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Electronic health records a strong priority for US government

Two years after Barack Obama's presidential campaign pledge to vastly increase usage of electronic health records (EHRs), the White House is following through.

The Obama administration is implementing aggressive and expensive plans rooted in the president's belief that EHRs are crucial to health care modernization and cost containment, says David Blumenthal, the Harvard information technology expert who serves as the United States government's national coordinator for health information technology.

"It's a very strong priority. The White House stays closely involved with our work," Blumenthal said in an interview. "They've been extremely supportive."

Key officials including the president's chief of staff, budget chief and health secretary have displayed a "very tight alignment" regarding EHRs, Blumenthal notes. Congressional support is also strong, he says: "It's remarkable how much they seem to get it."  

After promising to ensure that all Americans benefit from EHRs by 2014, Obama's administration is now making a breathtaking financial investment.

Under legislation passed last year, the US government will invest as much as $27 billion in recently launched incentives aimed at encouraging physicians to abandon their paperwork and join the information age, estimates Blumenthal. Physicians can receive subsidies up to $44 000.

But the US government's commitment doesn't stop there: A further $2-billion is earmarked for coordinating the effort and ensuring success with key issues like the development and adoption of national standards for new electronic health record technologies.

Government leadership is showing results: crucial government-operated elements of the largely privately operated US health care system — such as the $47-billion Veterans Health Administration, which insures 23 million veterans and employs more than 239 000 staff at over 1400 sites — have almost completely implemented electronic health records, which are being made available to patients over the internet.

With the US now engaged in a crash program to put EHRs to work, some observers worry that the frenetic pace may be unrealistic and unsafe.

Dean Sittig, a medical informatics researcher at the University of Texas at Houston worries that even with huge investment in electronic records training programs, a lack of skilled labour poses risks as the technology is integrated into clinical setting.

Sittig also worries that many of the technologies are untested in clinical settings and may be far from fail-safe. "Many of these technologies are not mature," Sittig warns.

Tom Leary, senior director for federal affairs at the Chicago-based Healthcare Information and Management Systems Society (HIMSS), says the escalation of federal investment from pre-Obama levels as low as $20 million to a total federal commitment now approaching $50 billion reflects the government's belief that a national EHR system will create as many as 50 000 new jobs while propelling cost-saving efficiencies and health care improvements.

These benefits have been demonstrated at the VHA and within numerous privately operated systems such as Kaiser Permanente, which has invested at least $4 billion to implement EHRs within its system, which operates facilities delivering care to 8.7 million patients.

Leary notes that government expenditures are only part of the overall US investment in EHRs. According to data from HIMSS US hospitals will spend $1.9 billion in 2010 on information technology. Major health management organizations are investing billions more.

Leary says the next phase of the federal effort must address the need to ensure that patients achieve access to their records via the internet. "Putting EHRs in the hands of patients is the next step we've identified for the government.

Here again, federal leadership on this issue is providing instrumental, says Leary, who notes that the federal Office of Personnel Management, which manages health plans for millions of federal employees and retirees, is now legally required to ensure its health beneficiaries get access to EHRs.

For Canadian observers, the US approach is highly instructive — although in many respects, discomfiting.

Blumenthal's Office of the National Coordinator of Health Information Technology is mandated to ensure that electronic health record products are not marketed without national certification — which Blumenthal says he views "as a kind of consumer protection."

By contrast, Canada Health Infoway, which has received $2.1 billion from Ottawa since 2000 to coordinate and co-finance development of national EHR capabilities, has left certification in the hands of the provinces.

Last November, federal Auditor General Sheila Fraser warned that Infoway has applied an "inconsistent implementation of standards" that poses "a risk to national compatibility." 

Ten years after launching operations, Infoway has agreed to address this problem "on a go-forward basis, for new investment approvals."

The US government's approach to offering subsidies for physician implementation of EHRs offers another point of contrast.

While the US incentives are nationwide and accompanied by tough measures to ensure that physicians actually use the EHRs paid for with government subsidies, Ottawa has left physician implementation to the provinces and has not tracked implementation.

The federal auditor general signalled that this is unsatisfactory. "To ensure Parliament and Canadians have sufficient information about progress achieved, Infoway should report on the extent to which electronic health record systems have been adopted by health care professionals and are compliant with standards," Fraser said in a report last November.  

In response, Infoway has belatedly agreed to "endeavour to develop measures on the extent to which EHR systems have been adopted by health care providers."

With two studies in press comparing Canadian and US approaches to EHRs, Robin Tamblyn with the McGill University Clinical and Health Informatics Research Group says US officials could learn from Canadian mistakes.

In many respects, Tamblyn believes, Canada's approach to EHRs has overlooked patient needs.

While the US approach is strongly oriented to patient needs and a growing demand among patients for access to personal medical information, the Canadian approach "faces the barrier of being an old-fashioned system" in which decisions are seldom driven by patient involvement.

Bill Pascal, chief information officer for the CMA, also worries that EHR capability is being pursued using top-down approaches rather than patient-centred approaches, such as the push for patient utilization of EHRs underway in the US.

Added Tuesday, March 23rd, 2010 by Canadian Medical Association Journal

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