Problem No. 2: Solving the technology issues
About $17 billion of the $19 billion allocation for EHR goes to incentive payments. Most of the rest goes for IT research in how to address all the technology issues. Industry analysts warn that roughly $2 billion is far from enough. The stimulus does not really address the Rube Goldberg task of making all the IT infrastructure work together.
Consider the case of Kaiser Permanente, which has rolled out EHR systems in all eight of its regions in the United States. The first region to implement an EHR system was Northwest, which by 1998 reached its goal of no paper records for its 450,000 to 500,000 members. Everything from lab test results, radiology tests, X-rays, and medications dispensed from the pharmacy is stored electronically. "We are ahead of the rest of the health care industry with the exception of the VA [the U.S. Veterans Administration]," Kaiser's Chin says.
But does that mean if you are a member of Kaiser Permanente in any of its eight regions, your records are available to any other region? The answer is a surprising no. Chin says that the Epic Systems EHR application that Kaiser Permanente uses is so complex that Epic will not work with any medical group with less than a hundred physicians due to the cost of implementing the system.
The problem is that the small medical groups that make up about 75 percent of all practices in the United States can't manage an EHR system and its ongoing cost of maintaining an IT department.
The expectation is that such small practices will either band together for EHR cooperatives or use a managed EHR service delivered over the Internet. But such sharing and cloud-based provisioning raises the tricky issue of keeping patient records offsite, which in turn brings up many legal issues due to the strict patient privacy requirements of the 1996 federal HIPAA (Health Insurance Portability and Accountability Act) law.
The good news is health care IT is likely to become a magnet that will surely attract IT professionals in other industries who know how to manage and maintain big enterprise systems, whether used by large hospitals and medical groups, provider collectives, or cloud-based EHR providers.
What exists today is an alphabet soup of governing bodies, protocols, standards, near-standards, suggested best practices, and competitors, all well-intentioned but also contributing to the complexity. That situation requires both simplification at the process and standards level, as well as serious integration work at the IT level.
For example, among the many unresolved IT-related issues are decisions about coordinating how records and prospective readers of those records are authenticated, the adjudication among the different privacy policies across states so that information exchange can occur, and the creation (and management) of a single glossary or dictionary of procedural and diagnostic terminology to be used by all health care providers. Standard communications and networking protocols also have to be agreed on to permit data exchange, as well as a file format or file standard for interoperability.
Sorting out the standards
At one time, the solution to all these issues seemed simple enough. The Veterans Administration pioneered electronic medical records with its Vista system, and many lawmakers thought the best idea was to mandate the adoption of Vista as the single, national system, making it available at no charge to health care organizations along with subsidies to speed its adoption.