Protocol Manual: Health Care

Electronic health records haven’t delivered on their promise. Could COVID-19 change that?

The COVID-19 crisis laid bare all the ways that EHRs have fallen short — and what needs to be done.

Health records at a doctor's office.

EHRs were meant to replace cumbersome paper health records, but they haven't always been an easier solution.

Photo: John Moore/Getty Images

Just a few months after he took office in 2009, President Obama authorized $27 billion in spending to incentivize hospitals to ditch their paper records and adopt electronic ones. At the time, with the country reeling from a devastating recession, Obama trumpeted the cash infusion, which was part of the so-called HITECH Act, as a way to simultaneously create jobs and modernize the United States' flailing health care system.

Weeks before he left office in 2017, Obama listed the rollout of electronic medical records as one of his health care platform's biggest failures."In terms of areas where we haven't seen as much improvement as I'd like, one thing that comes to mind is on the electronic medical records," he said in a January 2017 interview with Vox. "We put a big slug of money into encouraging everyone to [digitize] and catch up with the rest of the world here. And it's proven to be harder than we expected."

Three years since that interview, the COVID-19 crisis has laid bare all the ways electronic health records, or EHRs, have fallen short. The most recent government figures show that as of 2017, nearly 86% of hospitals used some type of EHR. And while this has given health officials quicker access to information about the health care landscape than paper records ever could, EHRs still haven't delivered on their full promise.

Since the HITECH Act, smartphones went from fringe products to the most important devices in people's lives. Yet patients showing up alone to an emergency room with COVID-19 symptoms, for example, still can't easily click a button on their phone and transfer all their medical history to the doctor on call. Government officials still struggle to get comprehensive, real-time snapshots of trends forming at the city, state and federal level. And it still takes physicians an average of 16 minutes and 4 seconds per patient to enter data into notoriously clunky EHRs, according to a recent study. As hospitals have been overrun with COVID cases, that's time no one has to waste.

Why is it still this way more than a decade and many billions of dollars later? As with any systemic problem, there are endless root causes.

One of them is the lack of uniform standards for how data is entered into EHRs to begin with. When the HITECH Act was being negotiated in 2009, the debate over data standards had been raging for years, according to David Blumenthal, who served as the country's National Coordinator for Health Information Technology at the time. Different clinicians and professional societies disagreed about the best way to define medical conditions and treatments. In the interest of getting the law passed in a timely manner, the Obama administration didn't tightly regulate the standards that needed to be used in EHRs, Blumenthal said.

"Those arguments would have continued for decades if we had tried to insist they be resolved before the records could be implemented," said Blumenthal, who now serves as president of The Commonwealth Fund, which funds health care research. "We would still be waiting for electronic health records."

But some experts, including Ross Koppel, an adjunct professor at the University of Pennsylvania's medical school, who specializes in health care IT, view this decision not to enforce uniform data standards as the original sin. Now, Koppel argues, the country is stuck with a disjointed system of tools in which everyone is speaking a different language.

"Even if you can get the data, the transfer of the information is so spotty and screwed up, you can't process it," Koppel said, noting that there are dozens of ways to report something as simple as blood pressure.

Obama acknowledged this issue himself in the Vox interview. "[E]veryone has different systems," he said. "They don't all talk to each other."

Even if physicians were speaking the same language, though, the technology itself often isn't interoperable. That's no accident. There are obvious economic reasons why hospitals might want to prevent patients from taking their medical records elsewhere. "Because of the way health care is paid for, there's some incentive for a hospital to hold onto its data and not let too much out, because that would have a competitive disadvantage," said Jonathan Teich, an emergency physician at Brigham and Women's Hospital and chief medical information officer at InterSystems, which builds a tool to help hospitals and health officials merge data from different EHRs.

The same holds true for the companies that make the systems, which Blumenthal said have not been eager to make it easier for hospitals to replace them.

But money's not the only thing standing in the way. EHR vendors have also cited privacy concerns in their resistance to regulations that would require more interoperability between systems. Until recently, one of the largest EHR vendors in the country, Epic, vocally opposed a new rule from the Department of Health and Human Services that mandates data sharing between systems through APIs. Last year, Epic spent some $500,000 lobbying Congress on issues, including interoperability. "By requiring health systems to send patient data to any app requested by the patient, the […] rule inadvertently creates new privacy risks," the company wrote in a blog post in January.

It's not that interoperability capabilities don't already exist, said Hans Buitendijk, speaking in his capacity as incoming chair of the Electronic Health Records Association, a trade group representing the EHR industry. Buitendijk also serves as director of interoperability strategy for Cerner, another giant EHR vendor. He pointed to health information exchanges at the state and federal level as examples of places where data is already being shared and used to create a fuller picture of the health care landscape. The problem, he said, is these attempts at data-sharing are not as widespread as they could be.

"We need to get everybody to get connected and take advantage of that. Across the board, it's more about adoption," Buitendijk said. "But we're not starting at zero."

All of this has created an environment in which hospital systems spend billions of dollars buying and implementing EHR systems, which they are then unlikely to replace, even if those systems turn out to be maddening to use — and they are almost always maddening to use.

One reason for what Koppel calls the "user-hostile" design of most EHRs is that they were designed not to assist physicians in providing care, but to assist hospital systems in getting reimbursed. "The more data recorded in many situations, the higher the payment," Blumenthal said. "That leads record manufacturers to create complexity, so reimbursement can be maximized."

EHRs also lead doctors and nurses to spend hours on paperwork they could otherwise devote to treating patients. "That's time taken away from following up on issues, going back and sitting by a bedside, explaining something more fully, having conversations with family and just being human," said Christopher Maiona, a practicing physician and chief medical officer of the Boston-based company called PatientKeeper. In the absence of upgrades to EHRs, so-called "EHR optimizers" like PatientKeeper have popped up, marketing user-friendly interfaces that plug into traditional EHRs.

Koppel, for one, argues that EHRs should be required to have standard designs. "When you get into a car you have a pretty damn good idea that the gas is on the right and the break is on the left. In EHRs the way you get to see your patient list can be different from system to system," he said. "We need commonality."

For all of EHRs' shortcomings, the COVID-19 crisis has also highlighted a lot of the upside to digitized records. For one thing, Blumenthal said, they've enabled telehealth doctors who may never have treated a patient before to have access to their full records. They also make it possible for multiple providers to look at a patient's record at once, which Blumenthal said can be key during emergency situations. And in the case of a new disease, like COVID-19, where the science and protocols are evolving by the day, EHRs make it easy to share information widely across a hospital system, so physicians know the relevant questions to ask and symptoms to look out for.

"The standardization of new insights into the care of a new illness creates advantages," Blumenthal said.

There are also ways in which the crisis has encouraged more collaboration in the industry and opened vendors and hospitals up to sharing information they might not have before. "There's clearly now much bigger awareness of what we need to work on to make this data flow better," Buitendijk said. He added that the pandemic underscored, for example, the importance of sharing data not only on lab results, but on hospital capacity.

It remains to be seen what the interoperability rule from HHS will accomplish when put into practice. But its goal, at least, is to make it possible for patients to more easily access their medical records by requiring both payers and health care providers to use APIs that can connect that data to third-party apps. "That is a big step forward," Buitendijk said.

The COVID-19 pandemic has also forced entities in hard-hit areas — including hospitals and vendors — that had previously viewed each other as competitors to begin working in a coordinated fashion to meet the scale of the emergency. That, Blumenthal predicts, could have lasting and positive effects.

"In the world of EHRs, things are often attributed to the technology that are actually reflecting the motives of humans using the technology," he said. "It is the urgency to collaborate, rather than the technology, that makes the exchange of information possible."

Next in Protocol's Health Care Manual: How drug pricing needs to change to fit the modern world

More from Protocol Manual: Health Care