EHRs – Communications of the ACM

The problem of the rising costs and uneven quality of healthcare is a worldwide concern. Industrialized countries spend on average 10% of their GDP on healthcare, with the U.S. spending nearly 15% in 2005. For comparison, U.S. defense spending is 4% of GDP. Left unchecked, U.S. healthcare costs are projected to rise to 25% of GDP within a generation as the U.S. population ages. Similar cost increases are projected for industrialized countries as well. Over the past decade, several countries such as Australia, the U.K., and the U.S. have started IT initiatives aimed at stemming rising healthcare costs. Central to each of these initiatives is the creation of electronic health record (EHR) systems that enable a patient’s EHR to be accessed by an attending healthcare professional from anywhere in the country.

The benefits claimed for EHRs are that by being able to quickly and accurately access a person’s entire health history, deaths due to medical errors (estimated to be 100,000 a year in the U.S. alone) will be drastically cut, billions of dollars in medical costs will be saved annually, and patient care will be significantly improved. Experience at the U.S. Veterans Affairs and Department of Defense (among the largest users of EHRs in the world) supports many of the benefits claimed.

However, the attempts at creating national EHR systems have been encountering difficulties. In Australia, the implementation cost has risen from an estimated AU$500M in 2000 to AU$2B today. In the U.K., the implementation costs have risen from an estimated £2.6B in 2002 to at least £15B today. In the U.S., the "working estimate” for a national EHR system runs between $100B and $150B in implementation costs with $50B per year in operating costs.

The U.K. Connecting for Health initiative calls for everyone in the U.K. to have EHRs by 2008. However, there have been ongoing problems with its implementation that spurred 23 leading U.K. computer scientists to write an open letter to the Parliament’s Health Select Committee in April, recommending an independent assessment of the basic technical viability. In their letter, they ask whether there is a technical architecture, a project plan, a detailed design, assessments of data volumes and traffic loads, adequate resiliency in the design, as well as conformance with data and privacy laws, and so on.

The U.S. approach to creating a national EHR system differs from the U.K. approach. Whereas the U.K. EHR system is publicly funded, the U.S. has decided to adopt a market-based approach, where the government acts as technology coordinator and adoption catalyst. Instead of funding the building of a single, integrated networked system with a central EHR database as in the U.K., the U.S. government is facilitating the definition of standards to allow the interoperability of commercially available EHR systems as well as interoperability certification standards. The U.S. government has high hopes for EHRs and views the development of an EHR system merely as a technological catalyst for changing how healthcare is delivered and paid for.

Some concerns are already arising with the U.S. initiative and whether its objective of providing most U.S. citizens EHRs by 2014 is realistic. For example, the government’s initiative has been chronically underfunded from the start. Medical researchers, pharmaceutical companies, insurance companies, EHR vendors, and other interested parties cannot agree on what functionality, form of information capture, and record access a national EHR system should support. Physicians working in small medical practices worry about the costs involved.

Whereas many of the issues encountered merely reflect specific instances of generic software system development problems, their number, complexity, and potential personal and political impacts magnify their importance. Thus, concerns arise from the absence of both a full business case for a national EHR system and a comprehensive risk assessment and management plan outlining the potential social, economic, and technological issues involved in creating and operating the system. As the U.K. is discovering, focusing on the technology of electronic medical records without considering the myriad socioeconomic consequences is a big mistake.

The implementation of a national EHR system presents an opportunity to constructively transform healthcare in the U.S. Whether it does will depend in large part on how well the relevant benefits and risks are understood and managed.