A near Complete Adoption of Electronic Health Records System in
the U.S. Lacks Interoperability and Physician Satisfaction
Raghid El-Yafouri
1a
and Leslie Klieb
2b
1
Management Technology and Innovation, Grenoble Ecole de Management, Grenoble, France
2
Business and Technology, Webster University Thailand, Bangkok, Thailand
Keywords: Electronic Health Records, EHR, Health Information Technology, EHR Policy, Physician Attitude.
Abstract: In this position paper, the satisfaction of health care providers with electronic health record (EHR) systems is
discussed. Based on a survey just before the deadline for EHR adoption incentive by the U.S. government,
we conclude that too many physicians and medical care providers do not like the current state of the systems,
feel forced to use them, and get insufficient benefits from them. We urge all involved parties to collaborate
and design systems that are more in agreement with the practices of the different parties and specialties in the
health care industry.
1 INTRODUCTION
It has been over ten years since the United States
enacted the American Recovery and Reinvestment
Act (ARRA) of 2009 which allotted about $20 billion
for health care spending to modernize Health
Information Technology (HIT) systems. The law
included the Health Information Technology for
Economic and Clinical Health Act, or theHITECH
Act,” which established $35 billion programs under
the Centers of Medicare and Medicaid Services
(CMS) to provide incentive payments for the
“meaningful use” of certified electronic health
records (EHR) technology. The goal was to expand
the adoption and use of HIT and benefit from a
reduction in health care costs and improvement in
quality of care.
The adoption rate did spike between 2009 and the
deadline for the incentives in 2015, reaching over
80% for basic, but certified, EHR systems according
to the CMS. Today, we stand close to 90% adoption
of systems that meetmeaningful use in major
hospitals, with smaller and rural practices
consistently less (CMS). A higher rate of adoption
and a wider spread of EHR systems can mean better
medical care for the patient (Gilmer, et al., 2012).
However, for this to happen, the systems require data
a
https://orcid.org/0000-0003-3735-5764
b
https://orcid.org/0000-0002-0881-5330
sharing and exchange with and between institutions,
a criteria that only 12% of the systems meet (Rathert,
et al., 2019).
Such discrepancy between individual facility
setup and cross-facility medical data sharing
questions the success of the national EHR
implementation. An EHR is the comprehensive
computerized record of one patient. It is composed of
medical records from multiple Care Delivery
Organizations (CDO) (Garets & Davis, 2006). In
times like during the Covid-19 pandemic or with
emergency medical needs, patients often visit the
closest care providers regardless whether they are in
their network or not. Real-time access to unified and
comprehensive historical records, without the explicit
release of data by individual physicians, is key in
making the right diagnosis and recommending the
right treatment.
Our position is that medical data transference
from one provider to another and real-time access to
the full historical records of a patient is a mandatory
condition for a meaningful EHR adoption. The
current official opinion about EHR adoption in the
U.S. is misleading. The government and its
policymaking alone are not sufficient to drive a
beneficial adoption of the EHR technology in the U.S.
Cooperation and collaboration with physicians, a
primary and large EHR system user group (Kapoor &
600
El-Yafouri, R. and Klieb, L.
A near Complete Adoption of Electronic Health Records System in the U.S. Lacks Interoperability and Physician Satisfaction.
DOI: 10.5220/0010320006000604
In Proceedings of the 14th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2021) - Volume 5: HEALTHINF, pages 600-604
ISBN: 978-989-758-490-9
Copyright
c
2021 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
Lee, 2013), is required to accurately assess the ease
of capturing data in the system, the impact on
workflow, the validity of cross-provider history, and
the impact of EHR systems on the overall medical
care quality, performance, efficiency, and cost.
2 ARGUMENT
2.1 Innovation in Health Care
The innovation implementation process of EHR
systems in the U.S. health care industry is lengthy and
complex, requiring multi-stage system setup,
adoption, and integration (Rathert, et al., 2019;
Kralewski, et al., 2008). It is promising to know work
is being done to build assistive decision support using
unstructured medical data (Barbantan & Potolea,
2016), leverage multiple view service-oriented
architecture to conform medical applications of
different types (França, et al., 2017), and learn from
the application of a standardized information and
communication infrastructure (Katehakis &
Kouroubali 2019). But we are not there yet. The
industry is composed of health care sponsors and
providers of both public and private sectors. All of
them bear responsibility for EHR system
development and advancement. Addressing and
resolving issues to reach mutually beneficial goals is
needed (Katehakis and Kouroubali 2019).
As a public health care sponsor, the U.S.
government supports the adoption of EHR
technologies to achieve cost and quality benefits and
has achieved a reduction in Medicare expenditures
(Lammers and McLaughlin, 2017). However, the
intentions of medical care providers have not been
clear. Physicians and clinicians have divided opinions
regarding EHR system’s advantages (O'Malley, et al.,
2010), and there is no consensus on how to achieve
EHR system benefits across the U.S. health care
system as a whole (Gaylin, et al., 2011). Furthermore,
and contrary to the government’s expectations,
certain benefits of EHR systems like convenient
access to tests, including electronic imaging results,
seems to encourage physicians to increase their
testing and imaging ordering, rather than reduce them
(McCormick, et al., 2012).
2.2 Opinions of Physicians
In mid-2014, just before the deadline for incentives,
we conducted a survey of 382 physicians (El-Yafouri
& Klieb, 2014) across 47 different U.S. states with
54% (206) private practitioners and 46% (176)
associated with larger institutions like hospitals or
public clinics to capture their attitudes and
perceptions toward their EHR systems. Of the 382
respondents, 71% (271) were male and 29% (111)
were female physicians. Linear regression analysis
revealed that physicians’ attitude is strongly affected
by their perception of how EHR systems can benefit
the industry, and attitude has the strongest effect on
their intention to adopt and use EHR systems. This is
confirmed by Hung (2019) where physicians’
satisfaction and continuance intention to use EHR
systems is highly impacted by their perception of the
system’s ability to improve patient care.
Figure 1: EHR Reduces Cost.
Figure 2: EHR Enhances Quality of Care.
Physicians opinions and satisfaction matter. Our
survey showed that physicians are split in opinion and
perception, with 58% of them believing that EHR
systems will not reduce costs (Figure 1), and 43% of
the physicians do not believe it will enhance quality
of care (Figure 2). They referred to EHR systems as a
No
58%
Not
Decided
18%
Yes
24%
No
43%
Not
Decided
10%
Yes
47%
A near Complete Adoption of Electronic Health Records System in the U.S. Lacks Interoperability and Physician Satisfaction
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disaster and described them as a nightmare. They did
not believe that EHRs are created or put in place for
the betterment of health care or patient care; rather
they are built for economic reasons and mainly to
facilitate the billing and payments by the government
and insurance companies.
67% of the participants agreed that the
government policy and mandate was the primary
reason for using the system (Figure 3), and 42% noted
that it did not meet their expectations or take into
consideration their needs as medical professionals
(Figure 4). They saw the systems as sophisticated
billing devices or glorified filing cabinets.
Respondents felt that the standards of EHR systems,
including the government’s meaningful use, were too
many required by the government, but useless to
medicine.
Figure 3: Government Main Reason for Adoption.
Figure 4: EHR Meets Physicians' Expectations.
When it came to privacy and data security, 57%
had concerns (Figure 5). They anticipated more
fraudulent documentation, breach of data, and
invasion to patient privacy. Physicians supported data
exchange but only a third could confirm compliance
with data exchange or ability to transfer records. They
noted that although many vendors were certified by
the government that their systems supported
meaningful use and data sharing, it was misleading.
Most systems were not compatible with each other
and had not shown or proven that they could in fact
share and exchange data with other EHR systems.
Figure 5: Privacy and Security Concerns.
Figure 6: EHR's Impact on Workflow.
61% of the respondents said that their EHR
system made their operations and workflow more
difficult (Figure 6) the system is not easy to use
taking lots of time to capture information and
worsening the doctor-patient relationship. Some
physicians felt that the role of doctors and nurses had
No
23%
Not
Decided
10%
Yes
67%
No
42%
Not
Decided
6%
Yes
52%
No
31%
Not
Decided
12%
Yes
57%
Harder
61%
Not
Decided
11%
Easier
28%
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changed to data entry clerks. Tai-Seale (2017) found
that on average, physicians were spending more time
practicing desktop medicine than face-to-face patient
interactions and communications.
Finally, 41% of the physicians had no to moderate
knowledge of EHR systems, their requirements, or
their anticipated benefits to health care. That is a
problem knowing that complex innovation
integration, like EHR systems, requires knowledge
creation and diffusion (Kukk, et al., 2015; Pombo-
Juárez, et al., 2017).
The results show that physicians feel coerced to
using EHR systems, a whopping 79% of the
physicians described the decision to use the EHR
system in their practice as mandated. They felt that
EHR systems were forced on the medical community
and enforced by those who are far from the medical
industry. They added that most systems were
designed and developed without the input of medical
clinicians, and thus not intended to meet medical
effectiveness.
The disconnect between the government’s
expectations and measure of success and the
physicians’ needs to do their jobs well has led to sub-
par benefits of the EHR innovation for the patient as
well as the industry. After more than a decade,
practices continue to struggle today in supporting
medical data transference and exchange due either to
technical limitations, undeveloped privacy policies,
or lack of trust of physicians in the captured
information from other practices.
2.3 Collaboration for Adoption
Although, according to Watkins et al. (2015),
governments have been known to “play a central
orchestrating role in the generation and diffusion of
innovation in a national economy” (p. 1408), it has
not been effective in the U.S. In the EHR diffusion
case, the traditional method of making policies to
steer the adoption of innovation in industries like
health care, may not be enough. Lack of
standardization is the biggest challenge according to
Rathert et al. (2019). And without standardization,
data sharing cannot happen. Other recent literature
shows that intermediary industry associations have an
increasing involvement in cooperative relations
between government and industry aimed at
influencing an innovation’s diffusion, adoption,
training, and standards (Watkins, et al., 2015). These
associations create and set industry protocols and
common best practices to which physicians are driven
to adhere, with an unbiased interests and proof that
the innovation can bring a clear advancement over the
current state.
This requires acknowledging that the decision to
diffuse electronic records is not held by the
government or any one party. Work is needed to
collaborate, converge the needs, and bridge the gap
between the expectations of the payer, provider,
public, and private groups, especially physicians.
This complements or becomes more prominent than
– the method of passing laws. Specific roles and
responsibilities must be identified and defined, and
then, each group should be made aware of and
experience the tangible benefits from the adoption of
technology in health care. A proven balance between
medical expenditure reduction, medical care quality
improvements, end user’s needs, and the patient’s
wellness is required to attain and sustain a national
patient health system diffusion with an
interoperability model.
3 CONCLUSIONS
The adoption rate of EHR in the U.S. according the
CMS and the government may just be shy of 100% at
this time, but this rate represents the technical and
tactical implementation of the system in practices and
medical facilities. It is reflective only of the decision
made by hospitals, laboratories, clinics, and offices to
install, use, and maintain the application at their
individual CDOs. It does not however reflect the
success of those separate systems to accurately and
consistently share or exchange data between
themselves or to tap into a central common repository
of medical information. Nor does it reflect the
support, satisfaction, and confidence of the
physicians, one of the largest user group, in the
system. The benefits have been one-sided. Billing and
claim tracking may be easier for the payer, but care
providers and physicians have yet to see the full
value.
More importantly, patients who seek to visit
multiple doctors, due to the need for different
opinions or due to a geographical inconvenience, are
still at the mercy of their physicians to transfer their
medical history, be it a digital or paper record. An
EHR system is meant to create an ecosystem in which
medical information is accessible by licensed medical
professional anywhere and anytime. Without this
feature, we can hardly claim that we are near
complete success. Success will require all parties,
public and private, to play supportive, engaging, and
cooperative roles and achieve genuine and unbiased
A near Complete Adoption of Electronic Health Records System in the U.S. Lacks Interoperability and Physician Satisfaction
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benefits to the industry. And that cannot be reached if
the satisfaction and convenience of physicians are
suffering.
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