Photograph of Chad Eckes by Chris Lake

Imagine that wherever you are across the United States, your complete health records are instantly available to any healthcare provider you authorize to see them. Your hospitalizations, radiology images, surgeries, lab results, allergies, medications, even your advanced directives are stored electronically and available via a secure nationwide network.

Your own doctor's office no longer has row upon row of patient records lined up on shelves; they've all been digitized. In every examining room, doctors enter their notes and view radiology images on laptops or PCs. If you need a prescription or a lab test, the doctor orders it online. When you're at home and have a question for your doctor, you e-mail her.

A nirvana of better care at lower cost? Or a security nightmare? It depends whom you ask. But with the cost of healthcare in the United States now at about $2.5 trillion a year, the pressure for a nationwide system of electronic health records (EHRs) is building. Because properly used computerized records can be a powerful tool to measure, track, and improve patient care, advocates say they could not only reduce the cost of care, but also improve its quality.

Progress varies from country to country

In Europe and elsewhere, health record digitization is well underway. Canada, England, France, South Africa, Australia, Hong Kong, and Taiwan all either have nationwide EHR systems or are developing them. In Scandinavia, more than 90 percent of primary care practices have EHRs.

In the U.S., the Veterans Administration has had electronic records for years. All of its 155 hospitals and 800 clinics—one of the largest integrated healthcare delivery systems in the world—use an EHR system called Vista. Individuals can opt to create their own available-from-anywhere electronic medical records using such online services as Indivo, Google's Health system, or Microsoft's Healthvault. EMC and some other companies offer employees the option of setting up private health records as an employee benefit.

But not only is there no nationwide EHR system in the United States, fewer than 10 percent of America's 5,000 hospitals and 17 percent of its 800,000 doctors have digitized their own patients' records.

Within the last few years, large urban medical centers in the U.S. have begun to set up EHRs. Cancer Treatment Centers of America, Daughters of Charity Health System, Kaiser Permanente, Palo Alto Medical Foundation in California, and Beth Israel Deaconess Medical Center in Boston are examples. But these systems can't communicate with one another.

Aligning incentives with needs

John Halamka, CIO of Boston's CareGroup and himself a physician, believes the major impediment to implementing EHR in the U.S. is that "incentives are not aligned with needs. EHR benefits medicine at large, but not necessarily the individual physician. Medicare and private payers will have to provide doctors with incentives for them to invest in it."

Under the Bush Administration, former U.S. Health and Human Services Secretary Michael Leavitt proposed a "Medicare demonstration system" to reward physicians adopting electronic records in the small- to medium-sized practices where Americans receive most of their care.

President Obama is going much further, making healthcare information technology a major component of his economic stimulus package. He has proposed that within five years all medical records in the U.S. be electronic and that health information be shared across a nationwide network.

What would it take for that to happen? And what could be the benefits?

The cost/benefit equation

Ignoring politics and looking solely at cost, estimates are that setting up a nationwide EHR system could cost $100 billion or more over the 10 years it would take hospitals to effect the conversion. Much of that amount would be needed to train and pay technicians to create the network, and right now there is an acute shortage of such talent.

Once those problems were solved, however, the payoff could be great.

The RAND Corp. has estimated that once widely adopted, EHRs could save $81 billion each year, largely by reducing the number of redundant tests, procedures, and treatment errors. Dr. David Brailer, who was President Bush's health information czar from 2004 to 2006, has estimated that a fully computerized health record system could save the healthcare industry $200 to $300 billion a year.

Furthermore, say advocates, when the costs of healthcare are reduced, healthcare insurance premiums could be stabilized or even lowered.

In the meanwhile, the story of EHR adoption at two large American hospital systems illustrates what is involved when individual systems make the conversion.

When the ER is a hospital's front door

California-based Daughters of Charity Health System comprises six hospitals and medical centers from San Francisco to Los Angeles. It has 1,400 beds and 7,500 associates, not including doctors, and primarily serves the poor.

Says IT Director Michael Day, "We began putting clinical data online five years ago, starting with our emergency rooms. For many of our patients, the ER is their doctor, so in effect, our ERs are our front doors. So that's where we now have laptops and workstations on wheels, affectionately called WOWs. Some of them have touch screens or voice recognition systems for physicians who don't type. It's much easier for doctors to treat patients with chronic illnesses like diabetes when they have their records at their fingertips."

Although the hospital system's conversion to EHR is still in progress, core clinical and surgical applications have been completed, so that radiology images and lab results are now available to clinicians virtually instantly. Day says the benefits of the system were obvious immediately, and that other hospitals frequently visit to observe it at work.

Cancer Treatment Centers of America (CTCA), which focuses on patients with advanced and complex cancer, is based in Schaumburg, Illinois, and encompasses hospitals and oncology programs in Arizona, Illinois, Oklahoma, Pennsylvania, and Washington. Drawn by the CTCA unique treatment approach, patients travel an average of 500 miles to visit CTCA hospitals, which combine leading-edge traditional treatments with an array of complementary therapies, including stress management, nutritional counseling, and spiritual support.

Explains CIO Chad A. Eckes, "We address the way in which cancer attacks the body, integrating the best traditional treatments available with therapies to strengthen the immune system and alleviate the stress and side effects of the disease. Our goal is to treat the whole patient."

Setting up an EHR war room

CTCA began considering EHR in 2005, says Eckes, because in treating advanced cancer, speed is critical.

"This was not an IT project," says Eckes, "it was a clinical project. We actually set up a war room, and we had a team of 60 operations and IT people at each site. I talked to the chief medical officer five to 10 times a day during the 18 months we were implementing the system. We involved everyone from nurses and pharmacists to doctors and administrators. "

The system went into effect not in stages, but in what Eckes calls "one Big Bang on March 28, 2008." It went live with 128 interfaces in operation.

Eckes says CTCA saw benefits immediately: "Everything was faster, accuracy improved, and everything was at clinicians' fingertips. Our doctors could hardly believe what an improvement it made in their ability to treat patients quickly and effectively."

The challenge of digitizing physician records

Converting individual doctors' records to electronic form presents different problems, because doctors must make a large up-front investment and learn to use new software.

In Massachusetts, Beth Israel Deaconess Medical Center, which is part of CareGroup, has established a cloud computing center in Marlborough, hosting EHRs for Massachusetts community doctors using a software-as-a-service model. Instead of paying the $40,000 to $46,000 it would cost to set up an EHR system of their own, physicians' groups pay $15,000 to buy into the cloud center service plus $300 per month per doctor.

Called the Beth Israel Deaconess Medical Center/Beth Israel Deaconess Physicians Organization EHR Hosting Center, its goal is to add six new medical practices per month throughout 2009 and 2010. So far, four practices have fully implemented the service.

But John Halamka wants to go much further. In a January 2009 blog post on geekdoctor.blogspot.com, he wrote, "Let's not wait until we have perfect systems [to roll out EHR].

"We can achieve substantial improvement in care quality and coordination by implementing the systems available now and not waiting until we have the perfect system. ... With some state and local variations, we already have a nationwide framework for EHR and public health record exchange."

Noting that it will take a combination of technological advances, new policies, and new funding to accelerate such a big change in healthcare IT, Halamka believes the current burst of activity shows that "EHR is on the radar screen of just about every state, and the pace of change is enabling interoperability."

Putting standards in place

Will the United States eventually evolve a nationwide standardized EHR system? If so, it will happen in stages.

The recently passed economic stimulus package includes $17.2 billion for "incentives to Medicaid and Medicare providers to adopt health information technology" and $2 billion to "provide additional financing for the Office of the National Coordinator for Health Information Technology." The package also expands HIPAA privacy standards to address concerns about patient confidentiality.

Shannon Kellogg, a Director in EMC's Office of Government Relations, says, "The health IT provisions in the new law are intended to increase adoption of electronic health records by doctors and hospitals significantly over the next several years—and the funding in the American Recovery and Reinvestment Act is a major down payment on that objective."

"We've wasted a lot of time waiting for government to solve this issue," says Chad Eckes of Cancer Treatment Centers of America.

"I think industry will have to solve the interoperability problems. But it will take some big event to make patients push the providers for [a nationwide electronic health records system]. I don't know what that might be. In the meanwhile, though, I think President Obama is getting the right brain trust together to tackle the problem."