EHR Lessons from Beyond the U.S. Borders
By Nancy Stafford
Fasten your seat belts, Electronic Health Records (EHR) are poised to take off in the U.S. It's time for an EHR geography lesson. Let's begin to think outside the U.S. borders. In EHR it seems that the U.S. is beginning at the beginning while our friends across the Atlantic, in India and Australia are already using EHR successfully.
Mostly we want to be the first and the best, especially in the technology arenas, but we in the U.S. will let other countries take the lead in something as important as say fish and chips or curry. So why isn't the U.S. way ahead in EHR adoption? Actually, why is this country so far behind in health care overall? The CIA World Factbook 2009 places the U.S. in 50th place out of 223 nationa in the life expectancy ratings (75 for men, 80 for women). This is not exactly encouraging in a nation that lauds itself as the greatest nation on earth.
As a comparison, the same list ranks Macau, China, with the longest life expectancy (men 81, women 87), Japan in third place (men 78, women 85), Australia in seventh (men 81, women 84), Canada in eighth (men 78, women 83), metropolitan France in ninth (men 78 women 84) and the United Kingdom in 36th (men 76, women 81).
How are we doing in EHR? Much the same. In 2008, a Robert Wood Johnson Foundation study on the lack of EHR progress in U.S. cited the top three issues slowing adoption. These were funding and participation, legal and regulatory, and technical. However, countries such as India (145 on the CIA list), Denmark (46 on the CIA ranking) and Australia already have well established EHR systems. Some, such as Denmark, the Netherlands (30 on the CIA list), and Norway (24 on the CIA list), started more than a decade ago. More remarkable to those of us in the U.S. is that nearly all their general practitioners are using EHR routinely; whereas here, only 20 to 30 percent report using EHR at all.
The Focus
Let's begin by examining where the initiative's momentum begins. In Europe, the top government health officials saw EHR as improving access, care quality and efficiency. The countries' aging populations were straining the healthcare systems. Established healthcare systems were asked to do more with less.
In Denmark, for instance, the goal was to allow a patient's data to follow the patient anywhere, which is a pretty good idea in an area of the world where a person in a passenger car can pass through several countries while out for a Sunday drive. The Danes identified 50 standard messages for their data exchange. Just 50. By addressing the patient's health data needs first, the decision makers focused on the healthcare needs instead of the technological requirements. Technology, in this case, was a tool to achieve the results required for effective health information communication. In many aspects of health care, like behavioral health care, a greater focus on the human side rather than the technological side is necessary when making improvements to processes.
However, in the United Kingdom, the reverse seemed to be true. The UK’s National Health Service (NHS) began the National Program for Information Technology, which focused on technology instead of efficient health data transfer. A Chief Information Officer was put in place to spearhead the program, and a new marketing campaign hopes to show the system's value to healthcare providers.
Here in the U.S. we are thinking much the same as the British with the technology being touted first and the healthcare value a distant second. How many times have you read “increased efficiency and improved patient outcomes”? What does that mean? Probably there are as many definitions as there are people to ask. The recent definition of “meaningful use” will certainly help, once we all understand it. In the meantime let's look at how other countries made their decisions on EHR.
In Europe, researchers set out to prove that, indeed, “improved patient outcomes” exist, and they did so using empirical data. They took several, specific studies and targeted an issue – a specific issue – and did studies on that issue. Let's say they began with medication errors. Then they had numbers...and could count those numbers and compare those numbers and think about those numbers and decide how to manage those numbers. They could ask specific questions about those patients and their relationship to those numbers. They were not thinking vaguely in “improved patient outcomes”' but the result was exactly the one highly sought: improved patient outcomes. However, these improved outcomes can be quantified with real numbers and real patient examples.
The Value
Now that the Certification Commission for Healthcare Information Technology (CCHIT) has defined “meaningful use,” the U.S. may be on a better track to figure out what to count and how to determine the value of an EHR system from both the business perspective and the patient care perspective.
In Europe, they measured operational times and learning times and then they could say “efficient” and know exactly the numbers they were talking about. They learned that patient care evolves and the EHR needs to be flexible. They re-wrote specifications and requirements. They recognized that some EHR decisions should be made locally while others needed to be more global in their scope. But where is the software development in the U.S.? We take what the development companies give us and try to make it work. We modify our behavior to fit into some predetermined form or set of actions. Shouldn't the software companies ask us, the professionals, what we want and need? Shouldn't we have a say on how the screens interact with the data we enter? This is why it is important to look for a technology vendor that listens to its clients, adjusts its product according to feedback, and truly cares about improving healthcare – not just selling software.
The U.S. could certainly learn from Europe, a continent that has found that stakeholder input should be valued.
In Europe they found that communications with stakeholders is essential. Vendors and providers work together to integrate the features the providers need in an EHR system. If the screens do not mirror the forms currently in use, the learning curve spreads out. So, the healthcare providers speak up and ask questions; they tell the vendors what works and what needs improvement. The vendors listen and produce useable, learnable software that providers do use.
Additionally, consider who benefits from EHR and who pays for it. Sure, you benefit, once you've passed the learning curve and can use the software efficiently, but it is your patients who benefit the most. They don't have to have tests over again. They are less likely to suffer from a medication error. They have fewer co-pays and finger sticks. Now, in the U.S. who is expected to pay for the technology? The practitioners are.
In Europe, EHR funding comes from the governments. In the U.S. very little funding has been available until recently. Now, there is money and support. From the European experience, this basic support is fundamental. The government is supported by the taxpayers who are the patients, who are the people who ultimately benefit from the EHR technology. Now, the U.S. is getting somewhere on the road to widespread EHR use.
Governments are not the only means of financial support that works. Some EHR initiatives have used private funding for their success. According to a graph by the World Bank World Development Indicators, 2008 as printed in The Economist, April 16, 2009, U.S. health care is supported about equally by public and private funding sources. In France, Japan, and Britain the funding is nearly all public. In India and China, the private sector funds the majority of the healthcare costs. Let's compare that to the life expectancy data listed above. Interesting?
VHS vs. Beta
Several European countries have been working at this EHR implementation for more than 10 years, some even longer. Their experiences highlight some issues that the U.S. could use to make their EHR journey less bumpy. For instance, data exchange, systems standardization and interoperability should be considered early in the EHR development. A wonderful EHR system is not very much good if it cannot “talk” to other systems available. Assigning a regulatory body is essential in expanding the EHR capability. Remember the VHS and Beta video recorder battle? Both were the best, according to their vendors, but when it came to which would win out, the VHS did and those of us with Beta couldn't get our favorite movies and had hundreds of dollars invested in electronic boat anchors. Wouldn't it have been great if we could have seen into the future and chosen the system that we would be able to use?
In the EHR development we do have a voice. Vendors are not the only group providers should be talking to. Healthcare professionals need to speak up to their political representatives as well. The providers will make EHR implementation a success or not, but they need the help of the political implementation teams and the funding.
Of course funding is basic. While the previous national administration saw the value in an EHR system, they failed to fund its implementation. Now, with billions available, the U.S. has the money to back the beginnings of a national information exchange. With the recent decisions on “meaningful use,” we are all one step closer to having a working EHR network.
And, the winner is....
The Journal of the American Medical Association reports that fewer than 20 percent of surgeries in America use Health Information Technology. But in India nearly 60 percent of the hospitals do. This sub-continent is selling their technology to the U.S. and showing us how to build our technology around our healthcare needs.
Many countries are showing success, but here we are still speaking in broad terms and not melting the information down into convincing statistics. We say things like “more efficient,” while statistics show that learning the most basic EHR programs is daunting and time consuming.
What does the United States need to learn from countries that have working EHR networks? The U.S. EHR developers and committees studying providers' needs might be well served to look at what is already working in these other countries. Why are nearly 100 percent of the general practitioners in Scandinavian countries using EHR successfully, while only a small percentage of U.S. doctors are online? The U.S. prides itself in being first and best, so it is difficult to think that we are not either when it come to EHR. Let's think beyond our borders to see how the EHR wheel looks in other countries.
For more information read “Accomplishing EHR/HIE (eHealth): Lessons from Europe” by Dr. Harald Deutsch, Fran Turisco.