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01.10

Electronic Medical Records — Sorting out the Alphabet Soup of Health Care IT

By Thomas Jepsen, Chair, IEEE-USA Medical Technology Policy Committee

The recent push to computerize health care has resulted in a confusing set of acronyms that even health IT professionals sometimes have trouble understanding.  The transition from paper medical records to electronic records has resulted in a proliferation of terms. The following is an attempt to sort out the “alphabet soup” of health care IT and expand some of the common acronyms that you may encounter.

To start with the basics — a medical record that is available in digitized form on a computer system is generally referred to as an electronic medical record (EMR).  An EMR contains information on a specific patient, such as vital signs, diagnosed conditions, current treatment programs, medications, and appointment history.  There is sufficient patient information to accurately identify the patient to a health care provider. The EMR is “owned” for legal purposes by the health care provider (hospital or clinic) that created it. Another term that is sometimes used to refer to an electronic medical record is the computerized patient record (CPR).

In the course of a lifetime, however, most of us will have multiple encounters with health care providers. Each routine physical, medical procedure, or emergency room visit may generate a separate medical record.  By using a common standard format, an EMR created by one health care provider can be shared with other health care providers as the patient transitions from one caregiver setting to another.  To differentiate between a medical record that is specific to one institution and one that is interoperable and shareable, the Health Information and Management Systems Society (HIMSS) Analytics subsidiary recommends standardizing on using “EMR” to refer to a provider-specific medical record, and using electronic health record (EHR) to refer to an interoperable and shareable medical record.

Instead of having to re-capture a patient’s whole medical history each time he or she visits the doctor, it would be much more efficient to have a lifetime medical history that is simply updated each time the patient has a medical encounter.  This led to the development of the continuity of care record (CCR) standard developed by the American Society for Testing Materials (ASTM).  The purpose of the CCR is to improve continuity of patient care and provide some measure of transportability when a patient transitions from one health care provider to another.  From a technical standpoint, the CCR uses extensible markup language (XML) to provide data portability.

Another standards group, the Health Level Seven (HL7) organization, created an XML-based electronic medical record standard called the Clinical Document Architecture (CDA) for the interoperable exchange of medical records.  Since the CCR and CDA standards were similar, it made sense to use a common format for both.  This led to the creation of the continuity of care document (CCD), which is a CCR using the CDA format.

One of the goals of health care IT adoption is to give the patient/health care consumer more control over their health care and wellness.  One way to accomplish this is by enabling health care consumers to have a personal health record (PHR) that they own and manage.  A PHR typically contains portions of the patient’s EMR or EHR, plus additional information added by the patient.  Such information might include non-prescription medications, immunizations, additions to medical history, and information on allergies. PHRs may be made available to health care consumers by health care providers, Internet service providers, or by health record banking associations (HRBA).

Sharing medical records and other health care-related information requires the creation of a nationwide health IT network.  Beginning with an executive order in 2004, the Office of the National Coordinator for Health Information Technology (ONCHIT)  of the U.S. Department of Health and Human Services (HHS) began the development of the Nationwide Health Information Network (NHIN).  The purpose of NHIN was to enable health care providers to exchange medical records, insurers to receive claims online, public health agencies to collect and transmit health information, and to allow quick access to emergency responders in the event of an accident or disaster.  The NHIN builds upon the existing Internet to provide secure and reliable transmission of health care-related information.

Implementing a concept as large as a national health care network requires us to think globally, but act regionally.  Building the NHIN needs to be done from the bottom up by interconnecting local networks, referred to as health information exchanges (HIEs) or regional health information organizations (RHIOs).  Each HIE or RHIO consists of a group of networked health care providers who have agreed to share medical records and other health-related information on a regional basis.  By interconnecting these regional networks, a national network can be built out in an incremental fashion.

Putting something as personal and private as a medical record online clearly requires enhanced levels of privacy and security.  Defining the privacy and security requirements for online medical records began with the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996.  While the primary purpose of HIPAA was to enable employees to transfer their health insurance coverage from one employer to another, it also mandated the creation of rules for privacy and security of online personal health information.  These rules became effective in the first few years of the 21^st century.

While the rules set up by HIPAA specified the steps that health care providers and their business associates had to take to ensure the privacy and security of  online medical records, many areas remained undefined.  The American Recovery and Reinvestment Act of 2009 (ARRA) included a section called the Health Information Technology for Economic and Clinical Health (HITECH) Act, which clarified some of these issues.  It specified what actions had to be taken to prevent security breaches, and gave requirements for breach reporting.  It set up a regulatory process for PHRs under the Federal Trade Commission (FTC), and empowered state attorneys general to enforce HIPAA under certain conditions.

ARRA also provided funding to enable health care providers to adopt online medical records.  Both the current and the previous administrations have mandated the widespread adoption of online medical records by 2014.  To provide guidelines for receiving funding and a standard means for measuring the adoption rate of EHRs, the ARRA requires the creation of “meaningful use” guidelines that can be used to demonstrate that health care providers are using EHRs in a meaningful way.

Incentive payments are for acute care providers who are using certified EHR systems in a meaningful way (i.e. meeting the “meaningful use” outcomes’ criteria) and providing care for Medicare or Medicaid populations, starting in 2011.  The Certification Commission for Health Information Technology (CCHIT) was established in 2004 to provide certification for EHR software implementations.  In 2005, the Health Information Technology Standards Panel (HITSP) was created to generate interoperability standards for medical records. HITSP’s output provides a basis for the standards needed for EHRs to be interoperable.

Much work remains to be done if we are to realize the goal of widespread adoption of electronic medical records in the U.S.  by 2014.  However, adopting standard terminology can make this an easier pill to swallow for medical practitioners and health care information technology professionals alike.

Thomas C. Jepsen is chair of IEEE-USA's Medical Technology Policy Committee.

Comments may be submitted to todaysengineer@ieee.org.