Electronic health records (EHRs) have become adopted for widespread use by a growing majority of U. S. physicians. It has been assumed that the wider adoption of EHRs would improve efficiency and patient safety, reduce diagnostic testing and medical errors, improve continuity and quality of care, and save money. Their use was accelerated by the Affordable Care Act (ACA) after its passage in 2010. The Centers for Medicare & Medicaid Services (CMS) have further stimulated their adoption by developing "meaningful use" criteria tied to reimbursement levels.
To be fair, EHRs have brought some useful capabilities to U. S. physicians, including electronic prescribing of medications, receiving clinical test results, electronic lab orders, electronic administration tools, and communication with patients. They have been helpful in home monitoring of high-risk patients, especially those with congestive heart failure, in reducing hospital re-admisssions. A 2015 survey of 600 U. S. physicians found that one in four physicians offered telemonitoring devices to patients to enable them to monitor their health care. That same study, however, found that less than one-half of surveyed physicians believed that EHRs improved patient outcomes. (1)Some adverse impacts on medical practice Although EHRs have largely replaced paper records and brought some efficiencies to the process of delivering health care, there are some important problems that call into question some of the assumptions made by their architects. These are some of the unintended consequences of the widespread adoption of EHRs as they now are:
- A 2016 national study in four specialties (family medicine, internal medicine, cardiology, and orthopedic surgery), however, identified some growing frustration with EHRs. Physicians were spending almost two hours of each clinic day for every hour of direct face-to-face time with patients. (2)
- Data entry is time consuming and inefficient; physicians are forced to type into the computer during patient visits; when that burden becomes too diverting from relating to and examining the patient, scribes are brought in to deal with computer entry.
- A 2013 report from the RAND Corporation confirmed the inefficiency of EHRs, noting inadequate exchange of health information and interoperability, and concluded that template-based notes degrade the quality of clinical documentation and care. (3)
- A 2014 study found that less than one-half of U. S. hospitals can transmit a patient care document and that only 14 percent of physicians can exchange patient data with outside hospitals or other providers. (4)
- Exchange of health information and interoperability are problematic as manufacturers resist standardization and customize EHRs to their clients; as one example, Wisconsin-based Epic, with the largest market share in the country for EHRs, has placed three different systems in nearby Madison's three hospitals, requiring attending physicians to learn each system.
- The hassle of dealing with EHRs has contributed to increasing frustration and burnout of one-third of their physician users. (5)
- A 2012 study found that physicians' access to EHRs did not reduce their ordering of unnecessary tests. (6)
- Another 2012 study found that EHRs led to increased costs of tests performed, and that many hospitals raised their ER billings to Medicare.
Based on the above, we need to conclude that EHRs have brought some efficiencies to U. S. health care but at a high cost, including high administrative costs and time, as well as adverse impacts on the doctor-patient relationship without evidence to date of improved patient outcomes. They have also become a billing tool that is vulnerable to gaming the reimbursement system by physicians and hospitals, contributing to the ACA's inability to contain health care costs.
What lessons can we draw from this mixed experience?
Despite grudging acceptance of EHRs by most physicians, they are here to stay. Nobody wants to return to paper records. The above adverse results are symptomatic of our profit-driven multi-payer financing system that reimburses physicians, hospitals, and other health care professionals and facilities within a hugely bureaucratic, fragmented and unaccountable health care system. EHRs have become a billing instrument for a system out of control. For separate reasons that add further complexity, believe it or not, we now have 140,000 different billing codes (not a typo!) (7)
All of the above outcomes will continue unchecked until we fundamentally change the financing system by adopting single-payer Medicare for All and simplified administration, including standardized EHRs that are interoperable and based on evidence-based services. Improvement of EHRs will probably require this level of financing reform before they can include the kind of readily accessible information about evidence-based services as well as sufficient personal information about patient preferences.
EHRs should become useful from physician to physician and among health care facilities anywhere in the country. Their content needs to be re-thought so that repetitive templates of unnecessary clinical information are eliminated. Quality measures should be improved so as to be better aligned with outcomes of care. (GAO, Report to Congressional Committees, October, 2016.) Billing codes need to be reduced to rational and meaningful levels. Such useful medical and billing records have been achieved by many other advanced countries around the world with one or another form of universal access based more on a service ethic than a competitive profit-maximizing business "ethic." They should be achievable if we have the political will, and should be the goals of our society on a non-partisan basis for the common good.
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans