Physician barriers to EMR acceptance

Recently, I had my first visit with my new primary care doctor.

I picked him based on recommendations (plus he’s one of the few that accepts my insurance), and also because he seemed to be an eager adopter of electronic medical records (EMR). On his website, there was a portal for making appointments on-line, asking questions of the doctor and staff by e-mail and once a registered patient, I could also use a secure system to access my medical records. With EMRs being portrayed as key drivers of quality and savings in health reform, I felt encouraged by my new doctor’s embrace of the technology.

But when he greeted me in the examining room, I was surprised to see the medical assistant hand my doctor a pad of paper with my height, weight and blood pressure written on it. As we talked and he examined me, he wrote notes down on the same pad—even though there was a computer in the room. When I asked how he felt about his EMR system, he said it was a great advance for his practice—but unfortunately it had crashed  that morning and the “tech guy” said it might take a while to get it back on track. “By next week or so we should have you in our system,” he sheepishly explained.

The federal government is committing some $27 billion over the next 10 years to support the adoption and use of electronic health records by doctors and hospitals. On July 13, they released “meaningful use” criteria for hospitals and doctors to meet in order to qualify for financial incentives—as much as $44,000 (through Medicare) and $63,750 (through Medicaid) per clinician and millions for hospitals, depending on their size. These criteria—which are described in detail here are meant to promote the use of EMRs for improving patient care and quality, not just to aid in billing. Maggie Mahar recently wrote this post about how electronic records can lead to truly “patient-centered” care.

The incentives are meant to spur more practitioners and hospitals to go the way of my new doctor. But although he saw the promise of technology early, in reality, many American hospitals and physicians have been quite slow in embracing the idea of electronic medical records—with large innovative medical centers like the Geisinger system and younger practitioners being among those quickest to adopt the technology.

In a study published in January 2009 that compared physician use of electronic medical records in seven countries, the Commonwealth Fund found that only 28% of US doctors used EMRs, vs. 89% in the UK and a whopping 98% in the Netherlands.

Another finding from this study: “In the United Kingdom, 88 percent of primary care physicians can easily generate lists of medications that patients take, including prescriptions from other doctors, compared with only 37 percent of doctors in the U.S. The ability to generate medication lists promotes coordination of care among doctors and can help prevent medication errors.”

The Center for Disease Control’s National Center for Health Statistics found that in 2009 an estimated 43.9% of doctors reported using full or partial EMRs in their office-based practices. Yet this increased use of the technology is deceptive; just 20% of  the physicians were using “basic systems,” and only 6.3% were employing “fully functional” systems in 2009. A basic system can perform the following functions: provide patient demographic information, patient problem lists, clinical notes, orders for prescriptions, and allow doctors to view laboratory and imaging results on-line. Systems defined as fully functional include all that and more: they can store a patient’s medical history, execute electronic prescribing and test ordering, provide warnings of drug interactions and reminders for guideline-based interventions, among other features.
The rest of the doctors (about 18%) were only using individual elements of the EMR, like electronic prescribing or computerized ordering.

With the push on to get all physicians and hospitals using EMRs by 2015 (or face financial penalties in the form of lowered Medicare reimbursement) it’s important to understand what has kept doctors from fully embracing the technology. It’s not just the financial investment needed to set up EMR systems, says Bruce Carlson, publisher of Kalorama Information, a market research firm in New York that focuses on health information technology. Carlson tells American Medical News (published by the AMA) that “barriers to adoption for physician practices, including a disruption to work flow and a preliminary loss of productivity, are so strong that ‘the stimulus alone is not going to push the issue.’”

On the blogs and in conversations with doctors, I’ve found this same resistance—especially from older practitioners. In a post from Internet Evolution, Mary Shacklett, president of Transworld Data relates some reactions to EMRs that she’s heard from doctors:

“‘I have been practicing medicine nearly thirty years,’ said one New York City physician. ‘Using EMR is time-consuming, and it gets in the way of my relationships with my patients.’ A Midwest general practitioner echoed the sentiment: ‘I am in a situation where the clinic where I work has mandated using EMR, and it takes me six to eight hours a week to learn how to use it and to input information. Instead, I could be using this time to see more patients.’”

Some of the resistance to and difficulty working with EMRs is, frankly, age-related. Shacklett cites a recent CDC study that found that only 7.6 percent of physicians older than 65 used some form of EMR, compared with 47 percent of physicians younger than 35. But, she notes, “the slow movement to EMR has more story lines to it than age.”

Colin Harrington, an associate professor of psychiatry at Brown University’s Alpert Medical School, falls in the middle of these age ranges and also has mixed feelings about the EMR. As a neuropsychiatrist, he sees patients in the hospital as well as in an office or clinic setting. The first application of health IT at Harrington’s hospital was the electronic conversion of lab data and it was a positive experience: “Being able to immediately pull up a patient’s MRI image is unbelievably powerful,” he says, “and being able to pull up lab data proper is out of this world great.” But Harrington does have complaints about the EMR—mainly with how the technology effects his interactions with patients.

“In an outpatient setting, I either don’t type when I’m talking to a patient because it’s rude and I can’t watch patients articulate and observe their movements. For a dinosaur like me, even if I were to type when talking with patients, it would be inefficient.” Instead, Harrington takes notes by hand and then inputs them into the computer later in the day. “The result is that I can see fewer patients and I don’t get paid for the extra time.”

Douglas Perednia, an internist and dermatologist, agrees with this assessment in his recent blog post for Perednia writes about a colleague who hired a “scribe” to input written notes into her practice’s EMR system. Although she’s paying the scribe $10-$15/hour for this service, it could be worth the expense, according to Perednia. “It’s well known that, in the vast majority of cases, EMRs make doctors far less efficient when seeing patients.”

“It’s relatively easy to write with pen and paper while listening and explaining. It’s far harder to keep two hands on a keyboard, a third hand on the mouse, one eye on the screen and another eye on the patient and his family. And the fact that most EMRs and user interfaces are designed by computer geeks with no knowledge of clinical care or workflow certainly doesn’t help matters. As soon as EMRs are deployed, physician productivity typically goes down by about 50%. It rarely gets back to where it was prior to installation.”

A study in the Canadian Family Physician also finds that family physicians feel that they don’t have the time (or rather would have to spend too much uncompensated time) to really learn how to implement health IT systems in their practices; for a fair number, their computer skills were lacking. “For each hour of seeing patients, physicians said they needed 20 to 30 minutes of extra time to process paperwork (eg, complete billing, write consultation letters, review laboratory results).” This helps explain why many of them report dissatisfaction with electronic medical records.

Perednia also mentions another barrier to EMR acceptance—some systems can be unreliable or ill-suited for a particular practice. The colleague who hired a scribe is on her second EMR system: “The first one – purchased for tens of thousands of dollars – was a total disaster and had to be scrapped entirely.” Poor tech support (something I experienced firsthand at my recent doctor visit) is another reason doctors cite for being slow to adopt these systems.

For many doctors—as well as smaller hospitals—choosing an EMR can be overwhelming. The Health and Human Services “meaningful use” criteria provide a basic framework of functions for EMRs that are designed to improve quality of care and safety, among other benefits. But there are more than 300 companies selling EMR software, and many of them are promoting their products as qualified for “ARRA” funding—i.e. they meet the meaningful use requirements to receive incentive payments through the American Recovery and Reinvestment Act of 2009. The truth is that EMR systems must also meet the specific needs of a particular clinical practice, otherwise they will be balky and hard to implement. For example, pediatricians need EMRs that keep track of vaccination schedules and can generate school and camp forms; internists who see a lot of diabetic patients need EMRs that notify staff when test results are unusual or blood pressure should be taken, among other features.

With the government taking a “hands-off” approach to regulating these systems—or even providing standards that will allow interoperability between individual doctors, government payers and hospitals—it can be hard for practitioners to make an informed choice about a system.

As it stands now, there is not even a monitoring system in place for recording adverse events caused by EMR glitches. The reason, according to The Huffington Post Investigative Fund, an independent, nonprofit journalism venture affiliated with the Huffington Post, is a “clash of priorities” between the FDA (the agency charged with making sure medical devices are safe and effective) and the Office of National Coordinator for Health Information, “whose central task is to promote the technology’s swift adoption.”

According to the Huffington investigation, “The clash of priorities became public in late February when FDA official Jeffrey Shuren tied 6 deaths and more than 200 injuries to health information technology and said these were likely the ‘tip of the iceberg.’ The data review, based on mostly voluntary reports to the FDA, suggested ‘significant clinical implications and public safety issues surrounding health information technology,’ according to an agency report.
“Shuren laid out three possible options for regulations, none of which have happened. They range from mandatory reporting of ‘adverse events’ to a full blown regulatory structure that would require all digital records system to be approved by the agency prior to marketing.”

The authors conclude; “That no process exists to report and track errors, pinpoint their causes and prevent them from recurring is largely the result of two decades of resistance by the technology industry, a review of government records and interviews by the Huffington Post Investigative Fund shows. The industry argues that even with flaws, digital systems are an improvement over current paper records.”

That may be so. But the improvements may not be immediate. Researchers at Arizona State University’s W.P. Carey School of Business set out to measure the benefits of health IT in a group of more than 300 community hospitals in California that adopted some system of electronic medical records.They were inspired by a 2005 RAND Corporation study that found that America’s health care system could save more than $81 billion annually and improve the quality of care if electronic medical records were widely adopted.  Instead, the researchers, whose work is described in The Fiscal Times “found that the use of IT in a group of California hospitals actually has resulted in higher costs, higher levels of nurse staffing and higher patient complications.”

The problem, note the authors, is that of execution. “Aside from the large, well-funded hospitals, most institutions don’t have adequate IT staffs to implement and operate such systems efficiently.” Some of these systems might be only partially implemented—with some medical records still in paper form. Finally, computerized records are only as good as the processes they are computerizing—if the hospital’s own methods for keeping track of in-hospital patient data are sub-par, then you end up “computerizing inefficient processes,” according to the authors.

The Huffington investigation revealed two major glitches with EMRs that occurred in the Trinity Health System, a large chain that operates 46 hospitals, most in Michigan, Iowa and Ohio. In late June, the computer system (sold by the Cerner Corp.) posted some doctors’ orders to the wrong medical charts in a few cases; then two weeks later, Trinity had to shut down its $400 million system for four hours at 10 hospitals because electronic pharmacy orders weren’t being delivered to nurses for dispensing to patients, according to the article. Neither of these system problems led to patient harm, but the authors point out that they do highlight fallibility in EMR—despite their great promise in improving quality and reducing health care costs.

Still, the W.P. Carey researchers did find that the California hospitals with EMRs in place had reduced mortality rates—presumably because the systems helped cut down on medication errors. And they remain optimistic about the long-term benefits of computerized patient records—with improved patient safety and better quality of care being realized sooner than cost savings. The problems being experienced now are “bumps” in the road as hospitals wrestle with new technology; “nobody questions IT’s value in enhancing productivity.”

Next year marks the start of the five-year push to get doctors and hospitals to adopt EMRs. The release of the “meaningful use” criteria is the first phase of this process. More government action—in terms of creating standards to drive interoperability between doctors, hospitals, ambulatory care centers and other parts of our vast health care system—will be necessary to help achieve the goals of health reform. And so will better oversight from the FDA or whichever agency takes responsibility for monitoring adverse events and other problems with these systems. Right now we are experiencing the growing pains of an emerging technology—a technology that can feel onerous, balky and time-consuming to many practitioners. But as Colin Harrington told me of his hospital’s EMR system, “I imagine this is going to be 90% good and 10% bad in the long-run. It is still an evolving process.”

Naomi Freundlich is a senior research associate of The Century Foundation who blogs at Health Beat, where this post originally appeared.

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