The Electronic Health Record Problem

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It’s no secret that many physicians are unhappy with their electronic health records (EHRs). They say they spend too much time keying in data and too little making eye contact with patients. They say their electronic records are clunky, poorly designed, hard to navigate, and cluttered with useless detail that colleagues have cut and pasted to meet documentation requirements. Meanwhile, the data they really need are buried almost beyond retrieval.

Not all physicians feel this way. Two-thirds of primary care physicians say there are satisfied with their current EHRs, according to a 2018 survey by The Harris Poll. But the critics have a point. Current EHRs are not well-designed to meet the needs of users. And they don’t do enough to make clinicians smarter and more efficient. This doesn’t mean we would be better off in the paper world of 10 years ago. But it does mean that EHRs need improvement.

As we think about improving them, we need to broaden the discussion of EHRs and their role. We need to reckon with the underlying causes of EHRs’ problems, how to correct them, and how to ensure that their enormous potential benefits are understood and realized.

The Causes

EHRs are a technology. Like most technologies, they can be used in a variety of ways for a variety of purposes. Their human masters decide.

In our current health system, EHRs have one critical performance requirement: generating clinical revenues. In the fee-for-service world, this means supporting providers’ billing and documentation to generate as much revenue as possible for each clinical service. EHRs also must help providers meet regulatory requirements that may have financial or accreditation implications.

This means that current EHRs were not created to support many of the things that physicians, patients, and policymakers value: better care experiences, reduced costs, or improved care quality and population health management. They were not created to make physicians better diagnosticians or more cost-effective prescribers. The reason: our health care system has mostly not rewarded these activities. They have not been mission-critical for providers or, therefore, EHR designers.

For that reason, EHRs have only the most minimal capabilities related to clinical decision support, which has been proven to increase the quality of care, or to the collection of information on duplicate and unnecessary testing, or on the aggregate health of providers’ patient populations.

To put it simply, improving EHRs will require changing the priorities governing their design. That means moving away from fee-for-service payment toward risk-sharing by providers and, ultimately, some form of prospective compensation. Until then, optimizing the usability and value of EHRs will be an uphill struggle.

EHRs’ Undervalued Benefits: Empowering Patients and Advancing Human Health

Because the benefits of EHRs may be less visible than their burdens, some of their contributions are overlooked and undervalued.

One of these benefits is giving patients access to their medical information. Meaningful-use requirements spurred the adoption of patient portals, which, though sometimes clunky, have enabled patients for the first time to routinely see their test and procedure results. Patients can also now download their entire digital record and share it with third parties that can analyze its contents and educate them on their significance. Apple, for example, has agreements with over 100 health systems and practices to perform this function, which is likely to spawn a deluge of consumer-friendly health care applications based on patients’ own information.

Another underrated EHR benefit is that, by capturing billions of patient encounters worldwide, electronic records are generating a vast store of digital health data that are available for novel uses, including research into the causes and cures of disease and the detection and prevention of threats to public health.

Think of these data as the equivalent of a new natural resource, like water or minerals; they sit in the cloud, ready for extraction, refinement, and application. Their value is increasingly understood by technology companies, new startups as well as old stalwarts, that are pouring billions into exploiting them. There are obvious privacy and security issues raised by this development. But never before in human history have we had access to this novel (un)natural resource.

In entering all that data at the point of clinical care, health professionals and patients are creating a public good. But they get little tangible in return — at least in the short run. This maldistribution of benefit and cost lies at the heart of the current EHR controversy.

What Next?

To make health professionals’ work easier, and to exploit the vast potential of EHRs, a number of interventions make sense.

The most important is unrelated to the technology. Clinicians unhappy with EHRs have a huge stake in moving from fee-for-service to value-based payment, so that providers and their EHR vendors start to prioritize the production of health and the reduction of waste in health systems. This will reduce documentation requirements, spur the creation of decision support and information exchange that make clinicians’ lives better, and focus attention on getting value from the information so laboriously recorded by doctors and other health professionals.

A second requirement will be to lower the burden of data entry. Many providers have started using scribes to take notes during visits. While many physicians love scribes, they are expensive. A better long-term solution would be to use natural language processing and artificial intelligence to enable clinicians’ conversations with patients and their subsequent assessment and treatment plan to be recorded in real time. Given the increasing power of these technologies, such applications will soon be available.

Another approach to assisting data entry is to systematically redesign records for ease of use and to prune away unnecessary recording requirements.recent New England Journal of Medicine commentary provided an excellent example of the benefits of this intervention.

A third requirement for EHR improvement falls to health professionals. When I was a medical student, I spent hundreds of hours learning how to take notes in the paper world. More experienced clinicians reviewed and graded these write-ups. Later, as a young physician, I observed the notes of clinicians I admired, and emulated them. This process of professional education in record-keeping unfolded over years and forever shaped my note-writing habits. If physicians are unhappy with how their colleagues use EHRs, they should start educating young physicians — and their peers — on how to properly keep records in the electronic world. What and how data get recorded are ultimately a professional responsibility.

Lastly, we need to find a way to correct the maldistribution of costs and benefits that now plagues the use of EHRs. By creating vast troves of electronic data and enabling patient empowerment, clinicians and their patients perform a valuable public service that has thus far been unrecognized and unrewarded. Reducing the cost of data entry will help, but as the benefits of EHRs and their data become monetized — as they will — some way to share those gains with clinicians and patients at the frontlines should be considered. This could be accomplished in a variety of ways such as voluntary contributions from businesses that rely on EHR data to an EHR innovation fund and/or directing a share of the taxes paid by these businesses to EHR improvement. But at least until EHRs become much more user friendly, this problem of unfair allocation of benefit and cost needs attention.

We are not going back to the paper world, but EHRs need to work better. As they pursue this goal, clinicians, policymakers, managers, and vendors need to understand and address the root causes of the problem they are trying to solve, and the full array of options for addressing it.





Top Ambulatory EHR Systems by Hospital Implementation

ambulatory ehr vendors market share


EHR system implementation has been on the rise over the past 10 years. This is, at least in part, attributed to the Centers for Medicare and Medicaid Services (CMS) Meaningful Use initiative that began in 2011. Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, eligible providers who demonstrated meaningful use of Electronic Health Record (EHR) technology received incentive payments. The intent was to encourage healthcare providers to utilize electronic data recording and sharing technology to improve clinical quality and care transparency.

More than 92 percent of hospitals in the U.S. use an EHR system, according to Definitive Healthcare data. The implementation rate is even higher among acute care hospitals, with over 95 percent of long- and short-term facilities using EHR systems. Vendors Epic and Cerner dominate the EHR market, holding a combined 52 percent market share. There are two varieties of EHR systems: inpatient and ambulatory. Inpatient EHR is designed for use on patients staying at a facility for at least one night and is therefore primarily used by hospitals. Ambulatory EHR is designed for outpatient facilities and small physician practices, where patient visits do not include an overnight stay.

Top 5 Ambulatory EHR System Vendors

  1. Epic
  2. Cerner
  3. Meditech
  4. CPSI (Evident and Healthland)
  5. Medhost

An EHR is the digital version of a patient’s medical history. Generally, a patient’s EHR includes demographic information, diagnosis history, prescription data, laboratory results, vital signs, immunizations, progress notes, and more. Digital records allow providers to quickly and easily share patient data with providers in other facilities, regardless of whether the facility is in-network. Electronic record sharing can improve patient care and experience by allowing providers anywhere to access and understand an individual’s medical history. This is particularly useful in cases where a patient may be unconscious or unable to communicate upon arrival to a facility, when a patient is visiting a facility out-of-state, or if a patient visits a retail clinic or freestanding urgent care clinic.


The Critical Skills for Leading Major Change in America’s Health System

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At a time of profound volatility in the U.S. health system, change management is an essential skill for public and private leaders alike. For these leaders — and young people aspiring to careers as health care managers — one very practical question emerges: What are the critical skills for leading major change in our health system?

As someone who has led large change management projects in both the federal government and a large private health system, my view is that effective leadership of fundamental change requires the following: a commitment to transparency; involving stakeholders so they feel that their voices are heard; making listening a personal priority of the leader; going overboard in communicating; emphasizing that the sought-after change is achievable; and developing a motivating narrative.

Two personal stories illustrate these points.

The first concerns the challenge of creating the meaningful use program for the HITECH Act when I served as national coordinator of health information technology from 2009 to 2011, at the beginning of the Obama administration. The second involves the task of replacing the electronic health record system (EHR) at Harvard-affiliated Partners HealthCare, the largest health system in New England. The latter was a project I led after returning to Partners in 2011. This was a $1.2 billion capital investment, the biggest in the organization’s history.

Both challenges were fundamentally political with a small “p.” And the road to success was in many ways the same.

The HITECH Act, which was part of the federal stimulus program enacted in response to the financial crisis of 2008, tasked the Obama administration and its Department of Health and Human Services with creating a nationwide, interoperable, private, and secure electronic-health-information system. The president made this goal even more formidable by promising that every American would have an electronic health record by 2014.

The HITECH Act provided a wide array of authorities:

  • As much as $30 billion in new spending under Medicare and Medicaid. This was for incentive payments and supplemental reimbursement for services provided by health professionals and hospitals that became meaningful users of IT.
  • $3 billion in discretionary spending authority for the national coordinator to set up the national infrastructure needed to support and facilitate the adoption and meaningful use of EHRs.
  • Authority to write new regulations defining meaningful use of these systems, creating a certification process for EHRs, and specifying standards that would enable records to support meaningful use, as defined by regulation.

The HITECH Act also included constraints — many about timing. Regulations setting out standards had to be issued within about nine months from the time I arrived. Furthermore, payments to providers for conforming to meaningful use were to be available under the law in less than two years — by January 1, 2011. So any infrastructure supports to assist providers in becoming meaningful users had to be in place very fast — by early 2010 at the latest.

Still another constraint — one of those important details that are appreciated by students of management — was that the Office of the National Coordinator that I inherited was tiny (a total of 35 FTEs) and had never written a regulation or made a grant before. There was, for example, no grants-management office even though we were expected to rapidly expend $3 billion in infrastructure grants and contracts to prepare the nation for meaningful use.

Though the implementation of the HITECH Act seemed superficially like a technology project, I gradually came to realize that it was much more than that.  Nothing in the law required hospitals or doctors to adopt or meaningfully use electronic health records. They had incentives to do so, but they could easily refuse.

In fact, we were actually engaged not in a technology-implementation program but in a huge change-management initiative. We had to convince hundreds of thousands of health professionals and thousands of hospitals and hospital managers to take on the difficult, complex, costly, disruptive, and frustrating task of changing the way they managed what is arguably the most critical resource used in daily patient care: information. We were in a contest for the hearts and minds of professionals running our health care system. This larger battle for hearts and minds conditioned everything we did in applying our authorities and meeting our practical challenges.

First, to create the credibility and trust we needed to lead this movement, we insisted on transparency. We formulated the meaningful-use regulation in public through a series of hearings and public deliberations, which were streamed live. Whenever we faced the option of whether to make a decision in public or private, we chose the public approach. We held scores of open meetings involving our advisory committees during the two years I was national coordinator.

Second, to deepen public trust, we made listening a priority. Understanding that people affected by government policy want to be heard, I took every meeting I could with representatives of health care stakeholders, especially physicians and hospitals. After one meeting, I got feedback about what a great exchange we had. In fact, I had said nothing at all beyond introducing myself at the outset.

Third, we communicated extensively. When we released the proposed rule, we did so with a press event in the Great Hall of the Department of Health and Human Services with a packed crowd. I then went on a national tour — to Tampa, Minneapolis, Tucson, Salt Lake City, Omaha, Burlington, Buffalo, Houston, and beyond — to explain the proposed regulation.

Fourth, we emphasized the feasibility of complying with the meaningful-use rule. We needed to make clear that becoming a meaningful user was not a superhuman task. We wanted adoption to be so manageable that non-adopters would be embarrassed among their peers at golf outings or weekend cocktail parties.

Fifth, we sought narratives — metaphors for what we were trying to accomplish — and I used them repeatedly in my speeches. The one that stuck was an escalator image: We were getting on an escalator toward increasingly sophisticated and powerful uses of EHRs. We were starting on the first step, but the rest would follow in due time.

We also spoke of inevitability. It was inconceivable, we argued, that within 10 years, physicians and hospitals would still be walled off from the information age. They could make the conversion now — with government support — or they could wait and do it on their own. But either way, they were going to have to make the change. They were going to have to get on that escalator.

The meaningful-use program has had its problems, but it did succeed in one of its most fundamental purposes: the adoption of EHRs, which are now ubiquitous in medical practice.  In the end, the program got very close to fulfilling President Obama’s promise that every American would have an electronic health record by 2014.

Now let’s turn to the task of implementing a new EHR in a large operating health system that included two major teaching institutions (Massachusetts General Hospital and Brigham and Women’s Hospital); multiple community hospitals; a rehab hospital; a nationally-known, inpatient, psychiatric facility; a half-dozen community health centers; a home-health-care agency; thousands of community-based physicians; and the largest non-profit, private, biomedical-research program in the world.

The Partners HealthCare System was already sophisticated electronically.  The problem was that it had multiple, homegrown, electronic health records onto which local physician-developer teams had layered a wide variety of specialty specific applications. The result was an electronic tower of Babel that was becoming increasingly expensive to service and modernize. But the key problem was that the records were not internally interoperable, which had become a growing barrier to improving quality and efficiency in an increasingly demanding local-health-care environment.

Before I arrived in 2011, Partners leadership had made the decision to replace all this complexity with a single, commercial EHR. It was my job to lead the process of picking one and rolling it out.

Now, though Partners was legally a single health-care-delivery system, I knew from having worked there for much of my professional life that it was in fact a loose confederation of independent institutions populated by equally independent and skeptical professionals. Winning their support, and that of managers throughout the system, was critical to success. Once again, we were battling for hearts and minds, which meant that many of the approaches we relied on in government were relevant.

Building trust through a transparent decision process was the first strategy we pursued. The initial and critical decision we faced was which EHR to purchase.  There were two finalists. To choose, we collected evidence, evaluated the alternatives, and made decisions in highly public and inclusive ways. We invited thousands of professionals to test and rate the two products. We reported the results publicly on a project website. We conducted site visits to health care organizations around the country using the products we were considering. Site visit teams were diverse and representative of major Partners institutions and stakeholders. They rated the sites’ experiences with the EHRs, using a standardized protocol. We reported results on the website.

Then, we held a public debate between advocates of the two contending records — in which teams argued about relative merits before the audience voted. The vote was highly influential in our final choice. This transparent and inclusive decision-making process included an enormous amount of built-in listening and feedback from affected staff, another critical part of the change-management process.

To address the need for inclusive governance and representative decision making, we put in place a governing council for the EHR project. Members included representatives of critical Partners institutions and stakeholder groups. This council approved all major decisions with respect to the choice of the EHR and implementation policy. We then took those approved decisions to senior management of Partners, and ultimately to the Partners board, for final endorsement. Obviously, the fact that a representative body had approved our recommendations enormously increased their weight with management and board members.

As in the case of the meaningful-use program, communication was important. It didn’t require traveling the country, but it did require visiting all the major Partners institutions to speak with their staff and management, to answer questions, and to take in feedback.

Finally, we needed a rationale and a narrative that conveyed the necessity of undertaking this admittedly expensive and disruptive change in Partners affairs.  The rationale and narrative focused on the institution’s obligation to its patients. This was conveyed first in a motto: one patient, one record, one billing statement. To make this motto concrete, we made a video of a patient describing how she had had to carry a paper record from one Partners institution to another — all of which had siloed EHRs — as she got care for her breast cancer: surgery at Newton-Wellesley Hospital, chemotherapy at Dana-Farber Cancer Institute, and radiation at the Massachusetts General Hospital. I recall vividly the impact this video had during a presentation I made to the academic chairs of departments at Mass General. Patients’ stories had an almost unimpeachable legitimacy, even with the most senior Harvard academic leaders.

Before I left Partners to join the Commonwealth Fund in 2013, we had chosen the EHR and begun the rollout of the new IT infrastructure. While that rollout has not been perfect and, typical of such massive implementations, there have been plenty of complaints about the difficulty of using the new record, it has largely proceeded according to plan.

Change management is at the core of everything that public and private institutions are striving to achieve in reforming national policy and care-delivery approaches in order to improve the quality and cost of health care services provided daily to Americans. The effectiveness of leaders in both the public and private sectors in managing ambitious change efforts will determine their ultimate success. And my experience suggests that the skills required in these two sectors are remarkably similar — because change management, regardless of setting, involves convincing human beings to give up something they know for something new and uncertain.

CMS Finalizes 2018 Meaningful Use Requirement Flexibilities

CMS revises 2018 meaningful use requirements

Revisions include a 90-day reporting period, exceptions for decertified EHR technology, and acceptable versions of certified EHR technology.

As part of a final rule for hospital inpatient reimbursement for 2018, CMS has also finalized a host of revision to the meaningful use requirements for eligible providers participating in the EHR Incentive Programs next year.

Chief among the revisions is the reduction of the EHR reporting period next year to 90 days for “new and returning participants attesting to CMS or their Stage Medicaid agency,” states the final rule to be published on August 14. The revised reporting period must comprise a continuous 90 days between Jan. 1, 2018 and Dec. 31, 2018.

According to the final rule, the motivation for finalizing revisions to meaningful use requirements in 2018 is “to continue advanced of certified EHR technology utilization, focusing on interoperability and data sharing.”

Many of the other finalized changes owe much to mandates included in the 21st Century Cures Act, such as an exception for Medicare payments adjustments for eligible professionals and hospitals affected by EHR decertification. For those providers unable to satisfy meaningful use requirements because their certified EHR technology is now or becomes decertify, they will be able to avoid meaningful use penalties (but also miss out on EHR incentives). EPs will have until Oct. 1, 2017 to submit their applications; hospitals, July 1, 2017 — barring further changes made by CMS.

Additionally, EPs who provide “substantially all” of their services in ambulatory surgical centers (ASC) will avoid Medicare payment adjustments in 2017 and 2018:

We proposed to define an ASC-based EP under § 495.4 as an EP who furnishes 75 percent or more (or alternatively, 90 percent or more) of his or her covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an ASC setting in the calendar year that is two years before the payment adjustment year. In addition, we proposed to use Place of Service (POS) Code 24 to identify services furnished in an ASC and requested public comment on whether other POS codes or mechanisms should be used to identify sites of service in addition to or in lieu of POS code 24. For the reasons discussed in section IX.G.4. of the preamble of this final rule, we are finalizing the definition of an ASC-based EP as an EP who furnishes 75 percent or more of his or her covered professional services in sites of service identified by POS 24.

As for the type of CEHRT required for meaningful use attestation, CMS has finalized a policy that allows eligible professionals to use 2014 Edition, 2015 Edition, of a combination of the two for the purposes of EHR reporting in 2018.

That being said, the federal agency determined that calls to revise meaningful use objectives and measures, meaningful use audits, the Merit-Based Incentive Payment System (MIPS), and CEHRT grant funding were beyond the scope of the final rule and therefore not met.

The federal agency faced considerable pushback from industry groups advocating for significant change to the EHR Incentive Programs. Last month, the American Hospital Association (AHA) called for the cancellation of Stage 3 Meaningful Use, which is set to begin in 2018. The association claimed that the phase’s meaningful use requirements were overly burdensome.

“These excessive requirements are set to become even more onerous when Stage 3 begins in 2018,” AHA stated in a letter to CMS. “They also will raise costs by forcing hospitals to spend large sums upgrading their EHRs solely for the purpose of meeting regulatory requirements.

Based on this final rule, the EHR Incentive Programs will carry on as planned.

Now that CMS’ Andy Slavitt has spoken, did meaningful use spawn or stall EHR innovation and interoperability?


Electronic health record vendors, hospital IT departments and clinicians have complained for years about the current state of EHRs. The revelation that meaningful use could soon be changed for the better may open new doors.

Congress votes to exempt procedures at ambulatory surgery centers from Meaningful Use

H.R. 3000 - just a bill, sitting up on Capitol Hill


Full Speed Ahead for Meaningful Use