Gone are the thick, color-coded folders lining the seemingly endless shelves of doctors’ offices, replaced by bytes of data stored on remote servers.
Electronic health records (EHRs) have arrived, replete with financial incentives and promises to revolutionize health care.
An EHR contains details of a patient’s medical history, each visit with a provider, and diagnostic test results. With the patient’s permission, these records can sometimes be shared with family members, other clinics, and entire health systems.
Proponents herald the advent of EHRs as an essential transformation in our nation’s health care system, prompting improvements in patient outcomes, cost-savings, and access to medical care.
Others maintain that such goals have yet to be achieved despite adherence to the “meaningful use” guidelines stipulated by the U.S. government to earn incentives for using EHRs.
These critics charge that the rapid adoption of EHRs instead contributes to less efficient patient care by increasing clerical workloads for clinicians and heightening the rate of burn-out. Cost growth, at best, is slowed, but not reversed.
This piece provides a brief, at times irreverent, review of the available literature examining the wide-ranging effects of electronic health records in the increasingly absurdist system of health care in the United States.
Despite many promises and much public funding, EHRs haven’t lived up to the hype consistently. Instead, they might be contributing to lower-quality health care.
From Humble Beginnings
On April 26, 2004, President Bush set an ambitious goal to “ensure that most Americans have electronic health records within the next ten years.”
The following day he signed an executive order to create the Office of National Coordinator of Health Information Technology (HIT) to establish standards for electronic health records and identify the necessary steps to promote health IT.
Prior to this announcement, Federal agencies worked steadfastly to accelerate the use of technology within health care. In 2003, the U.S. Department of Health and Human Services sponsored a report by the National Academies of Science, Engineering, and Medicine to define the key capabilities of an EHR.
Among the eight central features outlined in the original report are,
- the secure storage of health information and data;
- decision-making support for clinicians;
- computerized provider order entry (CPOE) for tests and medications; and
- electronic communication among providers and with patients.
At its core, an EHR should allow health care teams to securely chart patient visits, provide channels for communication and ordering, and equip clinicians with information to aid in diagnosis and treatment.
Sounds simple, right?!
With enactment of the HITECH Act under the American Recovery and Reinvestment Act in 2009, President Bush’s vision moved one step closer to being realized.
The legislation set about “improving health care quality, efficiency, and safety” by creating guidelines for the “meaningful use” of EHRs to incentivize their adoption by health care systems and medical practices.
These guidelines include the capture of patient health information, such as diagnoses, drug allergies, and laboratory results, as well as the use of CPOE and the ability of patients to access their health information remotely.
For clinicians who achieve meaningful use guidelines, financial incentives range from $44,000 to $63,750 over five years. Unlike kick-backs from pharmaceutical reps, however, all-inclusive travel packages to academic conferences in the Caribbean aren’t included.
EHR utilization nearly doubled in the years following the HITECH Act. By 2015, nearly 90 percent of office-based physicians in the United States adopted an electronic health record, up from 42 percent in 2008 and 21 percent in 2004.
In that time, however, the components of an EHR required for official certification by the Department of Health and Human Services ballooned to no fewer than 60 in the most recent version of their certification criteria.
Despite this onerous process, there are currently 684 approved commercial vendors of electronic health records, though five firms supply about 60 percent of all EHR-users (Epic, Allscripts, eClinicalWorks, NextGen Healthcare, and GE Healthcare).
While a free-market society might normally applaud this kind of ripe competition and the potential for
profits meaningful social change, this proliferation may prove malignant, carrying with it several unintended consequences for clinicians and patient care.
The Promised Land
During the initial push to widen adoption of health information technology in the late 1990s and the early 2000s, proponents anticipated several sources of cost-savings by increasing the efficiency and safety of clinical care.
A 2005 study estimated the use of EHRs would prompt $81 billion in annual savings by reducing adverse drug effects, shortening hospital lengths-of-stay, and improving chronic disease management.
Another study in 2003 calculated that over a five-year period of using an EHR, there would be cost reductions of $86,400 per provider, accrued from “savings in drug expenditures, improved utilization of radiology tests, better capture of charges, and decreased billing errors.”
Other prospective work outlined the advantages of EHRs to provide clinicians with access to a wider range of patient health information, alerts to screen for important risk factors, and the ability to collect anonymized patient data to spur research to improve medical practices.
When faced with such great expectations, it is prudent to recall the words of the great philosopher Mick Jagger:
Waiting for the Other Shoe to Drop
In spite of much anticipation for EHRs to usher in an era of health care reform guided by unstinting support from Federal agencies, there is mounting evidence that improvements in the quality and cost of care have yet to be consistently achieved in the United States.
In fact, in an ironic twist of fate, the expansion of EHRs may actually be reducing the quality of health care by detracting from interactions between providers and patients as well as heightening clerical burden and physician burn-out.
To be sure, there is some contemporary work that points to a marked increase in the quality of care and cost-savings from the use of CPOE and clinical decision-making support within electronic health records.
In a number of studies, EHR-utilization had significant associations with a reduction in ADEs and unnecessary diagnostic tests as well as improvements in the management of chronic disease, patient satisfaction,[17,18] and the likelihood that physicians deliver preventive behavioral counseling to patients.
These results, while encouraging, are few and far between.
In one 2010 study, EHR utilization was actually associated with significant decreases in quality improvement for acute MI and cardiac failure. An earlier study in 2005 also documented a rise in mortality associated with CPOE implementation.
There are also one-time installation and ongoing training costs associated with the adoption of EHRs.
Initial estimates in 2002 placed a cost of $50,000 to $70,000 per physician in a three-physician practice to adopt an EHR while a study in 2011 projected a cost of about $32,000 per physician in a five-physician group during the first 60 days of implementation.
EHR implementation might also initially reduce productivity as well as interrupt physician workflow, resulting in lost revenue between $7,500 and $11,200 per physician in the first year of adoption.
Adherence to the meaningful use guidelines stipulated by the HITECH Act may negate these start-up costs. Again, clinicians who achieve these benchmarks are compensated between $44,000 and $63,750 over five years.
Despite these benefits, there are often ongoing costs to maintain software and provide re-training in addition to initial set-up. Annual maintenance may range from about $8,400 to $17,000 per provider depending on the size of the practice[29,31].
The lack of convincing evidence that EHRs improve health care might be a result of regional variation in the cost and intensity of care in the United States, independent of health or socioeconomic status.
Indeed, the benefits of EHR use that are evident in certain regions might be negated negated by outcomes in other areas on the aggregate.
Another likely source for the meager performance of EHRs lies in the components of the software itself.
The Road to Hell is Paved with Good Intentions
In addition to CPOE and clinical decision support systems, channels for patient-to-provider and provider-to-provider communication are considered two essential features of an electronic health record.
Such coordination between providers is inevitably stifled by the absence of uniformity between the 648 EHR vendors, leading many health care facilities to resort to faxing or emailing patient health information along the continuum of care.
Shame. This capability has the potential to drastically improve patient outcomes, providing clinicians across networks and health systems with ready access to the details of a patient’s medical history and previous clinical indications.
Whereas providers are rarely, if ever, able to communicate effectively through EHRs, patients are arguably too able to contact their providers.
Most electronic health records contain robust patient portals, through which an individual can view their medical records, manage their appointments, and communicate with providers through secure messaging (SM).
Use of these portals tends to be highest among those managing multiple chronic conditions, whose specialized care frequently requires more extensive monitoring.[34,35]
As is the running theme of this piece, there is mixed evidence as to whether patient portals actually have a positive effect on health care.
In two systematic reviews, patient portals led to significant improvements to the quality of care and self-management of chronic disease as well as helped clinics improve patient satisfaction.
Use of portals was also associated with increased diabetic patient satisfaction with their care,[38,39] improved glycemic control,[16,40,41] more efficient face-to-face clinical visits, and decreased administrative tasks.
One 2017 study also finds that using a patient portal leads to savings of about $90 per patient over a three-year period and fewer patient visits.
Conversely, two other systematic reviews suggest there are no effects of patient portal use on health outcomes and that there is insufficient “evidence that patient portals improve health outcomes, cost, or utilization” in another.
Nearly 80 percent of clinicians surveyed in one study express that such portals have a neutral or negative effect on clinical efficiency. Overuse of these portals may subsequently lead doctors to accept fewer new patients, further decreasing the efficiency of and access to care.
More, some primary care physicians have expressed concern that the expansion of patient portals and health technology could alienate geriatric patients. Indeed, older adults, military veterans, racial minorities, and low-income patients are less likely to use a portal, due in part to low technological literary or lack of access to connected devices.[49,50]
Using a patient portal might actually increase a primary care clinician’s workload due to the volume of messages received, which necessitate responses from physicians and could drive up face-to-face visits.
The broader, more pernicious effects that EHRs wreak on physician workload and quality of life stretch far beyond the use of patient portals…
“You can do anything, but you can’t do everything.”
Burnout is “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.”
Often, burnout manifests as physical or emotional exhaustion, depersonalization (in which a physician is not “emotionally available” for their patients), and lack of efficacy (doubt in the meaning and quality of one’s work).
Burnout is commonly found to increase the rate of substance use and suicidality among physicians[56,57] as well as adversely affect the quality of care by increasing the frequency of medical errors[58-60] and lowering patient satisfaction[61-62].
Emerging studies document that the advent of electronic health records continues to place a sense of well-being and work-life balance out of reach for physicians.
One 2017 study observed that primary care physicians spend more than half of their workday interacting with an EHR, with nearly two-thirds of that time dedicated to “clerical and inbox work” unrelated to direct patient care.
Similarly, physicians in family medicine, internal medicine, orthopedics, and cardiology were found to devote two hours working in an EHR for every hour they spent with patients.
In a 2017 study, 26 percent of physicians surveyed reported it was likely or definite that they would leave their practice within two years; burnout and dissatisfaction with EHRs were significant predictors of this intention.
Another survey conducted in 2016 reported that 48 percent of physicians are planning to reduce their hours, take a non-clinical job, or retire, with 33 percent of all those surveyed reporting that EHRs have detracted from their practice.
Although reducing clinical hours is documented to improve a physician’s sense of control over their work environment without affecting quality of care,[69,70] it is sure to exacerbate the already mounting physician shortage facing the United States, particularly in primary care.
With fewer doctors and a continued reliance on a fee-for-service payment scheme, physicians are almost obligated to see more patients, heightening the cognitive workload they face and continuing a malicious positive feedback loop.
Where Do We Go from Here?
Despite the yet-to-be-fulfilled promises of using EHRs, returning to a system of paper charts and medical records is unfeasible and perhaps ultimately inefficient.
Focus must now turn to improving the functionality of health care technology to make its features easier to use and promote connectivity between providers using different products.
The last few years have seen strides in at least some of these respects.
Several of the largest EHR vendors (including Epic, eClinicalWorks, and GE Healthcare) now allow their users to exchange data on the Carequality interoperability network, pioneered by the Sequoia Project in 2015.
Currently, more than half of all health care providers are connected through this network,  permitting some 2.4 million medical documents to be shared each month.
In the literature, there also exists a litany of suggestions to improve electronic health records. Some of the most compelling recommendations include,
- Physicians lobbying EHR vendors to “ensure they understand how physicians think critically” to make using such software quicker and more intuitive
- Create modern user interface designs through voice commands, interactive patient data visualization, and algorithms from artificial intelligence (AI) to assist in medical billing
- Integrating team documentation in which non-medical and clinical personnel assist in updating and managing the medical record
Without the careful excision of particular components of electronic health records and a commitment to pioneering solutions, bringing high-quality health care to the highest number of Americans will remain a chimera.
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