Why have EHRs failed to deliver their promised efficiency benefits?

Why has health technology been so slow to deliver on its promised benefits to hospitals and physicians?

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Robert Wachter, MD, hospital medicine pioneer and recently appointed chair of the Department of Medicine at the University of California-San Francisco, cites a “productivity paradox” of information technology, which was advanced in the early 1990s by Erik Brynjolfsson of the Center for Coordination Science at Massachusetts Institute of Technology. It holds that while adoptees of new information technology expect to see a sharp uptake in their productivity from computerization, that uptake can fail to materialize for a decade or more.

Historically, the dividends of productivity-enhancing disruptive technologies are reaped more gradually, following an initial lag, once the opportunities have been fully assimilated and users have learned to rethink the nature of their work and question old ways of doing things. Wachter suggests that this kind of evolution will be true with hospital electronic health records, as well. It may take a decade or more before we see the predicted massive gains in productivity.

Wachter last year published a book on health information technology and its discontents, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. “For 15 years, I studied patient safety. It was logical to believe computers would come in and fix things, making everything simpler, easier and more straightforward,” he says. Wachter discovered that in many cases doctors stopped talking to each other, with something important lost from their computer-facilitated interactions.

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“A lot of my colleagues complain that computers have ruined their lives,” he says. “We didn’t understand how complex the transition would be from paper to digital-a massive transition over a short time.”

Wide rollout but high provider dissatisfaction

By conventional measures of success, the rollout and dissemination of electronic health records (EHRs), following more than $35 billion in financial incentives paid out to providers since 2011 by the U.S. government’s Office of the National Coordinator for Health Information Technology, has led to historic gains in adoption of the technology. By 2014, 83% of office-based physicians and 84 percent of hospitals had implemented EHRs, up from 29% and 9% eight and six years before respectively,  according to David Blumenthal, MD, MPP, president of the Commonwealth Fund.

“I think of information technology in health care as a resource-like a circulatory system,” Blumenthal says. “The use of the EHR is now the norm in the American health care system-like it or not. It’s an amazing change in behavior and a reflection of getting a recalcitrant system to begin to pivot.” Blumenthal was National Coordinator for Health Information Technology during early implementation of meaningful use incentives under the 2010 Health Information Technology for Economic and Clinical Health (HITECH) Act.

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But these numbers are only coming closer to the level reached by primary care physicians in many European health systems by 2009,[1] and reflect an investment in IT that lags far behind many other industries on a percentage basis. The problems of EHRs and other aspects of health information technology were also in evidence at a journalism workshop on Health Information Technology sponsored by the Association of Health Care Journalists and held in San Francisco, where presenters explored the opportunities and challenges of health information technology, including reports of burnout and high levels of frustration and disillusionment with EHRs by doctors and other providers. Speakers described a mismatch between the burdens and benefits of technology, even though studies have shown that EHR has positive effects on quality, safety, and efficiency.

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“I’m a big picture guy who’s stuck in a rut, and that rut is: new technologies were expected to change health care, but that hasn’t quite happened yet,” says speaker Matthew Holt, founder and publisher of The Health Care Blog [and co-chair of Health 2.0 technology conferences."

Tech companies accustomed to building new tools on top of Silicon Valley’s next-generation platforms are interested in getting into health care, Holt says. “In Silicon Valley, we move fast and break things-it’s natural behavior.” But that’s not a comfortable model for the risk-averse health care system, which at the same time is going through other disruptive changes aimed at pushing payment for value, bundled payments, and population health management.

How to interoperate

One of the biggest unsolved problems in health information technology development for the U.S. health care system is the interoperability of for EHRs-between vendors and health systems and across the country, so that patients’ medical records could follow them wherever they go. “Dr. Blumenthal told us the government concluded that health providers needed to operate in health information technology before they could interoperate,” Wachter says. Competing EHR vendors have not necessarily found it in their short-term financial interest to make their systems interoperable. But the pressure to achieve interoperability is very strong, he said, predicting that real interoperability could come in the next five years.

Current National Coordinator for Health Information Technology B. Vindell Washington, MD, asserts that the barriers to interoperability are not primarily technical. He outlined some of the drivers for its eventual success, such as building the business case for interoperability, providing recognized national standards and changing the culture to where providers expect and demand it.

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Washington says the 1996 Health Information Portability and Accountability Act (HIPAA), with its well-known patient privacy provisions, does not stand in the way of interoperability. “HIPAA protects personal health information from misuse, but it encourages exchange of data between health systems,” he explains.

“Our nation has made historic gains in the adoption of health information technology. Being digital has had a real impact in healthcare. The changes in technology have had real benefit for real patients,” Washington says. “And it didn’t just happen on its own. There were deliberate choices made by the government and by providers. ONC was charged to facilitate secure flow of electronic health information. Now it’s part of the course of normal business in health care. Our mission is also to unlock the data and put it to work.”

[1] Schoen C, Osborn R. The Commonwealth Fund 2009 International Health Policy Survey of Primary Care Physicians in Eleven Countries; see: http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2009/Nov/PDF_Schoen_2009_Commonwealth_Fund_11country_intl_survey_chartpack_white_bkgd_PF.pdf.