Monday, June 8, 2009


Currently, a number of discussions are going on, regarding various aspects of the Electronic Health Record (EHR), including its definition, contents, structure, uses, availability and access control. According to the Health Information Technology American Recovery and Reinvestment Act (Recovery Act) Implementation Plan, published by the Office of the National Coordinator for Health Information Technology, there are two major goals set forth by the Federal Health IT Strategic Plan:

  1. Inform Health Care Professionals: Provide critical information to health care professionals to improve the quality of care delivery, reduce errors, and decrease costs.
  2. Improve Population Health: Simplify collection, aggregation, and analysis of anonymized health information for use to improve public health and safety.

From my point of view, they translate into:

  • Paperless medical offices, including:
    - Computerized Physician Order Entry (CPOE)
    - e-Prescribing
  • Continuity of care, meaning:
    - Prevention of duplicate tests and diagnostic procedures
    - Comprehensive medical, family and social history
    - Awareness of allergies and avoidance of adverse drug interactions
  • Collection of diagnoses, treatment plans and outcomes, which would enable:
    - Discovery of environmental causes of disproportionally high or low probability of certain diseases among populations
    - Learning about effects of age, race, gender, etc., on the probability to develop a specific condition
    - Biosurveillance; early detection of epidemic outbreaks
    - Evidence-based decision support

Apparently, the items in the second list have little to do with and do not need much of personal information, so patient records can and should be de-identified. This is relatively easy to do as long as EHR data is well structured, and all sections and elements are distinctly separate. HIMSS defines the EHR as “… a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.” The Continuity of Care Record (CCR) schema adds advanced directives, family and social history. It provides a format for exchanging patient information between EHR systems and could become one of Health Information Exchange (HIE) interoperability standards. But this is a big topic, which I would like to touch a bit later in a separate post.

The complexity and features of an EHR system definitely depend on the environment it is used in, and will be different for a specialist office, family practice or hospital. But the system has to be able to communicate with other applications that deal with patient data, using standard exchange formats and protocols. This would be the first and most important step towards connected care.

Unfortunately, according to Wikipedia, adoption of EHR systems in the U.S. remains low. Among major reasons, the article mentions high start up and software maintenance costs, reduced productivity during the implementation phase, and, in most cases, lack of measurable gains, especially, for smaller hospitals and clinics. There is an apparent disconnect between potential benefits on the national scale and those for an individual provider or healthcare organization. Market has failed to create incentives for implementation of EHR systems, so the Government had to step in with the HITECH Act. I believe there is a good chance for an open source EHR system, such as OpenVistA, in an ASP model, which may remove most of perceived and real barriers to wider adoption of EHR.


  1. It's not the big, obvious things that are obstructing EHR adoption, it's the large collection of more subtle and obscure little things, many of which are manifestations of the uglier aspects of our health care system. The stuff nobody wants to talk about.

    It's the profit grabbing, business side of, what should be a public service. It's the injustice of the entitlement based narcokleptocracy that is the health care business, in this country. It's the absence of any real concept of patient rights in western healthcare. It's the undeniability of the fact that a patient's health record belongs to the patient.

    It's real easy for an armchair soldier to say, "This is relatively easy to do...". How many architects of clinical software have worked with clinicians in an inner city ER late on a weekend night? Do any of them have the conviction to stand at a workstation with a clinician struggling to use their poorly hacked together poor excuse of a user interface, and look them straight in the eye and explain why clinical software is so unusable?

    * it is NOT easy.
    * it is a dirty, filthy business.

    There will be no significant change in hewalthcare provision, in this country, until we decide that healthcare is important enough to warrant addressing these issues.

  2. You had me until you quoted Wikipedia. If you follow any of the health blogs, you would have immediate access to the percentages of U.S. hospitals and doctors who use EMRs. It's low. Interoperability is a major issue; so is privacy. Billing codes entered as diagnostic codes is yet another. The ability to share back and forth with patients is yet another. The VA has an EMR system in place, and they have seen success with it. Kaiser is testing, as is Mayo. There are a variety of stumbling blocks (I've even read that doctors are resistant to it because they are not tech-savvy), and all have their place in the discussion. Bottom line, EHRs can save time, prevent errors and eliminate duplications. And they should work with Web-based PHR programs, like Microsoft HealthVault, so that patients can share valuable data that is pertinent to their care, like daily blood pressure readings, or blood glucose levels. The biggest change here is the focus: the focus needs to be on improving patient outcomes, not on making money.