April 2019 President’s Message

Time for an honest report card on the electronic health record

by Michael Lievens, MD

Over the past 10-15 years, the practice of medicine in the United States has undergone an expensive and time-consuming transition to the electronic health record (EHR). It was encouraged/incentivized by the government, and many benefits were promised.

It is time to issue a report card, of sorts, on the results of the transition thus far, and maybe some hopes for the future of the EHR.

The many promises of the EHR included: more portability of health history data for patients, providers and payers; significant cost savings to the system overall; improved patient safety and improved efficiency, and thus the ability to “do more with less.”

Well, how are we doing?

I think it is clear we do not have much more portability of health records — not at the level of the doctor and patient, anyway. EHR systems do not talk to one another. Medicine is one of the few industries that still uses fax machines and “burns” information on CDs.

It is possible to log in to the hospital systems to get data from a hospital encounter of a given patient, but it is not seamless or quick. The only place this seems to work is in closed health care systems that own or employ all elements of care. Much of the information obtained from outside your system is scanned in, so the information is not as easy to access and use.

Clearly, we still have a long way to go in this area. I give it a grade of “C.”

Estimates of the cost of the transition to EHR are in the neighborhood of $36 billion. Health care costs continue to climb in the U.S., faster than the economy as a whole. It does not appear that the transition to EHR has had any beneficial effect on the upward trend in health care spending.

One of the promised benefits of the transition to EHR was its ability to control costs/save money. Objectively, it is hard to argue that it saves money. Hardware costs, software costs, and IT support costs are substantial to any practice or health system.

I give it a grade of “D.” Or maybe an “F.”

No database exists to track and study reports of deaths, injuries and “near misses” tied to software glitches, user errors and other system flaws. A recent Fortune magazine article, contributed to by Kaiser Health News, suggests that there are many thousands of such events. Many vendors have imposed “gag orders” to prevent customers from going public with examples of such problems.

Clearly, the EHR has fixed some problems such as reading illegible handwriting. But has it made health care safer? Has it reduced errors? I’m not sure we can answer this question, or give a grade at this point.

Has it improved efficiency? I find it difficult to see this. In fact, it appears that it may be hurting us.

In a 2018 Harris poll on behalf of Stanford Medicine, 74% of physicians felt that EHR increased the total number of hours worked per day, 69% felt that EHR takes valuable time away from patient care, and 71% felt that EHR contributes greatly to physician burnout.

Some of the “efficiencies” are actually inappropriate. The amount of “cut and paste” used in some notes is worrisome. Also, the numerous pages of data in an EHR progress note are typically consumed by information that is often only present for billing purposes, and it makes the note itself all but unreadable. We are spending more and more time producing notes that will only be read by auditors, coders and attorneys.

What busy physician has time to read a four-page note for a simple follow-up visit? Who even wants to read that?

On this point, I give EHR a grade of “D.”

So, what can be done? Where is this going?

Clearly, EHR is not going away. But I have hope. The technology exists to make this so much better. Superb voice recognition and activation is possible. The “Alexa” in my kitchen has better voice recognition than Dragon. And any Xbox has a better interface with its user than much more expensive EHR systems.

Augmented intelligence needs to be somehow carried with us, creating notes, making suggestions, sending prescriptions, ordering tests, doing the billing, and having it all finished by the time I walk out the door of the exam room. Just picture this happening. How much better would your day be? How much better would our care be?

This is possible. It irritates me that we don’t have this already. The market is enormous (see the earlier $36 billion figure). I hope the venture capitalists and technophiles out there are listening. Whoever produces this will join the likes of Bill Gates, Steve Jobs and Jeff Bezos in changing the lives of many people – and their own fortunes.