BACKGROUND ON ELECTRONIC HEALTH RECORDS FOR SMALL PRACTICES

Transcription

1 BACKGROUND ON ELECTRONIC HEALTH RECORDS FOR SMALL PRACTICES PREPARED BY: Andrew H. Melczer, Ph.D., Vice President Illinis State Medical Sciety Lesley Berkeyheiser, Principal The Claytn Grup Sue Miller, JD HealthTransactins.cm Mariann Yeager Principal, Emersn Strategic Grup, Inc. January Illinis State Medical Sciety

2 TABLE OF CONTENTS Intrductin...1 What Is an Electrnic Health Recrd?...1 Financing Electrnic Health Recrds Csts and Benefits...4 Financing Demnstratins... 7 Current Interest in Electrnic Health Recrds...8 Presidential Interest... 8 President s Infrmatin Technlgy Advisry Cmmittee... 9 CMS Interest Veteran s Administratin Physicians Electrnic Health Recrd Calitin Other Organizatins Natinal Health Infrmatin Netwrk...14 Reginal Health Infrmatin Organizatins CHI Initiative What Shuld Small t Medium Sized Practices Lk fr in an EHR System?...18 EHR Features...19 Web-based EHRs Cmpany Experience EHR Cst Survey f Electrnic Health Recrds...25 Organizatinal Recmmendatins Cmments...26 Acknwledgments...26 Authr Infrmatin...27

3 Intrductin Our cuntry and especially the health care industry have recently expressed a great deal f interest in electrnic health recrds (EHRs). Hwever, the cncept f EHRs is nt a new idea. In the early 1990s there was an initiative fr use f Cmputerized Patient Recrds (CPRs), which have evlved int EHRs. Fr many reasns, implementatin f such systems was nt widespread in the 1990s. The reasns included: a lack f technlgical standards; difficulty in using the systems; and system cst. There is significant evidence that implementatin f EHRs acrss the health care system can imprve the prvisin f cst-effective quality care and imprve the health status f the ppulatin. In additin, many f the technlgical impediments are being addressed. As a result, it appears that the health care system nw is pised t bradly implement EHRs ver the next 10 years. This white paper reviews the current status f EHRs. It is intended t prvide backgrund fr thse explring the implementatin f EHRs in a variety f small t medium sized settings. The white paper includes: a discussin f the csts and benefits f EHRs; hw t finance implementatin f EHRs; and the current state f the EHR industry. What Is an Electrnic Health Recrd? The idea f an EHR has been arund fr many years. It has been referred t as a Cmputerized Patient Recrd (CPR), an Electrnic Medical Recrd (EMR), and mst currently as an EHR. Over time the cncept has evlved, and an EHR is viewed as a brad recrd f a patient s health histry, status and treatment, wned r at least cntrlled in part by the patient, and used by the patient s health care prviders with the permissin f the patient. The visin fr EHRs is sweeping: EHRs will prvide a cmprehensive view f all patient infrmatin. When a patient sees a new physician r ther health care prvider, the patient will nt have t attempt t remember his r her medical histry, including all current and past cnditins, treatments, and medicatins. The EHR shuld represent a cmplete view f a patient s medical histry. Fr example, patients arriving at the emergency department will nt have t try t remember current medicatins and allergies: the EHR shuld have a histry f medicatins and all allergies available at the pint f care and easily accessible in emergent situatins. All f this infrmatin will be available in the EHR electrnically fr payment, treatment, and health care peratins and, fr ther purpses, with the authrizatin f the patient. It will even be pssible fr a patient t carry his r her cmplete medical recrd, including labratry results, x-rays, CT scans, and ther relevant infrmatin, n a memry stick n his r her key chain. This permits the EHR t be prtable and with the patient at the pint f care Illinis State Medical Sciety Page 1

4 Quality f care will be imprved. Physicians will mre easily be able t review the cmplete medical recrd. Each patient s medical infrmatin will autmatically be incrprated int a crdinated frmat by the EHR t make it easier t find and use relevant infrmatin and identify missing needed infrmatin, e.g., screening tests and immunizatins. An apprpriately cnfigured EHR will prvide alerts and ntices t help health care prviders incrprate best practices int patient treatments. The practice f medicine becmes mre and mre cmplex as ur knwledge abut apprpriate treatments cntinues t expand. Best practices are defined and refined fr a wide variety f cnditins. 1 There are ver 2,000 practice guidelines that have been develped by reputable medical rganizatins. 2 These practice guidelines, based n evidence-based medicine, ften are very cmplex, with what is best fr a patient with a particular cnditin depending n a variety f factrs, including the patient s histry, the patient s family s histry, ther cnditins f the patient and patient medicatins, and the availability f different mdes f treatment in a cmmunity. N physician is able t keep up with all the latest practices and apply them t the particular cnditins f each f his r her patients. Sweeping Visin fr EHRs EHRs will prvide a cmprehensive view f all patient infrmatin. Quality f care will be imprved. Physicians will mre easily be able t review the cmplete medical recrd. An apprpriately cnfigured EHR will prvide alerts and ntices t help health care prviders incrprate best practices int patient treatments. Medical errrs can be reduced. Treatment csts will be reduced. Administrative csts will be reduced. EHRs will have the ability t search all infrmatin in the patient s recrd, including the patient s medical histry and all past and current test results, and based n the latest medical practices, alert the health care prvider f additinal factrs they shuld cnsider when making treatment decisins. Alerts may range frm fairly simple ntices regarding immunizatins r recmmended screening tests t mre cmplex issues. Fr example, based n the patient s histry (r family histry), an EHR might identify the need fr additinal tests prir t making a diagnsis r treatment recmmendatin. T truly imprve patient health, these alerts r rules need t be based n best practices develped by medical specialty scieties and must be fcused n the prvisin f quality care, nt cst cntainment. If cnfigured crrectly, these alerts and rules will nt be hard and fast, and physicians and ther health care prviders will have the ability t verride them, if that is apprpriate. Public health will be imprved. Given that a best practice exists fr a particular treatment, every EHR shuld incrprate the same alerts and rules. Tward that end, EHRs shuld nt incrprate different best practices: all shuld be based n the currently accepted evidence-based medicine literature. Given that best practices are refined almst daily, sme mechanism will need t be develped t ensure EHRs are kept current and up t date with the latest treatment prtcls. Develpment f best practices will be enhanced. EHRs will eventually amass a huge vlume f infrmatin. Harvesting infrmatin frm EHRs, with apprpriate privacy prtectins, will allw the cllectin f a wealth f infrmatin related t particular diagnses and disease prcesses. This infrmatin can be used t track patients ver lnger perids f time and t develp the next 1 See Agency fr Healthcare Research and Quality (AHRQ) at 2 Ibid Illinis State Medical Sciety Page 2

5 generatin f evidence-based best practice prtcls. This can be accmplished much mre quickly and less expensively than is pssible using paper recrds spread amng a variety f prviders. Medical errrs can be reduced. EHR alerts can help t identify prblems befre they ccur. In additin, EHRs may be linked with cmputerized patient rder entry (CPOE) systems. Such systems reduce the need fr written rders which are subject t transcriptin errrs. CPOE systems als can be used at the patient s bedside t verify that the apprpriate test is being perfrmed r medicatin prvided, bth increasing the efficiency f the system and reducing adverse utcmes. 3 Treatment csts will be reduced. When accurate patient recrds are readily available, baseline infrmatin is available. This can eliminate the need fr cstly duplicative tests and help health care prviders make infrmed decisins regarding a patient s treatment. Amng ther things, knwing a patient s mediatins can prevent adverse drug interactins. In additin, having baseline infrmatin, e.g., an EKG, can help identify r rule ut particular diagnses. Medical liability csts als may be reduced with better dcumentatin. In fact, sme medical liability insurance cmpanies nw ffer discunts t health care prviders with an EHR. Administrative csts will be reduced. This will ccur in a number f ways. When the medical encunter is in electrnic frm, it shuld be pssible t autmatically pull the clinical infrmatin needed t submit a claim. Specifically, the claim must be supprted by the medical recrd, including bth the type and level f services billed and the diagnses. Cmbining an EHR with a practice management system shuld create a cmplete claim that is ready fr submissin at the cnclusin f each encunter r prcedure. When a payr needs additinal infrmatin t adjudicate a claim, it requests clinical infrmatin. This infrmatin is cntained in the EHR. It shuld be pssible t efficiently pull the infrmatin frm the EHR and submit it t the payr as an electrnic claims attachment. (The Claims Attachment is ne f the Administrative Simplificatin s Transactin and Cde Set standards currently under develpment by the Centers fr Medicare and Medicaid Services f the Department f Health and Human Services.) This shuld help t ensure the apprpriate infrmatin is prvided efficiently and expedite the claims adjudicatin prcess and medical necessity determinatins. Orders fr tests, treatments, and prescriptins can be autmatically and accurately frwarded t the apprpriate prvider reducing the need fr prviders t prduce paper rders. In additin, a prvider receiving an electrnic rder shuld be able t autmatically read the rder int the EHR, alng with relevant medical recrds infrmatin, speeding the dcumentatin prcess and reducing rdering errrs. Public health will be imprved. Autmatic reprting and cmpilatin f reprtable and suspicius diseases will autmatically and immediately be reprted t public health authrities t alert fficials f a disease utbreak r a ptential biterrrism attack. 3 See Institute f Medicine at and AHRQ s.pdf Illinis State Medical Sciety Page 3

6 Barriers t Widespread Adptin f EHRs Lack f standards Health care prviders have fund purchasing and implementing EHRs cstly Health care prviders have been able t custmize EHRs nly at a significant cst. Heath care prviders ften have nt trusted the reliability, privacy, and security f EHRs. Of curse, all f this must be accmplished in a secure envirnment that ensures the privacy f patient recrds. There have been many barriers t the widespread adptin f EHRs. These include: The lack f standardizatin has made it difficult and cstly fr different EHR systems t cmmunicate with ne anther, and much f the benefit frm EHR implementatin is the ability t electrnically gather the patient s cmplete recrd. The standards invlve the manner in which patient infrmatin is stred, the terminlgy used t stre the infrmatin, and the prcedures fr exchanging the infrmatin amng the varius systems. Health care prviders have fund purchasing and implementing EHRs cstly bth in mnetarily and time terms. The return realized by health care prviders has nt ften been apparent. This remains a cncern. Health care prviders have been able t custmize EHRs nly at a significant cst. Even with custmizatin, health care prviders ften are tld that they have t change the manner in which they practice medicine. Patient exams and prcedures must be mre structured as health care prviders input data int the EHR in the required mandated rder, and jumping frm screen t screen t enter infrmatin n the fly as ften is dne in a paper medical recrd can be difficult. In additin, sme EHRs tell physicians hw t practice medicine, and ften in a manner that is nt cnsistent with what the physicians believe is best practice. Heath care prviders ften have nt trusted the reliability, privacy, and security f EHRs. They d nt trust electrnic recrds and are cncerned that recrds may be lst r inapprpriately altered withut their knwledge. 4 Of curse, mst health care prviders als recgnize that there are many prblems with paper recrds; hwever, fr mst health care prviders the csts assciated with paper recrds have nt been high enugh t justify the expense f implementing an EHR. Financing Electrnic Health Recrds Csts and Benefits One f the biggest issues surrunding EHRs is the cst: wh will benefit and wh will pay. Frm a prvider perspective, the csts can be significant and the benefits t the prvider may r may nt ffset thse csts. In a small practice, the individual prvider r small grup f prviders usually need t d the fllwing: investigate varius EHRs, determine which, if any, make sense fr the practice (including 4 An article in the Califrnia HealthCare Fundatin s June 9, 2004 ihealthbeat fcused n dctrs cncerns ver the British Natinal Health Service s implementatin f a natinal patient recrd system. Accrding t the article, Sme British dctrs are ppsing a plan t create a database f patient recrds fr the Natinal Health Service unless patients first cnsent. Even if patients pt ut, their data will still be in the database in de-identified frm, available nly in emergencies Illinis State Medical Sciety Page 4

7 addressing such issues as interperability), cme up with the capital t purchase the EHR system and all necessary hardware, interface the EHR with the practice s ffice management sftware, take time t custmize the EHR s it wrks fr the practice, train all wrkfrce members, and cnvert at least sme f its paper recrds t the EHR. This is a daunting task fr practices that are verwhelmed with administrative hassle and facing the cnstant pressure f lwer payments frm the gvernment and ther third party payrs. Mst practices have lack the technical ability, financial resurces, and time t implement an EHR. Frm a prvider perspective, the csts can be significant and the benefits t the prvider may r may nt ffset thse csts. Custmizing the EHR can be a significant issue, and custmizatin may be limited by the EHR sftware and the resurces available t the practice. T the extent the EHR is rganized differently frm the manner prviders are used t/trained t treat patients, e.g., the screens d nt flw in the same rder as the prviders are used t treating patients, prviders may have t reengineer treatment prcesses. While nt necessarily a bad thing, such reengineering will be met with resistance, unless the benefits are clear. Of curse, there als are benefits t practices. The level f these benefits depends n many factrs, including the type f practice and the practice envirnment. Fr example: A high vlume primary care practice may be able t cut dwn administrative verhead by autmatically generating bills. On the ther hand, many primary care practices d nt submit many claims. Rather, they use a superbill and simply check ff the services prvided and any diagnses. Payment is due at the time f service (and calculated by a quick glance at the superbill). It is up t the patient t bill insurance, which ften des nt cver such primary care services. In a specialty practice, the EHR may als reduce administrative hassle. In this case, hwever, the administrative hassle may relate t gaining apprval fr payment fr necessary tests and prcedures. It may be easier and mre efficient fr a practice t extract the relevant infrmatin frm a patient s recrd and transmit it t a payr fr prir apprval r t substantiate the need fr the services (i.e., t send an electrnic claims attachment). On the ther hand, the vlume f requests frm payrs may be relatively small frm many specialty practices that tend t prvide services t a fairly small number f patients when cmpared t a primary care practice. All practices will be able t refer t an integrated EHR (at least in thery). This will enable new prviders t simply verify patient histry and current medicatins (as ppsed t having t recrd all f this infrmatin) and t review all recent tests and prcedures. This may enable prviders t speed up visits r t spend mre time listening t patients and less time writing the medical recrd. In a hspital the csts and benefits may differ. A hspital is a mre cmplex rganizatin which treats patients ver a prlnged perid f time. Accurate and efficient rder entry fr tests, prcedures, and drugs, better scheduling, and timely availability f test results and a reductin in lst test results all increase quality f patient care and reduce hspital csts. In the emergency department, having baseline infrmatin n patients can speed the treatment prcess and ften rule ut r speed up the determinatin f diagnses. Much f this cst reductin ges directly t the hspital s bttm line: many hspitals are paid a per-case rate fr many patients. The mre efficient Illinis State Medical Sciety Page 5

8 the prvisin f care, the mre likely the hspital is t cver its csts. This assumes, f curse, that the hspital has the necessary capital t make the investment in the first place. 5 Frm a payr perspective, including gvernment and business, which ultimately pays fr mst f the health care prvided in this cuntry, EHRs may be very beneficial. Frm a patient perspective, EHRs may prvide a significant benefit. Frm a payr perspective, including gvernment and business, EHRs may be very beneficial. Payrs will be able t get mre infrmatin electrnically. This shuld enable them t mre efficiently adjudicate claims (including claims attachments) and review quality f care, including HEDIS 6 measures. These administrative efficiencies shuld reduce health plan csts. and ther EHRs shuld reduce the need fr repetitive tests, reduce the ccurrence f lst r delayed test results, speed up the diagnsis f patients, and help t guide prviders t give apprpriate care t patients. In additin, EHR alerts and ntificatins shuld help t imprve patient safety, e.g., by adequately taking accunt f allergies, family histry, current medicatins, and current diagnses. Better infrmatin shuld result in better care and helping reduce the csts f health care resulting in lwer premiums fr purchasers and getting patients back t wrk mre quickly. 7 Frm a patient perspective, EHRs may prvide a significant benefit. Physicians and ther health care prviders will have a mre cmplete picture f each patient, especially ver time as each patient s EHR medical histry expands. Mst imprtantly, a patient will nt have t recnstruct his r her medical histry each time he r she sees a new prvider. The prviders culd simply cnfirm the infrmatin in the EHR. This includes current medicatins and allergies, which can be cnfusing fr many patients, particularly thse with multiple cnditins. Such infrmatin may imprve patient safety, e.g., by reducing the number f adverse drug interactins. In additin, having ready access t all test results and being able t cmpare test results ver time is a valuable surce f infrmatin that will enable prviders t better diagnse and treat patients in a timely manner withut the need fr repetitive tests. As the EHR becmes mre cmplete, prviders, with the assistance f EHR alerts and ntificatins, will be better able t determine the preventive and rutine tests, immunizatins, and prcedures needed by patients. Fr instance, it will n lnger be a manual prcess t determine the date f the last tetanus sht r mammgram r if there is a family histry f cln cancer leading t a 5 One Chicag-area hspital recently cmpleted implementatin f a $40 millin-plus EHR. It estimates that it will save $10 millin annually. It states: The new system is substantially enhancing patient care. The turnarund time fr btaining test results has fallen significantly, with mammgrams nw taking a day cmpared t up t three weeks, and cardigraphics reprts drpping frm as lng as 10 days t ne day. Entire categries f medicatin errrs and ptential errrs have been eliminated, including transcriptin errrs, errrs due t misunderstd abbreviatins and mix-ups due t lk-alike drug names. In additin, delayed administratin f patient medicatins has decreased 70 percent while mitted administratin f medicatins has drpped 20 percent acrss the rganizatin due t the electrnic medicatin administratin recrds and system tls that alert nurses f new patient rders and f verdue medicatins. See 6 See 7 Keep in mind that emplyers pay premiums fr many emplyees. Accrdingly, business has an interest in getting emplyees back t wrk as sn as pssible. In additin, emplyers are the ultimate payrs in many instances. They either buy insurance and pay fr premiums r they have ERISA health plans and pay the claims directly, usually using the services f third party administratrs (TPAs) Illinis State Medical Sciety Page 6

9 recmmendatin that the patient get a clnscpy prir t age 50. This kind f infrmatin has the ability t greatly increase the health status f the ppulatin. Keep in mind that it is nt necessary t start with a cmprehensive EHR system. Significant benefits can be gained frm implementing parts f the EHR. Fr example, cmputerized patient rder entry (CPOE) in a hspital can significantly impact medicatin errrs, increasing patient safety and reducing medicatin errrs. eprescribing can have a similar impact in the practice envirnment. It is imprtant t ensure that whatever EHR cmpnents are implemented serve as a basis fr mving frward and will nt have t be replaced with incmpatible systems when a mre cmplete EHR is implemented. Financing Demnstratins There are a few demnstratin prjects where payrs are helping t finance implementatin f EHRs. Sme payrs have recgnized that mving prviders tward EHRs can imprve patient care and business prcesses. Fr example, WellPint annunced an initiative earlier this year t prvide $40 millin in infrmatin technlgy t dctrs. 8 The initiative will help physicians imprve patient care, achieve greater efficiency and realize cst savings fr America's health care system. This initiative prvides almst 19,000 cntracting netwrk physicians with new technlgies designed t enhance the quality f patient care, reduce administrative csts and imprve physician cmmunicatins with patients and pharmacists. WellPint is prviding selected physicians with a prescriptin imprvement package r a paperwrk reductin package. While nt a cmplete EHR, WellPint has determined that these initial steps will help reduce its csts presumably the benefits utweigh the csts and will be accepted by many physicians. Sme emplyers the ultimate payrs fr mst private health insurance in this cuntry als are interested in prmting the use f EHRs. Fr example, Bridges t Excellence (BTE) is a nt-frprfit entity frmed by General Electric, Prctr and Gamble, Frd Mtr, Verizn, UPS, and ther emplyers t create significant advances in the quality f health care by develping reimbursement mdels that encurage the recgnitin f health care prviders wh demnstrate that they have implemented cmprehensive slutins in the management f patients and deliver safe, timely, effective, efficient, equitable and patient-centered care which is based n adherence t quality guidelines and utcmes achievement. 9 One cmpnent f BTE is the Physician Office Link prgram. Accrding t BTE, physicians wh use infrmatin technlgy in their ffices cnsistently tell us hw much easier it is t deliver the highest quality, mst efficient care. Thrugh Physician Office Link, Bridges t Excellence wants t help dctrs invest in their practices by sharing the savings that cme frm technlgy upgrades that supprt better care. Physicians can receive an annual bnus f up t $50 per patient if they demnstrate that they have implemented certain electrnic systems fr managing care in their practice. BTE estimates the savings frm these systems are abut 4% t 5% f the ttal cst f care and that the imprvement in the quality f care will be even mre significant. The federal gvernment als is pursuing a number f initiatives. The CMS effrts in this area are discussed belw (see page 10). 8 See 9 See Illinis State Medical Sciety Page 7

10 Current Interest in Electrnic Health Recrds Presidential Interest In his 2004 State f the Unin, President Bush stated: By cmputerizing health recrds, we can avid dangerus medical mistakes, reduce csts, and imprve care. On April 26, 2004, the White Huse utlined its plans. 10 Specifically, President Bush utlined a plan t ensure that mst Americans have electrnic health recrds within the next 10 years and established a Health Infrmatin Technlgy Plan t address lngstanding prblems f preventable errrs, uneven quality, and rising csts in the Natin s health care system. By cmputerizing health recrds, we can avid dangerus medical mistakes, reduce csts, and imprve care. President Bush 2004 State f the Unin Accrding t the White Huse Executive Order, the adptin f EHRs will address a number f challenges t the health care system, including mving innvatin and discveries frm the labratry bench t the bedside, reducing preventable errrs, uneven health care quality, and pr cmmunicatin amng dctrs, hspitals, and many ther health care prviders invlved in the care f any ne persn, and using technlgy in health care in a manner similar t ther American industries fr the benefit f patients. The President s gal is assuring that mst Americans have electrnic health recrds within the next 10 years. This means that cmplete health care infrmatin is available fr mst Americans at the time and place f care, n matter where it riginates and that electrnic health recrds will be designed t share infrmatin privately and securely amng and between health care prviders when authrized by the patient. T achieve his gal, the President tk a number f steps t urge crdinated public and private sectr effrts that will accelerate brader adptin f health infrmatin technlgy : adpting unifrm health infrmatin standards, increased funding fr health care infrmatin technlgy demnstratin prjects (t $100 millin), using the Federal gvernment (as the largest purchaser f health care) t fster the adptin f health infrmatin technlgy, and creating a new, sub-cabinet psitin f Natinal Health Infrmatin Technlgy (HIT) Crdinatr. The President issued an Executive Order n April 27, 2004, frmally directing the Secretary f Health and Human Services t establish within the Office f the Secretary the psitin f Natinal Health Infrmatin Technlgy Crdinatr. 11 On May 6, 2004, the Secretary f HHS, Secretary Thmpsn saying that health infrmatin technlgy has the ptential t greatly imprve health care even as it yields huge savings, named David J. Brailer, M.D., Ph.D., 12 t serve as Natinal HIT Crdinatr. 13 As stated in the press release: 10 See and Remarks by the President in a Cnversatin n the Benefits f Health Care Infrmatin Technlgy Department f Veterans Affairs Medical Center Baltimre, Maryland ( 11 See 12 Accrding t the press release, Dr. Brailer was a senir fellw at Health Technlgy Center in San Francisc, where he has advised varius reginal and natinal effrts n IT and health infrmatin exchange. He previusly served fr 10 years as chairman and CEO f CareScience Inc., ne f the natin's leading health care management cmpanies. While at CareScience, Dr. Brailer designed and versaw the develpment f the health infrmatin Illinis State Medical Sciety Page 8

11 Dr. Brailer, a natinal leader in harnessing health IT t prmte safe, quality and efficient health care, will head a new ffice at HHS, created by a directive frm President Bush. The ffice will supprt effrts acrss gvernment and in the private sectr t develp the standards and infrastructure t allw mre effective use f infrmatin technlgy t prmte higher quality care and reduce health care csts. One f the ffice s first tasks will be t study ptins t create incentives in Medicare and ther HHS prgrams t encurage the private sectr t adpt interperable electrnic health recrds. It is estimated that a natinal health infrmatin netwrk can save abut $140 billin per year thrugh imprved care and reduced duplicatin f medical tests. President s Infrmatin Technlgy Advisry Cmmittee It is estimated that a natinal health infrmatin netwrk can save abut $140 billin per year thrugh imprved care and reduced duplicatin f medical tests. In June 2004 the President s Infrmatin Technlgy Advisry Cmmittee (PITAC) released a reprt entitled Revlutinizing Health Care Thrugh Infrmatin Technlgy. 14 The reprt fcuses n the need fr an EHR fr all Americans that prvides every patient and his r her caregivers the necessary infrmatin required fr ptimal care while reducing csts and administrative verhead ; cmputerassisted clinical decisin supprt t increase the ability f health care prviders t take advantage f statef-the-art medical knwledge ; cmputerized prvider rder entry; and secure, private, interperable, electrnic health infrmatin exchange, including bth highly specific standards fr capturing new data and tls fr capturing nn-standards-cmpliant electrnic infrmatin frm legacy systems. PITAC presents 12 recmmendatins t address the technical issues in sme detail : Ecnmic incentives are needed t prmte investment in health infrmatin technlgy. PITAC recmmends increased federal supprt, particularly where benefits are nt directly returned t thse wh must invest in IT slutins. As discussed abve, this is a real cncern fr many health care prviders (see Financing Electrnic Health Recrds Csts and Benefits, page 4). Health infrmatin exchange standards are essential, particularly when patients receive care frm different health care prviders. In the absence f standards, EHRs cannt exchange infrmatin with ne anther. This is discussed further belw (see Natinal Health Infrmatin, page 14). Current laws shuld be changed t facilitate the sharing f EHR technlgies amng health care prviders. Currently such systems ften are nt shared due t current interpretatins f anti-fraud and anti-kickback laws. This is related t financing EHRs. Federal health IT investments shuld be leveraged thrugh the develpment f a single set f standards fr EHR systems that can be implemented acrss all federally implemented EHRs and shared with the private sectr. In effect, if the federal requirement sets vluntary standards fr EHR vendrs wanting t d business with the gvernment, vendrs will have n chice but t cmply with the standards and they will becme widespread in the private sectr. Keep in mind that almst all health care prviders treat federally funded patients thrugh the Medicare and Medicaid prgrams. exchange technlgy implemented in Santa Barbara Cunty, Calif. Dr. Brailer hlds dctral degrees in bth medicine and ecnmics. 13 See 14 See Illinis State Medical Sciety Page 9

12 At sme pint these prgrams might require r financially encurage the use f EHRs meeting the federal standards. This culd ccur in the cntext f nging quality imprvement prgrams and data reprting. A standardized clinical vcabulary needs t be develped. This is discussed belw (see CHI Initiative, page 16). A single set f data standards fr the mst cmmn frms f clinical infrmatin needs t be develped. Specifically, t be truly interperable EHRs need t be based n a cmmn infrmatin architecture with highly standardized data definitins [t] enable cmputer-aided decisin supprt, autmated medical-errr detectin, and rapid patient-ppulatin analysis. An efficient human-machine interface needs t be develped. One f the key issues with implementing EHRs is that EHRs ften require physicians and ther health care prviders t make significant changes in the way they apprach patients and analyze prblems. They may be frced int entering data in a certain (new) rder and may nt be able t address issues, particularly ancillary issues, in the manner in which they are accustmed. While changing prcesses may imprve patient care, it requires an extensive educatinal/retraining prgram and a significant cultural change. Crdinatin f Natinal Health Infrmatin Newtrk (NHIN) develpment acrss the federal gvernment is necessary. The gvernment must ensure that all departments and agencies are mving in the same directin s that EHRs will be interperable. Patients need t be identified unambiguusly. It is imprtant t ensure that EHRs accurately exchange infrmatin n specific patients, and unique patient identifiers are needed fr this purpse. This is a cntrversial area that must be addressed. Encrypted Internet cmmunicatins shuld be implemented. This will ensure patient infrmatin is cmmunicated securely and in a cnsistent fashin. There must by a trust hierarchy and strng authenticatin. Use f a public key system will ensure authenticatin and nn-repudiatin. Access requests must be traced. Such audit trails are necessary t ensure the security f EHRs and the cnfidentiality f EHR-based patient infrmatin. CMS Interest The Centers fr Medicare and Medicaid Services have a number f initiatives fcused n prmting the use f EHRs: The purpse f the physician fcused quality initiative 15 is t: (1) assess the quality f care fr key illnesses and clinical cnditins that affect many peple with Medicare, (2) supprt clinicians in prviding apprpriate treatment f the cnditins identified, (3) prevent health prblems that are avidable, and (4) investigate the cncept f payment fr perfrmance. It has tw key parts: the Dctr's Office Quality (DOQ) Prject and The Centers fr Medicare and Medicaid Services have a number f initiatives fcused n prmting the use f EHRs. 15 See Illinis State Medical Sciety Page 10

13 the Dctr's Office Quality Infrmatin Technlgy (DOQ-IT) Prject. 16 The DOQ-IT Prject prmtes the adptin f electrnic health recrd (EHR) systems and infrmatin technlgy (IT) in small-t-medium sized physician ffices with a visin f enhancing access t patient infrmatin, decisin supprt, and reference data, as well as imprving patient-clinician cmmunicatins. Quality measures develped in the Dctrs Office Quality (DOQ) prject will be reprted by participating practices in DOQ-IT via standardized EHR platfrm t the QIO Clinical Warehuse. The QIO Clinical Warehuse will receive, review and validate electrnically transmitted infrmatin regarding practitiner perfrmance and identify pprtunities fr imprvement. CMS is implementing the Chrnic Care Imprvement Prgram (CCIP). 17 The CCIP is mandated by the Medicare Mdernizatin Act passed in CMS is selecting rganizatins that will ffer selfcare guidance and supprt t chrnically ill beneficiaries. CMS expects rganizatins t rely n innvative uses f IT equipment, including electrnic mnitring, recrds, prescribing and alerts, t help them carry ut their prgrams. 18 As stated in the Federal Register Ntice annuncing the CCIP 19 : Many chrnic care imprvement prgrams have develped integrative infrmatin infrastructures, new applicatins f infrmatin and cmmunicatin technlgies, expert clinical systems that incrprate evidence-based guidelines fr multiple cnditins, and predictive mdeling capabilities t supprt their peratins. Others have been wrking t develp interperative electrnic health recrds and ther health infrmatin technlgy used at the pint f care t imprve quality and safety. We [CMS] are interested in receiving applicatins frm rganizatins that have prven t be successful in applying tls t meet the individual needs f participants and their prviders, reduce fragmentatin in patient infrmatin, and facilitate better cmmunicatins between chrnically ill beneficiaries and their prviders at the pint f care. In May 2004 CMS awarded $100,000 t the American Academy f Family Physicians (AAFP) t supprt prvisin f cmprehensive, standardized electrnic health recrd (EHR) sftware t the health care cmmunity. 20 Veteran s Administratin On July 21, 2004, CMS and the Department f Veterans Affairs (VA) annunced they are planning t make available t physicians, hspitals, and ther health care prviders the VA s electrnic health recrd prgram. The intent is t make it easier fr the private-sectr health care industry t make use f this electrnic system fr health care recrds. 21 The system is called VistA-Office Electrnic Health Recrd. Accrding t CMS and the VA: 16 See 17 See 18 See 19 See 20 See CMS and the VA annunced they are planning t make available t physicians, hspitals, and ther health care prviders the VA s electrnic health recrd prgram Illinis State Medical Sciety Page 11

14 VistA was chsen because it is in the public dmain and is a sftware package that is flexible and rbust. The system is used in 1,300 diverse sites f care and services 5 millin veterans annually. Mst imprtantly, hwever, ver the 20 years that VistA has been in use, VHA develped the Cmputerized Patient Recrd System (CPRS), clinician interface, int a well-defined and dcumented clinical data repsitry with a pwerful, physician-riented tlset. 22 Due t additinal needs in private practice, VistA will be enhanced t prvide physician-ffice patientregistratin; interface t existing billing systems; and reprting f quality measures. 23 It is expected that private-sectr health care prviders will be able t btain VistA at nminal cst during the later half f The lw cst is being set t encurage physicians t implement a high quality EHR prgram. Accrding t the VA: VistA ffers health care prviders a cmplete electrnic recrd cvering all aspects f patient care, including reminders fr preventive health care, electrnic entry f pharmaceutical rders, display f labratry results, cnsultatin requests, x-rays and pathlgy slides. A Usability Test f VistA is being cnducted by CMS. It is starting in December 2004, and the test is intended t ensure that the VistA prduct wrks apprpriately in the private sectr. Physicians Electrnic Health Recrd Calitin The American Medical Assciatin and 13 ther natinal medical rganizatins frmed the Physicians Electrnic Health Recrd Calitin (PEHRC) in July The gal f the PEHRC is t imprve the quality, safety and efficiency f health care by facilitating adptin f affrdable, standards-based EHR and ther health infrmatin technlgy. The PEHRC, which will assist physicians primarily in small- and medium-sized ambulatry care practices, will educate physicians abut the value and best use f EHR and help fcus the market n high quality and affrdable prducts. In additin t aiding physicians, the PEHRC will als wrk t participate in the develpment f the EHR certificatin prcess. 25 Apparently the PEHRC is planning t release specific EHR recmmendatins by the end f The recmmendatins will reprtedly be an easy t use frmat that will allw physicians t cntrast and cmpare EHRs. The review will The AMA and 13 ther natinal medical rganizatins frmed the Physicians Electrnic Health Recrd Calitin (PEHRC). apparently be specialty specific, s physicians will be able t evaluate EHRs that may be a better fit fr their specific specialty See 22 See 23 Ibid. 24 Other members include American Academy f Family Physicians, American Academy f Neurlgy, American Academy f Ophthalmlgy, American Academy f Pediatrics, American Cllege f Cardilgy, American Cllege f Emergency Physicians, American Cllege f Obstetricians and Gyneclgist, American Cllege f Ostepathic Family Physicians, American Cllege f Physicians, American Cllege f Rheumatlgy, American Ostepathic Assciatin, American Psychiatric Assciatin and the American Urlgic Assciatin. 25 See 26 See Illinis State Medical Sciety Page 12

15 Other Organizatins Many ther rganizatins are turning their attentin t EHRs. A sampling f sme f the key players, nt already referenced abve, is as fllws: The Medical Recrds Institute s (MRI) has taken a lead n EHRs. 27 MRI wrks t prmte and enhance the jurney twards electrnic health recrds, e-health, and mbile health, and related applicatins f infrmatin technlgies (IT). MRI hlds many cnferences and seminars, including its annual Tward an Electrnic Patient Recrd (TEPR) fcused n e-health and clinical IT issues. TEPR prvides practical educatinal prgrams and allws attendees the pprtunity t evaluate system vendrs. Mre than 150 cmpanies had exhibitins at TEPR MRI als has a number f wrkgrups and a series f useful publicatins related t EHRs. The Healthcare Infrmatin and Management Systems Sciety (HIMSS) has an EHR Initiative. 28 The HIMSS EHR Initiative seeks t assume a leadership rle in furthering integratin and interperability f an Electrnic Health Recrd (EHR). HIMSS has develped an extensive list f psitins, white papers, and reprts addressing varius issues related t EHRs. One key resurce is the CPRI Tlkit. 29 The Tlkit utlines general principles and prvides best practice examples f hw healthcare prviders shuld manage the security f their paper and electrnic recrds. The Califrnia Healthcare Fundatin (CHF) has a health infrmatin technlgy initiative. 30 The initiative is aimed at helping t accelerate the adptin and use f new infrmatin technlgies in health care t realize the ptential f the Internet fr imprving clinical and business practices thrugh better cmmunicatin and access t infrmatin. Tward that end CHF is invlved in a number f activities and has drafted a number f reprts. The ehealth Initiative seeks imprvement in the quality, safety, and efficiency f healthcare thrugh infrmatin and infrmatin technlgy. 31 One f its principal fci is Cnnecting Cmmunities fr Better Health (CCBH). CCBH prmtes prgrams cnverting paper-based medical recrds t an electrnic mdel and the use f health infrmatin technlgy t transfer infrmatin acrss institutins. Cnnecting fr Health is addressing barriers t develpment f an intercnnected health infrmatin infrastructure. 32 Cnnecting fr Health is addressing the plicy, technical and legal barriers t establishing an intercnnected health infrmatin infrastructure and t prmte its ptential benefits. Accrediting bdies als are starting t take a lk at EHRs. URAC annunced in May 2004 that it was cnvening a research and fcus grup t explre new quality benchmarks fr health infrmatin technlgy (HIT), including the pssibility f develping standards addressing electrnic health recrds (EHRs) and/r the infrastructure f HIT systems See 28 See 29 See 30 See 31 See 32 See 33 See Illinis State Medical Sciety Page 13

16 Organized medicine is taking an active interest. The American Academy f Family Physicians (AAFP) has established a Center fr Health Infrmatin Technlgy. 34 AAFP realizes health infrmatin technlgy is playing a grwing rle in health care. The Center was established t underscre the need f small and medium-sized medical practices fr lw-cst, standards-based infrmatin systems t replace the cumbersme and inefficient paper recrds currently in use. Cntinuity f Care Recrd: EHRs minimize the health care encunters where practitiners d nt have access t patient histry and recent treatment. Several natinal grups have cme tgether t develp a Cntinuity f Care Recrd (CCR). 35 The grups are: ASTM Internatinal Massachusetts Medical Sciety; American Academy f Family Physicians; and HIMSS. The minimum data set within the CCR is intended t enhance cntinuity f care by prviding the mst relevant patient infrmatin, including diagnses, recent prcedures, allergies, medicatins, recent care prvided, recmmendatins fr future care, and reasns fr a referral r transfer. The gal is t create a CCR that will enable the next prvider t easily access relevant infrmatin at the beginning f a first encunter and easily update and pass n the infrmatin when the patient ges t anther prvider. While this is nt a true EHR system, CCR is aimed at invlving significant numbers f clinicians, enabling them t exchange relevant infrmatin electrnically in a standardized frmat, and helping them learn the value f the electrnic exchange f patient infrmatin. Natinal Health Infrmatin Netwrk Building a Natinal Health Infrmatin Netwrk (NHIN) 36 is key t the success f EHRs. 37 The NHII is the result f many public and private rganizatins acknwledging the cntinuing crisis cnfrnting health care delivery in the United States: Infrmatin is nt interchangeable. Healthcare errrs are nt reprted. There is a lack f standardizatin. Building a NHIN is key t the success f EHRs. The NHIN is t be a netwrk f systems, technlgies, standards, applicatins plicies, and prcedures that will prvide anywhere, anytime electrnic health infrmatin and will supprt all facets f individual health care and prmte public health. NHIN is being crdinated and facilitated by the Assistant Secretary fr Planning and Evaluatin (ASPE) in HHS. There are n laws r regulatins mandating NHIN n the health care industry. Accrding t HHS, the NHIN is: 34 See 35 See 36 The NHIN has been referred t as the Natinal Health Infrmatin Infrastructure (NHII). The use f NHIN appears t be replacing NHII. 37 See Illinis State Medical Sciety Page 14

17 a system that wuld allw a dctr r ther health care prvider t access an always-upt-date electrnic health recrd fr a patient wh has authrized it, regardless f when and where the patient receives care. This wuld nt be a natinal database, but rather a set f standards and secure netwrks that wuld allw a dctr r hspital t immediately gather relevant infrmatin by cmputer netwrk such as test results, x-rays and medical histry as well as clinical guidelines, drug labeling and current research findings t best treat an individual patient. The NHIN will prvide the backbne necessary t supprt the use and expansin f EHRs. Accrding t HHS, the Natinal HIT Crdinatr will face several tasks related t building the NHIN 38 : Privacy and security are key t the success f EHRs. Patients and prviders must be assured that EHRs will be kept private cnfidential. In additin, apprpriate and reasnable security must be implemented in a manner that allws business prcesses, especially the prvisin f health care, t prceed in an efficient and timely fashin. The Natinal HIT Crdinatr will prepare a reprt fr the Secretary n privacy and security issues related t the develpment f a natinal health infrmatin infrastructure and t recmmend methds t assure apprpriate authrizatin, authenticatin and encryptin f data t prtect the privacy and cnfidentiality f persnal health infrmatin. Key Issues Facing Natinal HIT Crdinatr Privacy and security Incentives fr use f health infrmatin technlgy Cmmn medical language Defining the functin f an EHR Use f cmmn HIT standards by federal agencies Develpment f lcal health infrmatin exchanges Funding t highlight hw health infrmatin technlgy can imprve quality f care and patient safety Incentives fr use f health infrmatin technlgy must be develped. Currently mst health care prviders still d nt have enugh incentive t switch frm paper t electrnic health recrds. The Natinal HIT Crdinatr will lk at ptins t create incentives in Medicare and ther HHS prgrams t encurage the adptin f interperable health infrmatin technlgy. In additin, the Office f Persnnel Management will reprt n similar ptins fr encuraging the adptin f such technlgy thrugh the Federal Emplyee Health Benefit Prgram. It is hped that apprpriate incentives can be implemented t make it wrthwhile fr many mre health care prviders t adpt EHRs. A cmmn medical language is needed t ensure interperability f EHRs. Specifically, EHRs need t able t talk t each ther using a cmmn language. Right nw there is n cmmn language used by all EHR vendrs. HHS is mving frward in this imprtant area with the Cnslidated Health Infrmatics (CHI) Initiative. The CHI Initiative is discussed further belw. It is necessary t define the functin f an EHR. Health Level 7 (HL7) has established a draft standard defining the set f functins needed fr an electrnic medical recrd. This defines standards fr transmitting cmplete EHRs amng different EHR systems develped by varius vendrs. 39 Use f cmmn HIT standards by federal agencies is needed. As mentined abve, the federal gvernment is the largest purchaser f health care services. HHS (Medicare and Medicaid) is wrking with the Departments f Defense (CHAMPUS) and Veterans Affairs (CHAMPVA) t adpt health infrmatin standards fr use by all federal health agencies. The CHI Initiative is a 38 See 39 Mre infrmatin n HL7 can be fund at Illinis State Medical Sciety Page 15

18 majr cmpnent f this effrt. It is likely that the requirement t meet certain standards in rder t d business with the federal gvernment will drive the entire market t meet thse vluntary standards. After all, few health care prviders d nt d business with the federal gvernment. Lcal health infrmatin exchange must be develped, as health care is lcal. Tward that end the President s prpsed 2005 budget includes $50 millin t supprt state and lcal effrts t develp systems fr exchanging f health infrmatin in their cmmunities. These lcal demnstratin prjects are a key part f a natinal health infrmatin infrastructure. Prjects will be funded t highlight hw health infrmatin technlgy can imprve quality f care and patient safety. HHS' Agency fr Healthcare Research and Quality (AHRQ) has $50 millin t fund such prjects this year and the President has requested an additinal $50 millin fr FY In fact, AHRQ has recently annunced the awarding f a variety grants and cntracts related t health infrmatin technlgy ttalling $139 millin. 40 HHS als has a significant number f ther effrts aimed at harnessing health infrmatin technlgy. These initiatives may all link t EHRs, including bar cdes n drugs, a new BiSense initiative t detect utbreaks and biterrrism, eprescribing as required by the Medicare Mdernizatin Act, adpting natinal standards fr public health infrmatin, telemedicine initiatives in remte and rural cmmunities, and an Indian Health Service EHR. Reginal Health Infrmatin Organizatins Health care is lcal. It is prvided in lcal cmmunities and, fr the mst part, peple receive the vast majrity f their health care is a single gegraphic area. Accrdingly, it is expected that lcal implementatins f the NHIN will ccur in varius cmmunities in ways that are unique t its medical trading area. It is a gal f the NHIN that natinal standards be adpted in the develpment f lcal netwrks. By ding such, the lcal initiatives may evlve int the NHIN ver a perid f years. Tward that end, it is expected that Reginal Health Infrmatin Organizatins (RHIOs) will frm t implement the NHII\N in specific lcal gegraphic areas. As health care is predminantly lcal, the NHIN will really be made up f a number f number f initiatives brught abut by the RHIOs. RHIOs als give the lcal cmmunity sme say and cntrl in the deplyment f technlgy t meet its lcal needs. As stated in DHHS Framewrk fr Strategic Actin, RHIOs are critical t health infrmatin exchange that reflects the health care pririties f a lcal area as well as the legitimacy and trustwrthiness f this activity t clinicians and cnsumers. 41 CHI Initiative As stated abve, a cmmn medical language is needed t ensure interperability f EHRs. Specifically, EHRs need t able t talk t each ther using a cmmn language. Right nw there is n cmmn language used by all EHR vendrs. The federal gvernment is mving frward with the Cnslidated Health Infrmatics (CHI) Initiative. 42 The purpse f the CHI Initiative is t identify apprpriate, existing data standards and t endrse them fr use acrss the federal health care sectr. These standards will be used by all federal agencies as they update, develp and implement new health infrmatin technlgy systems. 40 See 41 See Framewrk fr Strategic Actin, page 17 ( 42 See Illinis State Medical Sciety Page 16

19 The CHI Initiative was established t ensure that federal agencies with health-related missins can share their health infrmatin. This health data sharing will enable them t make significant strides twards imprving patient safety, reducing errr rates, lwering administrative csts, and strengthening natinal public health and disaster preparedness. Tward that end, the agencies were charged with adpting cmmn clinical vcabularies and standard methds fr transmitting that infrmatin. [I]nterperability thrugh standards will enable us t share a cmmn electrnic patient medical recrd and in turn greatly imprve the quality f US healthcare. 43 Abut 20 federal department/agencies are invlved in the CHI Initiative. This includes HHS, the VA, the Department f Defense, the Scial Security Administratin, and the General Service Administratin. On March 21, 2003, the first set f standards was annunced. 44 As stated in the press release, HHS adpted the fllwing 5 standards: Health Level 7 (HL7) messaging standards t ensure that each federal agency can share infrmatin that will imprve crdinated care fr patients such as entries f rders, scheduling appintments and tests and better crdinatin f the admittance, discharge and transfer f patients. Certain Natinal Cuncil n Prescriptin Drug Prgrams (NCDCP) standards fr rdering drugs frm retail pharmacies t standardize infrmatin between health care prviders and the pharmacies (already adpted under the Health Insurance Prtability and Accuntability Act (HIPAA)). The Institute f Electrical and Electrnics Engineers 1073 (IEEE1073) series f standards that allw fr health care prviders t plug medical devices int infrmatin and cmputer systems that allw health care prviders t mnitr infrmatin frm an ICU r thrugh telehealth services n Indian reservatins, and in ther circumstances. Digital Imaging Cmmunicatins in Medicine (DICOM) standards that enable images and assciated diagnstic infrmatin t be retrieved and transferred frm varius manufacturers devices as well as medical staff wrkstatins. CHI Initiative Standards Health Level 7 (HL7) messaging standards HL7 vcabulary standards fr demgraphic infrmatin HL7 vcabulary standards fr units f measure HL7 vcabulary standards fr immunizatins HL7 vcabulary standards fr clinical encunters HL7 Clinical Dcument Architecture standard fr text based reprts Natinal Cuncil n Prescriptin Drug Prgrams (NCDCP) standards fr rdering drugs frm retail pharmacies Institute f Electrical and Electrnics Engineers 1073 (IEEE1073) series f standards that allw fr health care prviders t plug medical devices int infrmatin and cmputer systems Digital Imaging Cmmunicatins in Medicine (DICOM) standards Labratry Lgical Observatin Identifier Name Cdes (LOINC) Cllege f American Pathlgists Systematized Nmenclature f Medicine Clinical Terms (SNOMED CT) fr labratry result cntents, SNOMED CT fr nn-labratry interventins and prcedures SNOMED CT fr anatmy SNOMED CT fr diagnsis and prblems SNOMED CT fr nursing Health Insurance Prtability and Accuntability Act (HIPAA) transactins and cde sets Federal terminlgies related t medicatins, including Fd and Drug Administratin s names and cdes fr ingredients, manufactured dsage frms, drug prducts and medicatin packages, the Natinal Library f Medicine s RxNORM fr describing clinical drugs Veterans Administratin s Natinal Drug File Reference Terminlgy (NDF- RT) Human Gene Nmenclature (HUGN) Envirnmental Prtectin Agency s Substance Registry System fr nnmedicinal chemicals 43 See 44 See Illinis State Medical Sciety Page 17

20 Labratry Lgical Observatin Identifier Name Cdes (LOINC) t standardize the electrnic exchange f clinical labratry results. On May 6, 2004, HHS prvided an update n the CHI Initiative. 45 As stated in the press release, the fifteen standards are as fllws: Fifteen new standards were adpted. Health Level 7 (HL7) vcabulary standards fr demgraphic infrmatin, units f measure, immunizatins, and clinical encunters, and HL7 s Clinical Dcument Architecture standard fr text based reprts. (Five standards) The Cllege f American Pathlgists Systematized Nmenclature f Medicine Clinical Terms (SNOMED CT) fr labratry result cntents, nn-labratry interventins and prcedures, anatmy, diagnsis and prblems, and nursing. HHS is making SNOMED-CT available fr use in the United States at n charge t users. (Five standards) Labratry Lgical Observatin Identifier Name Cdes (LOINC) t standardize the electrnic exchange f labratry test rders and drug label sectin headers. (One standard.) The Health Insurance Prtability and Accuntability Act (HIPAA) transactins and cde sets fr electrnic exchange f health related infrmatin t perfrm billing r administrative functins. These are the same standards nw required under HIPAA fr health plans, health care clearinghuses and thse health care prviders wh engage in certain electrnic transactins. (One standard.) A set f federal terminlgies related t medicatins, including the Fd and Drug Administratin's names and cdes fr ingredients, manufactured dsage frms, drug prducts and medicatin packages, the Natinal Library f Medicine s RxNORM fr describing clinical drugs, and the Veterans Administratin's Natinal Drug File Reference Terminlgy (NDF-RT) fr specific drug classificatins. (One standard.) The Human Gene Nmenclature (HUGN) fr exchanging infrmatin regarding the rle f genes in bimedical research in the federal health sectr. (One standard.) The Envirnmental Prtectin Agency s Substance Registry System fr nn-medicinal chemicals f imprtance t health care. (One standard.) Full cpies f the CHI Initiative reprts n adptin f each f these standards can be fund at The adptin f these standards represents a significant step frward. While nt required by law, any vendr and pssibly any health care prvider wanting t d business with the federal gvernment will have t cnsider use f these standards. Given that the federal gvernment is the largest purchaser f health care services in the cuntry, it is likely that many vendrs will vluntarily adpt these standards and many health care prviders will demand EHRs and ther prducts that incrprate these standards. This will prmte interperability between EHR systems. What Shuld Small t Medium Sized Practices Lk fr in an EHR System? There are many EHR systems n the market. They are designed differently, functin differently, and include a variety f features. Fllwing is a discussin f what t cnsider when selecting an EHR. Keep in mind: There is n ideal system. Every system will have sme shrtcmings. 45 See Illinis State Medical Sciety Page 18