EHR – a long way to go!

EHR implementation in India is in a nascent stage with piecemeal implementation. It still needs to build infrastructure, integrate for interoperability, and support upgradation based on technological advancements.

The beginning of this new year has seen keen industry observers trying getting a handle on what health IT (HIT) will bring in the months ahead. HIT will play a critical role in 2020 to enable more effective processes. To mitigate inflated costs and retain patients, providers this year will implement savvier technology solutions to reach patients, such as telehealth visits or new ways of engaging with patients across their care journey to help them stay on top of their health and well-being. Healthcare also will see an increasing variety of innovative payment and business models to balance cost and outcomes.

When it comes to health IT, the healthcare industry is getting it all wrong. It is not about securing meaningful use incentives or checking codes to maximize reimbursement. In 2020, human-centered technology will take center stage. These are solutions that are designed around the patient so that their ability to access the care they need comes first.

The adoption of today’s new breed of advanced electronic health record (EHR)-integrated technology will continue to grow as providers seek to automate all of the things that get in the way of a patient-friendly experience – from online scheduling and rescheduling to capturing the key patient data required for pre-appointment.

For patients in 2020, that means shorter wait times, a better experience at the doctor’s, and, most important, better health outcomes.

Indian scenario
India has a mixed system of healthcare consisting of a large number of hospitals run by the central government and the state governments as well as the private sector. In general, the level of use of ICT in the healthcare sector in the country has been lower in comparison to other countries. At the same time, both union and state governments are working on several fronts to make use of the opportunities offered by ICT. Private sector hospitals are also in the process of implementing ICT projects, including electronic patient records.

The Indian EHRs market, which accounted for approximately 9 percent of the Asia-Pacific EHR market in 2019, is expected to grow at a compound annual growth rate of 5 percent through 2025, estimates GlobalData. Wide accessibility of EHR in specialty centers and hospital-attached research centers will spur the market growth over upcoming years. Several providers of electronic health record systems in India are focusing on innovation of EHR. Furthermore, growing awareness pertaining to the benefits of electronic health record will expand India electronic health record market growth over the coming years.

In July 2019, the Ministry of Health and Family Welfare released National Digital Health Blueprint (NDHB). The ultimate goal is to achieve Universal Health Coverage (UHC) through Ayushman Bharat. The two key objectives of this program are to set up 150,000 health and wellness centers for primary healthcare and provide healthcare coverage to over 100 million poor and vulnerable families.

UHC will generate a large amount of health data, and digital health records can provide support and accelerate this transformation. EHRs will provide the Indian government with access to direct and reliable healthcare data and information on health conditions. This data will help the government to regulate the cost of treatment and medical research.

However, the implementation of EHR is currently limited to major private hospitals, such as Max Health, Apollo, Sankara Nethralaya, Fortis, and a few government hospitals, such as AIIMS, mostly in urban India. Max Healthcare hospitals have achieved Stage-6 level of the EMR Adoption Model, which is used by the HIMSS for assessment of the level of adoption of EMR systems in any hospital. The Apollo Group also has implemented EHR in its hospitals and achieved Stage-6 in the EMR Adoption Model for four of its hospitals located at Chennai, Nandanam, Aynambakkam, and Jubilee Hills. Sankara Nethralaya (SN) has implemented an EMR system in its hospitals and satellite clinics in Chennai. It engaged Tata Consultancy Services (TCS) for implementation. SN and TCS also offer the EHR suite and hospital-management system to other hospitals. However, even in private hospitals, EHRs are rarely exchanged between hospitals. These remain in the same hospital and are referenced when the patient visits again. There is no authentic report on the number of patients whose EHRs have been stored so far.

Lack of awareness, high initial investment, scarcity of trained staff, and lack of mandatory guidelines to store healthcare records electronically are a few of the major barriers for low adoption of EHR in India.

An enormous effort by the government and support from clinicians is needed to make this project a success. In addition, a large population that the Government of India is planning to cover only understands local or regional language. Creating digital support systems in multiple languages is going to be a challenge. Safety and privacy of personal and health data are some of the other issues that the government needs to address

Global scenario
The global EHR market is expected to cross USD 38 billion by 2025, estimates Global Market Insights. Increasing government expenditure and funding for the development of healthcare IT solutions for better understanding of diagnosis and treatment pattern will contribute to considerable EHR market growth over the next 5 years. Additionally, rising internet penetration and campaigns conducted to increase awareness about the importance and benefit of EHR among the doctor community will significantly expand the business size. Thus, growing awareness of EHR in hospitals and healthcare settings will accelerate the demand for electronic medical record systems over forthcoming years.

Increasing implementation of electronic health records will foster the global electronic health records industry growth in the upcoming period. Electronic healthcare records are used for systematic collection of patient’s health records in a digital format for better understanding of diagnosis and clinical treatment procedure. Rising adoption of electronic healthcare record for streamlining workflow and enhancing patient-care delivery will positively impact adoption of electronic medical records in the forthcoming years.

However, the dearth of capable professionals to handle advanced technology and high cost of EHR systems may hamper the market growth over the upcoming years.

On-premise EHR software market held more than 48 percent revenue share in 2019. Simultaneous access to multiple users, automation of elimination of redundant processes coupled with better safety of patient information, are the major factors attributable to the segmental growth. Rising advancements in EHR technology, such as increased work efficiency in controlled medical vocabulary and clinical decision support system, should drive the consumer preference for on-premise EHR.

E-prescription application market is estimated to witness considerable growth over the next 5 years at a CAGR of 6.3 percent. E-prescription offers alternatives to the pharmacist to choose among various generic drugs as well as potentially allergic reactions. This feature enables safe and reliable documentation with less errors owing to illegible writing style of the prescribers. Additionally, flexibility of management of broad range of data points in drug-store management will offer attractive growth opportunity for e-prescription market growth in the future years.

Specialty centers segment of electronic health record market accounted for USD 3.9 billion market size in 2019. Escalating demand for diagnostics owing to rising prevalence of genetic and orphan disease forms the major impact factor in adoption of electronic solutions. Presence of special software for specialty centers further drives its adoption rate among specialty centers over the forthcoming years. Furthermore, developing healthcare infrastructure in emerging economies should augment the segmental growth in the forecast years.

The electronic health records market in Asia is at its initial growth phase, and hence, this region is expected to offer new opportunities in the coming years. Asia-Pacific has the highest population of individuals suffering from chronic disorders, such as diabetes, coronary thrombosis, tuberculosis, and others. The healthcare industry is facing problems, such as lack of trained workforce (technologically proficient employees in healthcare), lack of proper healthcare facilities in rural areas, and lack of awareness about healthcare options among population. However, with rise in demand for better healthcare services and improving healthcare infrastructure, the demand for EHR solutions is on an increase to manage the functioning of healthcare organizations.

Few notable players operating in electronic health record market are Allscripts, Cerner, eClinicalWorks, GE Healthcare, and Epic Systems, among the other industry players. Companies are implementing new product launch and product improvement strategy for capturing higher market share.

Challenges
There are many challenges in making electronic health records more integrated, including endless customization, vendor-market share protection, health-system market share protection, and technological factors. These are just some of the challenges of making EHRs more integrated.

Currently, if you are a health system running an instance of the leading enterprise EHR systems and across the street is a different health system using the same EHR vendor as you, the two systems would not directly communicate with each other because they have been customized to such an extent that the data elements would not directly match up. So, a patient who is seen at their doctor’s office, running Cerner, Epic, or Allscripts, may show up at a competing hospital’s emergency department who has the same software, but their discrete granular data from their doctor’s office would not appear in the other hospital’s records. The best we have done with interoperability is getting one system to send a pdf version of the patient data to the other system to view, which is essentially a modern version of the fax machine.

A question that commonly arises from the patient perspective is, “Why did it take an act of Congress to force electronic health record vendors to integrate their technology with each other?” Like most technology products, the more information that flows from one to the other, the more both sides would have access to better data about their users. We see that happen when websites allow you to login with Amazon or Google. But in the healthcare world, where data sharing amongst providers is arguably the most important realm, the established EHR vendors decided to set their own information-exchange platforms rather than coming up with an industry standard for sharing granular data. The backdrop is that the legacy EHR vendors have been in a battle for market share and keeping their customers hostage in their ecosystem means that they cannot switch away from their software without significant barriers and concerns about lost data. Under the Affordable Care Act, vendors were forced to open their data to exchanges and common communication languages, such as FHIR. This bold step has created an incredible opportunity for innovation to come to healthcare data that can be shared rather than siloed.

In spite of the initial slow acceptance of EHRs by clinicians and healthcare organizations, they continue to proliferate and improve over time. Electronic health records have been transformational for large organizations, but the reality is that medicine in this country is mostly practiced by small medical groups, with limited finances and IT support. As a new trend, some outpatient clinicians opt to re-engineer their business model based on an EHR. Their goal is to reduce overheads by having fewer support staff and to concentrate on seeing fewer patients per day but with more time spent per patient. When this is combined with secure messaging, e-visits and e-prescribing the goal of the e-office is achievable.

Buyers have a wide choice of features and cost to choose from. At this time, cost is a major obstacle as well as the lack of high-quality economic studies demonstrating reasonable return on investment. As more studies show cost savings, medical groups that have been sitting on the fence will make the financial commitment.

Outlook
EHR implementation in India is still in its nascent stage with piecemeal implementation where it is already being implemented. It cannot be considered to be a mature market as there is still a need to build infrastructure, integrate for interoperability, and also support up-gradation based on technological advancements. To date, it can still be considered one of the best markets for technology implementation as cost of high-quality care is low when compared to other markets. This can be said, based on the number of medical tourism visitors in the country. High-quality care is affordable at most of the private healthcare centers in the country, although there are some of the publicly owned centers that too provide the best of care.

ICT penetration in the country has been enabling successful implementation of the solution but the disparities still exist in rural and urban areas. This is due to the fact that technology penetration is low in rural areas, leading to lower chances of EHR implementation. However, low-cost solutions in place of full-fledged technology solutions like EHR can be made available using portable devices. This way, availability of patient records is enabled while also enabling future transitions of data to be integrated with network-based databases for multiple use and across multiple functions. Future enhancements in both rural and urban areas are possible and essential to improve quality of care through effective use of technology.

As the country’s technological infrastructure develops further to penetrate rural areas, it can be easy to implement technological solutions like EHR in the industry for economic development too. Factors affecting successful implementation can be addressed as the centers progress to implement the solution through the seven different stages of implementation. It is recommended that the government develop a regulatory framework to ensure that quality care is provided through all the stages of EHR implementation with smooth transitions between stages and technology up-gradations in future.