Disappointing outcomes despite a massive investment in EHRs


The Health Information Technology for Economic and Clinical Health Act of 2009 committed to the expanded adoption of health information technology, expecting electronic health records (EHRs) to transform medical care while promising dramatic improvements in quality, efficiency and safety.  Five years and $25 billion later, the results have fallen short of expectations, and there are multiple reasons for our disappointment.

First, EHRs were designed to document the provision of health care as it was just delivered.  Most EHRs arose from a programming background emphasizing billing and claims processing; software’s priority was data capture of past transactions.  As a consequence, systems were not designed to provide sophisticated guidance to health care practitioners for “what comes next” in the care of a patient. With some important exceptions, the most important part of a patient’s medical care is the ongoing plan, and – unfortunately — EHRs still don’t effectively facilitate planning the future of a patient’s care.

Second, EHRs have been woefully inadequate when used for population health care management.

Software companies are only belatedly realizing their obligation to enable analysis of health care needs and disparities across entire populations of patients. Without a well-designed and implemented patient registry, an EHR cannot identify groups of patients with similar needs, thus impeding a practitioner’s ability to direct limited care resources to patients who would benefit from intensive management.

Third, engaging the patient — presumably an important party in improving health care through IT — has been an afterthought.  Adoption of electronic patient portals has been slow, in part because the design and user interface of portals lack polish, and in part because portals fail to provide patients with actionable information to guide personal health care management.

One of EHRs largest failures is their inability to communicate with one another, a prerequisite to attaining the promised goals. The health care IT industry has been derelict in its responsibility to comply with standards of interoperability, and no funding mechanism has been established to develop the requisite interfaces among software systems in current use.  A patient who transfers from one physician to the next will most likely need to bring a print out of his or her “electronic” health record to be scanned into the “electronic” record in their new practice.  Diagnostic results and hospital records in one system are frequently unavailable within another electronic platform, requiring physicians to access multiple systems for these records, each system requiring a different username and password. If members of the general public were aware that “computers aren’t talking to one another” as patients navigated the multiple providers involved in their care, they would be shocked at the lack of planning and foresight.

Last, we have succumbed to an all-consuming demand for privacy of health care information without considering the implications.  Personal health care information provided to one’s practitioner during a visit is available only to that practitioner, ignoring the potential that the patient may present to another practitioner with a related problem — possibly in another community or even state. The critical allergy or important surgical history reported at one facility is not available when that patient — possibly incapable of providing the relevant history — requires urgent care in another locale.  We should reasonably expect that all relevant information is immediately available to any healthcare practitioner who needs it to provide safe and effective care, regardless of facility or location, and yet we have tolerated the development of laws and IT systems that make it impossible.  This is a dangerous outcome of our reflexive demand for total privacy, especially when the vast majority of patients correctly assume that healthcare information will be responsibly accessed and used.

Until EHRs guide practitioners in the future provision of care rather than simply serve to document care already delivered, facilitate stratification of patient populations by disparity or need, successfully engage patients in their own care, and “talk” to other systems involved in a patient’s care, we will fail to recognize significant benefits from our massive IT investment.  And without a more sophisticated concept of health care privacy, we will continue to hamstring efforts to use information technology to its fullest advantage.

Mark Nunlist is a family physician.  Betsy Nicoletti is president, Medical Practice Consulting and author of Auditing Physician Services. She blogs at Nicoletti Notes.


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