CHR: A black-box description of Community Health Records

Robert Gleeman talks with Mark Anderson of the AC Group about what's going on in the world of community health records.

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This is the transcript of our interview.

Robert Gleeman:  This is Robert Gleeman with EMR Update. I'm talking today, on Casual Friday, with Mr. Mark Anderson from the AC Group. Mark, thank you for being here with me, and have a happy holiday in case I forget to mention it.

Mark Anderson:  Same to you! It's been a while since we've done one of these.

Robert:  Yes it has! And I was hoping today you could get me caught up on what's going on in the world of community health records. Or, as we have dubbed it, CHR, as opposed to EHR. In the community, can you give me a black box description of what we're talking about, so we can fill everybody in on what is a CHR?

Mark:  Well, really a CHR is a combination of local practices' EHRs. The ability to do data exchange between a family physician, an orthopedic practice or cardiology practice, using either one EMR or multiple EMRs, where the practices, because they're independent, want to maintain separate databases of their practice management and EHR data for their patients.

Robert:  But this isn't a normal EHR. You need a special type of program for this, don't you?

Mark:  What you have to have is some strong EHRs with interoperability capability, like has been established in the 2008 CCHIT requirements. And then you have to have something that sits on top of it that does the electronic health exchange between the two of them, the different products that are out there. So the information from one EHR vendor flows up through some kind of separate product that captures the data and then can send it back down into a separate product. Basically following the old company pair record, now CCD standard, for data exchange for demographic and clinical information.

Robert:  So, essentially everybody has their own database, every doctor's office, every hospital, every community health clinic. Is that right?

Mark:  Yes. Now, they all have their separate databases. Now, if a clinic is owned by a hospital, it may be part of the hospital's database. But a lot of individual practices put separate EHRs and separate databases to still do data exchange. When the patient goes from one practice, and is referred to another practice, we can actually move over the clinical information. The nice thing about it, too, it has a community master patient index. If the patient has never been seen by me in the past, I can actually go into the system, look up the patient, find up their name, address, and chart information, and then download it directly into my separate practice management system so that I don't have to do the data entry work.

Plus, if somebody changes their address, everybody gets the address updated at the same time that's treating that patient.

Robert:  So in order to set up a system like this, do they all have to be on the same brand of software?

Mark:  No, right now they could be on different EHR products and different practice management systems, as long as they can meet the interoperability requirements that are out there. Again, the old CCR, or CZA, or CTD (they have so many three initials now), but basically the community data exchange requirements. So, you can have any system you want as long as you can exchange data meeting those requirements.

Robert:  And can you give us some brand names of software that people are using to do this. I know that one of them is eCW, eClinicalWorks, because we've seen the press releases. Can you name a few more?

Mark:  They're interesting right now, because if you look at the vendors that really are in this community data exchange model, you've got some of the traditional vendors, Axolotl, Healthvision, Wellogic. (We'll have to cut that little bit out, restart that part over again.) {Nick: ah, can't edit our FLV so we've included these impromptu moments}

Robert:  OK.

Mark:  I think of another member, RelayHealth. OK.

Robert:  RelayHealth.

Mark:  There are vendors like Health Logic. Forget that one. There are vendors like Wellogic, Axolotl, Healthvision, and Relay Health that are providing the community data exchange. Now we also have vendors like NextGen and eClinicalWorks that are providing a community portal that, in theory, can exchange data between multiple vendors. We think by probably first quarter of 2009 Allscripts, with the MyConnect product, whatever we're going to relabel it, will also be able to do that. There are also some things like Noteworthy that are able to do these community‑based systems today. We believe GE can also do that. We're kind of looking at who has press releases of this today.

Robert:  Last time we talked about community EHR or CHR, you gave me the impression that a doctor should wait for this community action to take place and then join it. Do you still feel that way, or can a doctor or an individual, a one‑man practice, start this and get into it on his own?

Mark:  I think there's two ways of looking at it. There's no reason to wait for a physician to say, "Hey, I'm going to wait for the community to be built." Because as long as your product is interoperable, meeting the standards, you should really get whatever product you want to connect into it. The difference is going to be, because of the change in the Stark law, the hospital may only allow a few vendors to get connected in the beginning because of the cost of the connection and everything.

So some of the doctors are waiting for the community to be built, and then going with whatever product the hospital, the IP [?], or the MSO is recommending because they can subsidize some of the cost.

So the question is, do you go with the product on the one that you hope will be connected, or do you wait to go with the product that a community might be putting together that's also subsidizing the cost.

What we're finding is about 70 percent of the small practices are putting off their decision, partly because of all of the confusion in the EMR marketplace, partly because of the economy right now.

And a high number of them are saying, "I'm going to wait to see what our community builds, because they're talking about it today." But you've got to get the right product to meet everybody in the community's requirements.

Robert:  You mentioned the CCHIT recently made some specifications for a community system. And this is fairly new. I believe you said in just last year, these specs came out?

Mark:  Well the 2008 CCHIT requirements really talked about interoperability, which is a foundation for building these community systems. Remember, the CCHIT 2008 standard only came out in July of 2008. And it's going to go all the way through June 30th of 2009. We have some vendors that have documented that they could do interoperability, besides other things that are in the CCHIT requirements. But just because a vendor's not on the list yet does not mean they cannot do it.

Again, they've only gone through one round of testing, and I believe another round of vendors will be announced either sometime this month or early in January of 2009.

Robert:  Now this brings up a point that we argued about in the EMR forum. Is CCHIT going to survive the new administration? What is your opinion on that, Mark?

Mark:  The interesting part, like I say, I believe the initial government funding is now up and that the CCHIT has to survive on its own going forward. And the question's really going to be, is do they have enough vendors willing to pay the fee to get certified? If you start looking at the numbers, remember we had 90 the first year, 50 the second year, and we have 10 so far this year. But a number of the vendors have not been certified yet.

Of course, they've added new categories. Now you can also be certified on the cardiology‑specific, pediatrics, I know they're working on mental health. They're also working on a personal health record certification. What they're doing is adding additional categories so they can get more certification plus more revenue coming in.

But it will be interesting to see if they have enough vendors willing to pay the fee to get certified going forward. You got to remember if you're not certified then hospitals are not allowed to really subsidize the cost of a product, the same with the MSOs, PHOs, and IPAs.

Right now it still requires a certified product within the last twelve months. Of course, a designate has to be CCHIT certified. Right now that's the only government certified agency that is providing any kind of certification. So it's the lack of requirement going forward.

Robert:  Do you feel that President Obama will be supportive of this community health record concept?

Mark:  Well let's look at the foundation for all of it and why are we even looking at community. And the whole idea was creating these RHIOs in the beginning. Sharing of data between multiple societies and groups that are out there probably sounded good. But from the research that has been done by Hens and other groups we found that most of the RHIOs did not survive because they were not having enough financial liability to go through. There' a few of them going on out there but most of them have not survived at all. So think of the models of these EHRs and it requires a lot of data entry by the physician. The patient has to fill out his social history, medical history, family history, view assistant, HPIs and everything else.

Why can't we just do it once? Why can't we have the patient filling out the information for the first time when they see the primary care doctor and then all of that information flows directly into the cardiologist, the orthopedic surgeon, the neurologist, the dermatologist and we save all that data entry time?

We can cut out about 70 percent of the traditional data entry if we share all of that information plus lab results and pharmacy medication the patient is on, diagnostic procedures. Because one of the problems with EHR has been that we have to get data into these systems.

We've got five years clinical data on a patient on paper but how do we get that information into an EMR and if a patient is going to five different doctors we have to enter it five times. Look at the chance of mistakes. On a community base system we enter it once and it populates multiple EMR products.

Now one of the questions that always pops up why would a hospital want to subsidize the building of these community base systems argument of it being obviously physician bonding. If we could connect all of this information together what would doctors like to work with our hospital?

But there's a real reason behind most these community based systems from the research we have done. And it's that for every 20,000 emergency room visits within a community we figured out the hospital can save about a half a million dollars in uncompensated emergency room care.

Because if the emergency room doctors have the information on the patient they know the name, address, their social, family and medical history, what procedures they've had, what lab results, what medications they're on, what their allergies are that gives them a wealth of information.

And the emergency rooms doctors have said if we have all that information about the patient we can get them in and treat it quicker and improve the quality of care within the emergency room much better if I had that information as a lot of duplicate test are run because we don't know enough about the patient.

And a lot of emergency room care is uncompensated or if the patient goes from the emergency room and gets admitted like a Medicare patient all of that emergency room cost is rolled into the in‑patient DRG.

So if we can have information about the patient at the bedside for the emergency room doctors on average we've shown that we can save about half a million dollars for every 20,000 ER visits today.

That pays for a community based DHR in most smaller and larger communities out there.

It's a win for everyone. We get better patient quality; we get a community based system where doctors can pick what EMR practice management system they want as long as it meets the standards.

And we're creating interoperability. This is kind of a model that they originally talked about with the RHIOS but we weren't able to connect everybody together allowing them to use their own EMR's. I think this is the future of health care and it's going to solve some of the problems dealing with cost and the major problem of getting all the data into the EMR.

Robert:  You've used the term RHIO how are you spelling it and what do you mean by it?

Mark:  Well the whole conversation that Brailer came up with a couple years ago was RHIOS, Regional Health Information Organization which is a way of sharing data between communities. The problem is there was no data to be shared in a lot of these communities, because most of the political businesses are paper based. We can share some demographics. They had a little bit of lab, but we really need to get the information from different practices. So the local joke always was back in the 90s we had CHIM, C‑H‑I‑M, then we had RHIO, R‑H‑I‑O, now it's because it was four initials. We need to go back to three initials on everything.

So HENS are talking about HIEs now, Healthcare Information Exchanges, you know we have EMRs, we've got EHRs, we've got PMS for Practice Management System let's create another three letters, CHR for Community Health Record. It's really a community electronic health record, electronic medical record, data exchange, EHI combining everything together to really get the benefits that people are looking for.

And I think if you go back and talk to Obama and his organization and everybody else this is what they've been talking about for a while but no one's really come up with the right model to make it work.

This is the model that would work for everybody. Financially sustainable for a community to do these and there's a number of small rural communities trying it today. And I think they're going to be very successful.

Robert:  As a consultant where do you come in, Mark? Who calls you? What do you do? I'm curious.

Mark:  Well we're getting a lot of calls obviously from regular physicians looking for systems or they're telling us that hey, I heard that the hospitals trying to do something. We just did a speaking engagement down in Florida where about 300 doctors were looking for an EMR and I approached them with this idea of creating a community based system around the hospital.

And it happens to be two local hospitals that kind of compete in that community. And I said, well, the physicians need to get together and say we need to build a community project, a community electronic medical system. Maybe get both hospitals involved in this and make it work for everybody.

So in this case I think we've got the physicians saying, hey, we're really encouraged about this, this sounds like a great idea. Now the physicians and hospitals have invited me back down in January to really talk about what is the model for a community health record? What's the benefit?

They need to hear about this. So we provide a lot of educational things, speeches, and hopefully someday in the future they'll decide they want to move forward and, ideally, for us or some of the other large nice big consulting groups like the Cofa Group or the AC Group we can go in there and help them determine who the right vendors are for them, maybe have one or two EMR vendors for the community building the community health record on top of it.

And the thing we really like doing is negotiating those contracts with those vendors. That's the part that really gets fun for me.

Robert:  And when you say negotiating with the vendors are you usually working on behalf of the individual doctors or the hospitals or both?

Mark:  Well, actually both because in this kind of model you're building a community based system through negotiating for whoever's kind of running or champion for the community. And then you're also negotiating for the individual doctors, because they may be picking different products. So you'll have a community that sits on top, a community system, you'll have individual contracts for each one of the physicians. And the goal is to really help everybody, because you have to admit if you look at those contracts from the vendors, right now they're there to protect the vendors. There's not a lot of protection for the community or the physician.

On average we've come up with about 60 to 90 changes in the contract term and service log agreement. And on most cases we've been able to save two to nine times our total cost. Just in the cost the vendors are charging the doctors. Especially is you're coming together as a community, you know two individual doctors give one pricing. So if I could bring eighty practices together we're going to get much better pricing for the whole community.

Again, coming together as a group, you're going to get much better pricing, much better support, much better ways of rolling these products out.

If we can get physicians to agree to champion the development of a community‑based system... Maybe we get the hospitals, the MSO, the IPA, or the PHO, to help fund this, or at least, another champion to keep it going.

Robert:  What would you suggest to a doctor that wants to be involved in this, but there is no hospital program? Is this something that one person can initiate and start, or does it take a hospital to start it?

Mark:  Actually, it takes a vision. There's a doctor that's up in London, Ohio, that has said, "I want to create a community‑based system. It's a one‑doctor. He's a pediatrician, but he has been the force for driving this whole community‑based project that's going on up there. There are little ideas that really try to build this community‑based, electronic health record, but his model's even bigger. He wants to tie the hospitals and all the physicians in the community together, along with home health, long‑term care, the local pharmacies, tie the 911 service into it, the police, the fire department. He wants to tie it all together, so all information about anybody who lives in that community, with the right security and HIPAA requirements, is out there.

In the case that the ambulance goes out and picks up somebody that happens to have a car accident, we're able to identify who that patient is. We know information about them, and that could be directed directly to the emergency room for better care, improved quality, and reduced costs.

In this case, one doctor, Dr. Alexander, has created a push for creating a community‑based system up in Ohio. All it takes is one doctor who wants to champion these things.

Then again, you have to be able to roll it all together, bring all the doctors together, and bring the hospitals together, into an overall view of how they want to do it. They're going to be rolling this out in the next year: a community‑based system for about 30 doctors, at a 100‑bed hospital, in a nice, rural setting.

I've got a couple of other communities doing the same thing. Spencer Hospital, up in Spencer, Iowa; same type of thing. They have about 25 doctors, and the hospital, all coming together to build a community‑based system. They're putting a community portal on top, with one personal health record, and electronic health records, the practice management systems, for all the physicians in the community.

It makes sense. It's going to save money, and probably is going to improve the overall quality of health care within that community.

Robert:  When you say they're coming together, people don't just come together. Somebody has to bring them together. Is that part of what you do as a consultant is set up meetings, have this person talk to that person and set them on a path? Is that part of it?

Mark:  Yeah, typically, we get somebody who's interested in this, and we set up what we call an educational session. On the evenings, we bring some doctors, we bring some of the hospital people together, and the other people in the community that also take care of the patients' health out there today. We bring them together and we talk about the potential out there. We talk about the benefits, what it's going to take, talk about the costs. It's amazing, when you get a community of people together. They have a lot of questions, but they come out of an educational session, and they're like, "This would work. This makes sense for all of us."

That's what we just need, a doctor who says, "Hey, I want to create this. I want to set up a meeting." Or a hospital, a CEO, or CIO, or CFO, who says, "This is a show. Why don't we bring everybody together just to talk about it?" Bring that community together to look at business, political, and health benefits for their whole community. It doesn't take a lot to do that.

Robert:  One time, you told me... I remember what people tell me, even though I don't remember my own phone number sometimes. This was comprising about 90 percent of your business at this time, which seems like a huge amount. Is that still the case, Mark?

Mark:  Yeah. We're still helping out a lot of the smaller practices, to the medical societies. Some of the dockets are still going out for the ones‑ and two‑doctors. But, really, the majority of our travel business... When I have to travel, it seems to be more involved in larger communities coming together where there's a hospital involved, and one or two practices. I'm doing a project in Ontario, California, right now, with an IPA, that has 300 primary care doctors, and about 1,500 specialists, trying to build a community system for there. We're seeing a lot more of the capital roll‑out, community roll‑outs, with different names and positionings of it, but it's all about: how do we find a way of sharing data in the community, to cut down on the duplicate data entry that is required for electronic health records.

That's why I think a lot of these systems have failed out there. There's a lot of EHR failures out there because it takes too much time to get all of the old data into the computer system to make it effective for the physician to use.

We've got to find a way of populating all these EHRs. Our philosophy is: populate it once, and populate many of the EHRs at one time. As long as the physician is treating that patient, why can't we just share the data? That's more of a community‑based system.

Buying standalone EHRs out there doesn't really help a lot of practices, because they don't have the time to do all the data entry to get the information in there. If the EMR is effective, to be able to look at the prior visit, look at health maintenance over a period of time, I have to have all the data in there. A community‑based system can do that for you today.

Robert:  Finally, I wanted to ask you: is there a convergence going on between EMR and EHR? And is that what community health records represent? This convergence?

Mark:  Yeah, we're seeing that most of the EMR vendors, now, are able to track health‑related information, the health maintenance alerts, and things like that. Almost all of them now either have their own personal health records, or they're working with one of the personal health record products that are out there. Of course, everybody's been talking about health malls, and some other things, the Microsoft, Google type settings. But I think we're moving toward a point where certain health‑related information is required out there, for the primary care, the pediatrician, the internal medicine, and the ob‑gyn.

You find a lot of other doctors are saying, "Look, I'm just treating this one problem, a sprained ankle, or a rash on an arm. I don't absolutely need to put all that information in, but if the data is available, I like to have that." I think what we're going to have is a combination of medical information, and health‑related information, brought together within the whole community.

But, again, why don't we have one person entering it? The patient, the nurse, or the physician, entering it, and then it populating through all of the other caregivers that are treating that same patient over time, getting all that to the emergency room doctor, when the patient has to go to the emergency room for whatever reason, that that data flows directly to them, so that we're sharing the right information, at the right time, at the right place, with the right caregiver.

Robert:  We're going to put your cell phone number at the end of this interview, Mark. Would you recommend people give you a call if they're becoming involved in the community health records situation, and get the lay of the land?

Mark:  Yeah, we take calls from all kind of people that are looking for things. We just say, "Look, if you're interested in this, if you want to have more information about it, what is your hospital doing, how to approach the hospital to get this stuff going..." We, basically, say, "Get on the phone. Give me a call." My cell phone is 281‑413‑5572. You don't have to apologize because you got my cell phone. I travel four or five days a week, and that's the best way to get a hold of me. Or you can just email me any questions you might have, at mra@acgroup.org.

Robert:  Mark, that's great. Again, I want to thank you for being with me on Casual Friday, and give you my best wishes for a happy holiday for you and your family. And also for all of our listeners and watchers out there in EMR Update land, happy holidays to you. Thanks again, Mark.

Mark:  Happy holidays for everybody that's in the EMR Update, and keep reading and keep looking at these great webcasts and videocasts that we're doing. Thank you.

Robert:  Thanks again, Mark. Have a great day.

Mark:  Right.

For more information about the subjects discussed here you can contact Mark Anderson at the details listed below.
See our other Getting Started resources here.

Mark R. Anderson CPHIMS, FHIMSS
CEO and Healthcare IT Futurist 
AC Group, Inc.
118 Lyndsey Drive
Montgomery, TX  77316
(c) 281-413-5572
(f)  832-550-2338
email: mra@acgroup.org
web: www.acgroup.org