For an industry that depends on highly sophisticated clinical technologies, health care lags surprisingly in leveraging IT to streamline patient data. The protracted paper trails created by patients" interactions with various health care entities don"t provide a meaningful, consolidated view of an individual"s health history. This lack of data integration can result in diagnostic and medication errors and duplicative tests that can dramatically raise the cost of health care and compromise patient safety.

These issues are driving a concentrated push toward the adoption of interoperable electronic health records. Ideally, EHRs would be real-time, workflow-enabled records that support computerized physician order entry and incorporate data from clinical systems. They could alert clinicians to potential diagnostic errors. They could incorporate data on public health surveillance, research and protocols, integrate with back-end accounting and billing systems, and get patients involved in their own health care through portals and other mechanisms. Through interoperability standards, EHRs could incorporate data from any health care entity with which a patient interacts and be accessible through a range of clients.

The potential of interoperable EHRs to improve the quality of health care is considerable, as are the savings they could deliver -- as much as US$400 billion annually. With that in mind, President Bush issued an executive order last April calling for the broad adoption of interoperable EHRs by 2014. He also appointed Dr. David J. Brailer to the new position of national coordinator for health information technology.

On the heels of these announcements, however, came questions. What, exactly, makes up an EHR? What will constitute the proposed National Health Information Network (NHIN) that would allow EHRs to interoperate? And who will finance such a massive undertaking?

"When I read the popular literature or even listen to President Bush, there"s this notion that we buy this electronic health record and slap it in and we"re done," says Rick Skinner, CIO at Seattle-based Providence Health System, which is undertaking an IT standardization effort in its network of hospitals. "But an EHR is a system of hundreds if not thousands of building blocks, all lashed together to provide a comprehensive information set around a person and their health. . . . I don"t know anybody that can say they have a complete EHR."

Last year, Brailer"s office issued a request for information (RFI) for developing the infrastructure that would enable secure EHR interoperability and other e-health initiatives, with responses due this month. Though the specifics of the NHIN architecture have yet to be defined, experts say concerns about privacy and other issues have the government pushing for a decentralized, federated architecture that doesn"t require a centralized repository for health data or universal patient IDs. Instead, health care organizations will have to adopt standards to allow interoperability among institutions storing the data that"s in individual health records.

"In the U.S., privacy concerns are one of the shapers of (EHRs)," says Gartner Inc. analyst Wes Rishel. "If you look at Brailer"s RFI . . . it"s clearly supportive of interoperability as opposed to a consolidated health information system where all data is collected. . . . Fear is driving the technology in a direction that technologists would rather it not go. They"d rather have a centralized repository because it"s easier to have good service-level agreements, response time and 24/7 availability of data."

Private-sector role

While the U.S. Department of Health and Human Services is working to establish standards for sharing health data among federal agencies, it expects the private sector to play a major role in drawing the road map for EHR adoption and interoperability.

Health Level Seven Inc. (HL7) and other organizations are defining enterprise interface, authentication, clinical terminology, coding and other standards. The Commission for Certification of Health Information Technology is working to specify required functionality for EHRs. Health IT vendors are beginning to provide standards-based suites that will ease enterprise integration, though the multitude of products for outpatient physician practices remains an implementation challenge.

Meanwhile, many health care providers are making significant progress toward EHR adoption. For instance, Sutter Health in Sacramento has committed to deploying an EHR system by 2006 that will connect 26 hospitals, more than 5,000 physicians and millions of patients in Northern California. One of the steps toward this goal is a move away from a traditional, best-of-breed approach to Sutter"s systems and toward standardization on systems from Epic Systems Corp. in Madison, Wis., says CIO John Hummel. Epic already houses Sutter"s Ambulatory Electronic Record and offers integrated inpatient/outpatient software.

"Our interface department builds over 800 interfaces a year to integrate all our vendors. By the end of 2006, we"ll have a lot of systems running in Epic, but we"ll still have applications from other vendors that we"ll need to interface to, so we"ll (be enforcing) XML, SOAP and the HL7 transaction stuff we already do through our (interface) engine," says Hummel.

In addition to the EHR work it has already completed -- which includes rolling out EHR access to patients in the Palo Alto area -- Sutter"s e-health initiatives include prescription bar coding and electronic intensive-care-unit monitoring. For the throughput needed to share the data that such systems demand, Sutter has moved from a frame-relay network to Asynchronous Transfer Mode Multiprotocol Label Switching. And to streamline patient identification, Sutter has chosen a master patient index product from Initiate Systems Inc. in Chicago.

Providence Health is introducing components into various provider communities and is trying to standardize on products from McKesson Corp. Although Providence Health can control deployment schedules in the hospitals and the physician practices it operates, matters are complicated by physicians it works with but doesn"t employ. Still, Skinner says, "from a decision-support standpoint, there"s no question that we"ve greatly improved our practice because of these EHRs."

Many hope that work being done through regional health information organizations (RHIO) -- competitive providers and payers within a region that have chosen to share data to improve health care delivery -- will serve as a model for the NHIN.

Members of the Central Appalachia Health Improvement Partnership began talking about sharing clinical data two years ago, says Richard Eshbach, CIO and assistant vice president at Johnson City, Tenn.-based Mountain States Health Alliance Inc., a network of hospitals and physician practices and a member of the RHIO. The partnership is using a small federal planning grant and other funds to develop a plan for technology adoption, governance and collaboration, which it expects to complete early this year.

Mountain States Health Alliance has committed $38 million over five years toward longitudinal EHR implementation, which includes re-engineering processes, integrating databases, defining metrics and standardizing on Soarian products from Siemens Medical Solutions Health Services Corp. in Malvern, Pa. Eshbach calls the project "daunting but exciting."

"More (health care entities) are committing to EHRs every year," he says. "In five years, if you haven"t taken steps, you"re going to be way behind the pack and at a huge competitive disadvantage in terms of quality and operational efficiency."

Gilhooly is a freelance writer in Falmouth, Maine. You can reach her at kymg@maine.rr.com.

Side bar

Eat your carrots (and sticks)

Interoperable EHRs will be a pricey proposition -- some estimates say implementing provider EHRs could add $10 billion to $12 billion to annual health care IT spending. Though large provider networks may have the financial wherewithal to implement EHRs, there are scads of small, independent physician practices that need to be incorporated into the infrastructure. For them, deploying electronic records can be cost-prohibitive.

"(Hospitals) will bite the bullet to do this, but the bulk of patient information is not generated through hospitalization; it"s through physician offices, and they don"t like to spend money on technology. Any technology that requires them to spend more time on it and less on patients means less money," says Brian Duggan, an analyst at Premier Health Care Informatics in Charlotte, N.C.

Many believe that payers -- the Centers for Medicare and Medicaid Services and large private health insurers -- stand to gain the most from the efficiencies of EHRs, so they should provide financial incentives. "If payers really want to see the quality improvements and the cost reductions through efficiency gains that can come from (EHRs), then they have to provide some incentives," says Gartner analyst Wes Rishel. Models could include pay for performance, as well as incentives for adopting certified EHR products and reduced payments for failure to do so.

"If (payers) are going to invest money in (EHR) adoption, they want to target that money where it does some good," Rishel adds. "They don"t want a physician using an Excel spreadsheet with every patient"s name and diagnosis and then applying for (EHR adoption) incentives."

As part of its effort to create a statewide network, the Massachusetts eHealth Collaborative, a nonprofit collective supported by 34 institutions, will explore reimbursement strategies, says Dr. Robert Mandel, vice president of e-health at Blue Cross and Blue Shield of Massachusetts Inc. in Boston. Blue Cross and Blue Shield has committed $50 million to seed pilot projects that will deploy EHRs and decision-support tools, as well as develop an infrastructure for interoperability, in three provider communities. The collective has issued a request for applications and will announce its selections in March.

Though he says the greatest benefits of EHRs will be health care quality improvements, Mandel acknowledges that financial questions surrounding EHRs are a key consideration and still largely unanswered.

"If payers end up reaping 70 percent of the (financial) benefits, it"s incumbent on them to redistribute that income to make physicians part of that sustainability. If providers or physicians reap the majority, they should invest on their own," Mandel says. "We"re very conscious of the fact that there needs to be some model to address how benefits accrue and costs are allocated."

-- Kym Gilhooly