Electronic Medical Records: Trends

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Electronic Medical Records: Trends

by Kirk Woodward

Docid: 00011351

Publication Date: 1802

Report Type: MARKET


The computerization of patient medical records has progressed in fits and
starts, but continues to grow and is now widely implemented. Technical
obstacles such as limited interoperability are still pressing issues that
healthcare facilities must consider when developing an electronic medical
record (EMR) strategy and evaluating EMR products. Also important is the protection of patient data against security

Report Contents:

Executive Summary

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Historically, electronic record keeping in healthcare focused mainly on
billing, with limited use of the potential for storing patient medical


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But today, many providers, from small family practices to large hospital
networks, are electronically performing functions such as ordering tests
and maintaining progress notes. Although computer-based records of patient
medical and contact information have existed in varying degrees for some
time, a group of loosely related developments has set the stage for a much
more extensive use of electronic medical records (EMRs). These
developments include an increased need for securing data to meet
regulations such as the Health Insurance Portability and Accountability
Act (HIPAA) and to address disaster planning concerns; greater use of
healthcare information systems such as picture archiving and
communications systems (PACSs); the development of standards and
certifications for such healthcare information systems; and the emergence
of programs that reimburse physicians based on results, not the types of
services performed.

There are numerous companies offering EMR software. The sector’s leaders
include Allscripts, Cerner, McKesson, and Epic. In addition to these
commercial providers, there is also an open source product, WorldVistA,
and a free tool, Practice Fusion, among the ranks of leaders. WorldVistA
was created by the US Department of Veterans Affairs, but it is now
available to other organizations, including those outside the US and
outside of government. Between these and other products there is no single
dominant company in the field.

There is still significant progress to be made in the development and
adoption of EMR technology. Most providers are not making full use of all
the capabilities available in today’s EMR systems. The use of these and
other healthcare information systems have improved efficiency and safety,
but a major limitation is that they only have access to data maintained by
their own or a linked system. Such information must be inputted by a
clinician, or the system must generate the information during use.
Consequently, information from other facilities or from several years in
the past is unavailable. Patients who assume that electronic records are
always sharable may be unfavorably surprised. Furthermore, unauthorized
“sharing” of records in the form of security breaches is a continuing

There is an effort to standardize EMRs to make their patient data
shareable across disparate healthcare providers. The result of this
sharing would theoretically be a single record for most or all patients
that would include a complete medical history compiled from all the
primary care physicians, surgeons, pharmacies, and other healthcare
providers that the patient has ever visited. This result is known as an
electronic healthcare record (EHR). The terms EMR and EHR are often used
synonymously, even by product vendors, but the concepts are distinct. EHRs
are an immature market, and it is uncertain when – and even if – a truly
universal record will become available. Therefore, potential customers
should not base purchasing plans on the expectation that true EHRs are
immanent. Facilities that are considering implementing an EMR should bear
in mind, however, that the EMR/EHR landscape could change significantly
over the next few years, particularly in terms of prevailing standards.

Market Dynamics

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The use of information technology to store, organize, and transmit data
has been slower to take hold in healthcare than in many other sectors.
Although electronic billing systems have been used widely for many years,
the adoption of electronic systems for patient record keeping has occurred
much more slowly. Over the past few years, however, this trend has
changed. A combination of factors has made it easier – and more imperative
– to implement electronic medical records (EMRs). Factors that are
spurring the adoption of EMRs include the following:

  • New Data Handling NeedsRegulations
    such as the Health Information Portability and Accountability Act
    (HIPAA) have forced healthcare providers to be more stringent in
    how they store and transmit patient medical data. Also, an increased
    emphasis on disaster recovery has encouraged the use of electronic
    record keeping.
  • Increased Interoperability and Data Volume – Over the
    past several years, the number of systems that use and store electronic
    patient data – and the overall amount of data such systems produce – has
    increased substantially. These systems include pharmacy information
    systems, which maintain information about a patient’s prescriptions;
    medication cabinets, which regulate the distribution of medications,
    often based on information received from pharmacy information systems;
    and picture archiving and communications systems (PACSs), which manage
    x-rays and other diagnostic imaging data.
  • Certification – There are now certifications for EMR
    products, such as the Office of the National Coordinator for Health
    Information Technology’s Certified Health IT Product List and the
    Surescripts Gold RX certification for EMR products with pharmacy
  • Standards – Established standards such as HL7 (for
    the interoperability of healthcare information systems) and DICOM (for
    electronically-stored diagnostic images) have enabled EMR products to
    more effectively exchange data and integrate into a healthcare
  • Pay for Performance Initiatives – Pay for performance
    is an emerging alternative to traditional ways of determining how much
    to reimburse healthcare providers for their services. Rather than basing
    payments solely on the type of service offered, this new approach also
    considers outcomes. Some healthcare industry observers contend that the
    traditional reimbursement system often encourages facilities to
    recommend diagnostic and treatment options based more on the revenue
    they generate than on the benefits to patients. For instance, a doctor
    may prescribe a certain test even though it has little chance of
    providing useful clinical information about a patient’s condition, or,
    conversely, a doctor might not recommend a potentially useful treatment
    option if the patient’s insurance plan does not cover it. The use of EMR
    products can help facilities to improve the criteria on which
    performance-based payments are calculated. For instance, it can help to
    reduce errors based on the misreading of handwritten notes from another
    doctor and can minimize the chance of a dangerous drug interaction by
    identifying the drugs a patient is currently taking, something patients
    are not always able to accurately do on their own. 
  • Government EMR Incentives – The US federal government
    offers financial incentives to providers for making use of electronic
    medical records, and penalties for not using EMR in Medicare

As these factors have pushed EMRs toward maturity and have encouraged
their wider use, a related new concept has emerged, the electronic
healthcare record (EHR). Although the terms are often used
interchangeably, even by product vendors, they are different in several
respects. An EMR is maintained by a single physician or a network of
physicians and includes data only about the services those physicians have
provided. Therefore, a single patient will typically have multiple EMRs,
each of which includes just a portion of his or her medical history.

As a result, there is an effort – begun by the US federal government but
now dependent upon many private sector participants – to develop an EHR, a
single, universal record of a patient’s entire medical history. Numerous
initiatives are underway to develop the technology and to agree upon the
standards for EHRs. Most of these initiatives are locally- or
regionally-based, and there is minimal coordination among them. Therefore,
it will be some time before a usable EHR will be available. Still, EHR
development efforts are promoting the expanded use of EMRs.

Market Leaders

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The top organizations in the sector include:
Allscripts. The company’s TouchWorks EHR,
designed for large organizations, includes a range of clinical support
features. The company also offers Allscripts Professional for small and
mid-sized organizations. In late 2017 and early 2018, Allscripts acquired
both McKesson and Practice Fusion (see below), significantly increasing
its product suite. It then sold McKesson’s content management system,
OneContent, to Hyland Software, indicating a continuing aggressive
approach to the EMR market.

CernerEven before it completed its
acquisition of fellow EMR vendor Siemens Health Systems in 2015, Cerner
was already one of the largest companies providing EMR software. The
company’s Acute Care Electronic Medical Record is designed as an
enterprise-caliber system for hospitals, and its Acute Care Electronic
Medical Record aims to provide an easy-to-use product for smaller
practices. The latter product is also available in a Web-based application
service provider version. Cerner has rebranded one of Siemens’ EMR
products as Cerner Soarian Clinicals.

eClinicalWorks. The company markets
eClinicalWorks EMR for both small and large medical offices. The product
integrates with the company’s Patient Portal, which allows patients to
view their own medical records and communicate with doctors, and with
eClinicalMobile, which is sold on popular app stores and provides remote
access to the EMR application using a mobile phone. There is also
integrated functionality for messaging and practice management.

eMDs. eMDs bought elements of the EMR product
line from McKesson in 2016, instantly positioning itself as one of the
leaders in the field. Its Practice Choice is a Web-based product designed
for medical practices with one 1-9 doctors.Medisoft Clinical is a
server-based product designed for practices with 10-25 physicians. The
company’s Practice Partner is design for larger organizations.

Epic. Epic focuses on enterprise environments,
targeting mid-size and large medical organizations. Its EpicCare Inpatient
Clinical System includes EMR capabilities along with pharmacy management
and outpatient support. But the company also offers a product
targeted toward physician offices, EpicCare Ambulatory EMR, which, like
the company’s enterprise software, includes capabilities for electronic
prescribing and other functions that complement EMR capabilities.

Practice Fusion. Practice Fusion is a free, cloud-based EHR
system that is a popular alternative to commercial products on the market.
Although free, Practice Fusion is competitive with many of the other systems
on the market, and it is likely to continue pressuring the makers of
commercial systems. Practice Fusion was acquired in February 2018 by
Allscripts, so its future direction will need to be clarified.

WorldVistA. The VistA EMR was developed by the
US Department of Veterans Affairs for use in its own facilities. Later, a
non-profit organization called WorldVistA was formed to further develop
VistA into a product that would be available to any healthcare provider.
Today, WorldVistA is one of the most advanced, most popular EMR
applications available. Many of its customers are agencies within the US
government, but it has been implemented by medical practices outside of
government and outside the US as well. There is also an open source stack
for WorldVistA.

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Facilities are gradually making use of a wider range of EMR functions,
and they are slowly increasing the extent to which they have implemented
their EMR systems. But they are doing so cautiously, and hardcopy records
such as handwritten notes and physical copies of X-rays are still
essential to some healthcare providers.

There are numerous EMR products on the market that are affordable for
small practices, making the technology available to a broad customer base.
The gap in functionality between products designed for small customers and
those designed for large customers is narrower in the EMR market than in
many other technology markets, so healthcare providers of different sizes
may find themselves considering some of the same products.

EMRs are beginning to find an additional use as a research tool. In this
capacity, researchers, not healthcare providers, use the information
stored in EMRs to analyze the effectiveness of particular treatments,
study how physicians screen for certain conditions, and perform other
analytical functions. One example of this is the Primary (Care) Practices
Research Network (PPRNET).

The public sector for years has been a driving force in encouraging the
development of EMRs and EHRs. For instance, the US Department of Veterans
Affairs was the original developer of WorldVistA, which is a now
commercial product, and the US federal government passed The American
Recovery and Reinvestment Act of 2009 (“the stimulus bill”). The
healthcare reform bill called for greater use of EMRs. Studies have
found that organizations were at first slow to meet the meaningful use
requirements, but that the pace has now increased.

For years, the federal government has been pushing to require that
medical offices use electronic records in a “meaningful” way in order to
receive reimbursements from Medicare and Medicaid. The requirement has
confusion and continues to evolve.

Many medical record applications are being offered over the Web in a cloud
version. In this scenario, the EMR/EHR provider might offer the application
while a hosting company would manage the servers and the provision of
services. There are clear security risks in this approach, with over 200
health care record security breaches reported in the first half of 2017

Strategic Planning Implications

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It will be at least a few years before the availability of standardized
EHRs that can be efficiently shared among all medical institutions, and it
is possible that a truly universal record will not come to fruition.
Therefore, EMR strategies need to balance the demand for near-term
benefits with the expectation that future EMR or EHR standards and
technologies could require products implemented now to be upgraded,
substantially modified, or even entirely replaced.

Even without a universal record, however, the use of EMRs by a healthcare
organization will be more successful if it is coordinated with the EMR
programs of other facilities. Offices that are part of a physician network
– or even those that frequently interact with a particular group of
third-party healthcare providers outside of any formal partnership –
should consider using the same EMR product or one that has been
demonstrated to be fully interoperable. This approach can facilitate
interoperability among organizations that commonly need to share
information, thereby yielding some of the benefits of an EHR.

There are many smaller EMR software providers whose reputations match
those of larger software developers, so healthcare facilities – even large
ones – should consider such products during their purchasing evaluations.
Although particular EMR products may not be explicitly designed for
certain types of practices – for instance, a certain medical field (e.g.,
dermatology, radiology) or a certain environment (e.g., community
hospitals, private offices, nursing homes) – they are likely to have some
characteristics that make them a better or worse fit for certain
situations. Therefore, potential customers should talk to colleagues in
similar sub-fields to help determine which products would be most suitable
for them.

Potential EMR customers can refer to the government’s HealthIT website,
which offers a database of EMR product reviews by medical professionals
who have used them in practice.

Security remains a primary concern for EMR products, as demonstrated by a
ransomware attack on Allscripts in January 2018 that affected service
delivery for several days.

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About the Author

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Kirk Woodward is a technical writer and project manager.
His areas of expertise also include enterprise software, hardware systems,
and the use of Internet resources.

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