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The National Health IT Agenda

In 2004, the National Health IT agenda listed ways that instituting EHRs would reduce health costs, correct the inefficiency of administration, and increase and improve care delivery. Prior to 2004, all patient medical records were kept in paper form, which made it difficult for hospitals, physicians, and other health care institutions to communicate effectively and share information regarding patients [1]. In order to adopt and institute a health IT program, the American Recovery and Reinvestment Act of 2009 was enacted with an investment of $26 billion.

A controversial report was circulated in 2013 by the Research and Development Corporation (RAND) about electronic health records (EHRs) to explain some illuminating and unsettling facts about EHRs.

Not All That Glitters is Gold

The 2013 RAND report named a number of troubling insights. 

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  1. The majority of the physicians interviewed felt the EHRs were “cumbersome and time-consuming” and did not optimize clinical workflows [2]. 
  2. Physicians believe that EHRs cause a declining physician-patient relationship, as face-to-face care declined. 
  3. Health Information Exchange (HIE) did not synchronize with other systems already in use. 
  4. Alert systems were too numerable and caused information overload for the users causing alert fatigue. 
  5. Template-based documentation was not as complete and factual as clinical data entry by physicians and nurses, which could be a significant threat to clinical quality metrics and professional satisfaction [3, 4]. 
  6. There was no relationship between overall satisfaction and the length of time since the EHR was installed, 
  7. Clinicians whose practices used a higher number of EHR functions were less likely to experience satisfaction.
  8. Training was necessary for all users of the EHR.
  9. No improvement could be realized if patients were given access to a web portal without training (22-24), or if patients had trouble using the EHR tools to track their health and self-report health information. The complex portal interfaces may actually present a barrier to its use (25) [7]. 

Conflicts of Interest

The difference between what RAND had in mind in 2005 and what was observed when EHRs were implemented in 2013 is alarming. A conflict of interest is obvious when the companies that developed and marketed EHRs under the federal mandate (e.g. GE and Cerner) were the actual sponsors of the EHRs. The advantages and the projected cost savings were overstated as they did not materialize [5]. Fortunately, the new 2013 RAND report was unsponsored. 

Lack of Due Diligence

The initial 2005 RAND report created a national furor and led to hasty purchases of IT systems that were exorbitant and caused significant difficulties in implementation and use by clinicians and other healthcare professionals. The maintenance costs were high and frequent, which had not been budgeted for or anticipated. According to one study conducted on some solo and small primary care practices, ongoing maintenance costs averaged $8,412 per FTE provider per year [6].

It is imperative that the US government perform its due diligence to make sure the various companies promoting the next-generation EHRs and many artificial intelligent (AI) software systems can deliver what they promise and that it will be a benefit to the delivery of health care.

References

1. Reisman, M., EHRs: The Challenge of Making Electronic Data Usable and Interoperable. P & T: a peer-reviewed journal for formulary management, 2017. 42(9): p. 572-575.

2. Collier, R., Electronic health records contributing to physician burnout. CMAJ: Canadian Medical Association journal = journal de l’Association medical Canadienne, 2017. 189(45): p. E1405-E1406.

3. Kroth, P.J., et al., The electronic elephant in the room: Physicians and the electronic health record. JAMIA Open, 2018. 1(1): p. 49-56.

4. Friedberg, M.W., et al., Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand health quarterly, 2014. 3(4): p. 1-1.

5. Hillestad, R., et al., Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood), 2005. 24(5): p. 1103-17.

6. Menachemi, N., & Collum, T. H. (2011). Figure 2f from: Irimia R, Gottschling M (2016) Taxonomic revision of Rochefortia Sw. (Ehretiaceae, Boraginales). Biodiversity Data Journal 4: e7720. https://doi.org/10.3897/BDJ.4.e7720. Benefits and Drawbacks of Electronic Health Record Systems. doi: 10.3897/bdj.4.e7720.figure2f

7. Meskó, B., Drobni, Z., Bényei, É., Gergely, B., & Győrffy, Z. (2017). Digital health is a cultural transformation of traditional healthcare. MHealth, 3, 38–38. doi: 10.21037/mhealth.2017.08.07

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