4 Advances in Proposed Rule for Electronic Health Records

Nearly all hospitals and medical practices in the United States rely on electronic health records (EHRs) to store and access the patient information that is vital to safe, high-quality care. But different systems  often cannot reliably share data about the same person, a fault that can lead to duplicative tests, treatment delays, and other gaps in care coordination. Patient safety risks, such as prescribing an improper medication dose, can also arise from problems with usability that stem from the design of these digital tools, how they are customized, and how clinicians interact with them.

In February, the Office of the National Coordinator for Health Information Technology (ONC), the federal agency that oversees EHRs, released a proposed rule that advances solutions to these challenges. The rule would implement provisions of the 21st Century Cures Act, passed by Congress in 2016. The proposals would enable better communication between EHR systems, allow medical providers and patients easier access to digital health data, and improve detection of potential safety hazards.

The Pew Charitable Trusts recently submitted public comments supporting key parts of the proposal and recommending changes in the final rule to further improve data exchanges between EHRs and reduce risks for patients. Here are four positive steps in the rule—and four ways to make it better.

Strides toward complete and accessible records

1. A standard for retrieving health data. ONC’s proposal would take advantage of an essential internet tool, application programming interfaces (APIs), to ensure that information stored in different EHR systems could be accessed securely and used by clinicians and patients. APIs let software systems exchange data seamlessly, such as with websites that gather fares from dozens of airlines or personal finance applications that assemble transactions from multiple accounts. Their benefits in health care, however, have been limited by variation in how EHR vendors build the interfaces and other challenges. ONC has proposed that health care APIs follow a common technical standard—known as Fast Healthcare Interoperability Resources—and that vendors provide secure access to these tools and documentation on how to use them.
2. More data to improve care. The proposed rule would expand the types of data that EHR systems must make available to medical providers and patients through APIs. The additions include clinical notes in which doctors often describe nuances in medical conditions and treatment plans. Having those insights can inform other clinicians' decisions while also helping patients understand test results and follow through with referrals. Making patient addresses and phone numbers available via APIs also would help different systems recognize that they have records for the same person and better link an individual’s records across different providers.
3. Strong incentives for rapid improvement. Under ONC’s proposal and existing regulations from the Centers for Medicare & Medicaid Services, hospitals and medical practices would have to deploy EHRs that meet the requirements within two years of a final rule taking effect or risk penalties from Medicare.
4. Improving pediatric care. The proposed rule would set specific criteria for EHR products used in pediatric care. The health care needs of children differ from those of adults, and pediatric patients can be harmed when EHRs are not designed or tested to account for these factors. As required by the 21st Century Cures Act, ONC’s rule would create new pediatric-focused EHR requirements. It identifies 10 clinical priorities in children’s treatment, including weight-based medication dosing, that EHR developers should address to prevent medical errors.

Opportunities for greater gains

1. Set a standard format for address data. In its final rule, ONC could increase the likelihood that different EHR systems would identify records for the same person by adopting the U.S. Postal Service standard to format patient addresses. This would reduce variations in EHR data—for example, using “Street” vs. “St.”—that can thwart the accurate linking of records. Adopting the Postal Service standard could improve record match rates by up to 3 percent, which could translate to tens of thousands of matches daily—or more—that otherwise wouldn’t be made. For example, an organization with a match rate of 85 percent could reduce the number of unlinked records by a fifth just by standardizing addresses.  
2. Support record matches with additional data. Expanding the types of data that EHR systems must make available could help link records for the same person. For example, email addresses aren’t often used for this purpose, although they are included in at least half of patient records. ONC should examine how to ensure that email addresses and other readily available demographic data be made available for matching.
3. Broaden allergy data in EHRs. ONC could further advance patient safety by requiring that EHRs document and exchange data on allergies to foods and other substances when available, rather than just medications. This information could alert clinicians when a patient might have a negative reaction to medications made with eggs or to foods served in hospitals.
4. Test EHRs with pediatric clinicians. ONC should require that doctors, nurses, and other end-users focused on children’s care be represented when testing EHRs for pediatric functions. The real-world experiences of these professionals could improve detection of safety risks related to EHR usability.

A final rule that retains the positive changes this draft includes and lays the groundwork for further improvements would move the nation closer to achieving the full potential of electronic health records to enable safer and better-coordinated health care for all Americans.

Ben Moscovitch directs The Pew Charitable Trusts’ health information technology initiative.