A near Complete Adoption of Electronic Health Records System in

the U.S. Lacks Interoperability and Physician Satisfaction

Raghid El-Yafouri

and Leslie Klieb

Management Technology and Innovation, Grenoble Ecole de Management, Grenoble, France

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 the “HITECH

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 meet “meaningful 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

https://orcid.org/0000-0003-3735-5764

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

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

58%

Not

Decided

18%

Yes

24%

43%

Not

Decided

10%

Yes

47%

A near Complete Adoption of Electronic Health Records System in the U.S. Lacks Interoperability and Physician Satisfaction

601

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

23%

Not

Decided

10%

Yes

67%

42%

Not

Decided

Yes

52%

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

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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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