Imagine if your physician could pull up all your allergies and active diagnoses on a laptop, saving you from having to recite your conditions at each visit. Imagine a prescription getting zapped electronically from your doctor to the nearest drugstore, sparing you from having to hand over a slip of paper to a pharmacist. Imagine getting your lab and test results online, just days after your doctor got them.These are just some of the standards for electronic medical records that U.S. health officials are proposing to nudge the nation's paper-based health-care system into the cyber age.
Today, only a fraction of U.S. hospitals and doctors' offices are fully computerized, and many database and software systems aren't "interoperable" -- meaning they don't talk to each other. If you show up in an emergency room in Phoenix with a broken leg, the electronic medical records of your doctor back in Nashville, which could flag your allergies to certain pain medications, wouldn't necessarily be available.
Flu Or Influenza?
But the U.S. Department of Health and Human Services is getting serious about resolving this mess. It's trying to standardize four categories for both health-care providers and the information technology companies that are computerizing the medical records.
Content-exchange standards would let providers share clinical information like prescriptions. Vocabulary standards would standardize naming conditions and procedures -- do you call it "flu" or "influenza"? Transport standards would establish the communication protocol among computer systems, and security standards would determine how to control and authenticate access to sensitive information.
Together, the standards could help the U.S. move closer to the goal of wiring up every doctor, hospital, pharmacy and insurance carrier into the so-called Nationwide Health Information Network -- an enterprise expected to cost as much as $276 billion over 10 years.
"The standards are going to go a long way toward improving interoperability," says Patricia Wise, VP of the Healthcare Information and Management Systems Society, an association in Arlington, Va., focusing on information technology. "I would characterize the standards as a road map," she says. "It does not mean that everyone wants to follow it. But it's clear the journey has been laid out."
'Meaningful Use' Criticized
Another set of related proposals, issued by the Centers for Medicare & Medicaid Services, has drawn criticism. These rules would require health-care providers to demonstrate "meaningful use" of electronic medical records to qualify for federal incentive money. (As part of the national stimulus program, medical providers can receive some $44,000 in federal incentives if they truly go paperless.) The requirements that spell out how electronic medical records should be used -- such as recording smoking status for patients 13 and older -- are intended to keep providers from buying the software and then keeping it on the shelf.
But the American Hospital Association, which represents more than 5,000 U.S. hospitals and health-care organizations, says the new rules could "severely limit" its members' ability to seek federal incentive money. The problem, the group says, is that the proposal's meaningful-use standards are too stringent. Hospitals that already use electronic medical records to track quality and reduce medical errors -- but not as the requirements suggest -- could lose out, AHA says.
"The eligibility requirements for hospitals and physicians are too restrictive," the group says in a statement. "Unless significant changes are made and the timelines reexamined, it is unlikely that the vast majority of hospitals can meet the proposed standards."
Work In Progress
Wise concedes that the proposed standards are a work in progress. (Proposed standards will have a public-comment period before the rules are finalized, which is anticipated to happen this year.) A hospital must meet 25 criteria to be considered a "meaningful user," she says.
One rule necessitates that 10% of all patient-care orders must be entered digitally by a licensed operator. But Wise wonders how a hospital would determine that it's reached that 10% computerized physician-order mark while processing thousands of handwritten orders every day.
'A High Bar'
Companies whose software lets medical providers ditch paper are racing to ensure that doctors and hospitals using their programs can meet the new criteria. "The bar that has been set by the new guidelines is high," says Ryan Howard, C.E.O. of Practice Fusion, a San Francisco software company whose Web-based electronic medical records are used by more than 25,000 medical providers. Howard praises the new standard: "It really is pretty impressive -- it really does affect the quality of care."
Meeting the new requirements, Howard says, could take longer for what he calls "legacy vendors." Companies like All Scripts (MDRX) and eClinicalWorks offer electronic medical records systems as software that must be installed; Practice Fusion's system is Web-based, hosted on an outside server. "Let's say they knew exactly what steps they had to take to meet the new criteria," says Howard. "It's still going to be a two-year process."
Rivals disagree. Allscripts said in a January 11 statement that it's rolling out a program guaranteeing that its electronic health-record system will quality for federal incentives. "Allscripts is making it safe and easy for physicians to adopt and use EHRs through our guarantee, financing and implementation programs," says Allscripts CEO Gren Tullman.
Worth the Effort?
There's still lots to be worked out before doctors' offices and medical providers, many still awash in paper, go electronic. Will the effort be worthwhile? A study from the Center for Studying Health System Change warns that electronic medical records can have the unintended consequence of "creating information overload that complicates providers' efforts to discern key clinical information."
Still, proponents of the switch from paper say that electronic records will improve care: They'll reduce medication errors by flagging potential patient drug allergies, for example, or providing wellness prompts reminding patients to get prostate or breast exams, they say.
"There are about a million ways points of care can be improved with electronic medical records," Howard says. With the U.S. health system on track for reform, even just a few improvements would be welcome.
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