By Guy Boulton

Almost all hospitals and physicians in the United States have put their patients' health records onto computers. But one of the goals of that transition remains a work in progress: building a nationwide system that would make key information about a patient available anywhere — in any hospital, clinic or doctor's office.

The goal is an essential step in making full use of electronic health records. It eventually could improve the coordination of care, reduce the number of unnecessarily duplicated tests and give doctors information that can help them make better decisions.

“In a fragmented, highly specialized health care system, you can’t deliver efficient, high-quality health care without sharing data,” said Mark Braunstein, a physician and a professor at Georgia Institute of Technology.

Emergency physicians would quickly be able to see information, such as medical conditions, medications, allergies and laboratory results, if a Milwaukee resident had a heart attack while visiting a relative in Texas or California.

The same would hold for a physician in Florida with a Wisconsin patient who spends the winter there — or, for that matter, a specialist at the Medical College of Wisconsin who is seeing a patient referred from Columbia St. Mary’s or an independent physician's practice.

It was one of the reasons that financial incentives to encourage hospitals and doctors to move to electronic health records were included by the Obama administration in the recovery act in 2009.

Like many grand goals, building a national network for exchanging key medical information has proven to be more complicated than initially envisioned. But that doesn’t mean there hasn’t been considerable progress.

A mishmash of networks has emerged that make it easier for many hospitals and doctors to find and exchange key information from a patient’s medical records, and more information is being exchanged every month.

Still, large gaps remain, and exchanging such basic medical information is just a start. The information must be easier to find and use when making clinical decisions.

The eventual goal of so-called interoperability is a seamless system that would enable companies to develop software for thousands of specialized tasks that could work easily with any system for electronic health records — whether it's produced by Epic Systems of Verona, or Cerner Corp., Epic's biggest competitor, or any other health software maker.

A nationwide system that not only allows medical information to be exchanged but also allows it to be pulled from and added to electronic health records — while protecting patients’ privacy — holds the potential of transforming medical research, public health and how care is delivered.

The information could be used to track the effectiveness of new drugs and other therapies and to monitor outbreaks of infectious diseases.

It also could enable companies to develop applications that help doctors and other clinicians make better decisions and that improve patient care in ways yet to be imagined.

That’s a ways off.

To start, there’s the complexity of health care. By one estimate, a system for electronic health records can have 150,000 data points, or discrete units of information, ranging from a patient’s blood pressure to genetic markers. And most of the systems are configured and customized differently by each health system.

“I often call interoperability deceptively simple,” said Julia Adler-Milstein, an associate professor of information and health management and policy at the University of Michigan.

But the federal incentives did result in hospitals and physician practices making the final push from paper records: 96% of hospitals and 78% of physicians now use electronic health records. And more information is being exchanged each year through the hodgepodge of networks that has emerged.

Nationally, 38% of physicians sent and received patient information to and from other physicians and health care providers in 2015, according to the Centers for Disease Control and Prevention.

Wisconsin, which was at the forefront of the move to electronic health records, does better than the country overall.

Half of the physicians in the state sent patient information and 65.5% received information electronically in 2015.

Most of the state’s health systems use software from Epic Systems and have access to its Care Everywhere network, which enables medical information to be exchanged with other Epic customers.

“We see advances across the board in people’s ability to share information,” said Sean Bina, a vice president at Epic.

Nationally, Epic customers exchanged an estimated 47 million medical records in March, up from 4.2 million in June 2014. The company estimates that its customers exchanged 420 million records last year.

Nearly every Epic customer — 1,200 hospitals and 34,000 clinics — is on its Care Everywhere network. The company also estimates that 25% of the medical records exchanged by its customers are with hospitals and doctors that don’t use Epic software.

Epic added Care Everywhere to its system for electronic health records long before a network for exchanging medical information was a national goal.

The idea stemmed from Judy Faulkner, Epic's founder and chief executive, after her husband, a pediatrician, had a patient die in an emergency department. He believed the death could have been prevented if the physicians had access to the child’s medical records.

Care Everywhere was an additional selling point for Epic, and it spurred seven software companies, including Cerner, to form the CommonWell Health Alliance in 2013 and announce plans to build a competing network.

CommonWell now has more than 50 members, including companies that sell software for nursing homes, home health care and hospice care.

They have agreed to build into their software the capability to exchange basic health information through the network.

For its part, Epic belongs to Carequality — a network of networks, such as Care Everywhere, for exchanging medical information among systems from different vendors.

Carequality includes some members of CommonWell, among them athenahealth and eClinicalWorks. Surescripts, which has the most widely used technology for electronic prescriptions, also is a member.

The country appeared to be on track to building two competing networks — CommonWell and Carequality — that weren’t connected.

That changed in December when CommonWell announced that it would join Carequality.

The agreement drew little attention beyond the industry but holds the potential of creating a framework for a nationwide system that would enable physician practices, hospitals, home health care agencies, nursing homes, pharmacies and others to exchange medical information.

To exchange patient information, a health system, physician practice or other provider has to agree to what are commonly referred to as “the rules of the road.”

They include what information will be shared and with whom, a way of verifying who is requesting the information and identifying the patient as well as general standards for how the information will be formatted and exchanged.

For now, physicians and hospitals have no way of knowing for sure that they have all of a patient’s medical records. They can only search and retrieve records from other physicians and hospitals that are on the same network or networks, and that varies by geography and software vendor.

“I use the word ‘patchwork’ a lot today,” said Adler-Milstein of the University of Michigan.

It’s the reason that a physician at Bellin Health in Green Bay doesn’t have electronic access to the key medical information for a patient who also has been seen at the Veterans Health Administration’s outpatient clinic in the same city, or the reason that a community health center in Milwaukee generally doesn’t have access to information from health systems in the metropolitan area.

To add to the confusion, there also are regional health information organizations — such as the Wisconsin Statewide Health Information Network, commonly known as WISHIN — that have had varying degrees of success. Many health systems and physicians are not on WISHIN.

Carequality eventually could supplant the regional health information organizations. But building out Carequality will take years.

The first exchanges of medical information on the network took place last summer. But so far, most of the more than 800 hospitals and 19,000 clinics on the network are Epic customers.

CommonWell must complete development work for its members to become part of the Carequality network. And then each health system, physician practice and health-care provider must decide to join the network.

What’s more, getting software vendors to commit to supporting the standards of one network — and getting health systems, physician practices and other providers to opt in — aren’t the only obstacles.

How the information is presented and finding what’s needed in the information that’s exchanged can be a source of frustration for physicians and other clinicians. And identifying patients and ensuring that the medical records match can be a problem.

“There’s the moving around of data,” Alder-Milstein said. “But then there’s the actual using of data and have it impact clinician decisions. We have a lot of work to do in the second part of that.”