The tail (EHRs) wagging the dog (patient care)

A few years ago, before Meaningful Use was a known and loaded term, EHRs were optional. We called them EMRs, a term that has gone out of style and been replaced with EHR to infer a more complete medical record. EHRs were a big business back then, but not even a fraction of what the market is today because in those early, pioneering days of turning a clipboard and paper templates into digital records, doctor offices and hospitals got to choose whether or not they wanted to implement an EHR.

During that era, EHRs had to compete on features that were market driven, not on certifying to some stage of Meaningful Use; interestingly, the tide is swinging back to this market-driven paradigm. This was the time when a massive integrated delivery system like Kaiser could choose a relatively unknown EHR vendor from Verona, WI, called Epic because its feature set perceptively fit Kaiser’s needs better than any of Epic’s competitors. The result of these market dynamics were products with more features driven by customers and prospects.

Then came the HITECH Act and Meaningful Use. Without going into too much detail, HITECH created a series of carrots and sticks to encourage or force providers to adopt Certified EHRs. The success of HITECH, which can in part be measured in adoption of EHRs, has been staggering. Before EHR programs in HITECH only about 10% of providers used EHRs. Within 8 years adoption of EHRs has risen to about 85% of providers. This is a really incredible statistic considering the main users of EHRs—providers—are notoriously horrible at adopting new things and changing clinical behavior.

What HITECH and Meaningful Use Set out to Accomplish

For those that aren’t aware of why the use of EHRs has exploded, it’s a matter of carrots and sticks for providers to implement them. These carrots and sticks were laid out by a branch of HHS in a framework called Meaningful Use, which had 3 stages when it started; the government has since given up on Stage 3 or, more accurately, rolled it into the new MACRA legislation. The total cost of the program has been close to $35B, quite the market force to drive demand. Those three staggered stages were:

• Stage 1 — data capture and sharing;
• Stage 2 — advance clinical practice;
• Stage 3 — improve outcomes.

Stage 3 of Meaningful Use was terminated, or migrated to a portion of MACRA, when it became clear that most EHRs and health systems didn’t have the features, or the stomach, to attest to its requirements. MU3 was intended to build on MU1 and MU2 with additional requirements around patient access to data.

The Unintended Consequences

Whether you believe the following consequences were unintended or just not publicized, the significance for healthcare will be felt for years to come and will shape billions of dollars of spending in the largest industry in the world. These consequences shape provider and patient experience, eat up budgets that could be spent on other solutions, and increase the power of EHRs.

Major EHRs win without competing

Before MU and the external market forces that artificially created demand for EHRs, EHRs would have to compete for customers and customers could take their time to wait for the right solution to emerge to solve the problems they actually needed to solve. To be clear, EHRs do solve some key problems for health systems. They standardize documentation and, in most cases, make it easier to find records. EHRs do not, however, solve some of the most pressing needs healthcare like:

1. improve efficiency of clinicians;
2. improve communications between and within care teams;
3. help systems participate in alternative payment models (APMs) that are becoming an increasingly large part of care delivery;
4. provide tools to put the patient at the center of care.

Health systems rushed to accept the EHRs that were MU certified. The major winners were Epic, Cerner, Allscripts, and Athena. These vendors, along with a few others, were so inundated with demand that in many cases they could not deploy new features that health systems needed. The irony is that innovation in EHRs was largely stagnant through the MU era.

Providers spend more time clicking than palpating and percussing

Clinicians don’t love EHRs. To be fair to EHRs, doctors don’t love anything that changes their practice or is forced on them from the outside. But lots of providers aren’t happy about using EHRs. I often wonder what lawyers, another highly paid and highly educated group of professionals, would say if they were forced to adopt digital versions of their yellow legal pads; digital legal pads would of course be certified by the government for features the government deems meaningfully useful to the practice of law and the legal system generally.

There’s some data to backup the clinicians side of the story.

• Emergency doctors click an average of 4,000 times during a 10 hours shift. Any profession would be unhappy about that.
• EHRs are so unfriendly to clinicians that we’re seeing practices and health systems hire scribes and scribe services to enter data into the EHR. It’s highly unlikely clinicians see value in the EHR if they are simply finalizing and approving notes.
• Patients feel neglected in care because doctors are spending so much of their time at the computer and not at the exam or interview of the patient; admittedly the linked survey is quite small (100 patients) but other patient surveys asked more about EHRs generally for the health system and not about how they feel EHRs affect care.

I’m not saying decisions and policies should always be made to optimize clinician happiness, but it’s hard to argue that the EHR hasn’t put an additional wedge between the doctor and the patient.

Cutting and pasting makes lots of garbage

Not surprisingly, it turns out it’s easier to cut and paste a digital note than photocopy a paper one. Cutting and pasting data and notes within an EHR is a massive problem that doesn’t get discussed much. It generates heaps and heaps of notes and data that isn’t super useful for anything really.

While certain aspects of a patient encounter and exam wouldn’t change much, EHRs enable clinicians to more easily cut corners in documenting when 1) they’re confident something hasn’t changed and 2) they know they have to do certain things during an exam to bill at a certain level — some EHRs have this up-billing decision support as a feature and prompt clinicians to ask certain questions or do certain things in an exam to change the level, and ultimately the revenue, from an exam.

Epic consultants make more than pediatricians

This is a representative problem in our health system and our health IT market. I was speaking with a CEO of a hospital, who also happens to be a physician, about EHRs and clinical practice when he told me his son-in-law, an Epic consultant, made more money than the CEOs daughter, who is a practicing pediatrician; this isn’t a universal discrepancy, but the average salaries for Epic consultants are close to the salaries for general pediatricians.

This is not to diminish the importance of Epic consultants, but does show how skewed our priorities are in healthcare when they are more highly valued, and presumably in higher demand because of the speed at which MU accelerated EHR adoption, than pediatricians, the people responsible for caring for our children and ultimately liable if they make a mistake in caring for them.

Why are we stuck?

The reason, fundamentally, that EHR systems, despite all their faults and limitations, won’t be replaced any time soon is that health systems have sunk millions, and sometimes billions, of dollars into their EHR systems. I’ve heard them referred to as “the billion dollar foundation for health IT”. More significantly, hospitals have changed workflows to fit with EHR systems, not the other way around. That’s the epitome of the tail wagging the dog in health IT. The reality is executive leaders and boards of hospitals can’t stomach the upheaval of changing something that is so interwoven into the fabric of the organization.

Glimmers of hope

The situation isn’t without a slight rainbow on the horizon. Today, increasingly, providers are realizing they have some power over their EHR vendors and are starting to exert it. This doesn’t happen within the first year of a go-live, or honeymoon period, but it does happen at some point when EHR customers come to realize their EHR vendors aren’t going solve every challenge in shifting to value-based care and those same EHR vendors aren’t going to add every category of digital health solution as a feature of their products.

And, as opposed to 3-4 years ago when the saying went — “you can’t get fired for hiring Epic”, you can actually get fired for hiring Epic, at least if you don’t manage the implementation effectively. That is a good thing because it means there’s accountability in EHR choices and the outcomes of implementations.

Additionally, clinical IT is becoming a real thing, sometimes on par and sometimes in place, though very rarely, of traditional IT. I’m not a proponent of clinicians being authorities on all things but I do think they increasingly have an informed voice when it comes to technology for care.

As all of these trends start to converge, we’re seeing health systems buying and implementing solutions from new vendors, solutions built to solve the rapidly emerging challenges of value-based care. These solutions are being bolted onto the EHR, which is a significant challenge unto itself, but this bolt-on paradigm is enabling new tools and services to be deployed while maintaining the central hub of clinical data and workflow — the EHR. It’s not perfect, but it’s the path we have for at least the next 3–5 years.