The use of health information technology in seven nations

international journal of medical informatics 77 (2008) 848–854 851Adoption of electronic health records in Canadian hospitalsis also in its infancy. Very few Canadian hospitals useelectronic prescribing, in part because they rely on local operatingor capital budgets rather than on national funding tosupport these programs. Similarly, Australia and New Zealandhave computerized patient administration systems and manyuse laboratory results reporting. However, computerized documentationis limited to electronic discharge summaries whichare sent directly from hospitals to general practitioners andthere is little to no electronic prescribing in the hospital setting.3.3. Health information exchangeDespite widespread interest, clinical data exchanged acrossproviders remains low in each country. In some countries, HIEhas begun in earnest with substantial resources dedicated tofurther expansion, though other nations are still in the planningstages.In the U.S., much of the focus on sharing of data betweenproviders has been organized around Regional Health InformationOrganizations (RHIOs). These entities have alreadybeen started in many regions [23]. RHIOs are generally nonprofitregional organizations whose primary aims are toconvene provider organizations with the hope of initiatinghealth data exchange. Preliminary reports suggest that onlya small number (fewer than a dozen) have begun to exchangeclinical data [24]. Furthermore, the financial sustainability ofRHIOs, a critical factor in their long-term success, remainsunknown.The Canadian approach has focused on Infoway, a nationaleffort to provide vision and strategy to increase the nationaladoption of EHRs. On the HIE front, Infoway promotes theinterchange of a wide array of clinical data, including laboratory,pharmacy, and hospital information. One of Infoway’sprimary goals is to implement an interoperable EHR for50% of Canadians by 2010. Because Infoway envisages aneventual pan-Canadian interoperable EHR, it is currentlydeveloping privacy and security standards [24]. Provincessuch as Alberta and Newfoundland are in the process ofimplementing province-wide programs to allow data sharingacross hospitals, clinical laboratories, and physicians’ offices[25]. However, poor underlying levels of EHR use in the primarycare and hospital settings have hindered widespreadHIE.HIE has received substantial attention from national policymakers in Europe. The National Programme for IT (NPfIT) inthe UK has prioritized sharing of clinical data across providersand the automatic transmission of electronic prescriptions topharmacies. To this end, the National Health Service has allocated£12.4 billion to NPfIT to build an integrated national EHRsystem, which will also be used by pharmacies and laboratories.Approximately 5% of prescriptions are being transmittedelectronically to pharmacies. A current pilot project is thePrimary Care Summary Record program, which pulls keypieces of data from the EHR and transmits a summary tothe National Spine for authorized professionals to access.As of fall 2007, approximately 14% of primary care practiceswere able to create and transmit this summary record. Furthermore,the GP2GP program, whose goal is to ensure thetransmission of the full EHR between GPs, is in early stages oftesting.While there is currently no provider-to-provider exchangeof clinical information in the Netherlands, it is a central goalof the Dutch government to obtain such interoperability. Theprimary focus is the SwitchPoint, a program intended to helpproviders communicate medication lists and clinical summariesto other providers. The SwitchPoint project is still ina nascent stage, with final tests having recently been completed.The pilot phase, which began in late fall 2006, will berolled out to regions that cover 1–2 million patients.We found no single approach to HIE in Germany. Whilemajor healthcare software companies have attempted to createan infrastructure for physicians to exchange clinical data,these efforts have had minimal success. Due to security concerns,many physicians prefer to store patient records oncomputers that are not connected to the Internet. Despitethis obstacle to HIE adoption, there are currently two pilotprojects focused on providing health information exchangecapabilities for providers. The first, called “D2D” (www.d2d.de)is a secure communication standard to exchange billinginformation and patient data. About 2300 (less than 2%) ofGerman physicians in private practice are participating inthe D2D pilot program, which conducts approximately 70,000data transactions per month. The second program, “VitaX,” offers EHRs and supports provider-to-provider exchange.While Vita X is also in its infancy, its use is expected tobecome more widespread, as it is provided by the same vendorthat supplies EHR systems to 50% of the German privatepractices.The most promising approach to HIE in Germany is theelectronic health insurance card. Although the card currentlyholds administrative data only, the next generation oftechnology will allow access to electronically stored patientmedical information. It will initially include only emergencydata set and medication history but all key elements of apatient’s EHR should be available. The voluntary programwill also support electronic transmission of prescriptions to apharmacy.There has been some implementation of HIE in bothAustralia and New Zealand with more likely to come.In Australia, the National E-Health Transition Authority(www.nehta.gov.au) has undertaken substantial planning forHIE implementation. In addition, a New South Wales pilotproject is encouraging hospitals and community providers toexchange clinical data for some 50,000 patients. Current HIE inboth Australia and New Zealand allows GPs with EHRs to automaticallydownload pathology reports and imaging reportsfrom a variety of public and private diagnostic sectors. Inaddition, both countries also have national immunization registries(and Australia has a cervical smear registry, as well),which can be fed and accessed electronically. Finally, in bothnations, hospitals are increasingly sending discharge summarieselectronically to GPs, who in turn are sending referralsand other communications to hospitals and specialists electronically.Some experts suggest that the lack of a singlenational identifier code has hindered HIE in Australia to a substantialdegree. New Zealand, by contrast, which does have asingle consumer health identifier, may have an easier timecreating a national HIE program.

852 international journal of medical informatics 77 (2008) 848–8544. DiscussionWe examined the state of electronic health record adoptionand health information exchange in seven industrializednations and found both similarities and striking differencesamong them. While the adoption and use of EHR systems inthe hospital setting was in its early stages in every nation,most nations were far ahead of the United States in adoptionof EHR in the ambulatory care setting. While fewer than 1 in 4ambulatory care physicians in the U.S. use an EHR and fewerthan 1 in 10 such physicians prescribe electronically, nearlyall general practitioners in the UK, Netherlands, Australia andNew Zealand do both. Germany lags behind these four nations,though it is ahead of the U.S., while Canada’s ambulatory EHRadoption is comparable to that of the U.S. Finally, while activehealth information exchange is in its early stages across allnations, several European countries have already made greatstrides in setting up the infrastructure necessary to effectivelyshare clinical data, and Australia has also conducted substantialplanning.There are several reasons for the variation in EHR useamong ambulatory care physicians. For instance, high ratesof adoption among UK physicians comes from a complex setof factors including a long history of computerization, drivenpartly by free or inexpensive hardware and software. TheNHS 2003 contract with GPs, which put in place large financialincentives for meeting quality standards, has spurredthe use of more sophisticated EHR systems with decisionsupport. The Netherlands and Germany have not employedthis level of direct governmental financial investment, butthey both benefit from the existence of relatively few vendors(for example, there are 8 in the Netherlands), nationalrequirements for electronic billing, high availability of computersystems and software, and therefore high levels of EHRuse among ambulatory physicians. Adoption in New Zealandwas driven by a combination of factors in which the governmentplayed an important but indirect role: requirementof GPs to submit claims and capture other data electronically[26]. By contrast, Canadian and American physicians,who receive no large-scale external funding, and reap fewincentives for quality improvement or other requirementsnecessitating the use of computers in clinical practice, havethus lagged behind substantially. In a few U.S. markets,pay-for-performance is becoming increasingly important, butthese are the exception and the level of reimbursement ismodest [27].It may be surprising that hospitals across the seven nationshave been slow to adopt EHRs. Hospitals generally have greaterresources than individual practitioners and much of the dataabout clinical benefits of EHRs have been demonstrated in thehospital setting. There are two related explanations for theslow EHR adoption in hospitals. First, in the nations we evaluated,policy makers have paid little attention to hospital EHRadoption. The U.S. is the farthest along in measuring hospitalquality [28] but even in the U.S., there are no clear financialincentives for hospitals to significantly improve the carethey provide. Second, hospital EHR systems are expensive,often disruptive, and require integration with legacy systems.Therefore, without clear incentives, most hospitals have seenlittle reason to adopt EHRs. Hospitals could potentially serve asmajor drivers for EHR adoption and HIE in communities; thus,the lack of progress of inpatient EHR adoption represents apotential target for policymakers.There are important lessons on HIE worth noting. TheUK has had to make sizeable financial investments—mostof which have come from the national government. Thereare substantial challenges to allowing physicians who usedifferent EHR systems to connect to a common platformand communicate with each other. When this has happenedsuccessfully, it has been with a restricted number of vendors,as in the Netherlands and UK. Large-scale HIE programssuch as the UK’s raise substantial privacy concerns and havegenerated a great deal of resistance despite the potentialbenefits.Employing a different approach, Canada’s Infoway projectis more limited both in scope and in investment; it focuseson several narrowly defined goals [29], such as electronicexchange of prescriptions, which might represent a successfulmodel, though the benefits would obviously be more limited.Finally, the U.S. approach, which the federal government hasencouraged rather than led, has been to let regional organizationsexperiment with local initiatives. Whether this willlead to successful models of HIE that will spread nationally islargely unknown, but there are major concerns about whetherthese entities can develop sustainable business models [24].Itmay be that these exchanges are a public good and, therefore,require ongoing government support.Our study has several important limitations. While we triedto rely on high-quality survey data whenever possible, we werelimited in our estimates of EHR adoption by the lack of data inseveral of the nations examined. To compensate, we vetted allestimates with a series of experts in each nation. Our comparisonsof HIE were also limited by the absence of data in most ofTable 1 – Comparison of rates of electronic medical record useAustralia Canada Germany Netherlands New Zealand United Kingdom United StatesPrimary careHER (%) 79–90 20–23 42–90 95–98 92–98 89–99 24–28CPOE (%) 75–81 5–11 59 85 a 90 >90 9Hospital careHER (%)

international journal of medical informatics 77 (2008) 848–854 853Table2–Major efforts in health information exchangeAustralia Canada Germany Netherlands New Zealand United Kingdom United StatesRHIOsNational Programmefor ITHealth InformationStrategyHealth Infoway D2D, Smart Cards NationalSwitchPointMajor policyNational E-Health TransitionAuthority (NEHTA)Less than 12organizationsexchanging anydata. Total patientpopulation involved≪1% of U.S.Several programsunder way. Smallfraction of GPs ableto create summaryrecords fortransmittal. Fullrecord exchange stillin infancyPlanning stages. HIEmostly focused onexchange of dischargesummaries, lab andpathology reports withGPsPilot phaseinvolving nearly20% of populationin effect. Fullimplementation ofHIE by end of 2008

854 international journal of medical informatics 77 (2008) 848–854AcknowledgementThe project was funded by the Commonwealth Fund, NewYork, NYreferences[1] J.M. Corrigan, M.S. Donaldson, L.T. Kohn (Eds.), Crossing theQuality Chasm: A New Health System for the 21st Century,National Academy Press, Washington, DC, 2001.[2] E.A. McGlynn, S.M. Asch, J. Adams, et al., The quality ofhealth care delivered to adults in the United States, N. Engl.J. Med. 348 (26) (2003) 2635–2645.[3] C. Schoen, R. Osborn, P.T. Huynh, et al., Primary care andHealth Aff. (Millwood) Suppl Web Exclusives (July-Dec 2004)w4-487-503.[4] B. Chaudhry, J. Wang, S. Wu, et al., Systematic review:impact of health information technology on quality,efficiency, and costs of medical care, Ann. Intern. Med. 144(10) (2006) 742–752.[5] S.J. Wang, B. Middleton, L.A. Prosser, et al., A cost-benefitanalysis of electronic medical records in primary care, Am. J.Med. 114 (5) (2003) 397–403.[6] J. Walker, E. Pan, D. Johnston, J. Adler-Milstein, D.W. Bates, B.Middleton, The value of health care information exchangeand interoperability, Health Aff. (Millwood) (2005), SupplWeb Exclusives: W5-10-W5-8.[7] R. Hillestad, J. Bigelow, A. Bower, et al., Can electronicmedical record systems transform health care? Potentialhealth benefits, savings, and costs, Health Aff. (Millwood) 24(5) (2005) 1103–1117.[8] J.G. Anderson, Social, ethical and legal barriers to e-health,Int. J. Med. Inform. 76 (5–6) (2007) 480–483.[9] A.K. Jha, T.G. Ferris, K. Donelan, et al., How common areelectronic health records in the United States? A summary ofthe evidence, Health Aff. (Millwood) 25 (6) (2006) w496–w507.[10] C. Schoen, R. Osborn, P.T. Huynh, M. Doty, J. Peugh, K. Zapert,On the front lines of care: primary care doctors’ officesystems, experiences, and views in seven countries, HealthAff. (Millwood) 25 (6) (2006) w555–w571.[11] D. Blumenthal, C. DesRoches, K. Donelan, Healthinformation technology in the United States: theinformation base for progress, Robert Wood JohnsonFoundation, 2006 (May 24, 2007).[12] A.M. Audet, M.M. Doty, J. Peugh, J. Shamasdin, K. Zapert, S.Schoenbaum, Information technologies: when will theymake it into physicians’ black bags? MedGenMed 6 (4) (2004)2.[13] D. Gans, J. Kralewski, T. Hammons, B. Dowd, Medical groups’adoption of electronic health records and informationsystems, Health Aff. (Millwood) 24 (5) (2005) 1323–1333.[14] C.W. Burt, E. Hing, D.A. Woodwell, Electronic Medical RecordUse by Office-based Physicians: United States 2005, NationalCenter for Health Statistics, Hyattsville, MD, 2006.[15] Reported IT use in the National Physician Survey, 2005(accessed at http://www.cma.ca/Multimedia/CMA/ContentImages/Inside cma/WhatWePublish/LeadershipSeries/English/howdoing.pdf).[16] Information management and technology in generalpractice, 2005 (accessed May 20, 2007, athttp://www.rcgp.org.uk/information/publications/information/PDFInfo/07 Feb05.pdf).[17] T. Benson, Why general practitioners use computers andhospital doctors do not. Part 2. Scalability. BMJ 325 (7372)(2002) 1090–1093 (Clinical research ed).[18] D.K. McInnes, D.C. Saltman, M.R. Kidd, Generalpractitioners’ use of computers for prescribing andelectronic health records: results from a national survey,Med. J. Aust. 185 (2) (2006) 88–91.[19] R. Didham, I. Martin, R. Wood, K. Harrison, Informationtechnology systems in general practice medicine in NewZealand, N. Z. Med. J. 117 (1198) (2004) U977.[20] J.S. Ash, P.N. Gorman, V. Seshadri, W.R. Hersh,Computerized physician order entry in U.S. hospitals:results of a 2002 survey, J. Am. Med. Inform. Assoc. 11 (2)(2004) 95–99.[21] D.M. Cutler, N.E. Feldman, J.R. Horwitz, U.S. adoption ofcomputerized physician order entry systems, Health Aff.(Millwood) 24 (6) (2005) 1654–1663.[22] M. Bywater, UK Findings from HINE European HospitalSurvey, Harrogate, England, 2005.[23] J.M. Overhage, L. Evans, J. Marchibroda, Communities’readiness for health information exchange: the NationalLandscape in 2004, J. Am. Med. Inform. Assoc. 12 (2) (2005)107–112.[24] J. Adler-Milstein, A. McAfee, D.W. Bates, A.K. Jha, The Stateof Regional Health Information Organizations: currentactivities and sources of funding, Health Aff. (Millwood) 27(1) (2007) w60–w69.[25] A. Ausford, N. Campbell, D. Gaudette, J. MacGregor,Implementing an EHR: is it possible to sustain themomentum? in: E Health 2005 Conference, Toronto, Canada,2005.[26] R. Didham, I. Martin, R. Wood, K. Harrison, Informationtechnology systems in general practice medicine in NewZealand N. Z. Med. J. 117 (1198) (2004).[27] M.B. Rosenthal, R.G. Frank, Z. Li, A.M. Epstein, Earlyexperience with pay-for-performance: from concept topractice, JAMA 294 (14) (2005) 1788–1793.[28] A.K. Jha, Z. Li, E.J. Orav, A.M. Epstein, Care in U.S.hospitals—the Hospital Quality Alliance program, N. Engl. J.Med. 353 (3) (2005) 265–274.[29] R.E. Scott, P. Jennett, M. Yeo, Access and authorisation in aGlocal e-Health Policy context, Int. J. Med. Inform. 73 (3)(2004) 259–266.[30] C. Nohr, S.K. Andersen, S. Vingtoft, K. Bernstein, M.Bruun-Rasmussen, Development, implementation anddiffusion of EHR systems in Denmark, Int. J. Med. Inform. 74(2–4) (2005) 229–234.[31] H. Yoshihara, Development of the electronic health record inJapan, Int. J. Med. Inform. 49 (1) (1998) 53–58.[32] I. Iakovidis, Towards personal health record: currentsituation, obstacles and trends in implementation ofelectronic healthcare record in Europe, Int. J. Med. Inform. 52(1–3) (1998) 105–115.