Electronic Health Records Today

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Challenges to Electronic Health Records Adoption
The biggest challenges to the success of EHR lie at the provider level. Most physicians have lacked the ability or desire to input data easily and do not trust that they can then retrieve it in a timely manner. Despite the HITECH gravy train of incentives, the challenge of coaxing physicians and surgeons away from paper remains. Consider these typical hurdles:

• "Most of the older physicians were hoping they would get out of medicine before electronic medical records," surmises Mara Bryant, associate VP of organizational excellence and health information management at White Memorial Medical Center.

• "When it comes to doctors offices, free is not cheap enough for technology," says Walter & Haverfield's Leopard. She likens technology spending for this group to the problem of the law of the
common identified by philosopher Adam Smith, saying, "People don't want to pay for this stuff."

• "Over 80% of physician practices have no electronic medical records system in place at all," is the view of MedPlus' Nayak.

As of now, there are 641,000 doctors and surgeons. Where they work has a lot to do with how likely they are to join the EHR bandwagon. Three-hundred-fifty thousand doctors and surgeons work in medical practices and 106,000 work in hospitals. Just less than 80,000 are self-employed, according to current data from the Bureau of Labor Statistics.

Hospitals are working hard to find ways to connect with physicians groups so those most closely affiliated with hospitals are likely to be the earlier adopters of EHR as well as groups large enough to see a return on investment. "The physician's progress notes, which are the bulk of the record, is the toughest nut to crack," observes Bryant. At White Memorial, they found that tablet computers were not effective because they did not hold up to the aggressive cleaning needed as they came out of infectious environments. So the hospital is piloting the use of netbooks, which are sturdier. Since they are basically wireless dummy terminals, they are also more secure because they hold no data and no longer work once they leave the premises. Even doctors who are willing to adopt EHR systems face challenges: Bryant points out that one physician may practice at 5 or 6 different hospitals, so he or she would have to remember 5 or 6 passwords and systems. "This," Bryant points out, "reflects the nature of medicine in large cities."

One way of looking at the problem is to sympathize with the decisions that doctors make. After all, they are smart people whom we trust with major decisions.

Todd Johnson is founder and president of Salar, Inc., a Baltimore-based company that provides clinical documentation and charge capture solutions to the ambulatory care groups of hospitals that eliminate paper, save time, and increase physician and hospital revenues. His view reflects a more pragmatic approach that attempts to get physicians comfortable with the medium: "One of the things that you see from physicians is paper-based documentation. Often what is overlooked is why paper is a good system-it is fast; it has great workflow because you can put it in your pocket and pull it out; and it is highly customizable."

"What Salar has done is to present [the user interface] in a similar fashion to paper like a paper template," says Johnson. His goal is to ensure that physicians can access a file as long as they can get to a computer, so that the system works well between multiple providers, and physicians can pass that document back and forth. Johnson adds that the EHR system provides things paper cannot, such as feedback for reimbursement, alerts on costs, and quality measures. He said that his customers also use tablet PCs and laptops on wheel carts, while many doctors just take the time after seeing patients to sit down at a computer; some use staff members called "physician extenders" to input the data after the doctor has gone on rounds.

The greatest challenge he foresees lies in the pace of change of the new rulings. "There is still a lot of ambiguity. There is clarity about what is expected in 2011, but 2013 and 2015 are unclear, and oddball requirements sneak their way in. But technically speaking, the specs are generally sound," Johnson says.

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