Electronic Health Records:
Challenges and Opportunities
In just a decade, medical documentation has transitioned from mostly paper records to mostly electronic records. According to the Department of Health and Human Services, 78% of office-based physicians and 59% of hospitals use a basic electronic medical record (EMR) or electronic health record system (EHR).
This move came about largely due to a strong governmental push that began in 2004 with the establishment of the Office of the National Coordinator for Health Information Technology (ONC) by then-President Bush. The office was tasked with the goal of supporting the expansion of EHRs and helping to create a nationwide network. Not long after, in February 2009, the American Recovery and Reinvestment Act was passed under President Obama, pushing $19 billion toward the development of health information technology through the HITECH Act. This was further bolstered the following year with the passage of the ACA, which infused even more money into the system, established Meaningful Use measures and began innovative pilot programs to study ways in which high functioning EMR systems could help to improve quality of care and reduce healthcare costs.
These rapid regulatory changes have presented major challenges to office practices and hospitals as they try to adapt to the new requirements while also remaining operationally and financially sound. Despite the huge investments that have been made in new technology, there are conflicting opinions about the value of EHRs and whether or not they will truly help improve quality of care while decreasing costs. A recent study by Medical Economics indicated that 67% of physicians are displeased with their EHR systems. Complaints about EHRs abound, but the most common include the following: high cost, weak functionality and interoperability, safety and liability risks, and interference with physician-patient and physician-to-physician relationships.
1. High Cost
Investing in EHRs can seem ironic when one of our major concerns in healthcare is skyrocketing costs. System-wide implementation of best-of-breed EHR systems, such as Epic, can run in the hundreds of millions of dollars. Beyond the up-front investment, budgets can also be blown by unexpected vendors’ fees, upgrades or ongoing maintenance needs. Unfortunately, it’s not uncommon these days to hear of hospitals going bankrupt as a result of underestimating their technology spending. Organizations must consider not only the hardware and software, but also the costs of implementation, training, support, and the potential loss of productivity during the startup phase. There’s also the concern that as consolidation occurs (with larger vendors buying up smaller ones), organizations may need to purchase entirely new EHR systems as their present systems become obsolete.
2. Functionality & Interoperability
Incredibly, there are over 1,000 electronic medical record platforms out on the market today. There are the big players with recognizable names — Cerner, Epic, Allscripts, NextGen, athenaClinicals — but there are also countless smaller vendors, some of which provide customized EMR systems for specialists. Functionality varies greatly with each system: data entry can be inefficient and time-consuming for certain systems, but not others. Other functionality issues can include slow processing, formats that are not user-friendly, or limited capabilities. Most of these systems are also highly proprietary and may not communicate well with each other. This lack of interoperability presents a barrier to the transparent communication of health information, preventing adequate coordination of care on the small scale and obstructing population health management on a larger scale. The ONC is currently working on an interoperability standards advisory that will hopefully better guide organizations as they try to develop networks with disparate EMR systems.
3. Safety & Liability
As the saying goes: “garbage in, garbage out.” An EHR system is only as good as the information that is put into it. If documentation is poor, unreliable, or unable to be accessed when needed, it poses a threat to quality of care. Additionally, there may be information in the record that should be reviewed but isn’t brought to a provider’s attention, which poses yet another kind of safety risk. We saw this happen at Texas Presbyterian Hospital in Dallas during the Ebola outbreak. Technology can also be at risk for programming errors, glitches, and power failures, paralyzing normal day-to-day functions. And, as we have heard many times in recent days, technology is at risk for data breaches, posing a threat to patient privacy and confidentiality by exposing personal health and financial information. In all of these cases, organizations can become susceptible to significant malpractice and/or liability risks.
4. Professional Relationships
Physicians like Dr. Adrian Gropper, CTO of the non-profit Patient Privacy Rights, are concerned that current systems are interfering with physician-patient and physician-to-physician relationship. Providers often complain that EMRs interfere with clinical care, making interactions more impersonal and less face-to-face, while also degrading clinical documentation. And disparate systems with poor interoperability make it difficult to communicate with other providers as well. Additionally, as organizations adopt legacy systems, referral patterns change, favoring those providers that are network-enabled and putting other, independent providers at risk of being marginalized. There’s also the growing pressure for physicians to meet state and federal health IT mandates. In an environment where there is already a shortage of primary care physicians, there is concern that EMRs will heighten physician dissatisfaction and drive a further shortage of physicians.
These challenges are formidable, but can they be overcome?
The broad adoption of electronic health records (EHRs) has presented healthcare professionals with numerous challenges. It’s not surprising that many of us are left wondering: Will all of this effort to rapidly adopt EHRs even be worth it in the end?
Where We Are Now
To better understand this, it’s helpful to first take a closer look at the current state of the U.S. healthcare system. In 2000, the Institute of Medicine released their landmark report, To Err is Human, which exposed the alarming number of deaths that occur as a result of medical errors in the U.S. This was a big shock to many who assumed that the American healthcare system was the best in the world. To add insult to injury, we also discovered around that same time that healthcare costs were skyrocketing — in fact, they had doubled from 1993 to 2004.
According to the Commonwealth Fund, the United States today has the most expensive healthcare system in the world, spending about $8,500 per capita, or nearly 18% of our GDP, while also consistently ranking dead last in overall performance and quality compared to all other industrialized nations. One can’t help but wonder: What are other countries doing that we’re not? Well, two things in particular stand out when we compare our healthcare system to theirs: 1. A lack of universal healthcare coverage; and 2. A lack of high-functioning, fully-integrated health information systems. It turns out that our international counterparts have surpassed us when it comes to providing high quality, affordable, and accessible healthcare. One of the key elements of their success has been harnessing health IT.
Opportunities to Consider
Considering all of this, it’s no surprise that we have had bipartisan support for the expansion of EHRs from both Presidents Bush and Obama and that we continue to invest in creating a fully interoperable, nationwide network for health information. If EHRs can be harnessed properly, they promise to deliver lowered healthcare costs, improved quality, increased access, and improved population health. Let’s take another look at those challenges presented previously. Where are the opportunities in these challenges?
Despite the high costs of implementing new EHR systems, there are also numerous studies that report that high-functioning EHR systems can help to decrease costs in the long run. One study found a 12.9 to 14.7% reduction of duplicative testing with the use of computerized provider order entry (CPOE) and clinical decision support (CDS) in an outpatient setting. Overhead costs may also be decreased through the reduction of chart pulls and from reduced paper, supplies, and storage costs, as well as via decreased transcription costs. Efficiencies can also be gained in billing processes with improved and complete documentation, improvements in the charge and capture process, and through decreases in billing errors. A study from Massachusetts found that paid malpractice claims may also be minimized with use of EHRs vs. paper records (6.1% vs. 10.8% paid claims).
It remains to be seen if EHR-induced savings will be favorable versus the cost expenditures required to operate them. But these studies show that there’s reason to be hopeful.
2. Quality & Communication
Investing in a high-quality EHR system has also been shown, in some studies, to result in higher overall quality, improvements in safety, and decreases in delayed medical decision-making. A study of hospitals in Florida found that those with greater investments in health information technology scored higher in quality measures. A similar study found that those hospitals with greater investments had lower patient complications and lower mortality rates as well. Other research has demonstrated that high-quality EHR systems improved prescribing patterns, too. In these ways, EHRs may support improved outcomes and thereby reduce malpractice and liability risks.
Highly interoperable EHR systems have also been credited with improving the communication and coordination of care between providers, and with decreasing delays in medical decision-making that can result from having to wait for the transfer of medical records. A strong health IT system can also enhance communication between providers and patients and help to foster increased patient engagement through the use of applications such as patient portals and interfaces with radiology, laboratory, and medical devices. Patients may be more apt to become actively involved in managing their health and participating in shared decision-making as a result of having easier access to their health information.
Another advantage of EHRs is that they can help to provide convenient and timely access to a patient’s health record. We’re still a far way away from a fully transparent nationwide (or global) healthcare network, but these advances are coming. In addition, as the telehealth and mHealth market grows, and as we see better integration of other platforms with EHRs, we will likely see a huge revolution in access to personal health information. This need is especially urgent in light of the dire shortage of primary care physicians. Telehealth capabilities of EHRs may very well be the solution to providing access to medical care for patients in underserved or remote regions.
4. Population Health
As we succeed in integrating systems and improving interoperability, we will have the ability to aggregate huge amounts of health data for entire populations of patients. This “big data” can be used to conduct population health research, which can help identify patterns such as risk factors for diseases. With this, physicians will be better able to recommend preventative measures and evidence-based best practices. This information can also be harnessed to change practice patterns and hopefully, to affect positive healthcare outcomes on a broader scale. EHRs can also help to enhance reporting capabilities, which may help identify potentially dangerous outbreaks or treatment-related risks quickly, so that they can be managed in a more timely and effective manner.
The Bottom Line
EHRs hold a great deal of promise to truly transform our ailing healthcare system. How well we succeed will depend in large part on how we can overcome and manage key challenges affecting cost, interoperability, safety, and patient-centered care. It remains to be seen if the cost-to-benefit will be ultimately favorable, but these preliminary findings and evidence of international success give us reasons to be hopeful.
This article was originally published at MedTechBoston.
Kirti A. Patel, MD is a women’s health physician at UMass Memorial Healthcare and a Master’s degree candidate in Healthcare Leadership at Brown University. She has 13 years of clinical experience as an Ob/Gyn, practicing both primary care and surgery. Prior to clinical work, Dr. Patel participated in scientific research across a variety of disciplines, including oncology, immunology, and molecular genetics. She received her BA from Boston University, her MD from the University of Medicine and Dentistry of New Jersey, and will receive her Master’s degree from Brown University in May 2015. Her Master’s thesis addresses the challenges of achieving interoperability of electronic health records. Dr. Patel avidly follows scientific and technology innovations in healthcare.