It's been about three years since San Diego's five major hospitals first convened to discuss sharing electronic medical record data in an effort to improve diagnoses, reduce errors and improve the quality of patient care. The group held several meetings and entered discussions with a vendor as a possible corporate sponsor -- and that was that.

"It really didn't go anywhere," says Dr. Joshua Lee, medical director of information services at the University of California, San Diego, Medical Center, one of the participants in the EMR discussion. While the system would have had a clear public health benefit, it was not in each hospital's economic self-interest to pursue it. "The financial and oversight responsibility would fall on the medical centers, even though it's a very intangible benefit to the medical centers," says Lee.

Today, if a child who is a UCSD patient at the pediatric clinic is admitted to the emergency room at Sharp Memorial Hospital down the road, the only way the ER doctor can view that child's known medical problems, allergies, prescriptions and other health data is by calling UCSD HealthCare, making a records request, and waiting for the information to be printed and either faxed or physically delivered on paper. Conversely, any treatments or medications given at Sharp won't be entered into the patient's EMR in the UCSD system. "It's not like we don't share on paper, but we don't institutionally share data," says Lee.

The situation in San Diego is the norm rather than the exception, but it doesn't have to be that way. "We have had the technology to do this for 30 years," says Shaun Grannis, medical informatics researcher at the Regenstrief Institute, an Indianapolis-based research organization that spearheaded a metropolitan health information exchange in its home city. One of the first US regional exchanges, the Indianapolis system is used by 34 health care providers.

Rather than requiring member providers to change their internal systems, the institute wrote middleware that integrates data from all of those proprietary systems and organizes it into a single data model. "We wrote the interface engines that do all of this stuff," says Grannis. If members simply want to view integrated patient data, they log into the community electronic health record (EHR) Web site. Alternately, the institute can push data out to providers that have their own EMR systems.

Ultimately, technology isn't the problem. Granted, the health care industry has been held back by loose and overlapping technical standards and by poor interoperability among the different types of health information systems sold by hundreds of vendors. But the biggest obstacle may be a payment model that offers little financial incentive for most health care providers to invest in using electronic records internally, let alone share them with other providers.

Electronic records systems do yield some savings, particularly in the area of filing, but the savings often aren't enough to justify the cost -- especially for single-physician and small group practices, which make up more than half of the health care services in the US.

Even in Indianapolis, there is no viable long-term business model for the health information exchange, and not all members have their own EMR systems. "We are largely grant-funded," Grannis says. Once those grants come to an end, other revenue sources must be found to sustain the programs.