'Huge Challenges' Could Hinder Electronic Record Adoption

The physician charged with implementing a $17 billion federal incentive program that will reimburse physicians for some of the costs of electronic health records recently highlighted problems that a national record system is likely to encounter.

David Blumenthal, M.D., who was appointed as the national coordinator for health information technology (HIT) at the Department of Health and Human Services in March, will oversee the implementation of an unprecedented federal effort to spur nationwide HIT adoption—including use of electronic medical records (EMRs) and e-prescribing—by clinicians and hospitals. In a commentary published April 9 in the New England Journal of Medicine, Blumenthal highlighted some of the difficulties facing such a national system.

The former Harvard Medical School professor wrote that “huge challenges” in efforts to establish a national EMR system could include low adoption rates for the technology, potential technical problems, high initial set-up costs, and data-privacy concerns by both clinicians and patients.

The patient-privacy concerns were highlighted by a telephone survey of a nationally representative sample of 1,238 adults by the Kaiser Family Foundation in March; 76 percent of respondents said they believed it would be very or somewhat likely that an unauthorized person would be able to access their medical record.

The privacy concerns and other challenges will need to be addressed by Blumenthal in his key role in implementing the federal program to reimburse physicians up to $44,000 over five years for their costs in installing digital record systems. That role was created by the American Recovery and Reinvestment Act of 2009 (ARRA, PL 111-5), which included $17 billion in grants to encourage the use of EMRs, HIT (which includes the software and hardware needed to operate EMRs), and e-prescribing (Psychiatric News, March 20). The law also includes penalties for physicians who have not installed EMR systems by 2015.

Cost estimates for the adoption of HIT systems vary widely. The Agency for Healthcare Research and Quality concluded in 2005 that the average cost to place EMRs in practices overall was about $32,600 per clinician, while smaller practices were likely to incur a somewhat higher cost—about $37,200 per clinician. A March analysis by Avalere, a health care consulting company, concluded that a solo or small-group physician practice implementing an EMR system could spend an estimated $124,000 over five years, or $80,000 more than the maximum federal reimbursement.

Eligibility for federal reimbursements will be limited to those who use“ certified” EMR systems, and that certification process and its criteria will be determined by Blumenthal's office. His role is expected to supersede the work of the Certification Commission for Healthcare Information Technology (CCHIT), which has been working with the health care industry—including physician groups—to develop HIT standards (Psychiatric News, January 5, 2007). The economic-stimulus law describes the CCHIT standards as a guide for future federal certification standards—due to be finalized by 2010—but those standards will not be constrained by CCHIT decisions.

Blumenthal wrote that many EMRs certified through the CCHIT process are neither user friendly nor designed to meet the stimulus law's goal of improving quality and efficiency in the nation's health care system.

“Tightening the certification process is a critical early challenge” for the national HIT coordinator, he said.

The push toward a nationwide HIT system, which the stimulus law is designed to accelerate, has been driven by the belief that the technology can improve health care efficiency, reduce costs, and boost the quality of care. HIT advocates maintain that an interoperable system for exchanging patient data among physicians' offices, hospitals, and public agencies will reduce medical errors and provide alerts about dangerous medication interactions.

However, some HIT experts have warned that poorly managed and badly designed systems could increase risks for patients through inadvertent loss of their medical data or poor system interoperability. Problems with EMRs also could arise from clinicians' trying to install the systems too quickly and without adequate technical support.

Blumenthal's commentary, “Stimulating the Adoption of Health Information Technology,” is posted at<http://content.nejm.org/cgi/reprint/360/15/1477.pdf>. The Web site of the Office of the National Coordinator for Health Information Technology is<http://healthit.hhs.gov/portal/server.pt>.▪