EHRs Aren’t Yet Perfect, But Why is Perfect the Standard?

April 11, 2019
While many complaints about EHRs are absolutely valid, keeping in mind the timeline of how and when these systems were put into practice is important

Reading the “Botched Operation” report put out last month by Kaiser Health News and Fortune was fascinating in a variety of ways. The lengthy feature, from the headline—Death By 1,000 Clicks: Where Electronic Health Records Went Wrong—to the collection of anecdotes from doctors, clinical informaticists and others, was incredibly detailed and well-sourced.

Right at the top of the story, the authors—Fred Schulte from KHN and Erika Fry from Fortune—described a patient in Vermont who sadly died of a brain aneurysm that could have been caught with a head scan, a test that was ordered by the patient’s local doctor. But the test request never made it to the lab due to a glitch in the clinician’s EHR system, which was developed by one of the major companies in this space, eClinicalWorks (eCW).

And unfortunately, this case was not a one-off situation. An investigation found that the eCW “spaghetti code was so buggy that when one glitch got fixed, another would develop,” according to the piece. The authors went on to write, “The user interface offered a few ways to order a lab test or diagnostic image, for example, but not all of them seemed to function. The software would detect and warn users of dangerous drug interactions, but unbeknownst to physicians, the alerts stopped if the drug order was customized.” Owen Foster, a newly hired assistant U.S. attorney with the District of Vermont, who looked into these EHR cases for the government, said, “It would be like if I was driving with the radio on and the windshield wipers going and when I hit the turn signal, the brakes suddenly didn’t work.”

The investigation into eCW eventually became a famous news story, and the health IT vendor ended up paying a $155 million settlement to the government over alleged false claims and kickbacks. Of course, eCW is hardly alone when it comes to EHR vendors being blamed by end-users, but the investigation and settlement set an important tone for the piece, and the health IT industry more broadly: that despite a $36 billion investment by the government to digitize health records, the results have been quite disappointing.

If the average person who only had basic knowledge about digital healthcare was to read this story, he or she would likely come away with the conclusion that EHRs have been a complete failure and waste of money. The piece is littered with EHR-related patient safety cases and a multitude of other instances of how these IT systems have not worked as promised. It references a 2017 Annals of Family Medicine study that found 44 percent of the roughly six hours a physician spends on the EHR each day is focused on clerical and administrative tasks, like billing and coding. As a result, physician burnout is as prevalent as it’s ever been.

The authors further wrote, “KHN and Fortune examined more than two dozen medical negligence cases that have alleged that EHRs either contributed to injuries, had been improperly altered, or were withheld from patients to conceal substandard care.”

As readers pore over the details of the feature, feelings of gloom and fear might emerge; after all, how could something so important as patients’ health records have been botched so badly? Many of the public reactions to the piece were predictable in this sense, but there was also a less vocal group of folks who came to the defense of EHRs.

There are always two ways to look at things. One viewpoint is to take all of the negative that has been written and reported on EHRs and assume they have been a massive letdown. But the other perspective is that while there are unquestionably lots of improvements that are necessary—perhaps most of all related to EHR design—these systems are not solely to blame for patient safety and medical error issues. On top of that, significant progress has actually been made.

It’s not popular to say that EHRs improve care, but doctors do admit they have such benefits. Stanford Medicine’s 2018 National Physician Poll, which was referenced in the story, found that about two-thirds of the more than 500 primary care physicians surveyed think EHRs have generally led to improved care (63 percent) and are at least somewhat satisfied with their current EHR systems (66 percent). These same survey respondents did also continue to report problems with these systems, however, and many (59 percent) said that EHRs need a “complete overhaul.”

What these findings tell me is that even though EHRs are not perfect in their current state, and likely won’t be anytime soon, they’re still much better than the alternative. After I read the KHN and Fortune piece, my colleagues and I were sharing our thoughts in the days following, and our Senior Editor David Raths brought up a great point: in the paper-based healthcare world, poor communications and lousy handwriting were the causes of many patient deaths as well—likely many more than EHRs have caused. David said to me, “EHRs now are like the first-generation word processors in the 1980s—clunky but better than typewriters!”

And he’s absolutely right. Compared to the alternative of medical records on paper, isn’t this imperfect digital healthcare world significantly better? Evidence linking EHRs to better care is still mixed, as shown above, but in time, as the systems continue to mature, that’s expected to change, according to research. In the KHN and Fortune piece, Dr. Joseph Schneider, a pediatrician at UT Southwestern Medical Center, compared the paper to digital shift to moving from horses to automobiles. But in this analogy, he said, “our cars have advanced to about the 1960s. They still don’t have seat belts or air bags.”

Even if that analogy is perfectly accurate, doesn’t it still signify that real progress has been made over the last decade? Today, 96 percent of hospitals have adopted EHRs, up from just 9 percent in 2008, as the story’s authors noted. And while adoption alone isn’t enough, it takes time to optimize these systems so that they work to the best of their abilities.

In reality, 10 years isn’t a whole lot at all; just three years ago, one-third of providers did not report using an EHR. So in just a few years’ time, we suddenly expect these systems to work flawlessly? Looking at other areas of technology, we have never had these same standards. Let’s look at banking, for instance. In the late 1960s, there were over a thousand ATMs worldwide, but it wasn’t until 1995 that online banking existed and years after that until mobile banking launched. Mobile phones, meanwhile, were first introduced in the 1970s and 80s, but how much longer did you have to wait for that mobile device to have the ability to surf the Internet?

Healthcare is different of course, as it’s an industry where peoples’ lives are on the line. And in the end, it makes sense that providers and others are frustrated with EHRs. Doctors are extremely busy people who want these systems to make their lives easier, not more complicated.

But for each of the stories written that will inevitably disparage EHRs in the coming months and years, if you just keep things in perspective, and consider the real-world timeline of their adoption and maturity scale, things could really be a whole lot worse. In the end, we’re just 10 years into HITECH—so perfect should not be the standard.

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