Thirty minutes. That's about how long it took me to find the record of a patient's kidney biopsy, completed at another hospital, in their electronic health record (EHR).
How did I find it? Short answer: I used [Ctrl] + F.
Long answer: I clicked through dozens of healthcare notes, searching through the "notes" and "diagnostics" tabs to no avail. I almost gave up, but I decided to give it one last try by once again searching "biopsy" across the whole EHR. Finally, I found the relevant hospital admission note, where "biopsy" was mentioned 100 times; the 90th result gave me my answer. I also saw a lot of the same, expensive workup for this patient, which had been redone at this current hospital for the present admission.
Thankfully, as a medical student, I had time to delve deeply into the records. But what about a busy resident who has to take care of 15 patients? If the records of this biopsy were critical to this patient's management, and we couldn't find them, would this patient have needed to go through another biopsy? How many times have lab tests and imaging been re-ordered because the provider didn't know, couldn't find, or couldn't access the results of previous hospital admissions?
Unfortunately, EHRs are not standardized between different hospitals, meaning if your patient goes to one hospital, all of their records stay there and cannot be accessed at other healthcare facilities unless providers request them, which can be a time-consuming process. It also means a lot of repetitive work of asking the same questions to get your patient's medical history from scratch -- medications, habits, family history, and so on.
This is not to say that providers should not be re-asking these questions upon each visit. In fact, it is necessary to ensure the patient's medical record is up to date and accurate. However, it's much easier to have the information available in case the patient is not able to answer questions, and to strengthen the foundation rather than constantly rebuild it, per se.
In 2011, CMS established the Medicare and Medicaid EHR Incentive Programs. CMS's goal was to get as many hospitals and medical groups as possible to adopt EHR technology by offering financial rewards. As of today, more than have entered the market to meet the increased demand, each offering different products tailored to various healthcare settings. Unfortunately, at the time the program was established, there was no incentive for EHRs to facilitate the easy transfer of data from one healthcare system to another.
This has left the U.S. with fragmented healthcare systems that do not talk to each other. Such only came . But it was too little, too late. By this time, many provider groups could not justify the costs associated with facilitating health information exchange (HIE) with other health systems.
Fortunately, this -- as of 2021, more than 6 in 10 hospitals engaged in all four key aspects of HIE (sending, receiving, querying, and integrating summary of care records into EHRs). Yet, there are disparities in who is participating: only about 50% of rural and small hospitals and participate in all four domains. So although more facilities are moving in this direction, gaps remain.
Among physicians who use HIE, electronically exchanging information with providers using a different EHR developer. Historically, there have been many barriers to interoperability, including health systems themselves. In a , 49% of respondents said that EHR vendors often released products with limited interoperability. Around 47% said EHR vendors often had high fees for health information exchange unrelated to cost, and 22% of respondents said hospitals routinely control patient flow by selectively sharing patient health information.
Theoretically, by withholding patient information and having exclusive access to their patients' data, health systems can maximize their profits and enhance their market dominance. Efforts to curb such information blocking have only recently begun to take effect, with heath systems subject to government regulations since April 2021.
Interoperability could generate significant cost savings, with potential savings of once fully implemented. that HIE was associated with faster outside information access (58.5 minutes on average), and faster access was associated with changes in emergency department (ED) care. For each 1-hour reduction in access time, visit length was about 52 minutes shorter, the likelihood of imaging and admission to the hospital was lower, and average charges were $1,187 lower. This study also estimated that, for the 437 patients for whom HIE was used, timely access to outside information saved 385 hours of patient time in the ED. This means patients would not have to stay as long in the ED, and more time could be devoted to very sick patients.
Physicians overwhelmingly report benefits from interoperability. who engaged in HIE experienced improvements in quality of care, efficiency, and patient safety. Furthermore, 8 out of 10 physicians who use HIE reported that it leads to reduced duplicate test ordering.
exemplify successful interoperability. Whether you go to your primary care doctor, a specialist, or the ED, those affiliated with Kaiser all share the same EHR. This promotes longitudinal, coordinated care. It would be easier for outpatient doctors to understand what happened to a patient at the hospital and reconcile medications.
To be sure, we have come a long way from the days when we needed a patient to sign a release, call medical records at the other institution, and fax the release. But there are many other inefficiencies with EHRs that remain cumbersome and overload clinicians with excessive data and administrative tasks. Interoperability is only part of the problem.
It would be very expensive to do a massive overhaul of the current system, and certainly not a job for the government alone to handle (their current EHR for veterans was invented in the 1990s, without significant changes for over 25 years, ). A cloud-based EHR system could offer nationwide accessibility using a universal patient identifier. Advancements in AI could streamline data retrieval in EHRs.
I have high hopes that if we have AI that can scour the entire internet and give a concise summary of its findings, then we have the know-how to create technology that will allow the seamless integration of health information wherever we may go.
Amy Thein is a third-year medical student in the MD/MPH program at the University of Miami.