EHR holdouts: Why some physicians refuse to plug in

Nearly 79% of primary care physicians (PCPs) are using electronic health record (EHR) systems, an 8% rise when compared to the previous year. At the same time, a growing minority of PCPs say they will never use EHR at their practice, despite losing out on incentive payments and facing future reimbursement penalties. Medical Economics 2013 Continuing Survey helps explain why they resist.

SEE THE DATA: Click here to view technology charts from the 2013 survey.

More PCPs are using EHRs than ever before, and that growth is expected to continue as the government’s meaningful use incentive period moves into its second phase next year. 

But the survey results also show that the number of EHR holdouts is growing. Nearly half of the PCPs surveyed who do not have an EHR system told Medical Economics they have no plans to ever use EHR at their practice, 10% more than last year. For the purposes of the survey, PCPs include family practice and internal medicine physicians.

In 2011, 27% of surveyed PCPs said they did not have an EHR system at their practice. In this year’s survey, that number dropped to 20%. 

But the number of PCPs without EHR systems who said they did not plan to purchase a system rose in 2012 to 48%, from 32% the year before. And it’s not just PCPs who are holding out. The survey data for all physician specialties follows the same trend. Last year, about 34% of all physicians without an EHR said they had no plans to get one. This year that number rose to 46%.

Who are the EHR holdouts?

Going without an EHR system means foregoing meaningful use incentives today and facing reimbursement penalties starting in 2015. That is a sacrifice many physicians seem willing to make if it means avoiding the hassles that come with an EHR, says Gray Tuttle Jr., CHBC, principal healthcare adviser with The Rehmann Group in Lansing, Michigan, and a Medical Economics editorial consultant.

Survey data shows that EHR holdouts work in smaller, lower-income practices. But the key variable appears to be age: The older the physician the lower the likelihood that he or she use an EHR system. While 81% of physicians younger than 50 use an EHR, only about 70% of physicians older than 50 use an EHR system.

Given the amount of change coming to how medicine will be practiced beyond this year, retirement may be the only option for many of these holdouts. Besides Meaningful Use penalties,  physicians in 2014 will also be forced to navigate the complexities of changing to the ICD-10 coding system in October 2014. That’s a daunting and perhaps impossible task without an EHR system.

Tuttle says he recently spoke with one of his clients, a physician in her 60s, who said she wants to retire and that avoiding the pressure to use EHR was “contributory to her decision to hang it up.” And that is a common sentiment among his older clients, Tuttle says.

“I’ve heard them say: ‘I will probably never install an EHR.’ They have accepted the fact that it will trigger retirement or accepted the fact that they will be paid less,” Tuttle says.

Michael D. Brown, CHBC, president of Health Care Economics, Inc., in Fishers, Indiana, and a Medical Economics editorial consultant, says he sees clear age break among his clients when it comes to EHR adoption. Younger physicians seem better able to adapt to EHRs while older physicians are more resistant. “They say ‘I went to medical school to treat patients, not to fiddle around on a computer,’” Brown says.

“I think you have to look at our physician populations out there. The ones that are learned and comfortable with computers, they blend in and go to EHR much easier. The ones that are over, say, the age 45, think it is nothing but a mess,” Brown says.

“They are scared,” Brown adds. “They are really fearful. Many of them haven’t even worked with a practice management system, and they are scared they are not going to be able to adapt themselves.”

The other important factors are practice size and income. The survey data shows that the smaller the practice size and lower the income, the greater chance a physician will be without an EHR and have no intentions of purchasing a system in the future.

These smaller practices with fewer resources have a harder time affording the upfront costs and regular fees associated with an EHR and more difficulty absorbing any revenue losses from the paper-to-EHR transition. Another ongoing issue is that they often can’t afford to hire staff members with the technical expertise to help them manage any technical problems.

“They don’t want to make the expenditure,” Brown says. “And many of these practices don’t have the right people on staff to be able to adhere, understand and soak-in the EHR.”

‘I don’t even think’ about EHR

Gigi Lefebvre, MD, who is in her 23rd year running a solo practice in St. Petersburg, Florida, says she will never use EHRs. Lefebvre says her decision to avoid EHRs is about running her practice the way she wants to, and being able to devote enough time to her patients’ needs rather than wrangling with a potentially clunky software system. 

As a small practice-Lefebvre has a two-employee staff and sees about 13 patients per day-she worries that she will not receive the technical support she needs if she ever went to an EHR system.

“If I had an EHR and had difficulties, I am so small that no one is going to come to help me,” she says.

Instead of using an EHR system, Lefebvre says she spends at least 30 minutes with each of her patients during visits and concentrates on providing good care with strong preventative medicine services. She says obtaining an EHR system as only getting in the way of an effective physician-patient relationship and as a needless cash drain on her already struggling bottom line.

“There is nothing worth it to me,” Lefebvre says. “Doctors get thousands of dollars from the government for EHR but I don’t even think about it. I can even lose more than that by being inefficient in my practice.”

Still, Ehrs remain the future of medicine

That is a common sentiment among physicians, who see themselves as increasingly beset on all sides and EHR as just another barrier to treating patients. When asked what are the biggest issues facing primary care, most said declining reimbursements, paperwork burdens, and healthcare reform. But 28% of survey respondents said EHRs. In write-in comments collected by the survey, physicians’ anonymously disparaged their EHR systems, saying they only add aggravation.

“Most physicians have enough worries about shrinking reimbursement and growing expenses,” Brown says. “They consider EHR as a total mess and another headache.”

Despite these complaints, a comfortable majority of physicians use EHR at their practice, and the adoption rates increase every year, even for older physicians. Between 2010 and 2012, older physicians contributed to the biggest increases in EHR adoption, according to the National Ambulatory Medical Care Survey of EHRs, which was conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

And acceptance of EHRs is much higher among younger physicians who grew up with computers in their midst, Tuttle says. As the EHR holdouts retire, younger physicians who are comfortable using computers and the cloud to store and process medical records will replace them. 

“Eventually, it’s safe to say that all physicians will use EHRs, but that’s still a bit away,” Tuttle says. “These people eventually are going to retire and they are being replaced with people who grew up using computers. I lecture residents, and they love EHR. You know why? They never knew it any other way.”

These resources make EHRs easier

Complaints about what EHRs have done to physicians’ practices are common, and such horror stories likely lead many physicians who remain without an EHR system to develop cold feet. Many physicians surveyed listed EHR systems as one of the factors contributing to dissatisfaction with their careers. These resources can help physicians make better decisions concerning their EHR systems:

The Medical Economics Top 100 EHR List: An exclusive ranking highlighting the top EHR vendors, including company revenue, system capabilities, and Meaningful Use readiness.

Certified Health IT Product List: This database provides a comprehensive list of EHR systems that have been tested and certified byThe Office of the National Coordinator for Health Information Technology (ONC).

Healthcare Information and Management Systems Society (HIMSS):  The nonprofit focused on health IT provides pages of online resources about EHR, from adoption to usability.