RD576 - Electronic Health Systems Records – December 2016


Executive Summary:
The use of information technology (IT) to include electronic health records (EHRs), electronic medical records (EMRs), and health information exchange (HIE) has been touted as a means to improve the patient experience with the health care system, the quality and safety of medical care, and to reduce redundancy in tests and procedures thus saving costs in our system. Additionally, data and information acquired from this technology has become the basis for new payment methodologies sometimes called “value-based purchasing,” which can align incentives to improve health and lower health costs over time. The recent Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) passed by Congress will increase the value of this capacity, as there is a requirement to move rapidly away from fee for service payments into alternative methodologies that are not volume-based.

Though the concepts of HIE have been promoted for two decades, the major impetus came with the American Recovery and Reinvestment Act of 2009. Not only were incentives created for hospitals and physicians to purchase EMRs, but penalties by way of reduced payments in Medicare and Medicaid were legislated if this was not done. The Office of the National Coordinator (ONC) was assigned to develop the criteria for “meaningful use.” With the pressure of the stimulus to “get the money out,” and with vendor resistance to important but costly regulations, these rules became a ceiling instead of a floor. It is fair to say that we have not reached meaningful use nationally or in the Commonwealth.

Though EMRs have now largely been adopted by physicians and health systems in the U.S. (see adoption rates by geography in appendix), there are a number of reasons that the vision has not been achieved.

1) The information in the records is of limited utility unless it is shared and is available when the patient is seen.

2) The proliferation of EMRs has come largely from the world of medical billing systems and not from clinical systems.

3) Exchange with other EMRs must be an integral component of each EMR, which in turn must easily work into the provider workflow.

4) The Health Insurance Portability and Accountability Act of 1996 was intended to provide assurance that health information could be exchanged with certain privacy and security restrictions. However, this has been interpreted to restrict instead of enable exchange.

5) Virtually every participant in the system has a proprietary interest in using the data for competitive advantage, and incentives have not been created to allow benefit from collaboration.

6) Because there are so few well-functioning HIEs, data analytic capacity – which could demonstrate value of collaborative data exchange to payers, providers, and patients alike – has been under-developed as well, except a few salient locations.

The 21st Century Cures Act of 2016 defined interoperability as “IT that enables the secure exchange of electronic health information” and blocking as “a practice that is likely to interfere with, prevent or discourage the practice of exchanging health information.” The legislation places new requirements on developers of certified health IT products to improve certification and transparency and blocking is proscribed.

Additionally, the new law requires electronic verification of personal care and home health services funded by Medicaid by 2019.

In its 2016 report on interoperability, KLAS, a company dedicated to collecting health data and recommending best practices, graphically displays the situation and challenge (see chart on second page).

To assess Virginia’s progress toward interoperability, the 2016 General Assembly passed HB 352. This bill calls for the Secretary of Health and Human Resources to work with stakeholders to evaluate interoperability within the Commonwealth, review the capacity to share patient information among providers and payers, and provide recommendations for improving information sharing to make health care services more efficient.

“§ 1. That the Secretary of Health and Human Resources shall work with stakeholders, which shall include representatives of hospitals and other health care providers in the Commonwealth, to (i) evaluate interoperability of electronic health records systems among health systems and health care providers and the ability of health systems and health care providers to share patient records in electronic format and (ii) develop recommendations for improving the ability of health systems and health care providers to share electronic health records with the goal of ensuring that all health care providers in the Commonwealth are able to share electronic health information to reduce the cost of health care and improve the efficiency of health care services. The Secretary shall report his findings and recommendations to the Chairmen of the House Committee on Health, Welfare and Institutions and the Senate Committee on Education and Health by December 1, 2016.”

Although there are significant efforts underway in Virginia to improve interoperability and the exchange of information, many are “one-offs” that are not well coordinated nor do they follow any standard practice. Virginia has not fully achieved the goals of connectivity and interoperability to ensure access to the right information in the right place at the right time. There are also various levels of understanding regarding services that are available through Virginia’s health information exchange and how ConnectVirginia’s governance and legal framework operate. While ConnectVirginia is not yet providing the functionality Virginia needs, it does offer a trust framework and local structure that can be used to coordinate and align interoperability efforts across Virginia.

Virginia is not alone in looking at strategies to move toward interoperability. The National Governors Association (NGA) recently published “Getting the Right Information to the Right Health Care Providers at the Right Time: A Road Map for States to Improve Health Information Flow Between Providers,” a guidance document for states. This document suggests a series of steps and eventual strategies for states will help to remove the significant legal and market barriers that currently impede providers’ ability to efficiently share health information.

NGA Suggested Steps

1. Assemble Core Team
2. Conduct Legal and Market Analyses
3. Determine Primary Barriers
4. Select Strategies
5. Implement and Evaluate