By Dr Marcella McGovern, ARCH
What are Electronic Health Records (EHRs)?
The Health Information Management Systems Society (HIMSS) definition of EHRs is the most widely used internationally and the definition adopted by eHealth Ireland. They define EHRs as:
‘a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting’ .
The wide range of eHealth architecture necessary to support an EHR in Ireland has been captured in eHealth Ireland’s Blueprint (http://www.ehealthireland.ie/Library/Image-Library/EHR%20Architecture.png), with the various packages of work summarised in Figure 1 below:
Figure 1: The National EHR
[Available at: http://www.ehealthirel`and.ie/Strategic-Programmes/Electronic-Health-Record-EHR-/]
Funding EHRs in Ireland
In May 2017, a cross-party Oireachtas Committee on the Future of Healthcare in Ireland launched a report entitled Sláintecare, setting out a 10 Year vision for Ireland’s healthcare system. The Dail’s unanimous decision to establish this Committee was described by its Chair, Roisin Shortall, in the Report’s foreword as ‘a unique and historic opportunity for TDs from across the political spectrum to come together to develop consensus on a long-term policy direction for Ireland’s healthcare system’ . It was intended that establishing a cross-party consensus on the future of Irish healthcare would help take the politics out of healthcare; whereby a best-practice policy agenda could be maintained beyond a single government term.
The final Report was the product of over a year’s work by this cross-party Committee, which considered national and international evidence, stakeholder submissions, public hearings from Irish and international experts and facilitated workshops. Connected Health was given prominence in this report, with the Committee concluding that ‘eHealth is the critical enabler to implement the change required to deliver an integrated, universal, high quality health system’ . The Report, published in May 2017, recommended allocating 875 million to eHealth over the first six years of this 10 Year plan to ensure that the eHealth strategy is implemented, with special priority given to EHRs. This funding represented the second biggest allocation (29%) under a transitional and legacy fund of €3 billion, intended to create the capacity, structures and processes necessary for the implementation of Sláintecare’s recommendations. This figure reflects the Office of the CIO’s National Electronic Health Record: Strategic Business Case  estimated that the rollout of EHRs would cost 875 million over a 10 Year period.
Budget 2018 revealed that the funding and implementation timelines proposed by the Sláintecare Report were only recommendations. Funding for EHRs did not feature in Budget 2018. In February 2018 however, a government commitment was given to fund the implementation of EHRs as a capital infrastructure priority under the National Development Plan 2018-2027 . A total of 10.9 billion (9% of a total investment plan of 116 billion) was committed to the area of Health, to fund 14 major investment projects and programmes, as well as two significant reform initiatives. One of these reform initiatives is the Sláintecare Reform recommendations for eHealth and ICT, including the National Electronic Health Record Programme. The budget specifically allocated to EHRs was not specified but the parallel commitment to deliver the National Children’s Hospital, as Ireland’s first Digital Hospital scheduled for completion in 2022, provides a deadline for the establishment of EHRs in the Irish context.
Opportunities and Challenges for the Connected Health Industry
The key opportunity of EHRs for the Connected Health Industry is that the development of the technical architecture required to support EHRs will likewise provide technical architecture upon which other digital health solutions can be supported. Accenture’s Infographic on Making the Case for Connected Health charts the journey to Connected Health in three stages:
1. Healthcare IT adoption – the planning, construction and use of a digital infrastructure
2. Health Information Exchange – the exchange of captured health information between clinicians, across administrative groups and with patients.
3. Insight driven healthcare – the use of advanced analysis of data to better inform clinical decision making, population health management and the creation of new care delivery models .
Figure 2: Accenture Infographic: Making the Case for Connected Health
[Available at: https://www.scribd.com/document/124079828/Accenture-Infographics ]
The HSE’s Electronic Health Record (EHR) Programme and the Health Identifiers (HIDs) Programme are crucial developments for Stage 1 and 2. With this technical architecture in place, the Connected Health industry will have the opportunity to drive Stage 3, using insight driven healthcare to enable care transformation.
Lessons from healthcare systems further along this journey however, have discovered that there are a number of key challenges. One key challenge is integration and interoperability. In the United States for example, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 ‘authorized the Centers for Medicare and Medicaid Services (CMS) to provide financial incentives of $30 billion to eligible hospitals and professionals through Medicare and Medicaid to adopt and meaningfully use certified EHR technology’ . Despite this substantial investment, a nationally representative longitudinal survey of hospitals in the US (N=2,636) found that progress toward interoperability in sharing patient information is slow and that progress is ‘focused on moving information between hospitals, not on ensuring usability of information in clinical decisions’ . This study examined four domains of interoperability: finding, sending, receiving and integrating electronic patient information from outside providers, and found that only 29.7 percent of hospitals were engaging in all four domains in 2015; up slightly from 25.5 percent in 2014. While there had been progress on sending (8.1 percentage points) and receiving information (8.4 percentage points), there had been no change on integrating information. In an interview with Healthcare IT News, the HL7 CEO Charles Jaffe suggested that progress was slow in resolving interoperability issues due to a lack of business case for industry, commenting that: “You can’t expect the for-profit vendors to connect everyone on their own dime…why would I want to share data with my competitor when I’ve been trying to keep data from him for about 10 years?” 
If the IT Industry commit to this logic however, Connected Health will fail. The challenges go beyond integration and interoperability. As detailed in a Connected Health Whitepaper by Dell, there are also legal, regulatory and reimbursement hurdles; security and liability issues; too much data and not enough insight; each of which demand a partnership approach by Government, Policy and the IT Industry to progress towards Connected Health .
Academia, through applied research centres like ARCH, should be leveraged as an independent third party in this partnership, capable of exploring, testing and refining strategies to overcome these challenges, with sensitivity to the unique sociotechnical conditions of the Irish healthcare system. This partnership can work to ensure that the Irish Government get value for money for their investment in digital health architecture and the Connected Health industry can flourish in producing innovative digital health solutions, which utilise this architecture to transform the health and social care services delivered.
- EHR definition. http://www.himss.org/library/ehr
- Houses of the Oireachtas Committee on the Future of Healthcare. Slaintecare Report. May 2017. Available at: https://www.oireachtas.ie/parliament/media/committees/futureofhealthcare/Oireachtas-Committee-on-the-Future-of-Healthcare-Slaintecare-Report-300517.pdf
- Office of the CIO. National Electronic Health Record: Strategic Business Case. May 2016, Version 1.0. Available at: http://www.ehealthireland.ie/Strategic-Programmes/Electronic-Health-Record-EHR-/Progress/National-Business-Case.pdf
- Government of Ireland. Project Ireland 2040: National Development Plan 2018-2027. February 2018. Available at: file:///C:/Users/Marcella/Downloads/NDP-strategy-2018-2027_WEB.pdf
- Connected Health: The Drive to Integrated Healthcare Delivery. 2012. Available at: http://akademia.nfz.gov.pl/wp-content/uploads/2016/07/Accenture-Connected-Health-Global-Report-Final-Web.pdf
- Marlow, L. Should Government Subsidize Electronic Health Records? Mercatus Working Paper. March 2017. Available at: file:///C:/Users/Marcella/Documents/EHRs/mercatus-marlow-health-records-v2.pdf
- Holmgren, J., Patel, V., & Adler-Milstein, J. Progress in Interoperability: Measuring US Hospitals’ Engagement In Sharing Patient Data. Health Affairs. 2017; 36 (10): 1820-1827.
- Davis, J. The biggest interoperability holdup? There’s no business case for it. Healthcare IT News. 27 November 2017. Available at: http://www.healthcareitnews.com/news/biggest-interoperability-holdup-theres-no-business-case-it
- Connected Health: The Past to Better, More Integrated Care and Health Outcomes. August 2016. Available at: http://i.dell.com/sites/doccontent/shared-content/data-sheets/en/Documents/Dell-Connected-Health-Whitepaper-final.pdf