New York Academy of Sciences and the Center for Advanced Information Management.
Electronic Health Records: Where Do We Go From Here?
Posted April 05, 2010
A central component of health information technology is the electronic health record (EHR), a computerized version of the familiar paper chart kept for each patient. Collecting these records in an electronic form will allow patient care data to be centralized, standardized, and mined for information, improving care both for the individual patient and for the population as a whole.
On February 5, 2010, a cross section of researchers in this field convened to discuss progress toward the implementation of electronic health record systems. The Center for Advanced Information Management (CAIM), a New York State Center for Advanced Technology located at Columbia University, and the New York Academy of Sciences presented a conference entitled "Electronic Health Records: Where Do We Go From Here?" The conference brought together representatives from industry, academia, and government organizations to discuss a broad array of topics including, incentives for implementation, developing standards, new EHR software, privacy concerns, and potential costs and savings.
Use the tabs above to find a meeting report and multimedia from this event.
Presentations are available from:
Rachel Block (New York State Department of Health)
John Gomez (Eclipsys Corporation)
George Hripcsak (CAIM at Columbia University)
Steven Labkoff (Pfizer Pharmaceuticals)
Edward Rogoff (Baruch College/CUNY)
Soumitra Sengupta (Columbia University/New York Presbyterian Hospital)
Jesse Singer (The New York City Department of Health and Mental Hygiene)
Jay Srini (University of Pittsburgh Medical Center)
Adam Wilcox (Columbia University)
Hui Cao (Deloitte)
Thomas Clancy (University of Minnesota)
Patricia Dykes (Partners Healthcare System, Inc.)
For a complete list of sponsors, please click the Sponsorship tab.
- 00:011. Health information technology general points of interest
- 02:112. Broad goals for health IT strategy
- 03:573. Building blocks for interoperable health IT
- 05:554. Key elements in governance
- 07:385. Vision for NY's health information infrastructure
- 08:166. Principles and function of health information network
- 10:337. Interoperability "rules of the road" adopted by NYS
- 11:008. Framework for NY's health IT strategy
- 11:259. State and federal efforts focusing on adoption
- 12:0010. Federal policies and funding: opportunities for alignment with NYS efforts
- 12:2211. Definition of "meaningful use" of EHRs crosswalk to NY's HIT
- 12:5512. Additional efforts needed
- 13:3213. High performance case studies: delivery system level
- 14:0314. General observation
- 00:011. Meaningful use of EHRs (overview)
- 01:132. Definition of Medicare eligible professional
- 03:413. Hospital incentives
- 04:494. Meaningful use workgroup
- 05:125. Timing of MU criteria: a balancing act
- 06:486. HIT enabled health reform
- 07:107. Stages of meaningful use
- 08:008. Stage 1
- 10:479. Stages 2 and 3
- 11:1410. Reporting
- 12:0811. Major changes from MU WG
- 12:4112. Meaningful use of health IT draft principles
- 17:2113. Now what
- 00:011. Overview
- 00:552. Patient record use and disclosure
- 02:403. Disclosure without authorization
- 06:304. Accounting for disclosures
- 07:125. Examples of external disclosures/operations
- 08:146. Security violations (malicious)
- 09:567. Security violations (accidental)
- 11:018. New York state breach confidentiality law
- 11:359. HIPAA
- 12:3010. ARRA/HITECH
- 15:0611. Accounting of disclosure rule: issues
- 17:1612. Audit logs
- 18:3113. IT related regulation
- 00:011. Primary care information project (PCIP) overview
- 02:142. Outreach progress to date
- 02:583. Objectives
- 05:344. Deal for the providers (what PCIP gives and what practices are responsible for)
- 07:005. Additional services as practices move through the pipeline
- 10:536. Vision: how healthcare maximizes health
- 11:357. Electronic healthcare record oriented toward prevention
- 12:188. Example
- 14:039. Care management
- 15:4610. Payment that rewards disease prevention and effective chronic disease management
- 17:0411. Payments per patient
- 18:1012. Automated quality reporting
- 18:4213. Summar
- 00:011. Meaningful use (Brailer's strategic framework)
- 01:042. Spectrum of care settings: care continuum occurs beyond any single enterprise
- 01:223. Revenue and volume
- 01:464. Small practices are the backbone of US healthcare delivery
- 02:015. Data aggregation is key
- 02:166. Evolution of integration
- 04:287. Pillars supporting evidence based medicine
- 05:128. The goal: semantic interoperability
- 06:139. Expanding via the "Affiliate Model"
- 07:0810. Most docs are not using electronic health records
- 07:2611. Overview of payer based health records
- 09:1712. Future state of EHRs
- 10:4213. Wellpoint's individual health record
- 11:1814. Personal health management
- 12:4815. AHA and HealthVault connection
- 13:1016. Google health and Mdlive care
- 13:3717. Movement into the community
- 14:0118. Conclusio
- 00:011. What is working in EHRs?
- 01:302. Features critical to success
- 02:593. History of hand-held devices in healthcare
- 06:044. Emergence of the smartphone
- 07:055. Decision support
- 07:296. Task correction (i.e. drug-drug interaction)
- 08:107. Checklist reminders
- 08:528. Prioritization
- 09:319. Follow up reminders
- 10:4310. Status updates
- 11:1411. Summary of decision support
- 12:3512. NYP Touch
- 16:2513. NY Touch success factor
Center for Advanced Information Management
Promotes collaboration between Columbia faculty and industry to develop and commercialize new technologies.
Company that designs and implements advanced health care IT systems.
Meaningful Use Workgroup
Group that makes recommendations to the Health Information Technology Policy Committee on the meaningful use of electronic health records.
New York State Department of Health
Established within the Department of Health (DOH) in 2007, the Office of Health Information Technology Transformation (OHITT) is charged with coordinating health IT programs and policies across the public and private health care sectors. The state also has a page describing its use of ARRA funding.
Primary Care Information Project
Organizations and projects at the New York State Department of Public Health involved in HER adoption.
Non-profit, integrated health system founded by Brigham and Women's Hospital and Massachusetts General Hospital.
Company that develops new technologies in a wide range of areas, including healthcare.
Government website that provides information on the distribution of ARRA funds.
Transforming Healthcare Through Secondary Use of Electronic Health Data
Consulting firm publication on the secondary use of EHRs.
Seeing the Big Picture of HIT and EHR Design
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Hripcsak G, Soulakis ND, Li L, et al. 2009. Syndromic surveillance using ambulatory electronic health records. J. Am. Med. Inform. Assoc. 16: 354-361. Full Text
Shea S, Hripcsak G. 2010. Accelerating the use of electronic health records in physician practices. N. Engl. J. Med. 362: 192-195. Full Text
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Sinha A, Hripcsak G, Markatou M. 2009. Large datasets in biomedicine: a discussion of salient analytic issues. J. Am. Med. Inform. Assoc. 16: 759-767.
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Rabadan R, Calman N, Hripcsak G. 2009. Next generation syndromic surveillance: molecular epidemiology, electronic health records and the pandemic Influenza A (H1N1) virus. PLoS Curr. Influenza RRN1012. Full Text
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EHRs as a part of clinical decision making and institutional workflows
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Cao H, Markatou M, Melton GB, et al. 2005. Mining a clinical data warehouse to discover disease-finding associations using co-occurrence statistics. AMIA Annu. Symp. Proc. 106-110. Full Text
Cao H, Melton GB, Markatou M, et al. 2008. Use abstracted patient-specific features to assist an information-theoretic measurement to assess similarity between medical cases. J. Biomed. Inform. 41: 882-888. Full Text
Han M, Song X, DeHaan J, et al. 2006. CPOE/EHR-driven healthcare workflow generation and scheduling. AMIA Annu. Symp. Proc. 940. Full Text
Dykes PC, Carroll DL, Benoit A, et al. 2007. A randomized trial of standardized nursing patient assessment using wireless devices. AMIA Annu. Symp. Proc. 206-210. Full Text
Dykes PC, Carroll DL, Hurley AC, et al. 2009. Why do patients in acute care hospitals fall? Can falls be prevented? J. Nurs. Adm. 39: 299-304.
Dykes PC, Hurley A, Cashen M, et al. 2007. Development and psychometric evaluation of the Impact of Health Information Technology (I-HIT) scale. J. Am. Med. Inform. Assoc. 14: 507-514. Full Text
Dykes PC, Hurley AC, Brown S, et al. 2009. Validation of the Impact of Health Information Technology (I-HIT) Scale: an international collaborative. Stud. Health Technol. Inform. 146: 618-622.
Dykes PC, Kim HE, Goldsmith DM, et al. 2009. The adequacy of ICNP version 1.0 as a representational model for electronic nursing assessment documentation. J. Am. Med. Inform. Assoc. 16: 238-246. Full Text
Goldsmith D, Zuyev L, Benoit A, et al. 2009. Usability testing of a Falls Prevention Tool Kit for an inpatient acute care setting. Stud Health Technol Inform. 146: 801-802.
Hurley AC, Dykes PC, Carroll DL, et al. 2009. Fall TIP: validation of icons to communicate fall risk status and tailored interventions to prevent patient falls. Stud. Health Technol. Inform. 146: 455-459.
Kim H, Dykes P, Goldsmith D, et al. 2009. A strategy for preparing contents for a computerized documentation system. Stud Health Technol Inform. 146: 752-753.
Clancy TR. 2008. Fractals: Nature's formula for managing hospital performance metrics. J. Nurs. Adm. 38: 510-513.
Clancy TR. 2009. In search of elegance: making the complex simple. J. Nurs. Adm. 39: 507-510.
Clancy TR. 2009. Self-organization versus self-management: two sides of the same coin? J. Nurs. Adm. 39: 106-109.
Clancy TR. 2010. Diamonds in the rough: positive deviance and complexity. J. Nurs. Adm. 40: 53-56.
Clancy TR, Effken JA, Pesut D. 2008. Applications of complex systems theory in nursing education, research, and practice. Nurs. Outlook 56: 248-256 e3.
Clancy TR, White-Delaney C, Mako M. 2009. Improving the academic programming process in a school of nursing using computational modeling and simulation. Stud. Health Technol. Inform. 146: 587-592.
Promises and potential pitfalls of EHR adoption
Chen ES, Hripcsak G, Patel VL, et al. 2003. Automated identification of shortcuts to patient data for a wireless handheld clinical information system. AMIA Annu. Symp. Proc. 809. Full Text
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Hripcsak G, Sengupta S, Wilcox A, et al. 2007. Emergency department access to a longitudinal medical record. J. Am. Med. Inform. Assoc. 14: 235-238.
Sengupta S, Calman NS, Hripcsak G. 2008. A model for expanded public health reporting in the context of HIPAA. J. Am. Med. Inform. Assoc. 15: 569-574. Full Text
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Kim D, Labkoff S, Holliday SH. 2008. Opportunities for electronic health record data to support business functions in the pharmaceutical industry—a case study from Pfizer, Inc. J. Am. Med. Inform. Assoc. 15: 581-584. Full Text
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Safran C, Bloomrosen M, Hammond WE, et al. 2007. Toward a national framework for the secondary use of health data: an American Medical Informatics Association White Paper. J. Am. Med. Inform. Assoc. 14: 1-9. Full Text
Buck MD, Atreja A, Brunker CP, et al. 2009. Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records. Am. J. Geriatr. Pharmacother. 7: 84-92.
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Dorr DA, Wilcox AB, Brunker CP, et al. 2008. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J. Am. Geriatr. Soc. 56: 2195-2202.
Kern LM, Dhopeshwarkar R, Barron Y, et al. 2009. Measuring the effects of health information technology on quality of care: a novel set of proposed metrics for electronic quality reporting. Jt. Comm. J. Qual. Patient Saf. 35: 359-369.
Van Vleck TT, Wilcox A, Stetson PD, et al. 2008. Content and structure of clinical problem lists: a corpus analysis. AMIA Annu. Symp. Proc. 753-757. Full Text
Wilcox A, Bowes WA, Thornton SN, et al. 2008. Physician use of outpatient electronic health records to improve care. AMIA Annu. Symp. Proc. 809-813. Full Text
New York State Department of Health
Rachel Block is deputy commissioner for Health Information Technology Transformation in the NYS Department of Health, where she oversees development and implementation of New York's statewide health information technology strategy. Before joining the Department in May 2009, she served as the founding executive director for the New York eHealth Collaborative (NYeC), a statewide multi-stakeholder organization committed to advancing health information technology adoption and use in New York.
From August 2003 to March 2008, she was the project director for the United Hospital Fund's Quality Strategies Initiative where she developed several initiatives to coordinate improvements in health care delivery and outcomes across the health care system in New York, including the planning process which led to creating NYeC. Prior to joining the Fund, Block worked in the public and private sectors leading strategic planning and policy development efforts to improve the effectiveness and efficiency of state health programs. She served as a vice president for health services at Maximus from 2002–2003. From 1994–2002, Block held several senior management positions at the Centers for Medicare & Medicaid Services (previously Health Care Financing Administration) where she directed policy development and operations of Medicaid, State Children's Health Insurance, and Federal Survey and Certification Programs, with particular emphasis on quality improvement, data and systems issues.
From 1992–1994, Block worked for then-Governor Howard Dean in the development of a comprehensive health reform plan for the state of Vermont. She also worked for the New York State Legislature from 1978–1992 where she concentrated on Medicaid, coverage for the uninsured, public health and professional licensing issues.
Block is currently the president of the board for the eHealth Initiative Foundation.
Hui Cao, MD, PhD
Hui Cao has diverse experiences across medicine, life sciences, public health, and biomedical informatics. She received her MD with a concentration in pediatrics and epidemiology and a MS in medical genetics in China, and a PhD with distinction, in biomedical informatics from Columbia University. While working at Columbia Presbyterian Medical Center, she participated in a variety of informatics projects covering a variety of informatics areas. Prior to Columbia, she was a research scientist in cancer genetics at a Chinese Medical University and a consultant for a large Chinese pharmaceutical company, where she designed R&D strategies in cancer therapy, and advised cost-effectiveness and other epidemiologic studies. Since joining Deloitte in 2006, she has worked with life sciences clients and provider clients in information management, marketing strategy, clinical transformation, performance improvement, Health IT, clinical information system selection, and hospital merger & acquisition. She has also served as an internal informatics SME on several projects and proposals. Externally, Hui serves a board member for Community Options, a non-profit organization that helps people with disabilities.
Thomas Clancy, PhD, MBA, RN
Thomas Clancy is a clinical professor at the University of Minnesota School of Nursing. Clancy received an MA in Physiology of Exercise/Cardiac Rehabilitation, an MBA, and a PhD in Nursing, all from the University of Iowa. Clancy’s research interests include computational modeling, simulation, social network analysis, and agent-base modeling.
Patricia Dykes, RN, DNSc
Patricia C. Dykes is Corporate Manager Nursing Informatics & Research with the Clinical Informatics Research & Development group at Partners HealthCare, Boston where she serves as informatics consultant for acute care documentation and conducts informatics and patient safety research. For the acute care documentation project, Dykes and her team inform nursing terminology knowledge base development, decision support, communication, interdisciplinary workflow processes and reporting. Dykes and her team study fall prevention in hospitals and are examining a decision-support and communication intervention for use by the care team, patients and family members to prevent patient falls. In addition, she is conducting research to evaluate the adequacy of the Clinical Care Classification system to support measurement of nursing workload as a byproduct of clinical documentation. Dykes has presented and published her work on nursing documentation, informatics and patient safety and is the recipient of the 2007 HIMSS Nursing Informatics Leadership Award and the 2009 AMIA Harriet Werley Award.
John Gomez is executive vice president and chief technology strategy officer at Eclipsys. In this role, Gomez helps Eclipsys successfully optimize the use of technology and architecture to support the company's strategic plan and the needs of its clients. He is charged with providing technical vision to complement the company's business vision, and develops the strategic technology plan by identifying, tracking, and evaluating new technologies.
Additionally, Gomez oversees the Eclipsys Business Development team, which is responsible for strategic partnerships, corporate strategy and mergers and acquisitions. He also is responsible for leading all of Eclipsys strategic business growth outside of North America.
A highly respected executive in the healthcare information technology industry, Gomez brings to Eclipsys a broad scope of experience in technology strategy, e-commerce, development and architecture. He worked on the pre-releases of .NET and currently is a featured lecturer and author on .NET and advanced technology. His most-recent position was senior vice president and CTO of WebMD, where he was responsible for all technology-related aspects of the company's consumer and physician portals.
George Hripcsak, MD, MS
George Hripcsak is the Vivian Beaumont Allen Professor of Biomedical Informatics and chair of the Department of Biomedical Informatics at Columbia University. His research focuses on understanding and using the clinical information stored in the electronic medical record. In a separate area of research, he has focused on the use of new technology such as wireless networks and handheld computers to improve communications among health care participants. Examples include community health information networks, portable computers for providers, home monitoring, and wearable computers for patients.
Hripcsak designed and manages WebCIS, the Web-based clinical information system for the Columbia University Medical Center and NewYork Presbyterian Hospital's Columbia-Presbyterian campus. It is used by over 7000 health care providers to access and enter data for 2,500,000 patients and contains data collected since 1979.
Hripcsak holds an MD from Columbia University and an MS in Biostatistics from the Mailman School of Public Health at Columbia University.
Steven Labkoff, MD
Steven Labkoff is a visionary medical leader with a track record of developing cutting edge strategies towards new healthcare delivery models. He has demonstrated success in the convergence of medicine, life sciences and policy across disparate organizations including government, non-government organizations (NGOs), health plans and academic institutions. He joined Pfizer in 1997. He was most recently senior director in the Medical Affairs group in Pfizer’s Primary Care Business Unit in support of National Accounts.
Prior to that he was the founder and leader of the Healthcare Informatics Group (HCI). The HCI group works in the external environment seeking out new opportunities that arise from the growth of health information technology in America and around the world. His previous role was in the US Business Technology department where he was an internal consultant and project manager for groups including Planning and Business Development, the Strategic Investment Group, Pfizer Health Solutions and the Pfizer Helpful Answers Program. His current areas of interest include secondary uses of healthcare data, the emergence of Regional Health Information Organizations, the National Health Information Network, the emergence of the personal health records, ePrescribing and standards development.
Previously, Labkoff was an instructor of Medicine and Medical Informatics at Brigham and Women’s Hospital, Harvard Medical School. He completed a postdoctoral fellowship at Harvard Medical School and Massachusetts Institute of Technology in Medical Informatics. He did his cardiology training at the University for Medicine and Dentistry of New Jersey, his medical training at the University of Pittsburgh and at the Albert Einstein Medical Center in Philadelphia. He is a fellow of the American College of Physicians, the American Medical Informatics Association, the Health Information Management Systems Society, and the eHealth Initiative and several other professional organizations.
Charles Lagor, MD, PhD
Philips Research North America
Charles Lagor is senior member research staff at Philips Research. Lagor earned a PhD in Medical Informatics from the University of Utah.
Kenneth Ong, MD, MPH, FACP
Ken Ong is currently the vice president of medical informatics at Catholic Health Services of Long Island. His present responsibilities include the enterprise-wide Clinical Information Transformation Initiative, physician practice EHR subsidy program, evidence-based medicine order sets, physician performance reporting and CHS's transitions of care work group. Ong is also adjunct faculty at Columbia University's Mailman School of Public Health and Columbia University's School of Medicine, Department of Biomedical Informatics.
Ong's past projects include developing and implementing an acute care EMR with CPOE; clinical decision support for the ambulatory EMR a hospital pharmacy system and, web-based results review, and physician charge capture. He edited the textbook on health information technology, "Medical Informatics: an Executive Primer"—winner of the 2007 HIMSS Book of the Year Award.
Ong is residency-trained and board certified in family practice, internal medicine, and infectious diseases. He is a fellow of the American College of Physicians, the Infectious Disease Society of America, HIMSS, and the New York Academy of Medicine. He received his MPH at Columbia University, MD at Wayne State University, and BS at University of Michigan
Edward G. Rogoff, PhD
Edward G. Rogoff is the Lawrence N. Field Professor of Entrepreneurship in the Department of Management of the Zicklin School of Business at Baruch College, The City University of New York. He is also chair of the Department of Management. He also teaches at the Columbia Business School and received a BA, MBA, MA and PhD from Columbia University where he wrote his thesis under the supervision of Nobel Laureate William Vickrey. Dr. Rogoff has served as the academic director of the Lawrence N. Field Center for Entrepreneurship at Baruch College, teaches, and conducts research in entrepreneurship, particularly relative to minority and later-life issues. Dr. Rogoff has been named the 2010 Outstanding Entrepreneurship Educator of the Year by the United States Association of Small Business and Entrepreneurship. He is the author of "Bankable Business Plans" and co-author of "The Entrepreneurial Conversation." His most recent book is "The Second Chance Revolution: Working for Yourself after 50," co-authored with David Carroll. He has published in such journals as The Journal of Business and Entrepreneurship, The Journal of Developmental Entrepreneurship, Family Business Review, and Journal of Small Business Management. Dr. Rogoff was a 2003 guest co-editor of the Journal of Business Venturing. In 2007, he is guest co-editor of the Journal of Developmental Entrepreneurship. He has written articles for the New York Times, Forbes, and Newsday, as well as having been a guest on CNN. He has trained and worked with hundreds of entrepreneurs in many industries.
Soumitra Sengupta, PhD
Soumitra Sengupta manages information security for New York-Presbyterian Hospital and Columbia University Medical Center as the information security officer, and teaches a course on clinical information systems, conducts research, and advises students as a faculty in Department of Biomedical Informatics at Columbia University. He has an Engineering (BE) and Computer Science (MS, PhD) training, which he has applied in clinical environment for past 22 years. He has worked in networking, network management, systems management, clinical information exchange, patient access to clinical records, and information security in context of a tertiary care environment with direct operational responsibility for these services. His current research and operational interests overlap in the areas of derivation of access roles from audit logs, and complex identity management systems.
Jesse Singer, DO, MPH
Jesse Singer is currently executive director of development for the Primary Care Information Project (PCIP) at the New York City Department of Health and Mental Hygiene. He is board certified in Public Health/Preventive Medicine.
Dr. Singer is responsible for the overall public health technology vision, software development, deployment, quality assurance and data validation at the PCIP. Specifically, he is responsible for developing prevention and public health oriented electronic health records that incorporate functions such as utilization measurement, quality measurement, syndromic surveillance, point-of-care clinical decision support, population management tools, health information exchange with local and state agencies and interfaces with public health entities such as the City Immunization Registry. Dr. Singer holds a DO and MPH from Nova Southeastern University and a BS in Neurobiological Sciences from University of Florida, Gainesville.
Jay Srini, MS, MBA, FHIMSS
University of Pittsburgh Medical Center
Jay Srini is currently the chief innovation officer for UPMC Insurance Services Division and is responsible for developing the methods, tools, and strategies that result in innovative health care solutions and positive consumer experiences.
For the past four years, Srini has held the position of vice president of emerging technologies for UPMC, providing strategic direction and input regarding emerging technologies and solutions to University of Pittsburgh Medical Center. Prior to that Srini was managing director for e-Health initiatives at Internet Venture Works where she led technology and industry assessments of opportunities presented by strategic partners, investors, and external sources and served in interim executive management roles for its' portfolio companies.
Srini has a Master's Degree in Computer Science from New York University and a Master's Degree in Business Administration from Bucknell University. Her executive education also includes the Kellogg School of Management. She is an active board member of HIMSS, Pennsylvania e-Health Initiative, MIT Forum, Rainbow Kitchen Community Services, and charter member of TIE Pittsburgh. Srini serves on the Deans advisory board School of Computer Science at Carnegie Mellon University. She also serves on the advisory board of several enterpreunerial companies and on the advisory committee of several national healthcare related conferences.
Adam B. Wilcox, PhD
Adam Wilcox is currently the project lead for Systems Technology Interfacing Teaching and Community Hospitals (STITCH) project, a clinical data exchange initiative at New York Presbyterian Hospital. His current interests are evaluation of clinical data exchange, information systems to support chronic disease management, and clinical information systems architecture and design. Prior to joining Columbia in 2006, he was a senior medical informaticist at Intermountain Healthcare (2001–2006) and assistant professor in the Department of Biomedical Informatics at the University of Utah (2001–2006), where he worked with information systems development for chronic disease management, collaborative systems in outpatient care, care management, emergency department information systems design, and research design in medical informatics. He has a PhD in medical informatics from Columbia University, where his thesis work was in clinical data mining and natural language processing.
Megan Stephan studied transporters and ion channels at Yale University for nearly two decades before giving up the pipettor for the pen. She specializes in covering research at the interface between biology, chemistry and physics. Her work has appeared in The Scientist and Yale Medicine. Stephan holds a PhD in biology from Boston University.
This event is funded in part by the Life Technologies™ Foundation.
The Center for Advanced Information Management is a NYSTAR-sponsored Center for Advanced Technology at Columbia University.
The great debate over health care reform is clearly one of the most contentious topics of our time. Yet despite vast differences of opinion on how and whether health care reform should be implemented, there seems to be one area in which most stakeholders (employers, consumers, insurance companies, medical providers, and others) have reached an agreement: the current pace of cost increases must be slowed down substantially if our overall health care system is to remain viable.
One way to contain health care costs is to take control of the immense stream of health care data that is produced each year. Tracking data on patient care and resulting outcomes can identify areas where care is not delivered optimally, avoiding expenditures that are wasteful and unnecessary. This data is already captured in some ways, but with millions of patients and hundreds of thousands of health care providers involved, it is clear that a much broader, more uniformly implemented system of health care information technology (HIT) is needed.
A central component of HIT is the electronic health record (EHR), a computerized version of the familiar paper chart kept for each patient. Collecting these records in an electronic form would allow patient care data to be centralized, standardized, and mined for information, improving care both for the individual patient and for the population as a whole. As one of the largest health care payers, in the form of Medicare and Medicaid, the federal government is a strong proponent of EHRs. The American Recovery and Reinvestment Act of 2009 (ARRA) provided millions of dollars in stimulus funds for health care institutions to invest in designing and implementing HIT systems that will collect, manage and facilitate sharing of EHRs between institutions.
On February 5, 2010, a cross section of researchers in this field convened to discuss progress toward these highly labor intensive and far reaching goals. The Center for Advanced Information Management (CAIM), a New York State Center for Advanced Technology located at Columbia University, and the New York Academy of Sciences presented a conference entitled "Electronic Health Records: Where Do We Go From Here?" The conference brought together representatives from industry, academia, and government organizations to discuss their work towards the common goal of implementing EHRs in a broad, cost effective, and meaningful way.
In the first of three sessions, researchers with experience working in the trenches of HIT implementation provided insights into the institutional and technological components needed to support EHR adoption and use. Rachel Block of the New York State Department of Health described the coordinated strategy underway in that state, providing an overview of the building blocks, such as policies, regulations, standards, definitions, and financial incentives needed to support widespread, effective adoption by the stakeholders involved. George Hripcsak of Columbia University's CAIM discussed the work of the federal HIT Policy Committee and its Meaningful Use Workgroup, which is charged with defining the standards to which HIT must be implemented in order for participating institutions to receive ARRA stimulus funds. Jesse Singer of The New York City Department of Health and Mental Hygiene described his work with the Primary Care Information Project, a program working to promote the implementation of EHRs among small primary care providers in underserved communities in New York City. On a much broader scale, Jay Srini of the University of Pittsburgh Medical Center presented her work towards developing HIT standards that will allow systems from different institutions to mesh and share information, while at the same time serving stakeholders with a multitude of different needs and perspectives.
The second session included two representatives of the HIT industry, followed by a panel discussion that included participants with different institutional viewpoints on how HIT can be designed to meet the needs of individual health care providers and their institutions. Charles Lagor of Philips Research North America described software programs developed by his company that are designed to use EHRs to support clinical decision making by physicians. These systems are intended to make care for complex conditions such as stroke more consistent and effective by reminding physicians of previous outcomes and relevant guidelines. John P. Gomez of Eclipsys Corporation analyzed the factors that play into the design of an HIT system, including the increasingly important role of the internet and social networking, the need for data sharing, and the possibilities for collective problem solving.
The ensuing panel discussion, which was moderated by Ken Ong of Catholic Health Services of Long Island, brought together an HIT consultant, a HIT manager working within a health care institution, and a computational expert to describe work on HIT design and implementation. Hui Cao of Deloitte Consulting described the process by which health care institutions select vendors to design and build HIT systems, with an eye towards developing systems that are integrated across the institution while meeting the needs of each individual component effectively. Patricia Dykes of Partners Healthcare System described her work on designing electronic versions of current workflows with the intent of improving efficiency and ensuring that the ability to meet future needs is built into the design of new systems. Thomas Clancy of the University of Minnesota explained how computational modeling and simulations can be used to predict the effects of implementing electronic workflows, providing a tool to help institutions better understand their own needs and to help visualize the effects of implementing a given system.
Speakers in the third and final session provided insight into some specific topics related to the adoption of EHRs, including security considerations, economic aspects, secondary uses of EHR data for pharmaceutical research, and the use of mobile devices in the HIT environment. Soumitra Sengupta of Columbia University/New York Presbyterian Hospital detailed security and privacy issues from perspective of an Information Security Officer, describing potential security risks of EHRs and the measures that institutions will need to have in place to conform with government regulations and disclosure rules. Edward Rogoff of Baruch College/CUNY provided a comprehensive analysis of the potential economic costs and savings associated with adoption of EHRs. Steven Labkoff of Pfizer Pharmaceuticals described how data extracted from EHRs might assist pharmaceutical companies in pursuing important comparative effectiveness and safety studies outside the framework of clinical trials, capturing the vast amount of clinical data that could be generated once a drug is in widespread use. Finally, Adam Wilcox of Columbia University described his work on the most effective uses of mobile devices in HIT, which is intended to find out what tasks these devices are most useful for and how they can fit effectively into electronic workflows to best support the clinical decision-making needs of health care professionals.
At the beginning of the day, George Hripcsak described how HIT was once considered a "crazy idea" that was not worthy of the attention of an academic researcher. While there is still a lot of work to do, there has been an immense turn around for this field, particularly since the advent of financial incentives such as those provided by ARRA. With the efforts of these individuals and many others like them, it appears that at least one aspect of health care reform will come to fruition, although the timeline, and ultimate price tag, for these efforts are still uncertain.
Rachel Block, New York State Department of Health
George Hripcsak, Columbia University's CAIM
Jesse Singer, New York City Department of Health and Mental Hygiene, Primary Care Information Project
Jay Srini, University of Pittsburgh Medical Center
- Widespread adoption of EHRs will require the development of significant regulatory infrastructure as well as buy-in from stakeholders across multiple institutions.
- EHRs can improve efficiency and quality of care among small medical "mom and pop" medical practices in economically disadvantaged areas.
- Meaningful use of EHRs includes data collection and dissemination, data use to improve quality of care, data sharing between institutions and public agencies, and demonstrated improvements in population health outcomes.
- EHRs should be designed for portability and flexibility to support sharing between institutions to facilitate their use for both clinical and nonclinical purposes and to provide individuals with access to their own health records.
New York State is an acknowledged leader in the adoption of health information technology having awarded more than $150 million in state grant funds since 2004, more than all other states combined. As the Deputy Commissioner of the Office of Health Information Technology Transformation, Rachel Block is closely involved with the distribution of these, in addition to state funds, as grants intended to reconfigure New York's health care systems. Block noted that the implementation of technology is not the ultimate goal of these projects. The overarching goal is in fact "transformation," in the form of comprehensive systems changes leading to more effective and efficient delivery of health care. She outlined many of the building blocks that need to be put into place to achieve these changes, which include everything from appropriate state policies and regulations, to identification of clinical needs and uses for technology, to buy-in by participants at every level of the system. She emphasized the importance of collaboration and consensus. New York's broadly coordinated strategy is one that is likely to be emulated by other states as they progress towards their own implementations of HIT systems.
As another representative of New York State, Jesse Singer provided a more ground level view of one of the many projects encompassed by the state's HIT effort. Singer is the Director of Quality Informatics for the Primary Care Information Project, a state program that is working to implement HIT in disadvantaged communities in New York City, as a means of improving care and overall population health in these areas. He and his colleagues are designing, and helping to implement, prevention-oriented EHRs that will improve health care provider workflows and patient self-management, and allow for detailed measures of quality of care in primary care practices. Many of the patients in these areas are uninsured, so this program will also provide an important source of data on such individuals. The program focuses on small physician-led practices, which provide the majority of primary care in the U.S. but are the least likely to implement EHRs because of the time and expense involved. These small practices will benefit from the efficiency of HIT, and those that show improvements in quality of care will eventually receive financial incentives as well. Echoing Block, Singer emphasized that HIT implementation is not the real goal of this project; rather, it is intended to have an positive impact on public health.
Because of the time and expense involved in implementation, incentives are an important part of the effort to promote EHR adoption at all levels of the health care system. As part of ARRA, the federal government established incentives that are tied to "meaningful use" of HIT by health care institutions. George Hripcsak is a member of the Meaningful Use Workgroup within the HIT Policy Committee of the Office of the National Coordinator of Health Information Technology. This workgroup is charged with defining the meaningful use of EHRs. It has identified three stages of meaningful use that can be achieved by health care institutions. Stage 1, which is the most fully defined to date, addresses five key areas: quality, safety, and efficiency; engaging patients and families; improving care coordination; improving population and public health; and ensuring privacy and security protections. Stage 2, which remains to be fully defined, is to begin using this data to improve clinical decision making, disease management and patient self-management, and to set up systems for sharing data with other institutions, including public health agencies. Institutions that reach stage 3 will be those that can show improvements in quality of care measures, population health, and other parameters that will indicate a successfully implemented program. As an institution reaches each stage, it will be rewarded with a new set of ARRA stimulus funds. Hripcsak and fellow committee members are working to define the rules that will govern whether an institution has reached each of these stages. He noted that they are seeking a balance between leniency and strictness, in an attempt to define rules that will encourage institutions to make improvements without becoming an undue burden. "The people at CMS [the Centers for Medicare and Medicaid Services] want to do what's right for the nation," he said, and are expending considerable effort to ensure that the program is fair and workable for all types of institutions.
Jay Srini is an expert on emerging technologies who spoke of her work on EHR design, particularly as it relates to creating data records that can be shared and utilized by a wide range of participants in the health care system, including institutions such as hospitals, community-based medical practices, and individual patients who may wish to access their personal health records. She envisions a national HIT framework in which data can be shared by multiple users, not just for clinical purposes but in order to provide for more efficient billing and reimbursement as well. Patient data records will need to be "liquid and portable," she said, if they are be used in the wide range of settings found within the health care system. In addition, EHRs will need to be designed to meet future needs that are already in development, such as remote patient monitoring and telemedicine. Srini said that she sees an opportunity for HIT designers to be creative, since standards are still in a state of flux. EHRs that are designed to meet the widest range of needs will have the most value to all users, facilitating more widespread adoption.
Charles Lagor, Philips Research North America
John P. Gomez, Eclipsys Corporation
Ken Ong, Catholic Health Services of Long Island
Hui Cao, Deloitte Consulting
Patricia Dykes, Partners Healthcare System
Thomas Clancy, University of Minnesota
- Patient treatment and outcomes data gathered from EHRs can be used to improve clinical decision making for complex conditions in time-dependent situations.
- The incorporation of internet-based tools, including the ready availability of EHRs in "the cloud" and the use of social networking sites, has the potential to improve medical practice.
- EHRs should be designed to fit into workflows that are optimized for individual use as well as to fit into departmental and institutional "mega-workflows" that are well-coordinated and work together efficiently.
As more than one speaker emphasized in the first session, HIT implementation is not an end in itself but rather a means towards the end of improving quality of care and promoting more efficient use of scarce resources. Two speakers from the HIT industry provided insights into the potential uses of EHRs to promote clinical decision making that is faster, conforms better to the expert guidelines intended to ensure high quality care, and takes advantage of group problem solving resources offered by social networking and other internet innovations.
Charles Lagor presented details on several systems that Philips Research has designed that use EHR data to support clinical decision making at the bedside. These systems are designed to solve specific clinical challenges. For example, despite the plethora of monitoring systems and alarms in the typical intensive care unit, physicians and other staff often do not realize that a patient's condition has worsened soon enough to head off serious consequences. Lagor described a system that uses data from previous patients to recognize complex patterns of changes in vital signs that indicate that a problem is imminent. Even if all vital signs are within normal ranges, certain combinations of changes will lead to an alarm that prompts early attention by the medical staff, leading to better outcomes for patients. In another example, he described a system that provides rapid decision making support for stroke, where the need for a quick choice of treatment often precludes the consultation of lengthy and complex expert guidelines. The Philips system would compare the present patient's condition to data on similar cases and make recommendations based on both previous outcomes and relevant guidelines. These systems are designed to utilize the data encoded in EHRs in a way that promotes better patient care and thus better health outcomes.
On a broader level, the EHR has the potential to be the "backbone of the health care ecosystem," according to John P. Gomez, who provided an overview of the potential impact of EHRs on medical practice in general. Gomez emphasized that freeing medical records from the physical location dictated by the use of a paper chart has the potential to make them available anywhere, anytime, on demand by the user. Placing EHRs in "the cloud" will remove barriers that currently prevent access to patient health care records by caregivers and patients alike, a particularly useful trait in emergency situations, where faster access to patient records means faster decision making. In addition, improved data sharing among individual practitioners as well as institutions will allow for increased collective problem solving, facilitated by the growing use of social networking and other internet innovations. Gomez noted that there are both positive and negative aspects to these developments. On the plus side, physicians will be able to work with data that is more accurate because it does not depend on patients' memories, and this more accurate data can be accessed in a more timely fashion. On the negative side, there is the potential for data to become corrupted, to overload clinical decision makers, to increase liability exposure, and to reduce control of clinical decisions by the individual practitioner. These are issues that will need to be addressed in the coming paradigm shift likely to occur as EHRs are more widely adopted and become available over the internet.
The ensuing panel discussion brought together individuals with a range of perspectives on HIT and EHR design. HIT consultant Hui Cao discussed the factors that institutions must consider when designing a new HIT system, including issues of integration into existing workflows, coordination across departments with different individual needs, and planning for future needs. She emphasized the need to look at the institution as a whole, designing "mega-workflows" in which EHRs will be used for different purposes. HIT manager Patricia Dykes described ongoing work in her institution to better define both present and future workflows so that needed information can be built into EHR design. Dykes highlighted usability as a critically important feature of HIT design, and described her institution's efforts to include end-users in the development process. Computational expert Thomas Clancy described his research, which takes a different tack towards developing efficient workflows. He has designed computer models that can simulate the potential effects of a specific workflow design, allow institutions to see ahead of time the implications of specific designs, and to better understand their needs. These simulations can test multiple scenarios, allowing for workflow optimization that is built into the design of the HIT system.
Soumitra Sengupta, Columbia University / New York Presbyterian Hospital
Edward Rogoff, Baruch College/CUNY
Steven Labkoff, Pfizer Pharmaceuticals
Adam Wilcox, Columbia University
- The use of EHRs creates a need for HIT systems that can track, manage, and safeguard disclosures of patient data.
- EHRs are likely to reduce wasteful spending on ineffective treatments and unnecessary or duplicated tests, but the overall cost-effectiveness of EHR adoption may ultimately be difficult to measure due to the high cost of adoption and because there may be unforeseen circumstances.
- EHRs could be highly valuable as a source of data on the effectiveness and safety of pharmaceuticals that have been used in large populations under real-life conditions.
- The widespread adoption of mobile devices makes it very likely that these devices will play an important role in future HIT designs, particularly for point-of-care applications.
The third and final session focused on practical aspects of EHRs, with speakers considering security matters associated with electronic data, whether EHRs will be cost-effective, the use of EHR data as an important tool in pharmaceutical research, and how the rapidly growing adoption of handheld devices, such as the iPhone, could be integrated in HIT systems.
Security expert Soumitra Sengupta started the session with a trip through the challenges posed by electronic health data, which include the need to protect patients' rights, the potential for malicious or inadvertent security violations, and the need to follow complex new regulations on disclosure set forth by ARRA. Patient records can be used within the institution to access data on treatment and payments, for example, or they may be shared with other institutions, in which case this access is defined as disclosure. Patients must authorize the disclosure of their data, except when it is requested by certain outside institutions such as law enforcement, courts, or government agencies working towards public health goals. Patients are also entitled to an accounting of any disclosures of their data within a certain period of time if they ask for one. Institutions also have a responsibility to ensure that patient data is not released to unauthorized parties, whether by accident or because of malicious intent. Sengupta described the system design consequences of these requirements, which include the need for components that identify users, create an audit trail that shows who accessed what data and when, and capture reasons for access that can be conveyed to patients when they are notified that their data has been disclosed.
What will be the economic impact of EHRs? Edward Rogoff considered this question from a variety of standpoints. The current estimate is that an approximately $19 billion investment will lead to $40 to $100 billion a year in savings for the U.S. health care system. This estimate is based on the potential savings generated by the efficiency of centralized patient records and the reduction of wasteful and unnecessary treatments and duplicated tests. Fewer physical records also means less staff is needed to pull those records. But the costs are considerable as well, for such things as new computers, staff to operate the computers, and training for physicians and others. It is also feared that physicians will order more tests to reduce their potential liability if patient records become more accessible to outside parties. Rogoff estimated that the true cost of implementing EHRs will be more on the order of $200 billion, but that it is likely to happen anyway, in the next 5 to 10 years. Will this conversion ultimately be cost-effective? In his estimation the adoption of EHRs will lead to "huge savings," but he cautioned that the savings may be hard to measure definitively.
One area in which EHRs could potentially lead to huge savings, as well as considerable reductions in morbidity and mortality, is the use of EHR data to collect post-marketing information on the effectiveness and safety of pharmaceuticals. Steven Labkoff described the dilemma of pharmaceutical companies, who are increasingly pushed to provide "real life" data on the effectiveness of their products outside of clinical trials, but who own only a fraction of the data generated once a drug has reached market. Labkoff suggested that such companies could partner with the academic and government institutions that own most of this data to build consortia in which post-marketing data would be shared, with appropriate controls, standards, and regulations. The companies themselves could also form cooperative organizations that would pool resources to develop HIT systems that would be able to use this and other data effectively. Such efforts could greatly reduce drug development costs by allowing the mechanisms and side effects of currently used drug classes to be understood more thoroughly.
The final speaker, Adam Wilcox, reminded listeners that the future of HIT will include not just full-fledged computers but also handheld computing devices. Smartphones and the like are no longer niche devices: it is estimated that at least 80% of physicians will use one by 2012. However, these devices have characteristics that are likely to make them very useful for some tasks and not as useful for others. They are not able to display large amounts of data, and typing on them is awkward, so it is unlikely that they will ever be useful for data entry tasks. Their greatest advantage is that they are highly portable and they are always near at hand, which means they would be most useful for tasks that need to be done away from a desk, whether at the patient's bedside or outside of the institution. Such tasks could include displaying checklists or standing orders for patient care, alerting physicians to medication errors or potential drug–drug interactions, and notifying physicians of laboratory test results. Away from the bedside and the patient, these devices could also provide follow-up reminders and patient status updates in a timely fashion. These devices are increasingly integrated into IT systems and it is likely that health-related IT will be no exception.
Will EHRs fulfill the promise of improving quality of care, including care delivered to disadvantaged populations?
Will systems designers and hospital administrators achieve their dream of integrated, effective HIT systems that improve workflows and reduce costs?
How much will the adoption of EHRs ultimately cost?
Will pharmaceutical companies be able to develop cooperative methods of sharing post-marketing drug data and will this data improve drug safety?
How will handheld devices be integrated into HIT systems?
Will ARRA funding provide the push that is needed to promote widespread adoption of EHRs?
What new, unforeseen opportunities with EHRs provide in the future for improving healthcare delivery and effectiveness in the U.S.?