Computers, more specifically, electronic health records (EHRs), will someday revolutionize the practice of medicine. In fact, successful computerization of medical care is the most critical step necessary to transform the American health-care system from its current sorry state to the 21st century system of our dreams. It is ironic, then, that today EHRs represent one of the worst problems plaguing medical professionals. At this point, many physicians would say that EHRs have created more problems than they have fixed. The most important question is how do we get from where we are to where we need to be?
First, it is important to discuss how we got to this current state. Initially, just about everyone assumed that the transformation from a paper-based system to a computerized one would be easy—it seemed a given that modern computer capabilities would automatically make things better. So, in the early 2000s, the Bush administration stood back, assuming the magic hand of the free market would create and distribute the best and least expensive computer systems to all physicians. This was a big mistake. Available systems were often very expensive, and many physicians complained that they were largely unusable. As a result, by 2010, only a small percentage of health professionals were using full-fledged EHRs.
In 2011, the Obama administration attempted to rectify this situation. This proved to be an even bigger mistake. Government bureaucrats assumed that high cost and resistance to change were the problem. They rolled out the “Meaningful Use” (MU) program, which for two years was voluntary, but by 2013, carried penalties for those who did not participate. The program offered $44,000, spread over five years, for physicians who used EHRs certified according to MU standards, and who used those EHRs (and reported data to prove compliance) according to complicated MU criteria. The combination of monetary incentives and penalties pushed physicians to purchase EHRs in great numbers.
And both EHR companies and users became obsessed with MU beyond almost anything else. That was because, number one, compliance was very difficult. Stage 1 of the MU program comprised 25 standards, which were a lot. And further, proving compliance, registering and reporting the data required by the MU program, created an entirely new layer of work. And number two, EHRs still didn’t work very well. They remained unusable, meaning that they made it harder to perform and document the basic work of caring for patients. So, today many physicians use unwieldy software, and spend an inordinate amount of time attempting to comply with an unwieldy MU program. And most physicians will tell you that Stage 2 of MU, which the government rolled out far too quickly, made things even worse.
So, how do we fix the mess? First, cancel MU or any reasonable facsimile (the MU program has now been rolled into the new government “value-based payment” system, MACRA, given the new name, Advancing Care Information). We need usable, affordable EHRs in the hands of all physicians first. I believe that if physicians had such EHRs, they would gladly use them “meaningfully.”
But what is “usability,” the seemingly mysterious attribute that has eluded EHR makers and so confounded government EHR regulators? It is actually a simple concept. A usable EHR would make documenting medical care, writing prescriptions and appointment notes, recording diagnoses and communications with staff and patients, etc., quicker and easier than it was prior to having EHRs. And usable EHRs would generate clinical data automatically, without extra work, and would communicate with one another seamlessly. And finally, EHRs should enable and prompt better care. I guarantee that physicians would want to use such a system.
How do we get that system? This would be a great opportunity for government to fix the mess that it created. The government should spearhead a national competition to create the first great, usable EHR (or EHRs). The competition should be open to both public and private EHR makers (when I say public, I mean existing systems like VISTA, the program used by the VA system). There should be simple criteria to guide development.
And then once there was a declared winner (or winners), that system should be offered to physician practices and health systems at low cost or even free of charge. A substantial investment will be needed to implement the system(s), and to properly train its users.
Only with such an EHR in the hands of all practicing physicians will we be able to transform American medicine to the system we need.