- Email: [email protected]
The muddle of US electronic medical records
World Report
The muddle of US electronic medical records Private health-care companies have provided the bulk of the money for the USA’s electronic medical records system, but poor government coordination for the project has allowed the network to evolve into a muddled collection of disjointed parts. Nellie Bristol reports. The USA’s reliance on private healthcare providers to develop the technology necessary to support electronic health records (EHR) means the country is trailing several others in implementation of this new medical technology. Commercial development by numerous different companies of computerised personal medical files, which are created by networks linking healthcare providers, means that the US network of health information technology now resembles a disjointed amalgam of parts, none of which communicates very effectively with the other. According to Mark Leavitt, medical director for the Healthcare Information and Management Systems Society (HIMSS), the proprietary nature of US health care is to blame for this lack of crosstalk. “There has been no incentive for [providers] to share data and really no incentive for ven-
Science Photo Library
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Electronic medical records should make piles of paper files a thing of the past
1610
dors to build interoperability into their products because the customers weren’t asking for it”, he explains. To try and make some sense of the muddle of different systems, David Brailer was appointed by President Bush last May as the country’s first National Coordinator for Health Information Technology. Describing himself as a “convener” and a “catalyst”, Brailer has set out a framework for EHR development and is now assimilating 500 suggestions from stakeholders into a complete strategic plan for a national health information network. A Presidential Commission on Systemic Interoperability is slated to produce its own comprehensive strategy by October. Among his top priorities, Brailer says, is addressing the “market failure” that has made EHR technology prohibitively expensive for small physician practices. While hospitals and larger practices have the capital to invest in EHR-supporting technology, physicians in smaller practices are reluctant to spend the up to US$36 000 per physician necessary to purchase a system, and are receiving little help from payers which view these investments as business overheads rather than part of patient care. Brailer is working on ways to encourage payers to contribute to EHR purchases. The first step to making the system more accessible to health-care providers is the establishment of a Certification Commission for Health Information Technology. Leavitt, who chairs the commission, says the panel will sort through the vast array of available EHR software and certify which systems meet specific standards, including interoperability, to make purchases less confusing. It
plans to have the full programme operational by the end of the year. Making systems more appealing to physicians is key to EHR adoption, because the system is not only expensive, but also requires a major change in the way practitioners work. Research shows a marked increase in physician work load as they convert from paper to screen. Dave Garets, CEO of the research arm of HIMSS, comments that widespread adoption of EHRs in the USA will occur when system prices drop to a level individual physicians can afford and when they offer easy-to-use clinical decision support, including prompts describing best practices and drug alerts. “The docs will adopt if they get value out of it”, he says. Robert Tennant, senior policy adviser for the Medical Group Management Association, argues that EHRs will flourish only when the Bush Administration steps up with more resources. “They’re not putting enough money into it”, he says. Since pledging last year that most citizens will have EHRs by 2014, Bush has requested a total of US$225 million for systems development, $50 million of which did not receive Congressional approval during the fiscal year 2005 appropriations cycle, but is being pursued by the White House again this year. Most of the funding is earmarked for grants and awards to aid establishment of local and regional networks. Tennant says the Bush Administration should offer providers direct financial assistance for purchasing EHR systems and that costs should be spread among “all the participants”, including payers. “The primary beneficiaries [of EHR cost savings] are going to be the health plans”, Tennant comments, www.thelancet.com Vol 365 May 7, 2005
World Report
www.thelancet.com Vol 365 May 7, 2005
data collection and storage still holds huge promise for research improvement as EHRs expand. Large collections of anonymous data could simplify the process of feasibility studies for clinical trials by identifying populations with specific conditions, Leavitt says. Use of EHR data for the studies themselves may be trickier, however, because the Food and Drug Administration now requires separate validation of medical-record data legitimacy. Leavitt predicts that some of those barriers could be eliminated, but comments, “some work needs to be done there”. Eliminating these barriers would diversify data available for research because the studies now done at major academic centres frequently involve similar populations, Leavitt notes. Electronic databases would also be far more sensitive than current systems for monitoring epidemics. Methods in use at the moment can spot clusters of unusual test results, but electronic databases would be sensitive enough to pick up trends involving more minor complaints, such as fever or diarrhoea, which may indicate the start of a bigger problem. Brailer’s office is currently working with the National Cancer Institute to develop ways to blend data from trials with anonymised information from clinical settings. The result, Brailer says, will be a “more timely, richer, and more complete real-world data set”. With its promise of better research data, lower costs, and improved patient care and safety, the complex enterprise of EHR engineering is being pursued by countries worldwide, each effort driven by the nation’s individual culture, political, and health system. “It’s really a big puzzle and people are working on different parts of the puzzle”, said Peter Waegemann, chief executive officer of the Boston-based Medical Records Institute. He adds: “There’s no consensus for what really is effective.”
Rights were not granted to include this image in electronic media. Please refer to the printed journal. AP
adding that the savings will most likely come in the form of reduced procedure redundancy and improvements in chronic-care management. Medicare, the health care programme for the elderly and disabled, and one of the largest US payers, is considering a pay-for-performance system for physicians that would reward use of electronic systems for improvements in quality of care. However, the bonuses are likely to be budget neutral, meaning non-compliant physicians could receive less money to pay for them. Tennant says that approach “runs the risk of backfiring”, especially since physicians already are facing a 4·3% overall reduction in Medicare payments in 2006. Other concerns with the Bush EHR approach centre on patient privacy, which experts say is not receiving high enough priority. “They’re going about this in an irresponsible way”, says Janlori Goldman, director of the Health Privacy Project. She says the Administration should be insisting that privacy standards be built into the system before any money is spent, adding that if patients don’t feel their information is sufficiently safeguarded, they could be reluctant to be honest with their physicians and care could suffer. Proponents argue that well-designed EHRs are safer than paper records because they can be encrypted, will require passwords, and provide an audit trail. Goldman counters that the magnitude of harm with a paper record passing through the hands of a few individuals is small compared with the potential injury associated with private medical information moving through cyberspace. She is advocating strengthening and making enforceable privacy rules contained in the Health Insurance Portability and Accountability Act. Privacy concerns derailed earlier efforts in the USA to establish unique patient identifiers, making it more difficult to use EHRs to develop a national database for clinical research. Nonetheless HIMSS’ Leavitt says the current regional approach to patient
Some US hospitals have already gone paper free
Countries that are farthest along are those with more centralised health systems, comprehensive strategic plans, and the willingness to make the necessary investment. Leaders include many European countries, Canada, Australia, China, South Korea, and Japan. US health technology advocacy group eHealth Initiative calls the UK EHR campaign “the largest-scale initiative underway in any country worldwide”. The goal is to have online records for 50 million citizens, with connections between all physicians and hospitals by 2010. However, the effort is marred by concerns about patient privacy and expense. The original cost for the network was estimated at £6·2 billion ($11·7 billion), but is now predicted to rise to as much as £18 billion–31 billion ($34 billion–58 billion). There also has been some discontent from the country’s physicians, who say the government’s top-down approach allows for little design input from those who will actually use the system. While the UK approach differs radically from the US campaign, both countries share the same goal: seamless, portable, cradle-to-grave computerised medical files that ensure patients receive the best care possible. And though it will take some time and effort, the ideal seems to be moving increasingly closer.
Nellie Bristol 1611
The muddle of US electronic medical records Private health-care companies have provided the bulk of the money for the USA’s electronic medical records system, but poor government coordination for the project has allowed the network to evolve into a muddled collection of disjointed parts. Nellie Bristol reports. The USA’s reliance on private healthcare providers to develop the technology necessary to support electronic health records (EHR) means the country is trailing several others in implementation of this new medical technology. Commercial development by numerous different companies of computerised personal medical files, which are created by networks linking healthcare providers, means that the US network of health information technology now resembles a disjointed amalgam of parts, none of which communicates very effectively with the other. According to Mark Leavitt, medical director for the Healthcare Information and Management Systems Society (HIMSS), the proprietary nature of US health care is to blame for this lack of crosstalk. “There has been no incentive for [providers] to share data and really no incentive for ven-
Science Photo Library
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Electronic medical records should make piles of paper files a thing of the past
1610
dors to build interoperability into their products because the customers weren’t asking for it”, he explains. To try and make some sense of the muddle of different systems, David Brailer was appointed by President Bush last May as the country’s first National Coordinator for Health Information Technology. Describing himself as a “convener” and a “catalyst”, Brailer has set out a framework for EHR development and is now assimilating 500 suggestions from stakeholders into a complete strategic plan for a national health information network. A Presidential Commission on Systemic Interoperability is slated to produce its own comprehensive strategy by October. Among his top priorities, Brailer says, is addressing the “market failure” that has made EHR technology prohibitively expensive for small physician practices. While hospitals and larger practices have the capital to invest in EHR-supporting technology, physicians in smaller practices are reluctant to spend the up to US$36 000 per physician necessary to purchase a system, and are receiving little help from payers which view these investments as business overheads rather than part of patient care. Brailer is working on ways to encourage payers to contribute to EHR purchases. The first step to making the system more accessible to health-care providers is the establishment of a Certification Commission for Health Information Technology. Leavitt, who chairs the commission, says the panel will sort through the vast array of available EHR software and certify which systems meet specific standards, including interoperability, to make purchases less confusing. It
plans to have the full programme operational by the end of the year. Making systems more appealing to physicians is key to EHR adoption, because the system is not only expensive, but also requires a major change in the way practitioners work. Research shows a marked increase in physician work load as they convert from paper to screen. Dave Garets, CEO of the research arm of HIMSS, comments that widespread adoption of EHRs in the USA will occur when system prices drop to a level individual physicians can afford and when they offer easy-to-use clinical decision support, including prompts describing best practices and drug alerts. “The docs will adopt if they get value out of it”, he says. Robert Tennant, senior policy adviser for the Medical Group Management Association, argues that EHRs will flourish only when the Bush Administration steps up with more resources. “They’re not putting enough money into it”, he says. Since pledging last year that most citizens will have EHRs by 2014, Bush has requested a total of US$225 million for systems development, $50 million of which did not receive Congressional approval during the fiscal year 2005 appropriations cycle, but is being pursued by the White House again this year. Most of the funding is earmarked for grants and awards to aid establishment of local and regional networks. Tennant says the Bush Administration should offer providers direct financial assistance for purchasing EHR systems and that costs should be spread among “all the participants”, including payers. “The primary beneficiaries [of EHR cost savings] are going to be the health plans”, Tennant comments, www.thelancet.com Vol 365 May 7, 2005
World Report
www.thelancet.com Vol 365 May 7, 2005
data collection and storage still holds huge promise for research improvement as EHRs expand. Large collections of anonymous data could simplify the process of feasibility studies for clinical trials by identifying populations with specific conditions, Leavitt says. Use of EHR data for the studies themselves may be trickier, however, because the Food and Drug Administration now requires separate validation of medical-record data legitimacy. Leavitt predicts that some of those barriers could be eliminated, but comments, “some work needs to be done there”. Eliminating these barriers would diversify data available for research because the studies now done at major academic centres frequently involve similar populations, Leavitt notes. Electronic databases would also be far more sensitive than current systems for monitoring epidemics. Methods in use at the moment can spot clusters of unusual test results, but electronic databases would be sensitive enough to pick up trends involving more minor complaints, such as fever or diarrhoea, which may indicate the start of a bigger problem. Brailer’s office is currently working with the National Cancer Institute to develop ways to blend data from trials with anonymised information from clinical settings. The result, Brailer says, will be a “more timely, richer, and more complete real-world data set”. With its promise of better research data, lower costs, and improved patient care and safety, the complex enterprise of EHR engineering is being pursued by countries worldwide, each effort driven by the nation’s individual culture, political, and health system. “It’s really a big puzzle and people are working on different parts of the puzzle”, said Peter Waegemann, chief executive officer of the Boston-based Medical Records Institute. He adds: “There’s no consensus for what really is effective.”
Rights were not granted to include this image in electronic media. Please refer to the printed journal. AP
adding that the savings will most likely come in the form of reduced procedure redundancy and improvements in chronic-care management. Medicare, the health care programme for the elderly and disabled, and one of the largest US payers, is considering a pay-for-performance system for physicians that would reward use of electronic systems for improvements in quality of care. However, the bonuses are likely to be budget neutral, meaning non-compliant physicians could receive less money to pay for them. Tennant says that approach “runs the risk of backfiring”, especially since physicians already are facing a 4·3% overall reduction in Medicare payments in 2006. Other concerns with the Bush EHR approach centre on patient privacy, which experts say is not receiving high enough priority. “They’re going about this in an irresponsible way”, says Janlori Goldman, director of the Health Privacy Project. She says the Administration should be insisting that privacy standards be built into the system before any money is spent, adding that if patients don’t feel their information is sufficiently safeguarded, they could be reluctant to be honest with their physicians and care could suffer. Proponents argue that well-designed EHRs are safer than paper records because they can be encrypted, will require passwords, and provide an audit trail. Goldman counters that the magnitude of harm with a paper record passing through the hands of a few individuals is small compared with the potential injury associated with private medical information moving through cyberspace. She is advocating strengthening and making enforceable privacy rules contained in the Health Insurance Portability and Accountability Act. Privacy concerns derailed earlier efforts in the USA to establish unique patient identifiers, making it more difficult to use EHRs to develop a national database for clinical research. Nonetheless HIMSS’ Leavitt says the current regional approach to patient
Some US hospitals have already gone paper free
Countries that are farthest along are those with more centralised health systems, comprehensive strategic plans, and the willingness to make the necessary investment. Leaders include many European countries, Canada, Australia, China, South Korea, and Japan. US health technology advocacy group eHealth Initiative calls the UK EHR campaign “the largest-scale initiative underway in any country worldwide”. The goal is to have online records for 50 million citizens, with connections between all physicians and hospitals by 2010. However, the effort is marred by concerns about patient privacy and expense. The original cost for the network was estimated at £6·2 billion ($11·7 billion), but is now predicted to rise to as much as £18 billion–31 billion ($34 billion–58 billion). There also has been some discontent from the country’s physicians, who say the government’s top-down approach allows for little design input from those who will actually use the system. While the UK approach differs radically from the US campaign, both countries share the same goal: seamless, portable, cradle-to-grave computerised medical files that ensure patients receive the best care possible. And though it will take some time and effort, the ideal seems to be moving increasingly closer.
Nellie Bristol 1611