Electronic Health Records… What’s the Big Deal?

Posted by Michael on January 10, 2013

By Nicholas Genes

When I talk to people about the frustrations and controversies surrounding the adoption of electronic health records, I get some confused looks. I mean, what’s the big deal, right? Why does it require a federal incentive program and billions of dollars, to prompt physicians to embrace EHR?

Most industries have adapted to new technologies without too much fuss. Some of us recall making the transition from pen & paper, or typewriter, to word processor a few decades ago. Why is US healthcare still on the fence about this? Isn’t switching from paper notes and clipboards and dictated orders just intuitively more efficient, and safer?

Well, medicine has many factors lined up against adopting electronic systems. Here’s three reasons that I come up against, routinely:  

  1. There’s no shortage of physicians who’ve made a name for themselves, pointing out the intuitive path is misguided or dangerous.
  2. Physicians in general grow comfortable with their authority, and are unaccustomed to hearing they’ve got to change how they do things.
  3. These doctors also happen to have a good point: EHR software is, for the most part, pretty lousy.

Unlike most software, you can’t find much in the way of examples or discussions of EHR online, so you’ll just have to take the word of the majority of physicians who use the software that it’s clunky and cumbersome – much less “usable” than most websites or systems we interact with on a regular basis outside the hospital.

There’s no shortage of examples, however, of the first two points. For instance, here’s a recent exchange I had, with a prominent figure in my specialty of emergency medicine, Rick Bukata:   

"Individual randomized controlled trials have involved tens of thousands of patients to determine if drug A is better than drug B when both are known to be similarly effective and nuances of difference are being sought. These studies can cost millions of dollars to conduct and often the results are not what the sponsors hoped they would be.

Randomized controlled trials often involve the assessment of complicated clinical procedures that are both costly and/or risky. In this setting it is even more important to find convincing evidence of the value of the procedure over other treatments.

Fast forward to 2012. We are looking at the most expensive healthcare initiative ever undertaken in the nation’s hospitals and physicians’ offices: the incorporation of clinically oriented health information technology. So, where are the randomized controlled trials? Where’s the beef?"

He goes on to cite research on some implementations of EHR, which didn’t result in better patient outcomes or cost savings, and argues that the federal government’s push to adopt EHR is misguided.

An excerpt of my response (at the bottom of the page):

"Wouldn't it be great if EHR had RCT data behind it, to demonstrate its safety and efficacy and ROI? Of course it would. It'd also be great if we had data on T-sheets vs. handwritten notes. Many of the tools and therapies we use aren't based on RCT data - and many others continue to be used, despite RCT data that shows ineffectiveness. And EHR implementation, unlike drug manufacturing and dosing, is dependent on a myriad of difficult-to-control factors. And any RCT on EHR would be obsolete as soon as next year's software upgrade is complete."

I go on to refer to some of my own (limited) studies with positive outcomes, and recommend more research in why some EHR implementations are disappointing, rather than abandon the endeavor.

But the truth is there is a lot of ambiguous data about EHR outcomes. While I work at a hospital that won the award for the country’s best implementation of EHR, I’m all too aware of colleagues at other institutions, who have distressing anecdotes about poor EHR usability leading to errors that harmed patients, causing delays, and preventing the promised cost savings.

And I can’t ignore this line of questioning – if EHR was demonstrably superior to the hodgepodge of low-tech and disjointed systems still in use, why does the federal government have to offer incentives for physicians and hospitals to adopt it? The feds have their own reasons for encouraging EHR adoption – from studying and reigning in practice variation, to minimizing fraud, to promoting guideline adherence. But for years, the industry and physicians asked the government to wait before offering adoption incentives, thinking their interference may prevent innovation, locking-in those difficult-to-use, cumbersome interfaces.

Now we find ourselves hoping that these incentives, which are spurring widespread adoption, are what finally jumpstarts innovation in EHR usability. Because even though there are many EHR enthusiasts and evangelists, it’s clear EHR installation is not a surefire path to improved safety, patient outcomes and cost savings – and the software still needs vast improvement.