It's a June morning in the cardiology ward at the brand new Georges Pompidou European Hospital in Paris. From one of the windows, you can see the top third of the Eiffel Tower. Inside the rooms, though, you won't see any bedside charts. Instead, Benoît Diebold, the attending physician, a resident, and two medical students go room to room equipped with a cellphone and a portable computer mounted on a wheeled cart. The computer's network cable trails awkwardly on the floor behind, and a patient standing in a doorway gives it a kick. Diebold announces cheerfully that he ordered a wireless link "yesterday."
Welcome to the (almost) digital hospital, a medical ideal where everyday operations and record-keeping are carried out and maintained almost exclusively with computers. At the heart of this ambitious model is the electronic patient record, or EPR. The idea behind it: to make all of a patient's medical reports, lab results, and images electronically available to clinicians, instantaneously, wherever they are [see ]. And, with an electronic record as a base, software tools that increase the accuracy of treatment can be added to improve patient outcomes and reduce cost.
Opened in August 2000, Georges Pompidou European Hospital, an 825-bed facility in Paris, was meant to be a showcase of 21st-century medicine. But its information technology system remains a work in progress.
EPRs have been a healthcare priority for years in many countries. The Institute of Medicine in Washington, D.C., the leading medical academy in the United States, has been pleading for an end to handwritten clinical data in the interest of safety and efficiency since 1991. But while the quality of the available information technology (IT) has improved greatly, progress in implementing EPRs has lagged behind, and only a minority of hospitals and clinics use them.
Considering what the needs of a modern hospital are, it isn't hard to understand why progress has been slow. Sharing data is fundamental to the concept of the EPR, but hospital medical departments, like surgery and intensive care, act like autonomous guilds, explained Charles Safran, chief executive officer of Clinician Support Technology, in Framingham, Mass., a leading provider of medical software. "Historically [they] haven't cared if their computers integrate with the hospital-wide information systems," he said. On top of that, issues of security, privacy, and confidentiality have not been addressed in any decisive way. Yet, easy access to electronic records holds the potential to make these data a more meaningful resource beyond the settings where they were collected and where, traditionally, they would remain.
As companies and hospitals try to design the software to implement and use EPRs, it is still unclear who will decide what information should be available, to whom, and how. For example, medical staff require a detailed chronological medical history to assess the status and needs of each patient. But researchers want to go beyond this level and integrate data about populations and subgroups that could contribute to medical knowledge. In another area, regulatory bodies and professional accreditation reviewers require documentation of patient care. And insurers of individual patients are interested in their genetic and medical histories.
Undeniably, balancing the rights to privacy and legitimate access will be no mean task. But perhaps the most surprising hurdles to implementing EPRs are the human factors. Finding a comfortable interface between people and machines (that is, making it easy for doctors and nurses to enter and use data) is a continuing challenge. In addition, financial and productivity incentives for adopting EPRs are not always clear, and training staff to use them is time consuming, expensive, and often must be customized for the peculiarities of each hospital.
Several leading teaching hospitals already have EPRs, developed mostly through years of in-house work, while others are trying to build a digital hospital from scratch. One example of the second group is a venture between HealthSouth Corp., the largest U.S. healthcare services provider, and database-supplier Oracle Corp., Redwood Shores, Calif. The pair recently announced plans for "the world's first all-digital, automated hospital," to be completed in 2003 near HealthSouth's Birmingham, Ala., headquarters.
The technical innovations in the HealthSouth/Oracle venture sound remarkably like those the Pompidou European Hospital is trying to implement. But the Pompidou already exists, and by that fact it provides a valuable object lesson on the struggle to digitize healthcare. Following a calamitous first year and a half of operation that included everything from strikes to two fatal outbreaks of Legionnaires' disease among its patients, the digital hospital and the EPR at its core are still a work in progress.