PHILADELPHIA—In medicine, there's the patient and there's the chart. And the chart is paper.

That's the stereotype. Actually, about 20 to 30 percent of all primary care physicians in the nation now use basic electronic health records, according to David Blumenthal, a Harvard Medical School professor who was the national coordinator for health information technology in the Obama Administration until a week ago. In fact, e-records are used almost universally in other industrialized countries, especially among primary care doctors, he added. Blumenthal spoke at a session here April 15 at the annual meeting of the Association of Health Care Journalists.

Moving from paper to electronic health records (sometimes called electronic medical records) has become more attractive to health care providers in the past two years under an act, funded with about $20 billion in economic stimulus funds from 2009, that provides incentives for physicians and medical practices to implement electronic health records.

The goal is to create a nationwide, interoperable, private and secure electronic health information system, and to promote the exchange of records across geographic and institutional boundaries. Doctors, hospitals and other health care providers who become "meaningful users" of electronic health record systems, which start at about $100,000 at minimum to purchase for an individual practice, can receive $40,000 or more from the federal government. The incentives will convert in 2015 to penalties for those who fail to adapt.

Practices or physicians using electronic health records make $44,000 more net income per year than those who do not, Blumenthal said, because the former tend to log every procedure performed, which triggers billing that can be overlooked via the paper method.

Allen L. Gee, a neurologist with the Wyoming Governor's Health Information Exchange Task Force and also part of the AHCJ session, said his first two efforts with electronic health records software in his private practice "didn't work." Now, his use of such a third system has reduced his costs by 3 percent and increased his revenue by 6 percent.

"I think IT can and will improve quality of health care if used effectively at point of care," he said. Such systems enable telemedicine and help to bridge the long distances between patients and various health care providers on a patient's team, some of whom work hundreds of miles apart in Wyoming. Still, Gee's pet peeve is doctors who have their backs to patients while entering data.

Other upsides can come from data aggregation that enables the tracking of epidemics in real-time as they enter a nation (think of H1N1), or the analysis of the relationship between a new therapeutic drug and occurrences of adverse event (think of the data that came out on Vioxx and higher rates of heart attacks). Alerts help health care providers avoid prescription problems, such as drug-drug interactions.

Blumenthal said he has benefited by using an e-record system that scans a patient's full database to avoid the ordering of redundant tests within the past three months.

Sources of resistance

Still, some U.S. doctors and practices are resistant to adopting such systems. The reasons for the resistance are psychological and cultural, not technological, Blumenthal said, and can occur up and down the rungs of the health care system.

The exchange of health information can be seen as a team sport, Blumenthal said. "Even if you are wholly capable of exchanging electronic health care records, you can't do it if no one in your circle of referrals is capable or interested in doing it. You have to have a communal capacity and level of interest."

Sharing health information is "not a natural act" in the fiercely competitive health care market, Blumenthal said.

"The idea that [some providers] would willingly exchange health information and thereby give competitors access to their patients' longstanding health information and thereby make it easier for competition to woo way their patients strikes a lot of CFOs as totally crazy," he said.

Blumenthal remains optimistic: "I think that the challenge of adoption will be almost certainly overcome."

An urban experience with e-records

Judy Klickstein, senior vice president of information technology and strategic planning, Cambridge Health Alliance in Massachusetts, said this healthcare system started using Epic Systems software for start up its electronic health records effort nearly 10 years ago, "before the [federal] dollars were dangled." The Alliance operates three hospital campuses, a network of 20-plus primary care and specialty care locations, with an emphasis on preventive care and serving the area's most vulnerable and diverse populations.

She showed the AHCJ audience an intake form for a walk-in patient that looked a bit complex. "Is it better than looking at paper? You bet, but it takes a while to get things going," she said. Earlier in her presentation, she reminded the audience of the easy interfaces that consumers encounter at ATM machine.

The process of implementing electronic health records has involved working with groups of health care providers to get them to agree on one practical way to get things done. "It's less about displaying data. It's more about 'How do people practice when using electronic records?' ranging from the person who answers the phone in a medical practice, the person who takes patients' vital signs and the doctor or nurse who sees a patient," Klickstein said. Training can take 20 hours of a doctor's time.

Klickstein described a case study of a homeless man found unconscious on the street. He was schizophrenic, diabetic and drug-addicted. This is a typical case in her system, she said, "I am not making this up." But the system worked effectively. His admission to an emergency room triggered his primary care doctor, who could be involved in his case. After a hospital stay, he was entered into a psychiatric day treatment program. All his records were available to every health care provider he worked with along the way. His homeless clinic was alerted as to his whereabouts. A treatment plan was devised. All this could avert future problems in a way that would be harder to coordinate without electronic health records.

"These are things that many of us take for granted. It's how you get your care. But this is the challenge of dealing with a population [the homeless] that doesn't have same supports as you and I," Klickstein said.

"Most providers say after they use [an electronic health records] system for six months that they would never go back," she said.

It will be standard for the next generation of e-health records software to enable "interoperability"—communication among databases held at different institutions and across distant and distinct health care systems, Blumenthal said. He also anticipates systems that will allow providers to just email in data that automatically is entered into multiple, interconnected e-record systems.

Even nurses' aides, who work at a minimum wage but spend more hours with sick, elderly individuals than any other health care providers, could assist by sharing observations, such as "Mrs. Jones is not quite right today…usually she is a chatterbox." This information, said journalist Irene Wielawski who moderated the session, could alert health care providers earlier to signs of infection before it's too late.

Image: U.S. Department of Health and Human Services