What took EHR so long?

Recently, I came across a question on Quora- “Would growth in EMR/EHR adoption continue if Meaningful Use stopped?” You can read my short answer to this question there, but I thought that it deserved a more in-depth analysis.

The question of whether EHR implementations would cease if Meaningful Use incentives stopped is a great starting point, but it has limitations. It’s speculative- What if I could fly? What if we changed the national currency to oak leaves? There are answers to these questions, but since it’s something that hasn’t happened yet, any answer would be an opinion based on current objective conditions. The more interesting question this leads to, I believe, is why has it taken so long for the US to adopt electronic health records? For this question, I will delve into the history of electronic records in the U.S. and abroad, and search for a more solid understanding of the current state of the healthcare industry.

For comparison, I first looked into the history of computerized banking records. There are many similarities in terms of the type and volume of data involved, so I thought it would be a useful starting point. In my search, I began to see some similarities in the types of problems the banking industry faced:

“The problem posed by the bank for solution by machine included all accounting that normally attends many thousand commercial checking accounts of a bank. Such a machine must be able to keep record of deposits and withdrawals for each client, make current-balance information available at an instant’s notice, watch for overdrafts, stop payments, and held funds. It must be able to provide, on a strict schedule, periodic statements of the account along with the accumulated checks. The machine must not only handle all necessary arithmetic but also handle the paper documents in whatever physical condition they exist after passage through many hands. All machine operations must, furthermore, be as exact as banking accounting calls for and be in constant step with hourly, daily, and monthly routines of the banking system.” via SRI International

Console of General Electric's commercial ERMA.

Many of these types of problems are what current EHR systems are being designed to solve. However, the banking industry commissioned this system to be designed in 1956. This was a time when the transition from vacuum tubes to transistors was still going on! They designed a system capable of solving all these problems, including character recognition and processing vast amounts of data very rapidly. So, it’s safe to say that what held back the implementation of EHRs in the U.S. was not a lack of technology capable of handling the information.

The U.S. is obviously not the only country to tackle the problem of nationwide EHR implementation. In “Electronic Health Records for Dummies“, 4 countries are recognized as being leaders in EHR adoption. These are the UK, the Netherlands, Australia, and New Zealand. Here are some common criteria these countries had in their approach to EHR Implementation. There’s a lot of information out there about these points, so to simplify I’ll use one for each country. Also, for the sake of brevity, I’ll leave out the Netherlands.

Government Investment/Grants
New Zealand has been a leader in Health IT for decades, due largely in part to Government incentives and forward thinking planning. Some of their accomplishments are:

  • A national health index to identify patients, dating back to the early 1980s
  • A national cancer register, dating back to 1948
  • Almost 100 percent usage of computer systems by general practitioners.

(Source: NZ Health Information Standards Organization)

Interoperability Standards
From www.nehta.gov.au– In Australia, the National E-Health Transition Authority Limited (known as NEHTA) was established by the Australian, State and Territory governments to develop better ways of electronically collecting and securely exchanging health information. Some goals of the NEHTA include:

  • Establishing standard clinical terms for use by e-health systems, so that systems use consistent terms to describe the same disease, therapy, medicine etc;
  • Designing specifications for secure electronic health records, to enable authorised healthcare professionals to view the collated health history of an individual while maintaining high standards of privacy;

Public Investment in Health Services
From nhshelp.co.uk– “The post World War II labour government created the NHS as part of its sweeping welfare state reform policy. The general hypotheses was that England had just proven, during the war years, that it was capable of employing almost the entire workforce and spend large amounts of money on wartime endeavours, and that those same resources could be focused on the public good … The resulting healthcare system ensured that everyone, regardless of background or income, would have access to medical treatment, and be able to seek the advice and service of doctors as they needed. All of this was funded solely through taxation, the Labour Party in England still touts the NHS as its greatest ever achievement.”

In the US, Meaningful Use has jump-started the drive to EHR implementation by getting us up to speed on the first two criteria listed above. We do not have any any system in place for widespread health coverage, which may be one of the reasons why we are lagging in EHR adoption. Without MU, I believe the adoption of EHR would be significantly hindered. However, what the ONC initiatives have achieved already is the creation of a culture of change in healthcare.

Culture of Change

What Meaningful Use incentives have done in the US is highlight the need for structural change in how we approach healthcare. Physicians were reluctant to embrace a new system until they see the benefits to their workflow and patients. New articles come out every day highlighting the benefits of EHR. There is an explosion in EHR software development, with over 300 vendors producing Health IT solutions. Once the MU incentive period ends, I believe we will see which solutions have real staying power. I also think that ONC initiatives designed to inform the public about EHR benefits will become increasingly important, as it will influence more physicians to embrace EHR adoption.

Creating an EHR Culture of Change


What took EHRs so long in US? I believe it was the lack of government incentives, the failure to embrace industry wide data standards, and the inability of the US to ensure healthcare coverage to its citizens. I initially stated that I thought EHR would continue if MU incentives halted, but now I’m not so sure. Are there any countries that have widespread EHR adoption on the scale that’s necessary that don’t meet any of the criteria listed above? Not that I’m aware of. The question would become whether the incentives already implemented by the ONC would be enough to sustain the momentum in the industry. However, that’s another speculative question. Luckily, there doesn’t appear to be any threat to MU right now, so we are on track to create a truly innovative health IT system that can enhance patient’s experience while cutting down on frustrating administrative tasks for physicians and medical staff. Keep it up!

[Special thanks to Erica Olenski @TheGr8chalupa for posing this question and Keith Boone @motorcycle_guy for pointing me in the right direction when I was researching it.]


About nateosit

I'm documenting my journey through the Health IT landscape, seeking to combine the disparate complexities of HIT to create Bio-Digital Jazz. My opinions are my own.
This entry was posted in Health IT, Technology and tagged , , , , , . Bookmark the permalink.

3 Responses to What took EHR so long?

  1. Nice post, and I agree with most of your conclusions.

    I do have to argue with one point on the availability of the necessary technology for EHRs. The comparison of EHR to banking is faulty. You’ve summarized pretty well the main set of transactions that are needed for a financial transaction, but healthcare is quite a bit more complex.

    Not too long ago, my daughter had to go to the hospital (she’s fine). I received four separate bills for that event. Yet, when I obtain service for my oil heater, I got one bill, even though it was attended to by 4 separate contractors (plumber, electrician, heater guy, and transport).

    A couple of years back I was referred to a specialist. That process took me from primary care, to the specialist, to an outpatient diagnostic facility, and back. Again, umpteen separate bills.

    The number of bills illustrates the complexity involved in the care. Each bill represents a separate organization that needs to be communicated with. And each provider needs to communicate hundreds of separate data items from one to the next (count them some day). The challenge in EHR today is that those 100 separate data items are called different things, use different standards, et cetera. The financial industry should be happy. They only need deal with debits and credits, checks and deposits, interest and penalties, et cetera. A typical healthcare transaction starts with a complaint or symptom, progresses to findings or test orders to obtain findings, to diagnosis, treatment, and follow-up care. It’s rarely ever a matter of a single transaction between two parties.

  2. nateosit says:

    Thanks for commenting, Keith!

    I think my point was not necessarily that the technology for EHR was available to address the specific complexities of the healthcare industry in the 50’s. Rather, that the banking industry is an example of what could have developed if the economic conditions were right for Health IT. You’re right in pointing out that there are significant limitations in my comparison. I’ve definitely experienced much of the complexity involved in healthcare transactions… Part of my job is to track down clinical documentation for our coding staff, which can be quite a frustrating endeavor. Hopefully EHR will make my position obsolete!

  3. Pingback: Getting Personal with Personal Health Records | WEGO Health Blog

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