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Dramatic increases in computing power and connectivity, combined with studies that prove the benefits of using electronic medical records, have left doctors with little excuse for failing to adopt computerized record keeping, says Daniel Masys, director of biomedical informatics at the University of California, San Diego Medical School. Yet a 2002 study sponsored by the Kaiser Permanente Institute for Health Policy reported that the health-care industry spends only 2 percent of its revenues on information technology, in contrast to the 10 percent spent by other information-intensive businesses. And a 2002 report by the Institute of Medicine called on the U.S. government, health-care organizations, and payers to commit to building a national health-information infrastructure that would “lead to the elimination of most handwritten clinical data by the end of the decade.” What will it take to get from here to there?

“We’re in a very strange cultural warp,” says Masys. “The system as it is now is optimized for the autonomy of individual practitioners.” Electronic  records, with their emphasis on practice guidelines, force doctors to alter their workflow and push them toward standardized care. Some doctors complain that the systems are an “intrusion into the practice of medicine,” says John C. Joe, director of medical informatics at Baylor College of Medicine in Houston. “Most of the physicians here are at the tops of their professions,” he adds. “They feel that their clinical judgment and the skills they have acquired are sufficient” for patient care.

Doctors also worry about time. When systems are first installed, using them slows things down. “Our surveys have shown that using a computer takes 50 to 100 percent more time” than traditional pen and paper, says Peter Waegemann, executive director of the Medical Records Institute, which advocates electronic medical records.

But hospitals that use electronic medical records find that doctors who adapt to the systems don’t want to go back. And increasing implementation is slowly changing attitudes. The VA, for example, is one of the nation’s largest physician-training grounds; its system influences the way thousands of health-care providers work. “We have a whole flood of physicians and nurses and other people coming through training programs, touching the system every day, and then going on to other settings,” says the VA’s Christopherson. These medical practitioners especially like the ability to access data anytime and from anywhere in the hospital, he says. “People are asking, Why can’t we have a system like the VA?’”

Even supporters of electronic records, however, face the issue of expense. The technology offers better care for patients and lower costs for insurers, but individual doctors often bear the financial burden. A computerized order-entry system alone can cost a hospital $5 million, according to Halamka. John Glaser, Partners’ vice president and chief information officer, estimates that simply maintaining its system costs $5,000 to $10,000 per doctor each year. Most smaller hospitals cannot accommodate such expenditures.

The problem is even more acute for a solo or small group practice that could have to pay $60,000 to $70,000 for a commercially available system that might require continual outlays to keep it up-to-date. From a doctor’s standpoint, says Glaser, adopting the technology can seem like all risk and little reward. “It’s expensive, it’s disruptive, and it’s hard to get used to,” he says. And during the three to six months it takes for most doctors to get used to a new system, productivity can fall by as much as 20 percent, Glaser says.

The health-care system itself provides little motivation for adopting the technology. What’s needed, Glaser believes, is a breakthrough in motivation. One possibility would be for insurance companies to offer higher compensation to doctors who use electronic records systems that meet basic standards-in essence, a reward for providing higher-quality care. Some major companies already have started to exert such pressure. The Leapfrog Group is a coalition of such major corporate-insurance purchasers as AT&T, General Motors, and IBM; its members make health-care purchasing decisions on the basis of hospitals’ compliance with specific safety measures, including computerized order entry.

Direct federal grants to help physicians implement computerized records could provide an even bigger boost. The countries with the most extensive use of electronic medical records-England, Australia, and Sweden-have significant government programs that fund doctors. In England, 99 percent of general practices use an electronic records system.

Standard Care

Most medical-informatics systems are proprietary. This lack of standards is “the number one hurdle” in achieving wider adoption of electronic medical records, says Waegemann. Creating uniformly accepted medical and lab vocabularies, as well as protocols for data exchange, would make it possible for far-flung medical-records systems, lab computers, and insurance networks to talk to one another. Doctors and patients could access medical histories, even as patients move from doctor to doctor and state to state.

A number of organizations, including Waegemann’s Medical Records Institute, are pushing hard to establish such standards. The Markle Foundation, a New York Citybased philanthropy that promotes information technology for the public interest, has created Connecting for Health, a public-private collaboration, to advance national clinical-data standards. Government health agencies could also help in the drive to establish such standards; the VA has embarked on a joint venture with the U.S. Department of Defense to do just that. Because the medical records of active military personnel eventually become the histories of veterans, the two departments are collaborating to create fully interoperable systems-possibly with a single user interface. The initiative goes even further, reaching across the federal government and into private health-care organizations such as CareGroup and Kaiser Permanente. Standards arrived at cooperatively by the federal government and the private sector “will become the tipping point to creating at least national standards, if not potentially helping to create international standards,” says VA advisor Christopherson.

Nailing down standards should bring another major gain: helping electronic medical-records systems comply with federal privacy regulations. That benefit alone could be huge. It’s possible, says bioinformatics specialist Masys, “to create a high-assurance, high-security architecture built on the fundamentally unsafe infrastructure of the Internet.” For example, the technology used to encrypt financial information on Web merchants’ servers can be used also to protect confidential medical data. The real challenge lies in making sure these measures are properly implemented. Connecting for Health aims to help physicians and hospitals achieve this goal by identifying and promoting procedures that address privacy and security issues in electronic medical-records systems. With such practices in place, a hospital would be no more likely to run an insecure computer system than to allow surgeons to operate without washing their hands.

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