Electronic health records in the United States are an important tool in delivering health care, but remain subject to criticism that they have underperformed at reducing costs and improving quality. Government, insurance companies and other medical institutions promote the use of electronic health records (EHR).
A 2006 Department of Veterans Affairs study estimated that its electronic health record system may improve efficiency by 6%/yr, while the monthly EHR cost may be offset by avoiding a few "unnecessary" tests or hospital admissions. A 2014 survey of the American College of Physicians members reported that family physicians worked 48 minutes more per day when using EHRs. 90% reported that at least 1 data management function was slower using EHRs, and 64% reported that note writing took longer. 34% reported that it took longer to find and review data, and 32% reported that it was slower to read other clinicians' notes.
Coverage In a 2008 survey by DesRoches et al. of 4484 physicians (62% response rate), 83% of all physicians, 80% of primary care physicians, and 86% of non-primary care physicians had no EHRs. "Among the 83% of respondents who did not have electronic health records, 16%" had bought, but not implemented an EHR system yet. The 2009 National Ambulatory Medical Care Survey of 5200 physicians (70% response rate) by the National Center for Health Statistics showed that 51.7% of office-based physicians did not use any EHR/EHR system.
In the United States, the CDC reported that the EHR adoption rate had steadily risen to 48.3 percent at the end of 2009.Are More Doctors Adopting EHRs? Retrieved 31 March 2011. This is an increase over 2008 when only 38.4% of office-based physicians reported using fully or partially electronic health record systems (EHR) in 2008.National Center for Health : United States, 2008]. Retrieved 15 December 2009. However, the same study found that only 20.4% of all physicians reported using a system described as minimally functional and including the following features: orders for prescriptions, orders for tests, viewing laboratory or imaging results, and clinical progress notes. As of 2013, 78 percent of office physicians are using basic electronic health records. As of 2014, more than 80 percent of hospitals in the U.S.have adopted some type of EHR. Though within a hospital, the type of EHR data and mix varies significantly. Types of EHR data used in hospitals include structured data (e.g., medication information) and unstructured data (e.g., clinical notes).
The healthcare industry spends only 2% of gross revenues on Health Information Technology (HIT), which is low compared to other information intensive industries such as finance, which spend upwards of 10%.
The usage of electronic health records can vary depending on who the user is and how they are using it. electronic health records can help improve the quality of medical care given to patients. Many doctors and office-based physicians refuse to get rid of traditional paper records. Harvard University has conducted an experiment in which they tested how doctors and nurses use electronic health records to keep their patients' information up to date. The studies found that electronic health records were very useful; a doctor or a nurse was able to find a patient's information fast and easy just by typing their name; even if it was misspelled. The usage of electronic health records increases in some workplaces due to the ease of use of the system; whereas the president of the Canadian Family Practice Nurses Association says that using electronic health records can be time-consuming, and it isn't very helpful due to the complexity of the system. Beth Israel Deaconess Medical Center reported that doctors and nurses prefer to use a much more friendly user software due to the difficulty and time it takes for medical staff to input the information as well as to find a patient's information. A study was done and the amount of information that was recorded in the EHRs was recorded; about 44% of the patient's information was recorded in the EHRs. This shows that EHRs are not very efficient most of the time.
The cost of implementing an EHR system for smaller practices has also been criticized; data produced by the Robert Wood Johnson Foundation demonstrates that the first-year investment for an average five-person practice is $162,000 followed by about $85,000 in maintenance fees. Despite this, tighter regulations regarding meaningful use criteria and national laws (Health Information Technology for Economic and Clinical Health Act and the Affordable Care Act) have resulted in more physicians and facilities adopting EHR systems:
Software, hardware and other services for EHR system implementation are provided for cost by various companies including Dell. Open source EHR systems exist but have not seen widespread adoption of open-source EHR system software.
Beyond financial concerns there are a number of legal and ethical dilemmas created by increasing EHR use, including the risk of medical malpractice due to user error, server glitches that result in the EHR not being accessible, and increased vulnerability to hackers.
Legal status electronic health records, like other medical records, must be kept in unaltered form and authenticated by the creator.National Archives and Records Administration (NARA): Long-Term Usability of Optical Media. Retrieved 30 July 2006. Under data protection legislation, the responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The implementation of a unified electronic health record would therefore require a change in the law to allow medical records to be stored offsite and to remove the legal requirement for local storage.Shabo, Amnon (2014): "It's Time for Health Record Banking!" editorial to special issue of Methods of Information in Medicine, Vol. 53, No. 2, pp. 63–65 "It varies from other approaches to HRB in the following aspects: First and foremost, it suggests a change in current legislation so that the copy of a legally-authenticated medical record stored in an IHRB is the sole medi- co-legal record and healthcare providers are no longer required by the law to hold archives of medical records. In this way, duplication of data as in PHR systems is avoided and integrity could be achieved." page 65, The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, has a right to view the originals, and to obtain copies under law.Medical Board of California: Medical Records – Frequently Asked Questions . Retrieved 30 July 2006.
The Health Information Technology for Economic and Clinical Health Act (HITECH) (,§2.A.III & B.4) (a part of the 2009 stimulus package) set meaningful use of interoperable EHR adoption in the health care system as a critical national goal and incentivized EHR adoption. The "goal is not adoption alone but 'meaningful use' of EHRs—that is, their use by providers to achieve significant improvements in care."
Title IV of the act promises maximum incentive payments for Medicaid to those who adopt and use "certified EHRs" of $63,750 over 6 years beginning in 2011. Eligible professionals must begin receiving payments by 2016 to qualify for the program. For Medicare the maximum payments are $44,000 over 5 years. Doctors who do not adopt an EHR by 2015 will be penalized 1% of Medicare payments, increasing to 3% over 3 years. In order to receive the EHR stimulus money, the HITECH Act requires doctors to show "meaningful use" of an EHR system. As of June 2010, there were no penalty provisions for Medicaid.
In 2017 the government announced its first False Claims Act settlement with an electronic health records vendor for misrepresenting its ability to meet "meaningful use" standards and therefore receive incentive payments. paid $155 million to settle charges that it had failed to meet all government requirements, failed to adequately test its software, failed to fix certain bugs, failed to ensure data portability, and failed to reliably record laboratory and diagnostic imaging orders. The government also alleged that paid kickbacks to influential customers who recommended its products. The case marks the first time the government applied the federal Anti-Kickback Statute law to the promotion and sale of an electronic health records system."EHR vendor eClinicalWorks reaches ground-breaking $155 million whistleblower settlement", Phillips & Cohen LLP Press Release, May 31, 2017 The False Claims Act lawsuit was brought by a whistleblower who was a New York City employee implementing ' system at Rikers Island Correctional Facility when he became aware of the software flaws. His "qui tam" case was later joined by the government. Notably, CMS has said it will not punish clients that "in good faith" attested to using the software.
Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level.
Starting in 2015, hospitals and doctors will be subject to financial penalties under Medicare if they are not using electronic health records.
Goals and objectives Improve care quality, safety, efficiency, and reduce health disparities
Quality and safety measurement Clinical decision support (automated advice) for providers Patient registries (e.g., "a directory of patients with diabetes")
Improve care coordination Engage patients and families in their care Improve population and public health Electronic laboratory reporting for reportable conditions (hospitals) Immunization reporting to immunization registries Syndromic surveillance (health event awareness)
Ensure adequate privacy and security protections Predict future health conditions through machine learning before diagnoses
Quality Studies call into question whether, in real life, EHRs improve the quality of care. 2009 produced several articles raising doubts about EHR benefits. A major concern is the reduction of physician-patient interaction due to formatting constraints. For example, some doctors have reported that the use of check-boxes has led to fewer open-ended questions.Cohen GR, Grossman JM, O'Malley AS (2010). "Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?". Center for Studying Health System Change, Issue Brief No. 131 (full text)
Meaningful use The main components of meaningful use are: The use of a certified EHR in a meaningful manner, such as e-prescribing. The use of certified EHR technology for the electronic exchange of health information to improve the quality of health care. The use of certified EHR technology to submit clinical quality and other measures. In other words, providers need to show they're using certified EHR technology in ways that can be measured significantly in quality and in quantity.
The meaningful use of EHRs intended by the US government incentives is categorized as follows:
Improve care coordination Reduce healthcare disparities Engage patients and their families Improve population and public health Ensure adequate privacy and security
The Obama Administration's Health IT program intends to use federal investments to stimulate the market of electronic health records:
Incentives: to providers who use IT Strict and open standards: To ensure users and sellers of EHRs work towards the same goal Certification of software: To provide assurance that the EHRs meet basic quality, safety, and efficiency standards