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Breaking Down the Barriers

When health-care providers exchange electronic medical records, costs go down and patient care goes up


The Wall Street Journal


April 13, 2010


To understand the potential of shared health records, consider the Bottone family.


Born prematurely with nonfunctioning kidneys, 4-year-old Jacob Bottone has been through dialysis, angioplasty and a kidney transplant, and

seen more specialists than most people will see in a lifetime. His doctors and hospitals had electronic medical-records systems, but no way to

access each other's, so his parents had to collect his growing paper medical records in a large accordion folder, haul it from doctor to doctor,

explain his medical history over and over again, and often wait for hours while referrals and test results were retrieved and faxed around to

different providers. "It was getting to be a bit of nightmare," says his father, Jason Bottone.


Enter electronic information exchange.


Three leading health-care providers in Colorado's Front Range region recently teamed up in an electronic health-record exchange program that

will allow them to share data on more than a million Colorado residents, including Jacob. The three—Children's Hospital in Denver, Kaiser

Permanente Colorado's physician group and Exempla Healthcare, which operates Saint Joseph and two other hospitals in Denver—have agreed

to share their records on a secure network that will allow clinics, doctors' offices and hospitals to exchange data on common patients instantly,

including lab reports, radiology images and medical history.


Instead of keeping a tattered list of Jacob's medications in the boy's diaper bag, his mother, Heather, knows that his doctors at either Kaiser or

Children's Hospital can call them up instantly on a computer. When the family rushed Jacob to the emergency room in December, fearing a

rejection of his transplanted kidney, they called ahead to Children's, where staffers pulled up notes from his latest doctors' appointments.

(Fortunately, he was suffering only gas pains caused by a virus common to transplant patients.) As for the accordion file, dubbed "Jacob's Bible"

by the family, "we don't have to carry it around anymore," says Mr. Bottone.


Still Rare


Unfortunately, programs like this are still a rarity. For starters, only about 10% of the nation's hospitals and less than 7% of doctors' offices have

full-fledged electronic medical records. And those that have electronic records typically don't share them with others unless they're part of the

same health system. Among the reasons: With dozens of different vendors, information systems often can't easily talk to each other. In addition,

health-care providers often view their information about patients as proprietary. And concern about violating privacy laws has made many

hospitals reluctant to join information-exchange efforts.


But those barriers are expected to come down as the federal government prepares to dole out $19 billion in economic-stimulus funds for

health-care providers to adopt electronic medical records. To qualify, doctors and hospitals must not only invest in electronic medical records,

but also demonstrate "meaningful use" of the systems, including the ability to exchange information with other providers. If they fail to do so,

their Medicare payments will be cut.


By 2015, "Americans ought to be able to expect there will be a relatively widespread exchange of health information in a safe and secure way,"

says H. Stephen Lieber, CEO of the Healthcare Information and Management Systems Society, whose members include professionals in healthinformation



The stimulus funds include about $700 million for states to help create information exchanges that would link multiple providers in a state or

region. At present there are essentially two kinds of exchanges—though the terminology is fluid and some arrangements overlap, making it

difficult to precisely quantify the extent of record sharing.


Regional Successes


So-called regional health-information organizations, known as RHIOs, typically are overseen by a state or local nonprofit organization that

coordinates the exchange of information among competing providers in their area over a common network. The other kind of exchange is an

agreement directly between competing health providers to share data. This is often called an HIE, for health-information exchange, though that

term is sometimes used more broadly.


The eHealth Initiative, a nonprofit group that promotes health IT, counts at least 193 active initiatives of all kinds to exchange information in the

U.S., but not all are off the ground; 57 reported they were operational last year, a 36% increase from 42 in 2008. However, a study published in

the journal Health Affairs last year found that most RHIOs were focused on exchanging test results alone, and only 41% reported receiving

sufficient revenue from participating providers to cover operating costs. The study concluded that RHIOs' "scope remains limited and their

viability uncertain."


To be sure, some RHIOs have been successful. HealthBridge, started in 1997 in the greater Cincinnati-northern Kentucky area, includes 24

hospitals and close to 5,000 doctors' offices. They share lab tests, radiology reports and other results over a secure electronic network that

enables different information systems to communicate with each other.


Patients aren't the only ones to benefit: The system saves its members an estimated $20 million annually just in staff, fax and postage costs for

records transfers, says HealthBridge's policy director, Trudi Matthews. And HealthBridge is extending its reach, working with three other

regional exchanges in Ohio and Indiana to connect their systems, so if a baby goes to a hospital in Indianapolis, a pediatrician in Cincinnati can

access the test results and radiology notes.


Direct exchanges of data between competing providers also remain rare, according to a recent study by research firm KLAS Enterprises LLC.

Jason Hess, the study's author, says the number is low in part due to technological barriers from incompatible records systems. And several

other issues have yet to be fully resolved, including privacy and cost concerns. "If I am a hospital exchanging information with a competing

hospital down the street," Mr. Hess says, "at what point am I not responsible for what happens to that information?"


It also isn't always clear who would pay for what in an information-sharing system, or whether doctors would be willing to accept images and

tests from another hospital. Some doctors might distrust a CT scan, for instance, from another hospital system and be hesitant to base their

prognosis on it. And hospitals make money from doing their own tests and procedures, another disincentive to share information.


National Ambitions


The ultimate goal is to move beyond regional efforts and create a national health-information network, says David Lansky, chief executive of the

Pacific Business Group on Health, a coalition of large health-care purchasers, and a member of a national advisory committee on healthinformation

technology. Such a network will need a set of "policies, standards and services that allow the Internet to be used for meaningful

exchange to improve health and health care," Dr. Lansky says. "And that is about trust—coming up with rules and agreements that give us the

trust to share information with each other."


The Denver-area providers say trust is largely what helped them agree on their health-information exchange. And they had another big

advantage: All three partners happened to have medical-record systems purchased from the same vendor, Epic Systems Corp. of Verona, Wis.

There also were personal relationships to draw on; both hospital partners admit many children who are patients of Kaiser pediatricians, for



Executives at Children's Hospital and Exempla say the main hurdles in the deal were administrative and legal, such as developing procedures for

obtaining legal consent from patients to transfer their records electronically when they register at a hospital or clinic, and ensuring proper

identification of patients, like those with similar names.


Though the electronic medical records were already in place, the partners had to make some new investments. Children's Hospital spent close to

$50,000 to make the transition and invested about 1,000 hours of labor; Exempla spent $200,000 on equipment and labor costs for the project.


"We never batted an eye at the investment," says Exempla's senior vice president and chief information officer, David Pecoraro. "The impetus was to provide safer and better care."


Ms. Landro is an assistant managing editor for The Wall Street Journal and writes the paper's Informed Patient column. She can be reached at



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