Panacea or placebo: electronic health records come to the US

By Jonathan M. Gitlin
Doctors' poor handwriting might be a cliché, but being able to accurately read medical records can often be a matter of life and death. The ubiquity of the personal computer has allowed the clinic to enter the digital age, and given that computers excel at managing information, the development of electronic health records (EHR) has been a no-brainer. Despite this, EHR adoption in the US and elsewhere has been slower than some might like, and at least one presidential candidate has made their widespread adoption a healthcare policy platform plank, promising widespread savings through increased efficiency.
Unlike other software markets, where a single player controls the market (such as Microsoft with Office), or where there are but a few solutions, the EHR field is one of byzantine complexity. There are dozens of different software packages and competing products. In this article, we'll look at the state of the EHR field, along with some of the benefits and problems associated with their use.
Inefficiencies in the system
Despite the US' position as the world's largest and most advanced economy, the US health care system is a model of inefficiency. Costs are more than twice those of any other nation in the Organization for Economic Co-operation and Development; the US spends more than $6,000 per patient per year. Despite this expenditure, health outcomes are, by most metrics, worse than almost every other OECD nation, whether it be life expectancy, infant mortality, years lived free of disease, and so on.
Part of this inefficiency is related to the availability of records. Currently, it's estimated that 20 percent of medical tests ordered by clinicians are repeats of previous tests, conducted because the originals have been lost. When those tests include expensive CT and MRI scans, you can see where some of those massive costs come from.
It's not just money-saving either; medical errors due to incomplete, inaccurate, or illegible records are a serious problem, and patients moving from one care provider to another can encounter problems if their records don't follow them.
To this end, a recent study by the RAND Corporation suggests that widespread adoption of EHRs could save as much as $81 billion each year, thanks to fewer redundant tests and procedures and fewer errors in treatment. But EHR adoption in the US lags behind other countries, with adoption rates by physicians' practices at less than 20 percent. By way of contrast, over 90 percent of primary care practices in Scandinavian countries have adopted EHRs.
An example of an Electronic Health Record
So, by increasing the uptake of EHRs, practices should be able to cut their costs, and do away with the mountains of paper records, along with reducing errors and duplicate tests. But even if every doctor in the land adopted EHRs tomorrow, that's no guarantee that things would magically be all right.
Illegible handwriting, digital style
Working in an office, if someone sends you a file you can't open, it's not usually a matter of life or death. On the other hand, an incompatible medical record file moves the problem of illegible handwriting into the digital age. A common complaint among doctors that Ars spoke to was that of EHR format incompatibility; it's no good having a file you can't read. Unlike productivity software, where programs with differing file formats—such as Word versus WordPerfect—get sorted out in the marketplace, with EHRs, there is a real need for common standards.
In 2004, the US government created, via executive order, the National Coordinator for Health Information Technology within the office of the Secretary of the Department of Health and Human Services. The Office of the National Coordinator exists to provide "counsel to the Secretary of HHS and Departmental leadership for the development and nationwide implementation of an interoperable health information technology infrastructure."
Part of that job is to ensure that interoperability standards exist within the health IT industry. I spoke with Dr. John Loonsk, director of the Office of Interoperability and Standards, about the some of the issues surrounding standards. Ongoing issues with competing standards in EHRs have led to the creation of the Healthcare Information Technology Standards Panel, a public-private partnership that works to harmonize standards within health IT.
In addition, another body, the Certification Commission for Healthcare Technology, provides a "seal of approval" of interoperability; solutions certified by the commission can be bought safe in the knowledge that they won't speak Greek to each other. The positives, Loonsk told Ars, will be "having EHRs that can follow the patients and can be accessible by two providers to support care is going to be helpful to improve quality of care, efficiency of care and reduce errors."
In order to help the spread of such standards among EHRs, the federal government has mandated that standards recognized by HHS have to be incorporated into federal contracts. This is designed to provide a base level of compatibility between the dozens of different solutions without dictating to the market in a way that would stifle innovation.
Dr. Loonsk acknowledged that there is still more work needed in this area; some of the pieces of the challenge are that health information is a broad information space. Unlike banking,which deals in numbers, health IT involves lots of complicated concepts, and there are different ways to communicate those concepts. Your bank balance is your bank balance, but your health records need to relate what a patient is feeling, where they're feeling it, and so on.