Under the HITECH Act, the United States Department of Health and Human Services is spending $25.9 billion to promote and expand the adoption of health information technology with the goal to improve care processes, the quality of care, and overall health system productivity. The HITECH Act set meaningful use of interoperable electronic health record (EHR) adoption in the health care system as a critical national goal and incentivized EHR adoption. In an article published in Health Affairs by Kellerman and Jones, if the health care industry could gain a 1.5% annual productivity improvement (equivalent to retail industry with computerization), this would amount to a 50% reduction in overall healthcare expenditure. However, thus far, the yields gained from EHR adoption on improving quality of care and the overall health system productivity is equivocal. What are the causes for this unrealized potential? Are we wasting a massive amount of resources that will not yield a more effective and efficient health care system?
Recently, I had a discussion with a colleague, a mid-career emergency physician, regarding electronic health records. He was frustrated at the inefficiencies associated with EHR at our hospital and was of the belief that EHRs were a massive waste of money and time with negligible benefits. He maintained that EHRs had reduced the role of a physician to a glorified data entry manager. Furthermore, he asserted that EHRs ultimately hindered patient care by burdening care processes and work flows. He waxed poetic about the “good ole days” of three line charts and verbal orders. I never practiced in those “days,” so his sentiments were completely foreign to me. However, there is data emerging that physician productivity and patient care are not improved by EHR and may in fact be negatively affected in a significant way due to documentation challenges. For example, in a recent study, physicians had a forty six minutes of decreased free time per clinic day because of the use of EHR and this was primarily due to documentation creation and navigation. In another study on ambulatory care processes, only 1 of 20 quality indicators showed significantly better performance in visits with computerized decision support versus visits without computerized decision support.
In my opinion, the meager gains from EHRs and the lackluster support of EHRs amongst providers are intertwined. Providers are frustrated at the overwhelmingly poorly designed EHRs that hamper workflow. Most of the current iterations of EHRs are laden with poorly designed interfaces that cause alert fatigue, encumber vital interaction between providers, and delay care with inflexible ordering formats. Furthermore, production of a note requires significant time because of ineffective computerized decision support that leads to foraging of key information by the provider. These cumbersome design features leads to persistent frustrations for providers who are accustomed to “good ole day” workflows. Providers are not interested in being data enterers but clinicians and the current iteration of EHRs makes that challenging. User interfaces must be optimized to facilitate workflow and data must be reduced down to actionable information for the provider, so providers can continue to be clinicians.
The federal government is making a considerable investment in the potential of EHRs to improve health care. However, there is a significant amount of EHR development (and additional costs) remaining before we can achieve a quantifiable return on that investment. If we make those investments and optimize EHR design for whole care processes, we can utilize clinical data for “secondary” goals such as disease management, care processes, population health surveillance, compared practices, and comparative effectiveness. These secondary goals are what will lead to overall improved health system productivity, decreased health costs, and overall improved health outcomes.