In the past decade , the U . S . health-care system has undergone a historic transformation from a paper-based system to electronic health records ( EHRs ), which – thanks to government mandates – have reached nearly 100 percent adoption among hospitals and physicians . 1

The rapid uptake of this technology has not been without incident , though , and many practitioners have what can best be characterized as a “ love-hate ” relationship with EHRs . The promises of easier data accessibility and better communication come at the cost of a greater documentation burden which , for many providers , means more time looking at the computer screen instead of the patient .

“ There is no question that EHRs have the ability to improve care , but there are still glitches with this relatively new technology ,” said Andrew D . Zelenetz , MD , PhD , medical director of quality informatics at Memorial Sloan Kettering Cancer Center in New York .

This month , ASH Clinical News spoke with experts in health information technology ( IT ) about the ongoing implementation of EHRs , how it has affected hematologists ’ practice and care delivery , and where the effort might be headed next .

HITECH Hijack ?

The Health Information Technology for Economic and Clinical Health ( HITECH ) Act was signed into law in 2009 , when fewer than one in 10 hospitals and 17 percent of physicians used EHRs . 2 The legislation , which received uncharacteristically strong bipartisan support in Congress , encouraged widespread adoption of health IT by providing financial incentives to clinicians and hospitals who demonstrate “ meaningful use ” of EHR systems . 3 The incentives worked : By 2016 , more than 95 percent of all eligible hospitals and more than 60 percent of office-based physicians had demonstrated meaningful use of certified health IT through participation in the Centers for Medicare & Medicaid Services ( CMS ) EHR Incentive Programs . 4 , 5

But adoption does not necessarily mean adoration . Providers commonly complain that the EHR interfaces are clunky and slow , Dr . Zelenetz noted .

“ HITECH incentivized users , but it didn ’ t incentivize vendors to make the best , most innovative strategies ,” he said . “ I ’ ve never understood why typing information

into an EHR [ can ’ t ] look and feel the same as typing in Microsoft Word . It feels like software developed in the 1990s because it is software developed in the 1990s .”

Slow interfaces mean more of doctors ’ limited time is spent on electronic documentation and the pervading sense that the medical profession has been hijacked by rules and regulations that have mostly served to make physicians unhappy – rather than improving the quality of patient-physician interactions .

“ The dysphoria in medicine revolves a great deal around the EHR , but not solely ,” said physician-author Abraham Verghese , MD , at a recent panel discussion on “ Medicine 3.0 .” He added that EHRs were “ imposed on us by federal fiat ,” mostly for better billing and quality reporting . 6

Doctor or Data Entry Clerk ?

So , are the headaches worth it ? “ I think EHRs offer better quality , better patient care , and better communication [ than paper records ],” said Bruce Brockstein , MD , medical director of the Kellogg Cancer Center and division head of hematology / oncology at NorthShore University Health- System in the Chicago area . “ But it takes us more time than when we had paper records , in part because we can do more things , and we can communicate more things to more people .”

For Dr . Brockstein , the question of whether physicians are happy with EHRs is beside the point . “ It ’ s been 15 years that we ’ ve been using EHRs in our hospital system , so most of the people here have never practiced without it ,” he said . “ After that amount of time , you either get settled or you abandon it , and we are quite settled at our institution , even though there is still much that can be improved .”

In 2011 , his group looked at the effect of EHR adoption on the culture of oncologists practicing in the four-hospital NorthShore University Health System . Survey results were largely positive : “[ EHR-conducted ] chemotherapy ordering is more complete and safer [ than in the paper-based system ]. Legibility errors are gone , communication is instantly available from any location , and both outpatient records of hospitalized patients and inpatient records of outpatients are available electronically .” 7

In a second report , the NorthShore group compared completeness of medical records between both systems , finding that ,

with EHR-based computerized physician order entry ( CPOE ), 93 percent of expected data points ( i . e ., patient information , treatment plan , laboratory results , etc .) were documented , compared with 67 percent in paper charts ( p < 0.001 ). 8 “ The nurses and physicians reported good satisfaction , statistically better than with the paper charts , in using the EHR system ,” Dr . Brockstein added .

The most-liked aspects of the EHR / CPOE system were the availability of previous laboratory results , identification of clinical trial participants , and completeness of chemotherapy orders . On the other hand , practitioners were least satisfied with how the system captured patients ’ past medical history and treatment calendars . However , these satisfaction ratings were still higher than the respective scores for the paper charts , he noted .

“ I think we are providing better care because , if you use the EHR correctly , things don ’ t slip through the cracks ,” Dr . Brockstein said , “ and communication with the rest of the health-care team is much easier .”

Patients also seem to be happier with the digitized system . “ Our patients can send a note in the middle of the night to say they are experiencing a certain symptom , and we can get back to them right away ,” he explained . “ They also receive their test results within 24 to 72 hours .”

Accelerating patients ’ access to their own test results , though , puts extra pressure on doctors to inform them of the results , before they receive potentially bad news electronically .

And , according to Dr . Zelenetz , any time saved by EHR-enabled communication with patients is eaten up by more administrative responsibilities . “ Unfortunately , the time we save with the EHRs is being taken up by demands for higher productivity , so I think part of the issue is that our practitioners don ’ t get to bask in the improvements ,” he said . “ It makes it hard to appreciate the advances we ’ ve made .”

In the process of gaining adherents , HITECH lost support with its meaningful use criteria . The broad definition of meaningful use is “ using certified EHR technology in a meaningful manner to :

• improve quality , safety , and efficiency ; and reduce health disparities

• engage patients and family

• improve care coordination , as well as population and public health

• maintain privacy and security of patient health information ” 9

Ultimately , CMS argued , meaningful use compliance would result in improved clinical outcomes , increased transparency and efficiency , empowered individuals , and more robust research data on health systems .

These criteria , according to virtually every U . S . hospital and provider , were overly burdensome . The former CMS Administrator himself , Andy Slavitt , MBA , was quoted in 2016 as saying , “ We have to get the hearts and minds of physicians back . I think we ’ ve lost them ,” in reference to the meaningful use rules . 10

In March , the new CMS Administrator , Seema Verma , MPH , announced a “ complete overhaul ” of the agency ’ s meaningful use program that will be aimed at reducing the time and cost burden of compliance for hospitals . Details of the renovation have not been released .

The Promises of Paperless

“ One thing that EHRs do unequivocally is give us immediate access to much more patient information , and with that data we can make much better choices about how to care for [ patients ],” said Dr . Zelenetz . “ No one complains about getting information from the system ; the complaints are about having to put the information into the system .”

Most research on EHRs reaches the same conclusion : They are a boon for clinical care . EHRs reduce medical errors and facilitate integrated care . Medication mistakes still occur , but mostly due to human error during manual entry .

“ Our CPOE system has dramatically reduced errors ,” Dr . Zelenetz confirmed . “ We don ’ t see lost orders or inaccuracies because someone couldn ’ t read the physician ’ s handwriting . The system has predefined [ chemotherapy ] regimens , so I just say what I want to give , and it ’ s all calculated based on the patient ’ s height and weight . It takes seconds to write [ the order ] and it gets transmitted to a verification nurse for review and then , boom , the pharmacy gets it .”

In their report on the rollout of the system , Dr . Zelenetz and researchers from the Memorial Sloan Kettering stressed that “ a