In a recent online survey of its readers, the physician business publication Medical Economics probed the views of physicians in practice regarding the purchase and implementation of commercial electronic health record (EHR) systems.
Among the survey’s findings: nearly 45 percent of readers had spent more than $100,000 on EHR systems; about 77 percent of the largest medical practices had spent nearly $200,000 n their systems; 45 percent said that patient care is “worse” since implementing an EHR; 65 percent said their EHR systems are resulting in financial losses for their practice; 67 percent dislike the functionality of their EHR systems; and nearly 79 percent, when asked if their EHR investment was worth the effort, resources, and cost, said, no it has not been.
As MedEc’s editors put it, “Physicians are frustrated with the current state of electronic health record (EHR) technology, according to data from a recently released national survey of nearly 1,000 physicians commissioned by Medical Economics and administered by MPI Group. System functionality and cost are the primary drivers of this sentiment. Interestingly enough, for doctors in practices with 10 or more physicians, functionality of the system takes on even greater significance. In fact, 74 percent of physicians reported it would influence their decision to switch systems, compared to 63 percent for physicians in solo practices. In addition,” the editors wrote, “about 57 percent of physicians in solo practice selected cost as a factor in switching EHRs. In contrast, 43 percent of doctors in practices with 10 or more physicians cited cost as a top influencer.”
Well. That’s quite a lot to mull over. Let’s begin by acknowledging the long-term editorial bias of Medical Economics as a publication. MedEc has for many years been the physician business magazine most focused on helping physicians to make the most money possible. Not only that, the magazine’s bias has always been in favor of solo and small-group fee-for-service practice, and certainly years ago, virulently “anti-managed care,” and continues to be anti-regulatory and anti-government-mandate.
So is it any surprise that the publication’s readers, who tend to be those physicians still practicing solo or in smaller-sized practices, would be overall as negative as they turned out to be, in their attitudes towards implementing EHRs, under the meaningful use mandate under HITECH (the Health Information Technology for Economic and Clinical Health Act)? The dissatisfaction with the amount spent on implementing EHRs is compounded, for small-practice physicians, by the fact that the average cost of an EHR is turning out to be about double the total amount of federal stimulus funding they can receive via HITECH. Then again, the point of the program was never to subsidize the entire cost of an EHR for physicians in practice, but rather, to compel forward EHR implementation in order to force automation on a healthcare system that remained the last major industry in America to remain paper-based, going into the second decade of the 21st century.
So, with regard to some of the results in the MedEc survey around the costs of implementing EHRs, my response is that it is clear that practicing with an electronic health record is, very appropriately, becoming the cost of entry to practicing medicine in an era of heightened accountability, transparency, and connectivity in healthcare.
Now to the other side of the conceptual ledger: at the end of the full article on the survey, the magazine noted that “The national survey underscores the major disconnect between the current state of EHR software and the needs of physicians.” And that’s where the MedEc survey results move into the realm of what is reasonable and worth seriously considering. What is very clear is this: even the best of the current electronic health record systems created by commercial software vendors still fall short when it comes to optimizing functionality around areas like population health management, advanced clinical decision support at the point of care, data analytics, and, most basically, core user-friendliness and usability.
To some extent, the faults in all the commercially available EHR systems relate to the history of the development of the electronic health record, and the purposes to which the EHR has been and is still being put. In our almost surreally complex U.S. healthcare system, an EHR is not simply a clinical documentation tool, or even simply a combination clinical documentation/clinical decision support tool, but rather, also a tool for documentation for payment and for regulatory compliance; and therefore, in contrast to the patient record systems used by physicians employed by government-run, single-payer systems in, for example, the Nordic countries in Europe, EHRs here have to fulfill so many roles, it’s no wonder that they remain sub-optimal in their functionality.
What’s more, it is only now that the full horizon of what will be required going forward is becoming plainly clear to all (or nearly all) physicians in practice in the U.S., with regard to value-based purchasing and clinical outcomes, population health, the patient-centered medical home, accountable care, and performance analytics. Meanwhile, at a very basic level, physician practice EHRs simply must be made more user-friendly and flexible to a variety of needs. So in that regard, the survey result of 67 percent of physicians being dissatisfied with the functionality of their EHRs accords perfectly with everything I’ve been hearing for years now, and feels far more legitimate than the griping about the cost of an EHR, which though it may have some legitimacy, needs to be put into context. In what other consumer-facing industry would the providers of any consumer service be allowed to remain paper-based anymore these days?
In the end, the expense of implementing an electronic health record is one that inevitably will not provide a 100-percent “return on investment” for practicing physicians in small practices in the U.S. And to the extent that physicians grumble about the costs, the reality is that the purchasers, payers, and consumers of healthcare—as well as their own colleagues—are demanding that doctors make the investment regardless of whether or not it delivers a one-to-one return. But when it comes to the functionality and usability of EHRs, physicians in practice in this country have a very legitimate collective gripe about what those EHR systems can do and about how much work healthcare IT vendors still have ahead of them to make EHRs the 21st-century tools they need to be, for the doctors who need to practice 21st-century medicine.