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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