EMR or EHR? The terms “electronic medical record (EMR) and “electronic health record” (EHR) are often used interchangeably, both by many physicians and by the public. I was curious as to the official differentiation between the terms, and after some poking around, found some perspective that should be as definitive as any. In January 2011, Peter Garrett, the Former Director in the Office of Communications and Joshua Seidman, the Director of Meaningful Use at the Office of the National Coordinator for Health Information Technology (ONC), published a memo entitled `EMR vs EHR – What is the Difference?` in the publication Health IT Buzz from the ONC desk.  The authors state that at the ONC, electronic health record or EHR is used almost exclusively. They clarify that the EMR term came along first, with most early EMRs “medical” in focus. They viewed EMRs as a digital version of the paper charts in the clinician’s office, containing the medical and treatment history of the patients within one practice (more local). In contrast, EHRs are intended to focus on the “total health” of the patient, and in particular, are designed to reach out beyond the organization that originally collects and compiles the information, to aggregate and share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. So they view EHRs as more global and comprehensive. Still, in practice, most everyone will understand what you are discussing if you use either term.

EHRs and Meaningful Use Through the Health Information Technology for Economic and Clinical Health (HITECH) Act, a major provision of the American Recovery and Reinvestment Act of 2009, the federal government injected billions of dollars in financial incentives into the health care system to spur adoption and Meaningful Use (often abbreviated `MU`) of EHRs. The HITECH law provided for a mix of carrots and sticks to achieve this goal. Doctors and hospitals received $28 billion (lots of carrots) in federal stimulus money starting in 2011 to install EHRs, with financial penalties (the sticks) if they failed to switch from paper records to EHRs after a suitable time period. However, when Congress created the EHR pool, lawmakers decreed that it was not enough to merely acquire such systems, but that health care providers also would have to make “meaningful use” of these technologies to be eligible for these incentives. Rather than define Meaningful Use in the law, Congress left it up to the Department of Health and Human Services (HHS), in particular the ONC, to do so. In July 2010, HHS released an initial set of regulations defining what constitutes Meaningful Use, although over time, ONC officials plan to expand the definition. Initially, Meaningful Use requirements include a number of clinical functions, such as prescribing medications electronically, as well as measures of clinical quality. Critically, in order to meet the Meaningful Use criteria, providers must adopt certified EHR systems.

How Did we Get to Now? The HITECH Act quickly produced dramatic changes in several interrelated directions. First, as intended, the vast incentive pool rapidly accelerated the adoption of EHRs by both hospitals and by private practices. Second, and not surprisingly, federal engagement in promoting EHR development drew in large numbers of private firms and investors. From 2007 to 2012, the EHR market doubled in the intensity of its production, from about $10 billion to about $20 billion in yearly activity. As a result, health care institutions and providers found themselves with a large selection of options. Third, the emergence of these HITECH funds served to crystallize the business model of the hospital-medical complex, towards the overwhelmingly dominant goal of obtaining as large a portion of these MU dollars as possible. Therefore any EHR vendor who could maximize the hospital’s potential take would generally become the preferred choice, virtually independent of other implementation attributes.

Now, independent of the HITECH Act, the Affordable Care Act (signed in 2010) led to significant consolidation within medicine in an aim towards synergy, with hospitals buying up many (especially smaller) medical practices as a result of significant financial incentives to both sides. But this system integration into larger, merged hospital systems fed a burgeoning, megalithic beast. Most of these larger systems have now evolved from a previously medical-centric to an administrative and business-centric environment. In retrospect, this should hardly be surprising on two counts: (i) ascendancy within very large-scale organizations is Darwinian; and (ii) many of the new mega-systems are monopolistic within a local area, so that the staff (including newly `acquired` physicians) had no option but to swallow administrative mandates, unless they chose to either move far away or retire. To this more business-centric environment, the HITECH Act basically became a bolus $28 billion dollar gift (or bomb, depending on which side of the table you sit on). So the last two sentences of the previous paragraph are then reiterated, except now in BOLD and in a substantially larger point size.

Incidentally, for you political junkies, while the Affordable Care Act, AKA Obamacare, is an endlessly debated product of the present administration, the HITECH Act in effect was very much a bipartisan effort. Its aim was to achieve nationwide use of health IT by 2014, a goal originally set in 2004 by President George W Bush and reaffirmed by President Obama in 2009.

Where does Epic Systems Fit In? Epic was a solidly regarded EHR vendor prior to the HITECH Act, although hardly the leading company in the business. Their profile initially escalated when in 2003, Kaiser Permanente chose it over two larger companies (IBM and Cerner) to provide the EHR for its 36 hospitals and more than 8 million members. However, the decisive tipping point occurred when the HITECH Act was being formulated. As a 2014 RAND research report (RR-308) clarified, Epic’s CEO, Judith Faulkner was selected as the only head of a health IT company to serve on the Obama administration’s Federal Health IT Policy Committee. (I will have much more to say from this report, entitled Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value, in later essays.) This gave Faulkner and Epic a critical and especially timely edge, as Faulkner was then able to advise the national coordinator for health IT and other federal officials as they crafted a policy framework to develop a nationwide health information infrastructure, including criteria ultimately adopted to satisfy Meaningful Use (MU) in the HITECH Act. Unsurprisingly, then, potential users found that Epic was especially well-suited to help them meet MU criteria and thus get them many millions of dollars in government subsidies once the HITECH Act went live. Word-of-mouth gets around, and major operators often emulate the strategy of other centers that have been highly successful in a similar business endeavor. This has ultimately led to the present state of affairs, in which, as the RAND report describes, “Epic has established itself as the enterprise-wide solution of choice for large private health care systems and academic medical centers, irrespective of ongoing concerns about its limited interoperability and less-than-ideal usability.”

So, we reconfirm two key points. First, the particulars of the HITECH Meaningful Use criteria drove most users’ selection process of a preferred EHR vendor that best assured certification, and second, in any business-centric (hospital or medical) system, little else counted.

Is Epic the Main Issue for Physicians? In a word, NO. Epic was the best prepared of the business-oriented EHR vendors to meet MU criteria, and therefore to generate lots of revenue for its clients. Epic is the dominant EHR vendor within the most famous academic medical centers, a sound, albeit quasi-monopolistic business strategy. It is the 800 pound gorilla about which many anecdotes are told, and certainly is the system with which I am most familiar, given that it is the system that the Yale-New Haven Hospital uses. And YES, it is a pain to use. But if Epic were not primary, any of its main competitors, such as Cerner or MEDITECH might have become dominant, or alternatively, the EHR market might be even more fragmented than it is today. In any event, from a strictly business vantage-point, the $28 billion HITECH incentive is driving the focus of all major EHR vendors in this game. Most, if not all of Epic’s primary competitors in market share are also strongly billing-centric, and likewise share secondary administrative characteristics. So for a physician who is now part of a major hospital system, a change in EHRs would likely produce negligible change to either their increased patient volume and or to their new, heavily administrative requirements. And most of the issues that I am concerned about here would remain.

No, what I believe is required is balance or counterweight in EHR requirements, beyond the present MU criteria, to ensure that human (providers’ and patients’) needs are properly fulfilled, as well as business needs. I think that this is achievable by regulating the EHR vendors as public utilities, with health care the underlying public good, and I discuss this in the essay entitled `Solution Proposals`. In the absence of such a balance in requirements, although it still might be possible to leverage Epic to be more cooperative in interoperability, little else would likely change at a structural level for physicians.