A Contrarian View of EHRs

 A Contrarian View of EHRs

(From the owner of an EHR Company)

This issue of Physician’s Resource Office is filled with articles extolling the virtues of Electronic Health Record (EHR) systems, the potential financial windfall provided by the HITECH (Health Information Technology for Economic and Clinical Healthcare) legislation, and how you, the physician, needs to rush out and adopt an EHR ASAP.  Public Enemy, one of my favorite hip-hop groups of the 1980s, famously rapped: “Don’t Believe the Hype.”  Those words have never been truer than in the case of EHRs.

What gives me the right to criticize EHRs at all?  Allow me to establish my bona fides. To begin with, I am board-certified Family Physician, practicing in Rhode Island since 1996.  Secondly, I have been using personal computers to track my encounters with patient since 2001.  That was also the year I learned Microsoft’s Visual Basic programming language and coded my own software application for entering and tracking my patients.

Why did I go through the trouble to teach myself software programming when there were plenty of EHR systems commercially available at the time?  The truth is that I tested most of the popular programs and found that a few things were true across the board.  They were ludicrously priced. They were confusing.  They couldn’t document a brief follow-up visit in the time I could do it by hand or dictation.

Despite their high price tags, most of them were also unbelievably difficult to use because they were created by software programmers who majored in computer science, not by physicians who actually live and breathe the practice of medicine.  For example, nearly all EHRs force you to tediously record aspects of the encounter by navigating through menu after menu and checking box after box. Hey, if I wanted to be an inventory specialist, I would have gone to work for Home Depot or Wal-Mart. Seriously, though, the number of clicks and windows that needs to be navigated to document a note is truly astounding.

Some physicians do prefer to document their encounters in this way, and there is nothing wrong with this approach per se.  Personally, though, I believe that the practice of medicine is more an art than a science, and frequently it is the information documented “between the lines” that really tells a physician what is going on. Today’s EHRs have removed this ability simply by the way their workflow is designed. This “Checkbox Hell,” as we’ll call it, is the hallmark of overpriced and unusable EHRs and may single-handedly take the true patient issues out of the documented note.

We’ll come back to the issue of usability in a moment, but let’s jump to the loudest hype - the promise of money to physicians who adopt a “certified EHR” and show “meaningful use” of the system.  The $18.2 billion HITECH Act has certainly stimulated a ton of talk and quite frankly, BS, mainly from vendors, but also from healthcare officials and local, state, and federal government representatives towing the party line.  I spend every day trying to understand this stuff, and there are many more questions than answers, despite what you may be told.

Although as an EHR vendor I have spent over $40,000 dollar to get my software certified by CCHIT, the presumptive governing body, no official standard for “certification” has been named to date.  In other words, you could rush out to purchase a CCHIT-certified EHR system tomorrow, and then discover in three months that there is a new/different standard and your software does not qualify for the government handout.

The definition of “meaningful use” has also not been clarified.  CCHIT is currently trying to add it to their certification criteria, but even they have said it will be difficult to implement testing of “meaningful use” systems anytime soon.  We know that it will probably require integration with government health information exchanges (HIE), but this too has yet to be defined – not the specifications on what health information data is to be exchanged, nor how the data will actually be exchanged, nor where this data will actually be stored, nor who will have access to the confidential information.  I am all for better public healthcare through de-identified surveillance of populations, but that idea remains a pipe-dream.

In fact, to date, there is no good evidence that EHRs reduce overall cost or improve patient outcomes. So while these are the regularly touted benefits of using an EHR – it is all simply hype.

Personally, I believe the most significant reason why studies have not shown a clear benefit of using EHRs is because most are so tedious and difficult to use that physicians and their staff don’t actually use them in a way to harnesses their true potential. This usability issue has been mostly ignored, but will slowly become the most critical issue in picking an EHR system. Currently, though, there is a lack of objective evaluations and ratings such as you find in other categories of personal and business software.  The closest thing to objectivity has been provided by the American Association of Family Physicians (AAFP) Center for Health IT (www.centerforhealthit.com) where actual EHR users rate their experiences with their EHR systems. This survey-type data is a start, but unfortunately this information may be difficult to obtain if you are not a member of AAFP.  

Survey comparisons of EHR systems are also available from KLAS, which claims to offer “accurate, honest, and impartial” vendor performance information.  But these results are tainted for two reasons.  First, vendors submit the names of users to be surveyed by KLAS.  Do you think vendors are giving KLAS the names of their unhappy users?  Second, vendors are asked to become “participating partners” by paying a fee to KLAS.  This would seem to ensure that the results will be skewed to those vendors who both pay a fee and submit the names of their most satisfied users.

The good news is that the issue of usability is finally getting some recognition, and some industry associations, like the Healthcare Information and Management Systems Society (HIMSS), are also looking to improve the data available on this issue. In fact, HIMSS has begun to determine how usability can be analyzed and quantified, and have started preliminary work and are preparing to publish a roadmap for vendors.  Unfortunately, the final results are still months, if not years, away from being released. 

The problem for most users today, and the fundamental flaw of most EHRs, is that they are just too complex, resulting in little or no improvement in either patient outcomes or physician efficiency.  There is no better evidence of this allegation than the fact that physicians need to be trained (at their own expense!) to use these systems.  It seems obvious that anyone who graduated medical school should be able to use an EHR straight out of the box without any formal training. If not, the EHR has clearly not been designed to be used by a physician.

Even if the issues of usability, meaningful use, and certification are actually solved anytime soon, there are still a few outstanding questions that need to be answered before anyone starts counting on the maximum $44,000 incentive under Medicare ($64,000 for Medicaid) that the Federal government has said will be distributed starting in 2011 to those showing “meaningful use” of a “certified EHR.”  Most obviously, the government has just embarked on an unprecedented stimulus spending spree that may or may not lift us out of the current “Great Recession.”  Faced with multitrillion dollar deficits over the next several years, there’s no reason to assume that the HITECH funding is some kind of sacred cow that won’t end up cut by the administration or Congress.  

As a tax payer, I wonder if it is even morally fair to hand out financial assistance to physicians for adopting over-priced software that has not been shown to boost efficiency, lower costs, or improve patient outcomes.  In fact, it has always amazed me that the government has chosen to provide subsidies based on use of EHRs rather than the actual cost of the hardware and software.  The latter approach would give vendors an incentive to lower their prices, whereas the former simply encourages them to price their products as close to the maximum subsidy amount as possible.  For many doctors, in fact, the most sensible and economically approach will be to purchase the least costly and most effective system possible, and then pocket the difference between the actual cost of the system and the amount of the incentive.

I have plenty of other unanswered questions around the actual reimbursement process.  Is the $44,000 over five years for each physician in a practice, or a practice as a whole?  Is the money also available for nurse practitioners and physician assistants?  How does a physician actually get the money? Is this via CMS reimbursement, and if so, how will this payment be made.

While many EHR vendors may tell you they know the answers to these questions, no one is really sure.  Unfortunately, the current state of affairs in the EHR market is a potent mixture of wishful thinking and vendor hype. This is too bad because EHRs may actually be able to do a lot of good for the practice of medicine and the health of our nation as a whole.  The message I want you to take away from this article is simple: do not be cajoled into buying an EHR solution now that you will regret later.  Go slow, and give the market more time to mature and evolve.  Physicians who adopt EHRs by the end of 2011 will still be able to collect the full amount of the incentive.  A lot may happen over the next 18 months to provide clarity to the issues of certification, meaningful use, and most importantly of all, usability.   

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Jonathan Bertman, MD, FAAFP is the founder and president of AmazingCharts.com, an EHR company. He is also the Editor-in-Chief of MDNG Interactive and has a private practice in Rhode Island.