Health care reform is a hot button topic. No one seems to be exactly sure what it is, or how it will be achieved, but it is a priority of the Obama administration. A cornerstone of reform is the application of computer technology to the creation, communication and maintenance of comprehensive patient health records. To this end, the American Renewal and Reinvestment Act of 2009 (ARRA) authorized Medicare to pay incentives for “meaningful use of certified electronic health records”. The incentives are intended to compensate for the cost of implementing EHR systems, which will save Medicare enormous sums by eliminating the handling of paper documents related to health claims. Private insurers, too, would benefit from electronic patient records and can be expected to push for adoption of EHR by physicians who deal with them, so that eventually, EHR will be effectively mandatory for all US practitioners.
The health care community, however, is pushing back. To begin with, neither Medicare nor the private insurers will be passing much of their savings on to the health care providers: no more than 11% by one recent estimate. Despite the allowances specified in ARRA, the perception is that Medicare is allowing only a small percentage premium on billings for services on which compensation is already constrained, so it is unlikely that many practitioners will realize the maximum amounts authorized by the law.
Yet it seems to me from my discussions with physicians that neither the high (and uncertain) cost of EHR nor the inadequacy of incentives is the major cause of resistance. Two other issues have far greater significance: integrating the system into the practice, and the potential for personnel displacement.
The integration problem is crucial, because if EHR cannot be integrated into the practice and its workflows, it will be abandoned. The issue centers on the limitations of the man-machine interface, and the need for a user to focus attention on that rather than on communicating with the patient in an encounter situation.
Most people of my generation think nothing about using a computer, or a PDA for that matter, for a variety of tasks throughout our work day. It has become almost second nature to us to use a mouse to point and click on a text field, and then type something in the field or select a value from a drop down list. We can easily turn checkboxes on and off, select radio button options, and all the rest of the Xerox PARC functionality set that has been incorporated into both the Windows and Macintosh operating systems. No big deal, right?
Well, maybe. In a patient encounter, the keyboard and mouse of a standard PC setup is very distracting. A more appropriate implementation is a tablet PC equipped with handwriting- and/or voice-recognition for entering text, on which the doctor can work much as he does with paper charts. But paper is passive. It just lies there while the practitioner does his examination and writes his results. The computer responds to inputs, and the user must recognize that response and take appropriate action. It can be a major distraction if the pattern of that computer dialog is incompatible with the user’s workflow preferences or the exigent circumstances..
Successful implementation of EHR requires three things. First, the practice must select a software product that is designed or can be configured to be compatible with the way the practitioners work. With three hundred or more products on the market, there must be at least one that meets this requirement, but if only a half dozen programs are considered, it is not likely that the best product will be found. Second, a hardware platform must be selected that the users can feel comfortable with and that maximizes the benefits of the selected software. Vendor input here is very helpful, but beware of “bundled” deals, as the bundled hardware may not be the best choice for the practice. Third, adequate time must be spent on the specific configuration, including the design of templates that will be used in encounters so that the practitioner thinks about the patient, not the computer. Altogether, that is a great deal of responsibility for a physician to take on while also trying to run a practice. Add to that the perception of risk (sometimes based on prior experience) that the program still will prove too hard to use and will be abandoned anyway, and this becomes an almost insurmountable barrier to adopting EHR.
The other major obstacle is one I have not seen discussed in print, but it is always the elephant in the room. That is the eventual displacement of one or more of the practitioner’s support staff by the automation of their functions.
A private practice, one that is not administered by a hospital or large clinic, requires a number of individuals to handle the business of the practice. If this work is not outsourced, these may include (besides a nurse or physician’s assistant and a technician) a receptionist, a billing specialist, an insurance specialist, and possibly a medical transcriptionist. With a staff that small, the employer/employee relationship is unavoidably close and personal. There is no such thing as an impersonal business decision on human resources. Every decision has personal consequences, and they are all acutely visible in the medical office. If the practice decides to adopt an EHR, a significant proportion of work that is currently done by the practice staff will be taken over by the computer. The usual business result of such “business process automation” is a lay-off of employees. I believe that this is a major disincentive to investing in EHR.
Due diligence in selecting a software package involves not only matching the attributes of the software with the needs of the business, but also planning for the change in operating procedure that will be required. This includes the shifting of functional responsibilities among employees, which can be like a game of musical chairs. In the event that someone is left with essentially nothing to do, a transition plan can be developed and implemented early, including severance and assistance with job placement. But the planning process can also identify new revenue opportunities with new functional responsibilities, such as on-line consultation, that may help to avoid any layoffs.
It seems clear at present that physicians who expect to retire by 2015 are not going to invest in EHR. Physicians who are just starting out and don’t yet have their own practice are looking for positions with hospitals, clinics, or practices that already use EHR. The vast majority of established practitioners who will be pressed into acquiring EHR need to be convinced that the risks are manageable and the intrinsic benefits, even without equitable incentives from third party payers, are sufficiently compelling. And they need to start the acquisition process sooner rather than later, so that there is adequate time for due diligence. The consequences of waiting until next year or the year after that are that eventually a deadline will be imposed that is too stringent, and as a result EHR will be an onerous burden instead of a valuable tool.