My friend Bill recently complained to me that he doesn’t like his personal health information recorded on a computer, he thinks the electronic medical record is responsible for raising his health care costs, and that “Obamacare forced this [type of record-keeping] on my Doctor.”

There are several things in that complaint I would like to discuss.

Why Did Your Health Information Go from Paper to Electronic?

It is easy to romanticize the past in many areas of life- but health care is especially ripe for nostalgia.

I, too, fondly remember my physician in a quiet exam room discussing my health with me- just the two of us- my personal record in a manila folder on her desk- fading to a softer shade of yellow as the years passed.

But really?

That folder wasn’t connected to anything (including my other physicians), existed solely in her file cabinet, and was subject to the whims of spilled coffee, a harried staff person’s misfiling, or a cataclysmic flood (such as the million or more health records destroyed in Hurricane Katrina in 2005).

To get a copy of my paper record, I had to ask my doctor, pay her staff, and wait days- and even then, access to my health information depended on the legibility of her handwriting minus the corruption of the text through copying and faxing.

The same was true for all Americans lucky enough to have consistent care from one doctor; many Americans didn’t have insurance coverage or financial resources necessary to assure dependable care from one source- and tended to have a patchwork of records inaccessible to those who were tending to their medical needs.

Hand-written prescriptions were particularly dangerous in a paper health care system- in 2010, AHRQ (the Agency for Healthcare Research and Quality) reported 21% of handwritten prescriptions contained at least one prescription-writing error. Medications ordered in hospitals required transcription into the record by someone other than the physician, creating another level of risk.

The problems with paper records increased when viewed at the level of population health. Difficulty in gaining access to data of sufficient size stymied public health and medical advances. Standardization of health care delivery (such as how best to treat a heart attack) and identifying safety traps (such as equipment in hospitals that made staff errors more likely) were limited by access to information.

These problems with paper medical records became untenable as the birth of digitalized information and the blossoming internet were transforming other industries, including banking (beginning in New York in the early 1980s), travel (the first “Pre-Online Travel Agency” launched in October 1985), and shopping for home goods (beginning in 1994, preceding the launch of both Amazon and eBay in 1995).

In 1991 the goal was standardization of medical data through the development of a “model medical record.” (As early as the Nixon Administration the dream of “Time-Oriented Patient Records and a Computer Databank” was afloat. In 1972 the first electronic medical record was created.)

In January 2004, President H. W. Bush called for “widespread adoption of interoperable electronic health records (EHRs) within 10 years” and created agencies within HHS to accomplish that goal.

The potential of digital health records- and concerns for the security of the information they contained- led (in part) to HIPAA [the Health Insurance Portability and Accountability Act], which became law in 1996.

Continuing advancements in digital technology, cybersecurity, and medical informatics resulted in additional federal protections of digital health records, including:

HIPAA Privacy Rule [April 13, 2003]
HIPAA Security Rule [April 20, 2005]
HIPAA Enforcement Rule [March 16, 2006]
Genetic Information Nondiscrimination Act of 2008 (GINA)
American Recovery & Reinvestment Act of 2009 (including the HITECH Act February 18, 2010)
HIPAA Omnibus Rule [September 23, 2013]

To my friend Bill, yes, Obamacare in 2010 was based largely on a digitalized health care system, but it did not require individual providers to adopt digital records.

How did the transition of Medical Records from Paper to Electronic Happen?

Paper records became digital records with difficulty– which continues to this day- in part because the logistics are enormously complicated.

Unlike stores, factories, and other industries that had UPCs and other tools to help them utilize new information technology, digitalizing health care required scanning billions of pages of hand-written records- many decades old- into computers.

Those technical difficulties paled in comparison to the frustrations experienced by health care providers- especially physicians who remained in solo or small office practices.

EHRs are expensive- $163,765 per implementing physician according to one 2015 estimate. They also cost time- calculated at 6 hours of data entry a day for a primary care physician in 2017. Medical practices must also invest in staff training, upkeep, and continuous IT support.

EHRs even changed the experience of practicing medicine- both physicians and patients report a loss of intimacy with a computer in the exam room.

Physicians bear the brunt of implementation; Physician resistance to electronic medical records is well documented, and EHRs are often blamed as the cause of physician burn-out.

All that being said- the march to the “Paperless Health Care System” envisioned in the early 1990s continues to advance: in a 2004 survey under 13% of physicians reported using an electronic record; in 2017 the CDC estimated 85.9% of office-based physicians used an EMR/EHR* system.

Again to Bill- electronic medical records were not “forced onto doctors” by any particular law- but indeed have led to significant dissatisfaction among many physicians- particularly older doctors who are more likely to be in small or solo offices.

Do EHRs Raise the Cost of Health Care?

EHRs have raised health care costs, nationally- but that was not the anticipated result.

The push toward EHRs was partly because of an expected reduction in health care expenditures nationally. The Rand Corporation projected $81 billion in savings annually to the American healthcare system in 2005.

However, billing for medical care has always been dependent on documentation. As EHRs made it easier to record care- it also became faster to bill. Physicians who had left money on the table with old paper records (because there wasn’t enough time to write everything down) could now bill what they were owed. Health care costs rose nationally.

With that facilitated documentation, some physicians began to bill beyond what was allowed– fraud that falls under the False Claims Act. Rooting out providers who use computerized records to over-charge became a priority of billing enforcement bodies as EHRs became more prevalent, and remains a concern for both government programs and private payers. This, too, led to the escalation of national health expenditures.

As a result, and ironically, the Rand Corporation that was singing the savings of EHRs in 2005 reported in 2013 that “evidence of significant savings is scant” and “increasing concern that electronic records have actually added to costs by making it easier to bill.”

To my friend Bill’s complaint- is it possible that the increase in your health care reflects increased costs due to EHRs? Yes, but not because increased administrative costs due to EHRs are passed on to you- that is not allowed in most circumstances. However, the increased charge for your care facilitated by the EHR would most likely increase your bill.

Would Paper Records be Better?

Thirty years into the transition to a “paperless” health care system, significant work remains before we will maximize the potential of EHRs.

But is a return to paper medical records the answer?

No more so than waiting for a book of paper airplane tickets to be delivered by snail-mail or sitting at the bank to pick the design of your new paper checks.

So, with sympathies to my friend Bill and others who dislike EHRs- there is no going back.

All we can do is continue to work to make this new digital health care world better for us all.

*initially electronic health data systems were called “EMRs” for Electronic Medical Records- over time the accepted title segued to “EHRs” for Electronic Healthcare Records

Want to Know More?

HIPAA is a very broad law covering many issues (including the expansion of Fraud & Abuse law and the portability of insurance after a person leaves a job), but what most people identify it with is patient privacy. If you want to know about your rights as a patient under HIPAA- plus watch a brief film- go here. There are extensive resources for physicians and other health professionals on how to be HIPAA compliant here.
If you enjoyed this brief history of EHRs- you might also enjoy this graphic with a bit more information here.