The national health information network is coming—it must be, because
so many people say they want it. With the White House and political leaders as
diverse as Sen. Hillary Rodham Clinton (D-N.Y.), former House Speaker Newt
Gingrich, and Senate Majority Leader Bill Frist, M.D. (R-Tenn.), advocating
the concept; with health policy experts of every stripe hailing information
technology as a key to quality, efficiency, and cost containment; and with the
AMA and specialty organizations, including APA, preparing for it, it would be
surprising if the electronic health record failed to materialize.
An aura of inevitability surrounds the vision of rapid and secure
electronic transfer of patient medical information across systems and over the
span of a patient's life—a vision that would essentially relegate the
time-honored, paper-based medical chart to the dustbin of history.
Moreover, it is a vision that is linked in many minds to "value-based
purchasing" of health care, quality improvement, and the movement for
greater transparency in medicine—other fast-moving trains in American
health care. Concepts such as pay for performance, for instance, are largely
dependent on widespread adoption of electronic health records.
"I think we are going to see health care dramatically transformed,
and I think that use of this technology both in terms of decision support for
providers and in patient self-management can and will be
transformative," said Dean Rosen, director of health policy in Frist's
office in a Webcast on health information technology sponsored by
Frist has cosponsored the Healthy America Act of 2005, one of at least a
dozen bills in Congress promoting adoption of "individually owned,
privacy-protected electronic health records" (see facing page). The bill
would provide federal support for a "public-private collaboration to
enable rapid and safe exchange of electronic patient
"The benefits are so obvious," said Rosen, "that I think
once people understand it, once we knock down barriers and help lay some of
the basic framework for it, I think it will take off, and we will be in a lot
better position five years from now than we are today."
Yet for all its momentum, the national health information network is not
without an enormous number of complexities that could delay or derail it.
Political pitfalls could also spell trouble for its future.
In an interview with Psychiatric News, John Boronow, M.D., chair
of APA's Corresponding Committee on Electronic Health Records, described a
host of challenges—technical, logistical, and economic—and
provided an overview of the emerging network of initiatives, organizations,
and agencies dedicated to overcoming those challenges (see facing page).
Though the potential of the digital revolution for medicine has always been
apparent, it began to take flight a little over a year ago when President
George W. Bush appointed David Brailer, M.D., to head the Office of the
National Coordinator for Healthcare Information Technology (ONCHIT) and called
for widespread adoption of health information technology within 10 years
(Psychiatric News, June 4, 2004).
During the KaiserNetwork Webcast, Brailer described the mission of ONCHIT
as follows: "First, to give advice to the federal government about
health information technology, to raise the IQ of the government about this
new area. Second, to coordinate the federal agencies, of which there are more
than 30, that are involved in health information technology. Third, to
coordinate activities in the private sector to make sure it's a public-private
From the start, Boronow said, the buzzword has been"
interoperability," the ability of information software systems to"
talk" to each other so that there can be a seamless transfer of
information across the health care landscape—a concept that presupposes
widespread adoption of computerization.
But a major challenge remains how to make electronic record keeping
attractive to solo and small-group ambulatory care physicians. While many
hospitals and large health systems have adopted some form of computerization,
many smaller groups and individual physicians have not.
Last year, APA became one of 14 founding members of the Physicians'
Electronic Health Record Coalition (PEHRC), whose mission is to represent the
interests of physicians in small and mid-size ambulatory care practices in
discussions with ONCHIT and other federal agencies. Boronow and Darrel Regier,
M.D., director of the APA Division of Research and the American Psychiatric
Institute for Research and Education, have represented APA on the
John Boronow, M.D.: "A lot of damage has been done by the
sequestration and fragmentation of data."
The APA committee that Boronow chairs was also formed last year to advise
PEHRC about psychiatrists' concerns in these
Darrel Regier, M.D., heads up APA's staff efforts on the health
information technology movement.
"PEHRC is primarily an ambulatory physicians' group that came
together so it could influence ONCHIT and provide a forum for what the
physicians' stake was in this vision," Boronow, medical director for
adult services at Sheppard-Pratt Health System in Baltimore, said. "It's
very clear that while [the movement for electronic health records] is a
laudable project, it is also very ambitious. There are a lot of different
agendas in play, and a lot of unintended things can happen. All involved need
to articulate what their wants and worries and concerns are, and PEHRC seems
like a way for small-group ambulatory physicians to do that."
This month the journal Health Affairs is publishing the results of
a survey by the Medical Group Management Association querying doctors on their
level of comfort with, and knowledge about, electronic health records. As a
follow-up, Boronow said PEHRC will be using the same survey instrument to
question its 22 subspecialty members on this topic.
Boronow said physician groups considering investment in information
technology have been vexed by this conundrum: How do they know if the software
they purchase will be compatible with other systems as the electronic health
record evolves in coming years? This concern has left many physicians
reluctant to make a substantial investment in a product that may need to be
replaced in five years.
One critical step in overcoming this obstacle, Boronow said, is the
development of standards for software product certification.
The Certification Commission for Healthcare Information Technology (CCHIT)
is a voluntary, private-sector initiative to certify health care information
technology products. It is the creation of three industry
associations—American Health Information Management Association,
Healthcare Information and Management Systems Society, and National Alliance
for Health Information Technology—and has set as a goal the development
of standards for software manufacturers to begin meeting by the end of 2006,
The federal government also moved to hasten the development of standards
this summer when ONCHIT announced the establishment of the American Health
Information Community (to be called "the Community") to"
help nationwide transition to electronic health records—including
common standards and interoperability—in a smooth, market-led
So, what ultimately will the National Health Information Network look
If physician groups have their way, one thing it won't look like is a large
government-owned patient database. "Everyone is afraid of Big Brother,
of the idea of having one big massive database that everyone would draw
on," Boronow explained.
Instead, the consensus preference is for what has come to be called a"
brokered peer-to-peer network," he said. "Brokered"
refers to the fact that the network uses a central host that provides security
and linking functions, but does not store data. "Peer to peer"
refers to the idea that files containing clinical information would be
directly exchanged between users and that all content would be created by
"The idea is that data will originate in whatever office you see the
patient, and the network will consist of software that allows you to share
it," Boronow said.
The mechanics involved in making software systems interoperable are
daunting, as are the costs (see box on facing page).
Of more immediate concern to psychiatrists is the content of shared
information: What kind of information will be shared with whom under what
Boronow noted that the Health Insurance Portability and Accountability Act,
which provides rules to ensure the security of electronically transmitted
information, is in fact remarkably lax, and many states have stricter laws
that conflict with each other.
A movement is under way among policymakers to "harmonize" the
many conflicting privacy laws—a term that some privacy advocates take to
be code for elimination of privacy protections. But Boronow said that while
privacy is a paramount concern, he and members of the APA committee he chairs
are optimistic about the opportunities for improved patient care offered by
the vision of a national health information network.
"A lot of damage has been done by the sequestration and fragmentation
of data," he said. "In my fairly small state of Maryland, it is
very common for one of my chronic patients to have had six or 12
hospitalizations in six or 12 different places. You are lucky to know that,
and you are even luckier to get a fax from one of those places that would tell
you something about how [such patients] were treated. You end up reinventing
the wheel over and over again because you don't have an accurate history of
your patients. That is one of the problems we want to fix."
But will the vision of a National Health Information Network come to
Boronow acknowledged that the politics involved are "mind
boggling," and added, "If you are skeptical, it may never happen.
There is a lot of ways you can imagine it failing."
But he suggested that the countervailing forces propelling such a network
may be inexorable, and he cited the Institute of Medicine's landmark report"
Crossing the Quality Chasm," which underscored the importance of
a dramatically improved information technology infrastructure to support a
21st-century health system.
"There is a lot of momentum behind this," he said. "At
this point things are on track, without too much disarray."
Even if the most ambitious goals of the National Health Information Network
are postponed or not achieved, psychiatrists should not be deterred from
taking seriously the need to computerize their practices or from joining the
national discussion about health care information technology.
"I think psychiatry should participate in this," he said."
Everyone expects us to, and the opportunities for us to improve
practice are huge. The membership needs to think through some of these privacy
issues and figure out how to live in this brave new world. I believe there
will be solutions that patients and psychiatrists will have confidence