Twenty years ago, the Medical Records Institute held its first conference called "Toward an Electronic Patient Record," which drew some 350 attendees. In 2004 there will be almost 10 times that number at the meeting in Fort Lauderdale, Fla. The interest in the issue continues to grow, but we are still a long way from implementing a full electronic health record, or EHR.
The benefits of the EHR were as obvious 20 years ago as they are now. The healthcare system moved in the 20th century from the single doctor taking care of a patient, even in the hospital, to a system where many specialists attend to the specific issues of a patient's health. However, the information system has not adjusted to this diversification; each provider keeps a separate paper-based medical record and one provider is usually not informed about what others are doing for the same patient. For instance, if the family practitioner does not know what medication or treatment plan a specialist prescribed, there is a great potential for duplication of prescriptions as well as adverse reactions from medications and other medical errors.
The vision of the EHR provides the hope of an answer to this problem.
Here are some of the benefits of EHRs:
* As the scientific body of medicine has grown so large that no practitioner can remember everything about any or all of their patients, EHRs can supplement the practitioner's knowledge by providing resources and guidance throughout the care process.
* Health information can be shared as a patient is referred or transferred to another provider.
* Decision-support systems can reduce medical errors and guide the decision-making process in healthcare the same way pilots are guided by their computer systems.
* Geographical, skill and technological differences can be leveraged through the "telemedicinelike" functionality of the EHR.
* EHR systems can support and enable patients, allowing them to become partners in the healthcare process, understanding and managing their health information in personal health records.
* EHR systems can create greater efficiency in healthcare in administrative, clinical and financial systems.
There is literally no one who could deny these benefits of the EHR. Why then, after decades of promoting this technology, are less than 5% of providers using the full EHR? There are five main reasons why more than 95% of providers have paper-based medical record systems that are not much different from those medical records created 150 years ago before electric power was introduced:
* Healthcare is very complex as its knowledge base is moving from medicine as an art to medicine as a science.
* Practitioners are by nature independent. This means that there is a lack of "corporate structure" and trust in others' information.
* There is a lack of return on investment to the individual provider to implement those systems.
* Standards are missing.
* The general concept of EHRs has been flawed.
Of these five hurdles, the last one is most significant. Although there is as yet no true consensus on the EHR, it is important that the healthcare community understand the principles that have emerged from current work.
Stewardship. For decades, a debate has been going on regarding the ownership of health information. A consensus seems to be emerging that providers should be stewards of the information they create.
Selectiveness of exchange. Rather than sharing a complete medical record, only relevant patient information should be exchanged.
Privacy. We will not have a national patient identifier system, nor should we plan on linkage systems that allow a person to connect to all health records. Instead, there should be a system of loosely connected records containing protected health information.
With those principles in mind, we need to rethink our strategy for creating the EHR. For each provider that means creating its own electronic medical record that allows the sharing of relevant patient information with appropriate people while keeping other information such as decision management functions in-house.
Another key to the EHR process is the continuity-of-care record, a standard specification being developed jointly by ASTM International, the American Academy of Family Physicians, the American Academy of Pediatrics, the American Medical Association, the Healthcare Information Management and Systems Society, the Massachusetts Medical Society and the Patient Safety Institute.
Although not an EHR, the continuity-of-care record, or CCR, is intended to foster and improve continuity of patient care, to reduce medical errors and to ensure at least a minimum standard of health information transportability when a patient is referred or transferred to, or is otherwise seen by, another provider. As the CCR is not dependent on other technological developments, it can be implemented now to ensure that the practitioner is not acting blindly when a patient is moving from one physician to another, or to a hospital, nursing home or home healthcare.
As EHR activities are gaining momentum, it is important to understand that we cannot continue with old concepts. It is time for a new start that is more practical and ensures immediate benefits even if it is not the grand solution.
C. Peter Waegemann is the chief executive officer of the Medical Records Institute, Boston.