The Physicians Practice Tech Survey confirms that physicians aren't fans of EHRs and health IT, in general. Here's a look into why this is the case.
As EHRs and related health IT products became more commonplace in the past decade, physicians interested in going digital saw a chance to get free of paper files while increasing efficiency and productivity. Then along came CMS' Meaningful Use program in 2010, which required physicians to adopt certified EHRs - which would contain specific qualities outlined by the government - and imposed financial penalties on those who didn't make the jump, whether they were ready or not. If physician dissatisfaction is any indicator, this rush to adapt to health IT has brought more problems than it has solved.
Physicians are frustrated with hassles and challenges their EHRs have created, from data input taking time away from face-to-face patient care, to an inability to customize software to their practice's needs. A 2016 report from Medical Economics found that 37 percent of physicians surveyed reported that their EHR "detracted from the care they provide to some extent." In this year's Physicians Practice Technology Survey, 67.9 percent of respondents said their practice did not see a return on investment from their EHR. Moreover, as experts note, disparate health IT systems often silo data, making sharing between practitioners difficult and creating work flow frustrations.
Perhaps the most damning statement on health IT came from former CMS administrator Andy Slavitt in February2017 at the annual Health Information Management and Systems Society (HIMSS) conference, when he called health IT a "failed industry."
Slavitt isn't the only one that feels this way. Nearly three-fourths of respondents to the Physicians Practice Tech Survey agreed with the former CMS chief that the health IT industry is failing because doctors don't like the technology they use.
Slavitt and other health IT experts spoke to Physicians Practice on why doctors hate their EHRs and concerns that health IT may not overcome its biggest failures any time soon.
Who's to Blame?
Slavitt's opinion of health IT has not changed since February, and he says that "almost everybody gets a piece of the blame," though he lets physicians off the hook, when it comes to the abundance of inadequate health IT products. He points primarily to the government for "over-engineering regulations," and the EHR vendors "for not building software that is user driven and solves problems," and for designing products with limited interoperability, which "have made the industry much more siloed," he says.
Slavitt says vendors need to take a step back to reevaluate whether their products are achieving the goals that physicians need them to, and suggests they take inspiration from almost any other industry. "All we have to do is make a travel reservation to see there is tons of intelligence at work that helps us find the right flight in a user friendly way. We don't get that in healthcare," he says.
Indeed, Jose Almeida, MD, a vascular surgeon and director of the Miami Vein Center, has experienced the hollow reality of the technology that hasn't lived up to the hype. "The idea of an EHR was utopian in a sense, everything digitized, all the data structured and reformattable for different purposes [and able to move across different provider settings]." Instead, his practice is now on its fourth EHR in eight years.
"The first vendor that came in made this fancy little marketing speech and once we implemented it, it just bogged down the practice tremendously." Almeida says that something that once took five seconds took "twenty minutes" on the first several EHRs. However, even with its current EHR, "Drop down menus are cumbersome and slow. We must sort through extraneous data to get the information we're looking for. In the old days, one would open a paper chart, and quickly find the notes with relevant information." These failings have made it necessary for his nurses to do data entry so he can connect face-to-face with patients, and led to a general feeling of burnout.
In fact, burnout is a common frustration among physicians regarding their health IT, according to Bridget Duffy, MD, Chief Medical Officer of Vocera Communications, a vendor in the health communications space. Dr. Duffy was an early pioneer in the creation of hospitalist medicine and helped establish the Earl and Doris Bakken Heart Brain Institute, in Cleveland, Ohio.
She feels that this burnout contributes to errors in quality, safety, and poor patient satisfaction scores. "The number one culprit is the [EHR] because it's forced [clinicians] to be digital entry clerks versus looking the patient in the eye and asking them questions," she says.
She feels that health IT should not only enable clinicians to communicate more seamlessly with patients, but with each other. Doctors and nurses often enter their notes into the EHR separately, without talking to each other. "The art of medicine comes through the human interaction," she says.
Duffy believes that if CMS had known at the time that the rollout of Meaningful Use would result in physicians "[hitting] the valley of despair and be so burnt out, I think they would have done the deployment differently."
However, Reed Gelzer, MD, MPH, an EHR and Health IT Systems and Policy Analyst at PRI, a woman-owned small business, provides quality assurance, program integrity, and other program effectiveness support to federal agencies. says that blaming the industry is a fundamental misunderstanding of what EHRs were designed to do. "One of the major reasons clinicians are dissatisfied is none of this was ever intended to make things better for them in the first place. [EHRs] were never intended to accomplish practice improvement." Instead, he argues they were designed to allow a subset of vendors who had not been able to get their EHRs approved by the certification commission for health IT (CCHIT), which came before Meaningful Use.
Increasing the competition would be a good place to start, Slavitt agrees. "So long as we are locked into four major [EHR] companies, I don't think we are going to see progress," he says.
Smoothing Out the Software
In the near decade since EHRs have gone mainstream, despite advances in IT across nearly every other industry, they haven't adapted quickly enough to meet physicians' satisfaction.
Duffy speaks from personal experience about how technology should serve the needs of physicians who take their jobs home at the end of the night in more ways than one. "This isn't a job where we're building cars or widgets; people's lives are at stake."
Joel Selanikio, MD, a former epidemiologist with the Centers for Disease Control, a software designer, and CEO of Magpi, which makes software for mobile data collection used by the global health sector, says that one of the problems is that EHR software didn't follow traditional methods of software introduction to the market. In the traditional sense, products are evaluated and tested with an audience before customers ever buy it. Instead, the few vendors on the market took advantage of Meaningful Use to rush products to market, he says. Since physicians were either rewarded or penalized for adopting the technology, many felt backed into a corner. "It's sort of the carrot and gun to your head approach," Selanikio says. "I think it was a really poorly conceived effort that forced [clinicians] to implement EHRs at a time when there really weren't good EHRs to implement."
Selanikio calls the experience of health IT "horrifically bad" and gives an example of an EHR in his practice where a button to close a page was right beside a button to clear all data from a page. "If you had any experience using computers or designing software interfaces, you'd have to ask why is there a button on the screen you are never supposed to press. Further, why is the button right next to the button you always press?" These examples of bad design, he adds, could easily be fixed to improve usability.
The Future of Health IT
Some of the problems physicians encounter with their health IT could be solved by making patient data portable. Not only does waiting on other practitioners for patient information slow down the process of offering the best patient care, but, Almeida says, patients themselves "usually don't have a great handle on what their true medical history is." He spends a lot of extra time entering patient data into the EHR. The result is "a lot of uncertainty, lots of unhappy, demoralized doctors" whom he says feel like "they've been sold a false bill of goods."
He believes that cloud-centered data is likely the future of patient data, but he does worry about how secure the data will be.
Slavitt hopes that EHR vendors get serious about innovation. He envisions a "world where EHRs are middleware, and people can build and buy applications that are much more customized to their own workflow, and the data moves in and out easily." The EHR would still serve record keeping purposes, but wouldn't require as much direct interaction with the physicians.
Slavitt says what's needed are technology companies to "take some big structural action" to design and build products and services around the needs of physicians and patients, which he feels the "big players" have not shown themselves willing to do so far. "What physicians need [from health IT] is more time, better information, and more ability to get better insights."
Indeed, health IT is clearly a work in progress. "Even when you look at places that have been at this for decades, like Kaiser Permanente, they're still finding it difficult," says Gelzer. He says there's no "magic wand" that can make health IT perfect overnight.
Duffy would like to see doctors, nurses, and even patients "at the table" and engaged in decision making when institutions pick the technology they plan to use. "We need to meet regulatory requirements, but not at the expense of the well-being of our patients, or physicians and staff," she says.