Electronic Health Records: What's Taking So Long?

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Tim Pannell / Corbis

Prescription pads, clipboards and patient charts are so 20th century. In the era of CT scans, gene-splicing and stem-cell breakthroughs, handwritten record-keeping feels about as outmoded as the fluoroscope. It's more than just strangely retro; it's fantastically expensive.

Health care in the U.S. costs a jaw-dropping $2 trillion annually, or more than $6,600 for every man, woman and child in the country. Streamlining the industry by eliminating medical errors, labor costs and general clunkiness caused by paperwork alone could save an estimated $300 billion each year, according to the national coordinator for health information technology under former President George W. Bush. The consensus, of course, is that we must go paperless: link hospitals, doctors' offices and clinics via an interactive digital grid that allows patient histories, test results and other data to be called up at a keystroke and transmitted anywhere. Hospitals have been slowly converting to electronic health records (EHR) for several years, but with health-care reform, at last, high on Washington's to-do list, President Barack Obama has called for $19 billion in stimulus money to speed up the process. Before policymakers can determine how best to spend that money, however, they need to know how the digital switchover is going so far and what's holding things up. (Read about why going digital may increase health-care costs.)

That was the goal of a study published March 25 in the New England Journal of Medicine, led by a team of researchers from the Harvard School of Public Health and Massachusetts General Hospital. What the investigators found was not encouraging. Currently, only about 1 in 10 hospitals nationwide has adopted even basic electronic record-keeping — and when you look inside that one statistic, the situation gets bleaker.

The investigators began by sending questionnaires to roughly 4,500 general hospitals around the country, asking about their use of 32 different features of health information technology — including electronic patient histories, doctors' notes, lab and X-ray results, prescriptions, drug alerts and nursing orders. "We sent out the survey to the hospital CEOs," says health-policy expert Catherine DesRoches of Massachusetts General Hospital, who participated in the study, "and about 63% responded." (Read "The Move to Digital Medical Records Begins in Tampa.")

Not many of those 3,000 respondents had much they could boast about. Only 1.5% reported having a comprehensive EHR system in place in all clinical units. Another 8% to 11% had a basic system — defined as having eight to 10 of the 32 possible EHR functionalities in at least one unit of the hospital. Even one of the most straightforward functions — computerized drug-prescribing — had been implemented in just 17%. Physicians' notes — which can be confusing at best and flat-out illegible at worst — had gone digital in just 12%. The only bright spot in the findings was computerized results-viewing, which allows doctors and nurses to call up lab results onscreen instead of having to wait for them to be delivered by hand; that time-saving upgrade had been implemented by more than 75% of the hospitals surveyed.

"That suggests that we do have a good place to start," says lead author Dr. Ashish Jha of the Harvard School of Public Health. Capitalizing on that start, however, requires identifying the main factors that are stopping hospitals from adopting EHR, and Jha and his colleagues tried to do that as well.

The biggest obstacle — no surprise — was cost, cited by 74% of the hospitals that hadn't gone digital. A small hospital might have to spend a few million dollars to buy and install new technology; a large one could require hundreds of millions. And more than 30% of hospitals had doubts about ever getting a return on that investment. The government's bailout money helps, but $19 billion divided among just the 3,000 hospitals that answered the survey would mean a little more than $6 million apiece — plenty for some, not nearly enough for others. (See the most common hospital mishaps.)

Another major obstacle was simply resistance from physicians. Harried doctors, who barely have enough time to see all their patients and manage all their cases, do not want to bother with the added chore of learning a new computer system, no matter what the promise of its virtues. Past research suggests doctors are afraid that EHR could reduce their clinical productivity.

"Change is hard," says John Glaser, vice president of Partners HealthCare System, which responded to the survey. "Human beings struggle with that, and physicians are no different."

But most human beings can be persuaded, especially with cash. The study found that among hospitals that had implemented digital records — which tended to be teaching hospitals and larger hospitals in urban areas — 82% had received additional reimbursement for EHR use, and 75% got financial incentives for adopting the system. It also helped to have adequately trained staff and available tech support, which the authors suggest we'll need more of to make progress — particularly when it comes to the exchange of health information between hospitals. Try getting any two offices in any industry to integrate their computer systems so that all the software can talk to all the other software, and now imagine doing the same thing over a network of thousands of hospitals.

Of course the larger, more immediate problem is the 47 million or so Americans who lack any health insurance or access to health care and the other 250 million who struggle with care that keeps getting more expensive and less efficient. No one would argue that electronic health records alone will fix that, but few people deny that it's a critical first step. "It will require a whole lot of leadership and a whole lot of skill," says Glaser. Americans demanded no less when they went to the polls in November. Now it's up to Washington to deliver.

Read "The Year in Medicine 2008: From A to Z."

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