The federal government is happy to point out that more than 50 percent of physicians and 80 percent of hospitals are using electronic health record (EHR) systems, with those users having received some $14.6 billion in meaningful use incentives initially allocated in the 2009 stimulus.
But there's more to meaningful use than EHR adoption numbers. A number of studies suggest that healthcare providers are increasingly dissatisfied with the EHR systems they have, with nearly 40 percent saying they wouldn't recommend their EHR to a colleague and more than 30 percent saying they are buying a new EHR system to replace existing software.
Its a telling fact that the number has risen since 2010, when meaningful use was first defined, and has risen as EHR use as correspondingly gone up. The Annals of Internal Medicine suggests in a recent editorial that meaningful use had the unfortunate, unintended consequence of spreading the use of EHR systems that don't work well.
The bigger issue, though, is the EHR systems themselves.
EHR Use at a 'Tipping Point'
The recent Accenture Doctors Survey suggests that global EHR use has reached a tipping point, with 60 percent of physicians using EHR systems in a clinical setting and 91 percent doing so in a clinical or hospital setting.
Upticks in adoption are largely the result of public policy initiatives in the United States, Singapore, Canada and elsewhere, says Kaveh Safavi, Accenture's health industry lead for North America. The key in the U.S., as the HITECH Act of 2009 illustrates, was recognizing that the public sector needed to nudge the private sector into technology adoption. This is largely because the benefits of EHR use are realized by numerous stakeholders, ranging from patients and government agencies to insurers and healthcare organizations, while the costs are borne largely by physicians, he says.
According to Accenture, physicians are more likely than ever to characterize their EHR use as "routine." Two-thirds of those surveyed enter notes during or after a patient encounter, nearly half access clinical data about patients seen by different health organizations, and more than one-third receive alerts or reminders during an encounter.
"I don't think there's anyone who thinks this is a fad," Safavi says.
Many Doctors Don't Like the EHR Systems They Have
The picture isn't entirely rosy, though. According to HIMSS Analytics, the data and market intelligence arm of the Health Information and Management Systems Society, half of the nation's more than 18,000 ambulatory hospitals and clinics remain paper-chart based.
Those that have gone digital aren't always happy. According to a December 2012 HIMSS Analytics survey, 35 percent of those institutions plan to purchase, replace or upgrade the EHR system they do have. A spring 2013 Software Advice survey had similar findings. More than 30 percent of providers aim to replace their EHR system, the research firm says; of those who are replacing, more than 60 percent say the main reason is dissatisfaction with the system they have, with top reasons including a lack of key features, a cumbersome and complex interface, poor EHR usability and bad hardware.
Related: 11 Ways to Make Healthcare IT Easier
It's also been suggested that HHS is spinning EHR adoption numbers in order to tout the success of meaningful use, while others in the EHR debate see meaningful use and other regulations—including a Massachusetts rule that, as of 2015, ties medical licensure to meaningful use attestation—as an "external mandate" that only makes the practice of medicine "increasingly difficult."
Why are physicians so unsatisfied with the EHR systems they have? There are a few key reasons.
EHR Systems Don't Meet Physicians' Mobility Needs
First, contrary to popular opinion, physicians aren't Luddites. The vast majority own smartphones and many also have tablets. They want to use them at work. But they can't. Admittedly, some challenges stem from bring your own device (BYOD) security concerns, which are of greater concern to healthcare organizations than other enterprises given the sensitive nature of patient data.
The bigger issue is that EHR vendors have been slow to adapt their systems to mobile devices. A recent Black Book poll suggests that physicians want to use mobile EHRs to access patient data but find that most offerings fall flat. EHR vendors can't change smartphone screen sizes—physicians' biggest complaint—but they can build apps with intuitive, touch-enabled interfaces instead of simply moving what's often a legacy interface on the desktop to a mobile device.
Meaningful Use Threatens to Leave Many Doctors Behind
Next year begins stage 2 of meaningful use. It's more difficult than stage 1, as it progresses from simply using an EHR system to beginning to share information from that system with other healthcare providers.
Many organizations aren't ready. According to the Accenture survey, the following five features represent the least used EHR functionality:
- Electronic communication to support remote consultation and diagnostics.
- Electronic notification that a patient has interacted with another healthcare organization.
- Electronic communication with clinicians in other organizations.
- Use of clinical decision support systems to help make diagnostic and treatment decisions while seeing patients.
Each seldom-used feature gets to the core of information sharing and is therefore central to meaningful use stage 2. But these functions are seldom-used for a reason, Safavi says&mash;not every patient encounter requires higher-order decision support based on genomic research or an exhaustive study of drug efficacy.
That said, the meaningful use learning curve is hitting solo physician practices hard. In the wake of penalties for not using an EHR system, they increasingly face the prospect of joining a larger healthcare delivery network—and therefore losing coveted independence—or closing their doors for good.
As a result, there's been a call for a meaningful use stage 2 delay. The movement has six Republican senators on its side, as well as the American Medical Association and the College of Health Information Management Executives, which says a delay will help improve EHR functionality and interoperability.
EHR Implementation Is Too Difficult
Simply put, EHR adoption is hard. A recent study summarized by Becker's Hospital Review listed 10 common mistakes. These include undertraining staff, using shortcuts or other workarounds, entering too much data into the electronic record and failing to analyze clinical workflows before EHR system implementation.
Assessing workflow is critical, Safavi says. Again, this is less of an issue for large integrated delivery networks, which have been doing large-scale IT implementations for decades, and more of a problem for smaller physician offices. Not only must these practices deal with the conflict between the way information flows through an electronic system as compared to the familiar paper-based workflow, there are also challenges as granular as who answers the phone if everyone is now entering data into an EHR system, he says.
Providers also ignore the financial implications of EHR implementation at their own peril. In May, the Maine Medical Center revealed a $13.4 million operating loss for the first half of its fiscal year, a loss attributed in part to the "unintended financial consequences" of its $160 million Epic Systems EHR implementation. (High price tags for Epic EHRs, it should be pointed out, are nothing new.) These consequences include reduced productivity as users learn the new system, unforeseen investments in training, software add-ons and billing delays as EHR and financial systems learn to play nice.
Amid the furor, physicians may be tempted to pick up the clipboard. Unfortunately, going back to paper isn't the answer; reports suggest that Hybrid EHR-paper workflows contribute to medical errors, especially medication errors, largely due to miscommunication and poor documentation.
Lessons From an EHR Vendor That Users Actually Like
Not all hope is lost. There are, in fact, EHR systems that physicians do like—they just tend to come from EHR vendors with fewer customers (based on how many have successfully completed meaningful use attestation) and therefore a reputation for better customer support.
One such vendor is Watertown, Mass.-based athenahealth, which recently topped the usability rankings for ambulatory EHR systems in a KLAS Research survey. The firm touts itself as a service company, not a software company, CTO Jeremy Delinsky says, and in that spirit emphasizes a culture that aims to help physicians file claims faster.
To avoid customer churn, athenahealth sends out post-implementation monitoring teams who "proactively intervene" when things don't go well, Delinsky says. Call center staff are also specifically trained to handle inquiries from physicians, who often need assistance outside normal business hours and can be a bit embarrassed to admit that they need help.
In addition, all users run the same instance of the cloud-based athenaClinicals and receive software updates monthly. This makes it easier to address customers' needs, Delinsky says. It also helps athenahealth avoid the common EHR usability pitfall of adding functionality that users expect but don't actually need. Some of this stems from the company's measurement of how much time users spend in the system, which showed that physicians were spending far too much time documenting patient encounters.
Rather than "reimagine" the EHR experience, Delinsky says athenahealth is "trying to disrupt ourselves about what an EHR could and should be." This includes making an effort to share medical research with physicians through the EHR system, to improve patient engagement and to "illuminate" the ability of health data analytics to improve the care process. "We're in the early stages of creating an application that we love," he says.