The effective use of electronic health records continues to be a central public policy priority in the United States and around the world. In the United States, the HITECH Act of the American Recovery and Reinvestment Act of 2009 established a multipart federal program of financial incentives and penalties to promote adoption of electronic health records. The enthusiasm stemmed from the potential of electronic health records to provide large-scale improvements in the efficiency, safety, and cost-effectiveness of health care. Once a niche market served by specialty software developers, the field of electronic health records is now intensely competitive with offerings by large multinational software vendors. Mature products are available catering to the needs of individual clinicians, group practices, and large integrated delivery networks. Systems range from large-scale solutions to operate every aspect of an integrated delivery system, to software-as-a-service offerings for the solo practitioner, to targeted systems for specific subspecialties.
Providers and health systems often focus heavily on the selection of appropriate software when planning to adopt an electronic health record. Although appropriate software is critical, the challenge of adopting a new electronic health record is not primarily one of technical implementation but rather the challenges of process redesign, understanding and supporting workflows, and the economic and social aspects of organizational change. In part to assist purchasers in selecting clinical software meeting a baseline set of functional requirements, the HITECH act established a three-phased program of federal standards for certification of the “meaningful use” of electronic health records to qualify for the financial incentives available through the act. The original program called for declining financial incentives for meaningful use of an electronic health record over the duration of the program, and for penalties that were to begin after the end of the final phase. Each stage raised the bar for both the software vendors and the implementing health system or clinician. The first phase began in 2011 and the second in 2014; however, concerns arose over the expense and difficulty of meeting the stage 2 requirements, controversy as to whether the program was meeting its policy goals, and the program’s emphasis on process measures rather than the practical usability of electronic health record software or its benefits to patient care. A widely cited 2005 study by RAND estimated $77 billion in annual cost savings in the United States if electronic health records were broadly adopted, but in 2013, RAND acknowledged that the savings had yet to be seen. Subsequent legislation, particularly the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), replaced part, but not all, of the Meaningful Use program with the Advancing Care Information (ACI) program. The ACI program has similar policy goals but a more flexible scoring framework, with an emphasis on promoting interoperability between electronic health record software systems now that these systems are widely deployed. Electronic health records remain a point of vigorous debate at the federal level, and substantial policy changes may continue, with the prospect of further impact to federal electronic health record policies and incentive programs.
The challenge of workflow analysis and organizational change is a topic of ongoing industry and research interest and is necessarily local to each care setting. Many consulting firms specialize in health care information technology transformation or have health care IT practices to provide assistance. The roles of Chief Health, Medical, and Nursing Information Officers in health systems reflect the need for leadership that spans the clinical enterprise, as information technology departments are counted among the clinical service providers alongside radiology and the laboratory. Some of the currently most successful clinical software vendors distinguish themselves in part by providing a template for leadership in organizational change as a package with their software products.