Emerging electronic health record models present numerous challenges to health care systems, physicians, and regulators. This article provides explanation of some of the reasons driving the development of the electronic health record, describes two national electronic health record models (currently developing in the United States and Australia) and one distributed, personal model. The US and Australian models are contrasted in their different architectures (“pull” versus “push”) and their different approaches to patient autonomy, privacy, and confidentiality. The article also discusses some of the professional, practical, and legal challenges that health care providers potentially face both during and after electronic health record implementation.
The electronic health record (EHR) is an evolving concept defined as a longitudinal collection of electronic health information about individual patients and populations. Primarily, it will be a mechanism for integrating health care information currently collected in both paper and electronic medical records (EMR) for the purpose of improving quality of care. Although the paradigmatic EHR is a wide-area, cross-institutional, even national construct, the electronic records landscape also includes some distributed, personal, non-institutional models.
Emerging EHR models present numerous challenges to health care systems, physicians, and regulators. This article provides explanation of some of the reasons driving the development of the EHR, describes three different EHR models, and discusses some of the practical and legal challenges that health care providers potentially face both during and after EHR implementation.
Information technology (IT) has become the principal vehicle that some believe will reduce medical error. In the United States, the non-governmental and highly influential Institute of Medicine (IOM) has committed to technology-led system reform [
The electronic record is at the center of the IOM's goal of eliminating most handwritten clinical data by the end of this decade [
Error reduction aside, business concerns and structural changes in health care delivery are driving EHR implementation. Although some of these phenomena are unique to the US model of health care financing and delivery, mature systems in other countries must also accommodate stresses from similar developments. First, the shift from in-patient to ambulatory care (and other episodic models) has accelerated the need for accurate and efficient flow of patient medical and billing information between organizationally and geographically distinct providers. Second, the operational aspects of managed care, such as the data needs of “gate keeping” physicians, demands by payers for performance “report cards,” and system administrators' increasing needs for sophisticated utilization review and risk management tools, have increased the need for data transparency [
In addition to safe, high-quality care, patients expect privacy, rights of access and correction [
I don't want much - just for my medical records to be seen only by those whom I authorize, and for the record to be readily accessible to them wherever they are. . . . I would like a bigger say in what goes into my notes, and if I don't like something I would like it taken out. [
Providers continue to embrace confidentiality to foster an environment in which patients will disclose information related to their health. However, in the realm of health information, the needs of those delivering, regulating, and paying for health care may be at odds with the principles of privacy and confidentiality [
In addition to maintaining confidentiality, providers are subject to legal and ethical obligations to evaluate and document the encounter. Providers engage in narrative with the patient and form opinions throughout and across interviews [
Although there has been debate among providers about the feasibility and safety of having all patient information computerized and available across institutions, the authors accept the premise that EHR implementation is inevitable because of the support for the idea from health care regulators, third-party payers, hospital administrators, and physician advocacy groups such as the American Medical Association [
As EHR models have struggled towards maturity, some key questions have arisen. Debatable issues include the following: whether the originating record should supply complete data or a summary; whether the data subsequently generated is episodic or longitudinal; and whether patients and providers will either control which information is “pushed” to the central record or be spectators as comprehensive data is “pulled” by remote systems. The EHR models that are developing in Australia and the United States suggest some divergent answers to these questions. Although less visible than institutional (provider or governmental) models, a third EHR model focuses on a web-based, distributed “personal” longitudinal record. This model raises discrete quality and confidentiality issues.
Australia's proposed national health information network is called Health
A Health
The patient controls which elements of the centralized record may be used for which purposes or displayed in which “views” [
The IOM has been critical of the rate of technology adoption by US hospitals [
In the United States, as is the case in Australia and the UK [
At this stage in the development of the US national model, its architects are concentrating on the interoperability and comparability of
Most EHR initiatives are national in scope and frequently government initiated or funded. EMR initiatives are typically hospital- or system-wide, yet are being designed with an eye to broader push or pull systems that will make wide-area use of such institutional data. A personal EHR model is quite different in concept. It assumes that individual patients will aggregate their diverse records and then make them selectively available to new or emergency providers. There are several subscription, web-based personal EHR systems such as PersonalMD.com [
While Australia's Health
Considerable uncertainty exists regarding the costs associated with electronically mediated health initiatives and their allocation [
Equally, there are practical, economic, political, and professional barriers that impede the acceptance of electronic records systems. Individual physicians or small practice groups have particular concerns about the costs and learning curves associated with electronic records systems [
An EHR system must satisfy its users regarding privacy, confidentiality, and security [
Australian state [
The US PIHI rules regulating the disclosure of health data have less certain application outside traditional bricks-and-mortar providers, such as those engaged in Internet prescribing and web-based medical advice [
Privacy and confidentiality aside, providers already face legal costs with regard to their records. For example, a US provider's failure to maintain timely, legible, accurate and complete records will likely breach state licensure standards [
EHR systems inevitably will contribute other costs for users because of interactions with the legal system. Emerging EHR systems, particularly those linked to CDSSs, will be vulnerable to actions focusing on design or other operational flaws [
On April 26, 2004, President Bush announced the goal of assuring that most Americans have EHRs within the next 10 years [
If properly funded and nationally implemented, the US EHR model has the following potentials: to interconnect with and enhance other error-reducing and cost-saving technologies such as decision support systems; to streamline health care dataflow using an interoperable and standardized nomenclature; to improve quality by encouraging accurate and legible communication among providers; to automate adverse event and medical error disclosure; and to facilitate reliable and reproducible outcomes research and reporting [
As EHR progress continues, several important questions remain unanswered. Which is the preferable EHR model—a shared summary system or a full interpretational longitudinal record? How much say will or should patients and providers have regarding which health information is shared across systems? Would an interactive EHR increase patient interest and involvement in their own care? And, of course, will electronic records conquer the technical problems they pose, avoid the security and privacy costs their critics identify, and deliver lower costs and higher quality; or will they be responsible for still more costs and errors, while promoting the continued industrialization of health care delivery and subordinating patient autonomy and professional ideals to soulless systems?
It has never been more important for providers to be aware of emerging technology, to comprehend the tension between improved care and the preservation of patient privacy and autonomy, and to offer feedback to the American Medical Association and other professional bodies as these entities move to influence the development of the EHR.
None disclosed.
computerized decision support system
Consolidated Health Informatics
computerized physician order entry
electronic health record
electronic medical record
Health Insurance Portability and Accountability Act
health management organization
Institute of Medicine
information technology
National Committee on Vital and Health Statistics
Standards for Privacy of Individually Identifiable Health Information
Radio Frequency Identification