Hospital Use of EHRs Is In Nascent Stage
The first comprehensive survey of its kind, to be published March 26 in The New England Journal of Medicine, has found that hospitals' use of electronic health records is very limited. On the basis of responses from 3049 nonfederal acute-care hospitals, only 1.5 percent had what experts considered a comprehensive EHR, and 7.6 percent had a "basic" system that lacked decision support features, had only minimal order entry capability, and only had to be available in one clinical unit of the hospital. (To be classified as comprehensive, a system had to be used throughout the facility.) These figures are much lower than earlier estimates of hospital EHR penetration, based on less thorough surveys.
Interestingly, the same research team published a paper last year showing that the use of full-featured EHRs among physicians was also much lower than earlier estimates. Just four percent of physicians reported having a comprehensive system, and 13 percent said they used a basic electronic record.
Commenting on the results for hospitals, lead coauthor Dr. Ashish Jha, an associate professor at the Harvard School of Public Health, said, "HIT adoption levels are abysmally low in American hospitals--The $19 billion in federal help is a great start but it is only a down payment. This is a big mountain to climb."
Jha saw a couple of reasons for optimism, however. First, he noted at a press conference announcing the study results, federal hospitals were excluded from the survey. If they had been included, the rate of EHR adoption would have doubled, because all VA hospitals have EHRs. Also, he said, 75 percent of hospitals allow physicians to view lab and radiology results online. And 10.9 percent of hospitals have basic EHRs that don't include physician or nursing notes.
The biggest barriers to hospital adoption are cost, physician resistance, and lack of standards, said Jha. John Glaser, vice president and CIO of Partners Healthcare in Boston, added that EHR implementation is hard work that requires workflow changes, leadership and technical expertise. And the cost can range from $2 million for a small hospital to "hundreds of millions of dollars" for large health systems, he said. A more typical range is $20 million to $100 million.
What can the government do? Dr. David Blumenthal, director of the Institute of Health Policy at Massachusetts General Hospital, who has just been named National Coordinator of Health IT, noted that the health IT incentives in the stimulus legislation go beyond direct financial incentives. He said that there is also a commitment to helping hospitals and physicians implement EHRs, partly through regional extension centers that have yet to be defined.
The study authors note that even in the U.K. and the Netherlands--where most ambulatory-care physicians have EHRs--hospital adoption of the technology is fairly low. Perhaps the complexity of hospital operations is one reason for that.
For example, Dean Morrison, CIO of Concord Hospital in Concord, NH, explains that even putting in computerized physician order entry (CPOE) is difficult to do the right way, because it involves a complete change in the workflow of both physicians and nurses. His hospital is in the midst of doing this, but it's a real challenge. A doctor can be anywhere in the hospital and send the nurse an order, but the nurse doesn't know it has been written because she hasn't seen the paper order. "So you have to change the process of how the nurse knows about the orders and validates them and passes them downstream," he points out.
As Jha says, it's a very big hill.