Is "middle-out" the best Rx for health care IT?

Health reform efforts around the world are looking to electronic health records (EHR) as a means for squeezing more value and efficiency, and better outcomes from health care budgets that appear to be consistently shrinking relative to demand. Health care in the US tends to take a "go-it-alone" approach, with policy makers loath to look overseas for readily applicable solutions for successful implementation. Despite this practical myopia, it's probably worth considering the UK's national experiment with EHR to get a sense of what the US might be in for as it straps on its climbing boots and prepares to scale the slopes of health care IT implementation.

A previous review of progress in the UK wasn't very encouraging, you can read about that health care experience here. New analysis published in the British Medical Journal by Dr. Aziz Sheikh of the eHealth Research Group in Scotland and colleagues provide some overarching advice about EHR implementation. In 2002, the UK launched an ambitious plan to provide comprehensive EHR nationwide, backed by nearly $20 billion in funding. The UK approach was decidedly top-down: Backed by government mandates and standards. The US approach to date has been the opposite: A bottom-up process where providers and health care systems implement EHR somewhat randomly, and with no eye to overall interoperability.

Dr. Sheikh's group characterized the UK experience as being "long, complex and iterative". While the vision for useful, functional, interoperable EHR may still be realized, it may take decades to fully materialize. Among the complexities: Moving targets in the form of constantly evolving government standards; a variety of available EHR systems, with no clear indication of what's preferable; the desire for local control and systems tailored to local context, rather than national-mandate; and uncertainty about the evolving EHR implementation program. Despite the complexities, stumbles and set backs, British practitioners are still supportive of adoption, clearly believing it will improve their practice or their professional lives. Dr. Sheikh and colleagues believe that the UK's top-down approach may be one of the key reasons for the slow pace of change.

Bottom line? A "middle-out" approach to implementation may well be the most effective approach. This means implementing standards, systems, and interoperability on a more localized level: The health trust level in the UK, or the State level in the US. This has at least two major advantages over top-down or bottom-up approaches: The ability to tailor implementation or standards to peculiarities of local context, while still enlarging the interoperability envelope to encompass most of the practitioners that any given patient is likely to frequent. Since health care finance is often focused on the national level (whether it's the UK's single-payer system, or the US's systems of Medicare or large health insurance companies), could "middle-out" also help re-focus EHR on a clinical and public health mission rather than the mission of sending and collecting payment? That's unclear, but its possible.

(Previous research unearthed a half-dozen keys to successful EHR implementation outlined here.)