Medicaid Services. Electronic Health Records (EHR) Incentive Programs. Baltimore, MD.
9. Jamoom EW, Yang N. Table of electronic health record adoption and use among office-based physicians in the U.S., by state: 2015 National Electronic Health Records Survey. 2016.
10. https://www.cdc.gOv/nchs/data/databriefs/db261_table.pdf#l
11. NCHS, National Electronic Health Records Survey, 2015.
12. https://www.cdc,gov/nchs/data/databriefs/db26l_table.pdf#2,
13. https://www.cdc.gov/nchs/data/databriefs/db261 table.pdf#3.
14. https://www.cdc.gOv/nchs/data/databriefs/db261_table.pdf#4.
15. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdfS5.
16. HSS Office for Civil Rights. Data through June 26, 2015,
17. IBM, Ponemon Institute 2015 Cost Data Breach Study.
18. Кухаренко Е.Г., Янкевский А,В., Аминев О. Нормативно-правовое обеспечение функционирования инфоком муникационных систем в области государственного и муниципального управления // Сборник трудов XII Международной научно-технической конференции «Технологии информационного общества». Москва: Московский технический университет связи и информатики (МТУСИ), 14-15 марта 2018 г. В 2-х томах. Том 2. М.: ИД «Медиа Паблишер», 2018. С. 351-353.
Sources for Figures
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i iiterope rab i 1 i ty/nat i on w ide- i me rope га ЫI i ty - road m ар - fi n a I - ve rs i о n -l.O.pdf
3. https://www.cdc.gov/nchs/products/databriefs/db236.htm
4. https://www.cdc.gov/nchs/products/databriefs/db236.htm
5. https://www.cdc.gov/nchs/products/databriefs/db236.htm
6. https://www, с dc.gov/nchs/products/databnefs/db236, htm
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9. https://www.cdc.gov/nchs/products/databriefs/db236Jitm
10. https://www.cdc.gov/nchs/products/databriefs/db236.htm
11. https://www.cdc.gov/nchs/products/databrief5/db236.htm
12. https://www.cdc.gov/nchs/products/databriefs/db236.htm
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14. http://www.histalkpraetice.com/2010/10/12/news-l 01210/
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СОВРЕМЕННОЕ СОСТОЯНИЕ ЭЛЕКТРОННОЙ МЕДИЦИНСКОГО ДОКУМЕНТООБОРОТА В США
Кухаренко Елена Геннадьевна, МТУСИ, Москва, Россия, elena.kukharenko@mail.ru
Янкевский Алексей Владимирович, ФГАОУ ВПО "Российский Университет Дружбы Народов", Москва, Россия,
yankevsky@gmail.com
Аминев Ольга, ФГБОУ ВО "Московский технический университет связи и информатики", Москва, Россия,
oaminev@yahoo.com
Аннотация
Рассматривается динамика вопроса об организации электронного документооборота в медицинских учреждениях США. Представлена дорожная карта развития данного класса систем на национальном уровне на период с 2004 по 2015 годы. Рассмотрены этапы дальнейшего развития оборота электронных систем медицинской документации в долгосрочной перспективе с 2015 по 2024 год. Обзор основных положений по унификации данного класса медицинских информационных систем. Требования к предоставлению информации и передаваемого контента, информационной безопасности и защите информации. Приведены результаты аналитических исследований за период с 2013 по 2015 годы по использованию данных систем в государственных и частных медицинских учреждениях для каждого государства в отдельности и в стране в целом. Даны примеры практического применения медицинского электронного документооборота и систем обмена информацией, представлены образцы интерфейсов для пациента (расписание приемов врача, лекарства и схема приема, другая необходимая информация), и медицинского персонала (контакты, как персонал вовлечен в процесс лечения, результатах обследования и назначенных процедур и препаратов, расписание амбулаторного и пост-амбулаторного лечения).
Ключевые слова: здоровье, информационные, технологии, электронный, медицинский, учет, запись, система. Литература
1. The Office of the National Coordinator for Health Information Technology. Federal health IT strategic plan: 2015-2020. 2015.
2. The Office of the National Coordinator for Health Information Technology. Connecting health and care for the nation: A shared nationwide interoperability roadmap Version 1.0. 2015.
3. CDC/NCHS, National Electronic Health Records Survey 2013-2014.
4. CDC/NCHS, National Electronic Health Records Survey, 2014.
5. Jam Centers for Medicare & Medicaid Services. Electronic Health Records (EHR) Incentive Programs. Baltimore, MD.
6. Williams C, Mostashari F, Mentz K, Hogin E, Atwal P. From the Office of the National Coordinator: The strategy for advancing the exchange of health information. Health Aff (Millwood) 31(3):527-36. 2012.
7. Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med 363(6):501-4. 2010.
8. Centers for Medicare & Medicaid Services. Electronic Health Records (EHR) Incentive Programs. Baltimore, MD.
9. Jamoom EW, Yang N. Table of electronic health record adoption and use among office-based physicians in the U.S., by state: 2015 National Electronic Health Records Survey. 2016.
10. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdf#1
11. NCHS, National Electronic Health Records Survey, 2015.
12. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdf#2
13. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdf#3
14. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdf#4
15. https://www.cdc.gov/nchs/data/databriefs/db261_table.pdf#5
16. HSS Office for Civil Rights. Data through June 26, 2015.
17. IBM, Ponemon Institute 2015 Cost Data Breach Study.
18. Кухаренко Е.Г., Янкевский А.В., Аминев О. Нормативно-правовое обеспечение функционирования инфокоммуникационных систем в области государственного и муниципального управления / Сборник трудов XII Международной научно-технической конференции "Технологии информационного общества". Москва, Московский технический университет связи и информатики (МТУСИ), 14-15 марта 2018 г. В 2-х томах. Том 2. М.:ИД "Медиа Паблишер", 2018. С. 351-353.
Информация об авторах:
Кухаренко Елена Геннадьевна, ФГБОУ ВО "Московский технический университет связи и информатики", к.э.н., доцент, Москва, Россия Янкевский Алексей Владимирович, ФГАОУ ВПО "Российский Университет Дружбы Народов", к.э.н., доцент, Москва, Россия Аминев Ольга, ФГБОУ ВО "Московский технический университет связи и информатики", магистрант, Москва, Россия
