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Implementing EHRs

What can the U.S. Learn From Europe?

Studies have shown that providers deliver better care when they have access to accurate, complete and relevant clinical data. The ability to capture and exchange health information from electronic health records (EHRs) can reduce the number of redundant tests, improve quality and accelerate the processing of referrals, prescriptions and hospital discharges.

Despite these benefits, EHRs and health information exchanges (HIEs) have been relatively slow to catch on in the U.S. EHR adoption ranges from 4-20 percent depending on how one defines an EHR, and fewer than 38 percent of the HIEs in the U.S. are fully operational and exchanging clinical data. Commonly cited barriers to adoption include funding and participation challenges, legal and regulatory issues, and technical hurdles.

With major new incentives in place for using EHRs and more than $300 million in federal funding available to regional HIT efforts, many organizations are looking at these technologies afresh. European experiences with EHRs and HIEs can help organizations in the U.S. identify the key decision points and best practices for capturing and sharing health information electronically (often called eHealth).

European Efforts
EHealth efforts in the Netherlands, Denmark and the U.K. reveal about a dozen major decision points involved in implementing eHealth. These decision points fall under five broad categories: Planning and Sustaining the Initiative; Major Issue Management; Governance and Communication; Technology and Interoperability; and Implementation.

For example, to plan and sustain the initiative, an organization needs to set expectations for participants and define how value will be created and measured. Many eHealth initiatives in Europe were driven by Ministers of Health for the purpose of improving access, quality and cost efficiency. The same purpose is relevant to U.S. organizations, particularly hospital networks or large physician practices. Organizations must also determine the broad scope of IT requirements, and secure sufficient funding from those who stand to gain the most value. Without addressing these issues, the project will lack consensus, lose direction and waste valuable resources.

Organizations need to develop an open, communicative approach to managing major issues such as privacy and security and patient identification. European experiences in the Netherlands and the U.K. have shown that role-based access controls for providers, combined with procedures that allow patients to opt in, opt out, or opt in with specific restrictions, are an effective solution. In the event of an emergency, there should always be the ability to "break the glass."

Keys to Success
The key to governance and communication is to centralize the decision-making process as much as possible to promote standardization and consistency. In Denmark, officials first allowed requirements to be defined at the county level, only to switch later to a more centralized model to reduce the amount of local disagreement over data sharing requirements. Organizations should make it a priority to communicate with all of the stakeholders and constituencies involved, and provide education as needed.

Regarding architecture and interoperability, the HIT Policy and Standards Committees operating under the Office of the National Coordinator (ONC) are working to identify workable data and transmission standards. Interim reports indicate that these standards will be based largely on prevailing standards such as ICD-10 and the capabilities defined by existing groups such the Health Information Technology Standards Panel (HITSP). Use of a certified system, including the adoption of these standards, is required to receive federal incentives.

Finally, successful system implementation requires extensive planning and support. Preparations should be iterative and continuous to work out bugs and identify missing functionality as early as possible. In the Netherlands, implementation teams piloted the system on a small group of volunteer sites before rolling out the system to more than 1,500 sites on the national network. The U.K. used a similar process, allowing "early adopter" sites to act as test sites. This approach also gave the support team an opportunity to prepare its training program to accommodate a wide range of provider workflows.

U.S. efforts remain several years behind Europe in the implementation of eHealth. Hospitals and HIEs have made substantial progress in the areas of planning, governance and communications. Work in these areas has been consistent with best practices, but the difficult work is still to come. Organizations face tough decisions regarding patient consent, patient identification, data sharing and information architecture. The ONC Committees are working to identify and harmonize standards, but final recommendations may not be available until December 2009. Once these decisions are made, it will take an enormous effort to coordinate the resources required to install and upgrade thousands of systems.

Fran Turisco is research principal, Emerging Practices, CSC's Healthcare Group. Jared Rhoads is senior research analyst, Emerging Practices, CSC's Healthcare Group.

Articles Archives

Seems like a comprehensive PHR would successfully address the shortcoming of many EHR's and put the patient in charge of managing their health information as it should be. Your thoughts?

Joseph Teahan,  Dir. of Bus. Dev.,  noneSeptember 10, 2009
Boca Raton, FL


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