Groups Push Physicians and Patients to Embrace Electronic Health Records
Tracy Hampton, PhD
JAMA. 2008;299(5):507-509.
Experts agree that electronic health records can save lives and money by reducing the costs and harms associated with medical errors and by cutting down on redundant tests and procedures. But a number of unresolved issues, including affordability and privacy concerns, have made hospitals, physicians, and patients slow to adopt them.
Although those hurdles remain, government and nonprofit organizations, as well as technology giants such as Microsoft and Google, are attempting to drive the technology forward. What is envisioned is an easily accessible electronic system that, by coordinating the storage and retrieval of individuals' health records, increases efficiency, reduces costs, and promotes standardization of care.
Numerous vendors have been marketing patient health records that are managed and controlled by each patient, but only a minority of consumers are buying into them. Although most individuals have yet to be sold on the idea of a personal medical diary, experts say that new technologies and an expanded scope of their benefits may change their minds.
"Millions of people are going every day to the Internet to look for medical information. We are in a time where patients are being empowered, and they're looking for convenience," said C. Peter Waegemann, CEO and executive director of Medical Records Institute Incorporated, a Boston-based company that promotes adoption of health information technology.
One of the most recent and ambitious projects that strives to tap into this perceived patient empowerment is Microsoft's HealthVault, a free software and services platform aimed at helping people better manage and monitor their personal health information (
http://www.healthvault.com). "People . . . must navigate a complex web of disconnected interactions between providers, hospitals, insurance companies and even government agencies," said Peter Neupert, corporate vice president of the Health Solutions Group at Microsoft. HealthVault allows individuals to collect their health information from many sources, store it in one place, and share it with whomever they choose. They also can connect a wide variety of devices to a computer and upload the data to their individual HealthVault accounts.
Google plans to follow suit, although details are not yet available. Similarly, Intuit Incorporated, a provider of business and financial management solutions, is expected to come onto the scene and offer a system of its own. Other types of vendors also are striving to boost patient interest. Wal-Mart and Intel are leading a large employer coalition to develop a model called Dossia, and America's Health Insurance Plans and the Blue Cross and Blue Shield Association have worked together to develop a personal health record model that enables patients to transfer data when they change health insurers (http://www.chcf.org/documents/chronicdisease/PHRPerspectives.pdf).
Waegemann envisions a time when a personal health record site might include not only a patient's prescription data, but also a list of nearby pharmacies with information such as details on drug prices and hours of operation. "Or it might suggest that before you have your scheduled surgery, there's an alternative way through rehab," he noted. Some physicians will not be happy about these qualities, he conceded.
Efforts are being made to regulate and monitor such personal health record systems as they evolve. According to the National Committee on Vital and Health Statistics (the statutory public advisory body on health information policy to the Secretary of the Department of Health and Human Services), personal health records that are available today are heterogeneous, which makes collaboration and policy making difficult. The committee has published recommendations for realizing the full potential of personal health record systems to improve health and health care: vendors should clarify the respective rights, obligations, and potential liabilities of patients, clinicians, and other stakeholders; consumers should have the right to make an informed choice concerning the uses of their personal information; security should be ensured; and information should be exchanged with electronic medical records, which are documentations of care provided by clinicians to patients and are maintained by hospitals or health care practices (http://www.ncvhs.hhs.gov/0602nhiirpt.pdf ).
This last recommendation is particularly important, said Waegemann. Personal health records will be valuable only if accurate medical information is provided by physicians and other clinicians through electronic medical records generated at the point of care. "Microsoft and Google are trying to create partners in the electronic medical record world who can directly download information into a patient's personal health record," said Waegemann.
PHYSICIAN ADOPTION
But only a minority of practices and clinics currently use electronic medical records. A study of surveys on electronic health record adoption published last year found that approximately 24% of physicians used electronic health records and only 5% of hospitals used computerized physician order entry (Jha AK et al. Health Aff (Millwood). 2006;25[6]:w496-w507).
"There's a wide range, though," said Waegemann. "In Massachusetts, there are between 70% and 80% [of physicians who use electronic medical records], but in Mississippi, there are only single digits." He added that there also are differences among specialties.
The lack of widespread use of electronic health records can be attributed to a number of factors, from finances and logistics to privacy concerns and lack of interest. A 2007 poll of more than 800 health care professionals conducted by the Medical Records Institute found that the most commonly cited barriers to implementation of electronic medical records systems include a lack of adequate funding or resources, anticipated difficulties in changing to an electronic medical records system, difficulty in creating a bridge from paper to electronic documentation and record keeping, and an inability to find a system at an affordable cost (http://www.medrecinst.com/MRI/emrsurvey.html ).
In an attempt to encourage more use of electronic medical records, the Centers for Medicare & Medicaid Services (CMS) has announced a pilot program that will give higher Medicare payments to physicians who adopt them (http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1204776 ). The agency will begin recruitment in the spring and would like 1200 physician practices to participate. The program is part of President Bush's technology agenda, which seeks to have electronic health records for most US individuals by 2014 (http://www.whitehouse.gov/infocus/technology/ ).
In the first year of the CMS program, physician practices will receive extra payment for using an approved electronic medical record to manage patient care. Within the program, practices that perform better than others on designated clinical quality measures will receive larger bonuses.
However, critics say that many physicians in small- and medium-size practices cannot afford to establish and maintain electronic records. Physician organizations would like Congress to consider offering financial help, such as grants, loans, and tax credits for physicians who purchase the necessary technology.
The CMS anticipates that most physicians would improve the quality of care and save money over time by using electronic medical records. One cost-benefit study of ambulatory primary care settings found that the estimated net benefit from using an electronic medical record for a 5-year period was $86 400 per clinician (Wang SJ et al. Am J Med. 2003;114[5]:397-403).
PRIVACY ISSUES
One of the greatest concerns over adoption of either electronic medical records or patient health records is ensuring adequate confidentiality. In a 2006 telephone survey of 1003 US individuals by the Markle Foundation, a New York City–based organization that promotes information and communication technologies, 80% of individuals said they were very concerned about identify theft or fraud and 77% were worried about the possibility of their information getting into the hands of marketers (http://www.markle.org/downloadable_assets/research_doc_120706.pdf).
The Coalition for Patient Privacy—a bipartisan group of state and national consumer organizations—wants the federal government to pass privacy laws that will place patients in control of how their electronic records can be used and shared (http://www.patientprivacyrights.org/coalition ).
"Congress should restore every American's right to control access to their sensitive health and genetic records," said Deborah Peel, MD, founder of Patient Privacy Rights, a national consumer health privacy watchdog organization based in Austin, Tex, and a member of the Coalition. She noted that after signing their Health Insurance Portability and Accountability Act (HIPAA) forms, most US individuals believe their health information will not be disclosed without their permission. According to her organization, the HIPAA rule authorizes more than 4 million entities—such as insurers, health care clearinghouses, and clinical professionals—to use and disclose an individual's health information without his or her consent.
Microsoft has joined the Coalition for Patient Privacy in calling for legislation to include basic privacy protections for electronic health records. "Such protections are needed to ensure the creation of a health IT ecosystem that consumers can trust," said Frank Torres, Microsoft's director of consumer affairs.
Peel said the privacy protections built into Microsoft's HealthVault reflect the privacy principles of the Coalition for Patient Privacy. "They have set a new and high bar for the entire health IT industry—they're specifically stating up front that they're going to meet 17 principles for privacy from the Coalition for Patient Privacy," she said. Those include patient control of all access, no secret databases, and no data mining. Microsoft has stated that it will log every time records are created, changed, or read, leaving a clear audit trail.
While adoption of electronic medical records and personal health records are considered the way of the future, "the majority of them actually violate long-standing laws that information should not be released without consent," said Peel. She noted that most vendors of hospital-wide electronic medical record systems reserve the right to data mine and own patients' health information.
"We want health IT—it's going to do great things. But it's going to destroy people’s futures, including jobs and credit, if we don't build in privacy," said Peel.
