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Perspectives

Discontent Brews Over Dual Reality of EHRs

November 30, 2020

The electronic health record (EHR) has flourished since 2009 due to federal legislation. The HITECH Act provided billions in subsidies for medical systems to implement EHRs, but the behavioral healthcare industry was excluded. Our industry created separate EHRs without such support. Despite financial backing, EHRs have had uneven success in the medical world. Our industry needs to understand this.

Behavioral healthcare systems seem generally satisfied with the EHRs implemented in recent years. Yet complaints about medical EHRs are noteworthy given rapid healthcare consolidation and the long-term goal of interoperability among systems. There is growing rebellion as physicians find their systems burdensome to the point of being oppressive. My vantage point is as an observer, not an expert.

This is a $30 billion industry that is growing. The medical EHR is multi-dimensional, supporting all levels of care and service functions. The system overflows with administrative data. Yet doctors are avoiding or leaving primary care for many reasons, and the EHR is moving higher on their list of negatives. Many doctors report spending hours each day completing their charting, while others neglect it in anger.

Do not take my word for it. One might assume the critics of the EHR are outliers. Afterall, the systems were thoroughly evaluated before this massive change was approved. Yet the outrage and the condemnation of the EHR seems pervasive. Medical leaders are now vocal critics. Consider recent comments by prominent physicians in the New England Journal of Medicine:

The EHR, initially lauded for its potential as a repository of patient information, has become a tyrannical, time-consuming billing tool; it must be reconfigured to work for physicians rather than forcing physicians to work for it. (N ENGL J Med 382;26, June 25, 2020, pp. 2485-2487)

Many critics focus on how the EHR is part of the larger regulatory burden imposed on the medical system. Insurance companies and government programs require that doctors comply with demands related to EHR documentation, quality indicators, and other reporting requirements. Clinical notes must fit a specific format that is time-consuming and distracts from patient care.

I remember my own confusion when my PCP cheerfully informed me that a new person would join our medical exam. He would talk with me about my complaints while a technician would type them into a computer on wheels. This would allow him to pay attention to me. If I had any sensitive personal information to share, I could just ask the technician to leave the exam room. This is progress?

I later researched this weird experience. An ad for a medical scribe within my healthcare system reassured me that my imagination was not the problem. They are paid up to $26.92 per hour. The duties are transcribing medical data quickly and accurately while patients are being examined. These jobs are a sad attempt to compensate for how EHRs disrupt patient care and alienate doctors.

The boldness and the number of the critics today might suggest that change is on the way. Do not bet on it. The warnings given before this fateful step into medical technology probably sounded much like a plastic surgeon’s caution before a facelift. Be sure you like what we have designed because there is no going back. What can our industry do about this? Get educated. Push back when the time comes.

Our leverage: Behavioral healthcare data

Behavioral healthcare systems are increasingly being acquired by medical systems, and so many will be migrating to these EHRs soon. Yet many small businesses providing behavioral healthcare will be untouched for years to come. My sense is that people in our field, representing businesses of all sizes, do not know what is coming. Our leaders need to start an internal dialogue now.

Federal agencies and medical EHR vendors are putting physician discontent aside as they move forward to growth opportunities like our field. They want to incorporate behavioral healthcare data, citing improved coordination of care and reporting. Leaders in our field are carefully examining confidentiality issues. Yet warnings from physicians about EHR burden are little discussed. We will regret this.

Why did the EHR go astray? The likely culprits are good intentions gone awry and consequences no one predicted. I have some personal experience. I once collaborated in designing a very costly care management system that failed on every level. One of my main failures was trying to capture too much clinical information. I thought it was wonderfully comprehensive, but clinicians strongly objected.

I learned a good rule for information systems: less is more. The EHR debacle has confirmed this and added a corollary. Users of the system should have more decision-making clout, not just input. Another big lesson relates to end use. The EHR is seen as a “time-consuming billing tool” despite the collection of voluminous clinical data. Financial tracking may have always been the primary goal clouding all else.

Our industry has a brief opening when it will have some clout in the evolution of EHRs. Medical EHR vendors see our health sector as a major opportunity for growth. Payers and regulators want behavioral data to clarify the health status of populations. We have influence only while they need our data. As they seek to integrate our systems, we should highlight how and why EHRs are “tyrannical.”

Few summits are being called to address the anticipated consequences of accepting EHRs that are hated by so many physicians. Why? It is not a national undertaking. Change will happen gradually as contracts renew, M&A deals get signed, and piecemeal arrangements accumulate. The motivation is on our side, and the opportunity for exerting some control over key decisions will be brief.

Our industry leaders should be proactive in articulating priorities. Rather than passively watch our programs get absorbed, we might offer a national template with best practices. We might establish a common set of rules and prerequisites based on existing medical and behavioral EHRs. This is not intended to inflate hopes. This situation calls for serenity, courage, and wisdom, as the meditation goes.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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