HIT Lessons from Across the Pond

I often hear how other countries are ahead of the United States when it comes to using electronic health records and exchanging electronic health information. For example, Don E. Detmer, MD, president and CEO of the American Medical Informatics Association, referred to Scandinavia, the Netherlands, Denmark, the United Kingdom, Canada, and Japan as countries that are ahead of us in this arena at a recent Nashville Health Care Council meeting. "We can learn a lot from these experiments," he said, acknowledging that no one has it totally figured out yet. "It is a tapestry that has different bright spots."

That is why I found a recent report, Accomplishing EHR/HIE (eHealth): Lessons from Europe," by CSC, a global consultancy firm, so interesting. It focuses on those "bright spots" and pulls 25 lessons learned from initiatives in Denmark, the Netherlands, and the United Kingdom.

Granted there are key differences between these countries' efforts and the United States. The size of the European efforts is far smaller, for one. However, the initiatives are comparable and have encountered many of the same obstacles and issues. "The UK is 60 million people," says Fran Turisco, a coauthor of the report and research principal, emerging practices for CSC. While smaller than the US, "it is not eeny meeny," she says. Many of these countries also had a different starting place. In Denmark, The Netherlands, and Norway, EHR adoption by general practitioners is approaching 100%, compared to 20%, at most, in the United States, the report says. The U.S. effort is still focused on changing workflows and switching from paper to digital records in addition to exchanging data and becoming interoperable.

Turisco says that one of the most surprising results was that no one did any of these studies before, other than collecting anecdotal information such as the wait time for physician appointments. "We are spending billions of dollars easily, but there wasn't anything built into these initiatives to say, 'This is how we'll know we got value for our money,'" she says, adding that the UK is now going back and studying benefits. The U.S. is doing a better job on that front, she says, because the "meaningful use" matrix is tying elements like data capture, patient safety and quality reporting, and outcomes measurement to the technology.

The report offers lessons learned and best practices in six key areas: planning and sustaining the initiative; major issue management; governance and communication; technology and interoperability; and implementation. It also offers a comparison of the United States efforts at the end of each section that includes a HITECH update. Here are some of the best practices shared:

• eHealth initiatives should be supported by technology not led by it. The UK's program was called the National Program for Information Technology and led by a CIO at each hospital. That was the wrong approach, says Turisco. "There was a lot of backlash," she says, noting that in other countries it went more smoothly because it started as part of healthcare reform. "They are going through a whole rebranding effort to say, 'You misunderstood. This is healthcare reform in the UK and technology is needed to support healthcare reform,'" Turisco says.
• Those who gain value from HIEs need to be willing to pay for it. The report found that payers and patients are the beneficiaries of the improvements made by eHealth such as reduced length of stay, duplicative tests, and medication errors, yet the hospitals and physicians are the ones paying for it and supporting the clinical applications. U.S. providers should have a good business reason to join HIEs, says Turisco. For large-scale eHealth initiatives to be sustainable, financial balance is key. Everyone should "belly up to the bar and put some money into it," she says.

  Funding was not as much of an issue in Europe because the eHealth efforts were supported by a government-funded (Denmark and the UK) or private (The Netherlands) healthcare system. However, they all considered government funding as a crucial element to building the infrastructure, central services, core clinical systems, and providing ongoing financial support, the report says.
• Data sharing—automatically include patients and offer them the ability to opt out or opt in with restrictions. The report has a nice graph that summarizes the authorized access practices set up in the UK, Denmark, and The Netherlands. For example, patients in Denmark can access data via a user sign-on and password. But the UK and the Netherlands also require patients to have a smart card to access the system. They all had full auditing capabilities, so patients can see who looked at information, when, and for what reason, explains Turisco.

  The best way to get patient consent was to automatically enroll them with plenty of advance notice so that they can opt out of data sharing or opt in with restrictions, says Turisco. "Otherwise it will take forever to get adoption," she says, noting that the UK had less than 1% of people opt out. The Netherlands did not address informed consent until much of the system was built and was ready to be rolled out. They chose to send everyone a letter asking for permission. They received 300,000 letters that had incomplete or inaccurate information—all of which needed follow up, which resulted in a lengthy delay.

• Factor in a lot of time for communication and education. If you are going from paper to EHRs, it is worth taking the time to understand what processes will change and how that will impact physicians, nurses, and ancillary providers, says Turisco. There wasn't a lot of communication with the public about what was happening in the UK, so CSC ended up spending a lot more time than they had planned in terms of education, allaying fears, and getting people involved in the design, configuration, and testing of the system, she explains.

The United States is doing all the right things, says Turisco. But now it comes down to the tough part—getting the work done. "We are putting the right committees in place, funding, and incentives, but now we have to say here are standards and certification requirements," Turisco says.