For more than a decade, I've been hearing about how all the various paper components of patient charts – lab results, consultation reports, prescriptions and diagnostic images – in medical offices throughout the United States will eventually be replaced by tiny, efficient memory discs, cards or sticks. Thanks to computers, I've been told, offices will gradually (or in one fell swoop) convert to a paperless format, with resultant savings of time, space and money. Why has this revolution, for the most part, not yet happened?

Barriers to entry

Electronic medical records face several "barriers to entry" into the American medical mainstream: psychological, economic, practical and regulatory. First, we must remember that physicians, as a group, are among the most conservative and even skeptical of all professionals. They like doing things the way they've been doing them; they are extremely resistant to change, especially a project as ambitious and sweeping as electronic medical records. For the past five years or so, for example, developers of various software products that enable electronic prescribing have been trying to give away their products and services to physicians in the hope that the doctors will appreciate their value and eventually pay for those services. Those companies are met with incredible resistance. Remember, too, that this example just applies to prescribing and does not even touch the areas of electronic note-taking, lab data- and diagnostic film-sharing, or transfer of records.

If you can't give the stuff away, imagine the resistance when those offers dry up and the doctors are asked to pay upfront for the same or similar services! Doctors don't want to pay for anything these days, let alone some unproven, daunting, expensive system that they're not convinced will make their lives any better and that they didn't ask for in the first place!

Even if a physician is eager to install such a system, it requires a major investment not only in terms of money, but also the time it takes to train the doctor as well as his or her staff. The physical installation of these systems can also be costly and time-consuming, as well as disruptive to the physician, staff and patients (and reps!). Even the physical structure or layout of certain offices can prevent the installation of some of these systems, which often utilize wireless technologies.

Another problem is that, because the electronic medical record industry is essentially in its infancy, there is relatively little standardization among vendors, insurers, the government and other interested parties. So even if a doctor sets up a system to, for instance, have lab data beamed directly into the patients' charts, not all of the labs in town may be able to service that particular system. If a doctor has a hand-held device that enables faxing of prescriptions to pharmacies, it needs to be able to download the up-to-the-minute fax number of every local pharmacy. That system also needs to have a mechanism in place to predict and correct every problem that might occur, including things as seemingly simple as the pharmacy fax machine running out of paper.

An important step forward

There is a new movement that aims to standardize medical terminology so that when the players in the healthcare field do eventually adopt new technology, they will all be "speaking" the same language. One positive step in this process is the Food and Drug Administration's decision on April 19 to adopt the Systematized Nomenclature of Medicine (SNOMED) as the standard computerized medical vocabulary system to be used to electronically code important terms in the highlights section of prescription drug labeling. This move will allow healthcare professionals nationwide to electronically access and share critical health and treatment information more easily and efficiently. Andrew C. von Eschenbach, the acting commissioner of the FDA, recently said that utilizing SNOMED "moves us closer to our goal of establishing electronic medical records for most Americans within 10 years. Once we have implemented a national e-health record, health professionals will have quick, reliable and secure access to patient information that can be cross-referenced with critical treatment information."

Here is one example of why it is important to have a system such as SNOMED in place: What is commonly known as a heart attack can also be called a myocardial infarction, an infarct or an MI. SNOMED provides one code for all of these terms for use in product labeling, enabling the electronic exchange of important health information from system to system.

My next column will look at specific components of the electronic medical record.