Electronic Health Records (EHRs)

 VI. Key Issues: Financing and Delivery >> A. Health Spending >> Health Cost Containment  >> Improve Administration >> Health IT >> Electronic Health Records (EHRs) (last updated 1.27.22)

Lead Editor: Dana Beezley-Smith, Ph.D.

Meaningful Use Program

CMS (Updated, 10.6.15): The American Recovery and Reinvestment Act of 2009 (ARRA) (Pub.L. 111–5) was enacted on February 17, 2009. Title IV of Division B of ARRA amends Titles XVIII and XIX of the Social Security Act (the Act) by establishing incentive payments to eligible professionals (EPs), eligible hospitals, critical access hospitals (CAHs), and Medicare Advantage Organizations to promote the adoption and meaningful use of interoperable health information technology (HIT) and qualified electronic health records (EHRs). These incentive payments are part of a broader effort under the HITECH Act to accelerate the adoption of HIT and utilization of qualified EHRs.
Meaningful Use (MU) is a Center for Medicare & Medicaid Services (CMS) program that pays an incentive for “meaningful use” of an electronic health record (EHR). It is a separate program from PQRS (Physician Quality Reporting System). Those eligible for the Meaningful Use include doctors of medicine or osteopathy, dental surgery or dental medicine, podiatry, optometry, and chiropractic. Meaningful use is defined as use of certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities; Engage patients and family; Improve care coordination, and population and public health; Maintain privacy and security of patient health information.

Stages of Meaningful Use

2011-2012 Stage 1: Data capture and sharing
2014 Stage 2: Advance clinical processes
2016 Stage 3: Improved outcomes

Stage 1 Meaningful Use 

Stage 1 Requirements

• Use of a certified EHR in a meaningful manner (e.g. e-prescribing)
• Use of a certified EHR for electronic exchange of health information to improve the quality of health care
• Use of certified EHR technology to submit clinical quality measures (CQM).

Qualifying for Stage 1 Meaningful Use of an electronic health record (EHR) means that:

• The EHR meets all 20 objectives for meaningful use.
• Six clinical quality measures are reported.
• The EHR has been in use for at least 90 days during the first year and 12 months for all subsequent years.
• Three core measures plus three additional measures must be reported. If the provider does not qualify for the three core measures, three alternate core measures must be reported. List of core and alternate measures.

Stage 1 Specification Sheets 

The Centers for Medicare & Medicaid Services (CMS), which administers the Medicare and Medicaid EHR Incentive Programs, provides these sheets to help professionals and hospitals understand the requirements of each objective and demonstrate meaningful use successfully.

• EHR Meaningful Use Specification Sheets for eligible professionals (EPs) [PDF – 348 KB]
• Meaningful use specifications for eligible hospitals [PDF – 360 KB]

Stage 2 Meaningful Use 

On September 4 2012, CMS published a final rule that specifies the Stage 2 criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to continue to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. All providers must achieve meaningful use under the Stage 1 criteria for two years before moving to Stage 2.
To help providers better understand Stage 2 Meaningful Use requirements, CMS developed Stage 2 Meaningful Use Specification Sheets for EPs and Eligible Hospitals that provide detailed information on each Stage 2 objective.

Stage 2 Analysis

• Meaningful Use Round Two: New Rules of Engagement. (EHR Decisions, 10.15.12) “The rules for both Meaningful Use and the new Standards and Certification Criteria went into effect October 4, after the requisite 30 days since first posting in the Federal Register have passed. … All of these new rules are relatively confusing for a provider who is focused on caring for patients while attempting to play by the rules. Here are a few key points to guide successful attestations, using appropriately certified EHR technologies.”
• Where Meaningful Use Stage 2 Is Most Likely to Trip You Up. “Physicians preparing for stage 2 should look closely at other requirements, including lab orders, preventive care reminders, and medication reconciliation.” (Medscape Business of Medicine, 1.10.13)
• AMA Wants Major Changes in Meaningful Use. “Unless significant changes are made to the program, the AMA contended, more physicians will drop out of the meaningful use program; patients will face disruptions and inefficiency in their care; many physicians will incur financial penalties that hinder future technology purchases; and ‘outcomes-based delivery models, which require data driven approaches, will be jeopardized.’ The AMA’s point about physicians leaving the meaningful use program resonated in the industry because of a recent CMS report. Just a week ago, the agency revealed that, through March of this year, only 4 hospitals and 50 eligible professionals (EPs) had attested to the second stage of meaningful use. Not many EPs could have attested by then, because their 90-day reporting period started January 1. But the hospitals had had 5 months to show meaningful use.” (Medscape Medical News, 5.16.14)
• CMS Proposes to Let Docs Use Older EHRs in Incentive Program. “In another victory for organized medicine, the Centers for Medicare & Medicaid Services (CMS) proposed today to let physicians in its ‘meaningful use’ incentive program for electronic health record (EHR) systems use Stage 1 technology to satisfy Stage 2 requirements in 2014. The proposal also would allow some physicians to achieve Stage 2 meaningful use in 2014 using Stage 1 objectives and measures for patient care… Case in point is the debut of Stage 2 meaningful-use requirements that participants must meet in 2014 if they have earned bonuses in the program for at least 2 prior years under Stage 1. To comply, physicians must attest, among other things, to using a so-called 2014 edition of a certified EHR system designed for Stage 2. This is a step up from 2011 certified editions designed for Stage 1 of the program. Yet software vendors have been slow to roll out 2014-edition systems, sparking fears that many physicians will flunk meaningful use this year and incur a Medicare penalty.” (Medscape Medical News, 5.20.14)
• Docs Ask for Delay in Hardship Deadline for EHR Meaningful Use. Last week, the American Medical Association (AMA) and the Medical Group Management Association (MGMA) asked the Centers for Medicare & Medicaid Services (CMS) to delay a July 1 deadline for submitting a hardship exception application that could spare physicians a 1% Medicare penalty in 2015 for failing to demonstrate EHR meaningful use. That penalty applies specifically to physicians who have not previously achieved meaningful use before 2014 and who fail to do so this year as well. The penalty increases to 2% in 2016 for physicians who successfully achieved meaningful use in a previous year, but not in 2014. The deadline for requesting a hardship exception for the 2016 penalty is July 1, 2015. (Medscape Medical News, 6.30.14)
• AMA Urges CMS to Drop Meaningful Use Penalties. “The American Medical Association (AMA) has added to an earlier policy statement calling on the Centers for Medicare & Medicaid Services (CMS) to drop penalties for not meeting the meaningful use requirements of the electronic health records (EHR) incentive program…A key barrier to meeting the meaningful use criteria, the AMA says, is the lack of interoperability among disparate EHRs.” (Medscape Medical News, 11.11.14)
• EHR Meaningful Use Penalty Will Hit 257,000 Clinicians in 2015. “‘The AMA is appalled by news from CMS today that more than 50% of eligible professionals will face penalties under the meaningful use program in 2015, a number that is even worse than we anticipated,’ said Steven Stack, MD, the AMA’s president-elect, in a statement. At its interim annual meeting in Dallas last month, the AMA House of Delegates adopted a resolution urging CMS to suspend all meaningful use penalties. Like other medical societies, it has complained that meaningful use requirements established by CMS are too difficult for many, if not most, physicians to meet. Organized medicine also decries the program’s all-or-nothing approach to success. A physician can ace 99% of the requirements and still get penalized for flunking the remaining 1%, said Robert Wergin, MD, president of the American Academy of Family Physicians.” (Medscape Medical News, 12.17.14)
• Meaningful Use Reporting Span Will Shrink to 90 Days in 2015. “The Centers for Medicare & Medicaid Services (CMS) today formally proposed to shorten the reporting period for its meaningful use incentive program for electronic health record (EHR) systems in 2015 from 12 months to 90 days. The shorter time frame applies to physicians who are new to the program in 2015 as well as those who’ve participated before. In 2016, only first-time participants will be eligible for a 90-day reporting period… The government said in a news release that it would reduce the number of reporting requirements by winnowing out those that ‘have become duplicative, redundant, and reached wide-spread adoption.’ And some requirements that make the cut will become less onerous. Right now, 5% of patients in a physician’s practice must access their records electronically under a requirement in the program’s Stage 2 phase. Criticized for making compliance dependent on something a physician can’t control, CMS is proposing to lower this threshold to 1%.” (Medscape Medical News, 4.10.15)

Stage 3 Meaningful Use

For Stage 3 of the EHR Incentive Programs in 2017 and subsequent years, major provisions include:

• 8 objectives for eligible professionals, eligible hospitals, and CAHs:  In Stage 3, more than 60 percent of the proposed measures require interoperability, up from 33 percent in Stage 2.
• Public health reporting with flexible options for measure selection.
• CQM reporting aligned with the CMS quality reporting programs.
• Finalize the use of application program interfaces (APIs) that enable the development of new functionalities to build bridges across systems and provide increased data access. This will help patients have unprecedented access to their own health records, empowering individuals to make key health decisions.

All providers will be required to comply with Stage 3 requirements beginning in 2018 using EHR technology certified to the 2015 Edition. The Stage 3 requirements are optional in 2017. Providers who choose to begin Stage 3 in 2017 will have a 90-day reporting period. Objectives and measures for Stage 3 include increased thresholds, advanced use of health information exchange functionality, and an overall focus on continuous quality improvement.
CMS restructured the objectives and measures of the EHR Incentive Programs in 2015 through 2017 to align with Stage 3, and modified “patient action” measures in Stage 2 objectives.
CMS announced on 10.6.15 a 60-day public comment period to facilitate additional feedback about Stage 3 of the EHR Incentive Programs going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit-based Incentive Payment System (MIPS) and consolidates certain aspects of a number of quality measurement and federal incentive programs into one more efficient framework. (Center for Medicare and Medicaid Services, 10.6.15)

Stage 3 Analysis

• Alexander: Rushing Stage 3 Rule of Electronic Health Records Program a “Disservice to More than 500,000 Doctors, Thousands of Hospitals and Millions of Patients.” “The chairman of the Senate health committee today said that in rushing its rule for the third stage of the electronic health records program, the administration ‘is doing a disservice to more than 500,000 doctors, thousands of hospitals, and millions of patients.’… 116 members of the House of Representatives—including 20 Democrats—sent the administration a letter urging a delay in making the stage 3 rule final.” (Senate Health, Education, Labor, & Pensions Committee, 10.6.15)
• Physician EHR Comments on Stage 3 Meaningful Use Rule. “The Centers for Medicare & Medicaid Services extended the comment period for Stage 3 meaningful use this past month, and the comments continue to roll in. More than 170 stakeholders have weighed in on the CMS website so far – most sounding off, expressing frustration. Specific suggestions include: 1.Remove the MU program’s pass-fail approach; 2.Provide more flexibility; 3.Ensure EHR systems address interoperability challenges. Browse through all 174 comments here.” (HIEWatch, 11.19.15)
• Meaningful Use ‘Troubled,’ AMA Tells CMS, Proposes Fixes Ahead of Stage 3. “AMA has repeatedly called on CMS to address the challenges of the meaningful use program before moving on to Stage 3. The letter notes what the group has done to move forward on this score:
  • Physicians have told their stories of trying to comply with the regulations as part of AMA’s Break the Red Tape campaign.
  • The AMA partnered with RAND on a study that found cumbersome EHR systems are taking a toll on physicians who feel increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.
  • Also, to leverage the power of EHRs for enhancing patient care, improving productivity, and reducing administrative costs, the AMA has outlined a framework of eight priorities for improving EHR usability.
  • The AMA has also issued a blueprint for the future of the meaningful use program with recommendations to improve EHR functionality. (Health IT News, 12.16.15)

Stage 3 Resources

• CMS Stage 3 MU Overview 2015 through 2017
• CMS Webinar eHealth October 8 2015 Stage 3 MU Final Rule
• ONC Fact Sheet 2015 CEHRT

Meaningful Use News

• ONC Decertifies Two EHRs for Noncompliance. “Certifications for two electronic health record (EHR) systems have been revoked in a rare move by the Office of the National Coordinator for Health Information Technology (ONC). The systems, two versions of SkyCare 4.2, developed by Platinum Health Information Systems, Inc, lost their certifications for “failure to respond and participate in routine surveillance requests by InfoGard Laboratories Inc. (InfoGard),” which is one of the ONC Authorized Certification Bodies (ONC-ACB), the ONC announced September 2. That means 48 eligible professionals who have attested to meeting the stage 1 Medicare and Medicaid meaningful use requirements using SkyCare EHR products will have to switch to certified EHRs to continue participation in stages 2 and 3. Providers currently using the SkyCare EHRs can apply for a hardship exception under the Medicare EHR program as they transition… As for the 48 who must find a new system or risk paying substantial penalties for missing meaningful use deadlines, ‘It’s a huge blow to them… It’s a lot of time and money and not a trivial undertaking,’ she said. Additionally, because data traditionally have not translated well between systems, changing EHRs could cause big headaches in transferring data and open the door for errors in patient information, Dr Ancker said.” (Medscape Medical News, 9.9.15)
• Over 200,000 EPs Will See Meaningful Use Fines This Year. “Approximately 209,000 eligible professionals (EPs) will lose up to 2% of their Medicare reimbursement this year for failing to show meaningful use of electronic health records (EHRs), according to a fact sheet posted by the Centers for Medicare & Medicaid Services (CMS) on October 30, 2015. Whether those penalties will remain in effect if CMS ends the current meaningful program this year, as CMS Acting Administrator Andy Slavitt promised on Tuesday, is still unclear. For most EPs affected by Medicare payments this year, the penalty amounts will be less than $1000. While 13,900 EPs will lose less than $100, the payment adjustments for 103,000 EPs will be $100 to 1000. Penalties of $1000 to $5000 will be assessed to 30,400 EPs; 56,000 will lose $5000 to $10,000; and 5700 will receive a payment adjustment of $10,000 or more. A total of 44,579 EPs did not file any Medicare physician claims.” (Medscape Medical News, 1.14.16)
• CMS Promises Meaningful Use Replacement This Year. “Slavitt said CMS was in the process of making the much-reviled program more physician-friendly, with EHR technology built around ‘individual practice needs, not the needs of the government.’ ‘We have to get the hearts and minds of the physicians back,’ he said. ‘I think we lost them.’ Slavitt’s statements don’t mean that the incentive program is screeching to a halt this year, relieving physicians of reporting obligations and financial penalties. However, they could portend major changes in meaningful use as early as next year, according to medical society leaders interviewed by Medscape Medical News. The changes come in conjunction with a massive overhaul of how Medicare pays physicians. Slavitt said at the San Francisco healthcare conference that on the basis of consultations with the American Medical Association (AMA) and other physician groups, CMS was drafting meaningful use reforms that it would disclose over the next several months. The focus, he said, would move from rewarding physicians for using EHRs to rewarding them for patient outcomes. And EHR technology would be user-centered and interoperable — no more programs that can’t swap data.” (Medscape Medical News, 1.14.16)
• More on MACRA, Interoperability and the Post-Meaningful Use World. Comments from acting CMS administrator Andy Slavitt during an early March 2016 panel appearance at an HIMSS conference: “The first area we are addressing is the documentation overhead associated with the Meaningful Use program. Since we are a few months away from having details available with the proposed MACRA rule that we will be open for public comment, let me share our approach. Second, what we are we hearing from all of our sessions with physicians? Stop measuring clicks, focus instead on allowing technology to become a tool and focus on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control. Third, where possible, we favor ‘pull’ vs. ‘push’ incentives. What I mean by this is to let outcomes rather than activities drive the agenda.” (The Healthcare Blog, 3.4.16)
• CMS Reveals Successor for Meaningful Use Program.“As part of the proposed rule on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), the meaningful use electronic health records (EHR) incentive program will be folded into the Merit-Based Incentive Payment System (MIPS), effective January 1, 2017, Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), announced at a news conference today… The three priorities for this program are improved interoperability to facilitate health information exchange, increased flexibility, and “user-friendly” technology, according to a blog post by Slavitt and Karen DeSalvo, MD, national coordinator for health information technology (IT) and assistant secretary of health.” (Medscape Medical News, 4.27.16)
• Senators Introduce Meaningful Use Rollback Bill. “Six US senators have reintroduced legislation to roll back some meaningful use requirements. The measure would mainly affect hospitals, which are still subject to the electronic health record (EHR) incentive program of the Centers for Medicare & Medicaid Services (CMS)…The Senate legislation would remove the ‘all-or-nothing’ approach of the meaningful use program, which requires eligible hospitals and eligible professionals to meet all requirements to avoid subsequent financial penalties. ‘This bill would create a new threshold that requires eligible hospitals to meet no more than 70% of the required metrics to satisfy meaningful use requirements,’ the bill summary said.” (Medscape, 11.3.17)
• See Medicare Access and CHIP Reauthorization Act (MACRA) which, in part, replaces Meaningful Use for providers.

Electronic Health Records Adoption

• Solo and Small Practices Increase EHR Adoption, Survey Finds. “Results of a telephone survey of more than 270,000 US medical sites reveal that the EHR adoption rate for single-physician offices grew 11.4% to 53.7%, up from 42.3% the prior year, SK&A, a healthcare information research firm that tracks adoption rates for the government, said in its annual report. The adoption rate for offices with 26 or more physicians increased only 1.6%, to 77.5%. Overall, the rate of EHR adoption grew from 50.3% to 61% compared with the previous year, the report noted… Physician specialties with the highest adoption rates are dialysis (80.6%), internal medicine/pediatrics (75.8%), nephrology (70.5%), pathology (69.4%), and radiology (69.2%)… The top 3 vendors are Epic Systems Corp, eClinicalworks, and Allscripts.” (Medscape Medical News, 3.26.14)
• The Adoption and Use of Health Information Technology by Community Health Centers, 2009–2013. “Nearly all surveyed FQHCs (93%) now have an EHR system, a 133 percent increase from 2009, the year federal ‘meaningful use’ incentives for HIT were first authorized. Three-quarters of health centers (76%) reported meeting the criteria to qualify for incentive payments. Remaining challenges for health centers include achieving greater interoperability of EHR systems and ensuring patient access to their records. Mobile technology, such as text messaging, may help FQHCs further expand patient outreach and access to care.” (Commonwealth Fund, May, 2014)
• e-Prescribing: Over Half of Prescriptions Go Online for First Time in 2013. “For the first time, the majority of US prescriptions — not including those for controlled substances — were routed electronically to pharmacies through Surescripts in 2013, according to the company’s National Progress Report on health information technology (IT). That’s more than one billion prescriptions, or 58% of all noncontrolled-substance, eligible prescriptions written last year. Passing the halfway mark is a ‘large milestone,’ said Steven Waldren, MD, senior strategist for t the American Academy of Family Physicians’ (AAFP) Center for Health IT. ‘I think it demonstrates that we’ve solved the e-prescribing part of interoperability.’” (Medscape Medical News, 5.23.14)
• HHS Prescribes $840 Million to Help Doctors Transform Their Practices.“The federal government will spend $840 million over the next four years to help doctors move their practices away from a volume-based business model to one that’s focused on rewarding them for good patient outcomes. That’s one of the goals of the Affordable Care Act, which provided the funding for the Department of Health and Human Services’ Transforming Clinical Practice Initiative.” (American City Business Journals, 10.23.14)
• Office of the National Coordinator for Health Information Technology (ONC) Reports Most Physicians Have an EHR System. “Seventy-one percent of physicians have adopted an electronic health record (EHR), and 85% of adopters have an EHR certified for meaningful use, according to a new report based on 2013 data from the Office of the National Coordinator for Health Information Technology (ONC). An additional 10% of physicians plan to adopt an EHR, the report found. Eleven percent of physicians are uncertain, and 8% have decided not to adopt. Of those who have no plan to acquire a system, four in 10 are retiring. Solo practice physicians have the highest percentage of physicians who are uncertain about EHR adoption or who do not plan to adopt. Among different specialty types, surgeons include the largest group of physicians (9%) who do not intend to adopt.” (Medscape Medical News, 12.11.14)
• Use of Electronic Health Record Systems by Office-Based Pediatricians. “The number of office-based pediatricians who are using an EHR has steadily risen to almost 80%. EHR cost and reduction in productivity remain serious concerns. Despite the widespread adoption of EHRs by pediatricians, only few use a basic or fully functional EHR and even fewer have added pediatric functionality. There is a role for the EHR certification process to advance functionalities used by pediatricians and to increase efficiency, data exchange capability, and general EHR functionality.” (Pediatrics, 12.23.14)
• Transition to a Post-HITECH World.(9.18.15) The Robert Wood Johnson Foundation. “In 2015… a large percentage of acute care hospitals have at least a basic electronic health record (EHR) system. But many are not ready to meet Stage 2 meaningful use criteria—criteria that must be met in order to participate in the Medicare and Medicaid EHR Incentive programs. Key Findings: By 2014, 75.5 percent of hospitals had adopted at least a basic EHR, a substantial increase from 58.9 percent in 2013; Seventy-six percent of hospitals reported exchanging data with outside health professionals in 2014, up from 62 percent in 2013 and 41 percent in 2008, the year the survey began including this measure; Hospitals continue to face barriers toward adopting national standards enacted in 2009 to encourage technology investments and the development of health information exchanges.”
• Why Thousands of Doctors Still Don’t Use Electronic Records. “Ciampi doesn’t have anything against technology, but a failed attempt to go electronic several years ago left him frustrated. ‘What we found was a system that just wasn’t patient-centered,’ Ciampi says. ‘The primary function was to enhance billing, not to build a physician-patient relationship. Our productivity went down 25 percent.’ About one-fifth of doctors don’t have an electronic health record system, commonly called an EHR, implemented in their offices. For those who do, frustrations with the technology are well documented. Only 34 percent of doctors surveyed by the American Medical Association said they were happy with their electronic systems. Since 2009, the Obama administration has been offering financial incentives to certain doctors and hospitals that can demonstrate ‘meaningful use’ of EHRs; incentives can amount to as much as $63,000. This was likely a big reason the number of doctors using EHRs jumped to 50 percent in 2013 and then to 75 percent by the end of 2014. But the incentive program is going to be phased out by the end of the year, which leaves some wondering what can be done to reach physicians who still rely mostly on paper. Andy Boyd, a professor of health information sciences at the University of Illinois at Chicago, sympathizes with the holdouts. ‘If you have a smaller practice, it’s expensive,’ Boyd says. ‘You also can’t see the same number of patients while you get used to the system.’” (Governing, March 2016)
• Why is EHR Use Dropping? “A new report by SK&A Market Insights reveals that physician office EHR use has decreased by nearly 4% over the last year, clocking in at just 59% between 2015 and 2016. While dips in EHR use were consistent across practices of various sizes, smaller physician practices saw the largest year-over-year decline.
  • The amount of time required of physicians to use EHRs compared with writing or dictating notes is causing the numbers to go down, says L.E. Shepherd. a member of the National Society of Healthcare Business Consultants (NSHBC) and CEO at BizAdvantix, LLC, which provides business resources to the health care industry. ‘The physician has to become a Scribe with an EHR, which disrupts the focus on the patient’s issues and, reduces physician productivity by 10-30 % depending on the EHR system and the physician,’ says Shepherd. ‘What’s needed is better technology and higher reimbursement to compensate for the additional time required by the physician to use EHR.’
  • Physician age is another factor affecting implementation. While younger physicians have been using EHRs since medical school and are accustomed to them, those in the last 30% of their practice life are reluctant due to costs and habit, among other things. ‘The diversity of systems without a universal record format and interoperability are extreme barriers to this group,’ says Chris Zenger, CHBC, president of the NSHBC. ‘The 4 to 9% of potential Medicare payment reductions is not enough to push this group of physicians into the EHR pool, in my anecdotal experience. Many will retire before it matters.’” (Medical Economics, 6.20.16)

Impact on Health Sector

Also see Physician Stress and Burnout.

Productivity Losses

• Doctors’ 10 Biggest Mistakes When Using EHRs. “What doctors fear the most about EHR adoption is that they will lose productivity for a certain period, or maybe forever. In fact, Medscape’s 2012 EHR Report, in which physicians ranked the top EHR systems, showed that 32% of the respondents had not returned to pre-EHR levels of productivity, compared with 20% in 2010. But the most unfortunate doctor response to this fear is to give up trying to be productive, Mark Anderson says. ‘Before, they were spending 2 minutes documenting, and now they’re spending 10 minutes documenting. And they realize they’re seeing 5-6 fewer patients a day. But they just say, ‘Well, I have to do it that way.’ They kind of give in to the idea that they’re going to see fewer patients and make less money. But it doesn’t have to be that way.” (Medscape Business of Medicine, 5.1.13)
• Pay Doctors and Nurses for the Time They Spend Charting. “EMR is so inefficient, and patient volumes and acuity so high, that charting isn’t done real-time. Unless it is accomplished with scribes, or by dictation, doctors stay after their shifts, or chart from home, or come in on their days off in order to complete their documentation. Needless to say, this is unlikely to create the best possible chart. Not only is this true, I have watched as nurses sat for one to two hours after their busy ED shifts, catching up on the ever increasing documentation requirements in their EMR systems. Weary from a long day or long night, they sift through notes and charts, orders and code blue records, trying to reassemble some vague estimation of what happened in the chaos of their 8 or 12 hours on shift, when they were expected to function simultaneously as life-savers and data-entry clerks. Further, the nurses are frequently tasked with entering specific charges for billing as well. It all constitutes an unholy combination for any clinician. Dear friends, colleagues, Romans, countrymen; dear politicians and administrators, programmers and thought leaders, this is unacceptable. Entirely unacceptable.” Leap, Edwin, M.D. (KevinMD, 3.9.15)
• Mounting Frustration Among Gastroenterologists. “The compensation report asked respondents about their satisfaction with their career; gastroenterologists ranked sixth, with an overall satisfaction rate of 57%. However, a comparison in metrics of satisfaction with the same poll conducted 5 years prior highlights the larger trend towards dissatisfaction ‘Despite this being a fantastic field, there’s clearly a burnout based on the administration of all of these tasks we never had to do before… Dr Johnson’s experience is borne out by the results of this year’s Medscape Lifestyle Report, in which the three most commonly reported causes of burnout were too many bureaucratic tasks, spending too many hours at work, and increasing computerization of practice. ‘In my experience, most innovations actually make us less productive,’ said Dr Reau. ‘Electronic medical records absolutely did.’” (Medscape Gastroenterology, 7.6.16)
• Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. “For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.” (Annals of Internal Medicine, 9.6.16)
• Demoralized: Alabama Doctors are Spending Two-thirds of Their Time Doing Paperwork. “Dr. Beverly Jordan, a family doctor based in Enterprise, Alabama, told Yellowhammer that increased filing requirements mandated by The Family and Medical Leave Act of 1993 (FMLA), Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, and the Patient Protection and Affordable Care Act (a.k.a. ObamaCare) of 2010 are crushing doctors under an avalanche of paperwork… ‘Now my average daily note on a patient is five pages, and I am no exception to the rule.’ The increasing paperwork burden on physicians is have a significant impact on their business. ‘Anybody with a drop of business sense would be appalled at the redundancy and chaos of the paperwork physicians deal with,’ said Dr. Jordan. ’I have three staff members who do nothing but fill out forms, but most of it is mandated for the physician to complete, eliminating any chance for help. So I still spend easily two-thirds of my day completing paperwork.’ Even worse, evidence suggests that some physicians are becoming so disillusioned with the reporting requirements — particularly the Electronic Medical Records mandates — that they are leaving the field all together.” (Yellow Hammer News, 9.12.16)
• Beating Burnout: Are EHRs the Enemy? “It’s a very complicated issue, and I don’t think it’s fair to simply scapegoat the EHR as the sole problem. It’s not just the design of the EHR, although it certainly could be much better. The EHR should be designed to be delightful. But it’s also the implementation. In many organizations, rules such as meaningful use have been overinterpreted by the local institution, with the result that physicians are the ones doing all of the data entry, as if meaningful use requires that the physician does computerized order entry, which it does not. Computerized order entry can be shared among the team members, but many institutions overly interpret this, so that’s a pain point for physicians. It’s the design of EHRs, it’s the implementation of EHRs, and it’s the regulation. I think all of those have combined to make this a source of pain for physicians, and a barrier to providing the kind of care that we would like to and having the relationships that we would like to with our patients.” (Medscape Business of Medicine, 10.19.16)

EHR Design Problems

• AMA Calls for Design Overhaul of Electronic Health Records to Improve Usability. “Building on its landmark study with RAND Corp. confirming that discontent with electronic health records (EHRs) is taking a significant toll on physicians, the American Medical Association (AMA) today called for solutions to EHR systems that have neglected usability as a necessary feature. Responding to the urgent physician need for better designed EHR systems, the AMA today released a new framework outlining eight priorities for improving EHR usability to benefit caregivers and patients. ‘Physician experiences documented by the AMA and RAND demonstrate that most electronic health record systems fail to support efficient and effective clinical work,’ said AMA President-elect Steven J. Stack, M.D. ‘This has resulted in physicians feeling increasingly demoralized by technology that interferes with their ability to provide first-rate medical care to their patients.’” (American Medical Association, 9.16.14)
• The Rise of the Medical Scribe Industry: Implications for the Advancement of Electronic Health Records. “With federal meaningful-use incentives driving adoption of electronic health records (EHRs), physicians are increasingly concerned about the time spent documenting patient information and managing orders via computerized patient order entry (CPOE)… Poor EHR usability, time-consuming data entry, reduced patient care time, inability to exchange health information, and templated notes are central concerns. Physicians emphasize that EHR technology—especially user interfaces—must improve, and a new industry has emerged nationally to provide physicians with medical scribes.” (Journal of the American Medical Association, 12.15.14)
• High Noon for the Federal Electronic Record Systems? “Vast spending, frustrating software, angry doctors facing a punch in the wallet — and a hungry new Congress. It could add up to a powerful threat to the Obama administration’s $30 billion program to digitize the nation’s medical records… Now, as the government begins cutting payments to those who have failed to demonstrate ‘meaningful use’ of the electronic health records Washington began subsidizing four years ago, physician groups are fighting mad. And Congress wants to know why an industry with three freshly minted billionaires isn’t making better software.” (Politico, 12.28.14)
• Keep Calm and Interoperate On. “In a dialectic not odd in healthcare, HITECH is a success and disaster. The adoption of EHR, which increased from 10% to 70% of practices, would not have happened so quickly without the subsidies. The Blitzkrieg has consequences – many physicians loathe EHRs, viscerally. The paradox of automation is at once diminution and magnification – fewer but more catastrophic errors. Wachter narrates how a young male received an obscenely high dose of an antibiotic because of a user-unfriendly prescription interface. The bad tool might blame the workman. Whether the tool or the workman is at fault is a distinction without a difference. Why are doctors deskilled by EHRs when they use I-pads, power point and Yelp? EHR is like a library which throws all books all at once at you when all you wish to read are books by Herman Melville. The information overload fatigues. EHRs serve many masters including administrators, payers, risk managers and researchers. EHRs must also capture the nuances of a doctor-patient interaction. By bloviating the EHR with information rather than trimming the interface with context, the vendors have pledged their servitude to the comptroller not the foot soldier; which would be fine but it is the foot soldier who uses the EHR predominantly.” Saurabh, Jha, MD. (The Health Care Blog, 5.18.15)
• Guess What: Docs Don’t Like EHRs. “63% of physicians believed EHRs made their jobs less efficient. Also not surprisingly, their use was associated with a higher rate of physician burnout… That doesn’t sound like a good return on our $33b HITECH investment, does it? A separate study by researchers at Cleveland State University agreed that EHRs presented a number of ‘clear challenges,’ including increased workload for caregivers, issues around trust in the technology and the information in it, and a perceived over-reliance on technology. The CSU study found that, in many cases, physicians simply created ‘workarounds’ to circumvent aspects of the EHR, a finding that was echoed by a VA study looking at EHRs and test results. The VA study found that 43% of physicians used EHR workarounds to follow-up on test results, most commonly paper-based methods like sticky notes… EHRs causing workarounds and physician burnout are the proverbial canaries in the coal mine, signaling we are on the wrong path with them.” (Tincture, 6.30.16)
• Evolutionary Pressures on the Electronic Health Record. “At present, the spectacular effects of computers in science and in the secular world are not reflected in the EHR, which for physicians remains burdensome, all-consuming, and far from intuitive; this is not surprising, when the dominant EHRs are designed for billing and not primarily for ease of use by those who provide care. In fact, a measure of successful EHR evolution may be that physicians spend much less time with the EHR than they do now. Deimplementing the EHR could actively enhance care in many clinical scenarios.” (JAMA, 8.15.16)
• Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records. “It’s death by a thousand clicks, and it happens every day. We are frustrated by EMRs because they pull us away from our patients. We are driven mad by the fact that EMRs in different locations do not talk to each other. And we think it’s just wrong that much of the EMR’s busywork is about optimizing billing for the hospital. Who is to blame? Start with EMR manufacturers, who lobbied Congress to require every hospital and doctor’s office to install an EMR system; hospital administrators who bought technology that conveniently pushed billing duties onto doctors and nurses; and federal regulators, who imposed on EMRs numerous quality metric requirements that do nothing to improve care.” (WBUR, 5.12.17)
• ONC Set to Address Information Exchange, Compliance Burden. “Reducing the burden of electronic health records (EHRs) on physicians and promoting health information sharing will be the major priorities of the Office of the National Coordinator for Health Information Technology (ONC) going forward, Donald Rucker, MD, the new national coordinator, told reporters at a news conference today. Interoperability between EHR systems has long been at the top of ONC’s agenda, but the emphasis on EHR usability and lowering the administrative burden on small practices has not. Dr Rucker noted that, along with interoperability, this goal is very important to Tom Price, MD, Secretary of Health and Human Services (HHS). In introducing John Fleming, MD, deputy assistant secretary for health technology reform, HHS, at the press conference, Dr Rucker also observed that Dr Fleming, a former solo practitioner in Louisiana, is the first senior-level HHS appointee ‘who represents small practices.’” (Medscape, 7.11.17)

Costs to the Health Sector

• Doctors Overwhelmed By New Federal Rules. “EHR,  ICD-10 and PQRS may sound like alphabet soup. But most doctors around the country know exactly what those acronyms stand for. They are programs championed by the federal government to improve quality and bring medicine into the electronic age. But in Alaska, where small medical practices and an aging physician workforce are common, the new requirements can be a heavy burden… ‘This flurry of things one has to comply with,’ Korshin says, ‘means that unless you work for a large organization like a hospital that can devote staff and time to dealing with these issues, there’s no economy of scale, I can’t share these expenses with anybody.’” (Kaiser Health News, 11.24.14)
• Pricey Patient Record Systems: Who Pays? “Health care systems now find their EHRs staggeringly expensive, frequently not communicating as promised, in need of constant upgrading, and financially stressful for hospitals already under duress as they attempt to collect outstanding bills from unmanageable patient deductibles…For these systems, however, there is little that can be done to change course. ‘The high costs of the current implementations likely means most large institutions won’t have any realistic way to switch to another product in the near future if something better came along,’ David Hanauer, associate professor at University of Michigan Medical School, told LifeZette. Hanauer researches clinical and health informatics, with a focus on electronic health records. ‘The sunk costs are just too high.’” (Life Zette, February, 2016)
• Health IT Costs Up 40% per Physician Since 2009, Survey Shows. “Physician-owned multispecialty practices spent more than $32,500 per full-time physician on information technology (IT) equipment, staff, maintenance, and related expenses in 2015, according to the 2016 Cost and Revenue Report of the Medical Group Management Association (MGMA). The survey, the largest of its kind according to the company, also found that technology costs at physician-owned multispecialty practices have increased by more than 40% since 2009. The largest increase in technology costs occurred between 2010 and 2011, which was the year when stage 1 of the meaningful use electronic health records (EHR) incentive program began. ‘However, these incentives tapered down significantly after 2011, requiring practices to shoulder a larger percentage of the cost to upgrade and maintain the technology,’ MGMA said in a news release on the survey results. Physician-owned multispecialty practices have experienced steady year-over-year increases in IT staff expenses, the survey shows. The cost of IT staff has risen by nearly 47% per full-time physician since 2009. MGMA attributed this growth to the growing adoption and complexity of health IT. ‘Increased staff costs suggest that larger investments in technology have yet to result in significant administrative efficiencies for practices,’ the association noted.” (Medscape Medical News, 8.11.16)
• Open Letter to President Obama About His JAMA Paper: Electronic Medical Records: An Overlooked Cause of Inflation. “You have been a huge fan of EMRs. You believed the folklore promoted by the Institute of Medicine and the computer industry that EMRs would cut medical costs by more than the EMRs cost to install and maintain. Because you believed that folklore, you enthusiastically supported legislation (the HITECH Act, the ACA, and MACRA) that put financial pressure on doctors and hospitals to buy EMRs. The evidence indicates that the campaign to induce doctors and hospitals to buy EMRs (which began under Bush II) has raised total health care spending. A paper published in 2005 concluded that the cost of installing EMRs in all hospitals and clinics will raise national health expenditures by 2 percent. Not every clinic and hospital has purchased one of the clunky EMRs available for sale these days, so we can’t say the cost of buying and maintaining EMRs has reached 2 percent of our $3 trillion health care bill yet. But we’re getting there. By 2013, according to the CDC, eight in ten clinics and six in ten hospitals had purchased an EMR. Meanwhile, the evidence indicates EMRs are not cutting costs. We may conclude, therefore, that the ACA has contributed to health care inflation by putting pressure on doctors and hospitals to buy EMRs.” Sullivan, Kip. (The Health Care Blog, 8.24.16)

Lack of Interoperability

• Clinical Intelligence and Analytics: The Future of Healthcare Delivery. “Even with the rapid adoption of EMRs across the globe, the bulk of clinical data available to feed such intelligence applications remains siloed and fragmented across disparate systems and numerous departments in the typical hospital. This makes access to and sharing of patient information difficult, or even non-existent, as systems are unable to communicate with one another—and when they can communicate, information exchange is likely limited to a fraction or subset of overall data that they contain.” (EMC, 7.31.14)
• Inside the Struggle for Electronic Health Record Interoperability.  “In a study published in the September 2014 issue of Health Affairs, a number of analysts — including some working for ONC — found that:
  • While the rates of hospitals adopting basic EHRs continue to rise, only 5.8 percent of hospitals surveyed were able to meet all of 16 core objectives put forth in HHS’ Meaningful Use Criteria. The areas in which hospitals were most lacking were providing patients with the ability to view and download their information and sending care summaries between care settings.
  • In another study that examined EHR adoption in office settings, only four in 10 physicians had any electronic exchange with other health providers, and one in seven exchanged clinical data with providers outside their organization.
• Both studies found that in some respects, the more resources available to a hospital or an office, the more likely they were to have already implemented EHRs. In the study that focused on hospitals, more than half of all rural hospital respondents said they had ‘less than basic’ EHR implementation in 2013. In the study dedicated to office-based care, solo practitioners and specialty physicians lagged behind larger practices or primary care physician. Even with ONC and the Centers for Medicare and Medicaid Services delivering marching orders for providers to follow, Somplasky said smaller practices are considering taking the financial penalties that come with failing to meet the HHS meaningful use goals.” (FedScoop, 8.20.14)
• Planning for the Retirement of Clinical Legacy Applications and Ensuring Active Collaboration Between Clinicians and IT. “‘For all the benefits EMRs/EHRs have brought the industry, they still fall short of a complete patient-centric view. According to a recent Fierce Healthcare study on decommissioning legacy applications, ‘clinical and non-clinical staff in most organizations continue to struggle with scattered patient data stored across legacy platforms. Depending on which patient data they need to access, this requires staff to log onto multiple systems, creating not only inefficiencies, but also a risk to quality of care.’ At the same time, healthcare organizations are also experiencing a rapid growth in the volume of all forms of information. Their current applications and older legacy systems are bursting with information—patient data, clinical and administrative documents, voice recordings, and medical images. And to complicate matters worse, the healthcare industry as a whole is struggling to adopt a patient-centric approach to care while facing increasing challenges for better outcomes, lower costs, and regulatory compliance.” (Spark Blog EMC, 12.16.14)
• Roll Back the Federal 10-Year Strategic Plan for Health Information Technology: Statement for the Record. “A 2014 report for the RAND Corporation also concluded the federal [HITECH] money was invested poorly: ‘Unfortunately, the rules that the U.S. Department of Health and Human Services (HHS) issued to guide implementation of HITECH watered down the requirement for connectivity. The practical effect was to promote adoption of existing platforms, rather than encourage the development of interconnected systems. Although large vendors and many health care systems welcomed this decision, it was criticized by others. By subsidizing ‘where the industry’ is rather than where it needed to go, HHS rule-makers allowed hospitals and health care providers to use billions in federal subsidies to purchase EHRs that did not have the level of connectivity envisioned by the authors of the HITECH act.’” Graham, John R. (NCPA, 3.17.15)
• Obama Administration Report Slams Digital Health Records. “Spurred by $28 billion in incentives to date, nearly 80% of doctors and 60% of hospitals have converted from paper files to electronic health records, known as EHRs since 2009. But only 20% to 30% of providers are able to share records with outside providers, according to government and industry surveys. The Electronic Health Record Association, a trade group, said its members are committed to sharing patient records but building connections to the myriad systems used by hospitals, doctors, labs and others takes time and money.” (The Wall Street Journal, 4.10.15)
• $30B Digital Health Record Push Hits Big Roadblocks. “While about 62 percent of all U.S. health providers have adopted the technology, very few can actually share their digital files with other hospitals and providers – a feature that is required in order to receive financial incentives from the government. A survey by Modern Healthcare released this week found that just 11 percent of hospitals are able to routinely exchange electronic patient information with other providers across the country, while about 21 percent said they’re able to exchange patient information within their home states. Another 21 percent said they aren’t exchanging electronic patient health records at all… The report was requested by congressional lawmakers late last year after concerns by providers that the $30 billion push toward digitizing health records was benefiting IT companies, while not necessarily helping providers or patients, as it was intended.” (Fiscal Times, 4.15.15)
• As I Said, Let the Doctors Breathe. “The problem with the EHR, however, is that the pretense of universality leads to information collection that is largely irrelevant to the patient. And, more fundamentally, that the EHR technology, being in its infancy, is hopelessly inefficient. Hospital physicians will tell you endless tales about the wastefulness of the data collection and how the lack of interoperability defeats the very purpose of data sharing. As for my complaint about President Barack Obama and his fellow liberals: Again, I don’t oppose going electronic. What I oppose is the liberal instinct to impose doing so, giving substance to that old saw that a liberal is someone who doesn’t care what you do, as long as it’s mandatory.” Krauthammer, Charles. (Chicago Tribune, 6.5.15)
• Burwell: EHR Giants Epic, Cerner, Meditech Among Those Taking Pledge to Standardize Health IT. “Nearly every big name in healthcare technology has pledged to use standardized APIs, to make patient access easier and to not block information, Department of Health and Human Services Secretary Sylvia Burwell announced during her HIMSS16 keynote Monday night. ‘Companies that provide 90 percent of electronic health records used by hospitals nationwide as well as the top five largest private healthcare systems in the country have agreed to implement three core commitments,’ she said.” (HealthIT News, 2.29.16)
• Burwell: Interoperability is Coming. “In her HIMSS keynote on Monday night, HHS Secretary Sylvia Mathews Burwell announced that major vendors and providers have committed to improving health information access, allowing health information exchange and implementing national interoperability standards… What does it mean? It depends on whom you ask. POLITICO spoke to experts who note that the pledge is voluntary — and there’s no cost to breaking it.” (Politico, 3.1.16)

Information Blocking

• Information Blocking Revealed for the Hoax and Make-Believe Story That It Is. “I said from the start that this was an absolute made up story and nice to see Dr. Halamka at Harvard Medical address this. I have seen tons of articles written about this nonsense and now it’s all the way up to the FTC and members of Congress thinking this is real! It just goes to show you the power of News Rigging for political gain… The only thing close I can get out of this hoax that’s been going through the media for a year or so now is that some EMRs are not playing with someone else’s software so cleverly someone decided to make some EMR companies ‘the bad boys.’ Well who are they? Nobody ever has a name do they? It’s just this chatter and fear and the soaking of those who don’t understand data mechanics and code and look how well it stuck as a ‘fear factor.’ It is and was total bunk.” Duck, Barbara. (Medical Quack, 5.22.15)
• Tech Rivalries Impede Digital Medical Record Sharing. “Congress took a first step to address the problem in a bill signed into law last month. It said that doctors and hospitals must not deliberately block the sharing of information if they receive federal bonus payments for using electronic health records. A separate bill approved last week by a House committee defines ‘information blocking’ as a federal offense. Doctors, hospitals and technology vendors could be punished with civil fines of up to $10,000 for each violation… Ms. Miller said, federal money meant to foster an interconnected web of health care providers may inadvertently have subsidized the creation of ‘information silos,’ making it more difficult to share data and coordinate care for consumers.” (The New York Times, 5.26.15)
• Information Blocking: Is It Occurring and What Policy Strategies Can Address It? “Congress has expressed concern about electronic health record (EHR) vendors and health care providers knowingly interfering with the electronic exchange of patient health information. These ‘information blocking’ practices would privately benefit vendors and providers but limit the societal quality and efficiency benefits from EHR adoption. We found that information blocking is reported to frequently occur among EHR vendors as well as hospitals and health systems, and that it is perceived to be motivated by opportunities for revenue gain. Because information blocking is largely legal today, the most effective policy response likely involves a combination of direct enforcement and the altering of market conditions that promote information blocking.” (Milbank Quarterly, March 2017)

Provider Survey Data

2013

• RAND Study: The Pros and Cons of Electronic Health Records. “Physicians approved of EHRs in concept and appreciated having better ability to remotely access patient information and improvements in quality of care. However, for many physicians, the current state of EHR technology significantly worsened professional satisfaction in multiple ways.” RAND cited EHR technology and ‘the cumulative burden of externally imposed rules and regulation,’ especially Meaningful Use requirements, as noteworthy sources of irritation. EHR problems cited were ‘poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, inability to exchange health information, and degradation of clinical documentation.’” (RAND Health, 2013)

2014

• Medscape EHR Report 2014, July 15, 2014. Medscape invited physicians to participate in a survey of current EHR use; 18,575 physicians across 25 specialties responded during the period from April 9, 2014, through June 3, 2014. Fifty-six percent were employed in a hospital or health system.
  • Effect on Practice Operations: Despite complaints that EHRs make documentation too burdensome, 63% of our respondents said that an EHR improves documentation, and 39% felt that EHRs improve collections. Thirty-four percent of participating doctors maintained that an EHR improves clinical operations, yet 35% said it worsens them. Thirty-two percent felt that an EHR improves patient service; 38% said it worsened patient service.
  • Effect on Patient Encounters: Seventy percent of respondents said the EHR decreases their face-to-face time with patients, and 57% said it decreases their ability to see patients. Still, 35% said the EHR improves their ability to respond to patient issues, and 33% said it allows them to more effectively manage patient treatment plans.
  • Use Over Time: Eighty-one percent of respondents agree that their EHRs have become easier and more comfortable to use over time.
  • Patient Privacy Concerns: In the 2012 Medscape EHR Report, 77% of participating physicians said they had no patient privacy concerns. In 2014, only 17% of survey participants said they had no EHR-related patient privacy concerns.
  • Where Do Physician Stand on Meaningful Use? Seventy-eight percent of participating physicians said they were attesting to meaningful use Stage 1 or Stage 2 in 2014. Sixteen percent said they will never attest to meaningful use requirements, and another 6% of participants said they are abandoning meaningful use after meeting the requirements in previous years. Thus, 22% of physicians surveyed this year are opting out of or disregarding the meaningful use program.
  • Cost per Physician to Purchase and Install: Almost a quarter (23%) of respondents said their EHR system cost over $50,000 per physician to install. More than half of the respondents were unaware of the cost of the EHR.
  • Monthly Fees per Physician for a Web-Based EHR System: In 2012, only 4% of survey respondents said they were paying over $700 per month for monthly fees; in 2014, 12% are paying that amount.
  • Why Physicians Don’t Use an EHR (Note: Survey respondents were allowed to choose more than one answer.)
    • EHRs interfere with the doctor-patient relationship (40% of responses).
    • EHRs are too expensive (37% of responses). Besides the cost of the EHR, there are expenses involved in switching all current paper records to electronic records and lost work time during the transition and switchover. For doctors nearing the end of their careers, the cost and effort are not worth it.
    • The incentives offered and penalties levied by the CMS aren’t worth the hassle of adopting an EHR (32% of responses).

2015

• Doctors Say Obamacare’s EHR Mandate is Too Costly, Results in Worse Care. “According to the Department of Health and Human Services, Obamacare’s electronic health record mandate would ‘reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care.’ Now that the law has been implemented, it doesn’t appear that any of those goals have been met, at least not as far as a majority of American physicians are concerned… Medical Economics released the results of a survey of doctors on the functionality and cost of electronic health record (EHR) systems. Despite subsidies from the federal government, physicians reported that the EHR systems were not worth the cost, which includes licensing fees, training, hardware and increases in staffing. Doctors also reported that they have become less productive.” (Watchdog.org, 2.20.15)
• Accenture Doctors Survey 2015: Healthcare IT Pain and Progress. “Among the survey findings:
  • US doctors (79 percent) overwhelmingly agree that they are more proficient using electronic health records in their clinical practices today than two years ago.
  • Eighty-nine percent enter patients notes electronically (62 percent of doctors believe this helps them to provide quality patient care) and 83 percent e-prescribe (which half say is helping to provide quality care).
  • Routine use of all surveyed functions on the rise.
  • US doctors say patient updating of personal electronic medical records helps patient engagement.
  • Many doctors (58%) find their organizations’ electronic health records systems hard to use and see opportunities for improvement. Nearly all US doctors (90%) say that better functionality and an easy-to-use data entry system are important for improving the quality of patient care through healthcare IT. Interoperability remains an unmet need.
  • For most US doctors (71%), healthcare IT means less time with patients.
  • EMR has limits. Fewer US doctors see positive impact on treatment decisions, medical errors, and health outcomes than in the past; reducing medical errors still viewed as main benefit.” (Accenture, 4.15.15)
• Surveys Differ on EHR Satisfaction Among Physicians. “Nearly 40% of solo or small-practice physicians have moderate to serious concerns about the security and privacy of cloud-based EHRs. Conversely, 81% of physicians employing server-based EHR software claim they are concerned that their system, device, server, or files may be stolen or breached. Some 92% of small-practice users that switched to a cloud-based system in the last 6 months feel their chances of a major patient record data breach are lowered, but 52% report their fears of system downtime have increased since the switchover, the report shows.” (Medscape Medical News, 8.25.15)
• Physician’s Opinions of EHRs Worsen. “Physician satisfaction with EHRs has not improved over the last five years. In fact, experts say the situation has actually gotten worse. EHRs have been defined as cumbersome and, even with advances in technology, they still tend to cause doctors stress and are problematic in hospitals. A recent survey from American Medical Association and AmericanEHR Partners notes that, while 61 percent of respondents said they were satisfied with their EHRs five years ago, only 34 percent said the same now. ‘While EHR systems have the promise of improving patient care and practice efficiency, we are not yet seeing those effects’ said Shari Erickson, MPH, Vice President of ACP’s Division of Governmental Affairs and Medical Practice in a statement. ‘We need to focus on figuring out how we can help physicians and practices to more effectively implement and use these systems.’ According to iHealth Beat, the survey found:
  • 42 percent of respondents described their EHR system’s ability to improve efficiency as difficult or very difficult
  • 43 percent of respondents said they were still addressing productivity challenges related to their EHR system
  • 54 percent of respondents said their EHR system increased total operating costs
  • 72 percent of respondents described their EHR system’s ability to decrease workload as difficult or very difficult
• Fierce EMR reports that of the 940 physicians surveyed, primary care physicians were happier with their EHRs than specialists. Researchers believe this could be attributed to the fact that they’ve used their systems for a longer period of time and note that it takes at least three years for physicians to see the benefits of EHRs. ‘Perhaps we are getting over the curve in EHR adoption,’ said Erickson. ‘It may be that as we see more practices that have been using these systems longer we will see satisfaction begin to rise.’” (Health IT Outcomes, 9.1.15)
• Electronic Health Record Could Crash Medical System, Warns American Association of Physicians and Surgeons. “More than half of physicians are feeling burned out, and onerous, punitive federal mandates on electronic health records (EHRs) are one of the biggest reasons, reports the Chicago Tribune on Dec 12. Many family physicians are contemplating early retirement, as ‘busy work’ adds hours to their work day… In an AAPS internet survey of physicians and patients, more than 80% of 571 physician respondents said that the EHR impedes patient care, and 47% says it endangers patient safety. Fewer than 6% responded that ‘on the whole, it improves patient care.’ More than 63% said that it compromises confidentiality, and 76% said that it is ‘a cash cow for data miners.’ Responses from 100 patients were also highly unfavorable: 83% said the EHR compromises confidentiality, 62% that it is a cash cow for data miners, 52% that it compromises patient care, 45% that it endangers patient safety, and only 8% that it improves patient care.” (PR NewsWire, 12.15.15)

The AMA’s 2015 Review

• How EHRs Tied up Physician Time in 2015. “Burdensome regulations and technology have led physicians to spend considerable time struggling with their electronic health records (EHR). Fortunately, policymakers and health IT developers are starting to take note.
  • Problems with EHR systems. Physicians shared key insights about their EHRs in a survey by AmericanEHR Partners released this summer. The survey showed that physicians think the investments in EHRs are failing to offer substantial returns. Impractical technology has meant that too much time is spent on clerical work, stealing time that would otherwise be spent with patients…Problems with EHRs are so prevalent that a 2013 study by the AMA and the RAND Corporation found that EHRs are one of the top sources of physician dissatisfaction.
  • The meaningful use mess. Meanwhile, the federal meaningful use program has become an even greater cause for concern as rulemaking moved forward despite alarms raised by the medical community.
  • Physicians are speaking up, and people are listening. To curtail the ever-increasing burdens that EHRs and meaningful use have continued to press upon physicians and their patients, the AMA launched BreakTheRedTape.org, a grassroots campaign that spearheads physician efforts to change the burdensome federal program…On the vendor side, health IT developers will be working with physicians in the AMA Interaction Studio at MATTER. This new collaboration space places physicians in the same room with health IT developers to make sure physician input is a critical component in the initial stages of design.
  • What’s coming next? The Break the Red Tape campaign will continue to urge Congress to intervene in the meaningful use disaster in the months ahead. At the same time, the AMA will continue to work with vendors and others to drive EHR improvements that can advance the delivery of high-quality, affordable care, based on the eight guiding solutions developed in 2014. Expect to hear more about the AMA Physician Innovation Network, which aspires to connect and match physicians and health tech companies based on their interests and needs. The program is in beta development, but interested physicians can sign up today.” (American Medical Association, 12.11.15)

2016

• Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. “Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics… physicians’ satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.” (Mayo Clinic, July, 2016, Volume 91, Issue 7, Pages 836–848)

EHR and Federal Costs

• EHRs to Drive Federal Health IT Spending to $8.1B by 2023. “Spending on vendor-provided federal health IT goods and services is estimated to increase from $6.1 billion this year to $8.1 billion in 2023, according to a Health IT News summary of a market outlook report. That increase will largely be driven by EHR projects at the Department of Defense and Veterans Affairs. Spending will top out at $8.5 billion by 2022 and dip down to $8.1 billion the following year as systems roll out. The Coast Guard announced this week that it will be adopting DoD’s $4.3 billion Cerner EHR project, and the State Department is expected to adopt an EHR soon.” (Healthcare Diva, 4.12.18)

EHR and Impact on Patients

• Do Your EHR Manners Turn Patients Off? “Taking a patient history while sitting in front of a laptop, filling out check boxes, and navigating drop-down menus often forces doctors to pay more attention to the screen than to the patient sitting in front of them. Patients notice that. And make no mistake about it: With all of the new meaningful use regulations, computers are becoming a major presence in the exam room. How you handle that presence will determine whether the computer disrupts the doctor-patient relationship or supports it.”  (Medscape Business of Medicine, 9.17.13)
• Making EHRs Less Intrusive and Annoying for Patients. “Some doctors see electronic health records (EHRs) as a giant headache and a barrier to good relationships with patients, whereas others are convinced that it can assist in efficiency and accuracy and still allow doctors to relate well with their patients. Medscape’s recent article, Do Your EHR Manners Turn Patients Off?, provided a springboard for doctors to air their strong reactions to this challenging issue.” (Medscape Family Medicine, 11.18.13)
• Doctors Are Talking: EHRs Destroy the Patient Encounter. “The gripes cover three main areas: One, EHRs have made the patient encounter far more annoying and complex than it ever was before. Two, many physicians feel that EHRs take doctors who were trained to be independent thinkers and constrain their ability to make independent decisions, causing them to feel like data entry clerks, with a computer telling them how to practice medicine. Last but not least, a large number of physicians feel that EHRs erode the doctor-patient relationship by creating a barrier between the two.” (Medscape Business of Medicine, 5.22.14)
• Physician Computer Use Affects Patient’s Perception of Care. “Physicians in safety net hospitals who were assessed as high computer users during clinical encounters fared significantly worse than their low-computer-use counterparts in measures of patient experience, Neda Ratanawongsa, MD, MPH, from the Division of General Internal Medicine, University of California, San Francisco, and colleagues report in a research letter published online November 30 in JAMA Internal Medicine… High computer use was also associated with observable communication differences, the authors report. Patients in appointments with high computer use engaged in more social rapport building (‘chit chat’), whereas those in appointments with moderate computer use engaged in somewhat less rapport building, but had a more positive demeanor. In contrast, physicians with high computer use engaged in more negative rapport building, which involved statements that express disagreement or criticism.” (Medscape Medical News, 12.2.15)
• Electronic Medical Records: The Potemkin Village of Healthcare. “During medical school in the 1980s, we were taught to do a very extensive history and physical examination. This included Chief Complaint (why are you here?), History of Present Illness (what happened?), Past Medical History (what are your prior medical problems?), Family History (major medical problems that run in the family), Social History (occupation, hobbies, habits, alcohol, tobacco and drug use), Medications and Allergies, Review of Systems (detailed questions about other systems of the body, seemingly unrelated to the current problem), and then a thorough Physical Exam. After this we developed a differential diagnosis—a list of probable causes for the patient’s chief complaint. Only then did we order tests to confirm or exclude these possible diagnoses. Then we treated the patient. This is radically different from the medical mills where American doctors practice today. Today medical practice has contracted to: Chief Complaint, Test, Treat. My patients tell me of 5 minute visits, and I have witnessed them for family members. Currently the average doctor visit is 15 minutes or less. But that is really 8 minutes, plus 7 minutes of documentation in the computerized medical record. The traditional approach requires at least half an hour. There is no way around it. You can’t do it right in 8 minutes.” Gianoli, Gerald J. (American Association of Physicians and Surgeons, 2.29.16)
• The Costly Medicare Boondoggle that’s Wasting Tax Dollars and Infuriating Doctors. “In the last decade, the federal government has undertaken considerable steps to control the way doctors care for their patients. Its goal is to improve healthcare quality and lower costs, but the very regulation tasked with achieving this has created a paperwork nightmare that actually does the opposite: it impedes care and increases costs… The failure of this misguided government initiative is even worse when one considers the costs. A 2016 Health Affairs study showed that physician practices in just four specialties (cardiology, orthopedics, family medicine and internal medicine) spent $15.4 billion annually to comply with quality measure reporting. This translated to $40,069 per physician — money that could have improved patient care through investment in medical technology, or helped the economy through hiring of employees. No study has ever shown that this program improves patient care or doctor quality. Quite the opposite: a 2014 study by the Medical Group Management Association showed that 84 percent of doctors’ practices did not feel quality reporting improved their ability to provide high-quality care, and more than 83 percent felt the program adversely affected practice efficiency, support staff time and physician morale.” Lam, Andrew, MD. (Kevin MD, 11.2.16)
• Doctors are Overloaded with Electronic Alerts, and That’s Bad for Patients. “The electronic patient records that the federal government has been pushing — in an effort to coordinate health care and reduce mistakes — come with a host of bells and whistles that may be doing the opposite in some cases. What’s the problem? It’s called alert fatigue. Electronic health records increasingly include automated alert systems pegged to patients’ health information.” (Washington Post, 6.13.16)

Patient Access to EHRs

• Health IT Chief DeSalvo Urges More Patients to Seek Access to Electronic Records. “The chief federal information technology policymaker stopped short of denouncing a recently released CMS proposed rule that patient-engagement advocates say is a step backward for their cause…The current Stage 2 provision requires that participating hospitals, office-based physicians and other ‘eligible professionals’ induce 5% of their patients to electronically view, download or transfer their records kept in the providers’ EHRs. Getting patients to be more involved in their care, including seeing, reviewing and correcting their records if need be, has long been a policy goal promoted by the ONC. The CMS revision, however, part of a 210-page proposed rule issued Friday aiming to add more flexibility to the federal program, would require a participating provider to attest only that a single patient had used the view, download or transfer function in the provider’s EHR in an entire year. Mostashari said he’s fearful that without the 5% target, providers will only perform the minimum requirement, undermining one of the ‘pillars of interoperability … the HIE of one,’ that is, the willing patient.” (Modern Healthcare, 4.15.15)

Impact on Care Quality

• Hazards Tied to Medical Records Rush: Subsidies Given for Computerizing, But No Reporting Required When Errors Cause Harm. “President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems. The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood…The systems can be complex, time-draining, and frustrating to use, especially early on. Hospital staff members routinely override automatic warnings, cut corners, and develop ‘workarounds’ as they struggle to balance caring for patients with the demands of cumbersome drop-down menus and other forms that appear on their computer screens.” (Boston Globe, 7.20.14)
• Eight Malpractice Dangers in Your EHR. “‘The Health Insurance Portability and Accountability Act (HIPAA) specifically states that the healthcare provider is the covered entity responsible for maintaining the integrity of the patient’s medical record — not the EHR vendor, not the consultant, not the systems integrator,’ he says. ‘A doctor can be held liable because most vendors’ contracts essentially say, “We do not practice medicine; it is up to the physician to make sure this EHR is being used correctly.” Practices must understand what they’re using and verify that the system is appropriately set up to document the care they provide.’” (Medscape Business of Medicine, 8.26.14)
• Texas Hospital Makes Changes to EHR After Ebola Patient Turned Away. “The Dallas hospital that mistakenly sent home a man who had Ebola says flawed software and not human error caused doctors to miss the diagnosis. Health officials and local residents have been asking how the hospital could have missed what would have appeared to be an obvious potential case of Ebola: a Liberian citizen who said he recently traveled from Liberia, with fever and abdominal pain. ‘Protocols were followed by both the physician and the nurses,’ the hospital said in a statement issued Thursday night. The nurse who took Thomas Eric Duncan’s medical history did the job correctly, the hospital said. ‘However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case,’ it added.” (NBC News, 10.2.14)
  • Dallas Hospital Retracts Explanation for Missed Ebola Diagnosis. “The Texas hospital that failed to initially identify and isolate the country’s first Ebola patient in its emergency room is now backtracking on its explanation for the error… ‘There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event,’ the hospital said in a written statement. But as of Saturday afternoon, no other explanation for the oversight has been given. Emails to the hospital with specific questions from Yahoo News have not been returned for days.” (Yahoo News, 10.4.14)
  • Did Bad EHR Software Lead to Ebola Patient Being Sent Home? “We may never know exactly what happened in the Texas ER.  But we do know that poorly designed EHRs can impede physician workflow and jeopardize patient safety.” (Forbes, 10.5.14)
  • Ebola, Electronic Medical Records, and Epic Systems. “Texas Health contracts with Epic Systems for its electronic medical records system—and the Dallas hospital isn’t the only client that has complained about its costly information-sharing flaws and interoperability failures.” (Michelle Malkin, 10.7.14)
• Electronic Health Records May Not Improve Outcomes in Ischemic Stroke Patients. “Electronic health records may be necessary for a more high-tech and transparent health care system, but hospitals with electronic health records for ischemic stroke patients did not demonstrate better quality of care or clinical outcomes for those patients when compared to similar hospitals without electronic health records, according to a study published today in the Journal of the American College of Cardiology… ‘EHRs do not appear to be sufficient, at least as currently implemented, to improve overall quality of care or outcomes for this important disease state,’ said Karen E. Joynt, M.D., M.P.H., lead author of the study and a cardiologist at Brigham and Women’s Hospital and Harvard Medical School in Boston.” (Eureka Alert, 5.4.15)

EHR Privacy and Security Concerns

• Your Medical Records Are for Sale. “As hospitals shift to digital medical records, administrators promise patients better care and shorter waits. They often neglect to mention that they share files with state health agencies, which in turn sell the information to private data-mining companies. The records are stripped of names and addresses, and there’s no evidence that data miners are doing the legwork to identify individual patients. Yet the records often contain patients’ ages, Zip Codes, and treatment dates—enough metadata for an inquiring mind to match names to files or for aggressive companies to target ads or hike insurance premiums.” (Bloomberg Business, 8.8.13)
• Big Data Peeps At Your Medical Records To Find Drug Problems. “To do a better job of spotting unforeseen risks and side effects, the Food and Drug Administration is trying something new — and there’s a decent chance that it involves your medical records. It’s called Mini-Sentinel, and it’s a $116 million government project to actively go out and look for adverse events linked to marketed drugs. This pilot program is able to mine huge databases of medical records for signs that drugs may be linked to problems…Their health records include nearly 180 million Americans. If you have insurance through a private health plan, the chances are ‘pretty good’ that your data may have been used in one of these studies, says Dr. Richard Platt, the principal investigator for Mini-Sentinel and a professor at Harvard Medical School’s Department of Population Medicine.” (NPR, 7.21.14)
• Are Your Medical Records Vulnerable To Theft? “As more doctors and hospitals go digital with medical records, the size and frequency of data breaches are alarming privacy advocates and public health officials. Although health care providers face serious penalties if they allow patients’ electronic records to be breached, thieves also have tremendous incentives to get around protections because health records contain so much valuable information.” (Kaiser Health News, 8.21.14)
• Feds Plan for 35 Agencies to Help Collect, Share, Use Electronic Health Info. “The Department of Health and Human Services (HHS) announced the release of the Federal Health IT Strategic Plan 2015-2020, which details the efforts of some 35 departments and agencies of the federal government and their roles in the plan to ‘advance the collection, sharing, and use of electronic health information to improve health care, individual and community health, and research.’”  (The Weekly Standard, 12.9.14)
• Also see Health IT and Patient Privacy.

EHR Reliability Problems

• Internet Brownout Exposes Risk of Cloud-Based EHRs. “The Internet cracked a bit under its own burgeoning weight last week, and as a result, internist Erik Ilyayev, MD, in Flushing, New York, could not access his cloud-based electronic health record (EHR) system for an entire day. ‘Why can’t I log in?’ Dr. Ilyayev wrote in an angry post on the Facebook page of Practice Fusion, his EHR vendor. ‘What do I tell the patients who are in the office now?’ Other Practice Fusion customers experiencing downtime asked the same questions. The answers are not comforting for physicians who increasingly use Web-based software for patient care, as well as billing and collection.” (Medscape Medical News, 8.22.14)
• A Hospital Paralyzed by Hackers. “The hackers that broke into the Hollywood Presbyterian Medical Center’s servers are asking for $3.6 million in Bitcoin, a local Fox News affiliate reported. Hospital staff are working with investigators from the Los Angeles Police Department and the FBI to find the intruders’ identities. Meanwhile, without access to the hospital’s computer systems, doctors and nurses are communicating by fax or in person, according to an NBC affiliate. Medical records that show patients’ treatment history are inaccessible, and the results of X-rays, CT scans, and other medical tests can’t easily be shared. New records and patient-registration information are being recorded on paper, and some patients have been transferred to other hospitals.” (The Atlantic, 2.17.16)

State EHR Mandates

Minnesota

• Minnesota Requiring all Health Care Providers to Use EHRs Starting January 1, 2015. “By January 1, 2015, all hospitals and health care providers must have in place an interoperable electronic health records system within their hospital system or clinical practice setting.” (Officer of the Revisor of Statutes, 2014)
• MN Senate and House Pass Bill with EHR Amendment That Will Free Some Doctors From Intrusive and Expensive EHR Systems. “The Minnesota Department of Human Services policy omnibus bill contains several matters of health reform, including an amendment that exempts solo practitioners in private practice and cash providers from EHR systems. Starting January 2015, providers must comply with the state’s electronic health records mandate. ‘We’re pleased that lawmakers have included this important amendment in Rep. Tara Mack’s bill that will allow small clinics and practices to continue to serve patients in Minnesota,’ said CCHF president and co-founder Twila Brase. ‘Many small clinics and practices cannot afford the cost of the EHR system, and many practices do not want to make their patients’ data accessible online. ‘This amended bill will allow small clinics to thrive in smaller communities,’ she continued. ‘And it will allow single doctor’s offices to keep their doors open, rather than be forced to join a big practice. Patients would be able to search for practitioners who hold their medical data truly confidential and for doctors that look them in the eye rather than turning their back on them and typing into a computer.’ Minnesota is the only state that, until now, did not allow health care providers to opt out of expensive, intrusive online-accessible EHRs. The federal HITECH Act mandates EHRs, but allows any provider to opt out. This amendment begins to give Minnesota the level of freedom and privacy available to doctors and patients in the rest of the nation.” (Citizens’ Council for Health Freedom, 5.21.15)
• Minnesota House Committee Accepts CCHF Amendment on Electronic Health Records State Mandate. “The language exempts small practices of up to seven health care providers from Minnesota’s mandate that every provider use an electronic health record and have it hooked up to the grid. Many small practices cannot afford the cost of the EHR system, and many practices do not want to make their patients’ data accessible online. ‘This language would allow smaller practices to thrive in smaller communities,’ she continued. “It would allow smaller practices to open—and to keep their doors open—rather than being forced to join a big practice, and it would allow smaller clinics to offer privacy to their patients. Patients would be able to look for practitioners that hold their medical data truly confidential and for doctors that look them in the eye rather than turning their back on them and typing into a computer.” (Citizen’s Council for Health Freedom, 3.30.15)
• Psychologists’ Reaction to Minnesota’s Mandatory EHRs. Survey is found here. “It is striking to note that 30 respondents state that they plan to retire specifically because of the mandate. Also, only about 7% have purchased an EHR in response to the mandate… Another striking finding is that about 43% of the respondents are ‘extremely’ concerned about confidentiality problems that may be associated with EHR communications.” (Mental Health Concierge, 1.18.15)

New York

• As NY Demands Paperless Prescribing, Doctors Are Mixed. “The scribbled, cryptic doctor’s prescription note is headed toward eradication in New York, where the nation’s toughest paperless-prescribing requirement takes effect March 27. Instead of handing patients slips of paper, physicians soon must electronically send orders directly to pharmacies for everything from antibiotics to cholesterol pills to painkillers, with some exceptions. Otherwise, prescribers face the possibility of fines, license loss or even jail. E-prescribing has surged nationwide in recent years. Every state now allows it, but only New York has a broad requirement that carries penalties. The requirement is meant to fight painkiller abuse, reduce errors and expand a practice that doctors and patients often find convenient. But physicians say digital scripts can present roadblocks for some patients and doctors shouldn’t have to fear punishment over a prescription format.” (AP, 3.19.16)

EHR News

• EHR Vendor Hit With $155 Million Fine in Whistleblower Suit. “eClinicalWorks (ECW), one of the largest developers of electronic health record (EHR) systems, will pay $155 million to settle a False Claims Act lawsuit alleging that the vendor misrepresented the capabilities of its software and paid kickbacks to certain customers to promote its product, according to the US Department of Justice (DOJ). Observers say that this case may prompt other developers to pay more attention to their customers’ complaints and perhaps to improve the safety of their software. The federal suit against ECW was brought in the District of Vermont by Brendan Delaney, a software technician formerly employed by the New York City Division of Health Care Access and Improvement.” (Medscape News and Perspective, 6.2.17)