A prescription for electronic health records: converting paper files into electronic health records (EHRs) can lower costs, reduce medical errors, and save lives, but the development expenses and technological challenges are great.

Imagine sitting down at a computer and being able to access, download, and print your medical records. If you move across the country, you will still be able to access your and your Family's medical records online, as will your new doctors, hospital, pharmacy, and insurance company.

In many nations around the world today, this is now or soon will be reality for patients. But the United States is just beginning to explore the possibilities of making electronic health records (EHRs) accessible to patients, doctors, and hospitals from anywhere, which experts say could significantly improve the quality of care, better protect patient records, and reduce harmful medical errors.

Countless studies have shown that the archaic information systems of U.S. hospitals and clinics directly affect the quality of care patients receive. When a patient visits a new hospital or clinic, it most likely will have little information about him or her and no way to track how other providers have treated him or her in the past.

According to The Journal of the American Medical Association, each year, as many as 98,000 patients die in U.S. hospitals from preventable medical errors, such as receiving the wrong medication. Nearly half of all patients do not get all the treatments or tests that they should have received. These problems persist because of industry-wide failures connected to the lack of reliable health information.

If U.S. patients' health records were connected in secure computer networks that safeguard privacy, healthcare providers would have complete records for patients and, thus, be able to more accurately treat them. New information systems also would provide nationwide data to develop standardized performance measurements, so patients could go online and get accurate information about how good a job their doctors or hospitals do.

According to research firm Harris Interactive, the major causes of medical errors include multiple physicians treating the same patient without all having access to all the patient's medical records and with each storing different, incomplete medical records in different places. There is near consensus among healthcare industry experts that the widespread use of EHRs, accessible to all those seeing and treating a patient as well as to the patient, would substantially improve the coordination and quality of health care. In addition, electronic prescribing would further reduce errors that result from handwritten, hard-to-decipher prescriptions.

Bush Announces EHR Initiative

In April, President Bush unveiled a plan to implement EHRs for every American within 10 years. In calling for the widespread adoption of EHRs, Bush said, "[t]he 21st-century healthcare system is using a 19th-century paperwork system." He said paper records contain too many errors and inefficiencies, and they hinder communication between healthcare providers.

Bush has appointed a new Department of Health and Human Services (HHS) official dedicated to digitizing the U.S. healthcare industry. The national health information technology coordinator is responsible for developing, maintaining, and directing "the implementation of a strategic plan to guide the nationwide implementation of interoperable health information technology in both the public and private healthcare sectors that will reduce medical errors, improve quality, and produce greater value for healthcare expenditures."

According to Bush's executive order, "the work of the National Coordinator must be consistent with a vision of developing a nationwide interoperable health information technology infrastructure that

* ensures appropriate information to guide medical decisions is available at the time and place of care

* improves healthcare quality, reduces medical errors, and advances the delivery of appropriate, evidence-based medical care

* reduces healthcare costs resulting from inefficiency, medical errors, inappropriate care, and incomplete information

* promotes a more effective marketplace, greater competition, and increased choice through the wider availability of accurate information on healthcare costs, quality, and outcomes

* improves the coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through an effective infrastructure for the secure and authorized exchange of healthcare information

* ensures that patients' individually identifiable health information is secured and protected"

At an HHS-sponsored information technology summit held in May, HHS Secretary Tommy Thompson announced a series of initiatives to speed up development and implementation of a national infrastructure for EHRs and vowed the federal government would beat Bush's call for every patient to have an electronic record within 10 years. Thompson said a good information technology system for health care "could save our economy, conservatively, $140 billion a year--that's 10 percent of what we spend right now [on health care]."

Thompson said international health group HL7 has approved standards and a model for an EHR, which he termed "a critical first step" toward development of an "interoperable" system that will allow different health facilities to talk to each other. According to Bush, new technical standards will be issued by the federal government by the end of the year so that hospitals and doctors can share information nationwide.

Bush has proposed doubling the current $100 million in federal spending on health information technology. Helping the healthcare system find ways to collect and share information electronically has been one area of significant bipartisan agreement in the U.S. Congress this year.

U.S. EHR Successes

There already are many plans to implement EHR systems in hospitals across the United States.

Vanderbilt Medical Center in Nashville, Tennessee, enables doctors, nurses, and lab technicians to access medical records from a computer, instead of having to track down paper files. Vanderbilt also uses computer databases to inform doctors about best practices for treating patients. With Vanderbilt's EHR system, a click of a mouse pulls up a patient's full medical record. The computerized system can alert doctors to everything from a patient's current medications to drug allergies.

When it is integrated with the Vanderbilt Medical Center's EHR system next year, a computerized prescription-writer program will significantly limit opportunities for medical error. The program will automatically check each new prescription against a patient's known problems and other medications to find potential problems such drug allergies and potentially dangerous drug interactions. The program will issue an alert if anything appears wrong with a prescription. The prescription writer will also eventually use the patient's weight and age to calculate and recommend a safe and effective dosage.

Prescriptions created with the program will automatically appear in the problems section of the patient's EHR, improving communication regarding which Vanderbilt patients are taking which medications--information that can be critical in an emergency situation. Writing a prescription will be as easy as typing in a string of terms to identify details such as the drug, dosage, and duration. Using a library of terms and clinical logic, the program converts the user's raw input to a more complete and standard grammatical form for the prescription. The program's eventual links to insurance company formularies will help Vanderbilt doctors quickly learn important information about which drugs are covered by a patient's insurance plan.

Capital Health Plan, also in Nashville, recently announced a program to give its members Internet access to their medical records. When CHPConnect goes online this fall, the interactive system will give patients a coded password that will allow them to update certain records, such as their medical histories, via their personal computers. The company said the system will encrypt data and will use only dedicated, private phone lines to transmit and receive data in order to prevent hacker attacks.

Kaiser Permanente, Legacy Health System, Oregon Health & Science University, and Providence Health System are spending millions so that Portland-area health systems can roll out systems that enable patients to view files online, doctors to call up data electronically, such as x-ray charts, and patients and doctors to consult via e-mail. They are also laying the groundwork to make records portable if patients transfer health plans or move away.

This year, Kaiser's Northwest region is phasing in computerized exam rooms at the 80 percent of its outpatient clinics that do not already have them. The system allows multiple doctors to call up a patient's record simultaneously, enter new data, and warn doctors about such things as possible dangerous drug interactions and overdue procedures. Kaiser will spend at least $100 million during the next 10 years to improve its EHRs at outpatient facilities in the region. The region is spending about $5 million less a year to maintain the electronic system than it did to keep up its paper records, according to Kaiser's assistant regional medical director for clinical information systems.

Providence Health System plans to spend as much as $6 million in the next few years improving its EHR systems, which went live in 1996. The hospital network recently made X-ray images electronically available to doctors at Providence Milwaukie Hospital, eliminating the need to transfer film among offices and labs. This fall, the health system will make patient lab results available online, followed next year by their medication and allergy histories and a list that provides a summary of patients' medical problems combined with evidence showing the best ways to treat them.

By December, doctors at Providence Portland will begin entering all orders for lab tests, prescriptions, and other procedures on computers, instead of handwriting them. A system that enables nurses to barcode medications will come to Providence Milwaukie later this year and Providence St. Vincent in 2005.

Big challenges still exist, however. Time and cost requirements have prohibited many doctor offices from buying EHR systems. About 85 percent of doctors employed by Providence use the health system's EHRs to look up patient data, but only about 150 of the 1,800 doctors who have admitting privileges at Providence facilities have purchased the EHR systems, which cost about $10,000 per year per doctor, according to Providence's chief medical information officer.

Whether they have implemented EHR systems or not, more healthcare providers are beginning to offer medical advice and "visits" via e-mail. According to a Boston Globe report, Blue Cross & Blue Shield of Massachusetts will pay primary care physicians at Beth Israel Deaconess Medical Center, Caritas Christi Health Care, and Baystate Health System for conducting "Web visits" with patients. Harvard Vanguard Medical Associates, a large Eastern Massachusetts doctors' group, and insurer Harvard Pilgrim Health Care, also are experimenting with doctor-patient e-mail programs.

"Blue Cross, following the lead of several large California insurers and employers, is expanding a pilot program that pays doctors to respond to patient e-mails--something many doctors are reluctant to do because they are too busy, worried about privacy, or not getting paid for it," the Globe noted.

Protecting Patient Privacy

As hospitals and clinics switch to electronic recordkeeping, access to private medical records will soon be very easy for anyone with a computer and Internet access. For that reason, implementing systems that protect privacy, yet are able to transmit needed information, "is the key to whether the healthcare system moves forward or back," said House Ways and Means Subcommittee Chairman Nancy Johnson (R-Conn.).

According to President Bush, privacy concerns over digitizing medical records are minimal. "[A]s you hear the idea of moving your information across the Internet, you've just got to know it's got to be with your permission," he told the media. "These are your records, it's your health, and you can decide whether or not people can use your records. This is important for people to understand that, that [sic] those of us in government who talk about spreading information also, first and foremost, keep your privacy in mind."

Experts say electronic records are more secure than paper files because access is more limited and tightly controlled. Next April, new healthcare information-security provisions designed to protect data transmitted and stored electronically will go into effect under the Health Insurance Portability and Accountability Act (HIPAA) medical privacy law.

But industry-wide, much work needs to be done before doctors and hospitals can share patient records electronically with health plans, insurers, and the myriad clearinghouses that process claims and billing, according to a new study from URAC, a nonprofit group that audits and accredits quality measures in healthcare organizations. In auditing more than 300 healthcare organizations for security accreditation, URAC found just three with corn prehensive security-management programs that enable them to comply with HIPAA standards.

The URAC report, which can be found at www.urac.org, warns that one year is not enough time for most organizations to get their networks in order. In fact, URAC said many medical organizations are unprepared to safeguard the confidentiality of patient data as the healthcare industry prepares to move from archaic paper files to EHRs. According to URAC, most haven't done the most basic risk analyses, have "inconsistent and poorly executed risk management strategies," and aren't adequately addressing the technical issues and employee practices that affect security. Some hospitals, small clinics, and doctors' offices cannot afford sophisticated technology that includes firewalls and encryption systems.

Other Challenges

While almost every expert who has written or spoken on the subject agrees that electronic prescribing and EHRs would greatly reduce medical errors, implementing such changes can be slow, difficult, and expensive. Important considerations for doctors and hospitals include costs for purchasing and/or upgrading hardware, buying new software, training staff to use EHR systems, and uploading paper medical records into an EHR format. In many cases, there are no financial or other incentives for physicians or health systems to implement them--and to fully benefit from EHR technology, the entire U.S. healthcare system must be wired to send and receive all patient information in a digital format and in a common language that is understood by all providers.

More than 70 countries worldwide are already in the process of implementing EHRs, including the United Kingdom and Canada, of which both plan to launch EHR systems by 2010. The United Kingdom already has committed $11 billion to transitioning patient records to an electronic system. Today in the United States, however, fewer than 10 percent of doctors practice in a system with EHRs, according to Rand research. Rand's study found that while such systems are expensive initially, they would pay off in the long run in lower costs and better patient care. But getting there will not be easy.

References

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"E-Health: Better Health and Healthcare Through the Use of Information and Communications Technology." Europa. 3 May 2004. Available at http://europa.eu.int/rapid/pressReleasesAction.do?reference=IP/04/580& format=HTML&aged=0&language=EN&guiLanguage=en (accessed 9 June 2004).

Govern, Paul. "Computerized Prescriptions Can Reduce Medical Errors." The Reporter. 23 April 2004. Available at www.mc.vanderbilt.edu/reporter/?ID=3220 (accessed 9 June 2004).

Herzog, Boaz. "Keeping Track of Patients--Online." Oregonlive.com. 12 May 2004.

Landro, Linda. "As Health Records Go Electronic, Security Is Issue." The Wall Street Journal. 29 April 2004.

Lawrence, Stacy. "Panel Suggests Steps Toward Electronic Medical Records." EWeek. 20 April 2004. Available at www.eweek.com/article2/0,1759,1592685,00.asp (accessed 9 June 2004).

Scott, Rocky. "CHP Connects Patients to Records." Tallahassee Democrat. 12 May 2004.

Webb, Cynthia L. "Bush's Silicon Rx." The Washington Post. 28 May 2004. Available at www.washingtonpost.com/ac2/wp-dyn/A62784-2004May28?language=printer (accessed 9 June 2004).

White House Executive Order. "Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator." 27 April 2004. Available at www.whitehoase.gov/ news/releases/2004/04/print/20040427-4.html (accessed 9 June 2004).

RELATED ARTICLE: The EU's prescription for EHR success.

A 2001 Harris Interactive survey found that the U.S. trails other English speaking countries in the use of electronic health records (EHRs) and electronic prescribing. A survey of doctors conducted for the Harvard School of Public Health and the Commonwealth Fund's International Health Care Symposium in 2000 found that the use of EHRs is much more advanced in Britain, New Zealand, and Australia than in the United States or Canada.

According to Harris, this gap can be explained by the fact that those countries with the highest percent age of EHR use are those with national health services or universal government-funded health insurance. They each have a single payer that sets the rules and can dictate a single nationwide system. If it requires physicians to use EHRs, then they must do so.

In May, the European Commission enacted an action plan to use information and communication technologies to deliver better quality health care Europe-wide. The "e-Health Action Plan" covers everything from electronic prescriptions and EHRs to using new systems and services to cut waiting times and reduce errors. The plan calls for a "European e-Health Area" across member states through the use of EHRs, patient identifiers, health cards, and the faster rollout of high-speed Internet access for health systems. By the end of the decade, the commission says e-Health will become commonplace for EU health professionals, patients, and citizens.

European Community research funding has invested 500 million euros ($600 million U.S.) in e-Health since the early 1990s, with total investment, including co-financing, around twice that amount. By 2010, it is estimated that up to 5 percent of health budgets will be invested in e-Health systems and services.

The e-Health plan includes the following actions:

* By 2005, member states should develop their own roadmaps for e-Health, and an EU public health portal should be up and running to provide one-stop access to health information.

* By 2006, work should be advanced on key issues such as developing a common approach to data, allowing patients to be identified, and implementing standards so that all the different parts of healthcare networks can talk to each other and read and exchange patient information.

* By 2008, health information networks should be commonplace, delivering services over fixed and broadband networks and making the most of networks within so-called "grids" to boost computing power and interaction among different systems.

The action plan is only part of the European Union's response to the challenges that its health services are facing. Two other examples announced in April addressed action on patient mobility and the benchmarking of national reforms of healthcare systems. Europe is at the forefront of EHRs in primary care and deployment of health (smart) cards, including the recent introduction of a European Health Card to make it easier for patients from one member state to obtain treatment in other member states. According to European Commissioner for Enterprise and the Information Society Erkki Liikanen," It is not about technology but about patients. It can reduce errors, speed up treatment, and offer immediate cost savings."

The percentages of physicians who were "sometimes" using EHRs in 2000/2001 were:

* United Kingdom--59 percent

* New Zealand--52 percent

* Australia--25 percent

* United States 17 percent

* Canada--14 percent

The percentages of physicians who were using electronic prescribing "often" in 2000/2001 were:

* United Kingdom--87 percent

* New Zealand--52 percent

* Australia--44 percent

* United States--9 percent

* Canada 8 percent

The countries with the highest proportions of physicians using EHRs were:

* Sweden 90--percent

* The Netherlands--88 percent

* Denmark--62 percent

* United Kingdom--58 percent

* Finland--56 percent

* Austria--55 percent

Nikki Swartz is Associate Editor of The Information Management Journal. She may be contacted at [e-mail].