Editor’s note: The American College of Surgeons (ACS) Board of Governors has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating Governors’ concerns to the ACS Board of Regents. The 2015 Governors Survey, which had a 76.2 percent response rate (208/273), addresses multiple topics that have been identified as areas of concern for practicing surgeons. The following article on the effect of the electronic health record (EHR) is the first in a series of feature articles on key issues addressed in the Governors survey. The next two articles will focus on the Affordable Care Act and graduate medical education, respectively.
Although the creation of a paperless medical record was suggested as early as 1991 in an Institute of Medicine report, the first real progress toward the creation of an EHR came in April 2004, when President George W. Bush issued an executive order that gave the Office of the National Coordinator for Health Information Technology (ONC) the task of implementing EHR nationwide within 10 years.1,2 At the time, many health policy experts believed that health information technology had the potential to do the following:3
- Improve quality of care
- Reduce medical errors
- Lower administrative costs
- Provide new support for health care professionals
- Improve security and privacy of medical records
- Provide patients with greater access to and control of their personal health information
- Connect clinicians by building an interoperable health information infrastructure so that records could follow the patient
In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act, which provided financial incentives to eligible professionals (EPs) and hospitals through the Medicare and Medicaid programs that adopted and showed meaningful use of certified EHRs.4
The 2015 ACS Governors Survey asked a series of questions about the use of EHR in both the office and the hospital setting. Of the respondents, 78 percent reported using an office EHR, and 89 percent said they use a hospital EHR (see Figures 1 and 2).
Despite the federal incentives for implementing an office EHR system and Medicare reimbursement penalties that took effect in 2015 for EPs who did not participate in the Medicare EHR Incentive Program, 22 percent of the Governors reported that they do not use an office EHR system.
Governors were asked how confident they were that the information in their office and hospital EHR system was current, complete, and accurate. For the office EHR, 70 percent of the respondents were either adequately confident (27 percent) or somewhat confident (43 percent) in the quality of data from their office EHR. The remaining 30 percent were either not confident at all about the quality of data (25 percent), or felt that the data were rarely complete, accurate, or even available (5 percent) (see Figure 3).
Likewise, when asked about the hospital EHR, 70 percent of the respondents stated that they were either adequately confident (29 percent) or somewhat confident (41 percent) in the quality of hospital EHR data. The remaining 30 percent either lack any confidence in the data (25 percent) or stated that the data were rarely complete, accurate, or even available (5 percent) (see Figure 4).
Governors were asked how often they exited the office or hospital EHR and searched through multiple data sources to obtain all of the information they needed. With respect to the office EHR, 61 percent of the respondents said that they rarely or never needed to exit the EHR for more data. The remaining 39 percent stated that they needed to exit the EHR for more data frequently or very frequently (see Figure 5).
For the hospital EHR, 67 percent of respondents stated that they rarely (55 percent) or never (12 percent) needed to exit the hospital EHR to get data from other sources, whereas 33 percent stated that they either frequently or very frequently needed to exit the hospital EHR (see Figure 6).
Governors were next asked how the use of the EHR in their office and hospital affected their overall workflow and efficiency. With respect to the office EHR, 67 percent of the respondents said they experienced either a decrease in efficiency (36 percent), a major disruption of previous work flow (23 percent), or a severe disruption of workflow in their office (8 percent). In contrast, 21 percent of respondents reported that their overall workflow and efficiency in the office had significantly improved, and 12 percent said they experienced no change (see Figure 7).
For the hospital EHR, 54 percent of the respondents stated that their overall workflow and clinical efficiency in the hospital had decreased either slightly (33 percent) or significantly (21 percent). In contrast, 46 percent reported that their overall workflow and clinical efficiency in the hospital had either improved slightly (23 percent), improved significantly (14 percent), or had not changed (9 percent) (see Figure 8). It appears that the hospital EHR is less disruptive to workflow and efficiency than the office EHR.
Rising levels of dissatisfaction
Results from the 2015 ACS Governors Survey clearly show that Governors have many concerns regarding the effects EHRs have had on clinical practice. In a study sponsored by the American Medical Association, a RAND Health report found that EHRs had an important impact on physician professional satisfaction.5 This report listed nine effects that led to reduced professional satisfaction (see Table 1).
Table 1. EHRs and reduced professional satisfaction
|Issues that surgeons noted regarding EHR included the following:
Evidence in the literature suggests that physician dissatisfaction with EHR is increasing. A survey conducted by the American College of Physicians and AmericanEHR Partners showed that dissatisfaction with ease of use of the EHR increased to 37 percent in 2012 from 23 percent in 2010.6 In that same time period, the percentage of clinicians who would not recommend their EHR to a colleague increased from 24 percent to 39 percent. This survey also showed that surgical specialists were the least satisfied group of physician EHR users.
According to a 2014 Medical Economics article, nearly 20 percent of EPs have dropped out of the meaningful use program.7 In 2015, the Centers for Medicare & Medicaid Services (CMS) penalized 256,000 physicians for failing to show meaningful use in 2013.8
Concerns also have been raised with respect to the limited real-time clinical analytical capabilities of current EHR systems. Health care networks that have sought to analyze large amounts of complex data regarding patient care have reported that private EHR vendors have attempted to control the flow of clinical information by blocking access to clinical information for analytics so that they can monetize the use of data housed in their products.9
Not all of the literature reports on EHRs are negative, however. In the RAND Health report cited earlier, almost all of the physician respondents expressed optimism about EHR development in the future.5 The RAND Health report also showed that EHR had several positive effects on professional satisfaction. More specifically, physicians noted that EHR can facilitate better access to patient data and may contribute to quality of care by providing information that may be used in the development of clinical guidelines and by allowing providers to track patient markers of disease control over time. Physicians also described enhanced communication through the medical record by allowing access to other health care professionals’ notes and eliminating the problems associated with illegible handwriting.
The College intervenes
The ACS has long been aware of the many issues that practicing surgeons face in their efforts to use EHR. The EHR Incentive Program page on the ACS website contains a wealth of information that is intended to help surgeons address challenges regarding EHRs.10 Also available on the website are links to an EHR Incentive Program Reporting Options Timeline, a Basic Starter Guide, a Guide for Vendor Selection, and Contracting Advice for negotiating with EHR vendors. Several ACS Bulletin articles on the EHR Incentive Program are also available for download on this site, as well as links to federal regulations regarding EHR use.
Furthermore, the ACS has partnered with AmericanEHR Partners, which works to assist physicians in the effective use of EHRs. Through this partnership, ACS Fellows can obtain information on EHR vendor ratings and request proposals from vendors.
The ACS also is working with other physician organizations to voice surgeons’ concerns about health information technology and the EHR to the federal government. The ACS and multiple other physician organizations sent a letter to CMS in May 2012 and to Rep. Diane Black (R-TN) in March 2013 in support of the Electronic Health Records Improvement Act, which the congresswoman introduced.11-13 The College also signed onto a joint letter that was sent to the ONC in April 2013.14
ACS Executive Director David B. Hoyt, MD, FACS, has written detailed letters to CMS expressing the many concerns surgeons have regarding the EHR.15-16 Dr. Hoyt wrote a similar letter to the ONC in February 2015.17
Under Dr. Hoyt’s leadership, the College has implemented an EHR Workgroup composed of members of the Electronic Medical Record (EMR) Subcommittee of the ACS Health Information Technology (HIT) Committee, the EMR Workgroup of the Board of Governors, and other interested Fellows. The workgroup’s mission is to help guide the College’s leadership in the increasingly complex environment of what has become known as the electronic clinical data ecosystem. This group is tasked with fostering the development of electronic data management tools that will facilitate the provision of surgical care. The two primary pillars of this group’s work are transforming feedback from Fellows regarding EHR-related concerns and complaints into strategies for improvement and collaborating with the rest of the College to develop and deploy applications that will facilitate delivery of surgical care and enhance clinical outcomes. Currently, the online HIT and EHR ACS Communities provide forums for discussion and the exchange of ideas among interested Fellows.
On January 11, 2016, CMS Acting Administrator Andy Slavitt announced that the current meaningful use program will likely be redesigned and rebranded this year and replaced with a more effective system for use under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act.18 A January 19 clarification on The CMS Blog stated that although the EHR incentive programs were designed to encourage the adoption of new technology and measure the benefits for patients, CMS recognizes that the existing program may place too much of a burden on physicians and pull physicians’ time away from patient care. This blog post stated that future Medicare payments will be linked to getting better results for patients, providing better care, distributing health care dollars more wisely, and keeping people healthy. New regulations will be proposed later this year. These revised rules will be guided by the principles of rewarding providers for the outcomes that technology helps them to achieve with their patients, promoting innovation and the development of new apps and analytic tools so that data can be securely accessed and directed, and prioritizing interoperability through the implementation of national standards.19
The results of the 2015 ACS Governors Survey reveal the many concerns that the Governors, as practicing surgeons, have about the EHR. These results serve to reinforce the position the ACS has taken for many years, with the goal of improving the EHR system so that it can function as a tool to enhance and improve the care of surgical patients.
- Institute of Medicine. The Computer-Based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press; 1991.
- Bush GW. Executive order: 13335: Incentives for the use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator. April 27, 2004. Available at: www.gpo.gov/fdsys/pkg/WCPD-2004-05-03/pdf/WCPD-2004-05-03-Pg702.pdf. Accessed February 15, 2016.
- U.S. Department of Health and Human Services. Thompson launches “decade of health information technology.” Press release. July 21, 2004. Available at: http://archive.hhs.gov/news/press/2004pres/20040721a.html. Accessed February 15, 2016.
- Library of Congress. Public Law 111-5. American Recovery and Reinvestment Act of 2009. Available at: www.congress.gov/111/plaws/publ5/PLAW-111publ5.pdf. Accessed February 15, 2016.
- RAND Corporation. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Available at: www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_RR439.pdf Accessed February 16, 2016.
- American College of Physicians. Survey of clinicians: User satisfaction with electronic health records has decreased since 2010. March 5, 2013. Available at: www.acponline.org/newsroom/ehrs_survey.htm?hp. Accessed February 16, 2016.
- Marbury D. EHRs continue to hinder physician job satisfaction. Medical Economics. June 26, 2014. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/ama/ehrs-continue-hinder-physician-job-satisfaction. Accessed February 16, 2016.
- Terry K. Over 200,000 EPs will see meaningful use fines this year. Medscape Medical News. January 14, 2016. Available at: www.medscape.com/viewarticle/857252. Accessed February 16, 2016.
- Coffron M, Opelka F. Big promise and big challenges for big health care data. Bull Am Coll Surg. 2015;100(4):10-16. Available at: nowherefacs.wpengine.com/2015/04/big-promise-and-big-challenges-for-big-health-care-data/. Accessed February 26, 2016.
- American College of Surgeons. Electronic Health Records Incentive Program. Available at: facs.org/advocacy/regulatory/ehr. Accessed February 25, 2016.
- American College of Surgeons. Comments on Health Information Technology for Economic and Clinical Health (HITECH) Act. Available at: facs.org/~/media/files/advocacy/ehr/black%20support0313.ashx. Accessed February 16, 2016.
- American College of Surgeons, et al. Joint response to Medicare and Medicaid Programs; Electronic Health Record Incentive Program. Available at: facs.org/~/media/files/advocacy/ehr/stage%202%20joint%20comment.ashx. Accessed March 16, 2016.
- Library of Congress. Public law H.R.1331. Electronic Health Records Improvement Act. Available at: www.congress.gov/bill/113th-congress/house-bill/1331. Accessed February 16, 2016.
- American College of Surgeons. ACS responds to CMS and ONC request for information on advancing interoperability and health information exchange. April 22, 2013. Available at: facs.org/~/media/files/advocacy/ehr/rfi%20cms%200413.ashx. Accessed February 16, 2016.
- American College of Surgeons. ACS response to modifications to 2014 EHR program. July 21, 2014. Available at: facs.org/~/media/files/advocacy/regulatory/cms%20ehr%20rev%20cehrt%20definition%20072114.ashx. Accessed February 16, 2016.
- American College of Surgeons. ACS response to the EHR stage 3 rule. May 29, 2015. Available at: facs.org/~/media/files/advocacy/ehr/acs%20ehr%20incentive%20program%20stage%203%20proposed%20rule%20comment%20letter.ashx. Accessed February 16, 2016.
- American College of Surgeons. ACS response to federal IT strategic plan 2015–2020. February 6, 2015. Available at: facs.org/~/media/files/advocacy/regulatory/federal%20hits%20strategic%20plan%20021615.ashx. Accessed February 16, 2016.
- Centers for Medicare & Medicaid Services. Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan annual health care conference, January 11, 2016. The CMS Blog. January 12, 2016. Available at: https://blog.cms.gov/2016/01/12/comments-of-cms-acting-administrator-andy-slavitt-at-the-j-p-morgan-annual-health-care-conference-jan-11-2016/. Accessed February 16, 2016.
- Slavitt A, DeSalvo K. EHR incentive programs: Where we go next. The CMS Blog. January 19, 2016. Available at: https://blog.cms.gov/2016/01/19/ehr-incentive-programs-where-we-go-next/. Accessed February 16, 2016.