EHRs: 50 things to know

Spurred by healthcare reform and government incentives, healthcare providers are adopting electronic health records at staggering rates.

Here are 50 things to know about EHR adoption trends, the digital divide, the current EHR market, the cost of EHRs, EHR implementations, the effects EHRs have on physicians and patients and the ongoing quest for interoperability.

EHR adoption statistics

In 2013, 59 percent of non-federal acute-care hospitals in the U.S. had adopted at least a basic EHR system, according to the ONC. This is an increase of 34 percent over 2012 and a five-fold increase since 2008. Additionally, about 93 percent of hospitals were in possession of a certified EHR technology in 2013.
A majority of physicians — 83 percent — report they are using EHRs, according to a recent Medscape survey.
One of the main drivers behind EHR adoption has been the meaningful use and other EHR incentive programs. So far, CMS has paid out almost $25 billion in incentive payments to hospitals and physicians for the adoption and use of EHRs. Of the 4,737 active hospital registrants in the program, 4,578 have received at least one payment since 2011, totaling $14.6 billion.
However, the requirements of meaningful use stage 2 are proving challenging for many providers. Ten hospitals have attested to stage 2, and just 128 hospitals have attested to any stage during the 2014 reporting year as of July 1, representing 3 percent of all eligible hospitals.
The difficulty of meaningful use, especially the stage 2 requirements, have caused some providers to not attest in 2014 or drop out of the program entirely. In March, Salt Lake City-based Intermountain Healthcare stated it would not attest to meaningful use in 2014, deciding the risks, especially to patient safety, of pursuing meaningful use attestation during its organizationwide transition to a Cerner EHR platform outweighed the benefits. On the physician side, a recent Medscape survey of 18,575 physicians found 6 percent to be dropping out of the program after previously attesting to stage 1. Additionally, 16 percent of physicians had no plans to participate in the meaningful use program at all, up from 14 percent in 2012.

The digital divide

It is widely acknowledged a digital divide persists in EHR adoption, where larger organizations with more resources are able to implement better EHRs more quickly than smaller or community hospitals, giving these larger providers an advantage in receiving federal incentives and realizing promised quality and efficiency gains. Industry groups and lawmakers have pointed out the current meaningful use timeline is exacerbating the digital divide by making acquiring, implementing and training staff on the new software even more of a challenge.
By 2013, 89 percent of critical access hospitals had installed full or partial EHRs. However, despite this high adoption, CAHs were less likely than any other types of hospitals to have met meaningful use criteria in 2013 due to significant challenges in fully adopting and using EHR software, including high costs, a lack of qualified staffers and unavailable or insufficient broadband connections.
By 2012, about 90 percent of federally qualified health centers had an electronic health record system. However, just a third of FQHCs had an EHR that met core meaningful use stage 1 requirements. These basic EHRs may not be delivering the expected quality and efficiency improvements to the FQHCs. Examining data on more than 1,100 FQHCs, researchers found the centers that could meet meaningful use stage 1 requirements were more than twice as likely as other FQHCs to receive federal recognition for quality care.

The current EHR market

At the end of 2013, 10 EHR vendors accounted for about 90 percent of the hospital EHR market, based on meaningful use attestation data from CMS. Those 10 vendors include Epic, MEDITECH, CPSI, Cerner, McKesson, Healthland, Siemens, Healthcare Management Systems, Allscripts and NextGen Healthcare.
According to a KLAS report, just three of these vendors expanded their market share in 2013 — Epic, Cerner and MEDITECH. The report found Epic and Cerner experienced the largest gains in both the large- and small-facility markets.
Allscripts, Epic, Cerner, McKesson and Quadramed are the most popular EHR systems among academic medical centers, teaching facilities and hospitals with more than 300 beds, according to a report from KLAS. Among small and rural hospitals under 100 beds and critical access hospitals, the top vendors are CPSI, Cerner, Healthland, Healthcare Management Systems and RazorInsights.
Recently, the EHR market has seen an infusion of providers seeking replacements for their current systems. Surveys suggest between 12 and 30 percent of providers are dissatisfied with their EHR. Girish Navani, CEO and co-founder of eClinicalWorks, said in 2013 more than half of his company's new clients came from another vendor.
The EHR market is expected to reach $9.3 billion annually by the end of 2015.According to a report from Kalorama Information, the EHR technology market will continue to grow through at least 2018, fueled by upgrades and replacements to meet meaningful use requirements and providers' functionality needs.
EHRs are part of the current debate over the appropriate amount of regulation for health IT products, medical devices and apps. Some Senators want to ensure EHRs avoid all Food and Drug Administration regulation. The Preventing Regulatory Overreach To Enhance Care Technology Act of 2014 would remove FDA oversight from health IT products not used for diagnostic purposes, including EHRs. The bill is currently being considered by a Senate subcommittee.

The cost of EHRs

EHR implementations and the large financial outlays required can negatively affect hospitals' credit profiles. Several hospitals have recently had credit challenges related to EHRs. For example, Crystal Lake, Ill.-based Centegra Health System's EHR implementation was a major factor in its recent credit downgrade. The large one-time expenditure, along with recent investments in physician alignment and new facilities, reduced the organization's operating margin to a low 0.5 percent and caused Fitch Ratings to downgrade it from "A-" to "BBB."
However, high EHR implementation costs don't bring every hospital down. Norton Healthcare, based in Louisville, Ky., recorded $59.2 million in operating profit in fiscal year 2013 — triple its operating profit from 2012 — despite spending about $80 million on its Epic EHR.
Hospitals and health systems are often unaware just how much an EHR implementation will cost, according to a study in the Journal of the American Medical Informatics Association. After interviews with leaders of hospitals and health systems undergoing EHR implementations, the researchers concluded the costs for all aspects of the implementation, from training to facilities to infrastructure costs, were often underestimated.
There are things healthcare providers can do to prepare for the financial impact of an EHR implementation. Officials at Winston-Salem, N.C.-based Novant Health outsourced legacy accounts receivable to free up staffers for needed EHR training while building up a revenue "cushion" to help offset anticipated losses of productivity after go-live.
Several larger health systems have begun offering versions of their own EHR systems in a software-as-a-service model to help smaller organizations avoid the upfront costs of implementation. Notable examples include Cleveland Clinic and Springfield, Mo.-based Mercy.
To improve care coordination and meet meaningful use stage 2 requirements, it is very helpful for nearby and affiliated physicians to use the same EHR system as a hospital. However, the high costs of installing an EHR can keep small practices from adopting the technology. To foster adoption among small practices, there are exceptions to the Stark Law and Anti-Kickback Statute, recently extended, that allows hospitals to subsidize a physician practice's EHR.
While the cost of adopting and implementing an EHR remains the most pressing health IT concern for physicians, the Physicians Practice 2014 Technology Survey suggests costs are less of a concern now than in previous years.
Ideally, EHRs will improve hospital and health systems' finances through improved efficiency. However, although recent studies have generally shown EHRs to reduce overall healthcare costs, those savings aren't always reflected in a provider's bottom line. Two recent studies by the same researcher illustrate this point — installing EHRs reduced outpatient care costs by 3 percent among several communities in Massachusetts though after five years, each individual physician had a negative return on investment of about $44,000.
A 2012 study from the Center for Public Integrity determined U.S. hospitals collectively overbilled Medicare for emergency department procedures that were "upcoded" in EHRs. This study and several other similar reports caught the attention of HHS and U.S. Attorney General Eric Holder, who responded with a letter to the major hospital and medical associations emphasizing the federal government's commitment to detecting and prosecuting such healthcare fraud. However, a recent study found no association between EHR adoption and higher Medicare bills.

EHR implementations

Clinical buy-in is a necessity for a successful EHR implementation. Since clinicians are the end users, it's important the new system is both useful and usable for them. Not engaging clinicians in the process is what precipitated the high-profile EHR troubles at Athens (Ga.) Regional Health System that were followed by the CEO and CIO's resignation, according to Cerner officials.
It's also important to prepare for workflow interruptions. According to a survey from the Healthcare Financial Management Association, 46 percent of organizations took between one and two years to resume normal workflow after an EHR install, and 11 percent took between two and three years.
While remaining rare, several hospitals have filed suit in recent years alleging an EHR vendor failed to deliver on implementation promises. For example, Mountainview Medical Center in White Sulphur Springs, Mont., sued NextGen Healthcare for allegedly failing to install a meaningful use-compliant system on time, and in 2013, Cerner agreed to pay $106 million to Trinity Medical Center in Minot, N.D., to resolve allegations purchased software did not function as promised.
Successfully implementing an EHR that meets meaningful use requirements does not mean a hospital or health system is necessarily reaping all the potential benefits. According to a survey conducted by Stoltenberg Consulting at HIMSS' annual conference in Orlando, Fla., in February, more than 70 percent of the 211 IT professionals surveyed said their hospital, health system or physician practice has successfully attested to meaningful use stage 1 but has not yet maximized the full potential of its EHR to improve care and workflow efficiencies.
Hospitals working toward meaningful use attestation often implement electronic health record parts and functions in a different order than hospitals not as focused on meaningful use, according to a recent study. The results showed a similar EHR adoption trajectory among hospitals — patient demographic and ancillary results functions went live first, and physician notes and clinical reminders were often put in place last. However, the researchers noted those hospitals going for meaningful use often implemented functionalities required by meaningful use stage 1, including clinical guidelines and medication computerized provider order entry, sooner than other hospitals.
New EHRs usually mean new IT staff, though qualified employees can be hard to find. The number of jobs for EHR technicians is expected to grow 22 percent between 2012 and 2022, from 186,300 to 227,400 positions, according to a report from the U.S. Department of Labor. However, according to a Towers Watson report, 73 percent of healthcare organizations seeking Epic-certified technicians are having trouble finding them, driving salaries up. In 2012, EHR technicians earned an average salary of $34,160 per year, or $16.42 per hour, according to the DoL report. However, this average salary has already begun to rise, especially for professionals with experience with popular EHR systems such as Epic or Cerner. According to the 2014 Dice Tech Salary Survey, IT professionals with Epic experience are now earning an average of $92,120 per year, and those with Cerner experience are earning $88,963.
Sixty percent of U.S. hospitals currently have a formal organizational entity that oversees the hospital's use of its EHR system and decides on any changes that should be made to the system's infrastructure, according to a recent survey from HIMSS Analytics.

Physicians and EHRs

Physician adoption of EHR systems remains a struggle for hospitals both adopting an EHR for the first time or working to achieve the stages of meaningful use, as physicians often find them difficult to use or time-consuming. To help spur physician adoption, experts recommend considering installing speech recognition software, working with the vendor to create a customized solution and place EHR-capable devices around the hospital where they will be most convenient for physicians.
Physicians do not use EHRs the same way, according to a recent study. Physicians responded to clinical decision support alerts differently, used panel management options differently and printed after-visit summaries with different frequencies.
The most-desired mHealth functionality among physicians is the ability to access EHRs on a mobile device, according to a survey from MedData Group. Currently, just 18 percent of physicians are able to do this.
The American Medical Association's new president, Robert Wah, MD, is a supporter of EHRs. While acknowledging barriers still exist to healthcare providers reaping the full benefits of EHRs, he believes the technology has the potential to improve patient-physician interactions and overall care quality.

EHRs and patients

One of the most common physician complaints about EHRs is that they reduce face-to-face time with patients, either through shorter consults because of the lengthy post-visit documentation process or because the physicians' face is now turned to a computer rather than the patient.
Some physicians think EHRs are a dangerous distraction. In an op-ed in Annals of Internal Medicine, two physicians compare entering information into an EHR during a patient visit akin to texting while driving, arguing such multitasking limits a physician's ability to notice warning signs in patients.
A growing number of medical errors have been linked to EHRs. A recent RAND report discussing various innovations within the healthcare industry points out that while EHRs have been shown to improve patient care, they can also compromise patient safety. RAND's findings are supported by recent literature as well as a report from the Maryland Department of Health and Mental Hygiene, which found "numerous" patient safety incidents stemmed from EHRs in 2013.
These patient safety issues are reflected in recent EHR-related malpractice claims. Harvard-affiliated CRICO, a medical malpractice insurance group, recently analyzed 147 EHR-related claims to determine the most common causes of the issues. Topping the list were incorrect information in the EHR, hybrid paper record/EHR conversion issues and system failures.
National Nurses' United, the country's largest nurses' union, has been one of the most outspoken critics of current EHR technology. In May, the union launched a national campaign called "Insist on an RN," featuring ads highlighting EHRs' potential patient safety issues.
In addition, EHRs can erode patients' trust. A recent survey found 83 percent of patients expect hospitals to use EHRs, but only 53 percent said they trust the safety and security of the software. Respondents between ages 18 and 29 indicated the highest level of trust for EHR safety at 61 percent, followed by respondents ages 65 and over at 59 percent. Respondents between 45 and 64 worry the most about EHR security at 46 percent, followed by respondents between 30 and 44 at 37 percent.
Patients' privacy fears may be well-founded — a recent report from HHS' Office of the Inspector General concluded the ONC has not done enough to ensure EHRs certified by authorized entities adequately protect patient health information.
EHRs may also make patients more likely to lie. A recent study linked EHR use to more dishonest patients, suggesting worries about privacy or security may keep some patients from being honest about their medical history when they see their physician entering the information into a computer.
However, EHRs have been shown to improve the patient-physician relationship. A recent survey conducted at Ronald Reagan UCLA Medical Center and UCLA Medical Center, Santa Monica, found patients reported higher levels of patient-physician communication following the implementation of EHRs. The most-improved areas include addressing the patient by the preferred name, communicating the treatment process and how long it will take, and quickly responding to patient requests.
To allow physicians to have a more natural conversation with patients while reducing documentation time, San Fransisco-based Dignity Health partnered with Augmedix to allow physicians to record patient interactions through Google Glass. Physicians can have a natural conversation with patients while wearing the technology, and the information from the consult is pushed directly to the EHR.

Interoperability

Interoperability is a growing concern for providers, as meaningful use stage 2 and a movement toward more coordinated care necessitate data exchange. The inability to share information between disparate systems can have negative consequences. For example, Arlington Heights, Ill.-based Alexian Brothers Health System suspended its efforts to launch a Medicaid accountable care entity after troubles connecting physicians' different EHRs.
A lack of interoperability among EHRs is second only to EHR implementations as physicians' top tech concerns, according to Physicians Practice Technology Survey.
To help improve interoperability, Commonwell Health Alliance, a group of 11 EHR vendors focused on fostering data exchange among healthcare stakeholders, created a standard health ID to help providers better share information.
Epic, notably absent from Commonwell, is part of another interoperability effort called Carequality. A partnership with Oakland, Calif.-based Kaiser Permanente, Walgreens, Surescripts and other organizations, the group's goal is to increase data exchange between hospitals, physicians, payers, retail clinics and other healthcare stakeholders.
Some vendors have made strides among themselves to improve interoperability. In February, NextGen and Cerner announced bi-directional data interoperability, and in June, NextGen announced it had achieved total vendor-agnostic interoperability.
Lawmakers from both sides of the aisle have recently issued calls for the ONC to investigate EHR vendors' lack of interoperability and de-certify any found to be actively blocking data exchange. Rep. Phil Gingrey, MD (R-Ga.) has specifically called out Epic as having a closed platform that limits data exchange.

EHRs: 50 things to know

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