A Big Pill to Swallow

According to a recent study by Massachusetts General Hospital and George Washington University, less than 25 percent of all US doctors use some form of electronic health records (EHRs) in their practices. Far fewer — only around 10 percent — have fully operational health information systems that collect patient health data, manage information such as orders for lab tests and prescriptions, and provide decision support.

Meanwhile, many of those healthcare facilities that are deploying EHR systems are having difficulty making the systems work. In November, an internal report by Kaiser Foundation Hospitals that was leaked to the press detailed hundreds of technical problems with the $US4 billion enterprise-wide EHR system supplied by the vendor Epic Systems. By 2009, the project, called HealthConnect, is supposed to provide doctors access to records for all 8.6 million Kaiser patients. But the system has suffered from excessive downtime, according to the report. In addition, users experienced problems accessing certain applications that allegedly did not scale well to Kaiser's vast network. Three days after the report became public, Kaiser CIO Cliff Dodd resigned, although the company won't comment on any connection with the troubled project.

Yet health policy experts say EHRs are what's needed to reduce the 225,000 deaths a year due to medical errors and adverse effects of mistakenly prescribed drugs, among other ailments of the healthcare system.

From 2004 until last year, David Brailer, a physician and the first national coordinator for health information technology, led a Bush administration initiative to persuade the nation's 885,000 physicians and the management of approximately 5000 hospitals to invest millions of dollars in electronic health information systems and connect them to form a national network. Brailer readily acknowledges the challenges of convincing clinicians to change long-standing business processes, of delivering an ROI, and of ensuring interoperability among doctors' offices and hospitals on a grand scale.

Meanwhile, John Glaser, CIO of Partners Healthcare System, and Hilary Worthen, a physician and senior director of clinical informatics at Cambridge Health Alliance, have laboured for years in the trenches to deploy EHR systems. Partners is a network of 7000 physicians and 10 hospitals, including Mass General, a teaching affiliate of Harvard Medical School. Cambridge Health Alliance includes 25 outpatient centres and three hospitals in the Boston area. The organization records some 600,000 outpatient visits and 20,000 hospital discharges a year. Most of its patients are low income or face language and cultural barriers to accessing health care.

CIO brought Brailer, Glaser and Worthen together in a conference call and via e-mail late last year to trade their insights about managing the transition to EHRs successfully.

CIO: Why do we need EHRs?

David Brailer: There are a large number of issues that have reliance upon accessible use of EHRs. First, there are efforts to get more affordability of healthcare services that are based on having information that can allow better decisions to be made. Second, dealing with the quality of care crisis, which is the direct outgrowth of physicians not having the information they need to provide proper healthcare. Our efforts to try to improve monitoring at the national level of bioterrorism are hampered because [such monitoring] relies upon a very antiquated paper-based system. And finally, the growing need for consumers who recognize that their information should follow them to help improve care. So all of these vectors have come together, resulting in a major change in the trajectory of healthcare IT.

John Glaser: We will have computer physician order entry by the end of this year in all of our academic and community hospitals. [These are systems physicians use to store and manage patient information and to order tests and prescriptions.] We have some early efforts on giving patients access to their data and some early, early efforts in genomic or personalized medicine that use EHRs to support research in genomic-based diseases. It remains a challenge to implement these things. The process redesign is hard. It can be hard to persuade physicians that this is really important to do. Nonetheless, we are shifting — because I think people understand the need to sign up — to an emphasis of effectiveness of use. Often, the physicians will still ignore the guidance that we give them. So, they have "adopted" it, but they are not using it well, and, as a result, the data is incomplete. It's inconsistent and we are seeing very uneven performance gains.

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