LOS ANGELES—Taylor Design, based in California, has built a nationwide reputation in the healthcare sector. The firm has five offices in California alone, and as part of a plan to expand its reach into the local healthcare sector, Taylor Design recently hired healthcare industry veteran Daniel Ortega, AIA, to head its new Los Angeles location.

Ortega has worked in the healthcare sector of the greater Los Angeles area for 30 years, including with the California Office of Statewide Healthcare Planning and Development (OSHPD). His design work and project management skills encompass project work in medical center master planning, assisted living, acute care facility remodels, medical education and conference centers, medical office buildings, outpatient clinics and surgery centers, and laboratories.

“I’m coming to Taylor Design at a point in my career where I can make a significant contribution, and also at a time that I believe works well with the firm’s expansion plans for Los Angeles,” Ortega said in a statement. “I am excited to be a part of an employee-owned firm with a culture of teamwork and camaraderie. Taylor Design approaches projects with energy and creativity, and I’m anxious to spread the word about this exceptional firm to clients and new employees in the Los Angeles area.”

“Los Angeles is one of the most dynamic metropolitan areas, not only in Southern California, but in the world,” Kevin Hinrichs, incoming president of Taylor Design, said recently of his firm’s new office and the hiring of Ortega. “We also have more resources in closer proximity to our existing and future clients in L.A., and this new location offers the firm more flexibility for staff that live closer to L.A. County than Orange County.

“Finally, and very importantly, we are adding Dan, an extremely experienced and talented designer and a leading healthcare expert in the region and the state.”

Taylor Design’s healthcare clients in California have included UCSF Medical Center, Stanford University, UC Berkeley, Scripps Health, UC Irvine Health, Hoag Health Network and numerous work for Kaiser Permanente.

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In the last year, 86 percent of patients with access to their health records used their online records at least once, and 55 percent used them three or more times per year. The findings were released this month in a report entitled “Engaging Patients and Families: How Consumers Value and Use Health IT.” The report is a follow-up to the partnership’s 2011 national survey that examined consumer views toward EHRs and health information technology (health IT).

Since 2011, there has been a considerable shift toward EHRs, according to the report. Eighty percent of adults said their doctor uses an EHR system, up from 64 percent in 2011. Online access to EHRs has also increased, with half of patients having access versus only 26 percent in 2011.

The report was released five years after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was enacted and the Medicare and Medicaid EHR Meaningful Use incentive program began. The program encourages the adoption of EHRs through financial incentives to providers. The report comes on the heels of the Office of the National Coordinator for Health Information Technology (ONC) releasing its 2015 Strategic Plan this month. The plan calls for financial and regulatory incentives to encourage the use of health information technology.

“As the National Partnership’s new data show, more consumers are accessing, sharing and using their health information, underlining the importance of interoperability of health data and systems. We are focusing our efforts in these areas to empower individuals to address not only gaps in information exchange and interoperability, but also enable them to take steps to improve their health and better manage their health needs,” said National Coordinator for Health IT Karen DeSalvo, in a statement.

In addition to a rise in EHR use among patients and providers, the study also found that consumers want more functionality and features when they access their records online. More than half want to see the ability to email their provider and to review treatment plans and doctor notes. More than 60 percent want to be able to schedule appointments; 59 percent want to be able to submit medication refill requests; and 75 percent want to see test results online.

Patients are able to trust in the privacy and security of EHRs more now than in 2011, and 77 percent of patients with online access to their health information have a higher level of trust in their doctor and medical staff versus 67 percent of those that don’t have online access.

The partnership surveyed more than 2,000 U.S. adults this year for its study.

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The Meaningful Use program is an electronic health record (EHR) incentive program initiated following the American Recovery and Reinvestment Act of 2009 that authorizes the Centers for Medicare and Medicaid Services (CMS) to award incentive payments to eligible professionals who demonstrate meaningful use of a certified EHR. The program has three stages, but incentives were only provided in Stage 1, which began in 2011. Stage 2 of Meaningful Use began this year and by 2015, eligible providers that have not adopted an EHR will face a financial penalty.

The AMA, headquartered in Chicago, is pressing for changes to the program after new analysis from CMS showed only 2 percent of physicians and less than 17 percent of hospitals have demonstrated Stage 2 Meaningful Use as of Sept. 30, the required reporting date for the 2014 fiscal year.

In response to the data, the AMA is urging policymakers to fix the program by adding more flexibility and shortening the reporting period to help physicians avoid penalties. Physicians representing the AMA also say that full interoperability is necessary to achieve the goals of EHRs — which are to facilitate coordination, increase efficiency and help improve the quality of care — but that is not widely available today.

"The AMA has been calling for policymakers to refocus the Meaningful Use program on interoperability for quite some time," said Dr. Steven J. Stack, AMA president-elect, in a statement. “The whole point of the Meaningful Use incentive program was to allow for the secure exchange of information across settings and providers and right now that type of sharing and coordination is not happening on a wide scale for reasons outside physicians’ control. Physicians want to improve the quality of care and usable, interoperable electronic health records are a pathway to achieving that goal.”

Although there are some systems on the market capable of interoperability, when data is transferred it is not always incorporated into the receiver’s EHR in a digestible way, making it difficult to act on and defeating the purpose of sharing, the AMA argues. Additionally, interoperability often comes at a price, which further hinders its use.

In addition to calling for EHRs to be more interoperable, physicians are also recommending that policymakers ease regulations to allow for EHRs to become more usable. To back its position, the AMA has been citing a 2013 report from AMA-RAND — a collaboration between the AMA and research firm RAND Corporation — that stated EHRs are a major source of dissatisfaction for physicians. The report found that physicians want to embrace technology, but they’re frustrated that regulatory requirements are forcing them to do clerical work and distracting them from paying close attention to their patients.

Physicians also raised concerns about interoperability in the study, saying that the inability of EHRs to "talk" to each other prevents the transmission of patient medical information when it is needed.

The AMA has provided the Office of the National Coordinator for Health IT (ONC) and CMS with a blueprint for improving the Meaningful Use program as well as a framework that outlines eight priorities for more usable EHRs.
 

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The director of New York’s Department of Quality & Patient Safety, Patrick Roohan, joined Hixny, which operates the health information exchange that serves the Capital District, northern New York and the Mohawk Valley to share an update on Nov. 25. They unveiled the portal that will enable patients to download their electronic medical records. The portal is available at six regional hospitals.

Earlier this year, the New York Legislature voted in support of the state’s electronic health records system, the Statewide Health Information Network of New York (SHIN-NY). The public network opens access for doctors and patients to electronic health records no matter where they live or work in the state. SHIN-NY aims to improve quality of care and to help reduce wasteful health care spending.

“Hixny and the Statewide Health Information Network of New York are essential to improving the delivery of health care in the Empire State,” said New York’s Health Commissioner Dr. Howard Zucker in a statement. “By giving doctors and patients the ability to access critical health data when they need it, these networks will help reduce health care costs, and more importantly, save lives.”

Hixny operates the health information exchange that serves more than 1.7 million patients in the Capital District, northern New York and the Mohawk Valley.

“We are proud to have established the first community-wide patient portal in New York State and we are excited for its ability to enhance care coordination for the 1.7 million patients in our region,” said Mark McKinney, CEO of Hixny, in a statement. “This community-wide portal is the latest step on behalf of our unique regional collaborative to support the triple aim of enhanced patient experience, improving population health and reducing health care costs.”

The six regional hospital networks that will be using the patient portal system are Ellis Medicine; Adirondack Health; The University of Vermont Health Network – Champlain Valley Physicians Hospital; Columbia Memorial Hospital; Nathan Littauer Hospital; and Saratoga Hospital. When patients are discharged from these hospitals, health care professionals create an account which allows the patient to securely access their electronic community health records.

“By accessing data through Hixny, Ellis physicians have been able to better understand their patients’ complete medical history, helping them provide better care more quickly,” said Paul Milton, executive vice president and COO of Ellis Medicine, in a statement. “The patient portal allows patients to take a more proactive role in their health care, leading to ultimately a safer, better experience. The more health care providers who sign up for the patient portal, the more we can do to improve care coordination to help keep the Capital Region healthy.”
 

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Authors from the Perelman School of Medicine, the Wharton School and the Center for Health Incentives and Behavioral Economics (CHIBE), which are all part of the University of Pennsylvania in Philadelphia, have published a study that is being published in the current issue of Annals of Internal Medicine. The issue is a special look at the research being done about innovative health care incentives.

“Prescribing brand-name medications that have a generic equivalent is a prime example of unnecessary health care spending because in most cases, generic medications are less expensive, similar in quality and may actually lead to better outcomes than brand names because of higher rates of patient adherence to generics,” said Mitesh S. Patel, MD, MBA, MS, assistant professor of medicine and health care management at Penn and lead study author, in a statement. “The results of this study demonstrate that leveraging default options can be a very effective way to change behavior.”
The study included four ambulatory clinics (two internal medicine and two family medicine) in the University of Pennsylvania Health System between June 2011 and September 2012. Researchers evaluated the difference in prescribing behavior for three commonly prescribed classes of medications — beta-blockers, statins and proton-pump inhibitors — between family medicine and internal medicine physicians.
The study analyzed almost 9,000 prescriptions in the pre-intervention period, the time when a person’s specific health problem is not known, and a total of 12,443 prescriptions during the intervention period, a time when the prescription would be used to improve a particular health problem. During the intervention phase of the study, the family medicine physicians continued to be shown both brand name and generic medication options within the EHR medication prescriber portal, but internal medicine physicians were shown a different display of only the generic medication options, with the ability to opt out. When compared to family medicine physicians that did not receive the intervention, internal medicine physicians had a significant increase in generic prescribing rates.
“Not only was changing the default options within the EHR medication prescriber effective at increasing generic medication prescribing, this simple intervention was cost-free and required no additional effort on the part of the physician,” Patel said in a statement. “The lessons from this study can be applied to other clinical decision efforts to reduce unnecessary health care spending and improve value for patients.”
A 2013 report from the Generic Pharmaceutical Association, which wasn’t part of the authors’ report, showed that over a 10-year period (2003 to 2012), generic drug use has generated more than $1.2 trillion in savings to the health care system.

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Funded by the Department of Health and Human Services Center for Medicare and Medicaid Services, the project will evaluate the impact of a consultation and referral platform integrated into an EHR. Referred to as “e-consult technology,” the web-based system helps primary care providers and specialists share information and discuss patient care.

UHC will be collaborating with the Association of American Medical Colleges (AAMC), Dobson DaVanzo & Associates, a health care consultant based in Washington, D.C., and five academic medical centers on the project. The medical centers include Dartmouth-Hitchcock Medical Center in Lebanon, N.H.; UC San Diego Health System; University of Iowa Hospitals and Clinics in Iowa City, Iowa; University of Virginia Health System in Charlottesville, Va.; and University of Wisconsin (UW) Health in Madison, Wis.
"Given the accelerating shift to value-based reimbursement, enhancing the efficiency and effectiveness of care delivery is critical to academic medical centers’ success," said Bob Browne, MPP, UHC vice president, clinical enterprise integration, in a statement. "Consistent care coordination and timely access to the input of specialists through the use of e-consultation/e-referral technology is a novel way for AMCs to improve cost, quality and access. UHC looks forward to collaborating with five of our esteemed AMC members and the AAMC to understand how this technology can have a positive impact on the future of health care delivery."
The University of California, San Francisco (UCSF) developed the technology that is being evaluated for the project. One advantage to the program at UCSF is that primary care physicians can send a message electronically to a specialist about a patient and receive an answer within 72 hours.
UHC says the system has been shown to significantly improve quality of care through improved coordination and timely access to specialist input, while reducing the costs of care by fewer referrals and reduced fragmentation of care. UHC will partner with the AAMC and coordinate with its participating members to evaluate the impact of the intervention on metrics such as quality, cost, access and patient and provider satisfaction.
Dobson DaVanzo & Associates will help to create a payment model for consideration by the Centers for Medicare & Medicaid Services to sustain and scale this innovation beyond the award period.

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The AMA said physicians are not happy with EHRs because the technology requires too much time-consuming data entry, leaving less time for patients, according to a study that the association did with the RAND Corporation in October 2013. Physicians that were surveyed expressed concern that current electronic health record technology interferes with face-to-face discussions with patients, requires physicians to spend too much time performing clerical work and degrades the accuracy of medical records by encouraging template-generated notes.

“Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work,” said Dr. Steven J. Stack, AMA president-elect, in a statement. “This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.”

The AMA said that numerous other studies support these findings, including a recent survey by International Data Corporation that found 58 percent of ambulatory physicians were not satisfied with their EHR technology. Most office-based providers find themselves at lower productivity levels than before the implementation of their EHR and workflow, usability, productivity and vendor quality issues continue to drive dissatisfaction.

In response to physician concerns, the AMA released a framework that outlines eight priorities for improving EHR usability. The association would like to see EHRs that do the following:

• Enhance physicians’ ability to provide high-quality patient care
• Support team-based care
• Promote care coordination
• Offer product modularity and configurability
• Reduce cognitive workload
• Promote data liquidity
• Facilitate digital and mobile patient engagement
• Expedite user input into product design and post-implementation feedback

The AMA said that these priorities were developed with an external advisory committee comprised of practicing physicians, experts, researchers and executives in the field of health information technology.

In 2012, the Affordable Care Act began requiring health plans to switch to electronic health records, which would reduce paperwork and administrative burdens, cut costs, reduce medical errors and improve the quality of care, the Obama administration said.

However, the incentives that were intended to drive widespread EHR adoption have exacerbated and, in some instances, directly caused usability issues, the AMA argued. The association urged the federal government to acknowledge the challenges that physicians face and to abandon the all-or-nothing approach. The AMA is also demanded that federal certification criteria for EHRs need to allow vendors to better focus on the clinical needs of their physician customers.

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HealthKit, an exclusive app for Apple, is designed to integrate health-monitoring data from multiple apps and devices such as Apple Watch. In June, Apple announced a partnership with Mayo Clinic, which has been working with the tech giant for two years to help design the HealthKit software and app. The HealthKit system has the ability to leverage engagement by alerting patients when their breathing is abnormal, for example, and then scheduling a follow-up visit with their doctor.

On Sept. 10, the American Telemedicine Association (ATA) praised Apple’s new technology, saying it demonstrates how advanced telecommunications can be used to transform the delivery of health services by allowing consumers to seamlessly monitor their own health and fitness information, and ultimately share the data with their health providers. The ATA said one of the most important aspects of the HealthKit system is that Apple has chosen to integrate its technology with health provider systems and electronic record platforms. It’s a stark contrast to competing health devices and apps, which have often chosen to compete with providers and market stand-alone products rather than work to streamline the patient-provider process.

“These developments enable consumers to take their personal health data into their own hands where it belongs,” said Jonathan Linkous CEO of ATA, in a statement. “We look forward to seeing how empowering consumers in this new way changes modern health care delivery.”

Apple has been reportedly promoting its HealthKit service to health providers at Mount Sinai in New York City; Johns Hopkins in Baltimore; and Madison, Wis.-based Epic Systems, an electronic health records provider.

Filament Labs, a health care tech startup based in Austin, Texas, announced on Sept. 10 that its care delivery platform, Patient IO, is one of the first electronic products to integrate with Apple’s HealthKit. The platform makes it easier for hospitals and health providers to communicate and engage with patients between doctor visits by creating a personalized care plan that delivers treatment-specific tasks, reminders, and educational content to smartphones. Bespoke healthcare software that is used by hospitals for the day-to-day management of various hospital tasks could also potentially be integrated with such remote monitoring devices, to enhance information systems in hospitals and enable better healthcare for all patients.

Wearable remote patient monitoring (RPM) is a booming business, according to New York-based ABI Research, which provides analysis for emerging technologies. A report from the company, “The Remote Patient Management Revolution: Wearable Devices and Open Management Platforms,” found close to 100 million RPM devices will be distributed over the next five years. Apple isn’t the only player in the patient engagement market; Google has released its Google Fit platform and Samsung has its Gear Fit device.

One barrier to widespread adoption of a health data repository, something that Apple is trying to become, is the limited scope of integration between all parties involved in patient health. The cloud-based HealthKit system, which promises to seamlessly connect technology, apps and health care facilities, may fuel interest.

“Data has traditionally resided in silos belonging to specific applications delivered primarily by device vendors themselves. New cloud platforms capable of collecting data from a range of vendor devices and sharing it securely with a range of related parties including patients, health care providers and payers will drive adoption and bring more connected devices to market,” said Jonathan Collins, principal analyst at ABI Research, in a statement.

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Michigan Health Connect and Great Lakes Health Information announced Monday they will combine to form Great Lakes Health Connect (GLHC). Network members of the merged organization cover more than 80 percent of the hospital beds in the state and include more than 20,000 independent and employed providers. These health care providers serve more than half of the state’s 10 million people.

“Michigan Health Connect and the Great Lakes Health Information Exchange recognized that our missions were essentially the same and that we could better achieve our vision for a healthier Michigan together, rather than independently,” said Brian McCardel, M.D., orthopedic surgeon and chairman of the Great Lakes Health Information Exchange board of directors, in a statement.

GLHC will coordinate the exchange of electronic health records (EHR) between more than 120 hospitals. The company will also be able to provide real-time notification to providers for admissions and discharges from hospitals, nursing homes and other facilities.

“The depth and breadth of our network means we have the experience, resources and connections to initiate industry-leading advances in health information exchange on behalf of Michigan citizens,” said Doug Dietzman, executive director of GLHC and former executive director of Michigan Health Connect, in a statement.

The merger is in line with one of health care reform’s key requirements for technology to play a central role in containing costs, improving access and improving the health of patients. There is a 2015 deadline for health care providers that have not adopted a certified EHR system or can’t demonstrate “meaningful use.” If providers have not adopted a system and are eligible for Medicare reimbursements, their reimbursements will be reduced by 1 percent in 2015, rising to 4 percent in 2018.

“We look forward to advancing an integrated platform of services across the state and making Michigan a leader in the nationwide move to health information exchange and improved health status,” added Patrick O’Hare, chairman of the Michigan Health Connect board of directors, in a statement.

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Designing an Implementation and Process Map
Integrating a new, comprehensive EHR system starts with designing a well-planned implementation and process map. To begin, the map should be mutually agreed upon by the facility owner, architects, engineers, contractors and other stakeholders, as it helps everyone involved successfully schedule the implementation process, from planning through design, construction, and system activation.
The process map includes comprehensive documentation of all required project steps. It starts with a building analysis, which can help minimize cost escalation and surprises as a project progresses. Next steps include code compliance; the selection of general contractors; costs of design, construction and technologies; detailed EHR construction documentation; safety-permit construction documents; clear identification of locations for new or renovated IT rooms; and comprehensive schedules incorporating work processes managed by owners, architects, contractors, and design/build trade partners.
Another element to consider is a campus-wide analysis of existing architectural and engineering systems and their mechanical, electrical, wireless, and data conditions. Facilities may also identify flexible spaces for use during phased construction, so that neither the patient experience nor caregiver workflow is disrupted. Flexibility is key, in order to accommodate unforeseen complications or surprises.
Staff training to ensure buy-in with the new EHR system, and to enhance work processes and decision-making, is also suggested. The implementation and process map also needs an attainable go-live date for the EHR system.

Instigating Infrastructure Upgrades
Developing an integrated, facility-wide EHR system includes infrastructure upgrades. These upgrades usually begin with routing new cabling and wiring, installing power and data outlets, and enabling Wi-Fi access. IT rack rooms or closets, located and identified in the implementation and process map, are moved and/or renovated.
Most health care facilities are already complex, multichannel organizations incrementally built over the years. Thus, existing systems should be leveraged wherever possible. Still, some existing infrastructure can create renovation challenges, even to simple cable updates. For instance, state and Federal codes often stipulate that if a new system touches an older system, then the older system (or room) and path of travel must be upgraded to meet current codes.
Also, as the architect identifies appropriate locations for new or renovated IT rooms-whether in offices, utility closets, or storage spaces-careful consideration must be given to other systems currently in use or nearby. For instance, is computer modeling reveals a potential increase in heating or cooling loads, HVAC upgrades may be necessary.

Measuring Success
A well-integrated EHR system is based on common-enterprise computer architecture, data standards, and privacy and security guidelines. Included in the system are such features as information model, standards and configurations; secure data exchanges; user identification and authentication; access management; clinician-access channels and event notification; and business intelligence enablement.
Thus a health care facility’s EHR implementation and process plan shouldn’t end with go-live activation. The new EHR system, in complement with additional technological infrastructure upgrades, should include a program for measuring the EHR system’s success with regard to health care quality, safety and security, and productivity.
As the evolution of tablets and smart phones ensures technology becomes more mobile, the patient and physician benefits of EHR systems will grow. In large health care facilities, for instance, patients may already be accessing their personal health information from their smart phone. At home, using a laptop, they will literally tap into the organization’s EHR system in order to easily communicate with their doctor, specialist, or pharmacist from a remote location.
Conversely, physicians and other medical personnel can share patient statistics across locations to ensure proper diagnosis and care. Outside of urban hubs, in more suburban or rural locations, EHR systems virtually bridge distances between locations, so that patients can remain safely in their homes while receiving consultations and care. For these reasons, new protocol for measuring the success of EHR systems is critical.

Conclusion
Such sharing of information resources is generally accepted as the key to substantial improvements in productivity and better quality of care. In addition, also the U.S. population becomes more mobile, national health care networks are increasingly used to facilitate the sharing of health care-related information among various stakeholders and participants.
EHRs add another level of complexity to systems integration. But the benefits of EHRs to health care organizations and their patients – secure access that eases communication between caregivers, specialists, and patients – will grow as mobile technologies continue to drive advances in communications within the health care industry.

About the Authors
Joey Kragelund, AIA, is associate vice president and health care principal with HGA Architects and Engineers in Los Angeles.

Beth Young, AIA, LEED-AP, is project manager with HGA Architects and Engineers in Sacramento.

About HGA
HGA is an integrated architecture, engineering and planning firm. With offices in Los Angeles, San Francisco and Sacramento, California; Minneapolis and Rochester, Minnesota; Milwaukee, Wisconsin; and Washington DC, the nationally recognized firm has developed expertise in the health care, corporate, government, arts, community, education, and science/technology industries since 1953. Our culture for interdisciplinary collaboration, knowledge sharing and design investiga¬tion helps prepare our clients for the future with responsive, innovative and sustainable design. Visit www.HGA.com or follow the firm on Facebook or Twitter.

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