Fueled in large part by government incentives introduced almost a decade ago, EHR utilization is now nearly universal across the US health system. But despite the ubiquity of EHRs and the growing evidence of benefits the systems can produce, physician dissatisfaction and interoperability constraints hinder optimal use and undermine provider confidence in the technology.

Assuming these challenges are addressed, observers expect future EHR functionality will spur more personalized care and increasingly sophisticated clinical decision support, as well as improved population health management strategies.

HITECH Incentives Spur Growth

Early EHRs were introduced several decades ago, but implementation was limited. Momentum began to shift in 2011 after introduction of the 3-stage incentive program created through the Health Information Technology and Clinical Health Act (HITECH)—informally known as the Meaningful Use Program (now Promoting Interoperability Program).

Utilization rates today are in excess of 85% for physician practices and 95% for hospitals. All told, more than $35 billion in incentive payments were paid to more than 540,000 Medicare and Medicaid providers between 2011 and 2018 to stimulate EHR uptake, according to the Centers for Medicare and Medicaid Services (CMS).

Tangible Quality and Safety Benefits

As EHR use has increased, evidence demonstrating the ways in which the systems can enhance clinical quality, safety and efficiency continues to accumulate. A physician survey conducted by Department of Health and Human Services’ (HHS) Office of the National Coordinator (ONC) in 2013 found that 3 times as many physicians reported the EHR had alerted them to a potential error as those who said the EHR had caused a medical error.

In addition, half of physician respondents reported the EHR had alerted them to critical laboratory values, and nearly half said the EHR had reminded them to provide preventive care. Majorities said the EHR facilitated direct communication with other providers (58%) or helped with referrals (52%).

More recently, a 2018 study of quality improvement strategies at more than 1,110 small to medium-sized primary care practices showed groups that extracted and harnessed EHR clinical quality data consistently generated higher quality scores than those that did not.

Other studies have determined that serious medication errors can be reduced by as much as 55% when computerized physician order entry (CPOE) systems are used, and by 83% when linked to clinical decision support (CDS) functionality that delivers alerts based on the physician orders.

EHR-driven decision-support also can play an important role in improving efficiency by controlling unnecessary or redundant laboratory testing. One study showed a 14% decrease in the volume of diagnostic tests per patient visit and a 13% decrease in associated costs when the EHR was coupled with CPOE and CDS.

EHR Barriers

Despite the EHR’s benefits, clinician unhappiness with existing functionality has emerged as a significant factor inhibiting optimal utilization. A 2018 survey of more than 500 primary care physicians revealed widespread dissatisfaction with EHRs: 40% or respondents believed EHRs presented more challenges than benefits and 49% said using an EHR detracted from their clinical effectiveness. Nearly 60% believed EHR functionality and operations should be “completely overhauled,” while 74% said the EHR had increased the total number of hours they work each day; 71% said EHRs “greatly contribute” to physician burnout.

Interoperability across all settings of care—or the ability to seamlessly share patient records between providers regardless of the platforms being used—remains the exception rather than the rule. In 2015, only 6% of providers could share patient data with other clinicians who used an EHR platform different than their own.

Multiple hurdles have contributed to the difficulty of achieving interoperability, according to a recent report by the HHS ONC. These include a lack of software and data standards, differing user interfaces, few financial incentives to share information, legal and trust barriers between providers, and outdated federal documentation, administrative, and reporting requirements.

The Way Forward

In 2015, Congress passed the 21^st Century Cures Act, which includes multiple provisions designed to bolster interoperability. Among other things, the law directs the HHS to:

• Establish a strategy for reducing the regulatory and administrative burden on providers relating to the use of EHRs
• Develop or support a trusted exchange framework for trust policies and practices and a common agreement for exchange between health information networks nationally
• Enforce the statutory provisions that penalize or deter information blocking
• Promote patient access to health information in a manner that ensures information is available in a reasonable and convenient form for the patient without burdening the healthcare provider involved

Emerging technologies, such as natural language processing and voice or speech recognition capabilities, raise the prospect of dictated physician notes and automated documentation to help ease clinician dissatisfaction and burnout. More broadly, the American Medical Association has adopted a policy of promoting EHR training in medical schools to help future physicians better prepare for utilizing the applications going forward.

Future State

As the limitations surrounding both interoperability and ease of use are mitigated, industry observers expect EHR capabilities will continue to accelerate. Specifically, EHRs likely will be able to support genomics-informed medicine to provide greater insight into disease formation, thus enabling clinicians to tailor treatment to the individual’s specific needs.

Next-generation EHR analytics also will incorporate machine learning to help reduce or prevent negative outcomes, and will contain richer historical data that will enable drill-downs relevant to the diagnosis. Artificial intelligence could synthesize information from the patient’s file with medical literature to provide the clinician with new options for care, while aggregated patient data should support a range of population health strategies.

Other possibilities include digital scribes that listen to patient-physician encounters and collapse complex interactions into concise notes that require no further documentation from the physicians, and smart phone apps that communicate relevant patient information directly back to the EHR.

As governmental programs supporting EHR utilization evolve and interoperability and ease-of-use issues improve, Avalere Health will continue to monitor the EHR environment to ensure we are able to provide clear and accurate guidance to providers, payers and others. Contact us today to learn more.

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