Electronic Health Records: The Vision
There is no doubt the paper-medical-record system that spanned ancient Greece to the 1990s (and still now) needs to be replaced. Unintelligible handwriting– long the most common joke about physicians- leads to patient injuries. Information in one setting (such as the doctor’s office) is unavailable in another (such as in the Emergency room). Paper is inherently at risk of destruction– such as an individual case of a spilled cup of coffee – or on a regional level as seen during Hurricane Katrina when tens of thousands of patient records were swept away.
Paper records are cumbersome to write out long-hand, and therefore can be incomplete. Documentation is critical for billing government programs or private insurance companies- so those same incomplete records mean in paper offices, many physicians (particularly primary care) leave money on the table because they do not have time to write everything they did on every patient every day.
People often have difficulty accessing a copy of their medical chart– and if their paper file is misfiled (a possibility with even the best record clerks) their information could be lost forever.
The “silo” nature of a paper medical office also makes monitoring physicians for quality of care, licensure violations, and fraudulent billing practices by both state and federal authorities more difficult.
Population-based research (can we cure the common cold?) is impossible in a paper world.
EHRs were going to change all of that.
The Slow Move Toward a Paperless Health Care System
The vision of a “Paperless Health Care System” began in 1972, but it wasn’t until the development of the internet in the 1990s that communication technology became relevant to health care.
Switching from a paper-based medical system has a long history of support from the White House. In 1991 President H.W. Bush championed a model electronic record, and that same year the Institute of Medicine [IOM] suggested that all physicians should switch to a computer-based record by 2000. HHS Proposed the first national standards to protect patients’ medical records under the Clinton Administration in 1999, in keeping with the HIPAA Privacy Act passed in 1996. President George W. Bush “pushed” computerized medical records in 2004; Barak Obama “proposed a massive effort to modernize health care by making all health records standardized and electronic” when he was still President-Elect.
However, even with the push from Washington- adoption, especially for individual physicians- has been slow.
From the outset- money has been a significant barrier (an electronic record system cost $32,606 per physician 15 years ago). Third-parties that may have been willing to help physicians purchase systems could not because of anti-kickback law.
Not only was the cost of a new system expensive- the necessary on-going technical support added to the ballooning overhead for most physician offices. Training costs for all office employees, plus compliance with wave after wave of security concerns and privacy protection regulations, added exponentially to the initial investment.
As this transition was occurring, 30% of physicians were “Boomers” who frequently lacked adeptness at a keyboard and felt stymied in their documentation and access to patient information.
From inception, adoption of an electronic record system has been voluntary (and remains so today). Multiple federal initiatives added incentives (and increasingly penalties) for doctors that said “no”- but many- with a conviction mirroring that of the late Charlton Heston– continued to hold their pens in their “cold (ok- alive) hands.”
The first real boost to physician adoption of EHRs came with the HITECH Act (part of the Recovery and Reinvestment Act of 2009), which offered financial incentives- for the first time- to physicians and hospitals investing in EHRs. By 2017 86% of office-based physicians were electronic- 96% of nonfederal acute care hospitals were on board as well. (It is worth noting that some physicians, admittedly a small minority, are reverting to their old paper records.)
However, as depicted so well in Death By 1,000 Clicks: Where Electronic Health Records Went Wrong, the achievement of near 100% participation in electronic health care records did not alleviate the problems with the technology. In many cases- the issues have become more entrenched. The top five discussed in detail by Kaiser/Fortune are:
- continuing patient harm
- ease of fraudulent billing
- gaps in interoperability and access
- doctor burnout
- secrecy due to policies that “keep software failures out of public view.”
David Blumenthal, President Obama’s National Coordinator for Health Information Technology and an “architect of the EHR Initiative,” reflects the disappointment– the gap from the vision to EHRs in 2019– in this quote: “EHRs have not fulfilled their potential. I think few would argue they have.”
Why Does Dr. T’s EHR Work for Her?
Looking back on Mom’s visit to Dr. T, how can I reconcile that technology-driven excellence in delivering care with all the above?
I believe there are five reasons why Dr. T’s EHR experience avoids so many of the problems with EHRs encountered nationally.
- length of use: Dr. T has been on an EHR for more than 15 years– she is “an early adopter.” The standard rule of thumb on EHR adoption is it will take a physician (and the staff in a medical office) 2 years to fully acclimate to this new model of record-keeping and communication. Partly Dr. T’s skill can be attributed to her years of experience.
- proper IT support/upkeep: Dr. T works in an office with multiple physicians, who collectively invest in readily available IT support. Many physicians can’t sustain the cost of on-site HIT support, notably the 15% that remain in solo practice.
- mobility (tablet) and eye contact: Another major complaint about EHRs from physicians is they detract from the closeness of the traditional physician/patient relationship; lack of eye contact is the number 1 patient complaint about EHRs most frequently cited. The small tablet Dr. T referenced from her lap allowed her to sit knee to knee with my Mom and establish the connection necessary to leave them both satisfied. However, tablet models of EHRs only became available in the last decade (The University of Chicago was the first hospital to work with tablets on a large scale in November 2010).
- recent technology: As is true with all technology, EHRs modify and advance significantly- and rapidly. In 2012, many purchasers of EHRs were on their second- even third- iteration. Dr. T represents a physician who has continued to update her technology as advances came on the market. However, the cost of new HIT software will keep many physicians holding onto older technology as long as possible.
- interoperability (at least within her system): As explained in detail in the Kaiser/Fortune article, arguably the biggest disappointment about EHRs in 2019 is the continuing lack of interoperability. Globally, that is also true in our hometown where Dr. T practices- but it is not true locally. Many hospital systems (large) and individual hospitals/medical communities (small) have conquered interoperability within their system. In a rural community where all providers are interwoven- local connections mimic what was imagined on a grand scale. Sitting in her office- Dr. T was connected to all the doctors and labs she was referencing in Mom’s care (save the one doctor in Rhode Island from before Mom’s move). The vision of EHRs can’t be realized without true interoperability across all barriers local, state, and federal- but in the interim, Dr. T can work happily on a local level.
How Do We Address the Problems With Our EHRS?
We are approaching 30 years from the birth of a vision for a national electronic medical record-keeping system- we are almost 20 years beyond IOM’s 2000 due-date for complete adoption.
Nonetheless, and as extensively detailed in the Kaiser/Fortune report, the problems with EHRs are enormous. But even those authors do not suggest the answer is to return to paper. The problems encountered in the old system are untenable in our technology-driven world.
The only way forward is to continue to improve the electronic record system we have- but to do so with a vigor we have not expended to date. We need a significant increase in federal funding and to draw the best minds in technology to build a fully integrated system. We need significant input from physicians and nurses to create EHRs that are intuitive, efficient, and reliable.
Most of all, we need to make technology companies responsible for true interoperability across the nation- with consequences if they fail.
Unfortunately, we also need more time.
A Moment of Personal Reckoning
Reading the Kaiser/Fortune article, I am humbled remembering my optimism in the early years. I naively picked up the “Paperless Health System” torch without recognizing the enormity of the challenge.
I admit, with chagrin, that I thought the problems with physicians were generational, not structural in the software.
I was dazzled by the possibilities of access to information, freedom from the problems of paper, the possibilities of population health. For these past decades I have been far too dismissive of the costs of insufficient EHRs on patients, physicians, and our health care delivery system.
I am thankful for the awakening Kaiser and Fortune provided me this week.
But even so-
I am reminded of an Obstetrician who attended a program I taught back in 2004. He was struggling to adopt this new technology in his practice but was gamely moving forward with his EHR. He stood up in the audience to tell his fellow physicians that he compared himself to a woman in labor: “You know the baby is a really good idea, but in the toughest parts of labor, some mothers lose sight of that.”
That long-ago wisdom from a stranger in an auditorium has stayed with me all these years. That, and my very personal and recent experience watching Dr. T’s fingers on her tablet- are why I am renewing my confidence in what is possible.
Someday, heaven only knows how distant- the vision of a “paperless health care system” will be realized. And I still believe that the end result will justify this long, arduous path to that goal.
Want to Know More?
1. Of all the problems with EHRs, interoperability may be the most frustrating (and core to all the other issues- including patient safety). Computers in our health care system don’t talk to each other!
This central problem has been recognized for decades, but technology companies have continued to make systems that are proprietary (example: the technology for an MRI must be compatible with that hospital’s EHR, both are made by the same company, which has now captured the entire system under their brand).
Technology companies weren’t legally mandated to work together toward interoperability until the Affordable Care Act [“Obamacare”] in 2010. In the current administration, the point person responsible for fixing this mess is Jared Kushner.
To start to understand more about the problem of interoperability, go here, here, and here.
2. If you want to know more about the history of Electronic Health Records– here is more from Becker’s Health and the AMA Journal of Ethics.