By Frank Ferrara of MD NetGuide
An infant technology that no one uses is not news; a technology with the potential to dramatically change the way a crucial sector of a nation’s economy operates most certainly is. So, when we see a trend that seems promising, we leap; we project, we extrapolate, we even advocate to some degree. And in our zeal to identify the upside of a trend, we sometimes overlook, or downplay, the other side.
Regular readers of MD Net Guide will know that we have long been enthusiastic supporters of electronic health records (EHRs). We have published articles examining the ways that EHRs could affect physician workflow, disaster response (www.mdng.com/departments/ 2006-september/pc_feature. html), the likelihood of medication errors, and the economics of medicine; we continue to believe that this technology has the potential to be utterly transformative.
On the other hand, a sizable percentage of our readership appears to have reservations. In July 2005, the American Academy of Family Physicians (AAFP) announced its goal of having 50% of its active membership using EHRs by the end of 2005 (www.aafp. org/online/en/home/policy/federal/ congressional-testimony/p4pmedicare. html). Nearly one year after this deadline, fewer than 30% of AAFP members have adopted EHRs. Adoption proceeds in fits and starts, and physician enthusiasm for EHRs has been modest. As a concept, the EHR remains firmly mired in the realm of potential.
Given physician reluctance to adopt electronic health records, we thought it was time to take a closer look at the downside of EHRs—the part usually relegated to a few quick paragraphs toward the end of an article otherwise cheerleading for the technology.
Our first step is to develop a coherent picture of how many physicians are using EHRs at the moment. Many physicians may use computer-based methods to store some types of information or perform some tasks, yet still rely on more traditional paperbased records for other data. In 2006, the Medical Records Institute (MRI) released its Eighth Annual Survey of Electronic Health Trends and Usage (www.medrecinst.com/survey/2006/ download.asp); the results included responses from 729 healthcare providers. According to the MRI, the number one priority governing health IT decision- making among respondents was the “need to improve clinical processes and workflow efficiency,” with the second priority the “need to improve quality of care.” Among the survey’s most interesting findings:
• 57.2%, 56.4%, and 55.4% of respondents used electronic billing applications, electronic scheduling applications, and electronic patient appointment applications, respectively.
• Approximately 60% of respondents used electronic means to capture and store patient demographic information. • Less than half of respondents used EHRs to capture and store any other type of information, including allergies, lab results, medication lists, vital statistics, medical history, or progress notes.
• Fewer than 40% of physicians used EHRs to access patient information from a remote location.
• Approximately one-quarter of respondents currently utilize some type of ePrescribing application.
US physicians’ collective response to electronic health records has been indifferent at best. The key question is: why?
Physicians have been characterized as being inherently technophobic. However, as Pflugerville, TX, family practitioner Everest A. Whited, MD, PhD, noted in a letter to MD Net Guide, this characterization is not accurate. “Physicians all carried beepers when almost no one else had them,” Dr. Whited told us. “For very little money, beepers allowed us to remain connected 24 hours a day to our hospitals and offices, [with] no special training required. Cell phones were also an instant hit with doctors.” Dr. Whited suggests that the problem with EHRs lies not in the physicians, but in the technology itself. Perhaps, he says, “EHR is just not ready for primetime.”
The Nature of the Beast
“Lack of adequate funding or resources” was cited by respondents to the MRI survey as the number one barrier to health IT implementation in general and EHR in particular; our own internal surveys have consistently confirmed this finding. In a speech given at the American Health Information Management Association (AHIMA) conference in Denver earlier this year, Douglas Henley of the AAFP and William Jessee of the Medical Group Management Association estimated that purchasing and installing an EHR system will cost a typical practice an average of $32,600 per physician; routine maintenance will generally run about $1,200/month. This means that for a single-physician practice, implementing an EHR will require an investment of around $47,000 for the first year.
Unfortunately, “the cost of the technology is not a closed system,” Douglas Hom, MD, told MD Net Guide. “It’s more akin to a hydra.” Most notably, the installation of an EHR is certain to disrupt office workflow while physicians and office staff acclimate to the new system; during this period of disruption—which may last six months to a year or longer—the practice will see fewer patients and thus bring in less income. “Or, conversely, I could just add three or four hours to my already 11- or 12-hour days,” says Whited. “What a sweet deal!” Meanwhile, he continues, “All EHRs that I have explored require much more data entry than is now required by any [paper] chart. All this extra data takes time to enter in the first place, and time to review at each opening of the electronic file.” This, in turn, leads to less time to spend with patients, often meaning less income.
Further, instituting an EHR system will require physicians to alter the way they practice, sometimes in ways that seem inefficient and counterintuitive. Using electronic records also requires doctors to spend the bulk of a patient encounter working on a PDA or tablet computer, a method that some feel reduces the humanity of the interaction. Finally, many physicians have continuing concerns about the security of data in an EHR.
But what of the upside? Proponents of EHRs—among whom we count ourselves— have posited any number of advantages to the computerized office, which collectively could outweigh the cost and initial inconvenience. These potential benefits do exist, but they are rarely as straightforward as they may seem to be at first. For example:
In Theory… Once the initial period of adjustment ends, EHRs will increase the efficiency of the physician–patient interaction, allowing doctors to see more patients and thus generate more revenue.
In Practice… This kind of ROI is incredibly difficult to quantify. There are always more things on which money could be spent than there is money to spend; physicians and institutions will understandably gravitate toward investments with clear returns. “Hospitals only have so much capital to invest,” says Henry Ford Health System CEO Nancy Schlicting. “If it’s between improving facilities and EHR…EHR often loses. You immediately get a new revenue stream from a CT scanner.” Moreover, if an EHR does lead to better and more efficient care, it could actually reduce revenue, according to CMS director Mark McClellan. “In every other sector, when IT is introduced and services improve, people pay more,” he says. “But in healthcare, you’re paid more if there are more complications and you provide more services. If payments drop when you provide better care, it’s difficult to convince providers to invest in IT.”
In Theory… EHRs will allow physicians to reduce costs associated with transcribing notes, organizing files, and other administrative tasks.
In Practice… This is certainly true. In 1980, a doctor in private practice employed an average of 2.2 people; today the figure is 5.6. Most of these additional employees are administrators, transcriptionists, and the like. EHRs would eliminate or reduce the need for these employees. Of course, this means that the cost savings in question comes as a result of firing staff members, a development that may not be welcomed by every physician.
In Theory… EHRs and related technology will reduce the likelihood of many forms of medical errors, including medication errors.
In Practice… The evidence on this count is inconclusive. In a study published in the March 9, 2005, issue of JAMA, Koppel, et al acknowledge that previous research has suggested that computerized prescriber order entry (CPOE) may reduce the incidence of certain types of medication errors by up to 81%. However, their own analysis found that CPOE actually facilitated new types of error, including “fragmented CPOE displays that prevent a coherent view of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system…and inflexible ordering formats generating wrong orders.” Establishing a system design that doesn’t create several entirely new classes of error would likely increase physician interest.
In Theory… EHRs are safer and more accessible in times of natural or other disasters and less likely to be destroyed by hurricane, flood, or fire.
In Practice… Hurricanes, particularly those as devastating as Katrina, are actually quite rare; computers break down much more frequently than levees. According to Dr. Whited, “In 30 years of practice, I have not met even one physician who has had his or her records destroyed by fire, flood, or locusts. On the other hand, I personally experience computer crashes or major glitches about every six months.” Hardware, software, or connection failures in a paperless practice can lead to unavailable records and rejected insurance claims. “My identity as a provider seems to be lost by the computer of one of our payors per year,” says Dr. Whited. He recognizes that electronic records might be useful in certain very rare emergencies, but maintains, “I am not sure that the unusual circumstance of urgent need for information that cannot be provided by the patient and family is really worth the cost to society [inherent in adopting EHRs].” In Theory… An EHR allows physicians from different practices, and even from different parts of the world, to share data on a given patient as part of a collaborative treatment effort.
In Practice… Every EHR system is different, and at present there are no universally accepted data standards that will allow disparate systems to communicate reliably with one another. In July 2004, AHIMA joined with the National Alliance for Health IT and the Healthcare Information and Management Systems Society to form the Certification Commission for Healthcare Information Technology (CCHIT; http://www.cchit.org); this body went on to create certification criteria for both ambulatory and inpatient EHR, which are available for review at http://www.cchit.org/physicians/learn/criteria. htm. More than two dozen products have received CCHIT certification to date, indicating that they are able to perform a set series of tasks, can exchange standards- based data with other systems, and meet several requirements related to security and privacy. Unfortunately, not every system is CCHIT-certified, and interoperability among even CCHIT products is imperfect at best.
A larger problem looms should the federal government ever establish national standards and require providers to adopt EHRs conforming to those standards. In such a case, the outlook for non-standard legacy systems is uncertain. Will physicians who pay $50,000+ to install an EHR in 2007 be required to make another $50,000+ investment in the future to comply with new regulations? If so, many physicians may understandably question the need to spend the money now.
Conclusion: Ask Again Later
The healthcare system has never been more plagued by inefficiencies and economic chaos; according to General Motors’ director of community health initiatives, Sam Shalaby, “if [GM] ran an auto plant like they run hospitals, we’d be out of business.” Even agnostics like Dr. Whited agree that “the theory behind EHRs is great,” even if the real-world execution of the concept has, thus far, been less than ideal. However, overcoming the barriers to adoption described above will be a considerable challenge. Ultimately, financial or other incentives for physicians who adopt EHRs—including the possibility of increased Medicare reimbursement for claims submitted using an electronic system—might help motivate cash-strapped doctors to make a change. The cost to the federal government to completely subsidize a nationwide changeover to EHR systems for every physician would be in the billions of dollars.
More importantly, as EHR technology continues to evolve, it is important that vendors work to devise applications that are highly customizable to the needs of the individual user. “What is needed is a stackable EHR,” says Dr. Whited, “in which a consultant could analyze a practice and build an EHR for the physician that was tailored to [his or her] individual needs.” In the meantime, while EHRs represent a viable solution for some practices, the majority of physicians will likely remain cautious when deciding whether to adopt an EHR system. The CCHIT website (www.cchit.org) includes a useful tool that allows individual practices to assess their EHR readiness; try using this instrument if you’re still not sure.