Doctors are being warned by the federal government that they’ll soon be penalized for not using electronic medical records, prompting a backlash from those who say the technology is fraught with problems.
The government has been handing out $30 billion in incentives to help doctors install and use these digitized patient medical histories to improve patient care. But critics say the incentives and penalties have the effect of mandating a technology that the government’s own research and officials acknowledge needs major improvement.
A group of 37 medical societies led by the American Medical Association sent a letter to Health and Human Services last month saying the certification program is headed in the wrong direction, and that today’s electronic records systems are cumbersome, decrease efficiency and, most importantly, can present safety problems for patients.
That same week, a coalition of 18 medical groups urged New York’s governor, health commissioner and state Legislature for a year-long delay of the late March requirement that all prescriptions be processed electronically. The group says many records systems now used aren’t certified by the Drug Enforcement Administration to enable e-prescribing for controlled substances.
The Centers for Medicare and Medicaid Services responded to the criticism late last week, saying it would ease reporting burdens on doctors in a proposed rule to come this spring. The rule, however, wouldn’t eliminate penalties.
Against that divided backdrop, a two-day conference kicks off Monday in Washington, D.C., to discuss safety, privacy and ways to make the systems actually communicate to improve health. On Friday, the Health and Human Services Department released its plan for how to move toward greater communication between systems, although officials said it might be a decade before all systems can “talk” to each other.
Even most critics believe electronic health records are the future. But it’s unfair to levy penalties at this stage, they say, while the technology is still so flawed that it takes time away from patient care, often won’t allow information to be shared between different offices, and can even create safety problems.
“Physicians passionately despise their electronic health records,” says Lexington, Ky., emergency physician Steven Stack, the American Medical Association’s president-elect. “We use technology quickly when it works. … Electronic health records don’t work right now.”
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Federal statistics show 78% of office-based physicians used electronic health records, or EHRs, in 2013, up from 18% in 2001. Much of the rise followed the high-tech provisions of the 2009 economic stimulus law, which sought to get doctors to use these systems in a meaningful way. The program came with the carrot of taxpayerfunded grants and loans as well as a stick — reduced Medicare reimbursements beginning with a 1% drop this year. More than 257,000 doctors are being notified they face that penalty.
Meanwhile, many are struggling with a host of difficulties that affect the way they care for patients:
► Usage — and user — errors.
Self-populating computer fields that must be meticulously checked, the potential for “dropping” information, and the ability to “cut and paste” from one record to another can lead to potentially dangerous medical errors.
In a federal survey last fall, 15% of 10,000 doctors responding said electronic records had led them to choose the wrong medication or lab order. Three times as many said the technology alerted them to safety problems, but critics say problems are still too much of a risk.
The hospital rating organization Leapfrog Group, found that physician order entry systems in many electronic health records fail to alert doctors about a third of the time to such issues as medication allergies — and hospitals sometimes remove double-checking mechanisms. The systems “are often clunky, badly designed (and) implemented with incredible incompetence …” says Leapfrog CEO Leah Binder.
► Time from patient care. Some doctors say they spend hours each day on computers, typing while seeing patients, between appointments and at the end of the day.” The current generation of EHR (systems) have doctors becoming secretaries and clerks rather than using their skills at the bedside providing care,” Stack says.
Ken Parrott of Louisville, says he has noticed the change as a patient. Before his primary care doctor started using electronicrecords, waits were shorter, and “he would spend a lot of time with me. … Now, he still tries, but I know he’s distracted. … It takes away from the care he wants to give.”
► High cost. Government incentives were capped at about $44,000 per doctor for systems that cost at least $100,000 and often closer to $200,000, presenting financial burdens for doctors, especially in small private practices. Costs also extend to maintenance, upgrades and sometimes new staff.
Plastic surgeon John Weeter of Louisville, who does a lot of breast reconstructions, says he would rather stick with the reams of paper in his records room than shell out that kind of money — which he believes is more than he stands to lose from the Medicare penalty this year. If the equation changes, he says he may retire.
► Conflicting computer systems, scant regulation
There are hundreds of different companies selling systems that often don’t communicate with each other. Compounding the problem, there’s no requirement that suppliers improve flawed technology, leaving physicianswith some systems that don’t work, but often without the money to make necessary fixes.
A 2013 AMA/RAND study found that electronic health records (EHRs) are the leading cause of physician dissatisfaction.
They are “being pushed down our throats,” says Douglas Gerard, an internist in New Hartford, Conn., who just received his Medicare penalty letter. “This is one reason I have not taken a new Medicare patient in years.”
The United Kingdom presents a cautionary tale for the U.S., pulling the plug in 2011 on its disastrous $20 billion attempt to connect patients’ records electronically following years of wellpublicized problems from a system that couldn’t even track immunization side effects.
A “death knell” for their system began in 2009 because “costs were escalating without evidence of benefits,” according to a 2014 case history by University of Cambridge researchers.
HHS officials say the U.K.’s problems stemmed from the use of a single electronic records system in a government-run health care program, rather than the hundreds of IT suppliers in thiscountry — but critics say that should have made it easier.
While almost everyone acknowledges today’s systems are far from perfect, some doctors say they are already helping them improve communication with patients and more quickly catch problems like medication allergies. “Any technology always has a ways to go, but we have many people using them for a decade, and they work very well for them,” says Mark Segal, chairman of the Electronic Health Record Association.
University of Chicago Medicine anesthesiologist William McDade, president of the Illinois State Medical Society, says electronic records “work out very nicely” in his academic medical system; it’s a common sight for doctors to roll computers to patient bedsides. “Would I go back to paper records? No.”
“We’re going to get to the point when we can realize the (technology’s) full potential,” such as researching data and trends across practices and populations, says Robert Wergin, president of the American Academy of Family Physicians. “Our feeling is the positives … over time will outweigh some of the frustrations with change.”
Andrew Gettinger, acting director of safety and quality for HHS’ Office of the National Commissioner for Health Information Technology, says many doctors and hospital complaints stem from a misunderstanding that what’s initially installed is the final product, when actually the systems have to be constantly upgraded.
“You don’t just plunk down EHRs and everyone’s happy. You use an incremental kind of approach (and) that takes time, thattakes energy and that takes effort,” he says, adding that they have to be rolled out to know where the problems lie.
Some critics, including Pittsburgh cardiologist Dean Kross, say the Food and Drug Administration should regulate the systems the way they do other medical devices and technology. At a minimum, doctors and hospitals need a way to report when systems malfunction or cause patient harm, says physician Reed Gelzer, now a consultant who cochairs two international standard setting committees for health care IT.
HHS points to its efforts with the outside research institute RTI International and struggling doctors to determine how to best set up a national health IT safety center. And the just-announced CMS proposed rule would change from a year to three months the period of time that health providers need to show they have been using their EHRs in a meaningful way.
Meantime, doctors and experts remain divided about Medicare penalties.
The AMA is calling on the government to remove them, but David Blumenthal, national coordinator for health information technology for President Obama from 2009 to 2011, says, “the threat of penalties is the only incentive (doctors) have to make it happen.”
Some in the health care world, such as Binder, want things to move faster than HHS’ 10-year plan for full communication between EHRs. “This is a major transition in a $2.7 trillion health care industry,” Binder says. “There’s too much at stake to wait until everyone is perfectly comfortable with the consequences on a day-to-day basis. It’s going to be rocky.”