7 Lessons From the U.K.

Charles Schade, chief science officer at the West Virginia Medical Institute, explains what the United States can learn from the United Kingdom's switch to electronic health records.

In the late 1980s, family physicians in the United Kingdom began using computers to store information about their patients. At first, only a few pioneers built registers for tracking preventive care, to identify women who needed cancer screenings and children whose shots weren't up to date. Later, these physicians realized that the registers could incorporate nearly all the relevant information about a patient's medical care, including diagnoses, treatment and supporting data.

The U.K. Department of Health data shows that by 2002 electronic health records were used by 9,500 general practice offices -- 98 percent of nationwide offices. Today, all members of the care team in every practice have access to the EHRs. The data is never lost, and new information is rapidly incorporated. Quality of care improved rapidly from 1998 to 2007, e.g. from 57 to 84 percent for coronary heart disease and 62 to 84 percent for diabetes.

The United States leads the world in technological innovation, touting the "best medical care in the world." Yet, in many doctors' offices, care is compromised because critical information is not available when needed or not organized for easy interpretation. Consequently, Americans seeing their doctors may repeatedly hear questions they've already answered, undergo unneeded tests, receive inappropriate drugs or miss out on life-saving preventive care.

According to the National Center for Health Statistics, only one in three U.S. family physicians use EHRs. Far fewer use them effectively. Since accurate information is essential to providing high-quality medical care, it is not surprising that a study by the Rand Corporation in 2003 showed that American doctors' care met quality expectations only about half the time. The Agency for Health Care Research and Quality argues that the quality of U.S. medical care has improved by a mere 1.5 percent per year recently.

How did physicians in the United Kingdom manage to get so far ahead in adopting EHRs? Four key factors are at work: physician involvement, centralized care, fewer financial barriers and reduced risk. And in total, these factors offer seven lessons that physicians in the United States can learn from those in the United Kingdom.

The U.K'.s EHR system first addressed the needs of doctors and their patients, not those of government or insurance companies.

Lesson 1: Doctors took the lead in developing and advocating EHR use. As a result, the individual office systems met their actual needs -- a "bottom-up" approach. The British government did not mandate EHR use, and the National Health Service was not uniformly supportive of early work. So physician pioneers used computers to solve simple but important problems first, such as identifying women who needed cancer screenings. They incrementally expanded into practice-wide record systems.

One less successful component of the U.K.'s e-health system has been its national network, which began in 2004 with an ambitious plan to centralize most health records. This "top down" approach, which disregarded the needs of doctors already committed to office EHR systems, may have contributed to its difficulties. We can avoid this pitfall if we stick to our current strategy of building local and regional data exchanges under national standards, as proposed in the American Recovery and Reinvestment Act.

One primary-care team delivers ongoing care to most patients.

Lesson 2: Each individual has a family doctor for primary care. That doctor’s practice is responsible for providing routine preventive and sick care, answering after-hours calls from patients, and arranging referrals for specialty care. Physicians are expected to see patients with urgent needs the same day they call. Patients have a choice of physicians and specialists, but they may not jump from physician to physician on whim.

In our country, people get medical care from their primary doctors, separate specialists, and emergency or urgent care facilities. While such care may sometimes be convenient, it is rarely efficient, with frequent duplication of services and gaps in essential care. But there is a move toward patient centered medical home, a new concept where care is handled comprehensively across a range of agencies, including hospitals, home health care, nursing homes, etc. and the patient's family or other personal network. Managing this care happens via registries, information technology, health information exchanges and other modern means of communication. EHRs are a key requirement of medical home practices.

Widespread adoption of medical homes may require changes in the way we pay doctors, as under fee-for-service there is no direct way of compensating doctors for the extra expense of managing care. In the U.K., family doctors receive a set amount per person for providing comprehensive care.

Instead of financial barriers, U.K. physicians see rewards from EHR adoption.

Lesson 3: Incentives for EHR use are built into the medical system in the U.K. The payment for quality that British family doctors receive depends on their reporting hundreds of detailed measures. Physicians in the U.K. realized that there was no feasible way of earning the extra income without computerizing their practices. To date, American physicians have received little incentive for installing EHRs, and pay for performance programs has varied. Medicare’s Physicians Quality Reporting Initiative is a tentative step in the right direction. Increasing the number of measures that all practices report, paying for quality as well as for data submission, and making the payout predictable will further encourage doctors to conclude that using EHRs will provide stable financial returns.

Lesson 4: The government buys the system. EHR systems may cost tens of thousands of dollars per physician for hardware, software and implementation. The U.K.'s National Health Service offers direct financial support to practices that purchase approved EHR systems. In the United States, physicians have largely been left on their own to find financing for system acquisition. As a result, larger medical groups with financial resources have been better able to afford information technology. Surveys have shown EHR adoption rates increase with the number of doctors in a practice. Insurance companies, state governments and hospitals have offered targeted assistance, helping some physicians to computerize their offices. The ARRA's revolving loan funds, coupled with payment incentives for EHR use, could solve this problem.

The risk of adopting new technology is minimized.

Lesson 5: The choice of EHR systems is restricted to a few known-reliable alternatives. In the U.K., there are six EHR vendors. The limited range of choice reduces risk, because all the systems are known to work and have active user communities. Thus, physicians can learn from their peers about which options would be useful. We have hundreds of EHR vendors in the United States, some of which are major companies, while others are “mom and pop” operations. Physicians face bewildering choices, with access to limited information about many of these vendors. Looming market consolidation means that doctors must worry about "buying the Betamax."

Lesson 6: The standards for EHR systems in the U.K. facilitate the reporting and exchange of information. The National Health Service mandates standards for EHR communication and internal data terminology. In the U.S., we have a number of standards, but certification is not yet mandatory. The national standards committee created under the ARRA has the potential to push us in the right direction, but only if we can overcome our aversion to mandates. Considering that we would not have a telephone or radio communication system without mandatory standards, such a development is long overdue.

Lesson 7: Physician practices have access to readily available, free support in the effective use of EHRs. In the U.K., the National Health Service has supported physician office computing with training and consultation for a number of years. Two publicly funded efforts, the Primary Care Data Quality project and Primary Care Information Services, have helped doctors and their office staffs get the most out EHR investments. The ARRA promises something similar in the United States, with the establishment of regional Health Information Technology Extension Centers. If the British experience is a guide, we will need these HIT centers indefinitely.

How do we know that replicating the conditions that spawned EHR use in the U.K. will produce the same results here?  Actually, it already has. About the same time as the U.K.'s cyber revolution was taking place, doctors and researchers within the Veterans Health Administration were experimenting with an open-source, locally customized EHR system. The VISTA EHR was deployed throughout the VHA in the late 1990s. Now nearly every encounter between physician and patient at the VHA is captured electronically. 

Meanwhile, VHA leadership focused attention on primary care and instituted a pay for quality program using information from these records to support continuous improvement. Incentives, support, doctor involvement and limited choice of systems -- the VHA met almost all the above criteria. The results? VHA outpatient care exceeds the measured quality of nearly all private health plans in the United States. With modern HIT systems and effective leadership, there is nothing to prevent the rest of our country's medical system from catching up.

Charles Schade is a medical epidemiologist and chief science officer at the West Virginia Medical Institute. Dr. Schade provides medical and epidemiologic support for the design, analysis and dissemination of results of the Institute's work. He also designs quality studies and data-collection procedures, guides data collection and analysis, and helps interpret findings for staff, health professionals and customers.