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Report Card: What Grade Do Electronic Health Records Get?

David Fairchild, MD, MPH is featured in the October/November 2018 edition of MCOL Thoughtleaders newsletter. The question asked was:

“What grade would you give the state of EHR in 2018 on a national basis with physicians and hospitals, and are there aspects that have fallen well short of your past expectations of where we would be today?”

I don’t know any physician who is “happy” with their EMR. As a practicing primary care physician in a large faculty practice group, and as a healthcare consultant who interacts with healthcare providers across the country, I talk with clinicians every day. Overall grade for EHRs: B-

By now nearly 96% of all non-federal acute care hospitals, and 99% of all hospitals over 300 beds, have installed some brand of HHS Certified health IT system with clinical notes. The challenge now is how to clear up the issue of interoperability among IT systems so that data sharing can provide a complete picture of a patient’s health status, and more fully open the door to innovation.

While progress is being made, the impediments to achieving interoperability are significant. There are multiple EHR vendors in the inpatient and outpatient market, and implementing, running, maintaining and modifying these different platforms is complex and costly. A recent HIMSS Analytics survey indicates that the average health system is running some 18 distinct electronic health record platforms across their inpatient and outpatient practice sites. A number of these are specialty EHRs in areas such as oncology or behavioral health that won’t be easily displaced by core vendors, which may explain why only a small percentage of hospitals have been able consolidate their EHR platforms down to a few vendors.

In short, if doctors are to “live” in their EHR, they need all relevant patient data to reside there as well. Providers don’t have time to go searching multiple locations for patient data.

While interoperability remains challenging, EHRs are meeting expectations in a number of ways.

First and foremost, EMRs provide easy access to the multi-disciplinary team of specialists and their clinical notes related to the referrals I make as a PCP. EHR technology also provides me with information in retrievable formats not available in paper records, and improves chronic disease management, prevention, and screening which is essential for value-based payment. Further, EHRs provide clinicians remote access to patient charts, lab results, and point of care data that enable us to manage patients better when we are out of the office.

Secondly, EHRs help empower patients. Our patients appreciate having the ability to check lab results, make appointments on line, and to e-mail their provider directly about questions which used to go unasked or unanswered. This is a benefit that doesn’t get talked about enough. Most patients believe that their clinical information is perfectly safe, and they like the way the EHR lets them collaborate in their treatment planning. That said, the capabilities of most EHR portals are a long way away from providing the “frictionless” interface that we have all come to expect from our phone apps.

Despite these positive benefits, there are other problematic issues. First among these is the unintended consequences created by the EHRs insatiable demand for data entry. My colleagues have complained that the need for documentation can take the focus away from having a personal relationship with their patients. Professional satisfaction for physicians is driven by their ability to deliver high quality care in an efficient manner. Dissatisfaction is driven by factors that impede this ability such as excessive regulatory, clerical, and administrative burdens coupled with inefficient practice environments.

Needed: data entry/collection mechanisms other than direct provider entry into the EMR, (for example, scribe entered or uploaded patient entered data)

The implementation of EHRs has been the major driver of change in physician practice patterns in the past 20 years. Despite the quality of care advantages, an unintended consequences of EHR expansion has been some loss of physician practice satisfaction. Some physicians groups report their physicians spend a one-to-one ratio documenting care in their EHR as they do providing face-to-face care. Clearly this is not the best use of our most expensive resource.

Overall, EHRs have enabled us to increase the quality of care that clinicians provide. However, this quality enhancement has been powered by requiring physicians and other providers to do a great deal of data entry. I believe that much of physician burnout can be traced back to the additional burden EMRs have placed on the backs of providers. A B- grade shows promise, but with a definite “needs improvement”.

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