The Future of the EHR is Now

We are in the age of patient information sharing - and electronic health records are making it possible along with great effort from public and private groups focused on establshing standards and healthcare facilities that are investing in EHRs.

It is as though massive Tectonic plates of healthcare informatics have shifted and an earthquake of seismic proportions and ramifications in healthcare information technology (IT) has begun, according to Mark Leavitt, MD, PhD, medical director of the Healthcare Information and Management Systems Society (HIMSS).

A coalition comprised of the federal government, professional IT and medical societies, private foundations, industry leaders and experts in the field has resulted in adoption of standards that enable interoperability, and other groundwork that will lead to the development of national health information networks. Thirty years in the making, the era of electronic health records (EHRs) - where secure and private patient clinical information and medical images can be shared safely and efficiently across the healthcare enterprise, the community and even across the nation - is upon us. IT professionals are ideally positioned to guide their institutions through the necessary steps to enable smooth transitions into the changes that are coming.

Digging Deeper: URLs of Interest for EHRs

Office of the National Health Information Technology Coordinator (ONCHIT)

SNOMED International

The Regenstrief Institute

The Markle Foundation

Connecting for Health

American Academy of Family Physicians Center for Health Information Technology

HIMSS Ambulatory EHR selector

CareWeb at Beth Israel Deaconness Medical Center
Patient site
Clinical portal
Powerpoint presentation with screenshots

"We are on the verge of the golden decade of healthcare IT, as it rolls out and becomes part of everyone's professional life in healthcare," asserts Leavitt. He suggests that these IT activities have moved from the position of questioning whether or not electronic health records are possible to the understanding that the sharing of clinical data are imperative and must be accomplished and the only question is what steps are vital to meeting this mission.


Public-private initiatives on the national and local level have begun to propel the development of interoperable networks to facilitate secure sharing of patient information between healthcare providers on a "need-to-know" basis. The federal government has established the Office of the National Health Information Coordinator (ONCHIT), headed by David Brailer, MD, to assist with coordinating efforts of the vendor community and healthcare providers designed to drive these endeavors forward. Professional medical societies have placed emphasis on enhancing their members' use of electronic solutions to information sharing. And many communities have begun establishing networks to connect their disparate healthcare providers to central data repositories.
The Markle Foundation in New York City convened the Connecting for Health Steering Group comprised of more than 50 leaders and decision-makers in healthcare to promote voluntary adoption of data standards and communication protocols for the sharing of healthcare information in 2002. In January, they renewed their commitment to advancing the use of electronic connectivity in healthcare.

David Lansky, PhD, director of the health program at the Markle Foundation explains that currently, we have an incredibly fragmented, complex and sub-specialized medical care system, which means that specific information about any individual patient is difficult to collate for use.

"The Markle Foundation's work in this area is to support interoperability from the very granular level of specific data standards that need to be adopted uniformly, to the policy level of encouraging governmental agencies and others to do their work in such a way that it encourages standardization and interoperability," says Lansky. IT professionals must become informed about the scope of these activities, and learn specific steps necessary to insuring smooth integration into regional information systems of the future.


As healthcare IT has evolved over the past 30 years, from IT activities solely directed at managing the financial aspects of a healthcare institution to the introduction of departmental IT systems to the current state of enterprise-wide IT solutions that integrate all of the disparate departmental systems, the terminology has evolved as well.

The medical informatics community introduced the concept of electronic medical records many years ago, according to Helmuth F. Orthner, PhD, professor and director of the department of health services administration and program director of the health informatics program at the University of Alabama at Birmingham. The notion of electronic health records (EHRs) is more recent.
"As we change the definition and terminology, it reflects the evolution to a more comprehensive approach," explains Orthner. This all-inclusive methodology requires structured interactive data, not merely scanned-in paper documents and images.

J. Marc Overhage, MD, PhD, president and CEO of the Indiana Health Information Exchange in Indianapolis, explains that although there are major differences between the EMRs in a hospital and those in the ambulatory setting, within an integrated EHR world, data must flow smoothly between these two environments.

In a hospital, the patient record is more self-contained, with results from imaging departments and laboratories and other well-defined sources of information under some measure of control within the IT domain. However, physicians in private practice who admit their patients to the hospital are considered "infrequent users" because their primary practice is in their office, and they may have admitting privileges in more than one hospital. Becoming proficient in several different EMR systems may present enormous challenges.

On the ambulatory side, the physician may receive data from a number of different sources, which means that the interfacing issues or connectivity issues become paramount. They may receive laboratory results from 30 different sites. Imaging is a bit different, because they are likely to receive imaging data from the hospitals or stand-alone imaging centers, but that would be fewer in number than the laboratories. The physician is more likely to use their EHR system day in and day out, so they become quite skillful in working with a wider variety of system features. However, there is no infrastructure of support, no IT department to manage the system, so challenges arise from that circumstance.

Another critical factor involves patient and physician identifiers. For physicians, this means they have an identifier number for the laboratory, and radiology and the echo lab, etc. Overhage says that as a general internist in Indianapolis, he has 47 unique identifiers. "We have this 'Tower of Babel' situation because we have all done what is easy and expedient for us individually. The key is to get people to look at the bigger picture, not just their tiny piece of the world." The same scenario holds true for patients who do not have a centralized patient identifier number that works for all of their encounters with the health system.


Paul Tang, MD, chief medical information officer for the Palo Alto Medical Foundation in California, says that with patient safety as a pressing issue, most people have recognized that the status quo is unacceptable, and the only way to improve the current situation substantially is to put a health information infrastructure into place.

"I would try to get up to speed on this stuff," he says. "If you don't have an EHR in place, there is an increasing chance that your organization or health system will be getting one within the next five to 10 years."

At Sutter Health, which is a huge health system with 27 hospitals in Northern California, they anticipate full deployment of their infrastructure within the next two years, investing about $154 million by the end of 2006. "Radiologists and IT professionals need to know this is something that is going to happen, and sooner rather than later."

John F. Quinn, principal and CTO of Capgemini Global Healthcare Practice in New York, agrees. He suggests that IT professionals must become knowledgeable about standards implications, such as the latest version of HL7 published in July as a baseline for starting to compare levels of compliance.

"People need to understand what HL7 version 3 is, what SNOMED is, and what it would take to create an environment that would interoperate in that type of standards environment," says Quinn.

The importance of an institution or healthcare network incorporating standards-based systems cannot be overstated. The future of the evolution of a nation-wide health information infrastructure is the development of Regional Health Information Organizations (RHIOs). If a healthcare organization does not adopt standards-based systems, they will not be able to participate when RHIOs are formed.

"If you're an IT professional and you're working in a provider organization right now, someone needs to look at your competitors and work with them, and your reference labs, freestanding imaging centers, referring physicians, local payors, pharma companies that work in your area, primarily the retail pharmacies, and start figuring out how you are going to organize into RHIOs," Quinn advises. "Get in front of the curve and be a leader in this. Don't wait for your competitor to figure out something and then ask if you want to join."

At this point, there are two or three demonstration projects that are up and running, with the most notable being the Indiana Network for Physician Communications, which is part of the Regenstrief Institute in Indianapolis.

Besides emphasizing the critical aspect of insuring that any new system acquisitions are based on national data standards to enable interoperability, Markle Foundation's Lansky urges IT professionals to become involved in the development of local networks. "The direction from the federal agency will be a regional network of interoperable systems. These will ultimately be made up of these self-generated ad hoc networks, but [healthcare professionals] must be aware of and plugged into their local initiatives."

Ultimately, the Markle Foundation envisions a time when individual patients will have control over their own health records. Lansky asserts that when people are asked if they want their medical records online, most will answer in the negative because they picture identity theft, hacking and other privacy issues. But if you ask if they want to be able to refill prescriptions online, or make appointments online, or see their lab results online, most people would answer a resounding "yes." Patients are the only individuals with the moral and legal authority to gather information about themselves from a number of different sources. This initiative will take some time because the public has not yet begun to demand it.

Overhage from Indiana urges IT departments to clearly define goals, beyond trying to go paperless, and determine precisely what they want to do in the EHR realm. "They must be very clear about what they are trying to accomplish by adopting an EHR. Are they trying to reduce their staff? Are they trying to improve quality of care? They can have more than one goal, but they must be clear and let that guide their decision."

Eric Brown, vice president in Healthcare and Life Sciences Research Team at Forrester Research, Inc. in Cambridge, Mass., raises the issue of making decisions about how much of an existing IT infrastructure should be retained. "There are digital hospitals built from the ground up with no legacy systems, and one of the large vendors does the whole thing end to end, conceived as a whole," says Brown. "But that is not typical." Most hospitals have adopted departmental level systems, and they cannot afford to discard all of those endeavors, but integrating after the fact can be challenging.


Because experts understand how daunting the task of selecting an EHR system can be - given the 100+ vendors offering systems - there are a couple of initiatives that specifically direct those efforts.

As any IT professional would anticipate, HIMSS has served on the forefront of these efforts. The Ambulatory EHR selector is an online product offered by HIMSS, as described by Leavitt. "It is meant to help the physician or practice manager winnow down their choices as they look at vendors to supply their electronic health record systems." Users enter data such as practice size, the key features that are important to the practice, and using a matrix of about 350 parameters, the selector offers a list of potential solutions. This subscription service, which costs $149 for a yearlong subscription, also is available for a 30-day trial period for anyone who attends the HIMSS Physicians Adopting Computer Technology conferences.

Another project that HIMSS has entered with multiple other organizations is the Certification Commission that is working to certify EMR products for ambulatory care. This group determines important standards, and whether or not vendor offerings are robust and will interoperate. Vendors participate on a voluntary basis, but end-users can use certification data in their decision-making process about which system to purchase.

Besides those initiatives, Leavitt urges IT professionals to attend the HIMSS conference in February in Dallas where they will feature two large interoperability showcases, one called the ambulatory showcase, and the other called the cross-enterprise showcase. Each will feature about 5,000 square feet of display space, and involve hundreds of vendors. These systems focus on interoperability between PACS, radiology systems, laboratory systems and hospital VHRs.

David C. Kibbe, MD, director for the Center for Health Information Technology in Washington, D.C., which is a division within the American Academy of Family Physicians (a professional organization representing more than 90,000 family practitioners), describes a software application on their website called the Physician Product Reviewer. Their members can access that service, and find more than 100 EHR products that have been reviewed by their physicians.

There are system-wide solutions that have been constructed in several communities that offer insights into important aspects of developing these network solutions.


After 30 years of waiting in the wings, electronic health records have moved to center stage for deployment. With all segments of the health informatics community engaged, these initiatives are predicted to accelerate into exciting new implementations. The importance of IT professionals to these endeavors cannot be overstated, and experts agree, they must become involved as a driving force.

Two facilities blaze the EHR path

Tom Smith, CIO of Evanston Northwestern Healthcare in Illinois - one of the winners of the 2004 Nicholas E. Davies Award for excellence in implementing electronic medical records technology - explains their process for integrating their EMR network comprised of three hospitals and 500 physician employees, who work in 68 different locations.

In late spring of 2001, their administration and professional leadership staff set the implementation of a system-wide electronic records initiative as their No. 1 corporate project for two years or more. In the summer of that year, they selected Epic Systems Corp. as their vendor, and their board of directors allocated $25 million for the project.

In January 2002, they began systematic workflow analysis, which allowed them to bring all of the end-users into the project. They produced about 2,000 detailed workflow patterns after consulting with their 500 high-level staff members. Each of those individuals described their processes at that time and how they could do it better with a computer. For example, in their original system, when a physician wrote an order, the nurse would often interpret and transcribe the order and send it to a pharmacy through another system, where the order would be filled. With electronic solutions in place, the physician now enters the order electronically, selecting from a list of approved medications and dosages, the system checks for potential drug reactions, or allergies, and the order goes directly to the pharmacy without the need for any interpretation.

Following their detailed workflow analysis, they used computer software to build their end product to make it work the way they wanted. After testing and training, they "went live" with their first office in January 2003, and the first hospital two months later.

"In all of our locations, we no longer use a paper record for their care," Smith says. "It's computerized from beginning to end in the offices, in outpatient and inpatient settings. It cost about $35 million over the entire period for hardware and software, but we have documented that we are now saving $12 million per year." At that rate, in a few years Evanston Northwestern should re-coup all of their capital expenditure.

John D. Halamka, MD, CIO of the Harvard Medical School and CIO of CareGroup in Boston, describes how they have linked their nine million patients and 3,000 physicians within their system.

"CareWeb interlinks all of the hospitals, all of the owned practices and a few of our referring practices in a framework that allows on a 'need-to-know' basis in an audited, secure way a look at problem lists, medications, allergies, laboratory and radiology studies," says Halamka.

To be able to accomplish this system, they first needed to interrelate all of the medical record numbers that a patient might have. The system functions with several hospitals that each has its own internal enterprise EMR systems and PACS. For example, one hospital uses an AGFA PACS, another uses a Philips PACS and the third uses a GE PACS. Because they all use DICOM as the underlying standard, interoperable images are available through the web, so the physician can view any image performed anywhere within the system. While all of the activity is accomplished on the internet, Halamka describes strong firewalls, and intrusion detection to insure that hackers do not gain access.

"Rolling out this technology is 15 percent a technology problem and 85 percent a process and organization problem. Convincing doctors to use it, dealing with legal problems and compliance issues means you cannot underestimate that there is much more to do than just get the servers running and the software up," concludes Halamka.

He describes another exciting initiative that they are pursuing that is designed to document cost savings enabled by adoption of EMRs. The state of Massachusetts currently spends $30 billion per year on healthcare. Experts have estimated that adoption of electronic patient records will eliminate about 15 percent of the expense of medical care. This means that in Massachusetts, they could save $4.5 billion per year. The Massachusetts eHealth Collaborative, with funding from Blue Cross/Blue Shield, will
conduct a pilot project where they completely "wire" three communities selected through a competitive process. They will analyze performance over two or three years to determine whether having all physicians in a network does really reduce waste and inefficient care as anticipated. If it works, they plan to ask payors to contribute the billions of dollars it would require to "wire" the entire state.