Electronic Health Records Performance Lags Behind Potential
The lack of consistency and interoperability between electronic health records is frustrating the federal government's effort to encourage conversion from paper records. Also contributing to the lag are a culture of prioritizing direct patient care over record-keeping among healthcare providers and a lack of vendor innovation. Still, the push provided by Washington has gotten the wheels in motion.
Major programs designed to reduce costs and improve healthcare through the automation of medical records have fallen short of the potential to do either, according to a recent Rand Corp. report.
The effort to convert paper health documents to electronic form got a huge boost from the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which became law as part of the American Recovery and Reinvestment Act of 2009.
The law provided nearly US$34 billion for payments to doctors and hospitals for converting paper records to electronic health records (EHRs). Individual physicians, for example, are eligible for as much as $40,000 in reimbursements. The incentives will eventually expire, at which point health providers will be penalized by reductions in their Medicare reimbursements if they do not meet electronic conversion deadlines.
"We are not saying that the value of converting to electronic records has diminished or that the benefits to efficiency and patient care are not achievable," Art Kellerman, M.D., a Rand health policy analyst and coauthor of the study, told the E-Commerce Times. "But there are some significant factors that have impeded progress in meeting those goals that still have to be addressed."
The study found that the cost-saving promise of health information technology and related tools has not occurred because the systems deployed are neither interconnected nor easy to use. "The failure of health information technology to quickly deliver on its promise is not caused by its lack of potential, but rather because of the shortcomings in the design of the IT systems that are currently in place," Kellerman said.
Attitude and Design Factors
The Rand study found that major impediments to productively using EHRs include the following:
- Provider culture: Doctors and hospitals instinctively rank patient treatment as their top priority, and often see little direct clinical impact for EHR. Health providers see IT training as somewhat of a bother, and have little tolerance for spending time on data management. "Hospital administrators express frustration about getting their staffs to get their butts into an IT training class," Kellerman said. Compounding this reluctance is the lack of evidence, to date, that EHR systems significantly result in efficiency or improved care for patients.
- Vendor shortfalls: Few health IT vendors make products that are easy to use. As a result, health professionals complain that IT systems actually slow them down. There is precious little information available to healthcare providers which would enable them to compare and evaluate vendor offerings -- hence there is little competitive incentive for vendors to improve their products. "We haven't done an in-depth study of the vendors per se, but the impression we get from healthcare providers is that the vendors haven't been all that aggressive in designing systems that are easy to use and really match the clinical environment," Kellerman said.
A related issue is that current healthcare IT systems lack interoperability features -- the ability of various health IT systems to communicate with each other. Healthcare providers may successfully convert to a well-performing records IT system internally, "but the information stored in those records is essentially useless if the patient seeks out-of-network care," the Rand study said. "Interoperability can be a problem even when two organizations acquire the same health IT system from the same vendor. In short order, the degree of local customization becomes so extensive that the systems cannot communicate with each other without costly interfaces. The lack of progress on interoperability is so stark that it has led some to speculate that major health IT vendors are opposed to interoperability."
Health IT Just Starting
"In some respects the Rand study is a bit harsh on the lack of progress. We are still at the beginning stages of a major process, and you have to appreciate that," Jennifer Covich Bordenick, CEO of the eHealth Initiative, told the E-Commerce Times.
However, "the study points out some valid factors that need to be addressed. For example, interoperability is a big problem and the federal government should play a lead role in dealing with that," she said. "Vendors may not be as far along in development as we would like, but to some degree they are in the same place as health providers in trying to figure out where they should be."
Federal support for EHR adoption came with a multi-phase program requiring health providers to meet quality standards for such functions as data collection, tracking clinical conditions, incorporating lab results and facilitating information to patients and families -- in a protocol known as "meaningful use" (MU) criteria. The second phase of the MU program is scheduled for release in 2014 and the third in 2016. Both vendors and health providers must be capable of compliance at various stages of the MU process.
"I think the meaningful use program, while it helps ensure quality, has slowed adoption somewhat. But on the other hand the HITECH program really helped to jump-start the health IT process," Covich said.
"The Rand study may be right about the systems failing to reach their full potential with regard to efficiency and economic cost-benefit savings, but I also think there have been improvements to patient safety as a result of EHR," Judy Hanover, research director at IDC Health Insights, told the E-Commerce Times. For example, computerized physician order entry (CPOE) programs utilize electronic entry of patient data and medical instructions communicated through a computer network to medical staff, including pharmacies and laboratories. The process saves time, reduces errors related to handwritten documents, ensures against incorrect dosages, and clarifies billings.
"There is still much to be done regarding process re-engineering, but I don't think usability is necessarily the whole problem with EHRs. Commercially supplied EHRs in use today have been designed to accomplish clinical documentation, mainly by moving the paper chart into electronic form, requiring as few clicks as possible," Hanover said. "The move from paper to electronic is done with little to no process re-engineering, and of course physician productivity will be lost in the process. Re-engineering still needs to be done. The shift from fee-for-service to outcomes-based care will help drive this," she said.
Next Generation of Health IT
"The supplier market in this space is immature, and there have been a lot of new functionality requirements for MU that have driven development of new functionality with minimal attention to usability. The platforms that today's EHRs rely on make changes to support usability time consuming and expensive for vendors to make and implement in highly customized systems," she said.
The Rand study concludes that a "compelling vision" is needed to guide future investments in health information technology and offers the following recommendations:
- Information stored in one IT system must be retrievable by others, including doctors and hospitals that are a part of other health systems.
- Patients should have ready access to their electronic health information, much as consumers now have access to their bank accounts.
- Health information technology systems must be engineered to aid the work of clinicians, not hinder it. Systems should be intuitive, so they can be used by busy healthcare providers without extensive training. Healthcare providers should be able to easily use systems across different healthcare settings.
Hanover envisions that the current impediments to optimizing EHR systems will be addressed in future iterations of IT offerings. "I do think a second generation of EHRs will probably be required to support re-engineering and if and when it does happen, I think these EHRs will be cloud-based, interoperable, and much less expensive to install and operate than the first generation."