e-HIM: From Vision to Reality

by Meryl Bloomrosen, RHIA, MBA

Health IT has been a hot topic in the two years since AHIMA published "A Vision of the e-HIM Future." Members of the original task force take a look back.

This fall marks the second anniversary of the AHIMA report "A Vision of the e-HIM Future." The report, published in September 2003, was the work of the e-HIM^® Task Force-key HIM, IT, industry, academic, and government representatives invited by AHIMA to articulate a vision of future, electronic health information management and explore the possible roles and requirements for HIM professionals. Two of the group's challenges were to:

• Identify the factors influencing healthcare industry trends and developments, including the emergence of the electronic health record (EHR)
• Develop a vision statement describing the EHR, with a description of corresponding HIM roles

Much has happened since. In light of the fast-moving events of the past two years, the Journal asked former task force members to revisit their report and check their eyesight, considering how the vision from 2003 is holding up to the "future," 2005.

Update on the Environment

Asked to create a vision of health information in 2010, the task force did so succinctly. They saw future health information as electronic, patient-centered, comprehensive, longitudinal, accessible, and credible.

Two years later, change on the ground has been minimal. Health information is flowing more freely within organizations and across communities that are embracing EHRs and other health information technology (HIT), but for the most part, patient data is still nonstandard, compartmentalized along the continuum of care, and stored in different formats.

The past two years have seen significant progress in the continued evolution of technology, ongoing regulatory and legislative shifts, increased program safeguard initiatives, and evolving payment systems and related coverage issues. Public health and safety concerns as well as significant healthcare policy and research initiatives are also under way. Communities are sharing information and implementing health information exchange projects. Pay-for-performance initiatives are working their way into mainstream discussions, demonstration projects, and policy efforts.

But the biggest changes are those that have been happening upstream of practice, say former task force members-work focusing on the infrastructure of data sharing. Former task force members highlight three notable developments: consensus that the nation must transition to e-HIM and adopt HIT widely, a strong federal role as facilitator, and initial work on national and regional health information exchange.

E-HIM Is In

Former task force members note that a wide consensus has emerged that the nation must replace its paper-based approach to HIM. The policy agenda for HIT and EHRs in the public and private sectors has developed rapidly. Since 2003, HIT is increasingly at the forefront of public and private sector efforts to improve healthcare safety, quality, and efficiency. Clear and compelling evidence has emerged demonstrating that HIT can play a critical role in addressing current healthcare challenges. At the heart of HIT is the ability to move health information seamlessly and securely.

Awareness of this need outside the industry has grown significantly. The general media has discovered EHRs and personal health records (PHRs). The federal government, Congress, states, and private-sector organizations have initiated diverse activities designed to improve the quality, safety, and efficiency of healthcare through HIT.

(For a list of major milestones, see "An HIT Timeline" later in this article.)

Uncle Sam Front and Center

Perhaps the biggest surprise of the past two years has been the federal government's role in facilitating the introduction and adoption of HIT. In 2003 the task force concluded that the federal government would need to play a greater role in standards setting if significant progress were to be made on a national health information infrastructure. Today, former members say that federal efforts have been more comprehensive and taken place more quickly than the task force originally envisioned.

This includes the president's 2004 state of the union address, the subsequent creation of the Office of the National Coordinator for Health Information Technology (ONC) within HHS, the release of the ONC and HHS strategic framework "The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care," and the number of proposed bills introduced in Congress that address various aspects of HIT.

Eyes on the Prize: Data Sharing

One result of the federal government's new role has been notable and accelerated discussions focused on the national health information network (NHIN) and regional health information exchange. At the time of the e-HIM report, it was relatively easy to keep track of the local, state, and regional networking initiatives. Numerous regional health information organizations (RHIOs) have since emerged, with the goal of facilitating health information exchange. Many of these have received federal funding.

RHIOs will drive the need for data exchange standards, and they will likely fuel HIT adoption. "I believe RHIO activity will convince physicians to implement electronic records in their offices," says former task force member Barbara Siegel, MS, RHIT. "Patients may begin to make provider choice decisions based on whether their physicians are willing to communicate with them via e-mail or whether their records can easily be transported between their winter homes and their summer homes."

Policy changes in the Medicare and Medicaid programs (such as those within the Medicare Modernization Act) are likely to accelerate HIT adoption, also, seeking to address goals around healthcare quality, safety, and efficiency.

Financial incentive programs sponsored by Medicare, purchasers, business coalitions, and health plans are beginning to accelerate the transition to e-HIM. However, little has been achieved to draw physicians to HIT; most remain reluctant to invest because they perceive that provider investment in HIT benefits payers and the government more than it benefits the provider.

Still Ahead: Three Factors Loom Largest for HIM

In 2003 the task force identified seven major factors affecting healthcare: rising costs, an aging and mobile population, a lack of data standards, growth of technology, shrinking HIM work force, the need for consumer education, and changing public imperatives. All seven remain central, but former task force members single out three in the forefront today: work force, technology, and data standards.

Work Force Issues

"Work force concerns are, unfortunately, languishing," says Danita Forgey, MIS, RHIA, CCS, CCS-P. Little progress has been made in the past two years. Funding for the Allied Health Education was defeated in the House of Representatives, and recruitment into baccalaureate degree programs remains a problem for many educational programs.

Siegel notes that Mike Leavitt, now secretary of HHS, as governor of Utah was very interested in training new coders to reduce unemployment and to meet HIM needs in the state. "Let's hope he continues to connect HIM professionals to health information domains, including the EHR," Siegel says.

Work force challenges haven't changed. In order to offer HIM expertise to HIT, the profession must train more HIM professionals in both traditional and emerging practice. Too few HIM professionals report to IT, are CIOs, or work for RHIOs, note former task force members. The need for federal dollars for work force development remains as critical now as in 2003.

Data Standards

The need for standards is receiving greater attention because of the government's efforts to establish an NHIN, note the former members. Regional efforts to develop electronic systems that link multiple regional healthcare providers have resulted in a bigger push for interoperable systems. Similarly, the need for interoperability spurred the National Library of Medicine to offer SNOMED for public use.

Siegel notes that advocacy for implementation of ICD-10 seems to be picking up in the industry press. The profession must "push harder on this," she says.

HL7 and several other organizations have been hard at work to establish standards and definitions. The free availability of SNOMED should aid tremendously in these efforts. Former task force members say they are encouraged by the partnerships formed in the standards-setting arena.

Much critical work remains to be done. Despite SNOMED's availability, for example, many vendors are not using it in the systems that they market to healthcare providers. Problems still exist with achieving seamless interfaces between different vendor systems.

Another challenge to interoperability is that most standards-setting work to date has emphasized the structure of the messages being exchanged rather than data definitions and organization. This has hindered interoperability and has required healthcare organizations to spend more time on the back end, translating data from one system to another.

A technology that has gained considerable ground since the task force met is computerized physician order entry (CPOE). It has been cited frequently as a means to improve patient safety and decrease costs. Much of this was driven by the Institute of Medicine's 2001 report on patient safety and the need for electronic records to facilitate information sharing, "Crossing the Quality Chasm." It has also been driven by organizations such as Leapfrog that have made CPOE a criterion for evaluating the quality of healthcare organizations.

In general, hospitals are investing more in information technology such as CPOE. The need to comply with HIPAA security standards has driven some of this investment. The recognized ability to decrease costs has also been a factor.

Increased consumer awareness is a third factor. Medicare now offers consumers provider-specific information online on outcomes in treatment of congestive heart failure, acute myocardial infarctions, and pneumonia. Healthcare providers are giving new importance to information systems that provide accurate, current performance data. Cynthia Hilterbrand, RHIA, also points to "forward movement of evidence-based medicine and care plans."

Public Awareness and Consumer Education

Public reporting initiatives related to quality and pay for performance have become hot topics, notes Siegel. Hospitals are on the hot seat to perform, Siegel says, because consumers are gaining easy access to hospital performance data on the Web.Employers also use performance data to direct their work forces to high quality providers.

One of the remaining unknowns is the extent to which HIM professionals will be involved in these initiatives. "This is an opportunity for health information managers to demonstrate expertise related to complete and accurate documentation and it's impact on coding and billing, pay-for-performance results, and consumer education," Siegel says.

President Bush's 2004 executive order on HIT has helped focus more attention on health information, as have reports on patient safety, the appointment of a national health information technology coordinator, and the increased costs of healthcare.

Forgey notes that the squeeze of rising healthcare costs is driving interest in public reporting. "Healthcare consumers paying more out of pocket will eventually result in consumers who seek more information about providers and disease management," she says. The same goes for employers, who look to organizations such as Leapfrog to identify providers that provide high quality, highly efficient care.

Siegel has been encouraged by continuing consumer education efforts. AHIMA's personal health record (PHR) consumer education Web site, myphr.com, and its consumer education toolkits are excellent initiatives, she says, and opportunities exist to expand these offerings.

Progress is lacking in the areas of patient-centered and comprehensive health information. Some provider systems now feature access to information by patients, but this is not widespread at this point, the former task force members say. These systems, however, have not really taken into consideration whether consumers have a good understanding of health information or even their ability to use the technology to store and retrieve their information. The increasing number of PHR options necessitates consumer education on maintaining accurate, current data in their personal records. Consumers also need education on determining the security of PHR Web sites.

Is Vision Correction Needed?

"A Vision of the e-HIM Future" set out to define health information in 2010. Former task force members believe the vision statement they wrote in 2003 remains relevant, applicable, and accurate.

The activity of the past two years does suggest enhancements, however. Susan Hanson, MBA, RHIA, FAHIMA, suggests the statement would benefit by addressing ownership of information. She also suggests addressing privacy directly. Were the task force asked to formally revisit the statement, security of patient information would likely be addressed as well.

Several former members suggest that a revised vision might therefore be: "The future state of health information is electronic, consumer-centered, comprehensive, longitudinal, accessible, credible, and secure. Ownership of health information is a shared responsibility between the consumer and the provider."

Meryl Bloomrosen (Meryl.Bloomrosen@ehealthinitiative.org) is vice president of programs, eHealth Initiative Foundation, and program director of Connecting Communities for Better Health in Washington, DC. The opinions expressed are solely those of the author and do not necessarily represent the official view of Health Resources and Services Administration/Office for the Advancement of Telehealth or the eHI Foundation.