One of the hot trends is the integration of patient-facing data into the electronic medical record. From Epic's new app store to Validic's partnerships with Cerner and athenahealth (to name just a few), EMR platforms are evolving to accept health and wellness data from devices to better define a patient's profile outside the medical encounter.
"It's not just physician documentation any more," says Girish Navani of eClinicalWorks. "The patient is part of that equation … but there have to be filters."
[See also: EHRs and wearables - their time has come?]
Does this mean the EMR is becoming obsolete? Or is it evolving into an EHR?
"What is the system of record?" asks Mandira Singh, senior business development manager at athenahealth and head of its "More Disruption Please" initiative. Consumers, she says, "are more involved in their healthcare, which puts the onus on (clinicians) to work with them, but we haven't seen much good data come out of the FitBits and other consumer-facing devices" that would make a doctor sit up and take notice.
"But it's coming," she adds quickly.
[See also: EHRs embrace health and fitness data]
Providers say they don't want all that extra information coming into the medical record, but they can't deny the value of health and wellness data in developing a care management plan for their patients. They're worried about validity – is data entered by the patient reliable enough to be included in clinical decision support?
At this point, the answer is no, and mHealth vendors and EMR providers understand this. As Navani points out, the data has to be curated first – collected, sifted and organized into something that a provider can trust and ultimately use. Some EMR companies tackle this issue by shunting consumer-entered data into a PHR or similar silo; the consumer then grants permission to the provider to parse over that data and determine what can be pulled out and ultimately entered into the medical record.
Jeff Margolis, CEO of Welltok – whose book, "The Healthcare Cure," includes a chapter appropriately titled "The Digital Alphabet Soup" – thinks both EMRs and EHRs are flawed because they're built around doctors, rather than consumers, and exist only to chart the intersections of the healthcare provider and patient. A true health record, he says, focuses on the consumer and accumulates all data that enables the consumer to be responsible for his or her health.
But where does the doctor fit in?
"Doctors have their hands full practicing sick care," Margolis says.
The proliferation of consumer-facing apps and devices has also given rise to a dichotomy in how mHealth data is collected. On one side stand platforms like Apple's HealthKit and ResearchKit, which gather consumer data for use by healthcare providers. On the other side are platforms like Qualcomm Life's 2net hub, which takes data from reliable devices – not the consumer – and goes to great lengths to ensure that such data is "medical grade."
Can both data streams share space in the same record? That depends on how EMRs and EHRs are defined.
In a 2011 blog on HealthIT.Gov written by Peter Garrett, former director of the ONC's Office of Communications, and Joshua Seidman, PhD, the ONC's director of meaningful use, EMRs are defined as "a digital version of the paper charts in the clinician’s office."
"An EMR contains the medical and treatment history of the patients in one practice," Garrett and Seidman wrote. "EMRs have advantages over paper records. For example, EMRs allow clinicians to:
- Track data over time;
- Easily identify which patients are due for preventive screenings or checkups;
- Check how their patients are doing on certain parameters—such as blood pressure readings or vaccinations; and
- Monitor and improve overall quality of care within the practice.
But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record."
EHRs, however, "focus on the total health of the patient," Garrett and Seidman added, "going beyond standard clinical data collected in the provider’s office and inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects and compiles the information. They are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. The National Alliance for Health Information Technology stated that EHR data 'can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.'"
But no mention of patient-facing information.
The idea of the imperfect EMR or EHR isn't a new one. At Partners HealthCare's Connected Health Symposium back in 2013, Andrew Watson, MD, medical director for UPMC's Center for Connected Medicine, openly wondered whether the EHR is necessary. He argued during a panel discussion that the most important information in the doctor-patient encounter comes from the conversations and notes jotted down on the side, none of which makes it into the EMR. The true patient record, he said, exists in the margins outside the EMR.
Now take that a step further. Much of the conversation between a doctor and a patient focuses on what the patient is doing outside of the doctor's office – in other words, the doctor is looking for data that today's health and fitness wearables are collecting. This means that all that information in the margins is now being pulled into the record.
If that's the case, then this truly is a health record, not a medical record.
"While an EHR does contain the medical and treatment histories of patients, an EHR system is built to go beyond standard clinical data collected in a provider’s office and can be inclusive of a broader view of a patient’s care," HealthIT.gov continues." EHRs can:
- Contain a patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results;
- Allow access to evidence-based tools that providers can use to make decisions about a patient’s care; and
- Automate and streamline provider workflow."
"One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one healthcare organization," HealthIT.gov states. "EHRs are built to share information with other healthcare providers and organizations – such as laboratories, specialists, medical imaging facilities, pharmacies, emergency facilities and school and workplace clinics – so they contain information from all clinicians involved in a patient’s care."
Margolis feels the both EMRs and EHRs will eventually be eclipsed by consumer-controlled platforms. Once the so-called 'gadget pageant" evolves so that clinicians can accept and use data from consumer-facing devices, he says, the playing field will be level, and the conversations that consumers and their doctors have will be more meaningful.
Just as today's healthcare system is trying to evolve from one that focuses on episodic care to one that encompasses the entire health spectrum, we're moving away from medical moments and going toward care management or health maintenance.