One big reason why electronic medical records are not taking off

Credit: Digital Cat via Flickr

Last week the New York Times reported on a new analysis from the RAND Corporation that indicates that a multi-year push towards electronic medical records (EMRs) by the federal government hasn't delivered expected efficiencies and cost savings. The report specifically focused on improvements predicted in a 2005 RAND report on the advantages of EMRs. RAND and the New York Times both note that healthcare costs have gone up since the government began pushing for electronic records via the 2009 HITECH Act rather than down as was expected with EMR adoption.

Both RAND and the Times recount a litany of common arguments as to why EMRs haven't become the norm and haven't delivered on the expected promises.

In an abstract of the report, RAND points the finger at a handful of factors.

  • Sluggish adoption of health IT systems
  • The choice of systems that are neither interoperable nor easy to use
  • The failure of healthcare providers and institutions to reengineer care processes

The Times also assigns blame to a focus on billing over service in EMR adoption saying that "available systems seem to be aimed more at increasing billing by providers than at improving care or saving money."

Having worked in health IT, I can say that there is some merit to each of these points, particularly when it comes to providing interoperability between solutions.

Having said that, both publications miss a key point that I'll call "the consumerization of healthcare technology." Simply put, that means that healthcare IT, like IT departments across every other industry, is in an unprecedented state of flux because of consumer technologies entering the workplace. In fact, adoption of consumer-oriented mobile devices has been bigger and more rapid in healthcare than in other industries.

Within days of the iPad launching in 2010, many doctors began trying to see how they could integrate the tablet into their workflows whether that meant in a hospital, private practice, or other care setting. The iPad quickly became the mobile device of choice among doctors, followed by the iPhone. Smartphones of all types quickly became favored reference and treatment tools of nurses, whether officially allowed or not. It was seen as a forgone conclusion that the smaller form factor of the iPad mini and similar smaller tablets would appeal to healthcare professionals because of the ability to easily stick one in a lab coat pocket.

All of this happened as the requirements of the HITECH Act, which was passed into law in 2009, began providing significant financial incentives for medical providers and facilities to adopt EMRs. That should have created a perfect storm of EMR adoption, but it hasn't.

One major reason relates to RAND's assumption that doctors and other providers haven't reengineered their processes for technologies like EMRs. Another way to consider the situation is that EMR providers didn't reengineer their products to match the technologies that doctors, nurses, and other healthcare workers have been adopting in droves -- iPads, iPhones, Android smartphones, and Android tablets.

Although iOS and web/cloud EMR systems like the free Dr. Chrono and the iOS feature sets for Apple-focused products like MacPractice were delivered for the iPad in short order, they largely focus on individual doctors in private practice. The solution advocated by major EMR vendors when doctors began adopting iPads and implemented by large-scale hospital and health group deployments was largely to use the Citrix Receiver app (or a similar virtual desktop solution). That is an approach that Brian Katz,  head of the mobility engineering at a major pharmaceutical company and consumerization of IT advocate, would call a "craplication." I'll be a little more kind and say that it's a stop gap measure to provide access to EMRs and related systems like electronic prescribing from mobile devices.

As a stop gap measure, virtual desktop solutions are a good choice for deploying to mobile. Aside from being a functional choice, the simple fact is most hospitals, medical groups, and providers rely on virtual desktop solutions like Citrix on PCs to access these same systems. Doing so prevents any patient data from actually residing on those PCs, which ensures compliance with privacy regulations (and it mean a longer shelf-life for those PCs since they're being used primarily as thin clients).

From a health IT perspective as well as from a patient privacy perspective, the approach was certainly a natural progression. Unfortunately, as in other industries, providing doctors with a monolithic desktop application (and potentially a full Windows desktop), fails to capitalize on the advantages of mobile technology. Providers often need to navigate around an interface never designed for a screen less five inches across and enter data using desktop-style interfaces. That isn't convenient, it isn't quick, it can be frustrating and it's not great from an ergonomic perspective.

Even though an iPad solution can deliver a experience very similar to a paper chart, putting a desktop EMR on it via virtual desktop takes away those advantages.

The result is often doctors and nurses trying to use a mishmash of less than ideal technologies. A mobile device in the hospital room, a PC in the office or at the nurses' station, and a laptop in a private exam room, for example. Healthcare professionals, like all professionals, will tend select the options that most immediately meet their needs and lacking a system tailored around those needs will create their own -- and that can easily mean a system that pays lip service to the EMR, but doesn't deliver practical engagement with or the full benefits of it.

Of course, I'd be remiss by not addressing the interoperability issue. In many ways the lack of mobile-focused technologies is an interoperability issue in itself. One of the biggest interoperability challenges, however, is the secure exchange of data between different EMR and related systems. The uptake of electronic prescriptions, which use industry-wide standards to transfer data between various systems in use by pharmacies and providers (and between pharmacies when transferring prescriptions), shows that such interoperability is possible and can spur greater adoption. In fact, my own doctor adopted electronic prescriptions sooner and more readily than EMRs. It's also worth noting that some countries have a much better track record in these areas. Often that is partly because their governments have been much more hands on in terms of defining the standards for EMRs, something that may be so palatable in the American government/political system.

While this paints a somewhat bleak picture for the U.S. healthcare system, there are clear signs of hope. Several large EMR vendors are now actively developing for iOS and/or Android clients. By and large, they're recognizing that successfully going mobile also means breaking apps down to specific in-the-moment task-style apps. The latest meaningful use requirements, progress markers that providers must meet to receive additional funding under the HITECH Act, include requirements specific to mobile technology. Industry-wide movements like mobile health initiatives and telemedicine are also helping to push forward a more flexible and mobile approach to medicine. All in all, the world of EMRs and the consumerization of healthcare technology are still in their first stages for America's medical community and they still offer a lot of potential once we get past the initial birth and growing pains associated with them.

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