The federal government has spent about $5.8 billion through the Meaningful Use program to encourage doctors to buy and use electronic health records in their practices. What have physicians, their patients, and taxpayers gotten for that money so far?
The Health Information Technology for Economic and Clinical Health Act of 2009 included $27 billion to help doctors, hospitals, and other healthcare providers buy and install electronic health record (EHR) systems. Through November of 2013, about $5.8 billion of that had been paid to physicians who had successfully attested to the first stage of the Meaningful Use program (MU1).
With the start of 2014, physicians can begin attesting to MU2, the program’s second stage, making this an opportune time to pause and ask what physicians-and the healthcare system generally-have gotten for that money.
As is often the case, the answer depends on whom you ask. For many primary care physicians (PCPs), especially those in solo or small independent practices, the answer would be “very little”-unless you count frustration, lost productivity, and sleepless nights.
Many policy analysts, however, and even some practicing physicians, say that it’s still too soon to know what the payoff from adopting EHRs will be, or in what form it will occur. They point out that in other sectors of the economy, such as manufacturing or banking, it took many years for widespread computerization to begin paying substantial dividends.
One thing that is certain is that the number of doctors using EHRs has increased-from about 17% in 2009 to about 50% through the first half of 2013, according to the U.S. Department of Health and Human Services, which administers the Meaningful Use program through the Centers for Medicare and Medicaid Services.
Practitioners’ unhappiness with EHRs was expressed throughout Medical Economics’ 2-year “EHR best practices study.” Daniel Goodman, MD, a solo internal medicine practitioner near Atlanta, Georgia, spoke for many when he said: “I can’t believe this is what I’ve been going through. I’ve been feeling this depression because I’m spending my time staring at a computer and trying to get it right to achieve meaningful use.” Andrew Garner, MD, a solo family practitioner in Glen Falls, New York, likened the time and effort required for installing his EHR to returning to medical school.
More broadly, a 2013 RAND Corporation study of factors affecting physicians’ professional satisfaction found that although many doctors recognize EHRs’ potential for improving healthcare delivery, the technology reduces professional satisfaction due to factors such as poor usability, time-consuming data entry, interference with face-to-face patient care, lack of interoperability among different systems, and degradation of clinical documentation. “Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, one that our findings suggest has not yet matured,” the report notes.
Ironically, another RAND study, from 2005, was one of the catalysts for the Meaningful Use program. The study estimated that widespread EHR use could reduce overall medical spending by $81 billion annually. But an editorial published in the January 2013 issue of Health Affairs noted that healthcare spending had grown from $2 trillion to about $2.8 trillion in the 8 years between the two studies, and that EHRs have yet to fulfill their promises of greater efficiency and lower costs.
The belief that EHRs could dramatically improve the quality and efficiency of healthcare rests on healthcare policymakers’ faith in the transformative power of collecting and managing large quantities of data, says Jason Mitchell, MD, director of the Center for Health Information Technology for the American Academy of Family Physicians.
“We work from the theory base that many of the key problems occurring with healthcare quality and efficiency are related to data management, Mitchell says. “And managing data in paper charts has been a key problem in why we haven’t been more efficient and able to monitor quality more effectively.” Consequently, the thinking went, doctors only need to digitize their patients’ records for the healthcare system to begin reaping the same rewards.
But healthcare has some unique traits that make computerization especially tricky, says Bob Rudin, PhD, an associate researcher with the RAND Corporation. One is the complexity of clinical workflows. “Medical offices have their own, customized way of doing things, and they all want the technology to fit into it exactly. It presents a very challenging technical design problem [for EHR vendors],” he says.
“Some practices just don’t have the capacity for change, or for focused quality improvement,” adds Mitchell. “So they install an EHR and expect it will make their lives better, when in fact it’s just a tool and they need the skills to adjust and manipulate the application of that tool so it can work effectively in their practice.”
Another challenge, notes Rudin, is the disconnect between those who perform the additional work EHRs require-physicians and their staffs-and those who reap the benefits, which are patients (in terms of better outcomes) and third-party payers (in terms of lower costs. “For a market to work successfully, the people who buy the product are the ones who should benefit from it,” he says.
He cites the example of e-prescribing, where EHRs include quality and safety tools such as dosage checking and clinical decision support. But taking advantage of these tools requires doctors to enter a great deal of data and clicking numerous buttons, “whereas before the doctor could scribble some note on a piece of paper, hand it to the patient, and move on to the next patient,” Rudin says.
Despite the frustrations EHRs have caused, it’s far too early to declare the meaningful use program a failure, experts say. For one thing, there is growing evidence of EHRs’ ability to improve patient outcomes. For example, a study published in the September, 2011 New England Journal of Medicine compared achievement of and improvement in quality standards for diabetes care among a group of paper-based and EHR-based practices in Ohio. It found that the achievement of composite standards for care and composite standards for outcomes were 35 percentage points and 15 percentage points higher, respectively, at the EHR sites than at the paper-based sites.
Doctors’ complaints about EHRs have to be viewed with some historical perspective, says Pat Wise, RN, MS, vice president of healthcare information systems for the Health Information Management Systems Society. Wise notes that practices had been using EHRs for many years before the Meaningful Use program began.
“The practices that moved to EHRs in the 1990s and early 2000s were most likely the practices that saw the power of the technology and recognized they needed to move for the business model of their practices, that it was the only way they were going to become more efficient,” she says. “So these practices already were motivated to make [EHRs] a success.”
Moreover, at least some of the practices adopting EHRs in the last few years are doing so to avoid incurring financial penalties starting in 2015. “These practices are on a shortened timeline, and they probably feel a lot more stress than the practices that did it at their own pace,” Wise says.
It’s also possible that EHRs are already affecting the healthcare system in ways that we don’t even realize, because we aren’t measuring them. Such was the case in the 1970s and 1980s, according to “Unraveling the IT Productivity Paradox-Lessons for Healthcare,” an editorial Rudin coauthored in NEJM in June 2012.
Rudin and his fellow researchers noted that during those earlier decades the economy’s overall computing capacity dramatically increased, even as the rate of productivity growth appeared to be declining. Later research showed that the “productivity paradox” occurred in part because of limitations in the data and methods used to evaluate productivity.
The same phenomenon could be occurring now in healthcare, the authors say. They cite the example of a physician who communicates with patients via telephone or e-mail, rather than face-to-face in office visits. These doctors “will all appear less productive on measures of productivity, even if they are actually delivering more convenient, accessible, and effective care.”
The article goes on to point out that significant productivity gains from information technology in other parts of the economy came only after investments in training and process redesign, and that a comparable process of re-engineering healthcare delivery is only now getting started.
EHRs will almost certainly become more user-friendly as vendors incorporate feedback from customers into newer versions, says Mark Snyder, MD, a specialist leader in the Health Care and Life Sciences area of Deloitte Consulting.
Snyder compares the current versions of most EHR systems to early e-mail programs and Internet search engines. “Those didn’t just spring to life as useful as they are now,” he says. “But that doesn’t mean we abandoned them. They continued to evolve, and now it’s hard to imagine how we ever got along without them.”
Taking a longer perspective, it may be that the biggest payoffs of widespread EHR use will take more time to accomplish. One of these is integrating individual patient care and population health management.
The AAFP’s Mitchell calls caring for an individual patient an “anecdote” of care. “But when we look across populations, EHRs help us aggregate those individual anecdotes into algorithms on how we are caring for patients, and what gaps in care are there,” Mitchell says.
“With the improved information management EHRs make possible, we get better methods for monitoring conditions, and applying the best available evidence to an individual patient’s specific circumstances. Then we can create a comprehensive care plan with the patient and other members of the care team that meets the patient’s needs and expectations.”
Finally, the data aggregation and improved communication EHRs make possible are essential for creating a system that rewards quality rather than volume through models such as the accountable care organization and Patient-Centered Medical Home. “When clinical data is on paper, you don’t have a prayer of using it for quality measurement in any efficient fashion,” says Rudin. “Whereas if it’s in electronic form, you can start to make those measures better, and start to create standards for them. The value-based models all need to be measuring the quality of their care. And the better the quality measurements we get, the better those programs will be.
“This is a huge undertaking, wiring the whole healthcare system,” Rudin adds. “And as much as we want a return on our investment right away, it really should be viewed as a long-term investment for which we’re just now laying the foundation.”