EHRs – less Love and more Money

There is a lot of unhappiness with electronic health records (EHRs) among nearly all my medical friends and colleagues, and I have heard all flavors of complaints about them. Many of the anecdotes are compelling, in fact at times bordering on the absurd, and given time and license, I can share many horror stories. But here I want to go beyond the anecdotes, in two different directions. First, many recent surveys on EHRs all point to a similar conclusion, from related yet distinct perspectives. I discuss these below as Sad Numbers. Second, I found a published 2014 research report by RAND Corporation, Redirecting Innovation in U.S. Health Care: Options to decrease spending and increase value (RR-308), to be very much on point here. As part of the analysis in this report, RAND undertook several case studies, which included an up-to-date analysis of the role of EHRs in health care. The report provides essential background, some executive level conclusions, and policy suggestions. In fact, there are two published `versions` of this report, each of which basically bears the same title. The more executive and slightly glossier version is denoted by RR-308; the second has a subtitle `Case Studies`, and goes into each of the eight studies in somewhat more depth than does the executive version. Nonetheless, they are very similar, and complementary. I found the content of both reports to be illuminating, confirmatory, infuriating, and saddening. Without question, the report is spot on the topic. I will simply refer to RAND or the RAND report below to indicate that the source is one (or both) of these versions. The link to the more executive version is: ,

while the link to the more detailed Case Studies version is

I’ll discuss the RAND report (in context) below by focusing on their contrast between two major EHR vendors, Epic and VistA, along with their conclusions. One point in RAND’s methodology does need to be clarified up top, since their analysis bridges several directions. They synthesized information from peer-reviewed and other literature, from a panel of technical advisors that was convened for the project, and from 50 one-on-one extended expert interviews. These interview subjects included health care industry and/or policy experts, drug and device inventors, regulators, providers, payers and insurers, venture capitalists, and researchers. A few of these interviews provided poignant quotes that pack a powerful, decisive wallop, and I wanted to share them here. So below, when I am quoting from the reports, to clarify who said what, I will indicate RAND commentary by [RAND]:, and commentary or quotations from one of the experts by [EXP]:, along with italicized text.

Sad Numbers As Melinda Beck reported in September 2014 in the Wall Street Journal, the depth of doctors’ dissatisfaction has been confirmed by several recent large-scale studies, with widespread complaints about poor design and usability, incessant needless alerts and poor work flows. 47% of physicians say that EHRs detract from patient care, according to a 2014 survey of 20,000 physicians by the nonprofit Physicians Foundation. In the same study, 46% of respondents indicated that they would give a D or F grade to the Affordable Care Act (ACA); 39% of physicians indicated that they will accelerate their retirement plans due to changes in the healthcare system; and 50% of physicians indicated that implementation of ICD-10 (the new system of narrowly defined and finely detailed medical coding) would cause severe administrative problems in their practices. A 2014 survey by the industry group Medical Economics discovered that 67% of doctors are “dissatisfied with [EHR] functionality.” In a 2013 AMA/RAND survey, 43% of physicians said that EHRs slowed them down, requiring them to spend too much extra time on data-entry, leaving less time for patients. Moreover, according to the results of a study published by the American Medical Association and the American College of Physicians’ American EHR division, physicians have become increasingly dissatisfied with EHRs during the last five years. The survey, “Physician Use of EHR Systems 2014,” found that only 22% indicated they were satisfied, and 12% “very satisfied” with EHRs, a sharp drop from the parallel study conducted five years earlier. An Accenture study in 2012 found that of the eight developed countries surveyed, the U.S. had significantly lower percentages of doctors who believed HIT improves diagnoses, health outcomes or quality of treatment decisions.

An October 2014 survey from the executive suite buttressed these findings. The study from Frost and Sullivan, “EHR Usability-CIOs Weigh in on What’s Needed to Improve Information Retrieval,” surveyed about 60 Chief Information Officers (CIOs), primarily from mid to large community hospitals. The CIOs themselves concluded that EHRs are falling down on the job when it comes to finding the information that they hold. The respondents reported that the EHRs were too slow and lacked precision when it came to information retrieval. These problems, as well as the difficulty in finding and reviewing the data, created `significant` productivity losses and increased potential risks to patient safety. Respondents also indicated that rudimentary search functionality and poor usability are more important causes of search problems than lack of end-user training or clinician dislike of technology. Moreover, the principal analyst Nancy Fabozzi predicted that as EHR data expand, the retrieval problem will worsen, and that regulatory response will be forthcoming. So if the experts, who presumably are hardly Luddites, determine that the EHR problems are with the systems and not with the users, there really is a major problem here.

Epic and VistA RAND chose to contrast two of the largest and most influential EHRs in the United States today, Epic Systems and VistA, to illustrate how market forces and public policy actually shape adoption of EHRs by hospital systems and medical practices.

Epic: As RAND describes, Epic is a privately held company that owns its proprietary technology. Among its clients are the vast majority of the United States’ elite academic medical centers, including the Cleveland Clinic, Johns Hopkins, Dartmouth-Hitchcock Medical Center, Kaiser Permanente, nearly the entire University of California system, and Yale-New Haven Health System. Epic has won several awards for both inpatient and outpatient EHRs, as well as for software used in scheduling, billing, and collections. It has been named “The Top EHR Vendor by Number of Meaningful Use Attestations.” Epic has been led by its founding CEO, Judith Faulkner, into a global company with approximately $1.5 billion in revenue in 2012. As RAND discreetly states it, “Epic does customized installations for each client, allowing health care systems to tailor Epic’s applications and functionality to meet their own needs.” The RAND report quotes from a article in Forbes, `In addition to the software, [Epic] customers pay dearly for hardware, and for an army of Epic-certified technicians that needs to be deployed to get the system up and running.` On point, this past June, Boston-based Partners HealthCare (the Harvard system) launched its Epic system, Partners’ single biggest investment ever, three years in the making at a cost of $1.2 billion. That’s correct – billion, with a B.  The RAND report then continues, “Although Epic is expensive, it works, and in the conservative world of health IT, that’s all that matters.”

This is perhaps more easily understood by distilling some information from the essay `Cheat Sheet`. First, the Health Information Technology (HITECH) Act of 2009 put many billions of dollars in federal incentive payments on the table for medical centers and private practices to adopt certified EHRs that demonstrated `Meaningful Use` (MU). Second, Epic’s CEO, Judith Faulkner was the only head of a health IT company to serve on the Obama administration’s Federal Health IT Policy Committee, when the HITECH Act was being formulated. This gave Faulkner and Epic a critical edge, as Faulkner was then able to advise federal officials as they crafted policy framework, including criteria ultimately adopted to satisfy MU in the HITECH Act. Naturally these official criteria would mesh well with Epic’s existing systems, or with relatively turnkey modifications and additions to their systems. Since the business decision of which EHR vendor to choose almost always reduced to the question of which vendor would max out Meaningful Use revenue, Epic had a very advantageous market position. And indeed, as of mid-2014, more than half of the $24 billion spent to date by the Meaningful Use program had gone to customers of Epic.

Let’s think about new pressures within the Harvard system, for instance, now that they just invested $1.2 billion for their spanking new Epic EHR. The business side of the house, which has acquired outsized power within most major academic medical centers, will surely want to recoup this sum `in an expedited fashion`.  In an age in which 78% of CEO’s say that they will mortgage the future (sell out) to meet the next quarterly earnings report estimate, I am fearful that physicians in the system will feel both implicit and explicit pressures to generate substantial (new) revenue streams. A permanent position versus being let go, tenure, a promotion, a named chair, a piece of the action – all of these incentives seem more tied to new dollars than ever before, entirely apart from the chronic pursuit of NIH grant money. So in the vast numbers of medical settings in which there are a justifiable range of possible actions, given the choice between further testing and procedures rather than `let’s just sit tight and keep a close eye on this for the moment`, or first trying lifestyle changes (in diet and exercise), I see a heavily tilted see-saw.

There are a couple of other important issues with EHRs as now in place that also require some serious attention. First, although Epic (and many other) EHRs are espoused as powerful tools to advance patient safety, they have inadvertently spawned new types of medical errors. For example, many EHRs impose severe alert fatigue, with very frequent alerts that numb the attending doctors and nurses to the point of tuning them out. In The Digital Doctor, Robert Wachter tells a frightening story about a 39-fold overdose of a common antibiotic given to a teenager, to a large extent the result of this fatigue. The protocol systems for alerts must undergo serious revision, and any revised models should be required to be rigorously field-tested by doctors, nurses and pharmacists for approval.

In addition, I experienced several instances of Epic crashes when I was regularly using the EHR, in which the system would be down for hours, paralyzing doctors, staff, and thus indirectly, patient care. In principle, there is a Help Desk, but responses would also be long in coming, and often nonconstructive. To be fair, this problem hardly seems unique to Epic – many friends and colleagues who use other large scale EHR systems have also experienced similar episodes, both in private practice and in hospital-based settings. Apparently this issue still persists today, perhaps with a little less frequency. But in a medical environment, this can be extremely dangerous. More back-up (redundancy) is imperative, in the name of patient safety. We have back-up generators to handle power failures. And some systems, such as mechanical ventilators, are classified as life-critical, requiring a very high degree of reliability. In an age in which we are becoming exclusively dependent on our electronic records system to function, we must likewise develop (and in fact, require) analogous highly reliable `solutions`.

VistA: As counterpoint to Epic, the RAND report then goes on to describe VistA, from which the following is excerpted. The EHR for the Veterans Health Administration (VA), denoted VistA, provides a sharp contrast to the Epic EHR. Developed in its present form in the mid- to late 1990s, it is very well regarded within the VA health care system for its user-friendliness, interoperability, and impact. VistA has received many accolades for reducing costs, improving both outpatient and inpatient care, and enhancing clinical outcomes in the VA health care system. VistA incorporated, and in some instances pioneered, computerized order entry, electronic prescribing, and bar code medication administration. VistA’s success has been attributed in large part to the collaborative nature of its development. Clinicians and information technology (IT) experts worked together to design its user interfaces and patient record system. Equally important, because VistA is built on a standard code, it is fully interoperable within the entire VA.  Today, VistA and derivative EHRs, are installed in every Veterans Health Administration (VA) facility in the country. Several recent major independent surveys, including ones by the American Academy of Family Physicians (AAFP) and by Medscape, indicated that physicians are broadly satisfied with VistA, which ranked as one of the very highest systems overall. Notably, VistA significantly outscored nearly all EHRs offered by large vendors, including those by Epic and McKesson. In particular, when the AAFP survey asked respondents to express their level of agreement with the statement, “This EHR enables me to practice higher quality medicine than I could with paper charts,” VistA received the top score.

`Higher quality medicine` – now there’s a concept worth holding on to.

Yet, as RAND concludes, “despite its known strengths and many favorable reviews by physicians, VistA has not been enthusiastically embraced by the private market. Medsphere, a company created to market a commercial version of VistA, has a modest share in the market, but most hospitals and providers have purchased commercial products that they believe are better designed to meet their needs, particularly billing.”

Or perhaps I would prefer to slightly edit the above to read “… , particularly billing.”  This is hardly surprising, since VistA was not developed with billing (of veterans) as a primary focus. Nonetheless, many doctors, including myself, would very much like to see many of VistA’s attributes incorporated into the EHRs that they are required to use. VistA clearly demonstrates that EHRs can be quite beneficial to medicine overall, not only in principle but in practice, at no expense to caregiver morale. However, the ruthlessly `business and billing-centric, all else is extraneous` model of EHRs that has emerged as a natural response to HITECH’s financial incentives throw us all under the bus in the name of near-term profit.

The $hort-term is Winning: Furthermore, the present reimbursement model (via HITECH) does more than `merely` bias towards procedures, as opposed to discussion and watchful waiting. Of at least as much concern to me, it is also accelerating the trend to favor short-term rewards over long-term benefits. Several quotations from the RAND reports strongly reinforce this observation. As one expert reported, [EXP]: “Payers tend to have a short-term perspective. A life saved in the future provides no financial value. Payers do not benefit from cancer prevention through screening.” [RAND]: “In the context of preventive services, some of which could decrease [long-term] spending,” another expert reported [EXP]: “when you look at preventive services, the reason that developers are deterred or discouraged from creating high-value technology that lowers overall spending revolves around reimbursement . . . we can’t set future value to justify the price of preventive services. There’s no market incentive.” [RAND]: “In addition, when a health system is siloed [compartmentalized] — few, if any, decisionmakers account for benefits or costs that accrue outside of their silos.” Then yet a third expert said [EXP]: “There’s little ability to do longitudinal holistic decisionmaking and evaluation of cost-benefit.” The RAND authors then conclude that “Limited time horizons and fragmented decision-making have played substantial roles in the development, adoption, and use of HIT.”

The RAND report notes that “EHRs’ principal economic impact to date has been facilitating clinical documentation to support timely and complete billing. … Viewed in hindsight, it is not surprising that introducing IT to health care did not immediately generate substantial gains in productivity. …  When other U.S. industries adopted IT in the 1970s and 1980s, productivity growth initially fell, often significantly. However, when these industries redesigned their IT systems to make them more usable by employees and customers and redesigned work processes to take advantage of IT’s capabilities, productivity soared.” In the present setting, the theoretical argument that EHRs will improve American health care and (probably) the economy is quite sound. However, academic studies have shown that the technology’s promised impact on patient care has been blunted, in likelihood by elective limitations in EHR design, usability, and the extent of its interoperability, in the overarching aim to maximize MU receipts. If and when suitable substantive changes are made to EHR design to better serve doctors and patients as well, there remains a strong possibility that EHRs will realize its promise. But that `If` must come from the top, not solely based on free market forces, and it must come shortly.

RAND has the last word here. They conclude that “it is not known how use of EHRs in the United States will evolve, but two points are clear: (1) EHRs are here to stay, and (2) how they are designed and employed will profoundly influence the quality, efficiency, and cost of American health care for decades to come.”

Indeed – profoundly. This is crucial. Let’s right the ship straight away.