6 Key Highlights from the New Electronic Medical Record Rating Standards Seminar

On October 30 and 31, 2018, the Chinese Hospital Association organized an interpretive session on the new edition of the Electronic Medical Record (EMR) grading standards. The following is a summary of key insights presented by Yuan Yongfu, founder of Duchang Information.

Yuan Yongfu, Founder of Duchang Information

The conference revealed that the scope of Electronic Medical Record (EMR) systems continues to expand, with some hospitals implementing integrated outpatient, emergency, and inpatient systems to achieve hospital-wide coordination. Any information technology module involved in medical activities is considered part of the EMR system.

Moreover, the scope of electronic medical records (EMR) has extended beyond hospitals, integrating with emergency care and resident health archives to enable broader applications. In my view, the development of traditional, purely finance-oriented Hospital Information Systems (HIS) has stagnated, leading to a decline in procurement demand. Traditional HIS vendors that rely solely on their existing legacy will inevitably face obsolescence.

Electronic medical records (EMRs) are patient-centered, and since patients are primarily concerned about costs, EMRs are likely to incorporate extensive cost-related information in the future. Additionally, as health insurance cost-containment measures become increasingly stringent, and given their close association with diagnoses and clinical pathways, EMRs are becoming more closely linked to financial data. These trends will further encroach upon the traditional domain of Hospital Information Systems (HIS).

Lecturing experts repeatedly emphasized that the construction of electronic medical record (EMR) systems is a top-priority initiative led by the hospital president, overseen by the Medical Affairs Department, with participation from clinical departments and technical support from the Information Technology (IT) Department. Moreover, as this briefing was organized by the Hospital Administration Bureau, it has elevated the political significance of healthcare informatization. In this process, the IT Department has transformed from a purely technical unit into a functional department, serving as the president’s strategic advisor on informatization and participating in the top-level design of digital hospital development.

Why Informatization Has Become a Top-Leadership Priority: My Perspective

The main challenge in the process of informatization lies in business process reengineering. This involves transforming previously extensive, manual workflows into refined, automatable processes. Such transformation entails a reallocation of interests and is prone to causing interpersonal conflicts. Most hospital IT departments lack the capability and resolve to carry out this transformation, resulting in suboptimal outcomes for informatization initiatives. In contrast, designating informatization as a “top-leader project” leverages strong administrative authority and enforcement power, enabling the forceful reallocation of interests and successful process reengineering.

Moreover, the essence of informatization is to migrate workflow diagrams from physical walls into computer systems and human minds. Integration into computer systems is relatively straightforward, whereas integration into human minds is far more challenging. Most IT departments are relatively weak and lack the leverage to embed these workflows into the mindset of clinical and operational staff. However, when driven as a top-priority initiative by senior leadership, these workflows can be effectively mandated and ingrained in the practices of business units from the top down.

Furthermore, with top leadership taking the lead, informatization efforts must shift from isolated initiatives by IT staff to an all-hands approach involving every employee. Only in this way can the work be solidly implemented and yield greater practical results.

In the current process of hospital informatization, many hospitals’ IT departments delegate all tasks to vendors, allowing them to handle everything end-to-end, including the accreditation evaluation process. As a result, these hospitals lack awareness of the scale and utilization status of their own hardware and software assets.

The lecturing experts disapprove of such behavior. They have repeatedly emphasized that the Information Technology Department must take greater initiative and can no longer afford to be complacent. Furthermore, active participation in this “Top Leader” project will enhance the department’s standing within the hospital.

Experts also specifically noted that when manufacturers handle everything unilaterally and the IT department fails to engage diligently, copying application materials from other hospitals can lead to fatal errors—such as leaving another hospital’s name in documents or images. This would cause the application process to fail abruptly and could adversely affect the ratings of the manufacturer’s other hospital clients.

Experts also emphasize that the fact that a vendor’s client has passed the Electronic Medical Record (EMR) grading does not guarantee that one’s own hospital will pass. This is because, during the grading process, the vendor serves only in a supportive role, while the primary responsibility lies with the hospital’s own efforts.

My understanding is that the original intent of the new rating system is to compel hospitals to shed complacency and take concrete, proactive measures, thereby promoting development through evaluation. Much like treating a disease, where physicians and medications serve only as adjuncts, the key lies in the body’s own immune resistance.

Rating is merely the beginning; the true objective lies in the continuous improvement of healthcare quality thereafter. While the specific criteria for rating may evolve over time, the ultimate goal should remain timeless. Hence, experts have earnestly urged hospitals to take proactive measures and leverage the rating process to drive institutional development.

For the first time, this conference established the foundational status of data itself within the new rating system. I have previously written a series of articles, including “The Rise of Data,” emphasizing the importance of data and foreseeing that data should be stored and utilized independently of specific business systems. Soon thereafter, the new rating system prominently elevated the status of data and stipulated numerous detailed implementation provisions.

Some lecturing experts also pointed out that when hospitals apply for government funding for informatization, clearly stating that the system will generate substantial high-quality data assets for future use upon completion can increase the likelihood of successful funding approval.

Previously, the government focused solely on the hardware and software capabilities of systems; now it has begun to recognize the intrinsic value of data, regarding data itself as a critical core asset.

In practice, some vendors use proprietary encrypted data formats to lock in hospitals. Previously, hospitals were satisfied as long as they could complete data entry, display, and printing; the issue of unauthorized data encryption remained undisclosed.

Currently, the subsequent utilization of data has garnered widespread attention. However, privately encrypted data is difficult to leverage for such purposes, thereby exposing issues related to data formats. Accordingly, my recommendation was adopted, and the new Level 5 standards explicitly stipulate: “01.06.5: The content of electronic medical records shall be stored in a universal format and made accessible to third parties authorized by the hospital.” This means that medical record data must be stored in a universal format, allowing third parties to access the information under hospital supervision. This approach nips the problem in the bud.

Experts point out that data governance can address disorder, but cannot create something from nothing.

In this regard, I believe that data in proprietary encrypted formats is tantamount to having no data at all. Proprietary encryption severely hinders subsequent data interoperability and reuse.

Data can be stored in encrypted form, but hospitals must possess the decryption passwords and have the capability to decrypt data independently of the original vendor. Data belongs to the hospital and its patients, not to the vendor. Vendors should uphold proper ethical standards and refrain from exploiting hospitals’ lack of technical expertise to hold them hostage. Meanwhile, hospitals should transition from ignorance to informed awareness by acquiring fundamental knowledge in health informatics, and diligently inventory and safeguard their data assets.

With the rise of data, independent data centers have become a necessity, and integration platforms, an important means of implementing data centers at present, are gaining significant traction. Many experts have showcased the application of system integration platforms in their respective hospitals.

A few days ago, I was chatting with the Chief Information Officer (CIO) of a hospital in central China. The hospital has 600 beds and is planning to implement an integration platform. I mentioned that the cost of such a platform could exceed RMB 10 million. He did not express any concern about the high price; instead, he enthusiastically sought out information on various vendors of integration platforms. In a project undertaken by a major company for a large hospital in East China, the electronic medical record (EMR) system cost RMB 8 million and required extensive long-term on-site development by a large team. Meanwhile, the integration platform cost RMB 20 million, despite involving a smaller implementation workload than the EMR system. The CIO of a Shanghai hospital stated that hospitals are certainly willing to invest heavily in IT infrastructure, but they struggle to find satisfactory products.

My interpretation is that the heyday of integration platforms has arrived. In higher-level Electronic Medical Record (EMR) system evaluations, an integration platform has become virtually indispensable. The central government has proposed hospital informatization construction centered on EMRs. Since an EMR system serves as a comprehensive container capable of incorporating diverse components, high-value assets such as integration platforms also fall within the scope of EMR systems.

However, high monetary value is not equivalent to high importance or utility. Effective medications are not necessarily expensive, and expensive medications are not necessarily effective. Hospitals must maintain a clear and rational mindset, acquire foundational knowledge of information technology, conduct thorough audits of their digital assets, formulate well-defined development strategies, and procure and utilize IT products effectively. Nevertheless, phenomena akin to “arsenic saving lives without recognition, while ginseng causing death with impunity” will likely continue to emerge.

Many of the rating demonstration hospitals represented by today’s expert speakers have developed their own systems in-house. These include Beijing Fuwai Hospital, Tsinghua Changgung Hospital, Edong Medical Group, Shanghai Ruijin Hospital, and Jiangsu Province People’s Hospital, among others. Other well-known hospitals with advanced health IT capabilities that did not present lectures, such as the Wenzhou hospital network, Dongyang Hospital, and Zhangjiagang People’s Hospital, have also engaged in varying degrees of in-house software development. This indicates that independent software development by hospitals contributes to achieving higher ratings.

Hardware technology has become relatively standardized and specialized, making it fully outsourceable. Switching vendors is convenient, pricing is transparent, and management is straightforward. In contrast, software technology lacks standardization, and hospitals require deeply customized software to achieve high-level accreditation. Software vendors, stretched thin by serving multiple hospitals, simultaneously strive to maximize the universality and productization of their software. This leads vendors to prefer that all hospital clients use a single software version. Consequently, achieving deep customization of software functions depends on the negotiation dynamics between hospitals and vendors, which can sometimes result in friction. In such cases, independent in-house development by hospitals emerges as a viable auxiliary approach to attaining high-level accreditation.

The greatest advantage of hospitals developing their own software is the ability to build an in-house information technology team. This team can integrate seamlessly with clinical departments, foster close collaborative relationships with medical staff, and remain dedicated to the long-term customization and maintenance of software tailored specifically for the hospital. In system procurement, such a team possesses the capability, willingness, and obligation to safeguard the hospital’s core interests, thereby transforming the hospital’s lack of expertise in informatization into informed competence.

Based on the author’s nearly 20 years of experience in software development, health informatics is a specialized discipline that requires not only theoretical knowledge but also extensive practical application. True mastery can only be attained through long-term coding practice; without hands-on coding experience, one cannot genuinely understand software. If a hospital has even a single individual who truly understands both software and hospital operations, it can avoid many pitfalls during software procurement, prevent significant waste, and reduce the frequency of system replacements. Such professionals can only be cultivated through the actual process of developing in-house software for the hospital. External technical hires may possess software expertise but lack understanding of hospital business workflows, rendering their impact limited in the short term.

However, the scope of hospital informatization requirements is so vast that complete in-house development is impractical. In this context, hospitals can develop core software internally while outsourcing peripheral software to vendors. Priority should be given to procuring software that provides secondary programming interfaces (APIs) to facilitate independent modification and integration by the hospital. Furthermore, the database schema accompanying the software must be fully disclosed; any vendor found encrypting data without authorization will be subject to immediate disqualification.

If conditions permit, request the source code from the vendor for backup purposes. Note that the source code must precisely match the hospital’s project. After each modification by the vendor’s on-site project team, the hospital should obtain the latest local version of the source code. Due to inadequate internal source code management practices at some vendors, the source code obtained from the vendor’s headquarters may not precisely match the hospital’s project.

When developing solutions in-house, hospitals can procure programmable software components or middleware to avoid the high technical complexity of low-level R&D. For instance, leveraging third-party controls such as electronic medical record (EMR) editors can reduce development difficulty and save workload.

Independent in-house development by hospitals is merely a supplementary factor for achieving high-level accreditation, and most hospitals lack the conditions to implement it. Nevertheless, it remains crucial for hospital staff to acquire as much professional knowledge in health informatics as possible, serving as an important auxiliary means toward high-level accreditation. While study visits to peer institutions are certainly necessary, diligent self-study and sustained academic effort are equally indispensable.

Regarding the new electronic medical record (EMR) grading system, I consider it the most significant event in the health information technology (HIT) industry in 2018. Hospitals striving for excellence must carefully study and comprehend the new grading criteria, and diligently advance hospital informatization with EMRs at its core. Informatization should be elevated to a top-priority initiative led by senior leadership, breaking through existing interest frameworks to facilitate seamless transformation. Clinical workflows must be internalized from wall charts into computer systems and staff mindsets, ensuring organization-wide participation. Most importantly, achieving the grading is merely the beginning; the continuous improvement of healthcare quality is an unending long march.

For IT vendors, the new rating system represents a significant boon, unveiling substantial business opportunities ripe for exploration. Yet prosperity can wane, and chaos can foster rise. Regardless of the era, enterprises must uphold sound values and stay attuned to trends. New entrants should showcase their vigor and edge, while established players must shed complacency and stagnation. Only by doing so can they maximize their odds of success and secure greater victories.