EHRs: Use of full-fledged, "federally correct" systems is woefully low

Only four percent of physicians use a fully functional EHR that satisfies federally promoted certification requirements, while another 14 percent have basic systems, according to a study in the July 3 issue of The New England Journal of Medicine.

The EHR wing of the US Department of Health and Human Services-called the Office of the National Coordinator for Health Information Technology-supported the NEJM study to get an authoritative picture of EHR adoption. The study noted that other recent estimates, ranging from nine percent to 29 percent of physicians, relied on small sample sizes or hazy definitions of an EHR.

The NEJM study, based on a survey of 2,758 physicians in late 2007 and early 2008, coincided with the June release of a four-year plan from the National Coordinator’s office that sets a target of 40 percent of physicians using certified EHR systems by 2012. That’s 10 times the current adoption rate of fully functional systems that satisfy a handful of key standards set by the Certification Commission for Healthcare Information Technology.

A private group working under contract with HHS, CCHIT has developed hundreds of requirements that an EHR for ambulatory care must satisfy before it can become certified. The feds view this vetting process as a way to promote interoperable EHRs that can plug into a so-called Nationwide Health Information Network and win the confidence of physicians seeking robust programs.

To win a CCHIT stamp of approval, an EHR must, among other things, have the ability to transmit a prescription electronically to a pharmacy, generate orders for lab tests and radiological imaging, warn an e-prescribing doctor about drug interactions or contraindications, highlight abnormal test results, and issue reminders about guideline-recommended interventions and screenings. All of these capabilities are included in the definition of a fully functional EHR in the NEJM study, but not in the definition of a basic EHR. Any programs that lacked these functions would flunk the CCHIT test.

Certification figures heavily into federal and state strategies to digitize healthcare. The feds, for instance, allow hospitals to subsidize 85 percent of the cost of EHR software for physicians, but only if it’s certified. Likewise, a Medicare pilot project that awards bonuses to physicians using EHRs and a Minnesota law that mandates EHR usage by 2012 specify certification.

While certified programs are federally correct, they can be 10 times as expensive as basic EHRs, according to Mark Anderson, president of AC Group, a healthcare IT consulting firm. Anderson says the cost of software, training, and support for certified programs typically ranges from $35,000 to $50,000 per doctor over three years.

Those intimidating price tags help explain why only four percent of physicians have CCHIT-level systems. The NEJM study identified cost as the top barrier for EHR adoption-47 percent among doctors already using an EHR, and 66 percent among doctors without one.

Catherine DesRoches, the lead author of the NEJM study, says adoption rates of certified systems could still hit the HHS target of 40 percent by 2012, however, if physicians receive more financial support and incentives to digitize, and if legal uncertainties about the privacy of electronic patient data are cleared up. “With some judiciously applied policy changes, it’s not an unreasonable goal,” says DesRoches, a researcher at the Institute for Health Policy at Massachusetts General Hospital.

DesRoches also points to other survey results that she considers promising for EHR adoption. In addition to the 17 percent of doctors who used some kind of EHR system, 16 percent said they had purchased a system, but hadn’t implemented it yet, while 26 percent said they intended to buy one within the next two years.

The study contains another piece of certifiably good news: Doctors with EHRs were generally happy about what they accomplished with these digital tools. Of those with fully functional programs, 82 percent said their systems had had a positive impact on making good clinical decisions and delivering chronic-disease care that met medical guidelines. Satisfaction levels for doctors with basic EHRs weren’t as high, but still topped 50 percent.