In 2004, president George W. Bush set an ambitious goal for the American health-care industry: by 2014, he wanted all citizens to have access to an electronic medical record (EMR). Earlier this year, President Obama reinforced the federal government's commitment to that target, and announced that nearly $20 billion in stimulus money would be available during the next five years to help health-care providers implement digital record systems.
EMRs are widespread in Europe, Australia, and elsewhere, but only 4% of American doctors have a fully functional system, according to the New England Journal of Medicine. Another 13% use a basic one. For patients, the benefits are obviousconvenience, portability, and efficiency. EMRs also offer benefits to health-care providers, including the reduction of clerical errors and computerized decision support. And scientists are excited by the technology's potential for furthering medical research.
For years, however, the economic incentives simply weren't powerful enough. Although studies suggest EMRs could save billions of dollars each year, the complexity and cost of developing, implementing, and managing the technology meant that American health-care providersmost of whom work in small practices with fewer than five physiciansfound little reason to adopt it. "When a physician invests in EMR, 89% of the benefit goes to someone else," says Blackford Middleton, director of Clinical Informatics Research & Development at Partners HealthCare in Boston. Insurance companies, Middleton notes, are often the primary financial beneficiaries, saving money by streamlining the claims process and reducing duplicate tests and procedures. It's an imbalance that the federal stimulus, which makes physicians eligible for up to $64,000 in incentives (and hospitals for up to $11 million) beginning in 2011, may help overcome. But EMRs also present a number of other challenges involving protocols and standards, privacy, and how physicians practice medicine.
Protocols and Standards
One of the main difficulties is the lack of protocols and standards. Several groups across the country have developed their own EMR systems, including Partners HealthCare, the Cleveland Clinic, and the Regenstrief Institute in Indianapolis. Hundreds of EMR vendors offer products, too. But standards for the collection, exchange, and retrieval of electronic medical information vary widely from system to system. The Healthcare Information Technology Standards Panel (HITSP), a private-public partnership, has worked since 2005 to harmonize protocols and standards, and the Obama administration has already convened two federal advisory committees to help tackle the problem. The trick, according to industry watchers, will be finding the right balance between standardization (which helps ensure interoperability and information sharing) and flexibility (which accommodates the various systems and architectures that different health-care providers need). Britain's National Health Service (NHS), for example, has fielded fierce criticism from clinicians about its plans to digitize the country's health system, which are derided as rigid and inadequate.
Privacy presents another formidable challenge in terms of how to keep patient data from falling into the wrong hands. In the U.S., health-care providers are subject to a set of stringent laws and regulations intended to keep patient data safe, most notably the Health Insurance Portability and Accountability Act (HIPAA). Other regulations vary from state to state, however, and it can be difficult to design EMR systems that comply with all the required policies. "Lawyers write these policies, and no one ever looks at them," says Annie Antón, a professor of computer science at North Carolina State University. "It's a huge problem." Formalizing rules that were intended to be interpreted by courts, rather than by programmers, is also challenging. Whereas European Union law grants its citizens ownership of their medical dataand thus a great deal of control about what happens to itU.S. laws are less clear-cut. HIPAA doesn't address data ownership, and though it gives patients access to their records in most situations, it also grants doctors plenty of authority such as the right to share data with insurance companies, for example, and with other medical specialists.
A more basic privacy-related challenge stems from the complexity of health-care delivery. How is it determined which providers can access patient data? In general, only individuals with a direct medical need should be able to access files. Yet in an emergency-room setting, dozens of people may need to examine a single patient's record, from doctors to dieticians to internsand speed is often of the essence. At Partners HealthCare's network of hospitals, emergency-room doctors can only access the records of patients who have already visited that hospital, and only view (but not modify) them. "It's an imperfect system," admits Cynthia Bero, CIO at Partners Community Healthcare, "but we have to balance providing the best care with preserving patient privacy." Other EMR systems enable hospitals to grant and revoke patient data access on a daily, and sometimes hourly, basis.
From a technological perspective, there are three different architectures: centralized models, where data is stored and held in a single database; federated models, where it is distributed across a network; and a hybrid of the two. Each model has advantages and disadvantages. Centralized systems are generally regarded as more secure and easy to manageand hence better for research purposes. Federated systems, however, may be easier for small practices to deploy, and to facilitate the aggregation of data across different networks. But they also force healthcare providers to rely on a third party to guard against data loss and breaches of privacy. It's not yet clear, experts say, exactly how architectures will evolve in the future.
Clinicians' Daily Workflow
To be truly useful, of course, EMRs must fit seamlessly into clinicians' daily workflow. Yet this, too, presents a challenge. From a physician's perspective, it's faster to scribble a prescription on a piece of paper than it is to log onto an EMR system and electronically enter the data. (Renewing a prescription, on the other hand, is much quicker with an EMR system.) HCI specialists like Jason Saleem, an investigator at the Regenstrief Institute, are therefore working to develop systems that are easier and more efficient to use. "By understanding doctors' workflow, we can design better EMRs," he explains. One lesson is that it may not be possible, or even desirable, for EMRs to fully replace paper. In a study published in the International Journal of Medical Informatics, Saleem observed that index cards and Post-It notes often serve as important extensions of EMRs when it comes to tasks such as remembering an important piece of information in the midst of juggling several other urgent tasks.
Standards for the collection, exchange, and retrieval of electronic medical information vary widely from system to system. EMRs hold great potential for clinical-decision support by translating practice guidelines into automated reminders and actionable recommendations.
Saleem's work is complicated by the fact that the practice of medicine is highly individualized. Indeed, physicians in the same specialty often work differently even when performing the same medical procedure. Here standardization and flexibility must also be balanced. Too much standardization, and clinicians chafe under rules that don't match their own work habits. Too little, and workflow becomes less efficient. EMRs hold great potential for clinical-decision support, for example, by translating practice guidelines into automated reminders and actionable recommendations. Yet as Partners HealthCare CIO John Glaser explains, "You want to guide [clinicians] rather than getting in the way." And striking the appropriate balance isn't always a straightforward task.
Technology, however, is only part of that equation. "It's really a much larger question that gets back to how we train our doctors," says Bero. Is medicine more art or science? Is good judgment more important than a rigid adherence to medical consensus? Though most people would agree that some variation in care is appropriate, the flexibility of EMR-encoded workflow depends on how you answer those questions. Economic incentives may also make a difference. Pay clinicians per procedure, as the U.S. health-care system typically does, and you give them little incentive to make workflow more streamlined or efficient.
As the U.S. debates these issues, the rest of the world is moving forward with its own initiatives. In Europe, EMR adoption rates are at 50% or higher in most countries, though as Middleton points out, that may be about more than just technology. "Where there are nationalized, centralized healthcare systems, there have typically been large investments in health IT," he says. The European Union is now trying to implement EMR standards that would enable country-to-country data exchange.
Meanwhile, thanks to a combination of frugal entrepreneurship and a more liberal approach to regulations, countries like India and Thailand have in many ways surpassed their rich-world counterparts when it comes to health IT. Several Indian hospital chains use locally built EMRs, as does Bumrungrad hospital in Bangkok. And the rich world is beginning to take note. Apollo Health Street, an offshoot of India's Apollo Hospitals Group, sells HIT software to American hospitals, while Microsoft purchased software, intellectual property, and other assets from the Bangkok-based company that developed Bumrungrad's systems in 2007.
Bates, D. and Gawande, A. Improving safety with information technology. N Engl J Med 348,25, June 19, 2003, 252634.
Blumenthal, D. and Glaser, J. Information technology comes to medicine. N Engl J Med 356, 24, June 14, 2007, 252734.
Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., Scoville, R., Taylor, R. Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs. Health Affairs 24, 5, 2005, 11031117.
Sittig, D.F., Wright, A., Osheroff, J.A., Middleton, B., Teich, J.M., Ash, J.S., Campbell, E., Bates, D.W. Grand challenges in clinical decision support. J Biomed Inform 41, 2, April 2008, 38792.
Stead, W. and Lin, H. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. The National Academies Press, Washington, D.C., 2009
Figure. The Spanish Peaks Regional Health Center, based in Walsenburg, CO, plans to make the transition to an electronic health records system before the end of 2010, which will eliminate the need for office assistants to wade through piles of paper-based patient records.
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