Electronic medical records: Does it take a village or a thousand points of light?

Everyone agrees that the current state of US health care information technology is unsatisfactory. Despite the enormous investment in health care in the US – two trillion dollars annually, equivalent to 15% of the GDP – transportability of medical information is chaotic, medical errors are unacceptably high, and deviations from evidence-based practice standards are endemic. Only 2% of the health care budget is currently thought to be consumed by information technology (IT) related activities. Fewer than one-quarter of physicians in the US utilize some form of an electronic medical record (EMR), and many of these are rudimentary. These numbers are much lower than in Europe and other developed nations; in some, the use of EMRs approaches 100%. In the UK, a single EMR for its 60 million citizens is under construction by the National Health Service. Many feel that the mediocre outcomes registered by the US health care system, compared with those of other nations with much smaller per capita health care budgets, can be traced directly to an inadequate IT infrastructure. For physician-scientists who bridge the worlds of medical research and clinical practice, the differences in the level of IT sophistication between the two worlds can be particularly jarring. In most biomedical research laboratories, IT is solidly in the 21st century, whether used to analyze a powerful imaging algorithm or perform a genetic experiment requiring the handling of billions of data points; in the clinic the impression is often that of a cottage industry unchanged from days long past, which might include searching for a missing record behind the top shelf of the file cabinet, writing a note on carbon paper, or having a medical student run a “STAT” written order down eight floors to the inpatient pharmacy. This is not to imply that the focused bioinformatics needs of a typical research laboratory have even remotely the same level of complexity as those facing EMR design and implementation – they do not. However, it is remarkable that IT occupies a central place in the workplace of modern science, yet appears to be an afterthought in many clinical environments. There are currently more than 25 different outpatient EMR systems in use. The most widely used EMR in the US is the Veterans Health Information Systems and Technology Architecture (VistA) system, used throughout the Veterans Affairs (VA) system for more than a decade. VistA incorporates inpatient and outpatient medical records, imaging handling capability, electronic prescribing, and clinical guidelines for the entire VA system serving more than 4 million veterans. The VistA software code and updates are in the public domain, with a number of commercial venders offering customization for adoption in a variety of settings. Several health care systems (including academic ones) currently use it, and advocates argue that it could serve as the foundation of a future national EMR. Enter Google, not surprisingly with a typically bold and creative new take on the problem. Their solution – Google Health – is a system designed for individuals rather than for any health care system. Medical records are assembled, maintained, and controlled by the patient in his or her individual Google account, and at the patient’s direction these can be shared, in whole or in part, with health care providers, insurers, family members, or others. The goal is not to replace the current array of EMR silos with a new product, but rather to give birth to a new “personal” EMR that is owned by the patient. On February 21, 2008 the beta version of Google Health was launched in a two month trial at the Cleveland Clinic. The sophisticated EMR system currently in place at the Cleveland Clinic will be electronically transferred to password-protected individual accounts of a small number of individuals, all volunteers, estimated at between 1,500 and 10,000. In a statement from the Cleveland Clinic, the decision to work with Google Health was motivated by a desire to stimulate the creation of a national EMR and also to help its members convey their medical data to providers when they require care outside the Cleveland Clinic Health Care system. Another recent entry into the patient-controlled EMR space is the software giant Microsoft. Last October, Microsoft launched HealthVault, a health records service, with an impressive group of partners including the Mayo Clinic and New York-Presbyterian Hospital. If successful, personal EMR ventures, such as Google Health and Health Vault, are likely to stimulate standard formatting of medical records across different EMR systems. Patients will demand that their health care system is compatible with their personal EMR, and health care systems will likely respond to this new market force. The result could accelerate the evolution of a universal language for EMR. Portability of our medical records is clearly desirable, as is efficient access to our health data in case of emergency; these needs are well met by patient-centric EMR systems such as