EHR Adoption: The Tipping Point Has Been Reached

EHR Adoption: The Tipping Point Has Been Reached
Regardless of your feelings about the particular pros and cons associated with meaningful use—and you know that I have not been shy about expressing my opinions in that regard—it is impossible to deny the EHR Incentive Program’s positive impact on the implementation of healthcare IT. Meaningful Use has brought us to the tipping point, where EHRs are perceived as a necessity rather than an option for a successful medical practice. The enduring impact of ARRA is that it pushed the EHRs across the chasm, changing the profile of the EHR user from innovative, tech-savvy physician to mainstream physician.

We have reached the point where a critical mass has adopted EHRs, and paper charts are no longer acceptable. Practices that are not digital will find it hard to attract new physicians. Referrals will be affected as primary care physicians will prefer to deal with specialists in the community with whom they can share clinical data electronically, rather than bear the unnecessary costs incurred by the alternatives of faxing, printing, or mailing. These benefits can only be accomplished via an EHR, a fact reinforced by Stage 2’s increased emphasis on interoperability.

I still maintain that the decision to purchase an EHR should not be driven by potential government incentives but rather by the value delivered to a practice—improved patient care and service, productivity/efficiency gains, and cost savings. In fact, I would argue that participation in the meaningful use program is optional—but clearly, EHR adoption no longer is.

6 thoughts on “EHR Adoption: The Tipping Point Has Been Reached

  1. EHRs are great for electronic inclusion of laboratory test results into the record, for creating (and submitting) prescriptions, for generating orders for other diagnostic tests – and for their ability to aggregate data across encounters to provide physicians with an “at a glance” chronology of key indicators they would like to follow for their patients over time. The fact that key prevention related services can be dated — and therefore have reminders generated is another positive aspect of EHR systems.

    But as an E/M auditor and educator, I have to say that I’m increasingly dismayed at the ability (inability?) of even the most recent versions of EHR software to generate a decent progress note. While admittedly, the software simply provides functionality and it’s up to the individual user to use it properly, time after time, vendor after vendor, I see vendors actually ENCOURAGING inappropriate use of their software’s functionality to create a decent progress note. A decent progress note is one that (A) creates a unique and clinically pertinent picture of what information the physician gathered during the encounter with this specific patient and (B) is an accurate depiction of what actually went on in the room during the doctor-patient encounter.

    In talking with physicians who have been the unfortunate recipients of copies to these encounter notes for patients referred to them by a colleague, most complain about the fact that there is so much clinically superfluous information recorded with these encounters that they can’t even tell what the heck is actually going on with the patient. My discussions with physicians regarding this issue has not been unique. Medical Economics/Modern Medicine stated the following in an April 2009 article referencing a study published the previous year in the New England Journal of Medicine:

    ““….In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that “Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians’ thoughtful review and analysis. They may be ‘efficient’ for the purpose of documentation but not for creative clinical thinking.”

    The study also reported an example of the consequences of these problems:

    “…..A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside……“

    Although the article was from a few years ago, my personal experience in 2012 is that the problem has done nothing but get worse. In talking with physician practices going through the process of implementing an EHR for their practice, what I hear is that vendors are actually encouraging physicians to utilize the alleged “time saving” functions that result in the kind of record described above. Yes, physicians bear the responsibility for how they utilize the functionality their EHR software creates, but I’d really like to see vendors stop encouraging physicians to build “normal templates” to then edit to reflect what actually took place in the encounter. The reality is that 99% of the time, when these “normal” templates are used, the document created does not accurately reflect the work actually done during the encounter (ie, if the encounter had been recorded (video+audio) what shows on the recording would not match what the documentation stated was performed and found).

    Accuracy and clinical relevance in order to promote/support quality medical care, and to facility patient safety and continuity of care should be the primary purpose of physician encounter documentation. The picture painted by the documentation generated by an EHR should reflect the clinically relevant and unique clinical picture of the patient evaluated that day.

    While I don’t doubt that EHRs are here to stay, IMHO, the industry has a LONG way to go in developing the kind of functionality that allows it’s clients to consistently accomplish those objectives. To the extent that software functionality focused “time savings” or “higher reimbursement” continues to be pushed by vendors as the “norm”, in the long run, I predict that patient care will ultimately suffer.

    While incentive compensation may hinge on the the software (and it’s user’s) ability to meet the “meaningful use” functionality the government requires, the ultimate in “meaningful use” is one aspect that “meaningful use” hasn’t attempted to define yet – and that’s a platform for encounter documentation that encourages the documentation of clinically relevant information and discourages (if not outright prevents) the inadvertent documentation of irrelevant or superfluous information.

    I tell physicians that if it wasn’t something you asked or did when you were hand writing your notes, (or would have dictated if you dictated your notes), it probably doesn’t belong in your EHR progress note either.

  2. Joan G is dead on. My belief is that it will take lawsuits challenging these documents to make a change. Too many of the systems are created to capture charges, not to provide patient care. I see templates that refer to the pulses in the feet of bilateral amputees. When law suits start to be lost because the template documented events that did not occur, the systems may finally start to change. I’d rather see physicians rise up in revolt of the inadequate systems but too often they are just the pawns in the begger scheme of charge capturing.

  3. Ironically, the voluminous templated chart notes are the unintended result of our insurance and legal system’s demands for documentation. Remember the saying “if it isn’t in the chart, it didn’t happen”? Well, the apparent corollary to that is “If it is in the chart, it did happen”. Physicians have been pushed by the system for more and more documentation, even when it is superfluous, and EMRs really help us along that road.

    More documentation is clearly to the advantage of the physician, even when it has no real relevance to clinical care. There’s an arms race between physicians and insurance companies (“Let’s add more documentation requirements so they won’t want to bother billing at a high level”) in particular. This is the “reductio ad absurdem” to which we are headed.

    Hopefully as time goes on the system will shake itself out and we’ll be able to get back to practicing medicine. The key will be getting EMR developers and designers (like Evan) who actually know clinical medicine. Then we can have systems that contribute to care, and not just to the documentation arms race.

  4. I can’t speak to the legal system issues (if you’re referring to medical malpractice risk avoidance), but I CAN speak to the insurance industry part of your post since E/M coding, auditing and physician education is my “thing”. I probably taught one of the first classes in E/M coding when the codes first came out in January 1992 – and to this day, the majority of the consulting and education work I do surrounds understanding the appropriate use — from a clinical perspective — these codes.

    As a result, I can say with a high degree of confidence that if the physician does just 2 simple things, 95% of the time they’ll have absolutely no problems having sufficient documentation to support the appropriate level of E/M service:

    (1) Practice good medicine
    (2) Be diligent about documenting what you did during the encounter. If it’s important enough to ask the question or to examine, it’s import to write down the response/finding, regardless of whether it’s a positive or a negative finding/response.

    There are a handful of codes where the appropriate level of service requires that the physician SOMETIMES do/ask what may not be clinically intuitive for the patient’s presentation. But for those instances, what the doctor needs to remember to do above/beyond what’s clinically intuitive is something that I literally could write for you on the back of a business card. Yes, with a couple of exceptions those are the HIGHEST level of service you could report for that category of code (the exceptions to that – in the office setting – are level 4 new patient visits and level 5 consults). But for the vast majority of physicians (all specialties) if you look at the acuity and/or clinical complexity of their entire panel of patients, the instances where that highest level of service SHOULD be reported (based on how cognitively difficult the encounter was) is a relatively low portion of all of the physician’s office E/M services.

    Or let me put it this way — I haven’t seen a work up of a problem(s) yet that was truly deserving of being reported as a 99214 service where the physician didn’t AUTOMATICALLY *need* to ask ROS questions in 2 or more systems, or didn’t need to do a detailed physical exam of the affected (and related) body areas/organ systems (“need to” here being defined as needed if the doctor was practicing good medicine).

    No – the biggest problem with there being a mismatch between the level of service reported and the volume of documentation in the record are the kinds of problems I’ve listed below.

    (1) It was a lengthy encounter – and one that would have qualified for billing the higher level of service, but the PHYSICIAN FAILED TO DOCUMENT THAT THEY WERE USING THE TIME RULE to select the level of service. Where more than 50% of the face-to-face time is spent in counseling and coordination of care, time should be used to determine the level of service. The physician must document that they spent “X minutes of a Y minute face to face encounter discussing…..” then include a sufficient SUMMARY of the discussion to justify the amount of time claimed (in other words, would another physician of your specialty have agreed that a discussion of those issues would have typically taken the amount of time claimed in the record).

    (2) The level of service selected was clinically appropriate given the cognitive difficult of the assessment, but the physician failed to document the negative exam findings and/or negative ROS responses obtained during the assessment. Had that work been documented, the level of service selected would have been supported by the volume of documentation too. (that where the “not documented, not done” mantra comes from).

    (3) When you look at the problem severity description for the E/M level selected, the problem(s) the physician was evaluating were more appropriately represented by the problem severity descriptor for a lower level of service. In other words, irrespective of the volume of documentation, the physician simply overvalued the encounter.

    So yes, we can talk about those things that aren’t clinically intuitive that you need to get into the record for your MORE COMPLICATED new patient and consult visits. And we can talk about whether (and how often) when 99215 is the right level of service, you’ve got to remember to document things that aren’t clinically intuitive in order to support the 99215.

    But for the rest of the encounters, I think you’ll find that if you haven’t made one of the 3 mistakes I described above, if you are diligent about documenting only what you actually did (and needed to do) during your assessment of the patient, the right level of service for that visit will be supported.

    And the best thing about that is that you’ll see that there’s absolutely no clinically superfluous information in those progress notes to essentially sterilize or confuse the clinical picture of what was actually going on with the patient’s health at the time of your assessment.

    No, the problem comes when you think that documentation drives the level of service. It doesn’t. The Medicare program published that rule way back in 2001 [Pub 100-4, Chapter 12, Section 30.6.1 (A)]. The AMA reminded us of the role of the contributory component – the nature of the presenting problem(s) (problem severity) – to assist physicians in their selection of an E/M service back in a CPT Assistant article from August 2006.

    If you can set aside your current perceptions about E/M codes and the documentation requirements and go back to the code definitions themselves – looking at the problem severity descriptors ALONG with the requirements for the key components of that code — I think you’ll see what I’m talking about. If you understand how the type of workup you need to do (from a clinical perspective) equates to which level of service, you’ll see that the AMA and CMS actually did a pretty good job describing what you need to do — clinically – along the continuum of cognitive difficulty from the fairly simply presentations to the most complex.

    Again, if they made me emperor, that’s not to say I wouldn’t change a few things! But the system, as it’s designed right now, usually doesn’t require you to document anything more than you found it medically necessary to do in order to support the level of service that’s consistent with the cognitive work you did. The few instances where “extra” documentation may be needed (and extra work actually performed), it’s limited to those encounters where the cognitive work you did was represented by a code that requires a complete history and/or a complete exam – and what you needed to do clinically was a couple of elements short of that.

    EHR’s are perpetuating the myth that documentation drives the level of service. In the long run, IMHO, we do our patients (and our physician colleagues) a disservice by buying into the hype.

  5. Dr. Cranmer is correct that our current insurance system drives the creation of unusable charts.

    In effect, US doctors get paid by the word. “Unchanged” is unlikely to even qualify as a Level I visit yet is far more useful than 2 pages which mean “unchanged”

  6. Evan, nice try, but I think that your vendor bias is showing… Are these newer editorials coming from your twin black-sheep-of-the-family sibling? You used to publish more straight-talk stuff without the bias, not opinion pieces meant to prop up your EHR user base. A couple of years ago your publications defined the state of HIT in the USA… you still write well, but your conclusions now seem somewhat slanted. I don’t think that you probably believe your conclusions nowadays…

    If you go to physician-only site,, you’ll see that the vast majority of physicians, some 150000 members, are usually very anti-EHR, anti-“meaningful use” and anti-more governmental intervention in medicine. There are numerous threads there about unhappy physicians in the process of deinstalling their expensive systems expecting a total loss. Evan, you yourself have discussed at your site the historical fact that the deinstallation rate for EHRs is about 50%. With numbers like this, we’ll never be near the tipping point in EHR adoption.

    As long as the actual users continue to shy away from the “meaningful use” of EHR due to the fact that the use of EHR is really an unfunded mandate costing over $60000.00 a year per license to purchase, use, and maintain these systems, you will only see them used mainstream only in hospitals and in large group settings (you came up with about $40000.00 per year long ago and also see here- Even in these places I predict that the use of the EHR will fail as the wish for interoperability fails and technology costs continue to mount. Worldwide, countries way ahead of us in promotion of EHR have failed in their endeavors and given up- western countries s.a. Canada and Great Britain since 2010, and just 2 weeks ago, Australia. What makes our situation any different? In the 2 hospitals that I used to admit to, in just over 2 years that role of hospitalists in the admission process has zoomed to over 85% as physicians have given up admitting to the facilities, mostly due to the introduction of the EHR and CPOE. Is that a good thing? I don’t think so…

    If you **really** study the numbers, you’ll see that:

    1) There are 624000 physicians that are in actual clinical practice as per the AHRQ ( There are 952000 physicians total as per the article “Medical Schools Can’t Keep Up,” WSJ, 4/12/2012.

    2) Active Medicare applications for “meaningful use” by physicians (MDs and DOs) so far are slightly under 140,000. Of these, slightly fewer than 50,000 providers have been paid to date. That comes out to about 36% (49,757/139,693) of applications being completed and paid for stage I MU. It also means that only 139693/624000 or 22% of MD/DO provider clinicians have signed up for the MU program, and only 8% (139693/952000) of all providers have signed up for MU. This also means that the completion rate for stage I MU among physician clinicians and total physicians is less than 8% and less than 3% respectively. No tipping point there…

    3) As per a recent AMA newspaper editorial “Stage 2 meaningful use rules sharply criticized by physicians” (5/14/2012, you get the sense that MU stage 2 is a bear (and it is, really), so most likely many physicians foolish enough to try for stage I will give up on stage 2. Groups s.a. physicians in small offices and those like me, who are 10 years from retirement will NOT do MU and are strongly asking for exemptions to the process which the CMS/Dept of HHS is so far unwilling to do.

    4) If the proposed 2015 penalties are enacted- something this article states is being lobbied by the AMA to be pushed back- you’ll see physicians get out altogether from Medicare, leaving the old folks without physicians to see them. Even if all of the 139,693 physicians (MDs and DOs) that have applied for MU actually go through the 3 stage process, that means that the Department of HHS will be penalizing 78% of physicians in clinical practice up to 9% eventually (2% PQRI, 2% eRx, 5% MU). If you take all physicians, the Department of HHS will be penalizing 85% of physicians.
    5) The most recent annual CDC report, published on 12/1/2011 put out their findings on EMR/EHR use and showed that although the overall EMR+EHR usage has gone up from 51% in 2010 to 57% in 2011, the HITECH ready EHR group percentage actually DROPPED from 26% to 23% over the past year. (

    This may mean that the future for HIT will be the use of simple, basic, EMRs +/- the paper chart which will never die. It’s been around for over 4000 years, and will still be viable long after you and I are long gone.

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