In September of 2014, at the height of the Ebola epidemic, the United States experienced the first Ebola diagnosis within its borders. Thomas Eric Duncan’s case shocked the nation. Within days of Duncan’s admission to the hospital, the public’s already-feverish concern about Ebola turned to panic as the media reported that Duncan had initially been sent home from the emergency room after arriving there with symptoms of Ebola. The million-dollar question: how did the medical staff at the hospital make an error with such grievous potential consequences?
The answer is simple: there was an error in Duncan’s electronic health record. His record was structured so that his doctor, unlike his nurses, did not see his travel history—a piece of information that would have instantly confirmed Ebola as a distinct possibility.
The Centers for Medicare & Medicaid Services (CMS) define an electronic health record, or EHR, as “an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that person’s care under a particular provider.” The U.S. government has long envisioned EHRs as a key way to improve medical care. EHRs enjoy bipartisan support, and the Obama administration has strongly supported their use. In 2009, as part of the American Recovery and Reinvestment Act, Congress passed the Health Information Technology for Economic and Clinical Health Act (HITECH Act).
The HITECH Act authorizes the CMS to provide incentives to doctors and hospitals to adopt and make “meaningful use” of EHRs. These incentives come at no small cost to taxpayers; CMS has allotted up to $27 billion for them. Medicaid’s program will pay “eligible professionals” a maximum of $63,750 over six years for adopting an EHR system; Medicare’s program will pay a maximum of $43,720. For hospitals, the minimum payment under either program is $2 million. Failure to adopt an EHR system carries a penalty for eligible professionals under Medicare, and standards for EHR use increase over time in stages. Beginning this year, Medicare will reduce payments to eligible professionals who do not adopt EHRs by 1% and continue to reduce payments over several years up to 5%. The Affordable Care Act similarly encourages EHR use; it rewards doctors for keeping patients healthy, and expects them to do so by using medical information technology like EHRs.
The federal government is making a mistake. In effect, it will now financially punish medical professionals who do not use EHRs and use them to its standards. EHRs have the potential to improve healthcare systems, but current regulations require substantial reform to make this goal a reality.
In theory, EHRs are an ingenious idea: a single document compiling a patient’s entire medical history, easily accessible to both medical professionals and the patient, which saves both physician and patient time and money. For example, if the emergency room physician can see on the patient’s EHR that the patient has previously had a test the physician otherwise would have ordered, he need not spend time ordering that test, and the patient doesn’t have to pay for it. The doctor needs less time to write a prescription, and risks fewer errors than with a paper medical document. The patient’s risk of receiving an improper prescription is minimized. But though EHRs are brilliant in conception, they are botched in execution.
The issues with EHRs lie in the gulf between idea and implementation. Conversion to an EHR system itself is expensive in terms of time and money—prohibitively so for many practices. According to Bloomberg, Kaiser Permanente, one of the nation’s largest healthcare entities, needed $4 billion and five years to implement the system which links its 37 hospitals. EHR companies can charge up to $25,000 per doctor per system, and systems typically require a monthly fee after initial implementation. A study published in Health Affairs, a leading health policy journal, found that for a five-doctor practice, the cost of implementing an EHR system will be $162,000, and maintenance of the system in the first year will cost $85,500. Time costs are also real; on average, a physician will need 134 hours of practice just to be able to use an EHR system in a clinical setting. In the long term, EHRs could potentially reduce costs—studies are mixed on whether EHRs increase or decrease medical costs. It is clear, however, that in the short term, EHRs are simply too expensive for many doctors, particularly those in small and independent practices.
Costs of EHR systems are not limited to physicians. The New York Times reported in 2012 that a study in Health Affairs found that doctors using EHRs are actually more likely to order expensive tests for patients. EHR systems can also present costs to the government in the form of fraud. The Center for Public Integrity reports that digital systems make it easier for doctors to practice what is known as “upcoding,” which has cost taxpayers at least $11 billion. Medicare uses codes to determine doctors’ reimbursement—the higher the code, the higher the reimbursement. EHRs make it more difficult for regulators to root out fraud because they generate much more data than paper records and can be easily manipulated to create excessive and unnecessary data that increases regulators’ workload. Regulators lack the capacity to handle this amount of data and verify it, making it easy for doctors to upcode and earn higher payments. According to the Department of Health and Human Services, 57% of Medicare doctors used EHRs in 2011. That percentage is expected to increase as EHR use is further encouraged, creating the potential for even greater fraud.
Even presuming that EHRs do save health care providers money in the long run, they lack standard content areas and complexity that would be necessary to effectively improve the healthcare system. Paper records may be more detailed than EHRs’ content areas allow, making it difficult to correctly convert information. EHRs’ information categories may make it more difficult for doctors to ask open-ended questions to patients that aid them in providing care. Doctors fear EHR use leads to a loss of face-to-face time with patients, a key component in quality care and the doctor-patient relationship. Furthermore, systems aren’t complex enough to meet physicians’ needs. In 2014, The Washington Post reported that in 2013, 58.9% of hospitals were using EHR systems, but only 25.5% of hospitals had a “comprehensive EHR.” For doctors’ offices, 78.4% had “any EHR,” but only 48.1% had a “basic EHR system.” In other words, EHR use had increased substantially, but the complexity—and thus, in many ways, value—of the systems varied widely. The Post also reported that just 6% of hospitals were ready for Stage 2 of the Medicare and Medicaid incentive programs, which increase standards. A central argument in favor of EHRs is that they would enable healthcare providers to share information with patients, but only 10.4% of hospitals can do so with their current EHR systems
Information sharing isn’t just an issue of provider-to-patient. Inter-system integration is necessary for effective EHR use, and EHRs have faced substantial problems in provider-to-provider sharing. EHR systems are produced by many companies, which have designed their software so that data can only be shared within their company’s system. The New York Times reported on this issue last year; essentially, a practice can have a fully-functioning EHR system, but if another practice down the road has a system produced by a different company, those practices can’t share information electronically. Instead, they have to fax it—just as they did before they switched to EHRs. The Times also reported that fewer than half of hospitals can share documents, while only 14% of doctors can. This issue is motivated by companies’ self-interest; they can either regularly charge users to share data with practices using other companies’ systems, or charge users for a one-time fix to the problem. This issue again emphasizes the differential costs of EHRs to large and small practices; a corporation like Kaiser can afford to pay to share data, but a small, individual practice cannot.
Should the government abandon its push for EHRs? Probably not. EHRs do have the potential to substantially improve data systems and lower costs. Their widespread use would also enable the study of public health data on a massive scale—a potentially huge benefit to medical study. The issue with EHRs is not the concept, but the execution. The HITECH Act and Affordable Care Act have encouraged rapid increases in EHR use without accompanying standards for effectiveness. Effective EHR systems must be sufficiently complex, flexible to physicians’ needs based on physicians’ own testimony, integrated between providers and different companies’ systems, ubiquitous in the healthcare system, and controlled for fraud and privacy. In addition to the aforementioned issues, in wide or universal use, EHR systems would contain a massive amount of patient data that would require effective privacy controls and cybersecurity protections.
The conversion to an EHR system is a massive change, and the federal government needs to reform its EHR plan accordingly. The healthcare system will require more time to convert to EHRs. Practices—namely small, rural, individual practices—that will face prohibitive costs for implementation need greater incentives to adopt EHRs. There must be uniform standards for EHRs’ complexity, based on what physicians themselves report as necessary. EHR producers must be required to share data with other producers’ systems at no cost to users so that systems are integrated. The Department of Health and Human Services must be given the resources necessary to effectively combat upcoding and Medicare fraud and protect patients’ privacy and data. In 2009, The Washington Post called EHRs “the machinery behind health-care reform.” EHRs can transform the American medical system, but without appropriate standards, the change won’t be for the better.
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