Rewind to the classic videotape format wars of the 1970s between Betamax and VHS (Sony v. JVC). Ultimately, the JVC’s grainier VHS format won out because it cost less and could record longer shows – up to four hours compared to the 60-minute limit for Betamax. More recently, the once dominant business-style Blackberrys have been pummeled by Apple’s iPhone, with its higher-res display, cool apps, super-easy internet browsing, and the ability to check Facebook and Twitter with just a thumb-stroke.
Now, shift to the world of electronic health records (EHRs), also big business: U.S. industry revenue was a staggering $6.5 billion in 2012. Even more impressive is its growth – up from less than $1 billion in 2009. The EHR explosion is sparked by new “meaningful use” requirements in the HITECH Act of 2009, where hospitals receive incentive payments for implementing EHRs and will face penalties for not having them by 2015.
EHRs these days are clearly today’s business “winner”. Much in the way that VHS clobbered Betamax, and iPhone eviscerated Blackberry, EHRs have dominated antiquated paper-based charting systems.
But wait! There is one glaring difference between the EHRs and the nifty iPhone you had no problem shelling out $500 to buy: iPhones are a design-marvel while some of today’s most successful 21st century EHRs have more in common with failed products that consumers never really liked such as the Pontiac Aztek, Apple’s Newton, and smokeless cigarettes.
Some ED EHRs these days are more “lemon” than supercar, slowing down fast-paced EDs, and even repeatedly causing dangerous medical errors through gawky, overly-complex design.
So how did the EHR industry grow more than six-fold in the past three years by marketing products that are just about as usable as 1980s TV remotes? The first reason is that the end user (in this case, the ED provider) is not the most important EHR customer. (Remember that end users decide which videocassette player or smartphone to buy). With EHRs, hospital chief executive and information officers make buying decisions. Factors such as price, interoperability across the hospital, and ensuring every dime of revenue is captured are important factors, while to ED providers, workflow and usability issues – such as being simple to use, reducing unnecessary clicks, and facilitating (not interrupting) ED workflow.
To be fair, some EHRs are better than others and really do facilitate emergency care. The problem is that some of the worst-designed systems are outcompeting best-designed ones, precisely because they seem like a better buy to the CEO and CIO, among other reasons. At this point, what can ED providers do to make our work-lives better and our departments safer in the 1.0 world of “lemon” EHRs?
The answer depends upon whether your hospital has already bought their EHR. If it hasn’t, then the strategy is to become the customer. While the ultimate decision may not be up to ED providers, getting a seat at the EHR decision table can have a big impact. The most important thing is to bring data. Talk to colleagues who’ve implemented various EHR systems and communicate their feedback.
A major “data” limitation is the paucity of ED literature that compares EHR products head-to-head. What is mostly out there is anecdote: stories of nightmare implementations that “ruined” an ED, laden with frustration, heartache, and inevitable staff migration.
There are consulting groups out there such as KLAS research who rate ED EHR systems, but their methodology aggregates provider survey feedback rather than comparing objective performance data such as changes in ED flow or quality after implementation. Studies in the peer-reviewed literature are sorely needed to help ED leaders advocate for the more usable systems.
Note: the more usable systems are the ones that were designed for the ED, where the ED “module” wasn’t an afterthought, retrofitted from the inpatient system where workflow and safety issues are different.
If the system has already been purchased and implemented, getting the hospital to switch systems is probably not going to happen. For example, if your mother accidentally buys an Atari 2600 instead of the Xbox 360, she can easily bring it back to the store. Not so with EHRs. High switching costs in the EHR business make the “just return it, mom, you bought the wrong one” argument impossible.
Given that whatever EHR your hospital chose is probably there to stay (at least for the short term), the first focus after implementation should be setting up a local committee of clinicians and IT professionals to monitor ongoing issues. The group should assess flow and safety concerns and implement workable solutions. The good news is that some of the EHR version 1.0 “lemon” problems are actually fixable with concerted effort.
But the real question is how can we motivate EHR vendors to innovate, and redesign their 2.0 systems for all ED providers to be less clunky and more user-friendly? Specifically, how do we get the EHR vendors to compete based on the needs of the end-user: the ED provider?
The answer is that we, as a specialty, need a coordinated approach. A first step is already done: an article from ACEP’s Quality Improvement and Patient Safety section that details quality and safety issues in ED EHR systems is provisionally accepted in Annals of Emergency Medicine.
But this is only a start. Next, we need to focus on studying EHR systems: what works and what doesn’t. Local successes should be spread widely through the peer-reviewed literature and other information portals – of course, while complying with your local EHRs disclosure clauses.
Once sufficient literature has been generated, we need to do what only providers can do: create evidence-based guidelines for EHR best practices in the ED. The next step is to move from guideline to quality metrics, and from quality metrics to value-based purchasing. Then, what will become important to the real EHR customer (the CEO/CIO) will be aligned with the end user (the ED provider).
But developing evidence takes time, money, and a coordinated effort, as does making quality measures. Wouldn’t it be nice if competition for EHRs worked the same way as iPhones? Unfortunately it doesn’t. Until then, it’s up to us to push the EHR vendors – who we may be stuck with – to refine their products to enhance flow and facilitate the safest delivery of emergency care possible.
Jesse M. Pines, MD
Director of the Center for Health Care Quality; Associate Professor, George Washington University
Meaningful Use – Propping up the EHR market without improving quality
EMRs were met with variable acceptance just a few years ago. The value proposition was often focused on recouping costs from reduced reliance on transcription and enhanced revenue from improved charge capture. That approach resulted in limited success with hospital CEO skeptics and CFOs looking for guaranteed return on investment for purchasing such a system. The tide turned when a guaranteed pile of cash was bestowed on any hospital meeting the “meaningful use” requirements. Ideally, this shouldn’t have changed the way CEOs and CFOs approached the question of whether or not to purchase an EMR and which vendors to consider. Unfortunately, it did. The penetration of EMR installs into the hospital market dramatically increased at this point. Did quality of the products improve? Did their ability to independently provide a return on investment improve? Not a chance. What flipped overnight, triggering a windfall for EMR vendors, was the influx of new cash into the market and an immediate return on investment.
The total EMR market has been estimated at $6.5 billion, compared to $973.2 million in 2009 when only 12% of hospitals had purchased an EMR. Has meaningful use meaningfully contributed to the quality of care delivery and the availability of information or just removed the financial obstacle for hospitals to adopt EMRs?
-Kevin Klauer, DO, EJD