The electronic health record (EHR) market is becoming one of the biggest revenue-generating segments in health care, according to a Healthcare Data Solutions report. At last year’s Healthcare Information and Management Systems Society conference, Accenture estimated that the EHR market was worth $23 billion by the end of 2015. But as the market expands, it also may become more competitive since providers now have a choice of over 400 EHR vendors. A KLAS survey found that 27 percent of medical practices are planning to replace their EHR system and 12 percent want to, but are unable to because of financial constraints.

The small and mid-sized EHR vendors are expected to be pushed out of the market and the major vendors will dominate. But as the providers’ needs broaden, the vendors will have to offer advanced capabilities or risk fizzling out of the market. Many of the challenges that providers face today are related to the poor usability of EHRs and the cumbersome requirements of the Meaningful Use program. Fortunately, organizations like the American Medical Association (AMA) are trying to bring about change, and the vendors seem to be on board.

Connecting all the parts
“The problem that we are having now is that the consumer is seeing how well things are being integrated, such as your smart TVs having apps on them, and they want to know why they can’t do that in health care,” says Matt Adams, health care information technology analyst at MD Buyline. When a nurse in a doctor’s office asks the patient a question, they want to know why the other nurse at the hospital or other specialty clinic has to ask the same questions. Unfortunately, part of the problem is the EHRs that vendors have designed. According to HIMSS, interoperability describes the extent to which systems and devices can exchange data and interpret that shared data.

“Interoperability is a big thing that vendors have been standing in the way of because some of them have invested billions of dollars to create a homegrown technology,” says Adams. “That is their most efficient technology and it’s not made to be efficient with other vendors’ technology.”

In late December, the Office of the National Coordinator for Health Information Technology released its standards and implementation specification to encourage interoperability between EHR systems. The ONC realizes that since the vendors have invested billions of dollars into their EHRs, it’s going to take billions of dollars of incentives to make the systems more “open code."

Another incentive for the vendors is the fact that the customers are going to choose which company adapts quicker. NextGen Healthcare has a free service called NG Share that allows its customers to send secure messages using a direct protocol to any other physician who has the direct address. There are now more than 250,000 physicians in the directory and it’s growing every day.

Epic has a service called Care Everywhere and it allows for information to be shared from other Epic systems, a non-Epic system or directly from a patient. However, when an Epic system is on both sides of the exchange, it involves a richer data set and additional connectivity options such as cross-organization referral management.

GE has also placed a lot of focus on this area. The goal is to have information flow around the health system, the community, the rest of the patient's care team and the payors, faster than the patients move around the hospital and community. “We probably don’t have any installation of our products where there is not some level of interoperability within the system or with a payor, or with another hospital department,” says Jon Zimmerman, general manager of clinical business solutions at GE Healthcare IT.

During the KLAS Keystone Summit in October, 12 companies issued a consensus statement stating that they agree to a set of objective measures of interoperability and ongoing reporting. Those companies include Allscripts, athenahealth, Cerner, eClinicalWorks, Epic, GE, Greenway, Healthland, McKesson, MEDITECH, MEDHOST and NextGen. The next steps are for those companies to put together a cohesive plan and then launch and monitor its progress.

Meaningful Use needs to be more meaningful
“The Meaningful Use program has been, from the beginning, overly complex, overly prescriptive, and a one-size fits-all program, which means that it has been guaranteed to be ill-equipped and ill-designed for everybody,” says Dr. Steven J. Stack, president of the AMA. “They grade it on an all-ornone, pass or fail grade, so you need to get 100 percent to get an A, and if you get a 99 percent or less you fail and get a penalty.”

In 2015, more than 50 percent of all physicians participating in the Medicare program got a one percent penalty, according to Stack. He adds that it’s hard to predict what 2016 will hold but he isn’t optimistic those numbers will get any better and there’s a possibility they will get worse.

In December, AMA released a set of recommendations to improve the program so that it accommodates the real-world needs of physicians and patients while focusing on promoting interoperability. The recommendations were included in comments the AMA sent to CMS on Meaningful Use Stage 3.

One of the things that AMA proposed is to simplify the program to provide more flexibility — there are eight different requirements with multiple measures — and eliminate the all-or-none to succeed metric. It also suggests that it focus more on the desire for outcomes.

“If they want data to be portable, quality reporting, and vaccinations to be reported to state health departments, they should allow for numerous different ways to fulfill those things and not define specifically that it must be a certain way,” says Stack. Stack also suggests that the program should remove all requirements that are outside of the physicians’ controls. Physicians should have to make records available to patients, but if the patient doesn’t look at the information, the physician should not be held accountable.

The vendors are also doing their part to help providers meet the requirements. Many of them host webinars and offer consulting to help them set up workflows to meet the measures.

Make them more usable!
A survey conducted by the American College of Physicians and AmericanEHR Partners found that the satisfaction and user ability ratings for EHRs have declined since 2010. User satisfaction fell by 12 percent from 2010 to 2012 and users who were “very dissatisfied” increased 10 percent during the same time.

“We live in a world where a two-year-old can use a smart-phone and a physician is crippled by an electronic health record,” says AMA’s Stack. “It’s not the doctor that is the problem here.” Physicians are reporting that the HER technology requires too much time-consuming data entry, which leaves them with less time for patients. According to Stack, physicians showing signs of burnout have increased from 45 percent to 55 percent from 2011 to 2014.

The federal government’s EHR incentive programs require that physicians use certified EHR technology. However, many of the physicians in the Medicare program have reported that the EHRs are so cumbersome that they are willing to accept the penalty because otherwise it would diminish the quality of care, says Stack. If Medicare-eligible professionals did not adopt and successfully demonstrate meaningful use of EHR technology by 2015, their Medicare physician fee schedule amount for covered professional services was reduced by 1 percent, according to HealthIT.gov.

In September 2014, the AMA released a new framework that outlines eight priorities for improving EHR usability. The priorities include enhancing physicians’ ability to provide high-quality patient care, supporting team-based care, promoting care coordination, offering product modularity and configurability, reducing cognitive workload, promoting data liquidity, facilitating digital and mobile patient engagement and expediting user input into product design and post-implementation feedback.

Stack says that if necessary, the AMA will see if there are legislative options available to modify the EHR technology to make it more usable. “Right now these tools, which have so much incredible promise to be helpful, are not realizing that promise, and in fact they are interfering with things the way they shouldn’t,” he says.

Alerts when needed
Alarm fatigue is another issue that physicians are running into when using EHRs. A study conducted by the University of Colorado found that one system in the emergency department put out over 123 unnecessary alerts to prevent one adverse drug event. “In my opinion, it is definitely a problem that deserves continued attention because it is the value between safety and productivity,” says GE’s Zimmerman. “Those are the two dynamic forces that say, ‘You’re alerting me on things that I already know.’ “

GE has tuning capabilities so that their customers can adjust parameters for thekinds of alerts that are put out system wide. They can adjust them based on their preferences and the kind of training that they provide to their teams on how to best use the EHR.

Epic also gives their customers the ability to define their own threshold for alarm alerts, but they also provide an analytics engine in the background that targets alerts to the right provider about the right patient at the right time. “We give a lot of guidance to our customers — letting them know which alerts others have found to be particularly useful so they know which ones are the most helpful for providers,” says Dr. Sean McCormick, a physician with the clinical informatics team at Epic.

In the ambulatory environment, NextGen Healthcare allows their customers to set the level of drug-to-drug interaction that they want to view and to minimize the ones that are not significant. “Physicians override drug allergy alerts when it’s really just an intolerance, or the interaction is really not a true allergy to the exact component, but one that is related to the class of drugs,” says Dr. Sarah Corley, chief medical officer at NextGen Healthcare.

Moving to the cloud
Client-server EHR solutions can cost up to $40,000 and that’s causing many smaller and mid-sized hospitals to turn to cloud-based EHRs, according to the Healthcare Data Solutions report. They’re attractive to that segment because they require little to no investment for infrastructure and maintenance, since all that is needed is an Internet connection.

The other benefits of cloud-based EHRs are the ability to access the EHR remotely and the fact that they allow for scalability. GE’s Zimmerman cautions against the use of the term “cloud-based” to mean when somebody in a data center far away is running the same code that the hospital has. To Zimmerman, “cloud-based” means that it is rewritten for a cloud operating environment like Microsoft Cloud or IBM cloud computing.

GE is currently investing in making their systems go through a journey from on-premise, to cloud-deployed to fully cloud-native. He believes that those are the three areas that we’ll see the industry go through.

Athenahealth offers a cloud-based EHR. With conventional EHRs, information is usually only able to be shared in the same physical location as the software and services, but with cloud-based EHRs like athenahealth’s, all of the software and clinical data is stored, shared and updated in the cloud. Cloud-based EHRs will also foster collaboration among patients’ care teams. “I think the opportunity of tomorrow is to unify that care team and make it easier for folks to work together across boundaries around a patient,” says Don Woodlock, general manager of cardiology IT at GE.

At last year’s Radiological Society of North America meeting, GE showcased a product on its GE Health Cloud called Multi-Disciplinary Team Meetings. It allows for a virtual “tumor board meeting” with a pathologist, radiologist, surgeon and general practitioner. “I think as these systems become more collaborative, they’ll be more part of the social fabric,” says Zimmerman. “The patients are not as much a part of the [EHR] ecosystem as they probably should be. The term, 'patient engagement,' I think, will drive a lot more patient access and patient activity in the [EHRs] themselves.”