EHR Around the World

Vol. 18 • Issue 24 • Page 18

The United States may be touted for its cutting edge technology, but when it comes to wide-scale adoption of HIT, funding issues and government hang-ups can dull enthusiasm. Last September, the Healthcare Information and Management Systems Society (HIMSS) Global Enterprise Task Force (GETF) released a study examining the state of EHR implementation in 15 countries, including the U.S. With the world on track to EHRs, is America leading the pack or dragging its caboose? ADVANCE checked in with industry experts to find out how the U.S. stacks up when it comes to not only building, but embracing HIT.

International Perspectives

While some countries have taken proactive steps to implement EHR, a fully electronic global environment is still a long way off. “Each [country] has a very different approach. There are also lots of opinions about how well they’re doing within their countries,” said Walter Wieners, HIMSS fellow and co-chair of GEFT.

Wieners said by observing progress around the world, health care leaders can gather new ideas and techniques to facilitate the development of EHRs. “There are lessons to be learned that are beneficial not just for the U.S. but for other countries as they look at one another’s programs and certain characteristics of those programs,” he explained.

Sandy Fuller, MA, RHIA, chief operating officer and executive vice president of the American Health Information Management Association (AHIMA), agreed that the world can benefit from taking a look at EHR adoption across the globe. Fuller has been working with leaders from the Canadian HIMA to develop more uniform standards for HIT and prepare for EHRs, and has also picked up advice to smooth America’s transition to ICD-10.

Fuller said despite having different approaches to health care, countries can benefit from coordinated efforts. “There’s still a lot to learn from somebody who’s been down the path before,” she explained. “Even if that path’s a little different, they’re still going to have come up against and overcome some obstacles.”

So amid talk of foundering EHRs, which countries are scaling barriers to get electronic systems up and running? Meet some of the leaders:

The Funders

In England, health care is nationalized, so the central government drives HIT implementation. England established the National Programme for IT in 2003, with the initial aim to spend £6 billion over 10 years, but recent estimates have gone as high as £20 billion, according to GETF contributors.

The National Health System (NHS) is currently working on an EHR initiative called the NHS Care Records Service (CRS), which will enable providers across the nation to access patient information electronically. The initiative also seeks to establish a portal where patients can view an electronic summary of their medical records, called a summary care record. Instead of storing records in isolated systems at individual facilities, patient data will be held in a central repository within the national infrastructure, aptly named “The Spine,” which also includes a portal and messaging hub for clinicians. According to the task force, general practitioners have already begun using the Spine, and adoption is expected to grow-albeit slowly-in the coming years.

Led by the central government, England’s national EHR initiative also encourages interoperability and common standards. Facilities and practitioners must use national applications and services to function within the Spine system. The “you’ll use this system” approach-as Fuller dubbed it-may reduce choice, but also avoids interoperability problems that arise when competing systems fail to link up. By footing costs, England’s NHS also offers practitioners an incentive to oblige.

The Enthusiasts

Responding to citizen demand for a safer, more efficient health system, Denmark is forging ahead in HIT adoption. The government has been promoting electronic communication since 1994, when it first formed MedCom, the national health care data and information network. Today, 100 percent of hospitals, pharmacies and emergency physicians and 92 percent of general practitioners use MedCom to securely exchange health data and communication, according to GETF. MedCom also controls the thriving Danish National Health Portal, a system that went live in 2003 and provides patients and providers direct access to health records and services. Patients can even decide which providers have right of access to their records.

In 2007, Denmark’s Ministry of Health made HIT a permanent policy focus by establishing the National EHR Organization, an independent group that works with both national and local authorities to coordinate and promote EHR implementation. As part of the new HIT initiative, Denmark is looking to adopt HL7 standards to enable global uniformity and interoperability. The National Panel for Standardization of Medical Informatics and the Danish Standardization Committee are working to coordinate IT solutions with international standards, so if a global EHR network comes around, Denmark will be ready to jump on board.

With several European countries launching EHRs, coordinated efforts to establish a European-wide network are already in the works. Launched in July, the European Patients Smart Open Services project plans to spend 3 years developing an electronic framework and infrastructure for secure access to patient summary records and e-prescribing across 12 countries. Twenty-seven beneficiaries, including the United Kingdom’s Department of Health and Denmark’s MedCom, are involved in the project.

The Planners

America’s northern neighbor is also paving the way for national EHR adoption through the coordination of provincial health systems. In 2001, the Canadian government established Canada Health Infoway Inc., an organization comprised of federal, provincial and territorial deputy ministers of health, to lead the national EHR effort. “Having the right balance of stakeholder participation and commitment to move forward [is essential],” Wieners said.

By involving several entities, Canada appears to be addressing that challenge.

More than $1 billion has already been funneled into Infoway projects, and total cost is

estimated at $10-12 billion CAN over 10 years, according to a report cited by the task force. But Canada expects to save an annual $6-7 million CAN, plus the benefits of improved patient care, once EHRs are fully implemented.

Recognizing the need for interoperability, Infoway created the EHR Blueprint to guide decision-making and standards adoption among provincial health systems. Unlike England’s mandated approach to systems adoption, Infoway’s Blueprint lets providers choose which system to implement, as long as its applications meet Infoway’s criteria. “Canada’s model with Infoway is very interesting because they incent it financially: ‘If you use these systems, which we’ve verified are going to work and be interoperable, then we’ll help pay for them,'” Fuller explained.

Infoway also founded the Infoway

Standards Collaborative, which develops, monitors and enforces EHR standards across the nation.

Over the past 7 years, Infoway has already marked success, completing 84 of 241 HIT projects by the middle of the 2007-2008 fiscal year, according to the GETF report. In two rural Northwest territories, electronic systems are bringing health care to isolated patients, while doctors in Alberta can provide superior care to diabetic patients thanks to a “complete and readily available” EHR, researchers observed. Infoway is now using these successes as models for other provinces to follow; lessons learned from each case are compiled in EHR “toolkits” that encourage other provinces to replicate the functioning system.

The Notable

A number of other countries have broken ground for EHR adoption. Australia has made progress through the National E-Health Transition Authority (NEHTA), which is collectively funded by state,

territorial and national governments. To facilitate interoperability, the NEHTA develops standards that state governments adopt. Australia is even taking precautions against duplicate records by developing a national system of unique patient and provider identifiers.

In Israel, physicians use electronic systems in 98 percent of hospital departments, according to GETF contributors. “They have a very high level of EHR implementation and use, even though there has not been a national program,” Wieners said.

While use is widespread, however, the systems are not interoperable. Information exchange functions through what the task force identified as “virtual temporary sharing”; instead of a central repository of information, data is kept in individual systems and can be sent to the point-of-care whenever needed.

EHR projects in Singapore and Hong Kong have also piqued researchers’ interests, Wieners said, while Fuller noted that at least one hospital in Taiwan has gone fully electronic.

The Individualists

So where does the U.S. stand? Despite spending the highest percentage of federal funds on health care, Americans still have yet to reach the level of EHR adoption that some developed nations have achieved. “[The United States] is in its adolescence compared to the maturity of some of the other countries,” asserted GETF Chair Steven Arnold, MD, MS, MBA, CPE.

In 2004, President Bush set a goal to establish EHRs for most Americans by 2014, but the federal government has been slow to fund implementation. Successful transitions from paper to electronic environments have been isolated, with individual facilities or even specific departments within facilities taking the initiative-and writing the checks-to go electronic.

In the U.S., the lack of federal funding has left EHR development to the private sector, including EHR vendors. Competing vendors keep the U.S. at the front of the pack when it comes to innovation, and other countries have taken note of America’s superior solutions.

“There’s a high focus on the individual, so we probably do have some of the best EHR installations and certainly some of the best application of technology in the world,” Fuller said. But, “We don’t have a uniform approach.”

America’s failure to establish a single framework has left communication gaps between disparate systems, so the product’s efficiency is often limited to the company’s unique network.

Communication issues pose obstacles when different facilities try to link EHRs into a shared network, so regional health information organizations (RHIOs) and health information exchanges have struggled. According to a Harvard study cited by the task force, of 145 RHIO projects in the U.S., 25 percent were defunct by 2007. However, individual successes, such as the Veterans Association’s EHR network and a RHIO launch in Bronx, NY, show promise for future projects.

Who Should Pay?

In an ideal situation, Dr. Arnold said, the U.S. federal government would play a larger role in funding EHR implementation, with health plans, payers and other stakeholders picking up the slack.

“I think the reason we should be more advanced is because the benefits far outweigh the costs,” Dr. Arnold explained. “So the issue is really not in the return on investment but the decision of who will pay for it.”

The federal government has made some effort to promote EHR implementation; the Office of the National Coordinator for Health Information Technology was established to stimulate adoption, but financial support has been limited. Legislative safe harbors permit physicians, facilities and health plans to accept donations of EHR software and training services, but such incentives have not been as effective as initially hoped.

“Physicians who might otherwise have purchased the system may now be waiting for hospitals or others to pay for it,” Dr. Arnold said, and many hospitals can’t afford to cover the cost.

In September, Rep. Pete Stark (D-CA) introduced a bill that would offer financial incentives to eligible hospitals and practitioners who adopt HIT applications. The Health-e Information Act of 2008 also proposed an eventual reduction in Medicare payments to those who do not implement approved systems that meet interoperability and security standards.

Fuller identified interoperability as a worldwide issue and said such challenges are not only linked to, but also magnified by funding. “From our work with Canada, from our discussions with associations in the Far East-Taiwan, South Korea, Japan-and what we’re beginning to learn more about HIM in Europe, you can’t really separate the way health care is paid for from their ability and their approach to adopting EHR technology.”

Working With the System

To overcome the obstacles associated with interoperability in the U.S., Fuller said the government and vendors will most likely have to work within the free market system, rather than develop solutions that counter it. Efforts by the Certification Commission for Health Information Technology (CCHIT), for example, ensure that systems meet functionality standards, but still leave options for facilities to choose from. The free choice approach incents the whole market, instead of a specific vendor, Fuller noted.

Dr. Arnold said CCHIT certification is a step in the right direction, but Americans will need to do more to scale adoption barriers. “Just because something is functional doesn’t mean it’s usable,” he explained. “If the average primary care physician has to see a patient in 7 minutes, the EHR has to assist them in seeing that patient within that 7-minute period of time.”

Wieners similarly noted that while the lack of federal funding makes cost the primary barrier to EHR adoption in the U.S., usability is a critical ingredient for success. Establishing a sufficient “threshold of participation” will take time, Wieners said. “There are many factors involved in [use], including having a system that supports the way practitioners actually work,” he explained.

Continuing Education

While individual countries are at different stages of EHR adoption, the global community continues to make a pointed effort to learn from each others’ strengths and weaknesses. Fuller said AHIMA is continuing to coordinate efforts with Canada to define HIT standards, and she sees potential in working with other countries to identify strategies for stimulating EHR adoption. “AHIMA certainly is interested in being a better partner around the world to advance the HIM profession and advance the best practices in HIM,” Fuller said.


HIMSS Enterprise Systems Steering Committee and the Global Enterprise Task Force. “Electronic Health Records: A Global Perspective.” August 2008. Available online at

European Patient Smart Open Services.

H.R. 6898: The Health-e Information Technology Act of 2008. Available online at

Cheryl McEvoy is an editorial assistant with ADVANCE.

Taking a “Global Perspective”

After researching and analyzing EHR adoption in other countries, Walter Wieners, HIMSS fellow and co-chair of the Healthcare Information and Management Systems Society Global Enterprise Task Force, concluded that all countries have a lot to gain by learning from other health care systems. He stated that task force members agreed upon the following conclusions based on his chapter, “The Global Perspective”:

1. National EHR programs are industry-wide transformations developing within the relatively immature HIT environments. A key success factor is a critical mass and core leadership to promote fundamental change.

2. Building and maintaining physician involvement in the political and implementation process is essential.

3. Developing support from all stakeholders, including national or regional governments, institutional and private providers, is a recognized success component. The active engagement of the vendor community is critical to success.

4. Adoption and adherence to data exchange standards must be achieved early in the program planning process.

5. Developing initial momentum among stakeholders is essential for building a critical mass of users.

6. National legal and regulatory agreement on privacy and consent issues is essential.

7. Substantial efforts must be ap-plied to stakeholder communication to ensure participation and continued financial support.

8. IT investment and strategies must be customizable; health care regions and organizations may be at different points in their use of IT.

“The Global Perspective” was originally published in Aspects of the Electronic Health Records Systems: Second Edition, edited by Marion J. Ball, EdD., Harold P. Lehmann, MD, PhD, et. al.

-Cheryl McEvoy

The (Cyber) Space Race

In 2004, President Bush demanded an EHR for every American by 2014. Just over the border, Canada Health Infoway set its digital deadline for 2016. Will Canada beat America to it?

“Based on what we know now and the current implementation and use of the systems, [Canada is] definitely further advanced than we are,” said Walter Wieners, HIMSS fellow and co-chair of the Healthcare Information and Management Systems Society Global Enterprise Task Force.

As the U.S. nears halfway to deadline, some patients’ records are online, but a nationwide EHR is still a long way off. EHR applications and software abound, but cost prevents many hospitals and providers from adopting the technology.

Last August, Infoway declared to be on-track to meet the 2016 deadline after marking a fourfold increase in EHR projects since 2004. In October, the organization was recognized for its enterprise EHR Blueprint, which provides a framework for the effective transition to an electronic environment.

Canada may be pulling ahead, but Wieners warned against jumping to conclusions. While adoption is necessary to get the ball rolling, usability is a more critical measure of successful implementation. “It’s one thing to have the systems installed, and it’s quite another to look at the degree they’re being used by providers and patients,” Wieners noted. “Sometimes the data is misleading.”

For the latest on Infoway’s progress, visit

-Cheryl McEvoy

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