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    Why have EHRs failed to deliver their promised efficiency benefits?

    Why has health technology been so slow to deliver on its promised benefits to hospitals and physicians?


    Related: Top 10 challenges facing physicians in 2017


    Robert Wachter, MD, hospital medicine pioneer and recently appointed chair of the Department of Medicine at the University of California-San Francisco, cites a “productivity paradox” of information technology, which was advanced in the early 1990s by Erik Brynjolfsson of the Center for Coordination Science at Massachusetts Institute of Technology. It holds that while adoptees of new information technology expect to see a sharp uptake in their productivity from computerization, that uptake can fail to materialize for a decade or more.

    Historically, the dividends of productivity-enhancing disruptive technologies are reaped more gradually, following an initial lag, once the opportunities have been fully assimilated and users have learned to rethink the nature of their work and question old ways of doing things. Wachter suggests that this kind of evolution will be true with hospital electronic health records, as well. It may take a decade or more before we see the predicted massive gains in productivity.

    Wachter last year published a book on health information technology and its discontents, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age. “For 15 years, I studied patient safety. It was logical to believe computers would come in and fix things, making everything simpler, easier and more straightforward,” he says. Wachter discovered that in many cases doctors stopped talking to each other, with something important lost from their computer-facilitated interactions.


    Further reading: Need for population health data drives practice to consider EHR switch


    “A lot of my colleagues complain that computers have ruined their lives,” he says. “We didn’t understand how complex the transition would be from paper to digital—a massive transition over a short time.”


    Wide rollout but high provider dissatisfaction

    By conventional measures of success, the rollout and dissemination of electronic health records (EHRs), following more than $35 billion in financial incentives paid out to providers since 2011 by the U.S. government’s Office of the National Coordinator for Health Information Technology, has led to historic gains in adoption of the technology. By 2014, 83% of office-based physicians and 84 percent of hospitals had implemented EHRs, up from 29% and 9% eight and six years before respectively,  according to David Blumenthal, MD, MPP, president of the Commonwealth Fund.

    “I think of information technology in health care as a resource—like a circulatory system,” Blumenthal says. “The use of the EHR is now the norm in the American health care system—like it or not. It’s an amazing change in behavior and a reflection of getting a recalcitrant system to begin to pivot.” Blumenthal was National Coordinator for Health Information Technology during early implementation of meaningful use incentives under the 2010 Health Information Technology for Economic and Clinical Health (HITECH) Act.

    Next: "One of the biggest unsolved problems in health information technology"

    Larry Beresford
    Larry Beresford is a contributing author for Medical Economics.


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    • Anonymous
      When I was a VA physician, I found the CPRS EHR system reasonably helpful, although there were serious flaws as well. In that setting I could visit with a patient and usually type at the same time. In private practice, however, I have not seen an EHR that works well at all. I have gone concierge and no longer deal with the managed care mafia. A paper record works just fine, as it always has. The EHR poses all sorts of problems, not the least of which is liability risk. Cut and paste is one problem, obviously. Checklist menus make the doctor a sitting duck in malpractice cases. When I was a younger physician, the medical record was a document intended to do two things: recording important information and communicating with other clinicians who would also follow the patient. In the past 25 years the record has morphed into a document that is supposed to be all things to all people, including patients who can read what you've written down. If the patient is depressed or abusing drugs or alcohol, a doctor will probably avoid writing comments that can be interpreted as negative or derogatory, despite the importance of those observations and findings. In other words, the sanctity of the medical record has been severely compromised. A good medical record should help me remember my impressions and what I've actually done. It should also help other clinicians understand my thinking about the case, including lingering questions and concerns. The EHR not only compromises my thought process, it complicates my treatment of the patient. Our brains don't work like computers. In daily life we solve problems by jotting notes, reminders, and important data; we don't organize our problem solving according to templates and someone else's idea of systematic problem solving. When we are thinking through a problem we don't want to be interrupted by "clinical reminders" that we are supposed to ask about the smoking history or inquire about allergies or childhood diseases. We don't want to be sidetracked by an alert saying that we have failed to answer the checkbox about most recent pap smear. In other words, the EHR can be very disruptive cognitively. And needless to say, the problem of having to spend an hour or more at the end of the day "cleaning up" the EHR is a real pain in the tushy. Some doctors are now using "scribes" to fill in the blanks during the clinic visit. I simply couldn't afford to do that, any more than I could afford to pay a typist to transcribe dictated notes. Perhaps it would be better simply to videotape every patient encounter so that if someone wants to pick over it and criticize, at least they could see what actually happened. We are using the EHR for the alleged benefits for everyone -- except the doctor and the patient.
    • [email protected]
      Lack of interoperability is a serious flaw, but does not generate the most ire at an EHR. Poorly designed physician's user interfaces force the doctor to perform endless tedious manual entry of data. Manual data entry, often redundant and unnecessary, is the most hated aspect of the EHR. Medicine is the only industry which was forced to computerize by federal mandate, which explains the confusion and lack of benefits expected, as well as the lost productivity.
    • Anonymous
      Perhaps it's because EHRs are being treated like cash cows by the software companies where they got a product together so it looks like it will work but the software engineers have no idea what really goes on and how doctors really use information, so the software just doesn't work well with what we really need. We end up having to do 5 things to accomplish what we could do with a pen stroke. Or, maybe there is a simpler way, but it's not obvious and the user interface is terrible since they are putting the minimum work into keeping people from reneging on their contracts so the money keeps coming in. When exactly does a doctor have time to stop patient care and learn the finer points of the software that might change with the next update anyway? If you look at the turnover of programmers at the vendors, it's absurd. How can they have a cohesive product when the people writing it are a completely new team each year?

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