To the Editor: In their study of the use of electronic healthrecords, Jha et al. (April 16 issue)1 report that only 1.5%of U.S. hospitals have comprehensive electronic-records systems,and 7.6% have a basic system that includes a capacity to storephysicians' notes and nursing assessments in at least one clinicalunit. Interestingly, doctors overwhelmingly say that electronic-recordssystems improve care,2 a view that is borne out by the VeteransHealth Administration (VHA) experience.3 Nevertheless, veryfew U.S. physicians use electronic health records. The reasonsrange from cost to the lack of a national standard.2
The VHA already has an excellent system, the Computerized PatientRecord System (CPRS), which has been successfully used for thepast 10 years to manage the care of approximately 8 millionveterans.4 This system is highly reliable, and because it isgovernment shareware, it is available free of charge (www1.va.gov/cprsdemo).The only criticism I have heard about CPRS is that it does notallow for billing, which is something that could be added. CPRSshould be made the nationwide standard tomorrow or, better yet,today.
Josh H. Lipschutz, M.D. Philadelphia Veterans Affairs Medical Center Philadelphia, PA 19104 jhlipsch{at}mail.med.upenn.edu
References
Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med 2009;360:1628-1638. [Free Full Text]
DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care -- a national survey of physicians. N Engl J Med 2008;359:50-60. [Free Full Text]
Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs health care system on the quality of care. N Engl J Med 2003;348:2218-2227. [Free Full Text]
To the Editor: Jha et al. have provided an important incrementaladvance in our knowledge regarding the use of electronic healthrecords in U.S. hospitals. The authors did not include an anesthesiainformation management system (AIMS) in their definition ofeither a comprehensive inpatient electronic health record ora basic electronic record. This is an important omission. AnAIMS is the anesthesia component of an inpatient electronichealth record.1 As such, it is the electronic record for a high-riskand expensive episode of inpatient clinical care. Approximately30% of U.S. hospital admissions involve surgical care.2
Jeff T. Mueller, M.D. Terrence L. Trentman, M.D. Mayo Clinic Hospital Phoenix, AZ 85054 mueller.jeff{at}mayo.edu
References
Egger Halbeis CB, Epstein RH, Macario A, Pearl RG, Grunwald Z. Adoption of anesthesia information management systems by academic departments in the United States. Anesth Analg 2008;107:1323-1329. [Free Full Text]
AHA hospital statistics 2009 edition. Chicago: American Hospital Association and Health Forum, LLC, 2009.
To the Editor: Jha et al. do not address the question of thepreservation of patients' confidential information. As Gillonwrote, "The principle of medical confidentiality is one of themost venerable moral obligations of medical ethics."1 And yearsago, Siegler was "astonished to learn that at least 25 and possiblyas many 100 health professionals at our university hospitalhad access to the patient's record."2 Will not the adoptionof electronic medical records further increase the number ofpeople with access to those charts?
Ivan D. Miziara, M.D., Ph.D. ABC School of Medicine 05411-000 Santo André, Brazil miz{at}uol.com.br
References
Gillon R. Confidentiality. Br Med J (Clin Res Ed) 1985;291:1634-1636. [CrossRef][Medline]
Siegler M. Confidentiality in medicine -- a decrepit concept. N Engl J Med 1982;307:1518-1521. [Web of Science][Medline]
The authors reply: We agree with Lipschutz that most physicians,once they overcome the challenges of adoption, are happy withthe use of electronic health records. Furthermore, the systemthat the VHA uses is an excellent tool. It is clinically intuitiveand has all the features necessary to allow clinicians to deliverhigh-quality care. Whether it is the right solution for everyphysician and hospital in the United States is less clear. However,given that the system is free and familiar to many clinicians,many providers may see this as an attractive solution.
With respect to the issue raised by Mueller and Trentman aboutanesthesia information systems: we agree that such systems arelikely to be helpful for managing the care of high-risk patients.There are other such "specialized" solutions, including informationsystems in cardiac suites and operating rooms, which are alsolikely to be valuable for hospitals. Unfortunately, the scopeof our survey limited our ability to examine these areas.
Finally, Miziara expresses concern about privacy, which is onthe minds of many clinicians and patients as we transition tothe widespread use of electronic health records. In contrastto paper-based records, which are highly insecure, enormousfocus has been placed on establishing privacy and security standardsfor electronic records under the privacy rule of the HealthInsurance Portability and Accountability Act (HIPAA). Indeed,as recently as February 2009, Congress further strengthenedHIPAA to ensure the privacy of health information.
Ashish K. Jha, M.D., M.P.H. Boston Veterans Affairs Hospital Boston, MA 02130 ajha{at}hsph.harvard.edu
Catherine DesRoches, Dr.P.H. Massachusetts General Hospital Boston, MA 02114
Sara Rosenbaum, J.D. George Washington University Washington, DC 20052
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