Government EHR Program: Potentially Harmful Unintended Consequences

I am really intrigued by the latest creation from the Department of Health and Human Services (HHS). Last week, HHS announced a contract to set up a group of experts to identify and attempt to fix any “undesirable” and “potentially harmful unintended consequences” that result from the stimulus legislation’s EHR incentives. According to the announcement, which was posted on the Federal Business Opportunities website: “Historical experience, as well as mounting evidence of unexpected problems, demands that we consider potential downsides.”

My curiosity is piqued! What are the unexpected consequences the government anticipates, and why is HHS so concerned? Awaiting the report from the panel of experts, I started thinking—and it didn’t take me long to create a list of my own.

My top three unintended consequences are the following: (If you’d like to suggest other potential unanticipated consequences—positive or negative—please submit a comment at the bottom of this page.)

  • There will be more EHR failures than successes, particularly among high-performance specialists.
  • “Certification” will stifle innovation.
  • Productivity and physician-focused EHRs will lead the market among high-performance physicians.

More EHR Failures:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. (5) Physicians will try to transfer data entry tasks to scribes and other lower-cost employees (assuming that the regulations allow CPOE to be done by other than the ordering provider), but this strategy will not make economic sense, either, since the additional costs will outweigh the government incentives. The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

“Certification” will stifle innovation:

Innovation will suffer, as it did in the past when many EHR vendors devoted all their development resources to complying with the long list of CCHIT-certification requirements. Forcing all vendors seeking certification to meet the same criteria will surely sap the drive for innovation. As vendors burn through precious development resources to meet evolving government standards instead of improving their core product, they will fail to respond to the interests of their customers, i.e., the physicians. Sales and marketing will drive physicians’ choices, rather than the EHR products themselves. Large companies, which have the largest sales organizations and marketing budgets, will be successful in the short term. Smaller vendors who follow the herd instead of their entrepreneurial and innovative instincts will be driven out of the market.

Productivity and physician-focused EHRs will lead the market:

The good news is that innovation will triumph in the end. Alternative solutions—like the hybrid EMR—will prevail as high-performance physicians find success with products that focus on their needs and enhance their productivity. It will take 4 to 5 years for physicians who have experienced government-program EHR failures to reapproach the market after amortizing their losses. These physicians will seek products that focus on clinical-workflow efficiency and physician productivity. The long-term winners in the EHR market will be those vendors who resist the temptation to chase the “windfall” stemming from the stimulus legislation, and instead focus on improving their products to deliver these benefits.

Please share your thoughts on other possible unintended consequences by submitting a comment below.

16 thoughts on “Government EHR Program: Potentially Harmful Unintended Consequences

  1. Garbage in = garbage out. If data entry is incorrect, mistakes will be made.

    Templates are good for spread sheets, not for people.

    Radiologists and pathologists often require accurate clinical information. Who is responsible for incorrect or missing data? Right now, we can’t get clinicians to accurately fill out requisitions. Are we going to have to read through pages of template garbage only to discover that the information we need has not been included or is incorrect?

  2. I am reading your article and the statement of “potentially harmful unintended consequences” that result from the stimulus legislation’s EHR incentives” and I find this is another big joke. The more I read about the private sector and government EHR debates, the sicker I get. More discussions, experts opinions, more certifications and now hybrids EMRs. Clearly there is no leadership. Interesting is the fact that I rarely see physician’s input at all in all these discussions. As a private practitoner and an EMR user I foresee the future. More of the same stuff we are plagued with now; lack of a standard, rising costs, multiple vendors who want their product to succeed, intercompatibility issues, poor technical support, company mergers, increasing maintenance fees every year, more nonsense government regulation, the vendors efforts to succeed and sell their product. After three years using an EMR at my office I do not see any of the benefit that so much is being talk about, except for legible notes. It is clear EMR is a big capital investment that given the way medical care is reimbursed in this country, most of physicians can not afford. We have seen extremely slow adoption and never a convincing economic justification. Yes, a lot about unfulfilled promises like Medicare payment incentives for e-prescribing.

    The issue at hand is simple, we want a cost effective product that works. It is clear a functional practical system does not have to have all the bells and whistles, fancy colors or graphics. Proposals I never listen are; Why not to expand the VA or Armed Forces system to the civilian population? We already paid for the cost of development. Also, why not look at other countries like France and Great Britain and learn from their successes. Their cost was not 20 billion dollars as our great Obama has proposed to give away to our private sector. It is obvious that those in power in America love to give money to their friends in the industry. Clearly, the beneficiaries will be those who support political candidates, hardware and software companies, lobbyists, trade associations and not the patients and health care practitioners. It is time to find a solution, satisfy the needs of the health care providers and put aside the intention of those who expect to become millionaires with EMR technology.

  3. Like anything new, EMR has theoretical potentials but like anything new, EMR has very definite drawbacks. One can appreciate the advantages in large institutions such as the VAMC where there is a constant flux of physicians or residents & interns, a large geographic area (i.e. USA) or where conventional records are frequently misplaced. In smaller groups or private practice offices, of any subspecialties, the disadvantages far outweigh the positives. There is no common platform – my EMR can not “communicate” with yours, or a lab’s, or a hospital’s.

    EMR’s strongly encourage copy-and-paste medical record keeping. The visit was <5 minutes, the exam per se was <2 minutes but the EMR for that visit is 7-8-9 pages long. As noted elsewhere, the first 4-5 pages are fluff. The exam findings are written on one line, usually the back page.

    EMRs strongly encourage back-to-the-patient interviews. You talk while you are typing in or copying the EMR. In most institutions, the EMR is completed before the exam is done. In some offices, the EMR is completed by a tech before the physician even arrives.

    EMRs by conservative estimates by anyone who has it, reduce physician efficiency by 20% or more. EMRs strongly encourage a diagnosis listing. Once a diagnosis is on that list, it is never removed or altered. Just get some EMR report from any VAMC. Some patients have 20-30 diagnoses, half of which they never personally heard of.
    All outside correspondence arrives in your office by hard copy. Someone (meaning someone in your staff) has copy it into the EMR. In larger or busier practices, that means literally weeks before it appears in the EMR.

    Unless someone breaks into my office or the whole building burns down, a patients hard copy medical record is safe. We all are well versed of the safety of info on the Internet.

    And I could go on. We have not even touched the whole topic of gov't sponsored physician ratings from their EMR. The bottom line is that the gov't mantra of "quality care"is an oxymoron when it comes to EMRs.

  4. The electronic medical records cost about $120,000 per physician to implement from scratch, they have been studied in two large military hospitals and have been found to drop efficiency by 20% (read that lost revenue…), and there are journal articles replete with practices who have spent hundreds of thousands of dollars only to abandon them and return to paper charts for cost and efficiency problems.

    Electronic records are ESSENTIAL if you are to have bureaucrats and politicians running healthcare because it allows easy access (remember the permission that each patient signs for release of their information to the appropriate insurance provider?) to the patient’s record, as well as the physicians notes, so that audits can occur (have you heard of RAC audits) and downcoding can be accomplished.

    If you have ever received an electronic record from a physician you realize what a joke it is. You see that given a certain diagnosis, the “discussion with patient and family” is automatically filled in, as well as the risks of their disease-two pages worth. We are in Wonderland, or 1984, and our major physician organizations have let us down! They should be saying all of this for us.

    Best regards,

    Jane Hughes, M.D.

  5. After 6 years of “paperless office” I couldn’t agree more with all the above. LSchoefflerMD

  6. All comments thus far have been very interesting. Like so much in life, we tend to identify faults and weaknesses in others and never in ourselves. He have some of the best medical care in the world and yet many patients die of avoidable complications, some have no access to basic care, and many are “injured” because of our reimubursement practices, i.e. reward procedures and tests and not clinical decision making. Innovation and communication go hand in hand; the electronic medical record as a non-interoperable object is not helpful and probably harmful. The goal should be the exchange of safe, meaningful, accurate, and real-time medical information that can be shared in the hopes of improving the quality of healthcare and eliminating waste (approximately 30% of our healthcare dollars go to waste). To this end, minimal standards have been developed and a common language identified; how we as cliniciancs embrace the need for change and help innovate or modify the end product (EMR/EHR) is up to us. The timing is ripe. There is no question that change is needed; and needs to be implemented at many fronts, health information technology is just one of those fronts.

  7. There are no shortages of opinions when the phrase EMR or EHR is mentioned. The reality is they are needed and it’s time to automate our healthcare delivery system. The other facts are there are 500+ EMR/EHR vendors most limping along with old technology that was developed 20 years ago, Unix based and very early Microsoft designed products. Stimulus will extend the life of those products. These vendors, including all of the largest, thats right all of the largest public companies, have not sold enough product to invest in a re-write to more current technology. Now add in the fact that physicians are buried in workload every day of their lives, it’s difficult for them to long range plan or take the time to evaluate the multitude of product available. I just spent a year evaluating product, and there are less than 5 vendors who utilize new technology, allowing the physician to modify the templates on the fly, and who utilize very intuitive standards so the physician can pick up the tablet and use it with just an hour or two of training. One last criteria to always consider is that the EMR/EHR has at least 2,000 doctors already using the product, bleeding edge technology will never work in a busy medical practice. I have 25 years of experience in medical software and I’ll tell you that after Stimulus is over, 50%+ of the doctors will end up with a workable EMR/EHR that will be sunset with a new chargeable version replacement by 2015 to 2020. That’s a real shame because physicians will be back on the treadmill paying for the next level of technology that is already available today. Simple questions will point to the best solution; Is it browser based technology? (make sure it’s not Citrix or WTS ). Does it have the ability to modify templates on the fly? Is the patient portal built in at no charge? Do you have over 2,000 physicians using the product? (not nurses or staff but physicians). These are just a few questions that if you get 4 yes’s you are with one of the better vendors.

    Good Luck and hope you find the right EMR/EHR for your practice.

  8. I have already decided: I will NEVER switch to EMR. Even if I have to pay a yearly penalty for doing so, It will still be far less than my costs – financial and otherwise- if I adopt EMR.
    And I am not planning to retire from medical practice for at least 20 more years!

  9. Billing and EMR, I hear all the time about this great EMR. You can have the best EMR in the world and if your billing does not work what’s the point? I think many people miss that when looking. EMR companies may have a great EMR, but then fall short on the billing side because it is not their focus. If you can’t get paid on on the hard work you have produced from the EMR, that does not make sense. People need to slow down and really look at all parts of their practice and how the flow will work. Are there checks and balances, etc…?

  10. I agree with much of what has been said. I feel strongly as a worker in the healthcare system that there are grave concerns about the use of EMRs, but I am realistic enough to know that they are already part of our world and will only grow to be a bigger part in coming years. I feel that the number one concern for all EMR software lies in protecting the consumers, both clients and medical personnel. Thus, I am concerned that there is not more involvement of those in the healthcare community, as this is not merely a software issue, but also a healthcare issue. I would like to see more activity by physicians and nurse in determining what is necessary to make the systems usable and to ensure that all of the potential benefits of EMRs are realized. I believe that cannot happen without more healthcare personnel input. I worry that the government will not handle this situation better than is has handled so many others and that as consumers, we will suffer the consequences. However, I can see no way around government involvement in our society, because our corporations, small businesses, etc. are not renowned for their willingness to work together and I do not see this changing in the near future, at least not as long as making a buck is the ultimate goal of developers and healthcare agencies. It will be interesting to see what develops if healthcare reform ever comes to pass, but for now, the government is, unfortunately, our only option.

  11. I also foresee many companies in the EHR industry biting the dust on the trail of the federal EHR stimulus program. There will be plenty of consolidation within the industry and many doctors will “be holding the bag” to many different EHRs that will not be technically supported. For example, my MediNote EMR works great for my ophthalmology practice but Eclipsys bought it for $70 million dollars in 2009 and now has decided not to support it or make it CCHIT compliant. The EHR companies rushing to cash in on this stimulus program will be the big winners here.

  12. When applications vendors buy another vendor, rarely do they do it because they like the product–they like that vendor’s customer base. They let the acquired product die, collect maintenance fees, and when the customer has had enough of it, the acquiring vendor flips the customers to their legacy product.

  13. I think today medical practitioners are looking to avail of this federal incentive by trying to comply with the definition of meaningful use but at the same time EHR providers are looking at their own set of profits.
    This misunderstanding is mostly I believe as a result of wrong interpretation of the federal guidelines. The EHR providers need to look at these guidelines from the prospective of the practitioners who deal with different specialties.
    Each specialty EHR has its own set of challenges or requirements which I believe is overlooked by in most EHR vendors in a effort to merely follows federal guidelines. This is resulting in low usability to the practitioners, thus less ROI, finally redundancy of the EHR solution in place.
    I think ROI is very important factor that should be duly considered when look achieve a ‘meaning use’ out of a EHR solution. Though one may get vendors providing ‘meaning use’ at a lower cost, their ROI / savings through the use of their EHR might be pretty low when compared to costlier initial investment.

    Also the introduction of REC’s through the HITECH act is a great way to avail of quality EHR solutions at competitive prices. The stiff competition among not only these REC’s but also among EHR vendors (to become a preferred vendor of a given REC) will result in lot of positives to medical practioners.

    Looking at the funding provided to the REC’s, the staggered grant allocation system also promises to be an unbiased way of allocating funds. It will also help in the concept of REC’s helping out each with their own unique business models. It can be one of the possible answers to the
    ’safe vendor challenge’ as discussed by many critics.

  14. For the physicians who are in their later years of practice, I believe there will be many who will not participate and, if it becomes mandatory, we will see many not only opting out of EMRs but out of practice.

  15. Evan Steele really summarizes with “The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.” And Jane Hughes makes great points about historical experience. It really does not matter who pays for the EHR if it is a bad product without interoperability and longevity. It is still a bad purchase! Another previous comment about paying the penalty (for not implementing EHR) as being less expensive than making the wrong decision is right on target.

    I think we will all be on EHR systems in 20 years, but forcing the evolution without allowing free market refinements over a period of time is a recipe for a bad outcome and real financial difficulty at a time when reimbursements are surely going to have downward pressure. There is no margin for error with this huge financial decision. Anthony P. Johnson, MD Greenville, SC

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