Cheryl Conrad no longer seethes with the frustration that threatened to overwhelm her in 2006. As described in IEEE Spectrum, Cheryl’s husband, Tom, has a rare genetic disease that causes ammonia to accumulate in his blood. At an emergency room visit two decades ago, Cheryl told the doctors Tom needed an immediate dose of lactulose to avoid going into a coma, but they refused to medicate him until his primary doctor confirmed his medical condition hours later.
Making the situation more vexing was that Tom had been treated at that facility for the same problem a few months earlier, and no one could locate his medical records. After Tom’s recovery, Cheryl vowed to always have immediate access to them.
Today, Cheryl says, “Happily, I’m not involved anymore in lugging Tom’s medical records everywhere.” Tom’s two primary medical facilities use the same electronic health record (EHR) system, allowing doctors at both facilities to access his medical information quickly.
In 2004, President George W. Bush set an ambitious goal for U.S. health care providers to transition to EHRs by 2014. Electronic health records, he declared, would transform health care by ensuring that a person’s complete medical information was
available “at the time and place of care, no matter where it originates.”
President George W. Bush looks at an electronic medical record system during a visit to the Cleveland Clinic on 27 January 2005. Brooks Kraft/Corbis/Getty Images
Over the next four years, a bipartisan Congress
approved more than US $150 million in funding aimed at setting up electronic health record demonstration projects and creating the administrative infrastructure needed.
Then, in 2009, during efforts to mitigate the financial crisis, newly elected President Barack Obamasigned the $787 billion economic stimulus bill. Part of it contained the Health Information Technology for Economic and Clinical Health Act, also known as the HITECH Act, which budgeted $49 billion to promote health information technology and EHRs in the United States.
As a result, Tom, like most Americans, now has an electronic health record. However, many millions of Americans now have multiple electronic health records. On average, patients in the United States visit 19 different kinds of doctors throughout their lives. Further, many specialists have unique EHR systems that do not automatically communicate medical data between each other, so you must update your medical information for each one. Nevertheless, Tom now has immediate access to all his medical treatment and test information, something not readily available 20 years ago.
Tom’s situation underlines the paradox of how far the United States has come since 2004 and how far it still must go to achieve President Bush’s vision of a complete, secure, easily accessible, and seamlessly interoperable lifetime EHR.
As of 2021, nearly 80 percent of physicians and almost all nonfederal acute-care hospitals deployed an electronic health record system.
For many patients in the United States today, instead of fragmented, paper medical record silos, they have a plethora of fragmented, electronic medical record silos. And thousands of health care providers are burdened with costly, poorly designed, and insecure EHR systems that have exacerbated clinician burnout, led to hundreds of millions of medical records lost in data breaches, and created new sources of medical errors.
EHR’s baseline standardization does help centralize a very fragmented health care system, but in the rush to get EHR systems adopted, key technological and security challenges were overlooked and underappreciated. Subsequently, problems were introduced due to the sheer complexity of the systems being deployed. These still-unresolved issues are now potentially coupled with the unknown consequences of bolting on immature AI-driven technologies. Unless more thought and care are taken now in how to proceed as a fully integrated health care system, we could unintentionally put the entire U.S. health care system in a worse place than when President Bush first declared his EHR goal in 2004.
IT to Correct Health Care Inefficiencies Is a Global Project
Putting government pressure on the health care industry to adopt EHR systems through various financial incentives made sense by the early 2000s. Health care in the United States was in deep trouble. Spending increased from $74.1 billion in 1970 to more than $1.4 trillion by 2000, 2.3 times as fast as the U.S. gross domestic product. Health care costs grew at three times the rate of inflation from 1990 to 2000 alone, surpassing 13 percent of GDP.
Two major studies conducted by the Institute of Medicine in 2000 and 2001, titled To Err Is Human and Crossing the Quality Chasm, found that health care was deteriorating in terms of accessibility, quality, and safety. Inferior quality and needless medical treatments, including overuse or duplication of diagnostic tests, underuse of effective medical practices, misuse of drug therapies, and poor communication between health care providers emerged as particularly frustrating problems.
Administrative waste and unnecessary expenditures were substantial cost drivers, from billing to resolving insurance claims to managing patients’ cases. Health care’s administrative side was characterized as a “ monstrosity,” showing huge transaction costs associated with an estimated 30 billion communications conducted by mail, fax, or telephone annually at that time.
Both health care experts and policymakers agreed that reductions in health care delivery and its costs were possible only by deploying health information technology such as electronic prescribing and EHR. Early adopters of EHR systems like the Mayo Clinic, Cleveland Clinic, and the U.S. Department of Veterans Affairs proved the case. Governments across the European Union and the United Kingdom reached the same conclusion.
There has been a consistent push, especially in more economically advanced countries, to adopt EHR systems over the past two decades. For example, the E.U. has set a goal of providing 100 percent of its citizens across 27 countries access to electronic health records by 2030. Several countries are well on their way to this achievement, including Belgium, Denmark, Estonia, Lithuania, and Poland. Outside the E.U., countries such as Israel and Singapore also have very advanced systems, and after a rocky start, Australia’s My Health Record system seems to have found its footing. The United Kingdom was hoping to be a global leader in adopting interoperable health information systems, but a disastrous implementation of its National Programme for IT ended in 2011 after nine years and more than £10 billion. Canada, China, India, and Japan also have EHR system initiatives in place at varying levels of maturity. However, it will likely be years before they achieve the same capabilities found in leading digital-health countries.
EHRs Need a Systems-Engineering Approach
When it comes to embracing automation, the health care industry has historically moved at a snail’s pace, and when it does move, money goes to IT automation first. Market forces alone were unlikely to speed up EHR adoption.
Even in the early 2000s, health care experts and government officials were confident that digitalization could reduce total health spending by 10 percent while improving patient care. In a highly influential 2005 study, the RAND Corp. estimated that adopting EHR systems in hospitals and physician offices would cost $98 billion and $17 billion, respectively. The report also estimated that these entities would save at least $77 billion a year after moving to digital records. A highly cited paper in HealthAffairs from 2005 also claimed that small physician practices could recoup their EHR system investments in 2.5 years and profit handsomely thereafter.
Moreover, RAND claimed that a fully automated health care system could save the United States $346 billion per year. When Michael O. Leavitt, then the Secretary of Health and Human Services, looked at the projected savings, he saw them as “a key part of saving Medicare.” As baby boomers began retiring en masse in the early 2010s, cutting health care costs was also a political imperative since Medicare funding was projected to run out by 2020.
Some doubted the EHR revolution’s health care improvement and cost reduction claims or that it could be achieved within 20 years. The Congressional Budget Office argued that the RAND report overstated the potential costs and benefits of EHR systems and ignored peer-reviewed studies that contradicted it. The CBO also pointed out that RAND assumed EHR systems would be widely adopted and effectively used, which implies that effective tools already existed, though very few commercially available systems were. There was also skepticism about whether replicating the benefits for early adopters of EHR systems—who spent decades perfecting their systems—was possible once the five-year period of governmental EHR adoption incentives ended.
Even former House Speaker Newt Gingrich, a strong advocate for electronic health record systems, warned that health care was “30 times more difficult to fix than national defense.” The extent of the problem was one reason the 2005 National Academy of Sciences report,Building a Better Delivery System: A New Engineering / Health Care Partnership, forcefully and repeatedly called for innovative systems-engineering approaches to be developed and applied across the entire health care delivery process. The scale, complexity, and extremely short time frame for attempting to transform the totality of the health care environment demanded a robust “system of systems” engineering approach.
This was especially true because of the potential human impacts of automation on health care professionals and patients. Researchers warned that ignoring the interplay of computer-mediated work and existing sociotechnical conditions in health care practices would result in unexpected, unintentional, and undesirable consequences.
Additionally, without standard mechanisms for making EHR systems interoperable, many potential benefits would not materialize. As David Brailer, the first National Health Information Technology Coordinator, stated, “Unless interoperability is achieved…potential clinical and economic benefits won’t be realized, and we will not move closer to badly needed health care reform in the U.S.”
HITECH’s Broken Promises and Unforeseen Consequences
A few years later, policymakers in the Obama administration thought it was unrealistic to prioritize interoperability. They feared that defining interoperability standards too early would lock the health industry into outdated information-sharing approaches. Further, no existing health care business model supported interoperability, and a strong business model actively discouraged providers from sharing information. If patient information could easily shift to another provider, for example, what incentive does the provider have to readily share it?
Instead, policymakers decided to have EHR systems adopted as widely and quickly as possible during the five years of HITECH incentives. Tackling interoperability would come later. The government’s unofficial operational mantra was that EHR systems needed to become operational before they could become interoperable.
“Researchers have found that doctors spend between 3.5 and 6 hours a day (4.5 hours on average) filling out their digital health records.”
Existing EHR system vendors, making $2 billion annually at the time, viewed the HITECH incentive program as a once-in-a-lifetime opportunity to increase market share and revenue streams. Like fresh chum to hungry sharks, the subsidy money attracted a host of new EHR technology entrants eager for a piece of the action. The resulting feeding frenzy pitted an IT-naïve health care industry rushing to adopt EHR systems against a horde of vendors willing to promise (almost) anything to make a sale.
A few years into the HITECH program, a 2013 report by RAND wryly observed the market distortion caused by what amounted to an EHR adoption mandate: “We found that (EHR system) usability represents a relatively new, unique, and vexing challenge to physician professional satisfaction. Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, which has, as our findings suggest, not yet matured.”
In addition to forcing health care providers to choose quickly among a host of immature EHR solutions, the HITECH program completely undercut the warnings raised about the need for systems engineering or considering the impact of automation on very human-centered aspects of health care delivery by professionals. Sadly, the lack of attention to these concerns affects current EHR systems.
Today, studies like that conducted by Stanford Medicine indicate that nearly 70 percent of health care professionals express some level of satisfaction with their electronic health record system and that more than 60 percent think EHR systems have improved patient care. Electronic prescribing has also been seen as a general success, with the risk of medication errors and adverse drug events reduced.
However, professional satisfaction with EHRs runs shallow. The poor usability of EHR systems surfaced early in the HITECH program and continues as a main driver for physician dissatisfaction. The Stanford Medicine study, for example, also reported that 54 percent of physicians polled felt their EHR systems detracted from their professional satisfaction, and 59 percent felt it required a complete overhaul.
“What we’ve essentially done is created 24/7/365 access to clinicians with no economic model for that: The doctors don’t get paid.” —Robert Wachter, chair of the department of medicine at the University of California, San Francisco
Poor EHR system usability results in laborious and low-value data entry, obstacles to face-to-face patient communication, and information overload, where clinicians have to wade through an excess of irrelevant data when treating a patient. A 2019 study in Mayo Clinic Proceedings comparing EHR system usability to other IT products like Google Search, Microsoft Word, and Amazon placed EHR products in the bottom 10 percent.
Electronic health record systems were supposed to increase provider productivity, but for many clinicians, their EHRs are productivity vampires instead. Researchers have found that doctors spend between 3.5 and 6 hours a day (4.5 hours on average) filling out their patient’s digital health records, with an Annals of Internal Medicine study reporting that doctors in outpatient settings spend only 27 percent of their work time face-to-face with their patients.
In those visits, patients often complain that their doctors spend too much time staring at their computers. They are not likely wrong, as nearly 70 percent of doctors in 2018 felt that EHRs took valuable time away from their patients. To address this issue, health care providers employ more than 100,000 medical scribes today—or about one for every 10 U.S. physicians—to record documentation during office visits, but this only highlights the unacceptable usability problem.
Furthermore, physicians are spending more time dealing with their EHRs because the government, health care managers, and insurance companies are requesting more patient information regarding billing, quality measures, and compliance data. Patient notes are twice as long as they were 10 years ago. This is not surprising, as EHR systems so far have not complemented clinician work as much as directed it.
“A phenomenon of the productivity vampire is that the goalposts get moved,” explains University of Michigan professor emeritus John Leslie King, who coined the phrase “productivity vampire.” King, a student of system–human interactions, continues, “With the ability to better track health care activities, more government and insurance companies are going to ask for that information in order for providers to get paid.”
Robert Wachter, chair of the department of medicine at the University of California, San Francisco, and author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, believes that EHRs “became an enabler of corporate control and outside entity control.”
“It became a way that entities that cared about what the doctor was doing could now look to see in real time what the doctor was doing, and then influence what the doctor was doing and even constrain it,” Wachter says.
Federal law mandates that patients have access to their medical information contained in EHR systems—which is great, says Wachter, but this also adds to clinician workloads, as patients now feel free to pepper their physicians with emails and messages about the information.
“What we’ve essentially done is created 24/7/365 access to clinicians with no economic model for that: The doctors don’t get paid,” Wachter says. His doctors’ biggest complaints are that their EHR system has overloaded email inboxes with patient inquiries. Some doctors report that their in-boxes have become the equivalent of a second set of patients.
It is not so much a problem with the electronic information system design per se, notes Wachter, but with EHR systems that “meet the payment system and the workflow system in ways that we really did not think about.” EHRs also promised to reduce stress among health care professionals. Numerous studies have found, however, that EHR systems worsen clinician burnout, with Stanford Medicine finding that 71 percent of physicians felt the systems contributed to burnout.
Half of U.S. physicians are experiencing burnout, with 63 percent reporting at least one manifestation in 2022. The average physician works 53 hours weekly (19 hours more than the general population) and spends over 4 hours daily on documentation.
Clinical burnout is lowest among clinicians with highly usable EHR systems or in specialties with the least interaction with their EHR systems, such as surgeons and radiologists. Physicians who make, on average, 4,000 EHR system clicks per shift, like emergency room doctors, report the highest levels of burnout.
Aggravating the situation, notes Wachter, was “that decision support is so rudimentary…which means that the doctors feel like they’re spending all this time entering data in the machine, (but) getting relatively little useful intelligence out of it.”
Poorly designed information systems can also compromise patient safety. Evidence suggests that EHR systems with unacceptable usability contribute to low-quality patient care and reduce the likelihood of catching medical errors. According to a study funded by the U.S. Agency for Healthcare Research and Quality, EHR system issues were involved in the majority of malpractice claims over a six-and-a-half-year period of study ending in 2021. Sadly, the situation has not changed today.
Interoperability, Cybersecurity Bite Back
EHR system interoperability closely follows poor EHR system usability as a driver of health care provider dissatisfaction. Recent data from the Assistant Secretary for Technology Policy / Office of the National Coordinator for Health Information Technology indicates that 70 percent of hospitals sometimes exchange patient data, though only 43 percent claim they regularly do. System-affiliated hospitals share the most information, while independent and small hospitals share the least.
Exchanging information using the same EHR system helps. Wachter observes that interoperability among similar EHR systems is straightforward, but across different EHR systems, he says, “it is still relatively weak.”
However, even if two hospitals use the same EHR vendor, communicating patient data can be difficult if each hospital’s system is customized. Studies indicate that patient mismatch rates can be as high as 50 percent, even in practices using the same EHR vendor. This often leads to duplicate patient records that lack vital patient information, which can result in avoidable patient injuries and deaths.
The ability to share information associated with a unique patient identifier (UPI), like other countries that use advanced EHRs, including Estonia, Israel, and Singapore, makes health information interoperability easier, says Christina Grimes,digital health strategist for the Healthcare Information and Management Systems Society (HIMSS).
But in the United States, “Congress has forbidden it since 1998” and steadfastly resists allowing for UPIs, she notes.
Using a single-payer health insurance system, like most other countries with advanced EHR systems, would also make sharing patient information easier, decrease time spent on EHRs, and reduce clinician burnout, but that is also a nonstarter in the United States for the foreseeable future.
Interoperability is even more challenging because an average hospital uses 10 different EHR vendors internally to support more than a dozen different health care functions, and an average health system has 16 different EHR vendors when affiliated providers are included. Grimes notes that only a small percentage of health care systems use fully integrated EHR systems that cover all functions.
EHR systems adoption also promised to bend the national health care cost curve, but these costs continue to rise at the national level. The United States spent an estimated $4.8 trillion on health care in 2023, or 17.6 percent of GDP. While there seems to be general agreement that EHRscan help with cost savings, no rigorous quantitative studies at the national level show the tens of billions of dollars of promised savings that RAND loudly proclaimed in 2005.
However, studies have shown that health care providers, especially those in rural areas, have had difficulty saving money by using EHR systems. A recent study, for example, points out that rural hospitals do not benefit as much from EHR systems as urban hospitals in terms of reducing operating costs. With 700 rural hospitals at risk of closing due to severe financial pressures, investing in EHR systems has not proved to be the financial panacea they thought it would be.
Cybersecurity is a major cost not included in the 2005 RAND study. Even though there were warnings that cybersecurity was being given short shrift, vendors, providers, and policymakers paid scant attention to the cybersecurity implications of EHR systems, especially the multitude of new cyberthreat access points that would be created and potentially exploited. Tom Leary,senior vice president and head of government relations at HIMSS, points out the painfully obvious fact that “security was an afterthought. You have to make sure that security by design is involved from the beginning, so we’re still paying for the decision not to invest in security.”
From 2009 to 2023, a total of 5,887 health care breaches of 500 records or more have been reported to the U.S. Department of Health and Human Services Office for Civil Rights resulting in some 520 million health care records being exposed. Health care breaches have also led to widespread disruption to medical care in various hospital systems, sometimes for over a month.
In 2024, the
average cost of a health care data breach was $9.97 million. The cost of these breaches will soon surpass the $27 billion ($44.5 billion in 2024 dollars) provided under HITECH to adopt EHRs.
2025 may see the first major revision since 2013 to the Health Insurance Portability and Accountability Act (HIPAA) Security Rule outlining how electronic protected health information will need to be cybersecured. The proposed rule will likely force health care providers and their EHR vendors to make cybersecurity investment a much higher priority.
$100 Billion Spent on Health Care IT: Was the Juice Worth the (Mega) Squeeze?
The U.S. health care industry has
spent more than $100 billion on information technology, but few providers are fully meeting President Bush’s vision of a nation of seamlessly interoperable and secure digital health records.
Many past government policymakers
now admit they failed to understand the complex business dynamics, technical scale, complexity, or time needed to create a nationwide system of usable, interoperable EHR systems. The entire process lacked systems-engineering thinking. As Seema Verma, former administrator of the Centers for Medicare and Medicaid Services,toldFortune, “We didn’t think about how all these systems connect with one another. That was the real missing piece.”
Over the past eight years, successive administrations and congresses have taken actions to try to rectify these early oversights. In 2016, the
21st Century Cures Act was passed, which kept EHR system vendors and providers from blocking the sharing of patient data, and spurred them to start working in earnest to create a trusted health information exchange. The Cures Act mandated standardized application programming interfaces (APIs) to promote interoperability. In 2022, the Trusted Exchange Framework and Common Agreement (TEFCA) was published, which aims to facilitate technical principles for securely exchanging health information.
“The EHR venture has proved troublesome thus far. The trouble is far from over.”
—John Leslie King, University of Michigan professor emeritus
In late 2023, the first
Qualified Health Information Networks (QHINs) were approved to begin supporting the exchange of data governed by TEFCA, and in 2024, updates were made to the APIs to make information interoperability easier. These seven QHINs allow thousands of health providers to more easily exchange information. Combined with the emerging consolidation among hospital systems around three EHR vendors—Epic Systems Corp., Oracle Health, and Meditech—this should improve interoperability in the next decade.
These changes, says HIMSS’s Tom Leary, will help give “all patients access to their data in whatever format they want with limited barriers. The health care environment is starting to become patient-centric now. So, as a patient, I should soon be able to go out to any of my healthcare providers to really get that information.”
HIMSS’s Christina Grimes adds that the patient-centric change is the continuing consolidation of EHR system portals. “Patients really want one portal to interact with instead of the number they have today,” she says.
In 2024, the
Assistant Secretary for Technology Policy / Office of the National Coordinator for Health IT, the U.S. government department responsible for overseeing electronic health systems’ adoption and standards, was reorganized to focus more on cybersecurity and advanced technology like AI. In addition to the proposed HIPAA security requirements, Congress is also considering new laws to mandate better cybersecurity. There is hope that AI can help overcome EHR system usability issues, especially clinician burnout and interoperability issues like patient matching.
Wachter states that the new AI scribes are showing real promise. “The way it works is that I can now have a conversation with my patient and look the patient in the eye. I’m actually focusing on them and not my keyboard. And then a note, formatted correctly, just magically appears. Almost ironically, this new set of AI technologies may well solve some of the problems that the last technology created.”
Whether these technologies live up to the hype
remains to be seen. More concerning is whether AI will exacerbate the rampant feeling among providers that they have become tools of their tools and not masters of them.
As EHR systems become more usable, interoperable, and patient-friendly, the underlying foundations of medical care can be finally addressed. High-quality evidence
backs only about 10 percent of the care patients receive today. One of the great potentials of digitizing health records is to discover what treatments work best and why and then distribute that information to the health care community. While this is an active research area, more research and funding are needed.
Twenty years ago, Tom Conrad, who himself was a senior computer scientist,
told me he was skeptical that having more information necessarily meant that better medical decisions would automatically be made. He pointed out that when doctors’ earnings are related to the number of patients they see, there is a trade-off between the better care that EHR provides and the sheer amount of time required to review a more complete medical record. Today, the trade-off is not in the patients’ or doctors’ favor. Whether it can ever be balanced is one of the great unknowns.
Obviously, no one wants to go back to paper records. However, as John Leslie King says, “The way forward involves multiple moving targets due to advances in technology, care, and administration. Most EHR vendors are moving as fast as they can.”
However, it would be foolish to think it will be smooth sailing from here on, King says: “The EHR venture has proved troublesome thus far. The trouble is far from over.”
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