A national integrated electronic health record system would benefit everyone

December 1, 2009

It is time to implement an integrated electronic health record (IEHR) system in every physician's office and hospital, according to Dr. Lockwood.

It is time to implement an integrated electronic health record (IEHR) system in every physician's office and hospital.

Virtually everyone involved in the healthcare reform debate argues for widespread implementation of sophisticated healthcare information technologies (IT). Yet, despite its appeal, only 1.5% of US hospitals have implemented a comprehensive IEHR.4 Another 7.6% of hospitals have basic EHRs containing only certain elements (see "Elements of an IEHR"). When hospital administrators were asked about their reticence to implement an IEHR, they cited costs, physician resistance, unclear return on investment, and lack of available IT staff as the main barriers.4

Costs: Implementation costs have been estimated to exceed $700,000 per hospital (15% of capital expenses), and hospital IEHR operating costs exceed 2% of operating expenses (about $ 1.7 million).5 Physician expenses are around $30,000 per doctor for implementation and $1,000 per year for operating costs.5,6 Although a number of public-private state initiatives have attempted to create local Web-based health IT "clouds" linking office and hospital-based IEHRs, a national effort requires federal involvement.

The Stimulus Act provides money to implement IEHRs and proposes progressive penalties for failure. Incentives for implementing IEHRs begin in 2011. There are two separate programs for physicians, one funded by Medicare and the other by Medicaid. The former provides each physician with up to $44,000 in bonus payments over 5 years; the latter provides up to $64,000 over 5 years. Hospitals may receive up to $2 million as a base payment from CMS. Furthermore, safe harbor provisions will encourage unprecedented physician-hospital cooperation in implementing joint IEHR systems.

After 2011, the definition of what constitutes an acceptable IEHR becomes progressively more complex and costly. Physicians and hospitals failing to adopt an IEHR will be progressively penalized through lower Medicare and Medicaid payments beginning in 2015. Then there are the benefits of an IEHR in meeting pay-for-performance and related quality-based reimbursement systems and the lost revenues that could result from not being able to supply such data. Hospital administrators and physicians really have no option. Cost alone is not an excuse.

Physician resistance: When first implemented, IEHRs can slow one's practice. But after 7 years of use, I am convinced that the time saved in finally being able to read my partner's notes, readily access lab and test results, order prescriptions, and make appointments actually saves time.

A national IEHR system could improve efficiency of healthcare in many other ways. Administrative data, such as patient demographics, emergency contacts, employer information, insurance data, consents, and advanced directives, can be automatically available without the need for repetitive reacquisitions of such data at every visit to a new provider or facility. All providers involved in the care of a patient can have instant, simultaneous access to the latest information regarding her condition, including lab and imaging studies, current and past medications, and present physical condition. There can be universal access to sophisticated clinical decision support modules that provide reminders of needed screening and diagnostic tests and preventive health measures, as well as warn of adverse events.7 Finally, the prospect of penalties by CMS and other third-party payers should be incentive enough.