By ARTHUR ALLEN
The government-led transformation of health information is driving doctors to distraction, igniting nurse protests and crushing hospitals under debt.
Most health care professionals accept the inevitability of going electronic and see its value. But they have a message for the administration’s multibillion-dollar push not so fast.
The government has already delayed parts of the program, but the American Medical Association and others want more relaxation of the rules, and warn of disaster if they aren’t heeded.Doctors largely supported the Obama administration’s $30 billion incentive program to switch the nation’s medical records from paper to electronic starting in 2009. They understood the potential of using health IT to reduce medical errors, increase efficiency and give patients and caregivers access to complete, portable and up-to-date records.
If that vision isn’t motivating enough, there’s also cash on the line. Doctors can get up to $44,000 per year for digitizing and meeting criteria for “meaningful use” of health technology. Those who cling to their paper records could face penalties next year.
But the transition has proved painful. Paperless records still don’t flow smoothly among doctors, hospitals and patients and they won’t for some time. Nor have measurable savings or widespread improvements been seen yet.
And there’s a difference between liking the idea of electronic health records, or EHRs, and liking the particular systems in use. Even Karen DeSalvo, who as national coordinator of health IT is responsible for implementing national use of EHRs, notes that her own husband, an emergency room physician, considers his EHR “clunky.”
In short, the current generation of EHRs has about as many fans in medicine as Barack Obama at a tea party convention.
When the Department of Health and Human Services opened the taps to pay for the records systems, after incorporating a health IT law in the 2009 stimulus law, the technology on the market wasn’t ready to respond. Many records systems were built atop software designed in the 1970s for billing, not for comprehensive tracking of 21st-century patient care.
Top HHS tech officials recognize the shortfalls.
“Government payment incentives forced people into early adoption of technology that in most of our views is not optimal for what people want to do with it,” said Greg Downing, director of innovation at HHS.
Many EHR products designed to meet federal guidelines are not user-friendly. They take months to learn, require lengthy data entries and often don’t communicate with other computer systems. Doctors complain that because of EHR design flaws, they spend so much time “clicking” that their hands hurt.
“Infuriating and cumbersome,” is how Steven Stack, president-elect of the American Medical Association, describes commercial electronic health record systems. “They slow us down and distract us from taking care of patients. And I’m a supporter of EHRs.”Despite all those gripes and barriers, adoption of at least partially electronic systems keeps growing. The share of office-based physicians using any type of EHR increased from 48 percent in 2009 to 78 percent in 2013, according to HHS. More than 60 percent of hospitals now rely at least partially on electronic systems.
In surveys, nearly all doctors say they are willing and eager to go digital — but most aren’t happy with their current systems. Some 22 percent of doctors have opted out of the meaningful use program, forgoing payments. Only a tiny percentage is currently on track to meet government deadlines set for next year.
The frustration is tangible.
“We’re basically key-punch operators, transcriptionists having to input the data ourselves,” said James Gilbaugh, a physician in Wichita, Kansas. “It has essentially tripled the time to complete a medical record. How do you accomplish that when we are already working 12 to 14 hours a day?”
There are no data available on the number of physicians taking early retirement because of the pain of implementing EHRs, but anecdotes abound.
Stack, an emergency room physician, tells the story of a 64-year-old urologist he called in for a consult at his Lexington, Kentucky, hospital. The older doctor, who said he was retiring when he turned 65, had difficulty using the hospital’s records system during the visit. “This is why I’m retiring,” he said.
The AMA is asking the Obama administration to waive meaningful use requirements for older and rural doctors, and doctors in small practices. Society needs older doctors to keep caring for the boomer generation, Stack said. EHR implementation costs are one factor driving them out. Government incentive payments help but not enough.
Bond rating agencies have lowered the ratings of hospitals because of debts incurred from purchasing expensive EHR systems that have yet to lower costs. After plunking down millions to implement the systems, hospitals dedicate about 5 percent of their operating budgets to maintaining them, as opposed to 2 percent 10 years ago, according to Thomas Payne, a physician and IT director at the University of Washington medical center.
DeSalvo recognizes the growing pains. Even though more doctors and hospitals have made the switch, she said in an interview that there are still “questions about whether it’s improving health care. That’s an important next chapter.”
In part because current EHR technology is so clunky, partly because it is also used as a tool to guide patient care, many physicians and nurses complain that the computers in their exam rooms harm their relationships with patients and reduce their professional autonomy.National Nurses United, the largest nursing union in the country, recently launched a campaign claiming that nursing positions are disappearing, in part because of hospital expenditures on computer systems. The campaign includes a satiric YouTube video in which a computer diagnoses a male patient as pregnant.
Debbie McKinney, a hospital nurse in Massillon, Ohio, describes operating rooms where paper flowcharts were replaced by a computerized system of prompts. “A nurse can’t monitor and type at the same time. So vitals aren’t getting entered, or the patient isn’t getting watched,” she said.
In a dozen interviews with POLITICO and on chat rooms and websites, physicians complain that the implementation of EHRs forces them to spend much of the time during a patient visit entering data into the computer. If they don’t fill out the records during each visit, they spend two or more hours at the end of the day completing records.
And it’s not just one IT system doctors have to master. Ranit Mishori, a Washington, D.C., family practitioner, has had to learn three — in her health network, in the hospital where she has privileges and a second hospital where she teaches in a residency clinic.
The system she uses at Georgetown Hospital “is not what we in the 21st-century English-speaking world are used to.” If she’s not careful to check the right boxes, for example, she’ll get a note from supervisors saying she hasn’t been asking enough patients about smoking — something she always asks.
“Anything that in a normal world would take at most two clicks, here it takes four or five,” she said. “Before, I took notes, wrote what I wanted to say. Now I write and I click. If you just click, the person who reads the record gets no idea of what the patient was going through, your thought process. So I still write as much, but I also click. By 5 p.m. I can’t use my hand because I have such bad carpal tunnel syndrome from clicking and typing all day.”
In a talk at Georgetown titled, “Why is your electronic medical record so bad?” Joel Selanikio, a health IT entrepreneur and Georgetown pediatrician, said doctors were being ordered to switch to IT systems at a time when the best software designers had fled such systems in favor of individual-oriented software.
“Everything that’s happened [in software] in the last 30 years is based on selling tech directly to individuals. That’s how software got so cheap,” Selanikio said. “Programmers of apps know they have to please you all the time.” But many EHR vendors make large, one-time sales, usually accompanied by service contracts.
Her EHR has some benefits, Mishori says. If she orders a lab exam or an X-ray within her system, the results are immediately available on her laptop. So are the reports of consulting physicians — if they are part of her company’s network. Some of her colleagues have created patient management groups — places in which data can be assembled to provide useful information about care goals for asthma and diabetes, for example.
She can work remotely, which she couldn’t do when she had to use paper charts, which stay in the hospital. “Now, I work all the time,” she said, “for better or for worse.”
Health IT specialists recognize these problems but say the only solution is to work through and past them. Medicine will be cheaper, safer and more effective, they say, when all health records communicate with one another better, so that patients can freely access and share their data with physicians no matter where they live or work. Such interoperability of health care records is envisioned as occurring during the final stage of the government’s program.
“I’m not aware of any doctors who’ve ripped out their EHRs and gone back to paper,” said Bob Kocher, a health IT evangelist and venture capitalist who helped implement meaningful use as a White House official during the first Obama term.
“If it’s so bad for them, they’ll stop using it,” he said. “The reason so many are inefficient is that doctors are inefficient. If they redesigned their workflows, computers would work better.”
