Ten Reasons Why the Current Hospital EHR Model Is Unsustainable

The idea to write this note has been incubating in my mind for a few of weeks. I finally decided that it would be useful to post a comprehensive list of what I personally think are the reasons that the current EHR model is unsustainable. I have blogged on a number of these topics in the past. By the use of the term "unsustainable," I mean that the current EHRs can't remain in place over the long term as a key foundation of our healthcare delivery system.

1. The major vendors of EHRs such as Epic and Cerner are now enjoying a near monopoly in the marketplace (see: Does Epic Exercise a Near-Monoply for EMRs in Larger U.S. Hospitals?). This is particularly true for most of the large teaching hospitals that are uniformly signing contracts with Epic. Because of this monopoly, a company like Epic is not under pressure to deliver better features and functions. For example, movement toward interoperability has come only because of the growing interest of the federal government in this feature (see, for example: NYT Op-Ed on EHR Interoperability Blames Vendors and Greedy Hospitals; Revisiting EHR Interoperability; Standardized Content and Vendor Strategy).
2. Hospital strategy is inextricably enmeshed with EHR functionality (see: What's Really Wrong with EHRs: Beginning a Deep Dive). Because most large hospital EHRs are provided by Epic, the company controls and dictates a large component of hospital strategy. Consider, for example, the dreadful state of hospital billing (see: Two Reasons Why Medical and Hospital Bills Are Such a Mess). The president of the largest hospital billing trade group has said that software companies determine what billing data is presented to patients. Hospital executives running an Epic EHR would thus be unable independently to change their billing system even if they wanted to.
3. Because of the monopoly advantage described above, there are few constraints on the total cost of ownership (TCO) for EHRs (see: The Cost of Deploying an Epic EMR and the "Oreo Cookie" Analogy). EHRs are thus depriving capital flows to other hospital programs to the detriment of overall services and care to patients. Some hospitals are even having their bond ratings lowered, partly in response to the deployment of an EHR (see: Some Hospitals Experiencing Financial Distress and Even Bankruptcy).
4. Contractual constraints imposed by the EHR vendors and enforced by hospitals have stifled discussions about design flaws in EHRs (see: Reducing EHR "Wrong Orders" by Limiting the Number of "Open Charts"). Hospitals are also inhibited from working collaboratively to apply pressure on the vendors to improve their systems. All of this has a deleterious effect on patient safety without an obvious path to an improvement. Compare with this adverse reactions to drugs where there is immediate and mandatory reporting required by the federal government.
5. For many physicians and nurses, the use of the EHR has resulted in "bloated" e-charts which are difficult or even impossible to interpret (see: Veteran Clinician Critiques the Current EHR -- Both Good and Bad). To cite the problem bluntly, hospitals have spent hundreds of millions of dollars on systems that don't work as promised and often compromise patient safety. Physician and nurse criticism of EHRs is often blunted by the hospital C-suite with executives wary of accusations of incompetence on the basis of their EHR purchase decisions.
6. The federal government has waded into this EHR controversy and provided financial incentives for hospital and physician office EHR deployments. Policies such as meaningful use (MU), nominally designed to improve the EHR functionality and quality of care, are being forced on vendors and hospitals (see: Opposition Mounts to the Government EHR Certification Process with AMA Letter). This over-regulation has resulted in a near-paralysis with the most benefits accruing to the major vendors that can hire sufficient regulatory personnel to interface with the government.
7. Professional organizations such as HIMSS that theoretically could have provided checks and balances on the EHRs companies are functioning mainly as their marketing arms. We thus have the spectacle of more than 43,000 people and 1,200 exhibitors participating at HIMSS 2015, fueled by the huge sums required to purchase systems (see: HIMSS attendance jumps by more than 5,000 attendees to 43,129). Where are the HIMSS lectures about how EHRs could better serve patients, physicians, and nurses? Where are the brakes on this rampant commercialism?
8. Today's EHRs are monolithic and potentially subject to failure. They are also so complex that they can only be modified tangentially. This is analogous to the situation in the 1980s when IBM was the dominant vendor of HISs (see: Why the Lack of a Significant LIS Presence at HIMSS?). IBM promised that such systems could meet all the IT need of hospitals, failed to deliver on this promise, and then disappeared. As we move primarily to enterprise wide solutions (EWSs) from a single vendor, "system failures" can result in near-total stoppage of critical services that may occur across multiple hospitals within an IDN. This would not be be case, for example, if the hospital LIS and RIS are supplied by a different vendor.
9. Because the central IT groups in hospitals contract for EHRs, they maintain the primary relationship with the vendor. This causes an exclusion of the content experts at the department level such as in pathology and radiology This also produces a "dumbing down" of the diagnostic systems provided by the EWS vendor and a loss of the talent and expertise of departmental informaticians that has been evolving over decades.
10. Because we are continuing to chase yesterday's technology with our EHRs, we deprive ourselves of the opportunity to deploy new and innovative IT solutions. For hospital computing, I believe that such solutions will involve a set of specialized, best-of-breed, cloud-based systems interoperating under a federated architecture (see: Predictions for the Post-EHR IT Era; Business Continuity Challenges). In the long run, higher system functionality will rule the day. However and like the previous abandonment of the IBM-supplied HISs referred to above, this shift will take a number of years to occur.