Promoting Electronic Health Record Adoption. Is It the Correct Focus?

Abstract

In 2004, President Bush set as a goal that every American would have an electronic health record by 2014. In the three years since that pronouncement, the Department of Health and Human Services (DHHS) has established the Office of the National Coordinator for Health Information Technology (ONC), and the American Health Information Community (AHIC) to oversee policy. It has set priorities and has anointed two existing organizations, the Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT), to play significant roles in establishing and promoting the standards necessary to achieve this goal. One theme that pervades all of the organizations involved in this broad mandate is the promotion of the adoption of electronic health records (EHRs) by physicians—a perennial issue with which the healthcare informatics community has struggled for several decades. The problem of slow EHR adoption by physicians has been described in the informatics literature as “the wave that never breaks.”1 With the emergence of the national mandate of the current administration to promote the adoption of EHRs, the introduction of legislation in Congress to fund EHR adoption and the focus of some of the 2008 presidential candidates on healthcare IT as a component of their healthcare plans, there is every indication that the wave could finally break before the end of this decade. It is therefore timely to ask if this is in the best interests of the country. The reason that EHRs are being promoted by this administration and many others is the assumption that they can be useful tools in promoting quality and reducing costs. The premise is that the ready availability of legible patient clinical information to physicians at any place and any time would reduce errors of omission and commission resulting from the lack of such availability in the prevailing paper-based records environment. The addition of clinical decision support functions in many EHRs to alert physicians to potential errors and influence their behaviors toward evidence-based decisions further enhances the potential of EHRs to promote quality and reduce costs. All of these positive aspects of EHRs have been widely documented over several decades in the broad healthcare informatics literature and particularly in JAMIA. These will not be reviewed here. The focus of this commentary is to question whether the current policy of promoting EHR adoption is appropriate given the current state of EHRs in the marketplace and the financial incentives currently in place to adopt them. There are some very troubling trends that have emerged in recent years that would suggest that this policy, if not modified, may backfire with regard to quality and costs. The current financial incentives to physicians to adopt EHRs are misaligned regarding the cost side of the equation.2 If, indeed, one of the benefits of EHRs is to reduce overall healthcare costs, those benefits largely accrue to the buyers of healthcare and not the providers, yet the providers currently pay for the systems. Therefore, in today's environment, there is a financial disincentive for physicians to adopt EHRs for the purpose of healthcare cost reduction. If one couples that disincentive with the administrative and workflow disruption that the introduction of an EHR has on a medical practice at least initially, one understands why the vendors of EHRs have had to promote other features to provider organizations to convince them to purchase their products. It is these other features which have the consequence of undermining the fundamental value proposition of EHRs. What are these other features that entice physicians to buy an EHR? They are: 1 Improved revenue from higher Evaluation and Management (E&M) codes. 2 Time saving devices for physician documentation. From a physician's point of view, these are both positive reasons to purchase an EHR and help overcome the financial disincentives that otherwise exist. Unfortunately, increasing the E&M codes increases overall healthcare costs rather than decreases them. It is not known whether this increase represents a correction of previous under-coding of the E&M code as some argue, or a form of “E&M code creep.” Regardless, the costs increase. One could argue that if the use of these EHRs reduces overall healthcare costs in other ways and/or measurably increases healthcare quality, an increase in E&M code payments could be justified. The problem is that the features introduced to enhance E&M codes and save documentation time are not the same features that improve quality or reduce overall healthcare costs. In fact, they are features that potentially degrade quality. The biggest problem EHR vendors have faced with physician adoption is that they slow physicians down, at least initially. The fact that they might improve quality is not a sufficient inducement to a physician to use an EHR if his or her overall produc