Saturday, January 18, 2014

They Shoot EHRs, Don't They?

For all of us who have been waiting for EHRs to revolutionize health care, well, I fear we may have to wait a while longer.  Many a lot longer.

That may sound odd, because there would appear to be lots of good news on EHR adoption.  Karen DeSalvo, the National Coordinator for HIT at HHS, thinks so.  She reports that nearly 80% of office-based physicians use some type of EHR, almost 70% of office-based physicians intend to participate in the federal EHR incentive program, and 48% use a system that qualifies as at least a “basic system.”   Indeed, CMS reports over $16b in EHR incentive payments – to 386,000 professionals and 9,400 hospitals. 

That’s all good news, right?  Not so fast: witness an article in The New York Times on the growing use of “scribes” to do the actual input into the EHR for the physicians – often being right in the exam room with the physician.  The article cites several sources who see the input as purely clerical.  “Making physicians into secretaries is not a winning proposition,” says one primary care physician in explaining the problem.  The cost for these scribes is typically borne by the practice, and is made up by improving the physicians’ efficiency in seeing more patients.

Somehow I can’t help but feel we’ve taken a wrong turn somewhere on the road to EHRs.

CMS has spent $16b to incent EHR adoption, hospitals and providers have spent some multiple of that amount to buy and install the EHRs, and yet practice overhead – and probably health care spending -- is going up in order to pay for scribes to actually use them?  No, that’s not good news.
It’s worse than that.  A report released last fall from RAND and the AMA found that the current state of EHR technology has significantly worsened physician dissatisfaction in multiple ways, including poor usability, data entry, impact on face-to-face interface with patients, and conflict with clinical workflow.  Physicians like the concept in principle – just not in actual execution.
ONC knows usability is an issue, and claims it is a priority.  They note that barriers include that fact that the buyers often aren’t the actual users, that it’s hard to change EHRs once implemented, and that they exist in the context of legacy software that is hard to change.   All are valid barriers, and none are ones that are likely to change in the near future.

One would like to imagine that all the EHRs that have been put into place reflect thoughtful analysis of the costs and benefits from the hospitals and physician practices, but that may not be the case.  The IOM just released a proposed standard model for evaluating ROI on EHRs, which seems like a good idea…five or ten years ago, before all those billions had been spent.  One wonders what kind of analytical models have been used in the meantime; I hope the purchase decisions weren’t simply due to the desire to not miss out on HITECH incentives.  

Even worse, another recent report from RAND did a meta-analysis of studies involving health IT, and found less-than-robust results.  As the authors say, “[A]lthough the health IT evaluation literature base is expanding rapidly, we are concerned that there has not been a commensurate increase in our understanding of the effect of health IT or how it can be used to improve health and health care.  They conclude, “the health IT literature is expanding rapidly but failing to produce a commensurate amount of useful knowledge.”  We’re not only not producing useful knowledge but we’re also not even quite sure how we should be studying the impacts of HIT.  

We may be in the era of “big data” in health care, but we’re not be in the era of useful data yet.

Adding insult to injury, a report from IDC Health Insights found that 38% of documents used in health care are still paper (and I find that way, way too low), a third of which just get typed into a computer at some point.  And, according to IDC, 62% of health care workers say volume of paper has increased or stayed the same over the past few years, despite the huge increases in EHR adoption.  Those findings illustrate that EHRs are simply adding work, not replacing it or making processes more efficient.

Hard as it is to believe, the increased physician dissatisfaction, lack of evidence of improved outcomes, and questionable ROI are not the only bad news.  OIG released a report earlier this year that warned that CMS has not done enough to deter fraud and abuse associated with EHRs, such as the use of “cut-and-paste” functions that may help providers document care that was not actually provided.  OIG warns such practices may have led to $75b to $250b in healthcare fraud.  That’s serious money.

So, yes, overall it’s hard to see that we’re getting the desired bang for our EHR buck.

I am deeply sympathetic to physicians, but -- unless they also had scribes for their paper records (or dictated notes for transcriptionists) – that sympathy has its limits.  Moving to EHRs undoubtedly requires significant changes to clinical processes in order to be fully effective.  I worry that physicians who employ workarounds such as scribes may not have truly evaluated what changes the EHR means for their practice.  Reengineering work processes is one of the hardest things for any business to do, but if any industry needs it – EHRs or no EHRs – it is health care.

Nor am I buying the argument that physicians are computer or technology phobic; a study last year from Epocrates found 86% of physicians use smartphones in their professional activities, and 53% use tablet at work.  Not exactly a bunch of Luddites.  I blame the design of EHRs.

A well-designed EHR shouldn’t be harder than paper records to keep, view, or add to, while they should provide much, much better ability to detect trends, receive real-time warnings or suggestions, and move data from one provider to another.  It should fit into and improve clinical workflows.  So why don’t we have such well-designed EHRs?

I wonder if HITECH has had the effect of impeding progress.  Lots of smart people have done lots of hard work in coming up with the federal certification process and meaningful use standards, but federal standards are not usually associated with innovation.  In fact, what other industry (besides education, which is its own sad story) needs federal incentives to computerize its processes and go digital?  Our big investment in EHRs is well on its way to being used to raise costs and decrease efficiency.  You have to admire the U.S. health care system for its chutzpah. 

I don’t normally drink the Apple Kool-aid, but when it comes to EHRs I’m wondering where the Apple-like products are, ones that surprise and delight their users.  Apple didn’t need federal funding to develop the iPod, iPhone, or iPad, nor did their users ask for incentives to buy them or to change the way they access music, movies, or a host of other parts of their lives.  Nor do those users typically hire other people to hit the keys for them.   

What I don’t think we’ve really done is fundamentally rethink the concept of a patient record.  We shouldn’t be simply putting the paper record in an electronic format; we should be creating a 21st century version of it – interactive, visual, collaborative.  It should be part of the clinical process – not an impediment to it -- and should serve as an added diagnostic tool.  Its use should delight clinicians and make their jobs easier, not force them to hire scribes to use them on their behalf.

If any organization is doing that, I’d like to know about it. 

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