New organizations are springing up almost weekly, each wanting a say in defining EHR standards. Different groups, from clinical researchers to insurance companies, are lobbying hard for what they believe should be included in EHRs. Requirements creep is bad in any IT project—what is happening here is requirements rush. It is not being overly facetious to suggest that President Bush’s 2014 target for EHR adoption may arrive before the first proposed draft of EHR standards is reviewed, let alone agreed upon, if everyone wanting to participate is involved. Are we heading towards a situation where we will end up with everything we asked for but nothing we want?

Similarly, will those who have already invested in EHR systems, such as Kaiser Permanente, which is investing billions of dollars as we speak, be willing to change to meet a new standard? Especially if the EHR standard requires major revisions of their currently working systems?

Advocates of the national health information network also agree that for it to be effective, there will be a need for massive cultural changes in financial incentives for physicians and in the way they practice medicine. Further, to achieve the postulated cost savings such a network would bring, patients must also assume greater financial responsibility for and decision making concerning their own health care. To expect three simultaneous revolutions in 10 years seems a bit optimistic.

So far, most of the discussion about the cost of the national network—estimated by a 2005 RAND study to be $156 billion to implement and another $48 billion a year to operate—has been about what doctors and other health-care providers will need to invest. Very little has been written about the impact on patients, who will ultimately be the ones to foot the bill. Are you willing to pay about $500 ($2000 for a family of four) for a network of medical records, along with another $150 yearly maintenance fee per family member? What about $750 or $1000, if the current cost estimates are too low? Will fewer people be able to afford to pay these kinds of premiums for health care? Studies of even small increases in copayments in Medicaid show that they force the poor to go without medical care.

Needed: A Comprehensive Risk Assessment

I have only touched on a very few of the multitude of issues involved in creating an NHIN. What disturbs me most is that I don’t see any comprehensive risk management plan for this effort, nor do I see much in the way of a desire to define one. As anyone who has been involved in large-scale endeavors, managing the risks involved from a total enterprise perspective is absolutely vital to achieving success. If the NHIN is so critical to the nation, if it will radically transform health care in this country, shouldn’t there be at least some systemic risk management plan with the risks defined, prioritized and where possible, mitigated?