Why are EHRs still so terrible?

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Keith Aldinger, MD, an internist who practices in Houston Texas. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.

It has been almost 60 years since Ford Motor Co. introduced the Edsel. It was designed to be a higher-end car that would compete with General Motor’s Buick. From the start, it was a dismal failure. In the years that followed, the word Edsel became synonymous with a flawed product or flawed concept.

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In the free enterprise system, when a product fails to perform or it produces no consumer interest, it will fail. Ford respected the market forces and withdrew the Edsel from the market. Is this the way the free market system should work? Possibly not! Can you say electronic health record (EHR)?

For some time now, the IT industry has performed remarkably well. It has given us countless technologies and electronic devices that have progressively improved over time. The industry has performed well, made our lives easier and created products that sold well in the market place. At no time has the IT industry been in need of government intervention to maintain its remarkable profitability. Then arrives the EHR.

To put this in perspective, it is necessary to review The RAND Corporation’s study on the effects of a wide adoption of the EHR.[1] In its media office report from September 14, 2005, it stated that a wide adoption of the EHR could save more than $81 billion annually and improve the quality of care.

Later in the report, it expands that projection with the following statement: “If the efficiency in the national healthcare system increased by an additional 1.5% per year-what economists generally agree was the impact of information technology on the wholesale and retail industry- savings could be as high as $346 billion annually.”[2]

You can do that? You can compare the wholesale and retail industry with the practice of medicine? The last time I looked, my patients do not come in with a bar code on their sleeve. It has been said that you cannot compare apples and oranges. Yes, but at least, they are both fruits.

Comparing the wholesale and the retail industry with the practice of medicine is like comparing apples and hand grenades. Unfortunately, the federal government has pulled the pin on the latter and tossed it into the exam room, resulting in an explosion of inefficiency and a disruption in patient care and communication.

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This study was highly touted in Washington, D.C. and was a significant factor in the passage of the Health Information Technology and Clinical Health (HITECH) Act of 2009. This was part of the American Recovery and Reinvestment Act of 2009. This bill tossed $30 billion into the EHR trough with a deadline for physicians to adopt the EHR technology and qualify for partial reimbursement of the costs for acquiring and implementing EHR systems.

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 Also, a deadline was set to demonstrate “meaningful use” of the EHR or else suffer penalties on subsequent Medicare payments. These certainly served as promotional incentives for the IT companies to push their products.

It may also have resulted in little, if any, incentive to produce a useful tool for the end user. They had a captive audience, threatened with penalties and loss of partial reimbursements, if they did not adopt the EHR within the deadlines. Not to mention $30 billion in the EHR trough that guaranteed payment.

It would be informative to look at another contemporary IT product. In January of 2007, Steve Jobs introduced the first iPhone. Over the ensuing years, the iPhone and its equivalents have performed well for their users. It has also improved in its capabilities and performance. It has earned its keep in the market place.

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However, over the same time period, how has the EHR performed for its end-users? Mediocre to poor may be an overstatement.

I would draw your attention to several recent physician surveys on the EHR. In the Deloitte 2016 survey of 600 physicians, seven out of 10 physicians thought the EHR reduced their productivity and three out of four thought it increased practice costs.[3]

In the Peer 60 Survey of 2016, which included 1,053 physicians, a different measure of overall satisfaction called the Net Promoter Score was used.[4] This asks the question, “How likely are you to recommend your EHR vendor to a peer or colleague?” Major academic research suggests that this is the most accurate measure of overall satisfaction. It is the percent of promoters minus the percent of detractors. The score can be anywhere from +100% to -100%. Nine of the top used EHRs were evaluated. The highest score was +5%. The other 8 EHRs scored from a -24% to a -73%. Seven of the nine EHRs scored from -42% to -73%. I would appropriately refer to this as canine country. At this level, you would not recommend it to a dog.

The above EHRs have been in existence for over 10 years. Allowing for that time frame, it represents a deplorable performance for an IT product. What other IT product has existed for ten years with such a dismal performance? For that matter, what other product of any type has existed for that long in the free market with such a dismal performance and yet had an extended period of profitability? Has the $30 billion EHR trough plus the deadlines for reimbursements and penalties removed any incentive for the IT vendors to improve their product? Perhaps it is more basic than that-just what are the properties of a computer that allow a physician to better interview and examine a patient (i.e., the tasks in the exam room)?

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Perhaps it has no such properties and only interferes with the physician/patient interaction in the exam room. There is a fundamental question that needs to be addressed. Should any clinical requirement, such as using the EHR in patient encounters, that will affect every, and I repeat every, physician/patient encounter be evidenced based?

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The answer should be a resounding yes! However, the evidence, after the fact, as noted above, demonstrates little evidence to support clinical use of the EHR. With that in mind, I would draw attention to a recent survey in which the authors in their conclusions make the following statement: “No other industry, to our knowledge, has been under a universal mandate to adopt a new technology before its effects are fully understood and before the technology has reached a level of usability that is acceptable to its core user.”[5] What was the rush? Then again, to paraphrase, fools rush in where wise men fear to tread, but with so few wise men in the federal government, how were they to know?

The computer, for the past 30 years, has been a boon to industry, the office, communications and leisure activities. Although many human endeavors are improved with the computer, it does not follow that all human endeavors are improved with a computer.

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In fact, some just might be hampered. Regarding the computer as a clinical tool in the exam room, I would ask the following: When in the annals of mankind has a human being had to change the way they do a task to accommodate the tool, and albeit, when that tool is used for that task, the task is more difficult, less productive and the end result is not better, and perhaps worse? In that scenario, who is the real tool?

It should be noted that in 2009, when $30 billion was tossed into the EHR trough, Ford Motor Co. did not participate in the federal government’s bailout of the automobile industry. They did it the free market way, the American way.

 Likewise, when Ford pulled the Edsel from the market, Ford was responding appropriately to the free market. The question arises, where would the EHR be today, if the free market forces were allowed to prevail? With the end-user not finding it useful, and no $30 billion incentive, we all know where it would be. Can you say Edsel?  Or better yet, will the real Edsel please stand up?

[1] Richard Hillestad, James Bigelow, Anthony Bower, Federico Girosi, Robin Meili, Richard Scoville and Roger Taylor. Can electronic medical record systems transform health care? Potential Health Benefits, Savings, And Costs. Health Affairs 2005;24:1103-1117.

[2] Rand Office Media Relations. Media Release, September 14, 2005  (https://www.rand.org/news/press/2005/09/14.html)

[3] Deloitte 2016 Survey of US Physicians: Findings on health information technology and electronic health records (medicalsoftwaresolutions.net/deloitte-2016-survey-us-physicians-findings-health-information-technology-electronic-health-records/)

[4] Physicians take on EHRs, Peer 60.com August 2016, p 1-33. (https://www.reactiondata.com/wp-content/uploads/2016/10/Physician-EHR-Report-Summary.pdf)

[5] Friedberg M, Crosson FS, Tutty M, Physician concerns about electronic health records: implications and steps toward solutions. Health Affairs Blog. March 11, 2014 (healthaffairs.org/blog/2014/03/11/physicians-concerns-about-electronic-health-records-implications-and-steps-towards-solutions/)