EHR evolution

If Mark Segal disagrees with the notion of post-MU, he does think the landscape is shifting – and could, a few years down the road, start to get truly exciting.

"I think what we're looking at right now is not so much a post-meaningful use, but an evolved meaningful use," says Segal, who, in addition to chairing the EHR Association, is vice president of government and industry affairs at GE Healthcare IT.

"Our customers are facing so many new initiatives, in the public and private sector, other than meaningful use," he explains. "You've got the Comprehensive Primary Care Initiative. You've got Shared Savings ACOs. You've got bundled payments. So if you think about the environment that our customers have to operate in, and where they need healthcare IT to help them, it's beyond meaningful use."

That's necessarily going to require some EHR horsepower beyond what most systems are currently able to provide. 

"I don't have a crystal ball, but I don't see us being in a post-EHR world as much as an evolved EHR world," says Segal. "If you look at some of the definitions of EHRs, some of the distinctions are (akin to) 'how many angels can dance on the head of a pin' – what's an EHR, what's an EMR, etc."

Increasingly, he says, "I think we'll be looking at a world where the EHR, from the standpoint of the clinician and the patient, actually lives in multiple solutions. In other words, some of the information that's relevant to a patient will be in a solution that's marketed as a certified EHR. Or it will reside in multiple EHR products, across different physician, hospital and post-acute settings. Or in a patient portal, or in an imaging information system. Increasingly, those will be interoperable."

From the patient's point of view, this seamlessly-linked aggregation of data would essentially "become their EHR – their longitudinal electronic health record," says Segal.

That idea was echoed early this year in an IDC report titled "IT Priorities for the Post-EHR Era." It won't be long, IDC Research Director Judy Hanover told Healthcare IT News, before the EHR is "just another" app in a larger technology space. 

As "larger organizations that have been successful with EHRs" start "maturing and moving on to the next step," said Hanover, they're casting a broader view of what clinical IT can accomplish. 

They're looking for "infrastructure and platform options that will help augment functionality, perhaps to go beyond what's available from the basic EHR in order to meet the needs of their workflow and how that's changed with accountable care," she said. "They're looking at storage environments that start to centralize and organize clinical and imaging data. They're pulling away from an EHR application-centered focus and looking at the broader IT ecosystem."

Still, there's a long way to go before that approach takes hold industry-wide – at least as long as providers are trying, by hook or by crook, to meet the many mandates of meaningful use.

"For the foreseeable future we will continue to see products that are developed, marketed and labeled as electronic health records," says Segal. "In part because of meaningful use certification, and in part because, for now, that's something the market looks for."

Meaningful innovation

Soon, though, he says those market demands will mature. "Functionality and data will be added to products that we think of, are developed and marketed as, EHRs: analytics, population health management, some aspects of genomics."

Similarly, "I think we're looking at a world where there will be more collection of data from various kinds of traditional devices, through standards-based interfaces and through various types of patient and consumer devices like Fitbits – and things we can't even imagine," he says.

Will vendors have much more latitude to innovate – perhaps even to offer providers capabilities they weren't even aware they wanted – once they're able to stop spending all their time and resources trying to meet meaningful use certification criteria?

"I think absolutely yes," says Segal. "CMS has stated that Stage 3 will be the last stage. And we're also hoping that ONC will not continue adding certification requirements. But I think basically we anticipate that developers will have more resources and more space to focus on market-driven product enhancements."

EHRA's vendor members "all serve different customer segments, by size, by geography, by specialty," he says. "We'll have more resources to do what our customers are asking us for. To put more resources into things like usability. And, ultimately, what we all really want to do, which is to delight our customers."

Post-meaningful use – or at least post-Stage 3 – "we absolutely think there will me more space to do that: To innovate, to take advantage of evolving technologies like cloud and mobile platforms, in new and emerging usability tools and frameworks," says Segal. "And then to compete against each other, using that competition to discover the best ways to do things."

Another boon for EHR creativity in the coming years is that the customer – the end-user, the physician, nurse or clinician – is now so much more sophisticated and familiarized with these tools than before meaningful use began.

"We are looking right now at a much more digital environment than we were five years ago," he says. "If you look at the adoption numbers for physician and hospital EHRs, the number of folks who are using these systems, the amount of data that's digitized, the networks that are available for exchange, it's just much bigger than it was three to five years ago, and that will be what our customers are looking for. 

"I think our customers are really going to be expecting us to be even more responsive to their requests, particularly as more resources become available as meaningful use demands reduce, he says.

Among the areas he sees a pent-up demand: usability, more seamless interoperability, and a new "a emphasis on mobile connections to various devices and their core systems," says Segal. "Something that often doesn't get talked about very much is support for new payment and delivery models, whether it's value-based payment or ACOs or patient-centered medical home. And I guess finally – and this is critical table-stakes – is doing all this with very strong, incredible security and privacy."

The coming data deluge

Beyond rigorous data protection and intuitive usability, this generation of clinicians, having grown so used to their smartphones, lightning-fast laptops and social media apps, "want their IT experience to resemble their IT experience in their personal life," says Segal. 

Increasingly, their IT experience may soon be much more reflective of the personal IT experience of their patients. With technology evolving at an incredible pace – gadgets, sensors, the Internet of Things, the Quantified Self – most EHRs are still relatively simplistic record-keeping tools. 

As David Lee Scher, MD, an electrophysiologist and medical technology blogger wrote recently, "The EHR does not represent the face of digital technology in healthcare. Mobile health technologies, wearable sensor technologies, aging at home technologies, and ingestible medication sensor technology populate today's digital health landscape."

Increasingly, those technologies are going to be brought to bear on care delivery, and the EHR is going to have to reckon with many of them. 

"We are at the dawn of a health data revolution," writes Drew A. Harris, director of the health policy program at Jefferson School of Population Health. Thanks to a galaxy of gadgets, apps and wearable technology, "our vital functions are fully tracked and reported, each of us will generate more data in a few minutes than our great-grandparents did in a lifetime."

"Emerging technologies such as genomics (your genes), proteomics (the proteins genes make), microbiomics (the colonies of bacteria essential to bodily functions), transcriptomics (RNA) and connectomics (neural connections) will generate terabytes of clinically significant data," wrote Harris.

Together with the plethora of constantly updated digits that comprise the quantified self, it all adds up to "an analytic nightmare," Harris writes. "Facebook, Google and Amazon can do more with your posts, searches and purchases to predict your future actions than the typical EHR can do to predict what diseases you will get."

Nonetheless, EHRs and other clinical systems are finally starting to catch up. And more data feeds into them, and as analytics get smarter with the help of technologies like IBM's Watson, he predicts the emergence of a new species of health data analyst: "These experts will work directly with the care team to analyze trends, merge disparate datasets, and develop better clinical interfaces to ensure health-related data points are turned into information and action."

There's been a lot of excited discussion lately about Apple's forthcoming, heavily-rumored HealthKit technology, for which the company has been working alongside EHR vendors Epic and Allscripts – and blue-chip provider organizations Cleveland Clinic and Johns Hopkins.

As of this writing, the app itself has not been officially unveiled, but early scuttlebutt suggested that at least one of the features would enable Epic customers to flow wellness data from HealthKit directly into Epic's MyChart, personal health record.

"Apple is going into this space with a data play," Forrester Research analyst Skip Snow told Reuters. "They want to be a hub of health data."

MyChart is a consumer-facing record, though. How far off are we from seeing data about our daily jogs and sleep patterns fed directly into the clinician facing EHR? Not so fast, says Mark Sullivan, writing – in an article titled, "Guess what? Doctors don't care about your Fitbit data" – on VentureBeat.

Never mind the fact that few clinicians have the time or resources to manage another constant stream of biometrics – let alone keep it all safe and secure – there's the bigger issue of the "quality of the data coming from consumer wearables."

"In order for the data from your Fuelband to matter clinically, it would have to flow securely into the electronic health record used (by) the clinic and/or hospital," he writes. "And in the cases of Apple's and Samsung's platforms that means the Epic electronic health record.

"Epic has proven to be very pragmatic and non-progressive when it comes to data sharing. So is Epic really a company that's likely to work hard to collect consumer biometrics data, crunch it, and display it in the EHR in a way that doctors can easily understand and use? It's easy to find people in the industry who have serious doubts."