The Slow Crawl Toward Improved EHR Usability and Interoperability

by Steven J. Stack, M.D.

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Well-developed electronic health records hold the promise of helping health care professionals improve patient care and deliver it more efficiently, and the American Medical Association recognizes that enhancing EHR usability and interoperability will further ensure our nation's goal of a high-performing health care system. Physicians are generally prolific users of technology: new patient monitoring devices, diagnostic imaging, equipment and advanced surgical tools, to name a few. In each case, physicians have adopted these tools quickly and became proficient users -- and they have done so without the need for a national incentive program. Why is it, then, that so many physicians are still trying to incorporate EHRs into their practices?

While the Medicare/Medicaid EHR incentive program can be credited with sparking a rapid adoption of health IT, it has also created negative consequences. Swift implementation of certified EHRs, needed to obtain incentives under the meaningful use program, has compelled physicians to purchase tools not yet optimized to the individual user's needs. These tools often impede, rather than enable, efficient clinical care. EHRs can also pose challenges as a physician attempts to meet documentation, coding and billing requirements. AMA has been an outspoken advocate for health IT improvements and continues to work with the federal government and other stakeholders to advance usability and interoperability.

EHR Usability

According to the Healthcare Information and Management Systems Society, "usability is one of the major factors -- possibly the most important factor -- hindering widespread adoption of [EHRs]." Surprisingly, the Office of the National Coordinator for Health IT does not provide physicians any information about the usability of EHRs that it certifies. Usability standards should be included in ONC's certification criteria to ensure that physicians are able to invest in the EHR system that fits the needs of their practice.

Many physicians report they are unhappy with the EHR products available to them, likely due to the fact that EHRs are still in an immature stage of development. They find them clunky, confusing and complex, and they are struggling to successfully incorporate EHRs into their workflow. According to a recent survey of physicians by American EHR Partners, approximately one-third of all surveyed physicians said that they were very dissatisfied with their EHR and that it is becoming more difficult to return to pre-EHR productivity levels.

Given this decrease in productivity, it is no surprise that since the start of the meaningful use program, we've seen continued escalation in physician dissatisfaction with their EHRs. According to the same American EHR Partners survey, the percentage of physicians who would not recommend their EHRs to a colleague increased from 24% to 39% between 2010 and 2012.

AMA also is concerned about the viability of the thousands of certified EHR products. We've heard from many physicians who have invested in EHRs that have gone out of business. These physicians, who were doing their best to adopt EHRs, are now faced with the financial hardship of purchasing an entirely new system. The uncertain future of an EHR extends beyond the product's business model to the security of the product's certification status. In fact, ONC recently revoked the certification of two EHR systems so providers cannot use those EHRs to satisfy meaningful use requirements. Physicians who have already invested in these now-uncertified systems will need to spend even more money on a new, certified EHR to replace their non-certified EHR or face a penalty.

EHR Interoperability

In addition to the usability challenges surrounding the use of EHRs, physicians also face a nascent and often uncertain health information exchange environment, including interoperability challenges associated with the ability of different EHR systems to share patient information with one another. Unless physicians and other health care providers are able to securely, accurately and effectively exchange health data about their patients, health IT's promise for enabling high-quality and efficient care cannot be realized. A survey by the Bipartisan Policy Center revealed that more than 70% of clinicians surveyed identified lack of interoperability, lack of an information exchange infrastructure and cost of setting up and maintaining interfaces and exchanges as major barriers to health IT use.

Interoperability of EHRs will become more of an issue as physicians attempt to successfully participate in advanced stages of meaningful use. The meaningful use program has been structured such that each stage calls for physicians to meet an increasing number of requirements, including ones that call for more robust data exchange. This requires expensive, customized EHR interfaces so physicians can connect with other systems. Simply increasing the data exchange requirements physicians must meet in meaningful use will not solve the underlying challenges that persist around the operability of EHRs and HIE, things that are generally outside the average practicing physician's control. Adding to this are the ongoing concerns that the requirements for meeting meaningful use are too one-size fits all and don't accommodate all the different physician practice patterns and workflows. Layering these requirements on top of requirements that mandate physicians use certified systems that are clunky to use makes for a challenging adoption environment. 

Physicians are doing their best to successfully adopt health IT, but more must be done to advance usability and interoperability. AMA is actively engaged with the administration to communicate the concerns of physicians and is pushing for criteria that would make certified EHR systems more user friendly for physicians and meaningful use Stage 2 requirements more flexible. While we believe that CMS and ONC's decision to postpone rulemaking for Stage 3 is helpful, more must be done to address concerns with Stage 2, which begins Jan. 1, 2014. AMA will continue to highlight these issues and press CMS and ONC to address them before that date.


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