In August 2006, President George Bush signed an executive order that called for healthcare agencies to provide electronic health records (EHRs) to most Americans by 2014. Since signing "Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Healthcare Programs," a great number of healthcare agencies in the United States have begun their own initiatives to develop EHRs. But many are looking for guidance as they work towards implementing these systems.
Studying both the triumphs and disappointments of international EHR initiatives provides a unique opportunity for information technologists to determine best practices as they look to create their own systems.
"We still have a tendency in healthcare to try to reinvent the wheel," says Denis Protti, professor of health information science at the University of Victoria in Canada.
Projects in Denmark, Canada, and Brazil, among others, have achieved modest successes in automating patient records. In contrast, however, several national large-scale efforts, like those in the United Kingdom and Australia, have been waylaid by a host of problems.
Finding right-sized opportunities
Bill Crounse, M.D., global healthcare industry director for Redmond, Wash.-based Microsoft Corporation, argues that attempts to build systems with too much functionality have been a source of problems for some. "The bigger the projects are, the more they are subject to failure. In less developed countries, there are often more right-sized opportunities."
Australia's EHR program, HealthConnect, is currently stalled in its implementation efforts. One reason, some analysts argue, is the indeterminate scope of the project. Sam Heard, CEO of Ocean Informatics, a Sydney, Australia-based EHR consultancy, contends that Denmark is setting a standard for shared record systems by keeping things simple.
"The Danes are leading the way in a fairly simple space — focusing on messaging, prescriptions and lab results. They haven't been too ambitious, and that's put them at the top," Heard says.
The city of Sao Paolo, Brazil, has also had great success with the evolution of the SIGA Saudé system. The initiative started with the National Health Card Project (NHCP) which defined standards for patient identification and registration information. After its successful implementation, SIGA Saudé built on the NHCP's foundation to create a more robust patient record system.
Beatriz de Faria LeÃ£o, M.D., Ph.D., a health informatics consultant who has worked closely with the SIGA Saudé project, believes that its success can be attributed to using project management and software development methodologies. "Health informatics should be conducted by a team of competent technical people that understand standards and the true scope of these projects," de Faria LeÃ£o says.
The importance of consensus
Another critical factor in the development of international EHR systems has been amassing buy-in at all levels of a project, from key government and project leaders to the physicians on the ground.
The National Health System in the United Kingdom started efforts on its EHR system with a more centralized, top-down approach, issuing mandates as to how the system would be implemented with little input from local agencies and doctors. That approach is now coming back to haunt the project as physicians have come forward to fight against implementation plans.
"The Brits were not addressing the day-to-day pressures of health service in their information technology strategy," says Protti. "They intentionally started with only small physician involvement. And now they have to bring doctors back in to the fold, three or four years after they initially started, and essentially begin again."
Canada, however, has developed a process that is allowing input from all levels — and all national provinces — to help shape its EHR implementations with the Canada Health Infoway project. Canada is unique in that each province, not the overarching national government, is responsible for healthcare. To make sure they were moving in the right direction and would not be plagued by similar issues as Great Britain, the Infoway project took the time to create accord on its EHR implementation plan which will allow it to move forward rapidly in the future.
"Infoway was initially criticized for being slow off the mark," says Michael Martineau, director of the eHealth Practice with Branham Group, an IT consultancy based in Ottawa, Canada. "But they had to build consensus. It takes a long time, but it creates tremendous momentum."
Throwing money at the problem
Crounse also sees an issue in the United States with how monies are being spent. "Everything in the U.S. has a multimillion dollar price tag," he says. "In lesser developed countries, where resources are really precious, they are examining how they can do things with great economies of scale." He argues that American companies tend to spend a great deal of money on systems that do not resolve critical EHR issues. "We need to solve before we buy," Crounse adds.
Michael Martineau concurs. "We should be looking at how we can deliver healthcare more efficiently and effectively, without throwing money at the problem all the time," he says.
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