Current EHR Developments: an Australian and International Perspective - Part 1

• Abstract
• What is an Electronic Health Record (EHR)?
• The Evolution of the EHR and EHR Systems
• Australian EHR Initiatives
• International EHR initiatives

Abstract
The idea of electronic health records (EHRs) began at least 40 years ago but the first implementations did not really begin until the 1980s and, with the exception of a few countries in Europe, the use of EHRs is still very low in most countries. This is beginning to change rapidly, however, and the emergence of purpose-built shared-EHR systems to underpin multi-disciplinary integrated shared care in a number of countries is adding a whole new dimension to the field. Australia is in the early stages of developing its national "HealthConnect" shared-EHR network and similar projects are also underway in several other countries such as Brazil, Canada and England. The US does not have any national EHR projects as yet but there is a groundswell of interest and initiatives in relation to the EHR in the US which could foreshadow rapid progress there in the next few years.

Lack of interoperability between EHR systems has been a major barrier to EHR deployment but the emergence of the openEHR model, the HL7 Clinical Document Architecture and archetypes has provided a significant stimulus to the development of interoperability and other necessary EHR standards within major international standards organisations such as ISO, CEN and HL7. There is a long way to go but there are encouraging signs that stakeholders are beginning to recognise that the very future of health systems depends on more efficient and effective information management. The EHR is arguably the most important foundation component in this pursuit.

What is an Electronic Health Record (EHR)?
The need to ask this question may seem superfluous to many "health-IT (information technology) literate" readers of this paper. However, my experience in this field over a long period has shown that the EHR means many different things to different people.

The concept of the EHR was (and still is) often described by other terms such as Electronic Medical Record (EMR), Electronic Patient Record (EPR) and Computerised Patient Record (CPR). These and many other variant terms reflect different shades of meaning depending on the defining source country, health sector and professional discipline. There have been few formal definitions of these terms until quite recently but the definitions which do exist display more similarities than differences with respect to the purpose, functions and goals of electronic records.

The International Standards Organisation (ISO) began a project in 2002 to develop an internationally agreed definition of the EHR. This project is now nearing completion and will be published in the form of an ISO Technical Report.^{[ 1 ]} Previous attempts to develop a widely agreed definition of the EHR have been unsuccessful due to the difficulty of encapsulating the many and varied facets of the EHR into a single comprehensive definition. After much early debate about how to approach this problem, it was agreed to have two formal EHR definitions and to illustrate the inclusiveness of these definitions through additional explanatory text and examples. These definitions make a clear distinction between the content and the structure of an EHR.

The simplest ISO definition of an EHR, termed the "basic-generic EHR", is defined in terms of its structure as "a repository of information regarding the health of a subject of care, in computer processable form". This definition is intentionally broad and encompasses most of the EHR variants in current usage. "It makes no assumptions about the health system of any country or region. It also makes no assumptions about the type or granularity of information in the record. More specifically, the definition is broadly applicable to all health sectors, professional health disciplines and methods of health delivery".^{[ 1 ]}

From a standards’ viewpoint, the basic-generic EHR is of little interest since it does not support any degree of interoperability. The ability to share and exchange EHR information between authorised clinicians, both within and between health care organisations, is of fundamental importance to the delivery of safe and high quality health care in modern, complex, multi-disciplinary health systems.

Accordingly, the second and principle ISO definition of the EHR is termed the "Integrated Care EHR" (ICEHR). It is a specialisation of the basic-generic EHR and focuses on the content, privacy, security and shareability of the EHR to support ongoing, holistic, integrated health care to individual patients/consumers. The ICEHR is defined as "a repository of information regarding the health of a subject of care in computer processable form, stored and transmitted securely, and accessible by multiple authorised users. It has a commonly agreed logical information model which is independent of EHR systems. Its primary purpose is the support of continuing, efficient and quality integrated health care and it contains information which is retrospective, concurrent and prospective."^{[ 1 ]}

The ISO’s draft Technical Report includes sections on the scope and context of the EHR as well as many definitions of concepts related to the EHR and of EHR variants such as Clinical Data Repositories. There is also discussion on EHR systems and the importance of making a clear distinction between EHR systems and the EHR per se, which must be completely independent of the system if patient information is to be shared and exchanged in a meaningful way. An EHR system is defined as "a system for recording, retrieving, and manipulating information in electronic health records", or more broadly as "the set of components that form the mechanism by which electronic health records are created, used, stored, and retrieved. It includes people, data, rules and procedures, processing and storage devices, and communication and support facilities".^{[ 1 ]}

The Evolution of the EHR and EHR Systems
The literature on EHRs goes back to at least the 1960s but there were very few EHR systems installed anywhere in the world until the 1980s. There were a few early pioneering EHR systems in the US in prestigious institutions such as the LDS Hospital, the Regenstrief Institute, Duke University and the Harvard Hospitals but early EHR systems were adopted far more quickly and widely in Europe than in North America during the 1980s. This disparity continues today, which is perhaps surprising given the pre-eminence of the US in nearly all areas of ICT (information and communication technology). The explanation probably lies in the nature of the US health system, which is largely privately funded and is even more fragmented than the health systems of most other countries.

Paradoxically, the US was a pioneer in advocating widespread adoption of CPRs/EHRs and the 1991 publication of "The Computer-Based Patient Record: An Essential Technology for Health Care"^{[ 2 ]} by the US Institute of Medicine was a landmark in the history of the EHR. The next major documentary landmark was the publication of "Information for Health"^{[ 3 ]} by the NHS in England in 1998. This was the first comprehensive national strategy and action plan for computerised health information management, including the EHR, and was followed soon after by similar reports in Canada and Australia.

The Scandinavian countries have been the most successful in adopting computerised clinical information systems in general and EHR systems in particular. The use of EHRs in primary care is generally much higher than in hospitals and approaches 100 per cent for general practitioners (GPs) in Norway, Denmark and Sweden. The Netherlands, Belgium and the UK were also early adopters of EHR systems in general practice but they have never reached the penetration or sophistication of the Scandinavians. In other parts of the world, New Zealand was an early adopter of clinical information systems, including EHRs, in General Practice and Australia has had a small but influential group of GPs who have had paperless practices since the late 1980s using an adapted version of a Norwegian EHR system. However, despite the now high usage of primary care clinical computing in many countries, the usage of EHRs beyond the most rudimentary form remains very low except in Scandinavia and even there, the ability to share and exchange EHRs (ie, interoperability) between different health care providers and organisations is almost non-existent.

In the acute care sector (ie, hospitals), the use of computerised clinical information systems is now quite common but the range of applications is generally limited to a few departmental systems which may be partially integrated using interface engines and clinical data repositories. Pathology and radiology results reporting are now common in most large hospitals in developed countries. Computerised order entry is becoming more common although it is still available in only about five per cent of hospitals in the US. "True" EHR systems are still a rarity in hospitals in most countries. Systems based on clinical data repositories enable a limited derived form of EHR which fits the ISO basic generic EHR definition but certainly not an Integrated Care EHR.

Australian EHR Initiatives
The increasing trend to multi-speciality, multi-disciplinary integrated patient care during the 1990s led to a need to share patient health information held in electronic form (ie, components of the patient’s EHR) both within and between different health care organisations - most notably, between hospitals and GPs. Some of this information, such as pathology, radiology and pharmacy orders and results, is well suited to the messaging paradigm and New Zealand has been a pioneer in the use of HL7 messaging for this purpose. However, direct sharing and exchange of parts of the EHR (called EHR extracts) are more efficient for most EHR information when interoperable standards-based EHR systems are in place. This led to the idea of developing purpose-built Shared-EHR systems which would support the Integrated Care EHR described above. Australia was the first country to publish a strategy for a national Shared-EHR system with the HINA report published in 2000,^{[ 4 ]} although Brazil was probably the first country to start actually building such a system with its National Health Card Project (NHCP).^{[ 5 ]}

The project which has evolved from the recommendations of the HINA report is called HealthConnect. It commenced in 2001 and is a joint initiative by the Australian Federal, State and Territory governments. The HINA report recommended a national distributed network topology of regional and state Shared-EHR nodes based on a common EHR architecture. It envisaged a 10-year time span for the project with the first two years being for research and development, followed by a three-year phase for building and initial implementation of the system, then a further five-year roll-out phase.

The R&D phase has extended from two to four years due to delays in establishing the initial clinical trials. Two fast-track trials were undertaken in Tasmania and the Northern Territory over an 18-month period beginning in September 2001 and more in-depth trials are now underway or being developed in Queensland and New South Wales. Despite the initial delays, a decision was recently announced by the Federal Health Minister to begin implementation of HealthConnect in Tasmania and South Australia in the second half of 2004, with other States to follow later.

HealthConnect will not replace existing point-of-care EHR and other clinical systems but will involve the systematic collection of clinical and demographic data from these source systems in the form of "event summaries" transmitted to HealthConnect nodes via HL7 messages and EHR extracts. HealthConnect will have national governance structures with representatives from both the public and private sectors and all main stakeholders including consumers. The system will be opt-in for both consumers and providers. An important principle is that the system will be consent driven and consumers will control access to their Shared-EHR information. Consumers will also have default access to their own EHR with limitations only in exceptional circumstances. Access to the system will be via secure internet connection.

A second national EHR initiative which actually preceded HealthConnect in its planning and early trials is called MediConnect. This project aims to implement the medication management component of the EHR and involves prescribers (mainly GPs), dispensers (community pharmacists) and consumers. Its genesis was quite separate from HealthConnect and until recently there was little interaction or compatibility between the two projects. This was clearly undesirable and the two projects are now being integrated under common governance and technical structures.

A third large and important EHR initiative in Australia is the NSW statewide EHR*Net project. It was conceived independently of HealthConnect and, like that project, is designed to be a purpose-built Shared-EHR system which will derive its information from existing point-of-care systems in hospitals, General Practice and community allied health organisations. The first trials of EHR*Net will involve chronic disease management in the regional setting of the Hunter Valley north of Sydney and the Child Health Information Network centred at the Children’s Hospital in Western Sydney. These trials will also constitute the NSW HealthConnect trials and the architecture and overall design of EHR*Net is being closely harmonised with HealthConnect. EHR*Net will in fact be the NSW state node of the national HealthConnect network.

International EHR initiatives
As already mentioned, Brazil was the first country to undertake a national Shared-EHR initiative, the NHCP. This project began in 1999 and a clinical pilot began in 2001. This could well be the largest health care pilot project ever, involving 44 cities in 11 States, 8 million consumer ID health cards, 3,200 point-of-care sites and 50,000 professional ID cards. The architecture of the NHCP is quite similar to HealthConnect with a health card being used mainly as an identity token, although it does contain a limited set of clinical information as well. The pilot project is currently being evaluated prior to commencement of the second phase which is expected to involve more than 500 cities and around 100 million (60 per cent of the population). Fourteen million health cards have already been distributed and 94 million people have been registered for the national unique health identifier.

Canada is another early pioneer of national Shared-EHR systems with its Canada Health Infoway project. This project also has similar objectives to HealthConnect and involves cooperation between the Canadian Federal and Provincial governments. The initial project blueprint was published in July 2003^{[ 6 ]} and early trials are now being designed and implemented. Since the Canadian health system is largely devolved to the provinces, the Infoway architecture must be very flexible to accommodate provincial health system differences whilst at the same time ensuring interoperability between the individual provincial Infoway nodes. In contrast, the English NHS is undertaking a national EHR project which, whilst divided into regional implementations, is nevertheless under strong central NHS control. This, of course, reflects the centralised nature of the UK health system. Some have described this project as the "big-bang" approach and the huge budget of £2.3 billion is probably the largest/most expensive ICT project ever undertaken in health. Hong Kong also has a national EHR project but this is limited to its public hospitals and should be much easier to achieve due to the relatively small population and number of hospitals. Denmark is another small country with a national EHR agenda and it is likely that this will be an impressive project given the EHR experience which already exists there.

The US currently has no plans for a national EHR project but there are some interesting initiatives and trends which could give a rapid boost to EHR deployment in the US. A bill was introduced into Congress in 2003 to develop a national health information infrastructure and a Director was appointed soon after within US Federal Department of Health and Human Services (HHS) to oversee this project. In January 2004, the Federal Secretary for Health, Tommy Thompson, stated that the US could save US$100 billion a year through fewer deaths and disabilities by greater adoption of IT in the health industry. The following month, the Harvard-based US Center for IT Leadership released a study which estimates that the US could save an additional US$86 billion per year through standardised information exchange, resulting from reduced tests and improved efficiency of automated data sharing among health care organisations. President Bush even called for the implementation of Computerised Patient Records in his 2004 State-of-the-Union address, which is unprecedented.

The HHS initiated a project in 2003 to develop a standard EHR-System (EHR-S) functional specification. This very important standards project was outsourced to HL7 and a Draft Standard for Trial Use (DSTU) was recently completed and successfully balloted. The importance of the DSTU is that HHS has foreshadowed that users of EHR systems which comply with the standard will be given ongoing incentive payments. This is likely to lead to an upsurge in the availability of standards-compliant EHR systems in the US through a "user-pull" process. The EHR-S DSTU does not address the broader question of EHR content or interoperability but it is still a very good start. It could also have positive effects in many other countries since HL7 has balloted the DSTU as an international standard, allowing for realm-specific implementations. The strong presence of US vendors in many overseas markets may also lead to an increase in international uptake of standards-compliant EHR systems, particularly in the acute care sector.

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