Electronic Health Records. Are We There Yet? What’s Taking So Long?

I am a family physician, but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. They are caring for patients while at the same time facing tremendous pressure to transform their life’s work.  That includes overwhelming pressure to adopt and use new information technology.

This level of change is hard, difficult and confusing—with both forward progress and slips backward. Nevertheless, doctors take heart because you are making progress. It may be slow at times, but it’s substantial—and it’s impressive. Thank you.

The Annals of Internal Medicine today published a study (I was one of the authors) finding that more than 40 percent of U.S. physicians have adopted at least a basic electronic health record (EHR),  highlighting continued progress in the rate of national physician adoption of EHRs. The study, also found that a much smaller number, about 9.8 percent of physicians, are ready for meaningful use of this new technology.

Some might say, “Wake up, folks!”   Look at those small meaningful use numbers.  Change course, now.  After all of this time and tax-payer expense, less than 10 percent of doctors are actually ready to use these important tools meaningfully. What’s up with that?

To me, though, this study is good news. All who care about health care transformation should be heartened by the progress—but also impressed by the enormous challenge that our health professionals have undertaken.

This study was also authored by Catherine DesRoches of Mathematica Policy Research, Karen Donelan of the Mongan Institute for Health Policy at Massachusetts General Hospital, and Anne-Marie Audet of the Commonwealth Fund.  The Robert Wood Johnsons Foundation (RWJF) and the Commonwealth Fund (CMWF) supported the project. Staff from the Office of the National Coordinator for Health Information Technology (ONC) reviewed and commented on the survey instrument.

RWJF has a long-standing commitment and interest in helping the nation understand where we are with the implementation of this important technology. We also have a long-standing collaboration with ONC in monitoring the rate of EHR adoption. RWJF has produced an annual report on the state of that adoption since 2006 and will release the next edition in a few weeks. We also value collaboration with other funders, as we’ve done here with CMWF.

Automation of clinical information in health care is vitally important for overall health care transformation. But—and this point is critical—it is obviously not sufficient. The issue here is not and never has been “just add a dollop of HIT” and presto—stand back and behold the transformation.   Adopting HIT is just one of many steps, albeit a significant one. Actually transforming physician practice using HIT and many other tools is significantly harder and more complex.

In this study we see ongoing increases in the rate of adoption of the basic EHR as well as the relatively small numbers of doctors ready to use the technology meaningfully. But nobody should be surprised at what only appear to be low rates of meaningful use. I believe we’re on a series of “change curves” –one for adopting the technology and another for actually using it. We’re at the early stage, maybe even a relatively flat part of that use curve. It is, however, interesting that this study also shows that about 40% of doctors are close—very close—to meeting meaningful use criteria.  That means the total for both currently meeting and nearly meeting meaningful use is actually about 50 percent. That number starts to be impressive.  We’d also expect to see even more doctors meeting criteria, and more getting close, in coming months and years.

What about the pending increasing rigor of meaningful use standards? That increasing rigor could seem very tough.  The “directive” parts of these rules can indeed send some wrong and irritating signals, but the toughness of the rule is not really the point.  Doctors want to provide great care for their patients, and they desperately need tools to help them do that. Once the other pieces of care transformation support their magnificent professional work ethic I know that American doctors will blow right by what might have seemed like tough standards and instead push hard for more and more capabilities in their relentless drive to provide masterful care.

It would be helpful if those developing the technology could be as empathetic as possible to the needs of doctors and others using use the technology—like, say, Apple developing and refining new products.  Also, health professionals should be extremely vocal, not against adopting and using the new technology, but about demanding that the technology be as useful as possible to them as they create awesome care experiences for their patients.

There is obviously no going back. We must transform care—to make it a gleaming American triumph.  We cannot do that gargantuan task without using health information technology.  While I suppose the nation could have taken a heavy handed, centralized approach, forcing one-size fits all technology on our doctors, nobody wanted or wants that.  It would have been the wrong path, and a disastrous one at that. Instead, we’re adopting, learning, creating and innovating—and making progress.

So, take heart, heroes. The journey is long—but we’re right about where we should be.

Michael W. Painter, JD, MD is the senior program officer at the Robert Wood Johnson Foundation.

20 replies »

  1. Dear Dr. Chen,
    My name is Boris Katz. I am an EMR/EHR software architect with over 20 years experience in the field. I would love to talk to you and listen to your thoughts and ideas as I do regularly with a group of physicians.

  2. No need to be afraid–you can use your real names. Those with legitimate arguments do.
    Is that because, in the twisted world of the policy elites, arguments only have validity based on the credentials of those who make them? Do you have any actual logic or evidence to support your suggestion that an argument is not valid based on its own merits, but only when the person making the argument uses their real name? When one does not live in the public policy arena but instead has an employer who may or may not approve of comments made in public by one of their employees, it is important to make at least some attempt to remain anonymous.
    As to your other points, I would be surprised if you were not a member of the AMA – are you in support of the recent AMA request (joined by other medical societies) for congress to make major modifications to meaningful use? Part of the argument is that the push to make the software capable of meeting meaningful use has stagnated any attempts to make the software more usable and clinically relevant. But of course, that might be a hard concept for someone who has never sat across from a real patient with a laptop occupying a prominent position between.

  3. I appreciate the idea that the health care professionals work with the makers of technology…problem is, I don’t think the makers believe health care professionals are the audience they’re paying attention to. That opportunity was lost (and hence the discontent in your comments) long ago when the ideas of meaningful use started coming to fruitiion and it became apparent that the only thing meaningful is not in the perspective of the independent private practitioner…it is only meaningful for administrators and insurance companies. Look at most of the EMRs right now and you can see that it is clearly not designed for clinical workflows and thought processes. It is designed from the beginning for billing purposes. Clinical documentation and ways to enter it are an afterthought. Several years ago, I tried to contact several EHR vendors for physician feedback, none of them wanted anything to do with physician input. I decided to make my own instead after the frustration with meaningful use. I doubt that the makers will change their mind – it would be too drastic of a design change to implement EMRs the way a physician thinks. I agree, physicians need to take charge here, but we need an viable alternative (see my website), outside the current mainstream of products that further minimizes our profession and our dignity.

  4. Rose–I think you are spot on–both about the daunting part of adopting and using new technology-and–even more importantly–that health care professionals work with the makers of the technology so it’s useful for…the best possible care experience.

  5. The 1,954 systems are FAR from “identical.” That they all have to certify to the small set of MU criteria is not the issue. “Interoperability?” Mandate a single comprehensive RDBMS data dictionary standard, problem solved. Let the vendors compete on features, speed, look & feel, usability (UX), price, and support. Win-win-win.

  6. As with many new technologies, the adoption process can be daunting and stressful. It is essential that healthcare professionals and the makers of the EMR systems be able to work together to provide a better care experience for the patients. Healthcare organizations should also have established training sessions with employees so that they can learn how to use these systems and produce positive results.

  7. Item #2 in the AMA’s open letter to the ONC (January 2013) says that one of the main problems with MU is that it takes a one-size-fits-all approach in terms of product functionality specifications. It’s not the market that made 1,954 identical EHRs.

    Item #5 says MU doesn’t do enough to promote interoperability/exchange. That’s the missing piece, the universal 120V AC standard from your analogy where all the appliances can be plugged in.

  8. But what is Meaningful Use if not a one-size-fits-all specification issued by the government?

    Actually, as of today, it’s 1,954 market based sizes misfit all (Certified EHRs, ambulatory and inpatient complete systems).

    Yeah, I know, ONE set of MU criteria, to be fair. Sorta like 102 Volts AC.

  9. ” but one who doesn’t currently practice and importantly, one who isn’t slogging day after day through health care transformation. I do not want to be presumptuous here because the doctors and other health professionals who are doing this hard work are the heroes. ”

    That says it all. The problem with bureaucracy is that WE ARE LED by people who themselves do not PRACTICE what they preach literally. As an EMR user since 2000, I find it amusing that the current MEANINGFUL use have no clinical meaning at all other than DATA MINING. These systems even the TOP 6 EMR’s that raked in 64 BILLION the last five years, DO NOT INVOLVE CLINICAL MD’S who are actually in the trenches. EPIC for instance do NOT communicate unless an additional fee is added by the institution. The law should mandate that HIPAA be addressed on INTER INSTITUTIONAL medical record sharing at NO EXTRA COST. The total government incentive is between 45 to 65,000 dollars in five years. The cost of an EMR implementation is the same cost in its first year and support cost is 20% of the EMR cost. This does not include the cost of hardware and the WORK flow disruption of the current EMR design. I am not against technology but TECHNOLOGY has to reconcile with our work flow

  10. Yeah Mike, you’re getting no love because meaningful use has nothing to do with use or meaning. It is a set of rules and check boxes to fulfill if you want to get reimbursed by the government for your EHR technology. It has nothing to do with whether the technology works for you or makes your life easier.

  11. Hey, guys-what’s with the hatred stuff? Look around you–don’t you feel the change? It’s happening–get ahead of it. Lead it. Direct it. Aren’t you doctors? Anyway, my point is empathy not condescension–or have you completely lost perspective? In any event, I am sincere-and would love to understand your pain even more than I do. And I do understand. Let’ talk. You can contact me on Twitter (i’m @paintmd) or contact me at RWJF–I’ll chat by email or phone-happy to do that. I want to understand your stories. By the way, what’s with the pseudonyms? No need to be afraid–you can use your real names. Those with legitimate arguments do.

  12. What have we here? A non-practicing physician extolling the virtues of meaningful use. A doc oblivious to the very real hatred those of us actually practicing have for those who dream up this s

  13. Gag me with a gleaming, transformational, American spoon. Patronizing and condescending.

  14. You’re against heavy handed government intervention but you seem to support Meaningful Use, along with its taxpayer-funded subsidies which EHR vendors end up pocketing.

    But what is Meaningful Use if not a one-size-fits-all specification issued by the government? How does it promote experimentation and innovation?

    The short answer is that it doesn’t. What should have been done instead is to expedite the roll-out of NwHIN and/or Direct. This would have created a real free market, where competition is based on who’s best at saving time and improving outcomes, rather than who’s best at answering a checklist to get a government handout.