Why have EMRs not been more widely adopted?

One of the nagging questions about EHR adoption is the following: why is there such a low EHR adoption rate at the same time that there is a broad consensus that EHRs are critical to future healthcare? Sebelius, the HHS secretary, recently noted that only about 10% of hospitals and physician practices are fully digitized. But I suspect that this number is more than generous. A recent Booz Allen report cited smaller numbers.

The difference is largely immaterial. The point is that EHRs are not nearly as widely used as one would expect given the broad consensus on the need for them.

Of course, different healthcare institutions have different kinds of challenges, but I think the challenges really amount to the three “Cs” of EHR adoption:

1. Cost;
2. Culture; and
3. Content.

Cost:

When you compare the relative cost of the computers, IT support, software, etc that are necessary to implement and use EHRs, there is no question that it is more expensive than grabbing a legal pad and a pen to jot down some notes and throw it in a manila folder. Now I am not so naïve as to think that this is really how MDs track and store medical information, but for many small practices, this isn’t far off.

Even with the efficiencies that can be gained through the use of an EHR, the start-up costs are so substantial that it may never pay for itself. But for many small practices, there are no efficiencies to really gain. If you are a single MD with a single receptionist/medical record keeper and you implement an EHR that gains you even a 25% efficiency on administrative time, what do you do? You can’t exactly reduce your staff by 25%, so is there ever going to be an ROI for you?

And for lager facilities, there may be administrative cost savings, but implementing an EHR is a major undertaking that takes many years for results that are even further down the road.

Culture:

By way of analogy, thirty to forty years ago, it would have been unheard of for a CEO to type his/her own letter. Now, they write their own emails all the time. Why? It is far more efficient and they get a much quicker response. I believe we are at the dawn of a similar cultural shift with regards to the recording of medical information. MDs have been used to recording things one way and EHRs are a major shift away from that. But the problem is twofold: 1) we must make EHRs that are intuitive to use for recording information, and 2) we have to make that information available in actionable ways to the MD. In other words, the cost/benefit of email is readily apparent to CEOs, so they use it. We have to build EHRs functionality with the end in mind. The information and analysis that physicians derive from an EHR must be worth the extra effort of the information they contribute to the EHR.

Content:

EHRs are, in many instances, less intuitive and more cumbersome than paper records that can easily be modified to fit the MDs needs. And the information it produces is not actionable by its intended user. Let me illustrate.

I have a good friend who is a nephrologist in Michigan. He regularly gets referrals from other MDs in the area—some of whom dictate letters, others of whom send over an EHR. Guess which one is more useful? The letter. Typically, the EHRs come over as six or seven pages of small font forms, with most of the boxes empty, and no narrative description of why the patient is being sent. He or his staff then has to hunt through the document to find recent lab scores, and other more useful information to determine exactly why he is being asked to see this patient.

Compare this to the following dictated letter: “Mrs. Johnson is 65 and has seen decreased kidney function over the last six months.”

Part of the challenge of EHRs and the sharing of healthcare information in general is NOT capturing all the information and making it available to all appropriate clinicians, but creating the right lens for the right clinician so that the most useful information is mostly present most of the time. And, of course, there must be opportunities for exploring the information in more detail, if necessary. Now that’s a tall order.

Thus the real reason we as a country lag behind most others in EHR adoption is that EHR products haven't sufficiently proven their value to MDs such that the cost savings, convenience, quality improvements demonstrably outweigh the start-up costs and inconvenience of using an EHR. Until EHRs solve this "content" problem, we will continue to stumble over "culture".

Next up: How will the HITECH provision of ARRA address EHR adoption?