Electronic Health Records: Can Promise Be Fulfilled?

In an interview with Psychiatric News, John Boronow, M.D., chair of APA's Corresponding Committee on Electronic Health Records, described a host of challenges—technical, logistical, and economic—and provided an overview of the emerging network of initiatives, organizations, and agencies dedicated to overcoming those challenges (see facing page).

Though the potential of the digital revolution for medicine has always been apparent, it began to take flight a little over a year ago when President George W. Bush appointed David Brailer, M.D., to head the Office of the National Coordinator for Healthcare Information Technology (ONCHIT) and called for widespread adoption of health information technology within 10 years (Psychiatric News, June 4, 2004).

During the KaiserNetwork Webcast, Brailer described the mission of ONCHIT as follows: “First, to give advice to the federal government about health information technology, to raise the IQ of the government about this new area. Second, to coordinate the federal agencies, of which there are more than 30, that are involved in health information technology. Third, to coordinate activities in the private sector to make sure it's a public-private solution.”

From the start, Boronow said, the buzzword has been“ interoperability,” the ability of information software systems to“ talk” to each other so that there can be a seamless transfer of information across the health care landscape—a concept that presupposes widespread adoption of computerization.

But a major challenge remains how to make electronic record keeping attractive to solo and small-group ambulatory care physicians. While many hospitals and large health systems have adopted some form of computerization, many smaller groups and individual physicians have not.

Last year, APA became one of 14 founding members of the Physicians' Electronic Health Record Coalition (PEHRC), whose mission is to represent the interests of physicians in small and mid-size ambulatory care practices in discussions with ONCHIT and other federal agencies. Boronow and Darrel Regier, M.D., director of the APA Division of Research and the American Psychiatric Institute for Research and Education, have represented APA on the PEHRC.

The APA committee that Boronow chairs was also formed last year to advise PEHRC about psychiatrists' concerns in these areas.

“PEHRC is primarily an ambulatory physicians' group that came together so it could influence ONCHIT and provide a forum for what the physicians' stake was in this vision,” Boronow, medical director for adult services at Sheppard-Pratt Health System in Baltimore, said. “It's very clear that while [the movement for electronic health records] is a laudable project, it is also very ambitious. There are a lot of different agendas in play, and a lot of unintended things can happen. All involved need to articulate what their wants and worries and concerns are, and PEHRC seems like a way for small-group ambulatory physicians to do that.”

This month the journal Health Affairs is publishing the results of a survey by the Medical Group Management Association querying doctors on their level of comfort with, and knowledge about, electronic health records. As a follow-up, Boronow said PEHRC will be using the same survey instrument to question its 22 subspecialty members on this topic.

Boronow said physician groups considering investment in information technology have been vexed by this conundrum: How do they know if the software they purchase will be compatible with other systems as the electronic health record evolves in coming years? This concern has left many physicians reluctant to make a substantial investment in a product that may need to be replaced in five years.

One critical step in overcoming this obstacle, Boronow said, is the development of standards for software product certification.

The Certification Commission for Healthcare Information Technology (CCHIT) is a voluntary, private-sector initiative to certify health care information technology products. It is the creation of three industry associations—American Health Information Management Association, Healthcare Information and Management Systems Society, and National Alliance for Health Information Technology—and has set as a goal the development of standards for software manufacturers to begin meeting by the end of 2006, Boronow said.

The federal government also moved to hasten the development of standards this summer when ONCHIT announced the establishment of the American Health Information Community (to be called “the Community”) to“ help nationwide transition to electronic health records—including common standards and interoperability—in a smooth, market-led way.”

So, what ultimately will the National Health Information Network look like?

If physician groups have their way, one thing it won't look like is a large government-owned patient database. “Everyone is afraid of Big Brother, of the idea of having one big massive database that everyone would draw on,” Boronow explained.

Instead, the consensus preference is for what has come to be called a“ brokered peer-to-peer network,” he said. “Brokered” refers to the fact that the network uses a central host that provides security and linking functions, but does not store data. “Peer to peer” refers to the idea that files containing clinical information would be directly exchanged between users and that all content would be created by users.

“The idea is that data will originate in whatever office you see the patient, and the network will consist of software that allows you to share it,” Boronow said.

The mechanics involved in making software systems interoperable are daunting, as are the costs (see box on facing page).

Of more immediate concern to psychiatrists is the content of shared information: What kind of information will be shared with whom under what circumstances?

Boronow noted that the Health Insurance Portability and Accountability Act, which provides rules to ensure the security of electronically transmitted information, is in fact remarkably lax, and many states have stricter laws that conflict with each other.

A movement is under way among policymakers to “harmonize” the many conflicting privacy laws—a term that some privacy advocates take to be code for elimination of privacy protections. But Boronow said that while privacy is a paramount concern, he and members of the APA committee he chairs are optimistic about the opportunities for improved patient care offered by the vision of a national health information network.

“A lot of damage has been done by the sequestration and fragmentation of data,” he said. “In my fairly small state of Maryland, it is very common for one of my chronic patients to have had six or 12 hospitalizations in six or 12 different places. You are lucky to know that, and you are even luckier to get a fax from one of those places that would tell you something about how [such patients] were treated. You end up reinventing the wheel over and over again because you don't have an accurate history of your patients. That is one of the problems we want to fix.”

But will the vision of a National Health Information Network come to fruition?

Boronow acknowledged that the politics involved are “mind boggling,” and added, “If you are skeptical, it may never happen. There is a lot of ways you can imagine it failing.”

But he suggested that the countervailing forces propelling such a network may be inexorable, and he cited the Institute of Medicine's landmark report“ Crossing the Quality Chasm,” which underscored the importance of a dramatically improved information technology infrastructure to support a 21st-century health system.

“There is a lot of momentum behind this,” he said. “At this point things are on track, without too much disarray.”

Even if the most ambitious goals of the National Health Information Network are postponed or not achieved, psychiatrists should not be deterred from taking seriously the need to computerize their practices or from joining the national discussion about health care information technology.

“I think psychiatry should participate in this,” he said.“ Everyone expects us to, and the opportunities for us to improve practice are huge. The membership needs to think through some of these privacy issues and figure out how to live in this brave new world. I believe there will be solutions that patients and psychiatrists will have confidence in.” ▪