Written by Omar L. Gallaga
Imagine an online service that could show you a comprehensive, continually updated portrait of your health history. Every childhood vaccination, notes and treatments for an emergency hospital stay while on vacation 10 years ago, several years’ worth of psychiatrist visits, even current progress being made for a 10,000-steps-a-day goal from a Fitbit fitness tracker. It would be secure from hackers, accessible from any device for you or any medical professional treating you, and very easy to use.
Not only does such a system not exist in 2017, but some in the health industry think it’s a bad idea entirely. Some question whether a trove of information such as this wouldn’t be sure to draw cybercriminals and whether its benefits outweigh costs and disruptions for physicians, hospitals, IT departments and even patients.
How We Got Here
The market for electronic medical records (EMRs) and electronic health records (EHRs) is currently about $28 billion with more than 1,000 companies creating software and systems to manage them. Over the last 10 years, the efforts to make digital records happen has mirrored, and in many ways lagged behind, the technological revolution that has put smart phones in every pocket and the Internet of Things in our homes.
Beginning in 2006 and continuing through 2009, the health IT industry ramped up, establishing major players in the effort to bring traditional health records to the digital age. The U.S. government’s investment in the space catapulted the industry into a higher gear, speeding adoption of large and complex systems significantly.
The 2009 American Reinvestment and Recovery Act, also known as the 2009 Stimulus Package, created the “meaningful use” standard for health care records, but also planted the problematic seeds that continue to plague implementation.
Zane Burke, president of Kansas City-based Cerner Corp., which leads the electronic health records space with annual revenue in the billions, says that while the stimulus package was well-intentioned, and created a Medicaid- and Medicare-incentivized boom in the market from which Cerner benefited, it also had unintended effects.
“It created a dynamic where the EHR became the enforcer and regulator of those standards,” Burke said. “When EHRs are not done at their finest, it can be seen as a regulatory requirement verses a tool to help me provide better care. When not done properly, it becomes a pure box-checking exercise for compliance and to meet government standards.”
While the incentives, which went into effect in 2011, could be lucrative for large medical organizations, six years’ worth of government subsidies worth about $63,750 to each facility didn’t make as much sense for small practices and individual physicians, who had to shoulder the expense of choosing a health-records vendor, implementing a new system with a potentially steep learning curve, and paying ongoing expenses for IT services in order to meet the government’s certification guidelines. Some opted out and waited for costs to go down and the quality of the software to improve. According to a 2016 survey from the Texas Medical Association, EHR adoption rose from about 22 percent in 2005 to about 73 percent in 2016. But physicians say the systems they have adopted are far from problem-free. In the same survey, more than a third of respondents said they experienced damage to patient safety and care as a result of EHRs.
Nora Belcher, executive director of the Texas e-Health Alliance, has been watching the EHR market long enough to come to some very definitive conclusions: It’s typically not medical records themselves that create problems, but more importantly it’s the systems behind them that are difficult.
“It just turned out to be a lot harder than anybody thought it was going to be,” said Belcher. “(The government) said, ‘We’re just going to dump all this money into this market, and it’ll fix itself,’ and that turned out not to be the case.”
Among the problems that emerged after the 2009-2011 boom in new EHR software were competing platforms that could not transfer complete medical information with each other, leaky security and tough-to-use software that caused health professionals to spend too much time staring at screens and training instead of treating patients. The Wall Street Journal reported The University of Texas MD Anderson Cancer Center, for example, cut about 5 percent of its workforce and attributed the decision to expenses caused by implementing an EHR rollout from Madison, Wisconsin-based Epic Systems Corp, another leading company in the space.
Improvements were slow to happen and did not create the kind of user-friendly experiences that patients and physicians were accustomed to outside the medical industry. “These technologies sound great in theory, but they’re really difficult to implement,” Belcher said. “Hospitals are big, complex systems that have safety issues that have to work. This isn’t Groupon. Nobody dies if you buy the wrong Groupon.”
Burke acknowledges that some of the biggest problems with EHR rollouts have been that physicians, nurses and technicians have been put in the role of keyboard jockeys instead of doing what they do best. “You have to continue this highly complex workflow, this highly specialized workflow, and account for ease of use. It has to be easy, fast and contextually aware of where that person is,” he said. “I often say our industry is one of the only industries that puts our rock stars behind keyboards.”
But the biggest problem many see in the industry has been a lack of clear standards and a lack of portability for medical data, sometimes held up for competitive reasons, other times simply a symptom of technical incompatibilities. Cerner and Epic have made efforts to standardize their EHRs with CommonWell Health Alliance and Carequality, which over the last few years have begun to tackle the huge problem of creating open, interoperable platforms that don’t sacrifice privacy and security with lots of work left to do.
The belief that patients should have quick and easy access to their medical data was behind a Texas e-Health Alliance push behind a health care privacy bill passed in 2011 meant to protect patient data and to help patients get copies of their electronic records more quickly.
Despite the bill’s passage, we’re still a long way from online portals that give consumers all the information they need, especially during a medical crisis. “Patients are frustrated their records aren’t all together, complete, all in one place,” Belcher said. “We’re not there. We’re getting there.”
In 2013, Dr. Kaylen Silverberg wrote a blog post on the Texas Fertility Clinic’s website titled, “Why Doesn’t TFC Use Electronic Medical Records?” In the post, he listed costs, waste in electronic records that end up printed out on paper anyway, lack of security and an adverse impact on the patient-doctor relationship as factors for opting out entirely from EHRs. More specifically, he says, the systems typically built to handle EHRs are meant for mainstream practices, not for a fertility practice with specialized needs and an even greater need for privacy.
Four years later, Silverberg says the clinic still relies on handwritten records with no regrets.
“Not only are we not all-in, we’re all out,” Silverberg said. “(EHRs) have been crammed down the throat of medicine. If you’re a cynic like me, you have to ask, why is all this information being collected?”
Silverberg believes digital records shift power to insurance companies and the government and don’t offer enough benefits to justify their cost, at least for a practice such as his. Texas Fertility Clinic has tested out systems geared toward infertility practices and Silverberg says they were all lacking. And it’s not, he insists, because he’s a Luddite.
“We use lasers on embryos. We do genetic testing. I love technology. We are absolutely up to speed,” he said. “We just oppose electronic medical records because we see no advantages and massive disadvantages.”
Security, however, has been the primary deciding factor for opting out of electronic health records. The practice’s website has been hacked repeatedly, but its sensitive paper records have not.
“Target gets hacked. Visa gets hacked,” Silverberg said. “The only way our patients’ medical information is going to be compromised is for someone to physically break in and steal the records.”
Editor’s Note: In upcoming issues of Texas Hospitals, we examine the current state of EMR implementation as well as what industry experts believe the future of these platforms will look like. This is the first in a series exploring leadership-level concerns as we examine how the last 10 years have played out and why the rollout of digital health records has been so tumultuous, costly and inefficient.