In the past decade, the U.S. health-care system has undergone a historic transformation from a paper-based system to electronic health records (EHRs), which – thanks to government mandates – have reached nearly 100 percent adoption among hospitals and physicians.1
The rapid uptake of this technology has not been without incident, though, and many practitioners have what can best be characterized as a “love-hate” relationship with EHRs. The promises of easier data accessibility and better communication come at the cost of a greater documentation burden which, for many providers, means more time looking at the computer screen instead of the patient.
“There is no question that EHRs have the ability to improve care, but there are still glitches with this relatively new technology, and … physician acceptance remains an issue,” said Andrew D. Zelenetz, MD, PhD, medical director of quality informatics at Memorial Sloan Kettering Cancer Center in New York.
This month, ASH Clinical News spoke with experts in health information technology (IT) about the ongoing implementation of EHRs, how it has affected hematologists’ practice and care delivery, and where the effort might be headed next.
The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law in 2009, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs.2 The legislation, which received uncharacteristically strong bipartisan support in Congress, was designed to encourage widespread adoption of health IT by providing financial incentives to clinicians and hospitals who demonstrate “meaningful use” of EHR systems.3 The incentives worked: By 2016, more than 95 percent of all eligible hospitals and more than 60 percent of office-based physicians had demonstrated meaningful use of certified health IT through participation in the Centers for Medicare & Medicaid Services (CMS) EHR Incentive Programs.4,5
But adoption does not necessarily mean adoration. A common complaint among providers is that the EHR interfaces are clunky and slow, Dr. Zelenetz noted.
“HITECH incentivized users, but it didn’t incentivize vendors to make the best, most innovative strategies,” he said. “I’ve never understood why [vendors] can’t make typing information into an EHR look and feel the same as typing in Microsoft Word. It feels like software developed in the 1990s because it is software developed in the 1990s.”
Slow interfaces mean more of doctors’ limited time is spent on electronic documentation and the pervading sense that the medical profession has been hijacked by rules and regulations that have mostly served to make physicians unhappy – rather than improving the quality of patient-physician interactions.
“The dysphoria in medicine revolves a great deal around the EHR, but not solely,” said the physician-author Abraham Verghese, MD, at a recent panel discussion on “Medicine 3.0.” He added that EHRs were “imposed on us by federal fiat,” mostly for reasons of better billing and quality reporting.6
Doctor or Data Entry Clerk?
So, are the headaches worth it?
“I think EHRs offer better quality, better patient care, and better communication [than paper records],” Bruce Brockstein, MD, medical director of the Kellogg Cancer Center and division head of hematology/oncology at NorthShore University HealthSystem in the Chicago area, told ASH Clinical News. “But it takes us more time than when we had paper records, in part because we can do more things, and we can communicate more things to more people.”
For Dr. Brockstein, the question of whether physicians are happy with EHRs is beside the point. “It’s been 15 years that we’ve been using EHRs in our hospital system, so most of the people here have never practiced without it,” he said. “After that amount of time, you either get settled or you abandon it, and we are quite settled at our institution, even though there is still much that can be improved.”
In 2011, his group looked at the effect of EHR adoption on the culture of oncologists practicing in the four hospitals within the NorthShore University Health System. The survey results were largely positive: “[EHR-conducted] chemotherapy ordering is more complete and safer [than in the paper-based system]. Legibility errors are gone, communication is instantly available from any location, and both outpatient records of hospitalized patients and inpatient records of outpatients are available electronically.”7
In a second report, the NorthShore group compared completeness of medical records between both systems, finding that, with EHR-based computerized physician order entry (CPOE), 93 percent of expected data points (i.e., patient information, treatment plan, laboratory results, etc.) were documented, compared with 67 percent in paper charts (p<0.001).8 Regimen complexity did not alter the fullness of the data in the EHRs. “And the nurses and physicians reported good satisfaction, statistically better than with the paper charts, in using the EHR system,” Dr. Brockstein added.
The most-liked aspects of the EHR/CPOE system were the availability of charts and previous laboratory results, identification of patients participating in clinical trials, and completeness of chemotherapy orders. On the other hand, practitioners were least satisfied with how the EHR/CPOE system captured patients’ past medical history and treatment calendars. However, these satisfaction ratings were still higher than the respective scores for the paper charts, he noted.
“I think we are providing better care because, if you use the EHR correctly, things don’t slip through the cracks,” Dr. Brockstein said, “and communication with the rest of the health-care team is much easier.”
Patients also seem to be happier with the digitized system. “Our patients can send a note in the middle of the night to say they are experiencing a certain symptom, and we can get back to them right away,” he explained. “They also receive their test results within 24 to 72 hours.”
Accelerating patients’ access to their own test results, though, puts extra pressure on doctors to inform them of the results, before they receive potentially bad news electronically.
And, according to Dr. Zelenetz, any time saved by EHR-enabled communication with patients is eaten up by more administrative responsibilities. “Unfortunately, the time we save with the EHRs is being taken up by demands for higher productivity, so I think part of the issue is that our practitioners don’t get to bask in the improvements,” he said. “It makes it hard to appreciate the advances we’ve made.”
In the process of gaining adherents, HITECH lost support with its meaningful use criteria. The broad definition of meaningful use is “using certified EHR technology in a meaningful manner to:
- improve quality, safety, and efficiency; and reduce health disparities
- engage patients and family
- improve care coordination, as well as population and public health
- maintain privacy and security of patient health information”9
Ultimately, CMS argued, meaningful use compliance would result in improved clinical outcomes, increased transparency and efficiency, empowered individuals, and more robust research data on health systems.
These criteria, according to virtually every U.S. hospital and provider, were overly burdensome. The former CMS administrator himself, Andy Slavitt, MBA, was quoted in 2016 as saying, “We have to get the hearts and minds of physicians back. I think we’ve lost them,” in reference to the meaningful use rules.10
In March, the new CMS Administrator, Seema Verma, MPH, announced a “complete overhaul” of the agency’s meaningful use program that will be aimed at reducing the time and cost burden of compliance for hospitals. Details of the renovation have not been released.
The Promises of Paperless
“One thing that EHRs do unequivocally is give us immediate access to much more patient information, and with that data we can make much better choices about how to care for [patients],” said Dr. Zelenetz. “No one complains about getting information from the system; the complaints are about having to put the information into the system.”
Most research on EHRs reaches the same conclusion: They are a boon for clinical care. EHRs reduce medical errors and facilitate integrated care. Medication mistakes still occur, but mostly due to human error during manual entry.
“Our CPOE system has dramatically reduced errors,” Dr. Zelenetz confirmed. “We don’t see lost orders or inaccuracies because someone couldn’t read the physician’s handwriting. The system has predefined [chemotherapy] regimens, so I just say what I want to give, and it’s all calculated based on the patient’s height and weight. It takes seconds to write [the order] and it gets transmitted to a verification nurse for review and then, boom, the pharmacy gets it.”
In their report on the rollout of the system, Dr. Zelenetz and researchers from the Memorial Sloan Kettering stressed that “a clear mandate and ease-of-use were crucial factors in obtaining buy-in and compliance from the clinical staff.” They also noted that “completion of a system’s implementation is never done,” and, even after established, the electronic system required constant monitoring.11 (See the SIDEBAR for other examples of how EHRs are improving practice.)
“The heart and soul of oncology is clinical trials, so systems that help us track studies and reduce costs and time involved in patient care are valuable,” said Dr. Zelenetz. His group is working on an easy way to record drug-related adverse events for use in clinical investigations.
The Interoperability Problem
Clearly, collecting EHR data has great implications for patient care and medical research, but EHR systems need to be able to “talk to each other” if any of those goals are going to be realized. “We have been behind in medicine in creating a standard for exchanging medical information,” said Dr. Zelenetz. He suggested this is as much a result of vendor competition as it is a technical issue.
Health-care IT has borrowed the term “interoperability” from the systems engineering world to describe the ability of EHR technology and software applications “to work together within and across organizational boundaries in order to advance the effective delivery of health care for individuals and communities.”12
Despite efforts by the U.S. Department of Health & Human Services (HHS) to make EHR information more readily accessible and useful for patients and clinicians, EHRs have, thus far, failed virtually all tests of interoperability.
There are multiple reasons for this overt failure, according to health policy and EHR expert Julia Adler-Milstein, PhD, from the University of California San Francisco School of Medicine.
“I think the source of the problem is that we put EHRs in place first, and then tried to figure out how to link them up,” she said. “EHR systems were not designed with that capability upfront. Also, there are no strong incentives for providers and vendors to overcome the complexity of making these systems interoperable.”
If the EHR system is having communication difficulties, switching vendors is no simple task. Changing systems, particularly for an entire hospital system, is costly, complicated, and disruptive.
“Lock-in is a problem, and it’s not a competitive market in that sense,” Dr. Adler-Milstein explained. While hospitals and providers can switch vendors, “you don’t want to do it if you don’t have to, so mostly people make do and tweak the system they have.”
At her institution, she noted, there are “hundreds of people” just working to improve their medical record system “because I think the sense is that Epic [the market leader in EHR software] can only go so far.”
In November, the U.S. Department of Veterans Affairs (VA) announced a plan to spend approximately $10 billion for a new EHR system from Cerner Corporation, a top EHR vendor.13 Interestingly, though, Dr. Zelenetz cited the VA’s existing system as an EHR success story: “If a patient has an appendectomy at the Bronx VA, he can walk into the Palo Alto VA, and the staff can open his record and see all his information. It’s not pretty or fancy, but the information is there. The VA is using technology, albeit not cutting-edge technology, and building a system that allows interoperability and improves patient care.”
How Much Sharing Is Too Much Sharing?
For many patients, it’s a not-too-subtle irony that hackers have an easier time accessing their personal medical information than they do. According to a 2018 analysis of health-care breaches reported to HHS or disclosed to the media, there were 37 breaches in the month of January alone, which affected 473,807 patient records.14
For his part, Dr. Brockstein is not aware of any data breaches at NorthShore, and Dr. Adler-Milstein has never heard of hacked data being used to blackmail an individual.
One solution to improve security is “disaggregation,” or allowing patients to store their own medical data in individual or family units rather than in centralized databases. CMS has thrown considerable weight behind the idea of putting individuals in control of their own medical records with a newly announced initiative called myHealthEData.15
“At a time when health-care data is being generated from so many sources, too often that data runs into the hard walls of closed systems that hold patients, and their information, hostage,” said Ms. Verma in prepared remarks for this year’s Healthcare Information and Management Systems Society’s annual conference.
A key part of the initiative is Medicare’s new Blue Button 2.0 program, a secure way for Medicare beneficiaries to access and share their personal health data in a universal digital format. The effort will improve interoperability so patients can “choose the provider that best meets their needs and then [give] that provider access to their data, leading to greater competition and reducing costs,” according to the CMS press release.15
It’s not yet clear where this new initiative will have the most impact. A 2017 report from the American Hospital Association found that 93 percent of hospitals and health systems allowed patients to view their health records online, up from 27 percent in 2012.16
“The problem with having patients holding their own data is that you still need the information to be vetted by the domain experts,” said Dr. Zelenetz. “If the patient is going to go around with his [or her] own portable health record, that information still needs to be evaluated, entered, and shared with other systems.”
Version 2.0 and Beyond
According to Dr. Adler-Milstein, the dissatisfaction with EHRs stems from the great expectations with which they were introduced. In context, she said, EHRs are still a young technology, and growing pains are to be expected.
“One mistake was framing EHRs as a near-term win, thinking we’re going to get the value back within three to five years. That was way too short of a timeline,” she noted. “We may be approaching the 20-year mark, but most of the progress has been made in the last decade. I would consider us still in the first generation of these technologies.”
With each new generation, Dr. Adler-Milstein expects successive improvements, including greater use of application programming interfaces (APIs), software intermediaries that allow applications to communicate. APIs will make it easier to get data in and out and will usher in “EHR Version 2.0.” “It will probably be another 10 years before everyone feels the technology’s working well and delivering value,” she predicted.
For all the complaints he hears, Dr. Zelenetz doesn’t think many clinicians would opt to go back to paper records. And for hematology/oncology, specifically, he sees great potential. “We have real opportunities, but we don’t yet have, for example, an understanding of how to best define an oncology history or how to integrate pathology diagnoses with the chemotherapy history so we can see it all at once. We have made big strides, but we haven’t solved all the problems.”—By Debra Beck
- Henry J, Pylypchuk Y, Searcy T, et al. Adoption of electronic health record systems among U.S. non-federal acute care hospitals: 2008-2015. ONC Data Brief. 2016;35:1-11.
- gov, “By The Numbers: Our Progress In Digitizing Health Care.” Accessed March 8, 2018, from https://www.healthit.gov/buzz-blog/health-data/numbers-progress-digitizing-health-care.
- Adler-Milstein J, Jha AK. HITECH act drove large gains in hospital electronic health record adoption. Health Aff. 2017;36:1416-22.
- gov, “Office-based Health Care Professional Participation in the CMS EHR Incentive Programs.” Accessed March 10, 2018, from https://dashboard.healthit.gov/quickstats/pages/FIG-Health-Care-Professionals-EHR-Incentive-Programs.php.
- gov, “Hospitals Participating in the CMS EHR Incentive Programs.” Accessed March 10, 2018, from https://dashboard.healthit.gov/quickstats/pages/FIG-Hospitals-EHR-Incentive-Programs.php.
- Medscape, “Abraham Verghese: ‘We Are Responsible’ for EHR Dysfunction.” Accessed March 11, 2018, from https://www.medscape.com/viewarticle/884352.
- Brockstein BE, Hensing T, Carro GW, et al. Effect of an electronic health record on the culture of an outpatient medical oncology practice in a four-hospital integrated health care system: 5-year experience. J Clin Oncol. 2011;7:e20-4.
- Harshberger CA, Harper AJ, Carro GW, et al. Outcomes of computerized physician order entry in an electronic health record after implementation in an outpatient oncology setting. J Oncol Pract. 2011;7:233-7.
- gov, “Meaningful Use Definition & Objectives.” Accessed March 11, 2018, from https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives.
- HealthcareITNews, “Meaningful use will likely end in 2016, CMS chief Andy Slavitt says.” Accessed March 11, 2018, from http://www.healthcareitnews.com/news/meaningful-use-will-likely-end-2016-cms-chief-andy-slavitt-says.
- Sklarin NT, Granovsky S, O’Reilly EM, et al. Electronic chemotherapy order entry: a major cancer center’s implementation. J Oncol Pract. 2011;7:213-8.
- Healthcare Information and Management Systems Society, “What is Interoperability?” Accessed March 12, 2018, from http://www.himss.org/library/interoperability-standards/what-is.
- S. Department of Veterans Affairs press release, “VA Secretary announces decision on next-generation Electronic Health Record.” June 5, 2017. Accessed March 12, 2018, from https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2914.
- Becker’s Hospital Review, “Hacking responsible for 83% of breached records in January, insiders 1%: 6 things to know.” Accessed March 8, 2018, from https://www.beckershospitalreview.com/cybersecurity/hacking-responsible-for-83-of-breached-records-in-january-insiders-1-6-things-to-know.html.
- CMS press release, “Trump Administration Announces MyHealthEData Initiative to Put Patients at the Center of the US Healthcare System.” Accessed on March 8, 2018, from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-03-06.html.
- American Health Association, “Expanding Electronic Patient Engagement.” Accessed March 8, 2018, from https://www.aha.org/system/files/2018-03/expanding-electronic-engagement.pdf.
Roadmaps, clinical decision support, big data analysis – these are some areas where EHRs shine brightest. Here is just a sampling of some EHR success stories in hematology:
- Researchers at the Children’s Hospital of Wisconsin developed a computable phenotype algorithm to identify patients with sickle cell disease through EHR data. The algorithm was validated in adults from a neighboring health system and was deemed to have reliably high sensitivity and positive predictive value for its intended use. The authors eventually hope to use their method to conduct research at the national level.1
- Providers were able to reduce the number of unnecessary blood transfusions (a well-recognized source of medical overuse) by embedding decision support within an EHR-based transfusion order set.2
- At Washington University in St. Louis, Missouri, a team in the medical school’s Pediatric Computing Facility is developing the electronic Oncology Roadmap Application. This program will allow for seamless sharing of comprehensive “treatment roadmaps” built in to a patient’s EHR and based on the Children’s Oncology Group care protocols. The same technology can be applied to adult medicine.3
- Recognizing that the data collected by randomized clinical trials (RCTs) are often similar to those found in EHRs, a group in the Netherlands merged a population-based registry with an advanced EHR system to generate high-quality data for observational studies in hematology/oncology. The approach is being presented as a means of bridging the gap between the RCT world and the real world.4
- Michalik DE, Taylor BW, Panepinto JA. Identification and validation of a sickle cell disease cohort within electronic health records. Acad Pediatr. 2017;17:283-7.
- Sadana D, Pratzer A, Scher LJ, et al. Promoting high-value practice by reducing unnecessary transfusions with a patient blood management program. JAMA Intern Med. 2018;178:116-22.
- Washington University in St. Louis School of Medicine, “Pediatric Hematology-Oncology Roadmap Builder.” Accessed March 8, 2018, from http://pediatrics.wustl.edu/pcf/Projects/eroadmap.
- Kibbelaar RE, Oortgiesen BE, van der Wal-Oost AM, et al. Bridging the gap between the randomized clinical trial world and the real world by combination of population-based registry and electronic health record data: a case study in haemato-oncology. Eur J Cancer. 2017;86:178-85.