For a new decade, rethinking electronic health records

While no one can predict what the future of EHR will look like, the combined wisdom of experts can give us a pretty good idea. In the coming decades, expect to see significant growth in accessibility, integration, IoT devices, and interoperability between EHRs and EMRs.

As a developing country, with the second-largest population in the world, India has an ever-growing need for quality healthcare. Digitizing healthcare is one of the key objectives of the government to ensure equal access to treatment at a reasonable cost. The Indian government is also keen on affordable drug discoveries and healthcare research through the use of data generated in the country. Electronic health records (EHR) are at the core of India’s goals of digitizing the healthcare system and moving toward universal health coverage (UHC). The Indian electronic medical records (EMR) market is projected to witness a compound annual growth rate of 6.67 percent to grow to ₹2203 crore by 2026, from ₹1463 crore in 2021. India is taking cognizance of the benefits of EHR systems in terms of improved patient coordination, increased patient participation, improved medical research, and reduction in healthcare costs.

In 2018, the government launched the UHC scheme, known as the Ayushman Bharat Yojana. This national health insurance scheme has two main components – the Pradhan Mantri Jan Arogya Yojana (PM-JAY), which aims to provide a ₹500,000-cover to the bottom 40 percent of the population for secondary and tertiary care and the establishment of around 150,000 health and wellness centers across the country for primary care, especially in rural areas. As a result, health data is being regularly collected for the said beneficiaries and there is a mandate from the government to digitize these records and take steps toward implementing EHR systems. Several national-level policies, such as National Digital Health Mission and National Health Stack are being formulated to create a pan-India digital health record system. At the provider level, large health systems like Tata Memorial Hospital, Apollo Hospitals, and Max Hospitals have implemented EMR systems and are moving toward EHR.

Some of the barriers to implementing EHR systems include the low government spend – only 1.5 percent of its gross domestic product (GDP) on healthcare. Data from the Organization for Economic Co-operation and Development (OECD) shows that India’s average spending on healthcare is lower than that of both developed and developing countries.

Issues with data sharing and data security. EHR systems across the globe are maintained through the effective use of a unique identifier. In the USA, the social security number and in the UK, the national insurance or NHS number is used for this purpose. Additionally, stringent laws like the Health Insurance Portability and Accountability Act (HIPAA) of 1996 in the US and the General Data Protection Regulation GDPR in the European Union (EU) ensure that health data remains secure. India does not have a comprehensive or sector-specific (for healthcare) Data Security Act; however, India has a unique identifier called Aadhaar.

Having said this, the lack of regulatory frameworks and policy with respect to the security of Aadhaar makes it difficult for use in handling sensitive patient information. More recently, the government has been trying to use Aadhaar for ensuring Covid-19-related vaccination but there are issues related to how to use it in the most efficient way without compromising on data security. The Aarogya Setu or the Indian Covid-19 contact tracing, syndromic mapping, and self-assessment mobile app, which was implemented by the government in the year 2020 came under severe criticism on grounds of data security and could not be made mandatory.

Lack of minimum viable standards. The government has not specified any technical standards for an integrated system of healthcare and service delivery. The EHR Standards 2016 mentions a list of ISO standards that hospitals may comply with. However, hospitals can voluntarily choose which standards they want to comply with. In countries, such as Australia and the USA, there are minimum standard requirements that entities must abide by for effective record management and interoperability. Only a select number of healthcare providers follow certain standards, and even then, there is no uniformity across this select group/global best practices, making it difficult to integrate EHR systems.

Other issues. Apart from poor infrastructure and broadband connectivity, which is core to an efficient digitization process, there are issues like low information technology (IT) budget of the hospitals for EHR implementation. In comparison to many countries that spend close to 5 percent of the total hospital budget on IT, Indian private hospitals tend to spend only 2.5 percent of the total hospital budgets on IT. The corresponding share is much lower in government hospitals. Compared to health IT, most of the budget is spent on revenue-generating components, such as hospital beds and wards. Further, there is skill and training gaps. Many government-run medical and nursing colleges at the state level do have courses on the use of technology as part of their curriculum of medical degree courses. Therefore, doctors, nurses and other medical staff are ill equipped to enter the data online and hospitals have to spend time and money on training of their staff in technology. In some cases, the staff themselves are not willing to enter patient data online as they pointed out that the number of patients per doctor is very high in India and data entry is time consuming.

India may need to solve these challenges as well as evaluate EHR models used in the developed countries and tailor them to match the country’s needs. Some recommendations to address these issues are:

Increase funding. As per the National Health Policy of 2017, the government wants to increase public health expenditure to 2.5 percent of GDP by 2025 from 1.5 percent in 2017. Survey participants pointed out that the target of 2.5 percent should be aggressively pursued, with a focused budget allocation toward digitization, along with attracting more investment through conducive policies and incentives. This should also include the cost of training medical professionals with the EHR systems, rules, and standards. There should be clear targets of complete digitization of district-level hospitals and primary healthcare centers.

Focus on quality of healthcare delivery. Private hospitals account for close to 60 percent of the healthcare system in India. These are concentrated in urban areas while public hospitals have a larger presence in rural areas. There is a need to equip all hospitals with basic technology, infrastructure, and training. A pan-India survey of hospitals to understand needs and gaps can help facilitate this.

Basic ICT infrastructure. Public hospitals and dispensaries have very little ICT infrastructure. Only some major public hospitals, such as the All India Institute of Medical Sciences (AIIMS) and the Postgraduate Institute of Medical Education and Research (PGIMER), have computers and connectivity. The number of public healthcare facilities is quite large in the country; therefore, a large investment in hardware and software is required. To reduce expenses, it is necessary to use open-source software systems, mobile devices, and the cloud computing environment. With the implementation of the National Optical Fiber Network (NOFN), broadband connectivity will be available in every village. Once connectivity becomes available, cloud-based healthcare delivery can be brought to the village level.

Robust data collection. A robust data-collection system is integral to EHR. It is important to define the data required, prioritize fields, and divide data fields across various user roles and stakeholders. The various datasets (e.g., laboratory results, diagnosis, clinical data, etc.) in a central repository for access and use. For benefitting from NHE, the use of fields supported by the central repository needs to be mandatorily followed by all individual EHR systems. Also, for unstructured data (like images, doctors’ notes, etc.), a mechanism to convert to structured data as defined by the repository should be implemented making health data easier to maintain. For identification, the UHID can be supported along with the Aadhaar card to provide more security in the form of dual authentication. For regions with low infrastructure, a process should be outlined to assist secure digitized data at regular intervals.

Maintaining standards. The National electronic Health Authority (NeHA) set up in 2015, and the MoHFW drafted the Digital Information Security in Healthcare Act (DISHA) in 2017 address the growing concerns for EHR standards. However, these standards were not enforced and stakeholders raise multiple concerns. In order to ensure secure interoperability, the MoHFW, in line with global best practices, should specify appropriate global EHR standards, such as the Fast Healthcare Interoperability Resources (FHIR) standards so that patient records are readily available, discoverable, and understandable.

Filling the gaps. Modern EHR systems require computers and high-speed seamless broadband connectivity, along with quality power supply. It is essential to first set up the required infrastructure before boosting health-tech. In order to allow for the easy implementation of health record systems, the government can give a mandate that clinical establishments across countries should have basic computers with internet connectivity. As a step ahead, the government in its primary care centers under the Ayushman Bharat Yojana should also provide practitioners with these facilities along with smartphones/tablets to allow real-time data collection. At the same time students in healthcare should be trained in use of technology as part of their course curriculum. The National Skill Development Council can partner with medical schools and hospitals on digital training. In this context, India can look at how some other countries have implemented their digitization process, and there can be more collaboration and partnerships through platform like G20 for which India is going to take up the Presidency in 2022.

Free and open-source EMR. As more than 75 percent of outpatients and more than 60 percent of inpatients are being treated in private healthcare facilities, it is necessary for the government to bring them on board for using EHR. In view of the size of the country, there is a need to take an FOSS approach to making good-quality software available to hospitals and individual practitioners. It should support all major national language scripts. If it is in the FOSS domain, even local entrepreneurs can provide technical support.

In conclusion, a number of countries have launched national initiatives to develop ICT-based health solutions, including EHR systems, and have progressed well despite several hurdles. Though an ideal situation, in which every citizen has his/her EHR stored and it can be accessed throughout the country, has not yet been achieved fully, substantial progress has been made. The adoption of EHR requires several technological and non-technological interventions, including standards, regulatory frameworks, etc. Different countries have taken different approaches as healthcare systems vary from country to country.

Though India has progressed well in the adoption of ICT in other sectors, such as banking, railway reservation, etc., and has an established IT industry, it has not yet utilized the potential of ICT in the healthcare sector. In public healthcare institutions, the usage of ICT is limited to billing and registration. The private sector has a limited form of EMR but it has not yet started the exchange of health information to improve quality of care. However, the situation is changing due to the efforts being made by the government and the industry.

The global EHR market size was valued at USD 23 billion in 2021 and is expected to hit USD 31.5 billion by 2030, poised to grow at a CAGR of 3.3 percent from 2021 to 2030. The rise in government initiatives to encourage adoption of digital technologies like EHR across the healthcare industry is boosting the growth of the global EHR market. Expert committees have been formed in respective countries to define EMR/EHR standards for national acceptance/implementation. The European Commission adopted the European Electronic Health Record Exchange to securely transfer health-related data across the European nations. My Health Record is a digital health record platform for the Australian citizens. The agency claims that by the end of 2022, all healthcare providers in the country will be able to contribute to and use healthcare information available on the platform. Moreover, the introduction of technologically advanced healthcare services is also expected to drive market growth.

The adoption of the EHR can eliminate paperwork and help in data storage and easy transfer. The increased government initiatives to develop a strong healthcare infrastructure and adopt digital technologies to enhance the operational efficiency of the healthcare units are expected to drive the EHR market across the globe.

The Covid-19 pandemic has put a lot of pressure on healthcare organizations since the beginning of 2020. The pandemic has adversely affected the revenues of major market players due to the decline in new business bookings as certain client purchasing decisions and projects are delayed to focus on treating patients, procuring necessary medical supplies, and managing their organizations through this crisis. Moreover, companies, such as Allscripts, experienced delays in deals with upfront software revenue and professional services implementations across their outpatient and inpatient base.

The web-based EHR segment led the market in 2021 and accounted for more than 54 percent share of the global revenue. Web-based EHR software runs on web platform that avoids the additional hardware and software installation, and eases implementation in small clinical practices. It helps practitioners to prevent interruption in cash flow with faster installation as compared to client server systems. Web/cloud-based software offers cost-benefit as it avoids additional expenses including licensing fees, frequent updates, and maintenance cost of hardware.

Additionally, it minimizes requirement of IT resources as installation, configuration, testing, running, and upgradation of software is assisted by SaaS providers. Thus, along with developments, cost-effectiveness of cloud based EHR systems in small healthcare organizations will propel the segment growth.

The client server-based product segment is anticipated to show significant growth in coming years. Client-server-based EHRs provide a safer alternative for users as it offers in-house data storage, hence preventing data theft. These can also be customized as per customer requirements and also are a favorable option in case of multi-physician facilities. Furthermore, they do not require a stable internet connection unlike the web-based systems, which further drives the segment growth.

North America EHR market captured over 48 percent of the market share in 2021 due to favorable government initiatives and deployment of supportive plans. This is simply attributed to the increased adoption of the EHR across the hospitals, especially in the small units in the US. The developed healthcare infrastructure and higher adoption rate of digital technologies in the region is the major factor that boosts the market growth. Furthermore, the presence of well-established IT and telecommunications infrastructure in the region is a significant contributor to the market. The presence of several market players and various developmental strategies adopted by them highly influences the market growth.

Asia-Pacific is estimated to be the most opportunistic market during 2021 to 2030. The increasing government investments in the development of healthcare infrastructure and adoption of latest digital technologies is boosting the demand for EHR. Further, the rising demand for quality healthcare services is encouraging the demand for EHR. The rising number of hospital admissions is generating huge volume of data, which needs to be stored and hence the growth of the market is augmented by the increased need for data storage in this region.

The major restraints that may hamper the growth of the EHR market are the cybersecurity and data breach issues associated with digital data storage. These issues need to be managed by the market players in order to have a sustainable growth. Moreover, lack of proper healthcare infrastructure in the underdeveloped economies is hindering the market growth.

The introduction of technologies like big data analytics and various developmental strategies like new product launches and mergers are expected to provide new growth avenues for the market players in the forthcoming years. For instance, in January 2021, Allscripts Healthcare Solutions announced a strategic partnership with the US Orthopedic Alliance (USOA). This partnership was aimed at introducing an efficient infrastructure designed to assist orthopedic practices scale with agility, improve EHR implementation timelines, provide evidence-based guidelines to support evolving clinical protocols, and create community-wide connectivity with value-based care analytics.

In April 2021, Cerner Corp. acquired Kantar Health for approximately USD 375 million. This acquisition combined Cerner’s collection of real-world data and technology and Kantar’s life sciences expertise and accelerated innovation in life sciences research and improved worldwide patient outcomes.

In December 2020, CompuGroup Medical acquired eMDs, a provider of EHR. The acquisition aimed at expanding and reinforcing the firm’s presence in the ambulatory segment in the US as well as fortifying its portfolio.

In March 2020, CureMD Healthcare launched a practice-continuity plan for providers to treat their patients remotely during the pandemic.

Major companies operating in the market are Cerner Corporation, Allscripts, Epic, and Meditech, among others. These competitors are adopting various business-growth strategies to strengthen their market footprint.

EMRs and EHRs have advanced by leaps and bounds since their invention in the 1960s, and they still have a long way to go. What does the future of EMR hold?

Soon, EMRs will be focused on a value-based care model as the industry switches over from volume-based models. Humans will continue to get sick and need care (at least until we all upload our consciousness into robots). Here are some EMR trends to keep an eye out for in the coming years.

Accessibility. The market will see a continued trend toward accessibility in EMRs, both in terms of how users access them – on mobile, for instance – and who can access the software. The main thing holding practices back from adopting EMRs has to do with accessibility. EMRs are incredibly expensive – up to six or even seven figures for the total cost. While hospitals and large multi-facility networks leverage government incentives to implement EMRs, the same is not true of smaller practices.

Integration and interoperability. Another serious issue with EMRs is their lack of ability to integrate with other systems. When a patient comes into a hospital, for example, that hospital needs records from outpatient practices and any other hospitals this patient has visited previously to get a full picture of their health. This accessibility seems like it would be a top priority for EMR developers, but that is not the case. Physicians and hospital staff must manually enter data, upload unsearchable scans of information or figure out a workaround to enter crucial patient data.

Dissatisfaction with EMR software is driving burn out across all care settings. The lack of interoperability caused by an absence of data-sharing standards, along with organizations engaging in data blocking, have created problems for patients who seek care from multiple organizations. This stress is shared by the clinicians who care for them. Without a set of robust standards for data storage, access and sharing, interoperability will continue to be the elusive unicorn of the EMR world. The industry will see a massive public/private partnership, focused on reducing the regulatory burden now placed squarely on clinicians and instead create an environment for progress toward true interoperability.

This is the year when interoperability is getting a lot of attention from the government, providers, and vendors. Hopefully, the needle will move, particularly where interoperability can help gather data for the physician that is useful at the point of care.

If EMR vendors pay any attention, interoperability and integration features will be at the top of their list for upgrades and changes in 2022 and beyond.

Searchability and ease of use. It is not just the ability to use an EMR with other EMRs that is causing trouble – just using one in general is a hassle. There needs to be more ease of use in terms of navigating through data. Despite advancements in technology, EMRs seem to be lagging in user-friendliness and ease of use.

The biggest challenge at the moment is to address the physician workflow and usability pain points. There is a vast recognition that physicians are overburdened with the documentation requirements. EHR and healthcare technology generally need to be better optimized so they can avoid routine clerical functions and interact with patients more fully.

If users cannot find, use, and organize an electronic health record better than paper files, what is the point? EMR vendors need to keep their users in mind and take physician feedback seriously in the future if they want to shake the reputation of being cumbersome and disorganized.

Standardization. One way to achieve legitimate ease of use is through standardization. The current standards that regulate EMR are very lax. For instance, according to Reich, one vendor had to pay USD 155 million in settlements because it gave customers kickbacks for falsely claiming it met meaningful use certification requirements.

If vendors are going to be held accountable for providing the features users need and upholding meaningful use standards, there have to be more regulations. To make this happen, data standards should be consensus-based, transparent, well-documented, and openly available in a nondiscriminatory way.

Changing dynamics. Rapid innovations in technology are already influencing the future of EMR. As AI and virtual assistants like Alexa and Siri become more accessible and powerful, they will begin to appear in health IT fields. This will happen soon, and in a big way. Virtual assistants are also coming online to help with those physician burdens, in particular the aspects of the physician workflow issues that computers can streamline. For patients, the big development is expanding online or smartphone access to health information and the ability to combine information from different providers and update it automatically.

Mitigating the main issues surrounding EHR use is a challenge, but shifting data-entry tasks away from overburdened physicians and staff is a start. EMR vendors will have to look beyond a patch for the problem.

Apple, Google, and Amazon are all entering the healthcare space. Their presence will pressure EMR vendors to innovate or perish. The large tech giants have the funds to invest in R&D and leading-edge UX and UI without endangering their bottom lines. They have witnessed the problems created by the lack of interoperability between systems and will not make those mistakes. It will be exciting for consumers and clinicians and not so exciting for current EMR companies.

This competition will force EMR vendors to make significant alterations to their systems or risk losing their competitive edge. There is no surefire way to know how it will play out, but big changes are definitely coming.

Blockchain and EHR. Though blockchain technology is more popular for its role in cryptocurrency, it is seeing recent use in healthcare. Blockchain uses cryptography to secure EHR data and makes it available only to those with access to it.

For example, blockchain can validate clinical trial and claims results, track medicine distribution, authenticate prescriptions, and prevent insurance fraud. Smart contracts can also use blockchain to take action based on predetermined results, reducing human involvement. The use of blockchain has just begun though several EHRs have incorporated it to ensure security, scalability, and confidentiality.

The coming decade will see unprecedented transformation as digitization will become a core offering of healthcare institutions. Disruptions caused by Covid-19 have brought a silent yet visible revolution in the way patients want to be cared for and how healthcare institutions can provide superior care and patient engagement.

While no one can predict what the future of EMR will look like, the combined wisdom of experts can give us a pretty good idea. In the coming decades, expect to see significant growth in accessibility, integration, IoT devices, and interoperability between EHRs and EMRs.

The industry will no doubt improve the searchability and ease of use of their products – increased EMR standardization regulation could be crucial to this. The changing world of healthcare tech, and tech in general, will continue to put pressure on the industry to change and adapt, hopefully for the better.