Written: May 2014
Electronic Health Records (EHRs) are part of the healthcare solution set, but also are part of the problem. For consumers, two key problems with EHRs are access and understanding. Providers of EHRs have not done a good job of explaining EHRs. There are multiple similar but unique kinds of EHR including: the EHR, electronic medical record, personal health record, and universal health record. Each has a different purpose and use depending on who is describing them. I use the abbreviation EHR throughout my writings.
Although EHRs are an important tool, it is not clear whether you should get the tool from your doctor, your hospital, pharmaceutical company, pharmacy, employer, an independent source, or all of them. Any of them can create an EHR for you. A lot of education will be necessary to understand the relative benefits. Access to an EHR for most people will be through patient portals created by hospitals or physician practices.
The New York Times published a story in January 2013, “In Second Look, Few Savings from Digital Health Records”.[i] The article said companies providing EHR software and services funded a prestigious study in 2005, which forecasted significant savings from EHRs thereby suggesting a conflict of interest. Eight years later, the same prestigious study group said savings have not been realized.
Both the Obama and the Bush administrations believed electronic medical records could provide many benefits for patients and healthcare providers. Policymakers developing the healthcare reform legislation recognized EHR benefits would materialize only if the EHRs were used in a meaningful way. The policymakers developed a set of standards, defined by The Centers for Medicare & Medicaid Services, called meaningful use. Meaningful use defined minimum U.S. government standards for EHRs outlining how clinical patient data should be exchanged between healthcare providers, between providers and insurers, and between providers and patients. Significant financial incentives were offered to healthcare providers who met the meaningful use criteria. Even a small hospital could earn millions of dollars if they met the meaningful use targets by a certain date.
Responsible healthcare executives made achieving meaningful use standards a top priority. If the team developed the comprehensive planning needed to ensure optimum implementation and maximum savings but missed the target date specified for meaningful use incentives to be earned, they would be leaving a lot of money on the table. The government incentives resulted in the desired acceleration of EHR implementations but not necessarily the cost savings expected. Some implementations were technically achieved on time but were not thoroughly tested. Clinicians and patients were not ready either. Although projected savings were missed and implementations were not as smooth as they should have been, the foundations were put in place to leverage the value of EHRs in the future.
Recently a physician friend and I discussed a broad range of healthcare issues, including the status of EHRs. We had both seen the USA Today article written by Dr. Kevin Pho, who presented a negative view of using EHRs.[ii] Dr. Pho’s main point was filling out electronic forms takes time away from the patient. I have experienced this from the patient perspective. It is frustrating to sit next to a doctor who never looks at you because he or she is too busy entering data. The time-consuming data entry task certainly detracts from the positive potential of EHRs, but it should not deter patients or doctors from embracing them.
The time-consuming nature of data entry is real for physicians. Medscape reported a survey from the American College of Physicians revealed, “As more and more physicians adopt EHR systems, they like them less and less.”[iii] Physicians not only find the data entry task demeaning, but they also have not been convinced of the benefits.
Most doctors do not find the EHR software intuitive or easy to use. The focus of the software design taken by the EHR vendors was to assure compliance with the meaningful use criteria set out by the government, not necessarily to make it easy to use. Using the EHR software can be tedious. It is especially laborious and time consuming during the transition from paper records to electronic records.
One of the solutions to the physician data entry problem is the use of scribes. A scribe is a low-level administrative assistant who is present with the doctor, and enters the data spoken by the doctor. This may make sense in an ER setting, but in the privacy of a physician examining room, it is a different story. Patients may not be comfortable fully describing symptoms or concerns with a stranger, the scribe, in the room. Technology can offer a much better solution than scribes. Voice recognition and dictation systems will make it possible for doctors to talk to the EHR instead of typing or using a scribe.
My reflections – 2022
Despite billions of dollars of investment in health information systems and technology and many years of widespread availability, the promised benefits of EHRs are still not being realized. After making an appointment in April 2022, the administrative person asked if I would like a copy of the appointment mailed to me. She didn’t mean email. She meant USPS paper mail. The paper culture is still deeply ingrained. Providers still view the fax machine as the lingua franca of healthcare.
Millions of Americans have second homes in a different state. Even if both healthcare systems use the same software vendor, it is often next to impossible to make all the data synchronized so physicians can easily see physician notes and test results from the other state.
Progress is being made but not at the pace needed to reap the potential benefits of digital healthcare. Apple has stepped into the fray and offers consumers a way to link multiple healthcare providers with the Apple Health app. This is great for the consumer, but it does not solve the lack of interoperability faced by the providers.
The use of scribes is growing and physicians I have talked to like it. Patients, however, don’t necessarily like having a person unknown to them sitting in the room during a conversation about their health concerns with the physician. Cloud based AI scribes are available. The virtual scribe receives extensive training across multiple medical disciplines. They can understand the nomenclature and clinical context of what the physician is saying. Over time, the virtual scribes can ensure consistently accurate clinical charting. Over the next five years, I expect virtual scribes to become more commonplace.
Another advance I believe will happen is the use of blockchain technology for storing EHRs. Blockchains were devised for providing the infrastructure to facilitate cryptocurrency transactions. However, a blockchain can store any kind of information including, digital art, home deeds, car titles, etc. in addition to EHRs. Storing an EHR on a blockchain can make it secure, private, auditable, and accessible to all relevant healthcare providers.
[i] Reed Abelson and Julie Creswell, “In Second Look, Few Savings from Digital Health Records,” New York Times (2013), https://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html
[ii] Kevin Pho, “Column: The Doctor Will See You Now — on the Internet,” USA Today (2013), https://www.usatoday.com/story/opinion/2013/01/13/doctor-medicine-internet-visit/1830743/
[iii] Robert Lowes, “Ehr User Satisfaction Declines in Meaningful-Use Era,” Medscape (2013), http://www.medscape.com/viewarticle/780336