In a recent article about the defects of the EHR in the Harvard Business Review, there was a passage that briefly but directly summarized many of the problems of current EHRs (see: To Combat Physician Burnout and Improve Care, Fix the Electronic Health Record). Note that the title of the article suggested that these EHR fixes were necessary in order to partly correct physician burn-out. Below is that passage:
The EHR is a lot more than merely an electronic version of the patient’s chart. It has also become the control panel for managing the clinical encounter through clinician order entry. Moreover, through billing and regulatory compliance, it has also become a focal point of quality-improvement efforts. While some of these efforts actually have improved quality and patient safety, many others served merely to “buff up the note” to make the clinician look good on “process” measures, and simply maximize billing. Mashing up all these functions — charting, clinical ordering, billing/compliance and quality improvement — inside the EHR has been a disaster for the clinical user, in large part because the billing/compliance function has dominated.
The pressure from angry physician users has produced a medieval solution: Hospital and clinics have hired tens of thousands of scribe sliterally to follow clinicians around and record their notes and orders into the EHR. Only in health care, it seems, could we find a way to “automate” that ended up adding staff and costs! As bad as the regulatory and documentation requirements are, they are not the largest problem. The electronic systems hospitals have adopted at huge expense are fronted by user interfaces out of the mid-1990s: Windows 95-style screens and dropdown menus, data input by typing and navigation by point and click. These antiquated user interfaces are astonishingly difficult to navigate. Clinical information vital for care decisions is sometimes entombed dozens of clicks beneath the user-facing pages of the patient’s chart.
I predict that anyone who has worked in the current hospital environment will understand that it will be impossible to quickly solve the problems of the EHR described in the quote above. I blogged three years ago about why I thought the EHR model is unsustainable (see: Ten Reasons Why the Current Hospital EHR Model Is Unsustainable). Here is my updated set of reasons for such a statement:
- The major companies providing EHRs exercise a near-monopoly in the market and it will be difficult, if not impossible, to provide incentives for them to extensively modify their systems in the short term as long as they continue to sell their product (see: Epic, Cerner hold majority of EHR market share in acute care hospitals).
- Major hospital CEOs will not be publicly quoted as being critical of their EHRs so there is no spirited and significant dialogue about them. This is, at least in part, the result of the "gag clauses" that are part of EHR contracts (see: Gag Clauses in EHR Contracts Documented; Concerns Raised about Patient Safety).
- Today's EHRs are complex, multifunctional, layered products that have evolved over years. They are monolithic and not easily modified excerpt by a series of small incremental steps the won't change their overall quality.
- EHRs are inefficient but mission critical for hospitals so their physicians and nurses will not tolerate any significant system changes even though they would ostensibly be intended to improve efficiency. Hospitals executives will thus only publicly lobby for gradual incremental changes if even that.
- Because of quirks and vagaries of healthcare reimbursement, health system executives have little deep understanding of their cost structures. Hence, arguments that inefficient EHR software has a drastic effect on the efficiency of their key professional workforce (i.e., physician and nurses) tends not to motivate them (see: Two Reasons Why Medical and Hospital Bills Are Such a Mess; Many Hospitals Struggle to Understand Their Own Cost Data).
- In order to solve this EHR inefficiency problem, and as noted above, hospitals will continue to hire scribes as one corrective measure to offload the workload improved upon them by their problematic EHRs (see: The growth of medical scribes and what it means for healthcare). In short, hospital executives will throw money at this problem and thereby continue to inexorably increase the cost of hospital care.
- With the advent of electronic home monitoring and health wearables, some consumer-generated data will be uploaded to hospital EHR databases. Unknown at this time is how such data acquisition by hospitals will be compensated. And yet, the net results will be to make EHR databases even larger and more unwieldy.
I also suggest here that it would be illogical to anticipate new entrants in the EHR market who would compete with the incumbent EHR vendors. Tech giants like Apple and Amazon will operate only at the margins and in the consumer-oriented and evolving fields. There will thus be no "white knights" that will enter the EHR market with an efficient, cloud-based solution. Instead and because of other significant changes in healthcare delivery, hospitals will continue to lose business and money, particularly in the ambulatory care sector and also for remunerative surgical procedures like knee and hip replacement, imaging, and lab testing (see: Tug of War between Hospitals and Surgicenters for Knee Replacements). Smaller hospitals will increasingly become insolvent and go out of business. Giant health systems will be declared "too big to fail" despite their extremely high cost structures. Hospitals services will become even more costly but probably borne by health insurance companies for the increasingly rare instances when hospitalization becomes necessary.