Turbulence in Electronic Health Record Adoption Signals Pressing Need for Research

Turbulence in Electronic Health Record Adoption Signals Pressing Need for Research


When I first read The New York Times headline "Why Health Care Tech is Still So Bad," (March 21, 2015) I thought: “Here’s another article by a doctor complaining about electronic health records (EHRs) and threatening to go back to paper-based patient records”. Yes, Robert M. Wachter’s piece piles on the growing chorus of frustration with EHR system implementations, but also helps bring into focus the core issues that need to be addressed through collaboration between researchers and practitioners.

Let’s summarize the major shortfalls with most implementations of "certified EHRs":

  • Lack of intuitive user interface with emphasis on data entry by clinicians;
  • Inflexible workflow support, requiring clinicians to change how they make decisions and interact with patients;
  • Alerts of potential interactions, contraindications, etc. that aren’t as intelligent as intended, resulting in too many false alarms and “alert fatigue;”
  • Inability to easily and economically exchange data with health care organizations using different EHR systems.

These issues are complex, reflecting challenges with culture, usability, interoperability, and adopting IT to support evidence-based medicine.  EHR vendors are currently focused on the Centers for Medicare and Medicaid Services (CMS) meaningful use rules, which (despite including criteria for usability and interoperability in the proposed rules for Stage 3), leave it up to the private sector to solve these issues. For example, eligible professionals and hospitals can meet the Stage 3 meaningful use objectives by simply demonstrating the sending of summary of care records; no standards for medical vocabulary or application interfaces are called for. EHR vendors lack the incentive or capacity to upgrade their systems beyond the minimal MU criteria; innovation and resources to address the major shortfalls I listed above need to come from elsewhere.

With many physicians already considering replacement of their EHRs because they are dissatisfied with their performance (see Manchikanti et al. and American College of Physicians survey) and scant evidence of an ROI from EHRs in terms of improved quality and efficiency of clinical practice, what is needed is a broad effort among health care researchers and clinicians in the field. Multi-disciplinary teams, involving experts in health services, medicine, human factors, and finance can change the EHR landscape. What needs to be done, using this interdisciplinary team approach:

  • Work side-by-side with nurses and physicians in the field-- to analyze workflows, build system prototypes, and facilitate in-depth reviews of HIT models, to substantially enhance the usefulness of applications used by clinicians in the direct care of patients;
  • Identify, evaluate, and advance proven usability techniques to optimize the human-computer interface for clinicians and their patients;
  • Conduct robust, well-designed quantitative studies on change in patient outcomes and clinician productivity when EHR systems are deployed.

The opportunity is to create (as IBM’s Eric Brown told Dr. Wachter), “…a technology that physicians suddenly can’t live without.” Perhaps this new technology isn’t based on EHRs, but instead is a new paradigm for using information technology in clinical settings?



James Gillespie's picture James Gillespie | March 31, 2015 11:50 pm MST

Great analysis Dr. Solomon.  I am particularly struck by two words in your post: culture and usability.  It is striking to me how subpar many EHR systems seem to be from a physician and nurse usability standpoint.  This, in turn, as resulted in the inability to establish strong pro-EHR cultures in organizations.  The 2009 American Recovery and Reinvestment Act requiring transition from paper medical records to completely electronic systems has been a mixed blessing.  On one hand, the use of EHRs grew from just 48% in 2009 to over 80 percent in 2014.  Unfortunately, the meet the deadlines imposed by the law, we know many, many systems neglected interconnectedness.  In addition, some programs limit the free transfer of information while assessing fees for every transfer outside the particular system.  These serve as powerful deterrents to information sharing.  Where does this net out and leave us?  It’s unclear.  For sure, as you so accurately note, we need a “new paradigm” or else this EHR turbulence will likely continue.  James Gillespie

Michael R. Solomon's picture Michael R. Solomon | April 2, 2015 11:30 am MST

Dr. Gillespie, 

During my trips around the country advising health information exchange organzations, I am struck by the resistance of many large health systems in particular to sharing electronic health records with other providers in the community. Major change in culture and competitive dynamics is still ahead of us. It's not so much the data that are a competitive advantage, but rather the information and knowledge that is created and used effectively by clinicians and patients to improve outcomes. So, we can share data with competitors and still gain a competitive advantage in the market with a robust health IT infrastructure to support managing the health of a population or improve medication adherence of patients, for example.