Around 1990, the health care industry began to become aware of the potential of electronic health records (EHRs). The ability to use this technology to improve efficiency, effectiveness, quality and safety felt like it was around the corner. To some, it felt like greater adoption of health information technology (IT) was near at hand, that the vision for this technology-enabled health care ecosystem would soon be realized. Now, more than 25 years later, there are still challenges in delivering true value to clinicians and patients. Certainly, great progress has been made, but as an industry we still seem far from the goal line.
"Not unlike the practice of medicine itself, effective implementation of EHRs can be partly science and a healthy dose of art"
This is what Deloitte’s 2016 Survey of US Physicians found. The majority of physicians surveyed hold relatively negative perspectives on some aspects of EHRs, and this has not improved since Deloitte’s last survey in 2014. Indeed, three out of four physicians believe that EHRs increase practice costs, outweighing any efficiency savings, and seven out of 10 physicians think that EHRs reduce their productivity. Moreover, physicians are less likely to think that EHR capabilities support clinical outcomes than they did in the 2014 survey.
This doesn’t mean that the Health Information Technology for Economic and Clinical Health (HITECH) Act’s Meaningful Use Program—which gave bonuses to clinicians who adopted certified EHR systems—has been unsuccessful. Case in point: Most (78 percent) physicians believe that EHRs are most useful for analytics and reporting capabilities compared to other attributes (such as supporting value-based care or improvements to clinical outcomes); this has also increased since the 2014 Deloitte survey. In fact, few physicians would stop using their current EHR system: three out of five would keep the current EHR system they have and not replace it.
What the survey did find, however, is that nearly all physicians would like to see improvements. Improvement wishes fell into two major areas:
• 62 percent want them to be more interoperabl
• 57 percent want improved workflow and increased productivity
These last points will likely be critical as the industry enters into the first phase of implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In passing MACRA, Congress intended it to be a transformative law that constructs a new, fast-speed highway to transport the health care system from its traditional fee-for-service payment model to new risk-bearing, coordinated care models. MACRA is poised to drive health care delivery and payment reform across clinicians, health systems, Medicare, and other government and commercial payers. EHRs and interoperability are a fundamental aspect of virtually every part of this initiative.
For example, while Meaningful Use will be phased out for eligible professionals, the US Centers for Medicare and Medicaid Services (CMS) has replaced it with the Advancing Care Information measure under the new Merit-Based Incentive Payment System (MIPS). MIPS is for clinicians who do not meet the Advanced Alternative Payment Model (APMs) thresholds. For most of the categories under MIPS, clinicians will be able to report using their EHR, too. Clinicians in Advanced APMs will not be able to avoid it either—only payment models that use certified EHR technology will qualify under the Advanced APM definition.
Interoperability is also a key issue getting attention under MACRA. The president of the American Medical Association, Steven Stack, has said that the lack of interoperable systems is one of the fundamental reasons why the potential of EHRs has gone unfulfilled. For that reason, and likely others, Congress made interoperability a core focus of MACRA. This comes after years of work by the Office of the National Coordinator for Health Information Technology (ONC), the Healthcare Information and Management Systems Society (HIMSS), and others to enhance data sharing and transparency across the system.
Health care’s reliance on technology is not likely to change. In fact, MACRA’s emphasis on utilizing and enhancing EHR systems and the charge to improve interoperability moving forward could strengthen the focus on technology. Those who are EHR “enthusiasts” should consider available research that indicates there is still work to do before health IT can deliver a clear and discernable value similar to the value many enjoy with online retail shopping.
Not unlike the practice of medicine itself, effective implementation of EHRs can be partly science and a healthy dose of art. The art of the EHR includes our ability to manage change, train clinicians in a holistic way, transform workflow, and truly take advantage of automation. The industry may well get there but, we should consider being responsive to the strong notes of concern from the clinical community.