Friday, May 21, 2010

EHR “Inevitability”and the Physician "Waiting Game"”

In my last blog,”EHRs – Size of Physician Market, Number Sold, By Whom, and Comprehensiveness of Systems Sold,” I reprinted a report by Software Advice, Inc, on the state of the EHR market “without editorial comment.”

I shall make that comment now.

Perception of EHR “Inevitability”

The perception persists in all quarters that EHR adoption is inevitable. This perception assumes payers, government and private, health consumers, and the public at large will come to expect and demand EHRs as the standard of care and the exemplar of quality. IT technologies and HITECH information technologies, the theory goes, will dominate. The Internet will reign, and we will all dance to its tune.

But for now the world of EHRs remains split between the conceptual and impatient “true believers” and the behavioral, more patient“late adopters,” who are dragging their feet and playing the “waiting game.”

Among the powerful true believers are,

• Big Government, specifically the Obama administration, who placed $20 billion in the HITECH basket in its February 2009 stimulus package.

• Related government enterprises – The VA, the Department of Defense, Indian Health Services, Community Clinics – all of whom are committed, pledged, and destined to adopt EHRs.

• The EHR industry and its 300 vendors, who foresee and thirst for hundreds of thousands of new jobs, new products, new revenues and the makings of an even vaster enterprise.

• Integrated delivery systems, like Kaiser, who has already poured $3 billion into adopting system-wide interoperable EHRs.

• Large physician organizations and societies – like AAFP, CAP, MGMA, and AMGA – which are committed to EHR adoption by its members.

• IT Giants, like Google, GE, Intel, and Microsoft. Microsoft has been in EHR market for three years now, has three products on the market, and is rumored to be anticipating acquisitions of one or more EHR vendors.

• Young IT savvy physicians, reared on computers and inspired by YouTube, Facebook and Twitter and now I-Pad, who take EHRs as a given and who migrate to groups, hospitals, and other physician employers with existing EHR platforms.

• Organizations like Health 2.0, a consortium of consumer-oriented health IT companies and vendors, who see EHRs and Personal Health Records as transformers of the health care landscape.

The Waiting Game

These are powerful and formidable agents and forces for change but practicing doctors continue to exhibit caution and to play the waiting game. Despite a 6 to 8 year push by government IT aficionados, industry, and Internet gurus, only 1.5% of hospitals and 6% of doctors have “fully functional” EHRs. A full-fledged “interoperable” system remains a pipe-dream, albeit one that continues to evolve and promises to burst into full flower sometime soon.

Reasons to resist change are legend – high installation costs, training and maintenance expenses, drops in clinical productivity, disruption of practice patterns, altered doctor-patient relationships, and little or no return in investment. Understated, but tangible nevertheless, is the feeling that EHRs violate or compromise doctors and patient privacy and confidentiality or will be misused to the detriment of both. To doctors, these are real, and sometimes profound, reinforced by the recession, and calls for cautionary waiting. Waiting for further developments, most doctors believe, at least those on the mean practice streets, is safer than plunging into the maelstrom.

Hospitals, meanwhile, are experiencing lower admission rates, declining revenues, and difficulties accessing capital. Doctors too are having trouble acquiring capital for recruiting new physicians, meeting operating expenses, and dealing with demands for more information infrastructure. It should be no surprise, then, that the AMA and the AHA are saying forced digitization demands are “too much, too soon” and are pushing back against too fast and too much EHR adoption.

We are in a period of watchful waiting for further developments.

• Waiting to see if EHR costs will come down with competition.

• Waiting to see which EHR companies will survive.

• Waiting to see if new “free” EHR business models, such as Practice Fusion, Inc, where advertisers, not doctors, pay for installation and maintenance, are for real.

• Waiting to see if payers, government and private, will demand EHR adoption for participation.

• Waiting to see if hospitals will offer more financial and technical support for EHRs. .

• Waiting to see if EHRs are as good as promised in reducing errors and improving care – as good in concrete practice as in the abstract theory.

• Waiting so to see if EHRs become more user friendly and functional in clinical use.

• Waiting to see if benefits to insurers and patients outweigh the headaches to doctors.

• Waiting to see if physician transitions and adjustments to new business models – HSAs with high deductibles, cash-only models, concierge practices, hospital employment – offer escapes from having to climb the EHR learning curve.

And so, the EHR waiting game and merry-go round continues. How fast forward it goes, when and where it stops, grinds to halt, or plunges over the cliff to a new nirvana no one knows.

A New Yorker cartoon captures the dilemma of waiting for EHR inevitability. A group of cavemen are keeping count by making vertical slashes in groups of five on the wall and counting with their fingers. The caveman leader explains to a visitor at the mouth of the cave,” It will take longer than we thought to go digital.”

Richard L. Reece, MD, is the author of Obama, Doctors, and Health Reform (2009) and Innovation-Driven Health Care (2007. He blogs at

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